Every finding on record at Parkview Health and Rehabilitation Center

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 43 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.Findings included:- On 08/18/25 at 09:35 AM, Dietary Staff (DS) AA was present in the kitchen and identified herself as the Dietary Manager. DS AA reported she was currently in classes to complete the Certified Dietary Manager course but had not completed the course at this time.The facility's Personnel/Training Policy, Chapter 7 policy, dated 2021, documented regular meetings with the registered dietitian nutritionist (RDN) or designee. Support staff work under the supervision of the RDN, certified dietary manager, director of food and nutrition services, etc. The RDN may delegate certain tasks based on the scope of practice and competency levels of each member of the nutrition team.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 43 residents who reside in the facility and received meals from the facility's kitchen. This deficient practice placed the residents at risk for foodborne illness.Findings included:- On 08/18/25 at 08:15 AM, during the initial tour of the kitchen, observations revealed:Dietary Staff (DS) CC and DS BB had facial hair and lacked beard and mustache covers.A fan located above the microwave area, blowing in the direction of the steam table, had an excessive amount of grey/black linted material on the blades, and front and back screens.The dining room refrigerator/freezer combination had two containers of chocolate ice cream without covers or dated to when they were placed in the freezer or when the expiration dates.On 08/18/25 at 09:35 AM, DS AA verified that DS CC and DS DD should have a beard and mustache covering, and the ice cream should have had lids and been labeled when placed in the freezer.On 08/19/25 at 11:56 PM, observation revealed:A fan located near the three-compartment sink, blowing toward the steam table with had an excessive amount of grey/black linted material on the blades, and front and back screens.DS BB checked the food temperatures without cleansing or sanitizing the thermometer between foods.DS CC began to sort spoons from a dishwasher rack with bare hands touching the rounded portion of the spoons.The Hydrion QT-40 chemical sanitizing strip had an expiration date of 07/15/25.The lower portion of the shelving throughout the kitchen was unclean and had food debris and dark particles on it.On 08/19/25 at 12:32 PM, DS AA verified the fans and lower shelving needed to be cleaned, DS BB should have sanitized the thermometer between food, the expired Hydrion QT-40 chemical sanitizing strips would be replaced with ones that had not expired, and DS CC should not touch the eating surface of spoons with bare hands.The Dining RD/Health Technologies, Guideline &Procedure Manual dated 2020 documented that employees will use effective hair restraints, such as hairnets, hair bonnets, and beard guards, to prevent contamination of food or food contact. Staff should be reminded that gloves become contaminated just as hands do and should be changed. often. Food shall be stored on shelves in a clean and dry area free of contaminants. All food items are to be labeled. The label must include the name of the food and the date by which it should be consumed or discarded. All staff will be trained on the frequency of cleaning. Staff will be held responsible for all cleaning tasks. If indicated, additional infection control procedures shall be followed for disinfecting high-touch point areas. It is recommended to use an approved disinfectant solution allowing for a minimum contact time. Spoons, knives, and forks should be touched only by their handles.

The facility had a census of 44 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 2 (January 1 - March 31/2025) indicated the facility had excessively low weekend nurse staffing.Review of the facility's weekend nursing schedules for the above Quarter revealed the facility had adequate staffing.The PBJ report provided by CMS for FY Quarter 3 2024 (April 1-June 30) indicated the facility failed to have licensed nursing coverage 24/hours a day on 04/20, 05/04, 05/05, 05/18, and 05/19. Review of the facility's licensed nursing coverage 24/hours a day on the above dates revealed the facility had adequate licensed nurse coverage.On 08/18/25 at 08:26 AM, Administrative Nurse A stated that corporate staff were responsible for submitting the PBJ, but she always checked it before corporate submitted it.The facility lacked a policy related to PBJ.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility's (QAA) Quality Assessment and Assurance program failed to provide good faith efforts to identify multiple issues of concern for 33 residents residing in the facility.Findings included:- The facility failed to treat R5 and R10 with dignity. Refer to F 550.The facility failed to complete R21, R53, and R54's beneficiary notices with the correct forms. Refer to F 582.The facility failed to provide R29 with a physician order, assessment, and updated care plan for R29's lap buddy. Refer to F604.The facility failed to provide documentation that a background check was conducted on HS U before her employment. Refer to F606.The facility failed to report R2's fall with a fracture and R8's bruised, swollen left index finger to the State Survey Agency (SA). Refer to F609.The facility failed to provide R7 and R52 or their representative with the bed hold policy and notify the ombudsman when they were transferred to the hospital. Failed to notify the ombudsman when R50 was discharged to the community. Refer to F628.The facility failed to revise R21's care plan with the appropriate use of prophylactic antibiotics. Refer to F637.The facility failed to place the care planned floor motion detector on for R24 when in his room. Failed to store chemicals in a locked laundry and supply rooms. Refer to F689.The facility failed to ensure a Registered Nurse (RN) was on duty eight hours, seven days a week. Refer to F727.The facility failed to post nurse staffing information on three of three onsite days. Refer to F732.The facility's pharmacy consultant failed to identify and report to administration the physician's rationale for continued use of a prophylactic antibiotic. Refer to F754The facility failed to obtain a physician's rationale for R21's use of prophylactic antibiotics. Refer to F561.The facility failed to ensure drugs and biologicals were not expired. Refer to F761The facility failed to employ sufficient staff with appropriate competencies to carry out the functions of food and nutrition services. Refer to F7801.The facility failed to ensure a clean, sanitary environment in the kitchen, staff wore beard guards, food items stored in the refrigerator were covered, and staff used sanitary procedures when contacting resident silverware, and sanitizer strips were not expired. Refer to F812.The facility failed to collaborate hospice services information into the facility care plan. Refer to F849.The facility failed to ensure the medical director signed in on quarterly quality assessment and assurance meetings (QAA). Refer to F868.On 08/20/25 1:29 PM, Administrative Staff A stated that every department head brings newly identified concerns to the QAA meeting, the facility conducted a mock survey, and the committee reviews weight trends. The facility failed to identify, develop, and implement appropriate plans of action to have an effective quality assurance program that identified and addressed the above issues involving multiple concerns, placing the 44 residents who reside in the facility at risk for mental, physical, and psychosocial decline.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to meet the professional standard of quality when preparing medications for administration to the residents. This placed the residents at risk of receiving the incorrect medications.Findings included:- On 08/18/25 at 08:49 AM, while checking the medication cart during initial entry into the facility with Licensed Nurse (LN) G, the medication cart located on the long-term care unit, the top drawer contained four handwritten resident-labeled medication cups with a variety of shapes and colored medications. LN G stated she had pre-set the medications and was aware this should not be done.On 08/20/25 at 02:00 PM, Administrative Nurse D verified that medications should not be pre-set before the resident is ready to take them.The facility's Medication Administration policy dated 03/19/25 documented that medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff failed to place R24's motion detector floor alarm on when R24 was in his room. The facility failed to keep chemicals in the laundry room and the west supply room locked and inaccessible to the residents. This placed R24 at risk for a fall and all the residents at risk for residents at risk for accessing hazardous chemicals.Findings included: - R24's Electronic Medical Record (EMR) documented R24 had diagnoses of macular degeneration (progressive deterioration of the retina) and pain. R24's Quarterly Minimum Data Set (MDS), dated [DATE], documented R24 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R24 required supervision with transfers and ambulation. R24's Care Plan, revised 06/18/25, documented R24 required partial, moderate assistance of transfer to a chair-to-bed or bed-to-chair. The plan documented 24 required 1 staff assistance with standing and walking in a room, corridor, or small space. The plan documented R24 at risk for falling and instructed staff to ensure the motion alarm was on when the resident was in his room. On 09/19/25 at 09:15 AM, observation revealed R24 sat in a recliner in his room, the floor motion alarm sat on top of a table, by the entrance door, and was not on. On 08/19/25 at 09:15 AM, Certified Nurse Aide (CNA) M entered R24’s room, the alarm did not activate, and verified it was not on, placed it on the floor, and turned it on. CNA M stated the alarm is to be on at all times when R24 was in his room. On 08/20/25 at 12:55 PM, Administrative Nurse D stated that if R24 was care planned to have the floor alarm on when he is in his room, she would expect staff to follow the care plan. Administrative Nurse D verified R24’s care plan, instructed staff to place the floor motion alarm on at all times when R24 was in his room. The facility’s “Accident and Supervision Policy,” revised 02/01/20, documented the residents’ environment would remain as free of accident hazards as possible, and each resident would receive adequate supervision and assistive devices to prevent accidents. - On 08/18/25 at 08:10 AM, observation revealed an unlocked laundry room door on the dementia unit. The unlocked room contained the following: Eleven containers of “Super Sani cloths (disinfecting disposable wipes),” 16 ounces (oz). The label on the container with the following precautions: “Keep out of reach of children, avoid contact with eyes and skin, and may cause eye irritation.” Two buckets of “Clean Slate liquid laundry bleach (laundry bleach),” 5-gallon buckets. The label on the bucket with the following precautions: “Keep out of reach of children, vapors may be harmful if inhaled, may cause severe harm if ingested, or if the product comes into contact with skin or eyes.” Two plastic jugs of “Clean slate lime scale remover (cleaner to remove lime build up from hard water on surfaces),” one gallon. The label on the jug with the following precautions: “May cause severe skin burn and eye damage.” Seven bottles of “Apollo Turbo cleaner pro disinfectant detergent (dislodges buildup from plumbing),” one gallon. The label on the bottle with the following precautions: “Keep out of reach of children, avoid contact with eyes, harmful if ingested.” On 08/18/25 at 08:20 AM, Maintenance Staff U verified the above finding, stated the laundry room door should be locked at all times. Maintenance Staff U locked the door to the laundry room. On 08/18/25 at 10:20 AM, Nurse Consultant GG verified she expected staff to store chemicals in a locked room. The facility’s “Accidents and Supervision” policy, dated 02/02/20, documented the resident’s environment would remain as free of accident hazards as possible, and each resident would receive adequate supervision and assistive devices to prevent accidents. The policy documented the facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.

The facility had a census of 44 residents. Based on observation, interview, and record review the facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk to receive ineffective medication. Findings included:- On 08/18/25 at 08:20 AM, observation in the facility's East medication room revealed the following expired stock medications:One bottle of Docusate sodium (laxative medication) 500 micrograms (mcg), 100 tablets, with an expiration date of 11/27/24.One bottle of Aspirin (medication to reduce pain, fever, inflammation, and blood thinner) 325 milligrams (mg), 200 tablets, with an expiration date of 01/23/25. One bottle of Vitamin B12 (Vitamin the body uses to make and support healthy nerve cells) 500 mcg, 100 tablets, with an expiration date of 03/07/25. One bottle of Ibuprofen (anti-inflammatory medication) 200mg, 100 tablets, with an expiration date of 06/05/25. On 08/18/25 at 08:25 AM, licensed Nurse (LN) E verified that the expired drugs should have been disposed of. On 08/20/25 at 12:20 PM, Administrative Nurse D verified that the night shift should check the medication cart for expired medications and each nurse administering the medications should check for expired medications and dispose if expired. The facility's Medication Storage in the Facility policy, dated 01/01/20, documented all medications in the premises would be stored in the medication carts or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitization, temperature, light, ventilation, moisture control, segregation, and security. The policy stated the medication rooms were routinely inspected by the facility designee for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with the facility's Destruction of Unused Drugs Policy.

The facility had a census of 44 residents. The sample included 13 residents, with five residents reviewed for immunizations: Resident (R) 6, R13, R15, R19, and R22, 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 offer, obtain an informed declination or a physician documented contraindication for the pneumococcal vaccination, including the PVC 20 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 R6, R13, R15, R19, and R22 clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine, including the PVC20.Review of R6's electronic health record revealed the resident was admitted to the facility on [DATE]. R6 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.Review of R13's electronic health record revealed the resident was admitted to the facility on [DATE]. R13 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.Review of R15's electronic health record revealed the resident was admitted to the facility on [DATE]. R15 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.Review of R19's electronic health record revealed the resident was admitted to the facility on [DATE]. R19 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission. Review of R22's electronic health record revealed the resident was admitted to the facility on [DATE]. R22 had not been offered or received a pneumococcal vaccine, including the PVC20, since admission.On 08/19/25 at 12:10 PM, Administrative Nurse E stated the residents immunization status is assessed upon admission and she would determine thru the Web IZ (a web-based computer system used in the United States to tract immunization records) portal what immunization the resident had received and what date they received them, then she would determine what vaccinations the resident would be eligible for and contact the physician if need for orders to administer the vaccinations. Administrative Nurse E verified the facility would provide a consent form with information regarding the vaccine to the resident and/or the Durable Power of Attorney (DPOA) to sign. Administrative Nurse E verified she had been doing a lot of jobs at the facility lately. However, she had determined what residents were eligible for what pneumococcal vaccine, but some of the residents' pay or source would not cover the vaccine, and she had not had time to research where each resident could get the vaccine and have their insurance cover the cost. The facility's Pneumococcal Vaccine policy dated 01/31/22 documented the facility would offer the residents immunization against pneumococcal diseases in accordance with current CDC guidelines and recommendations. Each resident would be assessed for pneumococcal immunizations upon admission, and each resident would be offered a pneumococcal immunization unless medical contraindicated or the resident has already been immunized. Following assessment for any medically contraindicated conditions, the immunization may be administered in accordance with physician approval standing orders. The resident receiving the immunization, or the resident representative, would be provided with a copy of the CDC's current vaccine information statement relative to the vaccine. The resident and/or representative retains the right to refuse the immunization, and a consent form shall be signed prior to the administration of the vaccine and filed in the resident's medical record. The type of pneumococcal vaccine (PVC15, PVC20, or PPSV23/PPSV) offered would depend on the residents' age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff administered an injection to Resident (R) 5 in the dining room, in view of residents and visitors, and failed to place a privacy bag on R2's urinary drainage bag. This placed the residents of the facility at risk for impaired dignity. Findings included:- On 08/18/25 at 12:05 PM, observation revealed Licensed Nurse (LN) H obtained a finger stick blood sugar from R5 and then administered insulin (a hormone that lowers the level of glucose in the blood) in R5's right upper arm, at the dining room table, with two resident and two staff sitting at the table and seven other residents' seated in the dining room.On 08/18/25 at 12:10 PM, Nurse Consultant GG verified the nurse should not obtain the resident's blood sugar reading or administer his insulin at the dining room table and should take the resident out of the dining room to a private area.The facility's Promoting/Maintaining Residents' Dignity policy, dated 10/21/23, documented the facility would protect and promote residents' rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment that maintains or enhances the resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain residents' dignity and respect residents' rights. The policy documented when staff interacted with the resident, they would pay attention to the resident as an individual and explain care or procedures to the resident before initiating the activity, and maintain the resident's privacy.

The facility had a census of 44 residents. The sample included 13 residents. Based on record review and interview, the facility failed to provide Resident (R) 28, or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055 and failed to provide R53 and R54 the completed Notice of Medicare Non-Coverage Form (NOMNC) Centers for Medicare and Medicare Services (CMS) form 10123, and the 10055 form. This placed the residents, or their representatives, at risk of making uninformed decisions about their skilled services and at risk of incurring charges if exercising their right to appeal. Findings included:- The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The CMS Form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy. The form included options for the beneficiary to receive specific services listed and bill Medicare for a decision on payment.The facility failed to provide R28, or her representative, form 10055, knowing the resident or the resident's representative may have to pay out of pocket. R28's skilled services ended on 04/02/25. The facility failed to provide R53, or her representative, forms 10055 and 10123. R53's skilled services ended on 03/27/25. The facility failed to provide R54, or her representative, forms 10055 and 10123. R54's skilled services ended on 03/17/25. On 08/20/25 at 01:00 PM, Administrative Staff A verified the facility had not provided R53 and R54 and/or their representative the CMS form 10055 or CMS form 10023, and failed to provide R28 the 10055 forms.The Advanced Beneficiary Notices policy, dated 05/07/25, documented that the facility would provide timely notices regarding Medicare eligibility and coverage. The Business Office Manager is the contact person for information regarding Medicare eligibility, coverage, and applying for benefits. A notice alerting residents and the residents' representative of this contact person shall be posted conspicuously in the facility. The Business Office Manager would provide Medicare information to residents/representatives upon request. admission paperwork would include a list of charges, including a list of charges for services not covered under Medicare by the facility's per diem rate. Any changes to these charges would be relayed to the resident/representative in a timely manner. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice would be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides an item or service that is usually paid for by Medicare but may not be paid for in a particular instance because it is not medically reasonable and necessary, or Custodial care. The current CMS approved version of the form shall be used at the time of issuance to the beneficiary (resident or resident representative). The Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the SNF ABN form CMS 10055. b. For Part A NOMNC, the facility shall use the form CMS 10123. The Business Office Manager, or designee, is responsible for issuing notices. The facility shall issue a notice each time, and as soon as it makes the assessment that Medicare payment certainly or probably will not be made. The notice shall be hand-delivered if possible to obtain the beneficiary or representative's signature. The notice shall be prepared with an original and at least two copies. The facility shall retain the original and give a copy to the resident/representative. The notice cannot be hand delivered; a telephone notice shall be made, followed up immediately with a mailed, emailed, faxed, or hand-delivered notice. Documentation shall comply with the forms' instructions regarding telephone notices. Mail, secure fax machine, and internet e-mail may also be utilized for delivery of the notice if in-person issuance is not able to be performed, and all methods of delivery must adhere to all statutory privacy requirements under HIPAA.

The facility had a census of 44 residents. The sample included 13 residents, with one reviewed for restraints. Based on observation, record review, and interview, the facility failed to provide a physician's order and assessment for a Lap Buddy (a cushioned pad that fits across the resident lap, placed in a wheelchair to remind residents to remain seated and to alert caregivers when a resident attempts to rise and prevents falls by discouraging independent movement) used to restrain Resident (R) 29 while in his wheelchair, placing the resident at risk for complications related to physical restraints. Findings included:- R29's Electronic Medical Record (EMR) documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), and traumatic subdural hematoma (SDH- serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain), muscle weakness, and unsteadiness on feet with abnormal gait and mobility.R29's Significant Change Minimum Data Set (MDS) dated [DATE] documented R29 had severely impaired cognition and required substantial/maximal staff assistance with chair-to-bed transfers and to sit-to-stand, personal hygiene, oral hygiene, and shower and bathe self. The MDS further documented R29 had two falls with no injury and two falls with minor injury and lacked the use of restraints. R29's Fall Care Plan, dated 08/04/24, documented R29 was at risk for falls related to impaired mobility, gait and balance problems, and unaware of safety awareness. The care plan directed staff to anticipate the resident's needs, check on him frequently, have the call light within reach, and ensure he is wearing appropriate footwear when ambulating. The care plan lacked documentation that the resident had a Lap Buddy in his wheelchair.R29's EMR lacked a physician's order or an assessment for the Lap Buddy.On 08/18/25 at 03:20 PM, observation revealed R29 seated in his wheelchair in the dining room-propelling himself around. Continued observation revealed Certified Nurse Aide (CNA) N told the resident she would push his wheelchair to the living room so he could watch some TV. CNA N pushed R29 in the living room close to a couch and recliner. CNA N left the area to assist a resident in changing her soiled clothes. Continued observation of R29 revealed that after a few minutes, he began rocking back and forth in his wheelchair and was able to stand with the use of the arm of the couch, and started taking approximately five steps from the wheelchair. R29 stood and began to ambulate with no staff in the area. On 08/18/25 at 03:30 PM, observation revealed CNA N returned to the living room and obtained a Lap Buddy, and placed it across R29's lap in the wheelchair. Continued observation revealed Administrative Staff D came to the unit and asked R29 if he wanted some coffee, and he stated yes, so she removed the Lap Buddy and pushed him up to the table and served him a cup of coffee. On 08/18/25 at 03:35 PM, CNA N stated the resident had falls and would attempt to stand, and had to remind him to sit in the wheelchair due to weakness and fall potential. CNA N they put the Lap Buddy on him to prevent him from standing and falling out of the wheelchair. CNA N states that two aides work on the unit from 2:00 pm to 10:00 PM, and the nurse will come from the other side of the facility to administer the resident's medication or when her assistance is needed.On 08/18/25 at 03:50 PM, Administrative Nurse D stated she thought the physician had recently ordered the Lap Buddy and thought she told the nurse to add the device to the resident's care plan. Continued review revealed the facility lacked a physician order for the Lap Buddy, lacked an assessment for the Lap Buddy, and lacked a care plan for the use of the Lap Buddy. Administrative Nurse D stated she would get the order, assessment, and then have it added to the care plan. The facility's Restraint Free Environment policy, undated, documented each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily., which restricts freedom of movement or normal access to one's body. Physical restraints may include placing a resident in a chair that prevents the resident from rising, placing a device in conjunction with a chair, such as a tray, tables, cushions, bars, belts that the resident cannot remove and prevents the resident from rising.

The facility had a census of 44 residents. Based on observation, record review and interview the facility failed to provide a background check for Housekeeping Supervisor (HS) U, who had been employed with the facility since 1979, left, and came back in 1991. This placed the residents at risk for abuse.Findings included:- Review of background checks revealed the facility lacked a background check on HS U.On 08/19/25 at 01:50 PM, observation revealed HS U pushed a housekeeping cart down the west side of the facility.On 08/18/25 at 02:00 PM, Administrative Staff A stated the facility lacked documentation a background check was conducted on HS U, because she had been employed with the facility since 1991.On 08/19/25 at 12:57 PM, HS U stated she was employed with the facility in 1979 or 1980, left, then was rehired in 1991.The facility failed to provide a policy.

The facility had a census of 44 residents. The sample included 13 residents. Based on record review and interview, the facility staff failed to identify an unwitnessed fall which resulted in serious injury as a potential allegation of neglect or abuse and report immediately to the State Survey Agency (SA), when Resident (R) 2, a cognitively impaired resident, had an unwitnessed fall with a fracture, and R8, a cognitively impaired resident, had a bruise of unknown origin. This placed the resident at risk for further injury and unidentified abuse or neglect. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and a fracture neck of the left femur (thigh bone).R2's Significant Change (MDS), dated [DATE], lacked a documented cognitive status. The MDS documented R2 required substantial to maximal staff assistance with most activities of daily living (ADL). The MDS documented the resident received an antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication. The Dementia Care Area Assessment (CAA) dated 07/22/25, documented R2 had dementia, inattention, and disorganized thinking. The Falls CAA dated 07/22/25, documented to see the therapy record, diagnosis list, pain assessment, and nurse assessment. R2's Fall Care Plan, dated 07/27/25, documented R2 had a fracture left hip on 07/06/25 and a right fractured hip on 02/04/25. The care plan instructed staff to anticipate and meet R2's needs, make sure the call light is within reach, and respond promptly to all requests for assistance. The care plan directed staff to have an anti-roll back on her wheelchair, monitor, and document pain. The Nurse's notes, dated 02/04/25 at 03:25 AM, documented the nurse was called to the resident's room by a Certified Nurse Aide (CNA) O. R2 was observed lying on her right side beside her bedside table, which was positioned beside her recliner. R2 was screaming and crying, unable to comprehend staff instructions or questions. R2 batted staff away when attempting to obtain vital signs and complete an assessment. R2 was unable to articulate what had happened and would occasionally point to the window, cry, and scream. R2 complained of right hip pain and was incontinent of bladder. Continued assessment revealed no skin tears, abrasions, lacerations, or contusions. R2's right leg was noted to be approximately 1-2 inches shorter than her left leg. The Nurses notes, dated 02/02/25 at 04:35 AM, documented the ambulance was notified of transport with a possible right hip fracture. The Nurses notes, dated 02/04/25 at 10:55 AM, documented the facility received a call from the hospital regarding R2's right hip fracture and condition. The hospital sent the resident to an out-of-town hospital for hip surgery.The Nurses notes, dated 02/07/25 at 03:00 PM, documented the resident returned to the facility per wheelchair for continued care as a prior resident of the facility.The facility's Incident Note, undated, documented on 02/04/25 at 03:25 AM, the nurse was called to the resident's room, and R2 was on her right side beside her bedside table, which was positioned beside her recliner. The resident was screaming and crying, unable to comprehend staff instructions or questions. R2 was unable to voice what happened but complained of right hip pain. R2 was incontinent of bladder and did not have any skin tears, lacerations, or abrasions noted by the nurse. The nurse noted the resident's right leg was shorter than the left leg. At 03:30 AM, the nurse administered PRN Tramadol (analgesic) to try to decrease the pain in an attempt to complete a more thorough assessment. At 04:30 AM, the Nurse Practitioner was notified of assessment findings, and an order was received to transport the resident to the hospital for further evaluation. The incident note documented the resident was care planned for I need assistance with my ADLs due to my dementia, and documented she makes her own decisions but sometimes needs staff assistance. The report had been documented on the top of the form Not Reportable. On 08/20/25 at 12:10 PM, Nurse Consultant GG verified the facility had not reported R2's unwitnessed fall with injuries to the SA due to the fact that the resident had a diagnosis of osteoarthritis, osteoporosis, was in a private room, her care plan was followed, and the fracture was not suspicious. Nurse Consultant GG verified the resident was cognitively impaired, was unable to explain what happened, and had a fall that resulted in a fracture. The facility's Resident Right to Freedom from Abuse, Neglect, and Exploitation policy, dated 2025, documented the facility would ensure the residents are free from abuse, neglect, misappropriation of their property, and exploitation. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility shall report the results of all investigations to the administrator his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation was verified, appropriate corrective action must be taken. The facility's Unexplained Injuries policy, dated 10/21/23, documented all unexplained injuries, including bruises, abrasions, and injuries of unknown source, would be investigated. An incident form would be completed. If an allegation of abuse is made or if the injury is of unknown source, reporting and investigating procedures shall be implemented in accordance with the facility's abuse policies and procedures. An injury should be classified as an injury of unknown source: when both of the following conditions are met:a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of The extent of the injury orThe location of the injury.The number of injuries observed at one particular point in time The incidence of injuries over time.Relevant information shall be documented in the resident's medical record, including but not limited to;Physical Assessment findings, includingObjective description of the injury Risk factors and conditions that could cause or could predispose someone to similar signs or symptoms. Notification of the physician and his or her response.Actions taken to meet the residents' immediate needs and implementation of the physician's order.Notification of the resident representative. The facility shall modify the resident care plan as needed to prevent recurrence, or to stabilize, reduce, or remove underlying risk factors contributing to the injury.- R8's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion,) major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and malignant neoplasm (tumor) floor of the mouth. R8's Annual Minimum Data Set (MDS) dated [DATE], recorded R8 had moderately impaired cognition. The MDS recorded R8 required limited staff for most activities of daily living (ADL). The MDS recorded R8 used a walker for mobility.R8's ADL Care Plan, dated 07/14/25, directed staff to provide supervision or touch assistance with transfers from bed to chair, getting on and off the toilet, tub/shower transfers, and assist the resident with walking. The care plan documented the resident had a diagnosis of dementia, and staff would provide an environment consistent to alleviate confusion and anxiety and allow adequate time to respond to instructions or verbal cues, and allow her to participate in her care as long as she is able. The care plan was documented due to the dementia; she often looked for her husband and children, who are all grown up. The Nurses Note, dated 03/31/25 at 01:54 PM, documented R8's left index finger was swollen and bruised at the base of the finger, and was soft and non-tender. A fax was sent to the primary care physician. The Nurses Note, dated 04/01/25 at 10:32 AM, documented R8's left index finger remains bruised and swollen on the back side at that time. R8's EHR lacked any investigative notes regarding the incident, including witness statements, root cause, or investigation.On 08/18/25 at 04:00 PM, observation revealed the resident sat on the edge of her bed, then stood up and ambulated over to her chest of drawers, and rummaged through a couple of drawers, then returned to the edge of the bed. The resident was dressed in street clothes and nicely groomed. On 08/20/25 at 12:20 PM, Nurse Consultant GG stated the medical records documented the resident had a swollen and bruised left index finger, but staff were unaware how the injury had occurred. Nurse consultant GG verified that the facility did not investigate, gather witness statements, or report to the state agency when the incident occurred. The facility's Resident Right to Freedom from Abuse, Neglect, and Exploitation policy, dated 2025, documented the facility would ensure the residents are free from abuse, neglect, misappropriation of their property, and exploitation. In response to allegations of abuse, neglect, exploitation or mistreatment the facility shall report the results of all investigations to the administrator his/her designated representative, and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation was verified, appropriate corrective action must be taken. The facility's Unexplained Injuries policy, dated 10/21/23, documented all unexplained injuries, including bruises, abrasions, and injuries of unknown source, would be investigated. An incident form would be completed. If an allegation of abuse is made or if the injury is of unknown source, reporting and investigating procedures shall be implemented in accordance with the facility's abuse policies and procedures. An injury should be classified as an injury of unknown source: when both of the following conditions are met:a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of The extent of the injury orThe location of the injury.The number of injuries observed at one particular point in time The incidence or injuries over time.Relevant information shall be documented in the resident medical record; including but not limited to;Physical Assessment findings, includingObjective description of the injury Risk factors and conditions that could cause that could predispose someone to similar signs or symptoms. Notification of the physician and his or her response.Actions taken to meet the residents' immediate needs and implementation of the physician's order.Notification of the resident representative. The facility shall modify the resident care plan as needed to prevent recurrence, or to stabilize, reduce, or remove underlying risk factors contributing to the injury.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification for Resident (R) 7 and R52 and notify the Office of the Long-Term Care Ombudsman (LTCO public official who works to resolve resident issues in nursing facilities) of the discharge for R7, R52, and R50 discharge from the facility. This placed the residents, and/or their representatives, at risk for uninformed care choices and impairs rights.Findings included:- R7’s Electronic Medical Record (EMR) included diagnoses of heart failure, generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), pain, tremors, Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), aftercare following joint replacement surgery, muscle weakness, and a history of falls. R7’s “Medicare 5 Day Minimum Data Set” (MDS) dated [DATE], documented R15 had intact cognition, had functional range of motion in both lower extremities, required partial/moderate assistance with toileting hygiene, bed mobility, and substantial/maximal assistance with sit to standing, transfer to chair, and toilet. R7 had occasional incontinence of urine. The MDS further documented that R7 received scheduled pain medication, received as-needed pain medication, and had trouble breathing with exertion, sitting at rest, and when lying flat, and had a surgical hip replacement. R7’s MDSs recorded: On 07/14/25 a Discharge Return Anticipated. On 07/18/25 Entry into the facility. R7’s “Care Plan” dated 08/11/25, documented R7 had a hip fracture related to a fall on 07/17/25 and directed staff to monitor/document/report as needed signs and symptoms of hip fracture complications. The “Progress Note” dated 07/14/25 at 10:26 PM, documented that the staff called to R7’s room due to a fall with possible injury. R7 had significant pain in the left and the back. An ambulance was called to transport R7 to the emergency room. The “Progress Note” dated 07/16/25 at 10:08 AM, documented a hospital call reporting R7 had a total hip replacement done and was doing well, receiving occupational and physical therapy, and was possible for discharge on [DATE]. The “Progress Note” dated 07/18/25 at 12:19 PM, documented R7 returned to the facility accompanied by facility staff. On 08/19/25 at 02:19 PM, R7 was taken to the therapy department via wheelchair to be weighed and work with therapy staff. On 08/19/25 at 12:49 PM, Administrative Nurse D reported that a bed hold was not provided to the resident or resident representative at the time of transfer to the hospital. On 08/19/25 at 03:19 PM, Administrative Staff A reported the last ombudsman notification was made in January 2025, and the ombudsman was not notified of R7 discharge on [DATE]. The facility’s “Transfer and Discharge” policy dated 02/01/20 documented for an emergency transfer/discharge, the facility provides a notice of the resident’s bed hold policy to the resident and representative at the time of transfer, as soon as possible, but no later than 24 hours of the transfer. The Social Service Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via a monthly list. - R52’s Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), osteoarthritis(degenerative changes to one or many joints characterized by swelling and pain), muscle weakness, repeated falls, heart failure, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R52’s “Quarterly Minimum Data Set” (MDS), dated [DATE], documented that R52 had intact cognition, had functional range of motion impairment of lower extremities, and used a walker. R52 required substantial/maximal assistance with lower-body dressing and putting on footwear. R52 required partial/moderate assistance with bed mobility and transfers. The MDS further documented that R52 received scheduled and as-needed pain medication and had pain that occasionally affected sleep and interfered with activities and day-to-day activities, and used continuous oxygen. R52’s MDSs recorded: On 08/03/25, Discharge Return Anticipated. On 08/06/25, Entry to facility. R52’s “Care Plan” dated 08/06/25 documented that R52 was at risk for falls related to impaired mobility. The Care Plan directed staff to anticipate and meet R52 needs, encourage use of the call light, and promptly respond to all requests for assistance. The “Progress Note” dated 08/03/25 at 12:43 AM documented emergency medical services left the facility with R52 in route to the emergency room. The “Progress Note” dated 08/06/25 at 08:52 PM documented that R52 had returned from the hospital at 03:00 PM, in the facility van, accompanied by staff. On 08/19/25 at 07:52 AM, R52 was using the exercise bike, with staff present. When R52 had finished on the exercise bike, staff assisted the resident into her wheelchair and took her to her room. On 08/19/25 at 12:49 PM, Administrative Nurse D reported that a bed hold was not provided to the resident or resident representative at the time of transfer to the hospital. On 08/19/25 at 03:19 PM, Administrative Staff A reported the last ombudsman notification was made in January 2025, and the ombudsman was not notified of R52's discharge on [DATE]. The facility’s “Transfer and Discharge” policy, dated 02/01/20, documented for emergency transfer/discharge, the facility provides a notice of the resident’s bed hold policy to the resident and representative at the time of transfer, as soon as possible, but no later than 24 hours of the transfer. The Social Service Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via a monthly list. - R50's Electronic Medical Record (EMR) documented R50 had 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) with foot ulcers (open sore or wound). R50's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R50 independent with most activities of daily living (ADL) and had an active discharge plan to return to the community. The “Care Area Assessment” (CAA), dated 06/16/25, did not trigger for return to the community. R50's Care Plan, revised 06/24/25, documented R50’s initial discharge plan was to return to the community. R50's Progress Notes dated 07/01/25 at 03:00 PM documented the resident was discharged to home/community. R50's clinical record lacked evidence the LTCO was notified of his discharge home. Review of the discharges from 07/24 to present revealed the last ombudsman notification sent in 01/2025. On 08/19/25 at 12:47 AM, Administrative Staff A stated that Administrative Staff B was responsible for sending notification of R50’s discharge to the LTCO. Administrative Staff A verified that the ombudsman was not notified when the resident was discharged from the facility. The facility's Transfer and Discharge Policy,” revised 02/01/20, documented a copy of the transfer and discharge notice would be provided to a representative of the LTCO.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the care plan to include Resident (R) 21's ongoing use of prophylactic (preventative in nature) antibiotics (class of medication to treat infections) related to a history of urinary tract infections (UTI- an infection in any part of the urinary system). This placed the residents at risk for physical decline, other related complications, and at risk for unnecessary medications.Findings included:- R21's Electronic Medical Record (EMR) included diagnoses of chronic kidney disease, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dehydration, hypertension (elevated blood pressure), restlessness, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (a progressive mental disorder characterized by failing memory and confusion), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues).R21's Quarterly Minimum Data Set (MDS) dated [DATE] documented R21 had moderately impaired cognition, used a walker, required partial/moderate assistance with toileting hygiene, and was independent with other activities of daily living, transfers, and mobility. R21 had occasional incontinence of urine and bowel, no infections, and no pain. The MDS further documented that R21 received an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), an antibiotic, and a diuretic (a medication to promote the formation and excretion of urine).The Urinary Incontinence Care Area Assessment (CAA) dated 03/20/25 documented that staff were to monitor for signs and symptoms of consequences of incontinence, such as infection, to help prevent infections and encourage fluids to help prevent infection.R21's Care Plan dated 07/30/25 documented the risk for incontinence due to chronic kidney disease. The Care plan directed the staff to provide peri-care after incontinent episodes and use a barrier cream as needed to keep R21's skin healthy. The care plan lacked a history of urinary tract infections or use of prophylactic antibiotics.The Physician Order dated 03/18/25, directed staff to administer Nitrofurantoin (antibiotic medication) 100 milligrams (mg) daily, of 30 pills with three refills.The Physician Order dated 04/30/25, directed staff to administer Nitrofurantoin 100 mg daily for 30 days.The Physician Orders signed on 05/02/25, 06/04/25, 07/02/25, and 08/05/25 continued to direct staff to administer Nitrofurantoin 100 mg daily for prophylaxis without a stop date.The review of the EMR the physician lacked review of the ongoing use of Nitrofurantoin daily to prevent UTIs. Administrative Nurse D was unable to locate documentation from the physician's progress notes of a rationale for the ongoing use of nitrofurantoin. On 08/19/25 at 09:02 AM, Certified Medication Aide (CMA) R administered the morning medications while R21 sat at the dining room table. CMA R verified Nitrofurantoin could be crushed and mixed with applesauce due to R21's history of pocketing medication in her cheek, then spitting them out into a napkin. R21 took the medications without concern.On 08/20/25 at 01:36 PM, Administrative Nurse D verified R21's care plan should include the use of prophylactic measures for the history of UTIs.Upon request, the facility failed to provide a policy related to care plan timing and revisions.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 21's long-term use of prophylactic (preventative in nature) antibiotic (medications used to treat infections). This placed R21 at risk for inappropriate use of medications.Findings included:- R21's Electronic Medical Record (EMR) included diagnoses of chronic kidney disease, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dehydration, hypertension (elevated blood pressure), restlessness, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (a progressive mental disorder characterized by failing memory and confusion), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues).R21's Quarterly Minimum Data Set (MDS) dated [DATE] documented R21 had moderately impaired cognition, used a walker, required partial/moderate assistance with toileting hygiene, and was independent with other activities of daily living, transfers, and mobility. R21 had occasional incontinence of urine and bowel, no infections, and no pain. The MDS further documented that R21 received an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), an antibiotic, and a diuretic (a medication to promote the formation and excretion of urine).The Urinary Incontinence Care Area Assessment (CAA), dated 03/20/25, documented that staff were to monitor for signs and symptoms of consequences of incontinence, such as infection, to help prevent infections and encourage fluids to help prevent infection.R21's Care Plan dated 07/30/25 documented the risk for incontinence due to chronic kidney disease. The care plan directed the staff to provide peri-care after incontinent episodes and use a barrier cream as needed to keep R21's skin healthy. The care plan lacked a history of urinary tract infections (UTI- an infection in any part of the urinary system) or use of prophylactic antibiotics.The Hospital Discharge Physician Order dated 02/14/25, directed staff to administer Nitrofurantoin (antibiotic medication) 100 milligrams (mg) twice a day for 10 days.The Physician Order dated 03/18/25, directed staff to administer Nitrofurantoin 100 mg daily, of 30 pills with three refills.The Physician Order dated 04/22/25, directed staff to administer Ceftriaxone (antibiotic medication) Sodium Solution reconstituted one gram intravenously in the morning for 10 days related to urinary tract infection.The Physician Order dated 04/30/25, directed staff to administer Nitrofurantoin 100 mg daily for 30 days.The Physician Orders signed on 05/02/25, 06/04/25, 07/02/25, and 08/05/25, continued to direct staff to administer nitrofurantoin 100 mg daily for prophylaxis without a stop date.The review of the EMR, the physician lacked review of the ongoing use of nitrofurantoin daily to prevent UTIs. Administrative Nurse D was unable to locate documentation from the physician's progress notes of a rationale for the ongoing use of nitrofurantoin. The Pharmacy Drug Regimen Review, dated 02/26/25, 03/12/25, 04/11/25, 05/15/25, 06/13/25, 07/08/25, and 08/17/25, lacked mention of the long-term use of Nitrofurantoin.On 08/19/25 at 09:02 AM, Certified Medication Aide (CMA) R administered the morning medications while R21 sat at the dining room table. CMA R verified Nitrofurantoin could be crushed and mixed with applesauce due to R21's history of pocketing medication in her cheek, then spitting them out into a napkin. R21 took the medications without concern.On 08/19/25 at 03:15 PM, upon request twice, Administrative Nurse E failed to provide the monthly review of antibiotic log use for R21's ongoing use of the prophylaxis Nitrofurantoin.On 08/19/25 at 12:47 PM, Administrative Nurse D reported that the CP reviewed the antibiotic use every six months and would currently do so for R21.The Pharmacy Service policy, dated 02/20/19, documented the facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the need for continued antibiotic (a class of medications used to treat infections) use for Resident (R) 21, which placed the resident at risk of receiving unnecessary medication.Findings included:- R21's Electronic Medical Record (EMR) included diagnoses of chronic kidney disease, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dehydration, hypertension (elevated blood pressure), restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (a progressive mental disorder characterized by failing memory and confusion), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues).R21's Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had moderately impaired cognition, used a walker, required partial/moderate assistance with toileting hygiene, and was independent with other activities of daily living, transfers, and mobility. R21 had occasional incontinence of urine and bowel, no infections, and no pain. The MDS further documented that R21 received an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), an antibiotic, and a diuretic (a medication to promote the formation and excretion of urine).The Urinary Incontinence Care Area Assessment (CAA) dated 03/20/25 documented that staff were to monitor for signs and symptoms of consequences of incontinence, such as infection, to help prevent infections and encourage fluids to help prevent infection.R21's Care Plan dated 07/30/25 documented the risk for incontinence due to chronic kidney disease. The care plan directed the staff to provide peri-care after incontinent episodes and use a barrier cream as needed to keep R21's skin healthy. The care plan lacked a history of urinary tract infections (UTI- an infection in any part of the urinary system) or use of prophylactic (preventative in nature) antibiotics.The Hospital Discharge Physician Order dated 02/14/25, directed staff to administer Nitrofurantoin (antibiotic medication) 100 milligrams (mg) twice a day for 10 days.The Physician Order dated 03/18/25, directed staff to administer Nitrofurantoin 100 mg daily, of 30 pills with three refills.The Physician Order dated 04/22/25, directed staff to administer Ceftriaxone (antibiotic medication) Sodium Solution reconstituted one gram intravenously in the morning for 10 days related to urinary tract infection.The Physician Order dated 04/30/25, directed staff to administer Nitrofurantoin 100 mg daily for 30 days.The Physician Orders signed on 05/02/25, 06/04/25, 07/02/25, and 08/05/25 continued to direct staff to administer Nitrofurantoin 100 mg daily for prophylaxis without a stop date.Review of the EMR noted the physician lacked review of the ongoing use of Nitrofurantoin daily to prevent UTIs. Administrative Nurse D was unable to locate documentation from the physician progress notes of a rationale for the ongoing use of Nitrofurantoin. On 08/19/25 at 09:02 AM, Certified Medication Aide (CMA) R administered the morning medications while R21 sat at the dining room table. CMA R verified Nitrofurantoin could be crushed and mixed with applesauce due to R21's history of pocketing medication in her cheek, then spitting them out into a napkin. R21 took the medications without concern.On 08/19/25 at 03:15 PM, upon request twice, Administrative Nurse E failed to provide the monthly review of antibiotic log use for R21's ongoing use of the prophylaxis Nitrofurantoin.The Antibiotic Stewardship Program Policy, dated 08/23/22, documented that the purpose was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

The facility had a census of 44 residents. The sample included 13 residents, with one reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 3, who was admitted to hospice on 06/19/25, which included a plan of care and a description of the services provided, which included contact information, visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving needed care.Findings included: - R3's Electronic Health Record (EHR) revealed a diagnosis of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of the breast and bones.R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented R3 had a Brief Interview of Mental Status (BIMS) score of six, which indicated severe cognitive impairment. The MDS document R25 was dependent on staff for most activities of daily living (ADL). The MDS documented R3 received hospice care services.R3's Care Plan, revised 07/09/25, documented R3 dependent on staff with most ADL care. R3's Care Plan documented the resident was admitted to [hospice services] on 06/19/25. The plan directed the staff to administer pain medications as ordered to assure an adequate comfort level, consult with hospice if pain was not controlled with the present regimen. The plan instructed staff to spend all of her family and R3's quiet, uninterrupted time together, anticipate ADL needs, and assist with all care to keep R3 comfortable. The plan instructed staff to notify hospice of significant changes, clinical complications needing plan of care change, and to offer R3 food, fluid preferences as tolerated and turn and reposition R3 as she would allow. 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 R3's clinical record revealed the resident was admitted to hospice care on 06/19/25. The hospice agreement, dated 01/01/25, documented Hospice and facility would jointly develop and agree upon a coordinated plan of care.On 08/18/25 at 02:21 PM, R3 sat in a recliner in her room with oxygen on per nasal cannula, feet up on footrest, without signs or symptoms of pain.On 08/20/25 at 01:01 PM, Administrative Nurse D verified R3's care plan lacked information regarding hospice visits, phone numbers, and medical supplies that Hospice services would provide.The facility's Coordination of Hospice Services Policy, undated, documented the facility and hospice provider would coordinate a plan of care. The plan of care would identify the care and services each entity would provide in order to meet the needs of the resident and his/her expressed desire for hospice care.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QA&A) that had the required membership in attendance. This placed the resident with a lack of quality care.Findings included:- Upon review of the facility's QA&A committee attendance signed roster for the monthly meetings held 10/08/24 to 07/29/25, the roster of attendance lacked the signature of the Medical Director on one of the quarterly meetings (03/11/25).On 08/20/25 at 02:00 PM, Administrative Nurse D stated the medical director had been in attendance on the 03/11/25 quarterly meeting but failed to sign the signature sheet.Upon request, the facility failed to provide a QA&A policy.

The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for one day of the onsite survey. Findings included:- On 08/18/25, 08/19/25, and 08/20/25, observations revealed the facility lacked postings of daily staff nursing hours. On 08/20/25 at 09:53 AM, Administrative Staff A stated the scheduler was responsible for posting the daily nursing staff hours and verified it was not posted on the on-site days of the survey.The facility's Nurse Staffing Posting Information Policy, revised 12/01/19, documented the nurse staffing information would be posted on a daily basis and would contain the following information:a. Facility nameb. The current datec. Facility's current resident census. d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN), and Certified Nurse Aide (CNA).

The facility identified a census of 46 residents with three reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to provide the necessary protective oversight to prevent ongoing sexual abuse. On 07/01/23 between 08:00 PM and 09:00 PM, Certified Nurse Aide (CNA) M went to Resident (R)1's room to offer activity of daily living (ADL) assistance. R1, who had severe cognitive impairment, a history of traumatic brain injury (TBI), pseudobulbar affect (a nervous system disorder characterized by an involuntary and uncontrollable reaction of laughter or crying that is disproportionate to an event), and impaired judgement and insight, had her door closed, which was unusual for her. When CNA M opened the door, she observed R2, an alert, oriented, and independently ambulatory male resident, standing in front of R1. R1 was seated in a chair; R2 had his penis in R1's mouth, and his hands on R1's head, moving R1's head. CNA M did not intervene but shut the door and reported the situation to Certified Medication Aide (CMA) R, who then reported it to Licensed Nurse (LN) G. LN G did not immediately report the incident to the administrator, since Administrative Nurse D was scheduled to arrive at 10:00 PM that evening. When Administrative Nurse D arrived, staff reported the incident and Administrative Nurse D spoke with R1 and R2, who both denied the event. Administrative Nurse D determined no abuse had occurred but asked R2 to stay out of R1's room. On 07/03/23, the facility updated R1's care plan to indicate she could have sexual relations but failed to involve R1's guardians or physician in the determination. The facility failed to implement protective measures to prevent and protect R1, and all cognitively impaired residents who lacked the capacity to consent (or had undetermined capacity to consent) from resident-to-resident sexual abuse. This failure placed those residents in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of traumatic brain injury (TBI - an injury that affects how the brain works, usually results from a violent blow to the head), pseudobulbar affect, major depressive disorder (major mood disorder), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required limited assistance from one staff for all activities of daily living (ADL) except eating, for which she required supervision after set-up assistance. The MDS recorded the resident exhibited no behaviors. The MDS recorded the resident was usually understood but had some difficulty communicating some words or finishing thoughts. It further documented the resident usually understood others but missed some part or intent of the message. She received antianxiety medication and antidepressant medication for all seven of the look-back days. The Annual MDS, dated [DATE], documented R1 had a BIMS score of five, which indicated R1 had severe cognitive impairment. The MDS documented R1 required supervision/set up help from one staff with bed mobility, transfer, ambulation, locomotion, eating, and toilet use. R1 required limited assistance of one staff for personal hygiene, dressing, and bathing. The MDS recorded R1 had inattention that fluctuated. The MDS documented R1 had daily behaviors 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). The MDS further recorded R1 stated it was very important to her to have her family involved in discussions regarding her care. She received antidepressant and antianxiety medication all seven days of the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had cognitive needs, traumatic brain injury, and pseudobulbar affect (which caused R1 to laugh loudly). R1 was alert and oriented to person only. The Activities of Daily Living (ADL)/Functional Rehabilitation CAA, dated 07/07/23, documented R1 required mainly supervision with her ADL to make sure the ADL were done appropriately. The Behavioral Symptoms CAA, dated 07/07/23, documented R1 had a traumatic brain injury that resulted in pseudobulbar affect which presented with uncontrollable laughing that would become disruptive to others. The Letters of Co-Guardianship, dated 07/13/22, documented R1 had two court-appointed guardians with full [NAME] and authority as provided by the law. R1's Care Plan dated 08/27/22 recorded R1 needed cues to activities that would meet her emotional, intellectual, physical, and social needs related to her cognitive deficits. The plan directed staff to encourage ongoing family involvement (08/27/22) and to ensure activities she attended were compatible with her physical and mental capabilities (08/27/22). R1's Care Plan dated 08/27/22 documented R1 had impaired cognition function/dementia (progressive mental disorder characterized by failing memory, confusion) or impaired thought processes related to R1's history of TBI. The plan directed staff to allow R1 to make daily decisions about clothing, daily cares, and meal alternatives. R1's Care Plan further recorded R1 had a TBI in the past and was unable to adequately care for herself; R1 had depression. The plan directed staff to allow R1 time to answer questions and verbalize her feelings, perceptions and fears (revised 12/08/22). The plan directed staff to consult with pastoral psychiatric, and social services (revised 12/08/22). Prior to the 07/01/23 incident, R1's Care Plan lacked direction to staff regarding R1's ability to consent to and/or engage in sexual relations. R1's Care Plan was updated with an intervention, dated 07/03/23 which directed she may have sexual relations with residents if she chose to do so though the clinical record lacked information regarding who made that determination. The Psychiatric Follow-Up Progress Note, dated 04/12/23, documented R1 had significant symptoms related to depression, anxiety, impulse control, and pseudobulbar affect. R1 presented with increased psychomotor agitation (uncontrollable laughing, which was loud and appeared to be in part precipitated by anxiety/expectations of others). R1's thought process was impaired. R1's attention and concentration were poor. R1's memory was impaired, and she forgot dates/times. She knew the state she lived in, but not the name of the president, or name of the facility she lived in; she could not subtract seven from one hundred. R1's insight and judgement were impaired. Review of R1's clinical record lacked evidence the facility assessed R1's capacity to consent to sexual relations, prior to the event. Review of R1's clinical record lacked evidence the facility notified R1's guardians or R1's physician regarding the incident, or the resident's capacity to consent to sexual relations, prior to the onsite survey. The facility's Written Report of Incident, dated 07/01/23, documented Administrative Nurse D was notified at approximately 10:20 PM, by CMA R that CNA M went to R1's room to check on R1 and assist R1 to bed. When CNA M arrived at R1's door, it was completely shut, which was unusual. CNA M knocked on R1's door and waited for a response. CNA M did not hear anyone say anything, so she opened the door. CNA M noted R2 standing in front of R1. R1 was seated in a chair. CNA M reported she saw R2's penis in R1's mouth. Administrative Nurse D requested that CNA M write out exactly what she saw on a witness statement. Administrative Nurse D went to R2's room first, and found him sitting quietly in his chair watching television. Administrative Nurse D asked R2 if he had been in R1's room earlier. R2 replied, Yes I went down to visit her. Administrative Nurse D asked R2 if anything else had happened. R2 replied, No, why? Administrative Nurse D explained to R2 what had been reported to her, that he may have had his penis in R1's mouth. Administrative Nurse D observed R2 sitting relaxed in his chair and R2 stated, No that is not true. That did not happen. I don't know why someone would have said that. Administrative Nurse D explained to R2 that he should not go to R1's room so people did not think there was anything going on that should not be. R2 stated he had been to R1' room before but he would not go down there anymore if that was what he needed to do. Administrative Nurse D documented R2 did not appear to be nervous, anxious, or uncomfortable with the conversation, R2 was alert and oriented, and his BIMS was 15, which indicated his cognition was intact. Administrative Nurse D then documented she went to R1's room to visit with her. R1 was in her pajamas but still awake. Administrative Nurse D asked R1 how she was and R1 acknowledged Administrative Nurse D and called her by name. Administrative Nurse D asked R1 if she had a visitor that evening and R1 replied, I don't think so, and started laughing. Administrative Nurse D asked R1 if she knew R2. R1 replied, Yes I know him. Administrative Nurse D stated it was reported by one of the CNA's that the CNA came to check on R1, and the CNA saw R2 and R1 having oral sex. R1 laughed and said, No I would never do that. Administrative Nurse D documented R1 seemed herself during the conversation and did not show any signs of anxiety, nervousness, or being uncomfortable. Both R1 and R2's care plans were updated that they may have sexual relations in private, if they choose. The Witness Statement by CNA M, dated 07/01/23, documented CNA M went to R1's room to assist her to bed. CNA M stated as she got closer to R1's room, she noticed R1's door was completely shut, and it was normally open. CNA M knocked on R1's door and got no response. CNA M walked in. CNA M stated she saw R2 in R1's room. R1 was sitting on her chair and R2 was standing in front of/above R1 with his penis in R1's mouth. R2 was holding R1's head and moving it back and forth. CNA M stated she instantly shut the door and did not say anything to them. CNA M stated R1 was not fighting it or trying to pull away. On 08/01/23 the facility provided an updated BIMS assessment done that day which recorded R1 had a BIMS of 10, which indicated moderate cognitive impairment. On 08/02/23, one month after the event and after the onsite survey, a Progress Note with a service date of 08/02/23 documented R1 was alert to person, place and usually time. R1's mental state varied from day-to-day and she made her own decisions in the nursing home when able. The note documented based on the scores from her mental testing, R1 had acceptable cognition but could make decisions as where will or will not participate and at that point and time, it was felt R1 could decide whether or not she would participate in sexual relations. On 08/01/23 at 10:05 AM, observation revealed R1 sat at the end of a long table playing BINGO as an activity. On 08/01/23 at 11:05 AM, observations revealed R1 walked down the hallway using her cane. R1 went to her room. On 08/01/23 at 09:45 AM, Administrative Nurse D stated on the night of the incident she had worked the 10p-6a shift. When she came on to shift, CNA M reported what was observed. Administrative Nurse D said she had CNA M write a witness statement as to what she saw. Administrative Nurse D then went and talked to R2 and asked him what happened when he visited R1. R2 stated nothing happened. Administrative Nurse D stated it was reported that R2 and R1 were having oral sex. R2 stated that had never happened. Administrative Nurse D told R2 to stay out of R1's room. Administrative Nurse D then went and talked with R1 and asked her if she had a visitor that evening. R1 didn't remember having a visitor. Administrative Nurse D told R1 that it was reported that R1 and R2 were seen having oral sex. R1 laughed and said, You know I'd never do anything like that. Administrative Nurse D stated R2 was her relative, and it was really hard to have that conversation with him. Administrative Nurse D went on to say R1 had been a friend of hers for years, as they grew up on the same block and went to school together. Administrative Nurse D stated one of her first thoughts was had this ever happened before, when R2 worked at the facility in housekeeping/maintenance. Administrative Nurse D stated she could not prove the situation ever happened, since R2 was a resident at the facility at the time of the incident and she felt like R1 had knowledge of what she did or did not want done to her body. Administrative Nurse D stated the nurse consultant told her all she needed to do was care plan the residents could have sexual relations if they chose. Administrative Nurse D did not report the incident to the state agency, R1's primary care physician, or R1's guardian. Administrative Nurse D stated she felt like it was none of R1's family's business what R1 did with her body. On 08/01/23 at 11:05 AM, R1 smiled and laughed and stated she could not understand why anyone would report such a thing happening, when asked about the incident. R1 adamantly denied she had performed any oral sex. R1 stated she loved living in the facility. On 08/01/23 at 11:30 AM, CNA N stated she was at the facility working the night CNA M walked in on R1 and R2. CNA N stated she did not see anything, but CNA M told her what CNA M saw. CNA N stated she told CNA M to report it to the CMA on duty. CNA N stated CNA M was really freaked out about the situation. On 08/01/23 at 12:34 PM, CNA M stated she had walked down the hall to get R1 ready for bed and noticed her door was closed which was abnormal because R1's door was always open. CNA M knocked on R1's door and did not get an answer. CNA M worried something was wrong with R1 so she opened the door and saw R1 sitting in her chair with R2 standing in front of R1 with R2's penis in R1's mouth. R2's hands were on the sides of R1's head moving her head back and forth. R1 did not appear to be struggling or fighting. CNA M backed out of the room and reported what she saw to the CMA on duty because the nurse was on the dementia unit at the time. CNA M stated she was certain about what she saw. On 08/01/23 at 12:45 PM, Administrative Staff A stated he felt like the facility handled the situation appropriately. Administrative Nurse D had investigated the incident and found that R1 and R2 both denied the incident happening. Administrative Staff A stated if the situation had happened, the residents could have sexual relations. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revised 11/06/2017, documented it is the facility's policy to provide for the safety and dignity of all of its resident's by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with Policy 00304. The facility must have evidence that all alleged violations are thoroughly investigated. The facility must prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. Report the results of the investigation to the administrator or his or her designated representative and to other officials in accordance with the State law, within 5 working days of the incident. The facility failed to implement protective measures to prevent and protect R1, and all cognitively impaired residents who lacked the capacity to consent (or had undetermined capacity to consent) from resident-to-resident sexual abuse. This failure placed those residents in immediate jeopardy. On 08/02/23 the facility completed the following corrective actions to address the immediacy: R2 no longer resided in facility. Education was provided to Administrative Staff A and Administrative Nurse D on the Abuse, Neglect, and Exploitation (ANE) policy, process, reporting, protecting, and identification of what would constitute ANE. Staff were re-educated on ANE which included types of abuse, and protection from abuse. Interviews related to safety and ANE were conducted with residents with a BIMS of 8 or above to determine others who could be affected. On 08/02/23 the surveyor verified the above corrections, and the immediacy was removed. The scope and severity remained at E.

The facility identified a census of 46 residents with three reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R)1 remained free from sexual abuse when the facility failed to prevent an episode of resident-to-resident abuse. On 07/01/23 between 08:00 PM and 09:00 PM, Certified Nurse Aide (CNA) M went to R1's room to offer activity of daily living (ADL) assistance. R1, who had severe cognitive impairment, a history of traumatic brain injury (TBI), pseudobulbar affect (a nervous system disorder characterized by an involuntary and uncontrollable reaction of laughter or crying that is disproportionate to an event), and impaired judgement and insight, had her door closed, which was unusual for her. When CNA M opened the door, she observed R2, an alert, oriented, and independently ambulatory male resident, standing in front of R1. R1 was seated in a chair and R2 had his penis in R1's mouth, and his hands on R1's head, moving R1's head. CNA M did not intervene but shut the door and reported the situation to Certified Medication Aide (CMA) R, who then reported it to Licensed Nurse (LN) G. LN G did not immediately report the incident to administrative staff, since Administrative Nurse D was scheduled to arrive at 10:00 PM that evening. When Administrative Nurse D arrived, staff reported the incident and Administrative Nurse D spoke with R1 and R2, who both denied the event. Administrative Nurse D determined no abuse had occurred but asked R2 to stay out of R1's room. On 07/03/23, the facility updated R1's care plan to indicate she could have sexual relations but failed to involve R1's guardians or physician in the determination. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of traumatic brain injury (TBI - an injury that affects how the brain works, usually results from a violent blow to the head), pseudobulbar affect, major depressive disorder (major mood disorder), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required limited assistance from one staff for all activities of daily living (ADL) except eating, for which she required supervision after set-up assistance. The MDS recorded the resident exhibited no behaviors. The MDS recorded the resident was usually understood but had some difficulty communicating some words or finishing thoughts. It further documented the resident usually understood others but missed some part or intent of the message. She received antianxiety medication and antidepressant medication for all seven of the look-back days. The Annual MDS, dated [DATE], documented R1 had a BIMS score of five, which indicated R1 had severe cognitive impairment. The MDS documented R1 required supervision/set up help from one staff with bed mobility, transfer, ambulation, locomotion, eating, and toilet use. R1 required limited assistance of one staff for personal hygiene, dressing, and bathing. The MDS recorded R1 had inattention that fluctuated. The MDS documented R1 had daily behaviors 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). The MDS further recorded R1 stated it was very important to her to have her family involved in discussions regarding her care. She received antidepressant and antianxiety medication all seven days of the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had cognitive needs, traumatic brain injury, and pseudobulbar affect (which caused R1 to laugh loudly). R1 was alert and oriented to person only. The Activities of Daily Living (ADL)/Functional Rehabilitation CAA, dated 07/07/23, documented R1 required mainly supervision with her ADL to make sure the ADL were done appropriately. The Behavioral Symptoms CAA, dated 07/07/23, documented R1 had a traumatic brain injury that resulted in pseudobulbar affect which presented with uncontrollable laughing that would become disruptive to others. The Letters of Co-Guardianship, dated 07/13/22, documented R1 had two court-appointed guardians with full [NAME] and authority as provided by the law. R1's Care Plan dated 08/27/22 recorded R1 needed cues to activities that would meet her emotional, intellectual, physical, and social needs related to her cognitive deficits. The plan directed staff to encourage ongoing family involvement (08/27/22) and to ensure activities she attended were compatible with her physical and mental capabilities (08/27/22). R1's Care Plan dated 08/27/22 documented R1 had impaired cognition function/dementia (progressive mental disorder characterized by failing memory, confusion) or impaired thought processes related to R1's history of TBI. The plan directed staff to allow R1 to make daily decisions about clothing, daily cares, and meal alternatives. R1's Care Plan further recorded R1 had a TBI in the past and was unable to adequately care for herself; R1 had depression. The plan directed staff to allow R1 time to answer questions and verbalize her feelings, perceptions and fears (revised 12/08/22). The plan directed staff to consult with pastoral psychiatric, and social services (revised 12/08/22). Prior to the 07/01/23 incident, R1's Care Plan lacked direction to staff regarding R1's ability to consent to and/or engage in sexual relations. R1's Care Plan was updated with an intervention, dated 07/03/23 which directed she may have sexual relations with residents if she chose to do so though the clinical record lacked information regarding who made that determination. The Psychiatric Follow-Up Progress Note, dated 04/12/23, documented R1 had significant symptoms related to depression, anxiety, impulse control, and pseudobulbar affect. R1 presented with increased psychomotor agitation (uncontrollable laughing, which was loud and appeared to be in part precipitated by anxiety/expectations of others). R1's thought process was impaired. R1's attention and concentration were poor. R1's memory was impaired, and she forgot dates/times. She knew the state she lived in, but not the name of the president, or name of the facility she lived in; she could not subtract seven from one hundred. R1's insight and judgement were impaired. Review of R1's clinical record lacked evidence the facility assessed R1's capacity to consent to sexual relations, prior to the event. Review of R1's clinical record lacked evidence the facility notified R1's guardians or R1's physician regarding the incident, or the resident's capacity to consent to sexual relations, prior to the onsite survey. The facility's Written Report of Incident, dated 07/01/23, documented Administrative Nurse D was notified at approximately 10:20 PM, by CMA R that CNA M went to R1's room to check on R1 and assist R1 to bed. When CNA M arrived at R1's door, it was completely shut, which was unusual. CNA M knocked on R1's door and waited for a response. CNA M did not hear anyone say anything, so she opened the door. CNA M noted R2 standing in front of R1. R1 was seated in a chair. CNA M reported she saw R2's penis in R1's mouth. Administrative Nurse D requested that CNA M write out exactly what she saw on a witness statement. Administrative Nurse D went to R2's room first, and found him sitting quietly in his chair watching television. Administrative Nurse D asked R2 if he had been in R1's room earlier. R2 replied, Yes I went down to visit her. Administrative Nurse D asked R2 if anything else had happened. R2 replied, No, why? Administrative Nurse D explained to R2 what had been reported to her, that he may have had his penis in R1's mouth. Administrative Nurse D observed R2 sitting relaxed in his chair and R2 stated, No that is not true. That did not happen. I don't know why someone would have said that. Administrative Nurse D explained to R2 that he should not go to R1's room so people did not think there was anything going on that should not be. R2 stated he had been to R1' room before but he would not go down there anymore if that was what he needed to do. Administrative Nurse D documented R2 did not appear to be nervous, anxious, or uncomfortable with the conversation, R2 was alert and oriented, and his BIMS was 15, which indicated his cognition was intact. Administrative Nurse D then documented she went to R1's room to visit with her. R1 was in her pajamas but still awake. Administrative Nurse D asked R1 how she was and R1 acknowledged Administrative Nurse D and called her by name. Administrative Nurse D asked R1 if she had a visitor that evening and R1 replied, I don't think so, and started laughing. Administrative Nurse D asked R1 if she knew R2. R1 replied, Yes I know him. Administrative Nurse D stated it was reported by one of the CNA's that the CNA came to check on R1, and the CNA saw R2 and R1 having oral sex. R1 laughed and said, No I would never do that. Administrative Nurse D documented R1 seemed herself during the conversation and did not show any signs of anxiety, nervousness, or being uncomfortable. Both R1 and R2's care plans were updated that they may have sexual relations in private, if they choose. The Witness Statement by CNA M, dated 07/01/23, documented CNA M went to R1's room to assist her to bed. CNA M stated as she got closer to R1's room, she noticed R1's door was completely shut, and it was normally open. CNA M knocked on R1's door and got no response. CNA M walked in. CNA M stated she saw R2 in R1's room. R1 was sitting on her chair and R2 was standing in front of/above R1 with his penis in R1's mouth. R2 was holding R1's head and moving it back and forth. CNA M stated she instantly shut the door and did not say anything to them. CNA M stated R1 was not fighting it or trying to pull away. On 08/01/23 the facility provided an updated BIMS assessment done that day which recorded R1 had a BIMS of 10, which indicated moderate cognitive impairment. On 08/02/23, one month after the event and after the onsite survey, a Progress Note with a service date of 08/02/23 documented R1 was alert to person, place and usually time. R1's mental state varied from day-to-day and she made her own decisions in the nursing home when able. The note documented based on the scores from her mental testing, R1 had acceptable cognition but could make decisions as where will or will not participate and at that point and time, it was felt R1 could decide whether or not she would participate in sexual relations. On 08/01/23 at 10:05 AM, observation revealed R1 sat at the end of a long table playing BINGO as an activity. On 08/01/23 at 11:05 AM, observations revealed R1 walked down the hallway using her cane. R1 went to her room. On 08/01/23 at 09:45 AM, Administrative Nurse D stated on the night of the incident she had worked the 10p-6a shift. When she came on to shift, CNA M reported what was observed. Administrative Nurse D said she had CNA M write a witness statement as to what she saw. Administrative Nurse D then went and talked to R2 and asked him what happened when he visited R1. R2 stated nothing happened. Administrative Nurse D stated it was reported that R2 and R1 were having oral sex. R2 stated that had never happened. Administrative Nurse D told R2 to stay out of R1's room. Administrative Nurse D then went and talked with R1 and asked her if she had a visitor that evening. R1 didn't remember having a visitor. Administrative Nurse D told R1 that it was reported that R1 and R2 were seen having oral sex. R1 laughed and said, You know I'd never do anything like that. Administrative Nurse D stated R2 was her relative, and it was really hard to have that conversation with him. Administrative Nurse D went on to say R1 had been a friend of hers for years, as they grew up on the same block and went to school together. Administrative Nurse D stated one of her first thoughts was had this ever happened before, when R2 worked at the facility in housekeeping/maintenance. Administrative Nurse D stated she could not prove the situation ever happened, since R2 was a resident at the facility at the time of the incident and she felt like R1 had knowledge of what she did or did not want done to her body. Administrative Nurse D stated the nurse consultant told her all she needed to do was care plan the residents could have sexual relations if they chose. Administrative Nurse D did not report the incident to the state agency, R1's primary care physician, or R1's guardian. Administrative Nurse D stated she felt like it was none of R1's family's business what R1 did with her body. On 08/01/23 at 11:05 AM, R1 smiled and laughed and stated she could not understand why anyone would report such a thing happening, when asked about the incident. R1 adamantly denied she had performed any oral sex. R1 stated she loved living in the facility. On 08/01/23 at 11:30 AM, CNA N stated she was at the facility working the night CNA M walked in on R1 and R2. CNA N stated she did not see anything, but CNA M told her what CNA M saw. CNA N stated she told CNA M to report it to the CMA on duty. CNA N stated CNA M was really freaked out about the situation. On 08/01/23 at 12:34 PM, CNA M stated she had walked down the hall to get R1 ready for bed and noticed her door was closed which was abnormal because R1's door was always open. CNA M knocked on R1's door and did not get an answer. CNA M worried something was wrong with R1 so she opened the door and saw R1 sitting in her chair with R2 standing in front of R1 with R2's penis in R1's mouth. R2's hands were on the sides of R1's head moving her head back and forth. R1 did not appear to be struggling or fighting. CNA M backed out of the room and reported what she saw to the CMA on duty because the nurse was on the dementia unit at the time. CNA M stated she was certain about what she saw. On 08/01/23 at 12:45 PM, Administrative Staff A stated he felt like the facility handled the situation appropriately. Administrative Nurse D had investigated the incident and found that R1 and R2 both denied the incident happening. Administrative Staff A stated if the situation had happened, the residents could have sexual relations. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revised 11/06/2017, documented it is the facility's policy to provide for the safety and dignity of all of its resident's by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with Policy 00304. The facility must have evidence that all alleged violations are thoroughly investigated. The facility must prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. Report the results of the investigation to the administrator or his or her designated representative and to other officials in accordance with the State law, within 5 working days of the incident. The facility failed to ensure R1 remained free from sexual abuse when the facility failed to prevent an episode of resident-to-resident abuse. This deficient practice placed R1 in immediate jeopardy. On 08/02/23 the facility completed the following corrective actions to address the immediacy: R2 no longer resided in facility. Education was provided to Administrative Staff A and Administrative Nurse D on the Abuse, Neglect, and Exploitation (ANE) policy, process, reporting, protecting, and identification of what would constitute ANE. Staff were re-educated on ANE which included types of abuse, and protection from abuse. Interviews related to safety and ANE were conducted with residents with a BIMS of 8 or above to determine others who could be affected. On 08/02/23 the surveyor verified the above corrections, and the immediacy was removed. The scope and severity remained at G to reflect the psychosocial impact determined by using the reasonable person concept due to R1's cognitive impairments including TBI and pseudobulbar affect, as well as the increase in behaviors and inattention as noted on the MDS 6 days after the event.

The facility identified a census of 46 residents with three reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately identified and reported an incident of resident-to-resident sexual abuse involving Resident (R) 1. On 07/01/23 between 08:00 PM and 09:00 PM, Certified Nurse Aide (CNA) M went to R1's room to offer activity of daily living (ADL) assistance. R1, who had severe cognitive impairment, a history of traumatic brain injury (TBI), pseudobulbar affect (a nervous system disorder characterized by an involuntary and uncontrollable reaction of laughter or crying that is disproportionate to an event), and impaired judgement and insight, had her door closed, which was unusual for her. When CNA M opened the door, she observed R2, an alert, oriented, and independently ambulatory male resident, standing in front of R1. R1 was seated in a chair; R2 had his penis in R1's mouth, and his hands on R1's head, moving R1's head. CNA M did not intervene but shut the door and reported the situation to Certified Medication Aide (CMA) R, who then reported it to Licensed Nurse (LN) G. LN G did not immediately report the incident to administrative staff, since Administrative Nurse D was scheduled to arrive at 10:00 PM that evening. When Administrative Nurse D arrived, staff reported the incident and Administrative Nurse D spoke with R1 and R2, who both denied the event. Administrative Nurse D determined no abuse had occurred but asked R2 to stay out of R1's room. On 07/03/23, the facility updated R1's care plan to indicate she could have sexual relations but failed to involve R1's guardians or physician in the determination. The facility failure to ensure staff identified situations of resident-to-resident abuse and report immediately to the facility administrator. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of traumatic brain injury (TBI - an injury that affects how the brain works, usually results from a violent blow to the head), pseudobulbar affect, major depressive disorder (major mood disorder), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required limited assistance from one staff for all activities of daily living (ADL) except eating, for which she required supervision after set-up assistance. The MDS recorded the resident exhibited no behaviors. The MDS recorded the resident was usually understood but had some difficulty communicating some words or finishing thoughts. It further documented the resident usually understood others but missed some part or intent of the message. She received antianxiety medication and antidepressant medication for all seven of the look-back days. The Annual MDS, dated [DATE], documented R1 had a BIMS score of five, which indicated R1 had severe cognitive impairment. The MDS documented R1 required supervision/set up help from one staff with bed mobility, transfer, ambulation, locomotion, eating, and toilet use. R1 required limited assistance of one staff for personal hygiene, dressing, and bathing. The MDS recorded R1 had inattention that fluctuated. The MDS documented R1 had daily behaviors 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). The MDS further recorded R1 stated it was very important to her to have her family involved in discussions regarding her care. She received antidepressant and antianxiety medication all seven days of the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had cognitive needs, traumatic brain injury, and pseudobulbar affect (which caused R1 to laugh loudly). R1 was alert and oriented to person only. The Activities of Daily Living (ADL)/Functional Rehabilitation CAA, dated 07/07/23, documented R1 required mainly supervision with her ADL to make sure the ADL were done appropriately. The Behavioral Symptoms CAA, dated 07/07/23, documented R1 had a traumatic brain injury that resulted in pseudobulbar affect which presented with uncontrollable laughing that would become disruptive to others. The Letters of Co-Guardianship, dated 07/13/22, documented R1 had two court-appointed guardians with full [NAME] and authority as provided by the law. R1's Care Plan dated 08/27/22 recorded R1 needed cues to activities that would meet her emotional, intellectual, physical, and social needs related to her cognitive deficits. The plan directed staff to encourage ongoing family involvement (08/27/22) and to ensure activities she attended were compatible with her physical and mental capabilities (08/27/22). R1's Care Plan dated 08/27/22 documented R1 had impaired cognition function/dementia (progressive mental disorder characterized by failing memory, confusion) or impaired thought processes related to R1's history of TBI. The plan directed staff to allow R1 to make daily decisions about clothing, daily cares, and meal alternatives. R1's Care Plan further recorded R1 had a TBI in the past and was unable to adequately care for herself; R1 had depression. The plan directed staff to allow R1 time to answer questions and verbalize her feelings, perceptions and fears (revised 12/08/22). The plan directed staff to consult with pastoral psychiatric, and social services (revised 12/08/22). Prior to the 07/01/23 incident, R1's Care Plan lacked direction to staff regarding R1's ability to consent to and/or engage in sexual relations. R1's Care Plan was updated with an intervention, dated 07/03/23 which directed she may have sexual relations with residents if she chose to do so though the clinical record lacked information regarding who made that determination. The Psychiatric Follow-Up Progress Note, dated 04/12/23, documented R1 had significant symptoms related to depression, anxiety, impulse control, and pseudobulbar affect. R1 presented with increased psychomotor agitation (uncontrollable laughing, which was loud and appeared to be in part precipitated by anxiety/expectations of others). R1's thought process was impaired. R1's attention and concentration were poor. R1's memory was impaired, and she forgot dates/times. She knew the state she lived in, but not the name of the president, or name of the facility she lived in; she could not subtract seven from one hundred. R1's insight and judgement were impaired. Review of R1's clinical record lacked evidence the facility assessed R1's capacity to consent to sexual relations, prior to the event. Review of R1's clinical record lacked evidence the facility notified R1's guardians or R1's physician regarding the incident, or the resident's capacity to consent to sexual relations, prior to the onsite survey. The facility's Written Report of Incident, dated 07/01/23, documented Administrative Nurse D was notified at approximately 10:20 PM, by CMA R that CNA M went to R1's room to check on R1 and assist R1 to bed. When CNA M arrived at R1's door, it was completely shut, which was unusual. CNA M knocked on R1's door and waited for a response. CNA M did not hear anyone say anything, so she opened the door. CNA M noted R2 standing in front of R1. R1 was seated in a chair. CNA M reported she saw R2's penis in R1's mouth. Administrative Nurse D requested that CNA M write out exactly what she saw on a witness statement. Administrative Nurse D went to R2's room first, and found him sitting quietly in his chair watching television. Administrative Nurse D asked R2 if he had been in R1's room earlier. R2 replied, Yes I went down to visit her. Administrative Nurse D asked R2 if anything else had happened. R2 replied, No, why? Administrative Nurse D explained to R2 what had been reported to her, that he may have had his penis in R1's mouth. Administrative Nurse D observed R2 sitting relaxed in his chair and R2 stated, No that is not true. That did not happen. I don't know why someone would have said that. Administrative Nurse D explained to R2 that he should not go to R1's room so people did not think there was anything going on that should not be. R2 stated he had been to R1' room before but he would not go down there anymore if that was what he needed to do. Administrative Nurse D documented R2 did not appear to be nervous, anxious, or uncomfortable with the conversation, R2 was alert and oriented, and his BIMS was 15, which indicated his cognition was intact. Administrative Nurse D then documented she went to R1's room to visit with her. R1 was in her pajamas but still awake. Administrative Nurse D asked R1 how she was and R1 acknowledged Administrative Nurse D and called her by name. Administrative Nurse D asked R1 if she had a visitor that evening and R1 replied, I don't think so, and started laughing. Administrative Nurse D asked R1 if she knew R2. R1 replied, Yes I know him. Administrative Nurse D stated it was reported by one of the CNA's that the CNA came to check on R1, and the CNA saw R2 and R1 having oral sex. R1 laughed and said, No I would never do that. Administrative Nurse D documented R1 seemed herself during the conversation and did not show any signs of anxiety, nervousness, or being uncomfortable. Both R1 and R2's care plans were updated that they may have sexual relations in private, if they choose. The Witness Statement by CNA M, dated 07/01/23, documented CNA M went to R1's room to assist her to bed. CNA M stated as she got closer to R1's room, she noticed R1's door was completely shut, and it was normally open. CNA M knocked on R1's door and got no response. CNA M walked in. CNA M stated she saw R2 in R1's room. R1 was sitting on her chair and R2 was standing in front of/above R1 with his penis in R1's mouth. R2 was holding R1's head and moving it back and forth. CNA M stated she instantly shut the door and did not say anything to them. CNA M stated R1 was not fighting it or trying to pull away. On 08/01/23 the facility provided an updated BIMS assessment done that day which recorded R1 had a BIMS of 10, which indicated moderate cognitive impairment. On 08/02/23, one month after the event and after the onsite survey, a Progress Note with a service date of 08/02/23 documented R1 was alert to person, place and usually time. R1's mental state varied from day-to-day and she made her own decisions in the nursing home when able. The note documented based on the scores from her mental testing, R1 had acceptable cognition but could make decisions as where will or will not participate and at that point and time, it was felt R1 could decide whether or not she would participate in sexual relations. On 08/01/23 at 10:05 AM, observation revealed R1 sat at the end of a long table playing BINGO as an activity. On 08/01/23 at 11:05 AM, observations revealed R1 walked down the hallway using her cane. R1 went to her room. On 08/01/23 at 09:45 AM, Administrative Nurse D stated on the night of the incident she had worked the 10p-6a shift. When she came on to shift, CNA M reported what was observed. Administrative Nurse D said she had CNA M write a witness statement as to what she saw. Administrative Nurse D then went and talked to R2 and asked him what happened when he visited R1. R2 stated nothing happened. Administrative Nurse D stated it was reported that R2 and R1 were having oral sex. R2 stated that had never happened. Administrative Nurse D told R2 to stay out of R1's room. Administrative Nurse D then went and talked with R1 and asked her if she had a visitor that evening. R1 didn't remember having a visitor. Administrative Nurse D told R1 that it was reported that R1 and R2 were seen having oral sex. R1 laughed and said, You know I'd never do anything like that. Administrative Nurse D stated R2 was her relative, and it was really hard to have that conversation with him. Administrative Nurse D went on to say R1 had been a friend of hers for years, as they grew up on the same block and went to school together. Administrative Nurse D stated one of her first thoughts was had this ever happened before, when R2 worked at the facility in housekeeping/maintenance. Administrative Nurse D stated she could not prove the situation ever happened, since R2 was a resident at the facility at the time of the incident and she felt like R1 had knowledge of what she did or did not want done to her body. Administrative Nurse D stated the nurse consultant told her all she needed to do was care plan the residents could have sexual relations if they chose. Administrative Nurse D did not report the incident to the state agency, R1's primary care physician, or R1's guardian. Administrative Nurse D stated she felt like it was none of R1's family's business what R1 did with her body. On 08/01/23 at 11:05 AM, R1 smiled and laughed and stated she could not understand why anyone would report such a thing happening, when asked about the incident. R1 adamantly denied she had performed any oral sex. R1 stated she loved living in the facility. On 08/01/23 at 11:30 AM, CNA N stated she was at the facility working the night CNA M walked in on R1 and R2. CNA N stated she did not see anything, but CNA M told her what CNA M saw. CNA N stated she told CNA M to report it to the CMA on duty. CNA N stated CNA M was really freaked out about the situation. On 08/01/23 at 12:34 PM, CNA M stated she had walked down the hall to get R1 ready for bed and noticed her door was closed which was abnormal because R1's door was always open. CNA M knocked on R1's door and did not get an answer. CNA M worried something was wrong with R1 so she opened the door and saw R1 sitting in her chair with R2 standing in front of R1 with R2's penis in R1's mouth. R2's hands were on the sides of R1's head moving her head back and forth. R1 did not appear to be struggling or fighting. CNA M backed out of the room and reported what she saw to the CMA on duty because the nurse was on the dementia unit at the time. CNA M stated she was certain about what she saw. On 08/01/23 at 12:45 PM, Administrative Staff A stated he felt like the facility handled the situation appropriately. Administrative Nurse D had investigated the incident and found that R1 and R2 both denied the incident happening. Administrative Staff A stated if the situation had happened, the residents could have sexual relations. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revised 11/06/2017, documented it is the facility's policy to provide for the safety and dignity of all of its resident's by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with Policy 00304. The facility must have evidence that all alleged violations are thoroughly investigated. The facility must prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. Report the results of the investigation to the administrator or his or her designated representative and to other officials in accordance with the State law, within 5 working days of the incident. The facility failed to ensure staff immediately identified and reported an incident of resident-to-resident sexual abuse R1. This deficient practice placed R1 in immediate jeopardy. On 08/02/23 the facility completed the following corrective actions to address the immediacy: R2 no longer resided in facility. Education was provided to Administrative Staff A and Administrative Nurse D on the Abuse, Neglect, and Exploitation (ANE) policy, process, reporting, protecting, and identification of what would constitute ANE. Staff were re-educated on ANE which included types of abuse, and protection from abuse. Interviews related to safety and ANE were conducted with residents with a BIMS of 8 or above to determine others who could be affected. On 08/02/23 the surveyor verified the above corrections, and the immediacy was removed. The scope and severity remained at D.

The facility had a census of 49 residents. The sample included 22 residents of which 2 were reviewed for nutrition. Based on observation, record review, and interview the facility failed to develop and implement effective interventions for 2 of 2 sampled residents. Resident #2 had a weight loss of 13.87% in 2 months, and Resident #7 had a weight loss of 16.29% in 6 months. Findings included: - Resident #2's medical record revealed the following [DIAGNOSES REDACTED]. adequate oxygen to body tissues), hypertension (elevated blood pressure), and Vitamin D deficiency. The quarterly (MDS) Minimum Data Set assessment, dated 10/22/2017, recorded the resident scored 14, on the (BIMS) Brief Interview for Mental Status, which indicated intact cognition. The resident required extensive assistance of 1 staff with bed mobility, transfers, dressing, toilet use, personal hygiene, and was independent for eating after set up help. The resident weighed 135 (lbs) pounds. The resident had no facial discomfort or difficulty with chewing, and did not receive a therapeutic or mechanically altered diet. The significant change MDS, dated [DATE], recorded the resident scored 3 on the BIMS, which indicated severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and required extensive staff assistance for eating. The MDS recorded the resident weighed 122 pounds. The resident had no mouth, facial discomfort or difficulty with chewing, and did not receive a therapeutic or mechanical altered diet. The (CAA) Care Area Assessment, dated 1/22/2018, lacked documentation the Nutritional care area triggered for the significant change assessment. The care plan, dated 1/22/2018, recorded the resident received a regular diet, as tolerated, no milk, and had the potential for weight loss. The care plan recorded the resident ate in his/her room for meals of his/her choice, and came out to the dining room at times. The physician's orders [REDACTED]. (initiated on 2/08/2016) The 5/01/2017 (RD) Registered Dietician nutritional assessment documented the resident's daily nutritional requirements: 1,400 calories, 85 grams of protein, 1,775 (cc) cubic centimeters of fluids. The assessment documented the diet ordered, without milk provided an average of 2000 calories and 85 grams of protein per day, and the diet ordered and consumed, meets estimated needs and the resident consumed 75-100%, per certified dietary manager. The 11/03/2017 (CDM) Certified Dietary Manager notes documented the resident ate in his/her room, received a regular diet with no milk, and he/she requested fruit instead of sweet, sugary desserts, due to his/her intolerance for a lot of sugar. The CDM documented the resident had tremors which made it difficult for the resident to get the food into his/her mouth, and was aided by a special fork and spoon his/her family member had purchased for him/her. He/she used a straw to drink fluids. The notes documented the resident had an allergy to dairy, eggs and cheeses, but could have the foods cooked in items in small amounts, and liked ice cream. Continued dietary notes documented the resident's current weight was 116.8 lbs, 1 month ago 114.1 lbs, 105.2 lbs 3 months ago, and 114.6 lbs 6 months ago. (On 2/05/2018 at 11:10 AM, registered Dietician CC verified the weights documented by the CDM were incorrect for the above assessment) The 12/12/2017 at 12:05 PM, nurse's notes documented the resident continued with tremors which caused the inability to eat independently, or hold a drink. The 1/13/2018 at 1:19 PM, nurse's notes documented the resident's family member visited with him/her in the morning and voiced a concern that the resident could not chew his/her breakfast. The staff offered the resident broth or a milkshake and he/she chose a milkshake, although once it was delivered, he/she took one drink, stated he/she did not want it, and accepted coffee and water. Staff brought the resident out to the dining room for lunch, he/she ate several bites of every item, less than 25% of the meal, and stated I'm just not hungry. The weight record revealed the following: 11/05/17 - 137 lbs 11/12/17 - 136 lbs 12/04/17 - 128 lbs 12/19/17 - 126 lbs 1/11/18 - 118 lbs 1/14/18 - 122 lbs 1/24/18 - 118 lbs (13.87% loss in 2 and 1/2 months) The clinical record lacked evidence the facility developed or implemented interventions to prevent further weight loss. The record lacked documentation the facility notified the physician or the registered dietician of the resident's continued weight loss. No speech therapy was ordered or recorded. The 1/08/2018 physician's orders [REDACTED]. On 1/29/2018 at 12:05 PM, observation revealed the resident, sat in his/her wheelchair at the dining room table, and staff served the resident, spaghetti, green beans, french bread, a small tossed green salad, and a bowl of sliced peaches. Continued observation revealed staff assisted the resident with his/her meal, and he/she ate approximately 25% of the entire meal. On 1/30/2018 at 10:00 AM, Nurse Aide O stated the resident was independent with eating until his/her hand shaking increased, then he/she required staff assistance with eating. On 1/30/2018 at 9:55 AM, Nurse G stated the resident lost weight recently, and he/she offered the resident a shake but did not document the resident did not want it. Nurse G stated staff currently assisted the resident because he/she was unable not eat very well independently. Nurse G verified the registered dietician came to the facility on ce a month and evaluated residents with weight loss, but there was no documentation the dietician evaluated the resident until 1/29/2018. On 1/30/2017 at 10:25 AM, (CDM) Certified Dietary Manager BB stated Administrative Nurse D or Administrative Nurse E alerted nursing and dietary staff, and the dietician, of the resident's weight loss, and at that time the dietician addressed the weight loss and made recommendations. The CDM reviewed the resident's medical records and verified the dietician had not reviewed the resident's weight loss, and the last date the Dietary Manager had reviewed the residents weight was on 11/01/2017. On 1/30/2018 at 1:20 PM, Administrative Nurse D verified staff had not notified him/her of the resident's continued weight loss since November. Administrative Nurse D stated on 1/29/2018 the Registered Dietician CC requested Administrative Nurse D review the residents weight variances, provide him/her with a list of residents with weight loss, pressure ulcers, new admissions, hospital returns, and address the residents' needs. Administrative Nurse D verified the RD visited the facility once a month, the charge nurses provide him/her the resident information, however due to the recent department head changes, staff did not provided the information to him/her. Administrative Nurse D verified the facility, did not have an efficient system in place to monitor the residents weights. On 1/30/2018 at 5:05 PM, Physician GG verified he/she had communicated with the facility regarding the residents medical concerns, and recently he/she decreased the [MEDICATION NAME] (pain relief patch) and the [MEDICATION NAME] (antipsychotic medication). He/she further stated that he/she did not recall the facility communicating with him/her regarding the residents weight loss. Physician GG stated the facility had a standing order to initiated Carnation Instant Breakfast if they identified a resident had a weight loss. On 2/05/2018 at 11:10 PM, Registered Dietician CC stated he/she had not been notified of the resident's weight loss until 1/29/2018 when Administrative Nurse D contacted him/her regarding the resident's weight loss of 19 lbs. Registered Dietician CC verified the last assessment he/she completed on the resident was on 5/01/2017, and had not been notified of any weight concerns until 1/29/2018. Registered Dietician CC verified the communication between the facility and the dietician was not consistent. The 6/24/2009 facility's Weight Loss Policy documented the residents would maintain acceptable nutritional status, unless the residents clinical condition demonstrates that it was not possible, and assure that residents receive a Therapeutic diet when there was a nutritional problem/weight loss. The policy recorded all residents would have his/her weight obtained within 24 hours of admission and readmission from hospitalization , unless directed otherwise by the primary care physician. All residents weight would be monitored weekly for the first 30 days of their residency, unless otherwise specific by their primary care physician. At the end of the 30 days, the charge nurse would evaluate the need for a continued weight schedule based on diagnosis, and over all physical/nutritional condition. At that time, a weight schedule will be determined and implemented. If a significant weight loss is noted at any given time, the charge nurse would notify the primary care physician. The charge nurse would attempt to obtain an order for [REDACTED]. If recommendations are made by the Dietician, the charge nurse will be responsible to notify the primary care physician of the dietary recommendations, and document in the nurses notes the reason for not implementing the recommendations. A copy of the dietary recommendations would also be sent to the primary care physician. It will be the responsibility of the charge nurse to monitor the weight and if continued weigh loss was noted, the dietician would be asked to reevaluate and make recommendations. The final decision on whether or not the dietary recommendations and implementation would be the sole decision of the primary care physicians. The facility failed to implement interventions to prevent Resident #2 from having a 13.87% weight loss in 2 and 1/2 months, and notify the dietician and the resident's physician of the weight loss. - Resident #7's physician order [REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 10/31/17, documented the resident had long and short term memory deficits, with severely impaired decision making ability, required extensive assistance of 2 staff for (ADLs) Activities of Daily Living, and required assistance of 1 staff to assist with eating. The resident had 5% significant weight loss, with no physician prescribed weight loss program, and had no oral, chewing or swallowing problems. The 10/31/17 nutrition (CAA) Care Area Assessment, documented the resident required staff assistance to eat meals, received a regular diet, with double portions for lunch and supper. The CAA further documented the resident had not eaten well recently, with a weight of 155 (lbs) pounds, compared to a weight of 177 lbs on his/her last MDS assessment, dated 8/6/17. The CAA documented the resident's dementia had progressed and he/she received (CIB) Carnation Instant Breakfast twice daily. The 11/20/17 care plan documented the resident had a potential for continued weight loss, due to the resident's progressing dementia. The care plan directed staff to provide assistance of 1 staff with meals, a double portion of the main dish with lunch and supper, cut up the meat, and to record the amount of food and fluids consumed. The care plan further directed the Dietary Consultant to evaluate the resident's food likes and dislikes. The care plan documented the physician ordered CIB, twice a day, on 10/13/17. The care plan documented the physician ordered CIB in 8 oz of whole milk with 4 ounces of ice cream, three times a day, served with meals on 12/28/17. The 5/2/17 at 11:52 PM, Nutrition Assessment, documented by Dietary Consultant CC, recorded the resident received a regular diet, with double meat, ideal body weight was 178 lbs, and a (BMI) Body Mass Index (defines normal weight, overweight, and obesity) of 25.4, which indicated the resident was healthy. The assessment further recorded the resident's estimated needs were 2775 calories per day, 78 grams of protein per day, and 2350 (ml) milliliters of fluid per day. The 8/16/17 physician order [REDACTED]. The 10/4/17 at 11:48 PM, progress note documented the physician visited the resident and had no new orders. The 10/13/17 at 8:38 PM, progress note documented the resident had recent weight loss and a decreased appetite. The note further documented the physician ordered CIB in 8 ounces of milk, twice a day for weight loss. The 10/16/17 at 12:59 PM, the progress note documented the physician ordered lab work related to the resident's weight loss. Review of the resident's 10/17/17 lab results documented the following abnormal values: A high sodium level of 147, (normal value of 135 - 145), (sodium helps regulate the amount of water that is in around your cells). A high chloride level of 108, (normal value of 98 - 107), (found in all body fluids for regulating fluids and digesting food). A high (BUN) Blood Urea Nitrogen level of 26, (normal level of 7 - 18), (reveals how well the liver and kidneys function). A low total protein level of 6.1, (normal value of 6.4 - 8.2), (test measures all the protein in the blood). A high (AST) Asparate Aminotransferase Test level of 69, (normal value of 15 - 37), (rises when the liver is damaged). A high (ALT) [MEDICATION NAME] Aminotransferase Test level of 179, (normal value of 12-78), (blood test that checks for liver damage). A normal (TSH) [MEDICAL CONDITION] Stimulating Hormone level of 1.52, (normal value 0.5 - 6), (test to determine if the [MEDICAL CONDITION] is functioning the way it should). A [MEDICAL CONDITION] T4, with a high level of 1.2, (normal value of 0.8 - 1.8), (indicates an underactive [MEDICAL CONDITION]). A high Homocysteine (identified a vitamin B12 or folic acid deficiency) level of 15.9, with a normal value of <11.4. A normal [MEDICATION NAME] (test for vitamin B-12) level, normal value of 0.0.4), (necessary for human metabolism and energy production). A high vitamin B12 level of 1136, (normal value of 200 - 1100), (can occur in residents with liver disease) The 10/18/17 at 11:00 AM, progress note documented the physician ordered a (CT) computed tomography (a combination of x-ray measurements taken at different angles) scan of the abdomen and pelvis in response to the elevated liver enzyme test. The 10/20/18 at 3:05 AM, progress note documented the physician stated the results of the CT scan recorded the resident was constipated. The note further documented the resident had an order for [REDACTED]. The 10/29/17 at 4:31 PM, progress note documented the resident had a decrease in weight. Review of the residents weights revealed the following entries: 6/23/17 - 180 lbs 6/30/17 - 179 - lbs 7/14/17 - 179 lbs 7/30/17 - 177 lbs 8/18/17 - 178 lbs 9/15/17 - 171 lbs 9/29/17 - 167 lbs 10/13/17 - 160 lbs 10/29/17 - 155 lbs 11/17/17 - 158 lbs 11/29/17 - 155 lbs 12/16/17 - 148 lbs 12/22/17 - 143 lbs (20.5% loss in 6 months) 12/27/17 - 146 lbs 1/19/18 - 149 lbs 1/27/18 - 151 lbs Review of the (MONTH) and (MONTH) medical record revealed the physician was not notified of the resident's weight loss in September, and there were no additional interventions for weight loss prior to the 10/13/17 order for CIB. Review of the medical record from 5/2/17 to 12/19/17 revealed the record lacked a thorough evaluation by Dietary Consultant CC, related to the resident's recent weight loss. The 12/19/17 at 2:13 PM, Dietary Consultant CC's progress note documented the resident's weight on 12/16/17 was 148.2 lbs and was down 6.3% in 30 days, down 13.5% in 90 days, and down 17.8% in 180 days. Dietary Consultant CC recommended a CIB increase from twice a day to three times a day with meals. Review of the resident's supplement intake for the CIB, from (MONTH) (YEAR) through (MONTH) (YEAR), documented the resident's average intake was 90% three times a day. Review of the residents meal intake from (MONTH) (YEAR) through (MONTH) varied from 25% to 75%, with an average of 25 to 50%. The 12/21/17 physician's orders [REDACTED]. The 12/28/17 physician's orders [REDACTED]. The 12/28/17 at 2:22 PM, progress note documented the resident's responsible party discussed the resident's weight loss with Administrative Nurse D and suggested ice cream, since this was the resident's favorite treat. On 1/5/18 the physician amended the order for a regular diet with a double portion of the main dish with his/her lunch and supper, originally ordered 8/18/15, to include ground meats, because the resident had difficulty chewing the meat. On 1/30/18 at 7:50 AM, observation revealed staff assisted the resident to eat his/her breakfast which included a soft cooked egg, oatmeal, muffin, orange juice, special milkshake, and a glass of milk. The resident ate with staff assistance, and encouragement, and consumed approximately 50% of the meal. Observation further revealed the resident had no difficulty chewing the solid foods, drank the supplement milkshake, left approximately 50% of other orange juice, and 25% of the milk. On 1/30/18 at 9:40 AM, Nurse Aide R stated dietary staff track and document the resident's intake percentage of food and fluids. Nurse Aide R stated the resident's appetite varied, he/she recently had weight-loss, received a milkshake, and was not aware of any other interventions tried. On 1/30/18 at 12:50 PM, Dietary Staff BB stated Dietary Consultant CC visited one time a month and was aware of the resident's weight loss. Dietary Staff BB stated the resident received CIB for an intervention in the form of a milkshake and nursing staff were to offer him/her snacks during the day and record the resident's intake. Dietary Staff BB further stated the aides should offer each resident a snack and stated he/she stocked the store room in the area with crackers, and similar snack items. Dietary Staff BB verified there was not a dietary consultant evaluation documented in the medical record from 5/2/17 to 12/19/17, during the time frame the resident had a significant weight loss. On 1/30/18 at 1:45 PM, Nurse I verified the resident had weight loss and a [DIAGNOSES REDACTED]. Nurse R further stated the resident continued to walk to meals and staff provided a restorative program to maintain his/her extremity range of motion. Nurse I stated the supplement intake was documented in the (MAR) Medication Administration Record [REDACTED]. On 1/30/18 at 5:20 PM, Administrative Nurse D stated staff were to offer each resident a snack in the morning, afternoon, and evening, verified the resident had significant weight loss, and stated the Dietary Consultant made recommendations for supplement changes. On 2/6/18 at 8:24 AM, Dietary Consultant CC stated the facility staff had not communicated the resident lost weight between (MONTH) and (MONTH) to him/her. Dietary Consultant CC stated the facility occasionally notified him/her of resident weight changes, but was not consistent. Dietary Consultant CC stated the facility recently developed a new procedure, following the survey, to address the communication of resident weight changes. On 2/6/18 at 9:33 AM, Physician HH stated the resident was at the end stages of [MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure) and did not have the mental capability to understand he/she needed to eat. Physician HH stated generally he/she expected the facility to notify him/her when the weight loss began, but was not able to recall when the facility notified him/her at the time. Consultant HH stated the resident was recently started (2/2/18) on [MEDICATION NAME] (an appetite stimulant) for the resident's weight loss. The facility's Weight Loss Policy, dated 6/24/09, documented if a significant weight loss was noted, the charge nurse would notify the primary care physician and attempt to obtain an order for [REDACTED]. If recommendations were made by the dietary consultant, the charge nurse would notify the physician of the recommendations. The charge nurse was responsible for monitoring the resident's weight and if continued weight loss was noted, the dietary consultant would be asked to re-evaluate and make recommendations. The final decision on whether or not the dietary consultant recommendations were implemented would be at the sole decision of the primary care physician. The facility failed to reassess and provide timely interventions for Resident #7, who continued to have significant weight loss.

The facility had a census of 57 residents. The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview the facility failed to protect all 16 opposite gender residents, in the Dementia Unit, from resident to resident sexual abuse, of inappropriate touching by Resident #1, which placed all opposite gender residents in immediate jeopardy. Findings included: - The 4/3/17 physician's orders [REDACTED].#1 had the following Diagnoses: [REDACTED]. Resident #1's admission (MDS) Minimum Data Set assessment, dated 3/1/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 13, indicating intact cognition, with no behaviors. The MDS recorded the resident required extensive assistance of 1 staff for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, toilet use, personal hygiene, bathing, and independent with eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, had no functional limitation in (ROM) Range of Motion in upper and lower extremities, required no mobility devices for ambulation, and received antipsychotic and antianxiety medications. The 3/1/17 [MEDICAL CONDITION] Drug Use (CAA) Care Area Assessment recorded the resident received [MEDICATION NAME] (an antipsychotic medication used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) and [MEDICATION NAME] (an antianxiety medication that calms and relaxes people with excessive mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension) routinely. The resident came to the facility from a Geriatric Psych Unit (behavioral health hospital for elderly), had some unsteadiness on his/her feet, but was alert, pleasant and cooperative, with no behaviors observed at that time. The Behavioral Symptoms CAA did not trigger. The Cognitive Loss/Dementia care plan, dated 3/3/17, recorded the resident had chronic cognitive loss and had a recent hospitalization at an inpatient geriatric psych unit. The care plan directed staff to administer [MEDICATION NAME] (an antianxiety medication that calms and relaxes people with excessive mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension), [MEDICATION NAME] (medicated patch used to treat mild, moderate, and severe memory problems used for dementia (progressive mental disorder characterized by failing memory, confusion) associated with [MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure), [MEDICATION NAME] (medication used to treat moderate to severe dementia of the Alzheimer's type), and [MEDICATION NAME] as ordered. The care plan instructed staff to approach the resident in a calm manner if he/she seemed agitated, encourage conversation, inform the resident of what you are going to do, and use verbal cueing to promote independence. The 4/4/17 care plan update instructed staff to perform 30 minute checks on the resident on location, for 72 hours, and then as needed. The care plan lacked documentation of the reason the checks were conducted. The care plan revealed staff discontinued the intervention on 4/8/17. The 4/6/17 care plan update recorded the (DON) Director of Nursing planned to visit with the resident and the resident's family member regarding the resident's inappropriate sexual behaviors and offer privacy when the family member visited the resident by placing a do not disturb sign if they both chose. Staff discontinued this intervention on 4/7/17. The 4/10/17 care plan update directed staff to ensure at all times, Resident #1 was not seated next to residents of the opposite sex in the dining room or TV area. The 2/23/17 psychosocial admission progress note documented the resident suffered from hallucinations (sensing things while awake that appear to be real, but the mind created) and at times could be unkind, with a grumpy demeanor, according to family. The note documented this facility admitted the resident from a Geriatric Psych facility. The 4/3/17 at 8:29 PM, nurse's note (recorded as a late entry on 04/04/2017 at 11:31 PM) documented a CNA (Certified Nurse Aide) (the note did not specify which CNA) reported that he/she entered the living/dining room area to see Resident #1 standing near Resident #2 with his/her pants open, exposing himself/herself to Resident #2. The nurse's note revealed the CNA also stated when he/she approached Resident #1, the resident stated I guess we can't get away with anything here, can we? The 04/04/2017 at 2:18 PM, nursing note recorded staff reported Resident #1 was in the hallway, and grabbed Resident #2 in the private area. While staff attempted to redirect Resident #1, Resident #2 kicked him/her in the rear. Resident #1 was asked why he/she had grabbed the other resident, he/she stated I didn't touch him/her, he/she kicked me in the butt. Resident #1 was advised that kicking, hitting or touching others was not allowed in the facility and was assisted by staff to another area of the living area apart from Resident #2. Review of the facility's investigation documented on 4/4/17, around 2:10 PM, Resident #2 was ambulating in the hall going south, and Resident #1 was ambulating in the hall going north. Staff were in other resident's rooms when they heard Resident #2 say no. When staff looked to see what was happening, they saw Resident #1 pull his/her hand away from Resident #2's buttock and continued to walk on by. Both residents continued walking in the hall. A few minutes later, staff heard Resident #2 scream. Staff observed Resident #1 grab at Resident #2's crotch area and laugh. Staff then observed Resident #2 kicked Resident #1 in the buttocks. No fall or personal injures noted. Staff separated the two residents and assisted Resident #1 to a recliner in the living area. The nurse intervened and visited with Resident #1 about his/her behavior. The nurse told Resident #1 the behavior was inappropriate and that it was not allowed in the facility. Resident #1 replied, I didn't touch him/her, he/she kick me in the butt. Resident #1 was placed on 30 minute checks for at least 72 hours. The investigation documented staff notified the resident's family member and physician, who ordered a (UA) Urinalysis (examination of urine), and staff obtained the UA. The (DON) Director of Nursing visited with resident's family member to try to allow for privacy when they were together. The DON visited with Resident #1 about the incident and he/she assured the DON that this would never happen again. Review of the resident's behavior monitoring revealed the following: February 2017-no behaviors March 2017-no behaviors April 2017-4/3/17-the resident tried to show another resident his/her private part. 4/4/17-the resident grabbed another resident's crotch. 4/5/17-the resident was threatening suicide and stated life was not worth living, which was reported to the charge nurse. On 4/26/17 at 9:25 AM, observation revealed the resident ambulated independently down the hallway from his/her room to the living room area, past 5-6 opposite gender residents, staff were not observing the resident at that time. On 4/26/17 at 4:53 PM, observation revealed the resident seated in a recliner in the living room area next to the courtyard exit door, watching a TV program (game show), and exhibited no behaviors. Observation revealed Resident #2 sat on the couch, with eyes closed, directly across from Resident #1, approximately 15-20 feet away. Observation revealed no staff in the area monitoring either resident. On 4/26/17 at 2:09 PM, Medication Aide C stated Resident #2 had an incident with Resident #1 a few weeks ago, on 4/3/17, when Resident #1 tried to expose himself/herself to Resident #2, who was sitting/lying on the couch. Medication Aide C stated Nurse Aide D separated the two residents and there were no further incidents the rest of the night. Medication Aide C stated on 4/4/17, the first incident, on that day, occurred in the hallway toward Resident #1's room. Resident #1 walked by Resident #2 and Resident #1 slapped Resident #2 on the butt and then walked away. Medication Aide C stated the second time, on 4/4/17, Resident #1 came out of his/her bathroom and went down the hallway toward Resident #2's room. Resident #1 stepped in front of Resident #2 to stop him/her and grabbed his/her crotch causing Resident #2 to slap him/her on the arm. Medication Aide C stated when staff came out to separate the two residents, Resident #2 kicked Resident #1 in the butt. Medication Aide C stated since these incidents, staff initially, had not done anything different for Resident #1 (regarding his/her sexual behaviors), he/she was on the 30 minute checks because he/she was making comments that he/she was going to hurt himself/herself. On 4/26/17 at 2:21 PM, Nurse E stated Resident #1 had no behaviors when he/she came to the facility, but became very anxious and agitated if his/her family member was talked to or about. Nurse E stated the behaviors became worse if the family member called or came by to see him/her. Nurse E stated he/she was informed Resident #1 grabbed Resident #2's crotch, and the previous night, Resident #1 exposed himself/herself to Resident #2 when he/she was sitting on the couch. Resident #1 told a nurse aide that he/she wasn't able to get away with anything anymore. Nurse E stated he/she talked to Resident #1's family member after he/she grabbed Resident #2, and the family member told the nurse Resident #1 had made a lot of sexual comments like it was getting larger and hot, but this wasn't unusual for him/her to say these things. Nurse E stated the day of the incident between Resident #1 and Resident #2 on the couch, Resident #2 was asleep, that was the first time staff have had an incident like that happen before. Nurse E stated when Resident #1 had outbursts, he/she would go off and wanted to deal with the top dog. Nurse E stated after the initial incident on 4/3/17, and since both incidents, staff have tried to make sure Resident #1 and Resident #2 were not in the same vicinity, and staff monitor and watch them both as much as possible. Prior to either incident, Resident #1 had not had any behaviors, like this. When Resident #1 exposed himself/herself, Nurse E stated he/she really had not thought too much of it, and maybe Resident #1 was trying to go to the bathroom. On 4/26/17 at 6:03 PM Administrative Nurse A stated Resident #1 had never behaved in this manner before and staff separated Resident #1 and Resident #2 and placed Resident #1 on 30 minute checks. Resident #1 stated he/she felt really bad about what happened. Administrative Nurse A stated there have been no problems since these two incidents happened. On 4/27/17 at 11:50 AM, per notarized witness statement, Nurse Aide D stated on 4/3/17, when he/she came around the corner, he/she observed Resident #2 sitting on the couch with his/her feet elevated. Nurse Aide D observed Resident #1 lean over Resident #2 with one hand on the arm of the couch and the other on the back of the couch behind Resident #2's head. Nurse Aide D stated Resident #1 did not hear Nurse Aide D come around the corner, and when Nurse Aide D cleared his/her throat to say something, Resident #1 turned around and stated you can't get away with anything here. Nurse Aide D stated he/she then noticed Resident #1's pants were unzipped, no skin observed. Nurse Aide D stated he/she thought Resident #1 was trying to expose himself/herself to Resident #2, so Nurse Aide D called for assistance from another nurse aide. Resident #1 was assisted to his/her room while Nurse Aide D sat with Resident #2 on the couch to comfort him/her. Nurse Aide D stated after approximately 10 minutes, he/she ambulated with Resident #2 to his/her room, assisted him/her to bed, and the resident cried the whole time, saying he/she knew that man/woman was doing something wrong. The facility's 6/22/2009 Policy/Procedure Prohibiting Mistreatment, Neglect, and Abuse of residents and their property stated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to: facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. The facility failed to protect all opposite gender residents from sexual abuse, regarding inappropriate sexual touching and behavior from Resident #1. This deficient practice placed the opposite gender residents in the Dementia Unit, in immediate jeopardy. The facility abated the immediate jeopardy on 4/28/17, when all staff received face-to-face inservices. On 4/26/17 at 6:45 PM the facility placed Resident #1 on 1:1 supervision at all times. All staff inservices included education on Abuse, Neglect, Exploitation Policy, staff role when witnessing any type of abuse, neglect or exploitation, immediate intervention, (will differ based on situation) who to report to, factual importance of witness statements, and appropriate documentation in the medical record. All staff received a copy of the Abuse, Neglect and Exploitation Policy. Charge nurse would be responsible for reporting to the Administrator and Director of Nursing or Assistant Director of Nursing, per the state regulations on reporting and the Administrator or Director of Nursing would be responsible for reporting to the state agency. Resident to resident altercations would be reviewed at the quarterly QA (quality assurance) meetings. The Administrator and/or Director of Nursing would review weekly, to monitor that no incidences were missed and discussed at the Department Head meeting at least weekly. This deficient practice remained at a scope and severity of an E.

The facility had a census of 57 residents. The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure Resident #2 was free from resident to resident sexual abuse, of unwanted sexual advances on three different incidents without appropriate interventions to prevent further occurrences. Resident #1 exposed his/her private area to Resident #2, Resident #1 touched Resident #2's buttocks, and Resident #1 grabbed Resident #2's crotch area, which placed Resident #2 in immediate jeopardy. Findings included: - The 4/3/17 physician's orders [REDACTED].#1 had the following Diagnoses: [REDACTED]. Resident #1's admission (MDS) Minimum Data Set assessment, dated 3/1/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 13, indicating intact cognition, with no behaviors. The MDS recorded the resident required extensive assistance of 1 staff for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, toilet use, personal hygiene, bathing, and independent with eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, had no functional limitation in (ROM) Range of Motion in upper and lower extremities, required no mobility devices for ambulation, and received antipsychotic and antianxiety medications. The 3/1/17 [MEDICAL CONDITION] Drug Use (CAA) Care Area Assessment recorded the resident received [MEDICATION NAME] (an antipsychotic medication used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) and [MEDICATION NAME] (an antianxiety medication that calms and relaxes people with excessive mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension) routinely. The resident came to the facility from a Geriatric Psych Unit (behavioral health hospital for elderly), had some unsteadiness on his/her feet, but was alert, pleasant and cooperative, with no behaviors observed at that time. The Behavioral Symptoms CAA did not trigger. The Cognitive Loss/Dementia care plan, dated 3/3/17, recorded the resident had chronic cognitive loss and had a recent hospitalization at an inpatient geriatric psych unit. The care plan directed staff to administer [MEDICATION NAME] (an antianxiety medication that calms and relaxes people with excessive mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension), [MEDICATION NAME] (medicated patch used to treat mild, moderate, and severe memory problems used for dementia (progressive mental disorder characterized by failing memory, confusion) associated with [MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure), [MEDICATION NAME] (medication used to treat moderate to severe dementia of the Alzheimer's type), and [MEDICATION NAME] as ordered. The care plan instructed staff to approach the resident in a calm manner if he/she seemed agitated, encourage conversation, inform the resident of what you are going to do, and use verbal cueing to promote independence. The 4/4/17 care plan update instructed staff to perform 30 minute checks on the resident on location, for 72 hours, and then as needed. The care plan lacked documentation of the reason the checks were conducted. The care plan revealed staff discontinued the intervention on 4/8/17. The 4/6/17 care plan update recorded the (DON) Director of Nursing planned to visit with the resident and the resident's family member regarding the resident's inappropriate sexual behaviors and offer privacy when the family member visited the resident by placing a do not disturb sign if they both chose. Staff discontinued this intervention on 4/7/17. The 4/10/17 care plan update directed staff to ensure at all times, Resident #1 was not seated next to residents of the opposite sex in the dining room or TV area. The 2/23/17 psychosocial admission progress note documented the resident suffered from hallucinations (sensing things while awake that appear to be real, but the mind created) and at times could be unkind, with a grumpy demeanor, according to family. The note documented this facility admitted the resident from a Geriatric Psych facility. The 4/3/17 at 8:29 PM, nurse's note (recorded as a late entry on 04/04/2017 at 11:31 PM) documented a CNA (Certified Nurse Aide) (the note did not specify which CNA) reported that he/she entered the living/dining room area to see Resident #1 standing near Resident #2 with his/her pants open, exposing himself/herself to Resident #2. The nurse's note revealed the CNA also stated when he/she approached Resident #1, the resident stated I guess we can't get away with anything here, can we? The 04/04/2017 at 2:18 PM, nursing note recorded staff reported Resident #1 was in the hallway, and grabbed Resident #2 in the private area. While staff attempted to redirect Resident #1, Resident #2 kicked him/her in the rear. Resident #1 was asked why he/she had grabbed the other resident, he/she stated I didn't touch him/her, he/she kicked me in the butt. Resident #1 was advised that kicking, hitting or touching others was not allowed in the facility and was assisted by staff to another area of the living area apart from Resident #2. Review of the facility's investigation documented on 4/4/17, around 2:10 PM, Resident #2 was ambulating in the hall going south, and Resident #1 was ambulating in the hall going north. Staff were in other resident's rooms when they heard Resident #2 say no. When staff looked to see what was happening, they saw Resident #1 pull his/her hand away from Resident #2's buttock and continued to walk on by. Both residents continued walking in the hall. A few minutes later, staff heard Resident #2 scream. Staff observed Resident #1 grab at Resident #2's crotch area and laugh. Staff then observed Resident #2 kicked Resident #1 in the buttocks. No fall or personal injures noted. Staff separated the two residents and assisted Resident #1 to a recliner in the living area. The nurse intervened and visited with Resident #1 about his/her behavior. The nurse told Resident #1 the behavior was inappropriate and that it was not allowed in the facility. Resident #1 replied, I didn't touch him/her, he/she kick me in the butt. Resident #1 was placed on 30 minute checks for at least 72 hours. The investigation documented staff notified the resident's family member and physician, who ordered a (UA) Urinalysis (examination of urine), and staff obtained the UA. The (DON) Director of Nursing visited with resident's family member to try to allow for privacy when they were together. The DON visited with Resident #1 about the incident and he/she assured the DON that this would never happen again. Review of the resident's behavior monitoring revealed the following: February 2017-no behaviors March 2017-no behaviors April 2017-4/3/17-the resident tried to show another resident his/her private part. 4/4/17-the resident grabbed another resident's crotch. 4/5/17-the resident was threatening suicide and stated life was not worth living, which was reported to the charge nurse. On 4/26/17 at 9:25 AM, observation revealed the resident ambulated independently down the hallway from his/her room to the living room area, past 5-6 opposite gender residents, staff were not observing the resident at that time. On 4/26/17 at 4:53 PM, observation revealed the resident seated in a recliner in the living room area next to the courtyard exit door, watching a TV program (game show), and exhibited no behaviors. Observation revealed Resident #2 sat on the couch, with eyes closed, directly across from Resident #1, approximately 15-20 feet away. Observation revealed no staff in the area monitoring either resident. On 4/26/17 at 2:09 PM, Medication Aide C stated Resident #2 had an incident with Resident #1 a few weeks ago, on 4/3/17, when Resident #1 tried to expose himself/herself to Resident #2, who was sitting/lying on the couch. Medication Aide C stated Nurse Aide D separated the two residents and there were no further incidents the rest of the night. Medication Aide C stated on 4/4/17, the first incident, on that day, occurred in the hallway toward Resident #1's room. Resident #1 walked by Resident #2 and Resident #1 slapped Resident #2 on the butt and then walked away. Medication Aide C stated the second time, on 4/4/17, Resident #1 came out of his/her bathroom and went down the hallway toward Resident #2's room. Resident #1 stepped in front of Resident #2 to stop him/her and grabbed his/her crotch causing Resident #2 to slap him/her on the arm. Medication Aide C stated when staff came out to separate the two residents, Resident #2 kicked Resident #1 in the butt. Medication Aide C stated since these incidents, staff initially, had not done anything different for Resident #1 (regarding his/her sexual behaviors), he/she was on the 30 minute checks because he/she was making comments that he/she was going to hurt himself/herself. On 4/26/17 at 2:21 PM, Nurse E stated Resident #1 had no behaviors when he/she came to the facility, but became very anxious and agitated if his/her family member was talked to or about. Nurse E stated the behaviors became worse if the family member called or came by to see him/her. Nurse E stated he/she was informed Resident #1 grabbed Resident #2's crotch, and the previous night, Resident #1 exposed himself/herself to Resident #2 when he/she was sitting on the couch. Resident #1 told a nurse aide that he/she wasn't able to get away with anything anymore. Nurse E stated he/she talked to Resident #1's family member after he/she grabbed Resident #2, and the family member told the nurse Resident #1 had made a lot of sexual comments like it was getting larger and hot, but this wasn't unusual for him/her to say these things. Nurse E stated the day of the incident between Resident #1 and Resident #2 on the couch, Resident #2 was asleep, that was the first time staff have had an incident like that happen before. Nurse E stated when Resident #1 had outbursts, he/she would go off and wanted to deal with the top dog. Nurse E stated after the initial incident on 4/3/17, and since both incidents, staff have tried to make sure Resident #1 and Resident #2 were not in the same vicinity, and staff monitor and watch them both as much as possible. Prior to either incident, Resident #1 had not had any behaviors, like this. When Resident #1 exposed himself/herself, Nurse E stated he/she really had not thought too much of it, and maybe Resident #1 was trying to go to the bathroom. On 4/26/17 at 6:03 PM Administrative Nurse A stated Resident #1 had never behaved in this manner before and staff separated Resident #1 and Resident #2 and placed Resident #1 on 30 minute checks. Resident #1 stated he/she felt really bad about what happened. Administrative Nurse A stated there have been no problems since these two incidents happened. On 4/27/17 at 11:50 AM, per notarized witness statement, Nurse Aide D stated on 4/3/17, when he/she came around the corner, he/she observed Resident #2 sitting on the couch with his/her feet elevated. Nurse Aide D observed Resident #1 lean over Resident #2 with one hand on the arm of the couch and the other on the back of the couch behind Resident #2's head. Nurse Aide D stated Resident #1 did not hear Nurse Aide D come around the corner, and when Nurse Aide D cleared his/her throat to say something, Resident #1 turned around and stated you can't get away with anything here. Nurse Aide D stated he/she then noticed Resident #1's pants were unzipped, no skin observed. Nurse Aide D stated he/she thought Resident #1 was trying to expose himself/herself to Resident #2, so Nurse Aide D called for assistance from another nurse aide. Resident #1 was assisted to his/her room while Nurse Aide D sat with Resident #2 on the couch to comfort him/her. Nurse Aide D stated after approximately 10 minutes, he/she ambulated with Resident #2 to his/her room, assisted him/her to bed, and the resident cried the whole time, saying he/she knew that man/woman was doing something wrong. The facility's 6/22/2009 Policy/Procedure Prohibiting Mistreatment, Neglect, and Abuse of residents and their property stated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to: facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. The facility failed to ensure Resident #2 remained free from sexual abuse, regarding inappropriate sexual touching and behavior from Resident #1 on 3 different incidents. This deficient practice placed Resident #2, in immediate jeopardy. The facility abated the immediate jeopardy on 4/28/17, when all staff received face-to-face inservices. On 4/26/17 at 6:45 PM the facility placed Resident #1 on 1:1 supervision at all times. All staff inservices included education on Abuse, Neglect, Exploitation Policy, staff role when witnessing any type of abuse, neglect or exploitation, immediate intervention, (will differ based on situation) who to report to, factual importance of witness statements, and appropriate documentation in the medical record. All staff received a copy of the Abuse, Neglect and Exploitation Policy. Charge nurse would be responsible for reporting to the Administrator and Director of Nursing or Assistant Director of Nursing, per the state regulations on reporting and the Administrator or Director of Nursing would be responsible for reporting to the state agency. Resident to resident altercations would be reviewed at the quarterly QA (quality assurance) meetings. The Administrator and/or Director of Nursing would review weekly, to monitor that no incidences were missed and discussed at the Department Head meeting at least weekly. This deficient practice remained at a scope and severity of a G.

The facility identified a census of 54 residents. The sample included 9 residents, of which 3 residents were reviewed for elopement risk. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent leaving the building, for 1of 3 residents, who eloped from the facility. Resident #1 displayed increased exit seeking behavior earlier in the day, and exited the facility without staff knowledge. This deficient practice placed Resident #1 in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The 1/24/17, annual (MDS) Minimum Data Set assessment documented the resident had a (BIMS) Brief Interview for Mental Status score of 10, moderately impaired cognition, was independent with his/her (ADLs) Activities of Daily Living, except 1 assist from staff for dressing, had steady balance when walking, used a walker, received anti-anxiety medication daily, and was able to make himself/herself understood and he/she understood others. The 1/25/17, (CAA) Care Area Assessment documented the resident had intermittent confusion, moderately impaired cognition, had a history of [REDACTED]. The 4/25/17, quarterly (MDS) Minimum Data Set assessment documented the resident had a (BIMS) Brief Interview for Mental Status score of 9, moderately impaired cognition, was independent with his/her (ADLs) Activities of Daily Living, had steady balance when walking, used a walker, received anti-anxiety medication daily, and was able to make himself/herself understood and he/she understood others. The 4/25/17 care plan documented the resident had confusion at times and had difficulty making decisions, which placed him/her at risk for increased confusion, failing health, and loss of independence. The care plan lacked specific interventions to address wandering or possible elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff). On 5/13/17 an untimed intervention was added to the care plan, which directed staff to place an alarm above the resident's room door to alert staff when he/she left the room. The 1/19/16 at 11:46 AM, Elopement Assessment documented the resident had anxiety at his/her home prior to admission and while at the nursing home, was independent with ADL's and documented the resident was not an elopement risk. The medical record did not include an updated Elopement Assessment. The 5/8/17 physician's orders [REDACTED].½ tablet, by mouth, twice a day for hallucinations. The physician changed the Seroquel order to 25 mg twice a day on 5/14/17. The 5/12/17 physician's orders [REDACTED].). The 5/13/17 (untimed) physician's orders [REDACTED]. The 5/13/17 at 2:52 PM, progress notes documented the resident had increased confusion throughout the shift. The resident had an unsteady gait at times when he/she walked independently with a walker and refused staff assistance. The progress note further documented staff members found the resident on two different occasions in the activity room looking for a way out, he/she stated I'm waiting for the bus. I've got to get out of here and my parents dropped me off last night, when they went drinking, and forgot to come back. The progress note documented Nurse H was notified and received physician orders [REDACTED]. Review of the medical record revealed the record lacked documentation of the resident's elopement on 5/13/17 at 6:25 PM. The 5/16/17 at 10:30 AM, progress note documented a discussion between the resident and Nurse L, addressing the resident's memory difficulties and safety concerns. The note documented the resident was aware his/her health and mental status declined, Nurse L provided education on how the memory support unit could better serve his/her needs, and the resident voiced nervousness about moving into the memory support unit. The 5/16/17 at 1:30 PM, progress note documented the staff moved the resident into the memory support unit. Wunderground.com recorded the outside temperature on 5/13/17 at 6:00 PM as 75.9 degrees Fahrenheit, with wind gusts of 32.2 miles per hour. On 5/19/17, Nurse Aide G's notarized witness statement documented on 5/13/17 between 6:30 PM and 7:00 PM, Nurse Aide F and Nurse Aide G assisted a resident in a room, at the time of the incident. Nurse Aide G documented the room door opened and Nurse E stated the Resident #1 had nearly gotten outside. Nurse Aide F left the room to attend to Resident #1, and Nurse Aide G, remained in the room to finish care. Nurse Aide G documented he/she had not heard an alarm sound. On 6/6/17, Nurse E's notarized witness statement documented he/she was visiting at the facility and exited the building on 5/13/17 at 6:25 PM. Nurse E documented he/she walked from the office door exit directly to his/her vehicle parked in the parking lot. Nurse E documented he/she fastened his/her child into the car seat, stood up to come around the car to get in, and observed the resident standing on the sidewalk. Nurse E documented he/she approached the resident and the resident stated he/she was going home. Nurse E documented he/she accompanied the resident back into the building, set the door alarm off, and no staff came. Nurse E documented he/she found Nurse Aide F and Nurse Aide G in another resident's room, informed the 2 nurse aides the resident was outside of the building, and directed the aides to report the incident to the charge nurse. On 6/7/17 at 1:40 PM, Nurse H's notarized witness statement documented on 5/13/17, at approximately 2:00 PM, Nurse I called the nursing station and informed Nurse H Resident #1 was wandering and asked what staff needed to do to keep a better watch on the resident. Nurse H directed staff to place a motion alarm on the outside of the resident's room door to alert staff when he/she came out of the room and to close the door at the end of the east hall to slow the resident down, and allow staff more time to respond. On 6/6/17 at 12:15 PM, observation revealed Nurse Aide C assisted the resident to transfer from his/her chair in the dining room to a standing position, with use of a gait belt and wheeled walker. Nurse Aide C provided stand by assistance to the resident, walked with him/her to a recliner in the living room, and the resident presented with a steady gait. Nurse Aide C placed a pressure alarm pad (initiated 5/31/17 for fall prevention) in the recliner prior to the resident sitting down in the chair. On 6/7/17 at 7:56 AM, observation revealed when the office door exit was opened, without pushing the button to stop the door alarm from sounding, no audible alarm was heard at the office door, but did alarm at the west nursing station. After approximately 2 minutes, Administrative Nurse A and Administrative Nurse K arrived at the entrance and stated the west nurse's station staff notified the 2 nurses, by walkie-talkie, to check the entrance. On 6/7/17 at 8:45 AM, interview with Administrative Nurse A stated the door alarms sound at the nurse's station, the staff can look down the hallway and look outside at the entrance, to see if anyone was outside of the entrance door. Administrative Nurse A clarified the staff are not expected to walk down the hallway and physically check the exit door. Administrative Nurse A verified newly hired staff received training on elopement upon hire and staff received training annually. Administrative Nurse A further stated staff complete an elopement assessment upon admission of a resident, annually, and with resident change to identify residents at risk for elopement. Administrative Nurse A verified the Resident #1's elopement assessment was not done annually or with a change in condition, was 6 months overdue, and the facility Elopement Policy and Procedure did not direct staff how to respond to a door alarm when the alarm sounded. On 6/7/17 at 10:45 AM, Administrative Staff B verified the incident was not reported to the mandatory state reporting hotline. On 6/7/17 at 11:35 AM, Nurse Aide F stated he/she and Nurse Aide G assisted a resident in another room, as he/she walked out of the room door, he/she observed Nurse E in the hallway with the Resident #1, and Nurse E stated the resident had gotten outside of the building through the office entrance/exit door, he/she brought the resident back into the building, but his/her family member was in the car, and he/she left the resident with the aide. Nurse Aide F stated Nurse E did not instruct him/her to report to the charge nurse. On 6/7/17 at 12:00 PM, Nurse E stated he/she was unaware how the resident left the building. Nurse E clarified the location of the resident on the outside of the building and stated the resident stood at the end of the sidewalk from the exterior office door, at the curb of the parking lot and further stated his/her vehicle was parked midway between the office door entrance and the west door entrance. Review of the medical record, revealed the progress notes lacked documentation for placement of an alarm above the resident's room door, including the date and time placed. The physician order [REDACTED]. On 6/7/17 at 2:35 PM, Nurse I stated on 5/14/17, during the breakfast meal medication pass, the resident was anxious, and Dietary Staff J reported the resident had eloped the previous night. Nurse I called Nurse E to obtain information on the elopement, since no information was provided during the report between shifts. Nurse I stated he/she discussed the incident with Nurse K, charge nurse for the evening shift, who was unaware of the incident. Nurse I stated he/she discussed the resident elopement with Administrative Nurse A, on 5/16/17, and suggested the resident be moved to the locked area of the nursing home. The facility's 1/9/16, Elopement Prevention Protocol documented elopement occurred when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The protocol documented the residents would be assessed for risk of elopement upon admission and throughout their stay, as deemed necessary by the interdisciplinary team and instructed the director of nursing or administrator to follow the appropriate reporting requirements to the Kansas Department for Aging and Disability Services. The protocol further documented staff would be educated on the reasons for elopement and possible strategies for avoiding such behavior from reoccurring, the social service director and/or charge nurse should document the elopement incident and interventions in the medical record, and the plan of care should be developed or revised as indicated for the resident. The facility failed to provide adequate supervision for Resident #1, who displayed increased exit seeking behavior earlier in the day, and exited the facility without staff knowledge, placing the resident in immediate jeopardy. The facility abated the immediate jeopardy on 6/9/17, when the facility completed an all staff in-service, which included a review of the elopement policy and procedure, with focus on reporting of elopement, elopement protocol, assessment and prevention, and completion of the Elopement Risk Assessment. The facility completed an updated Elopement Assessment for each resident, who did not reside in the locked memory support unit, to identify any other residents at risk for elopement. The deficient practice remains at a scope and severity of a D.

The facility had a census of 51 residents. The sample included 3 residents, reviewed for therapeutic diets. Based on record review and interview, the facility failed to ensure 1 of the 3 sampled residents received and consumed foods in the appropriate form, as prescribed by the physician. Staff served Resident #1 a whole corn dog, when his/her physician ordered a regular with ground meat diet. The resident choked and became unresponsive, staff performed the [MEDICATION NAME] maneuver (first aid procedure using abdominal thrusts to treat choking by foreign objects), and suctioned the resident to try to remove the corn dog. The interventions were unsuccessful, and the resident expired. This deficient practice placed the resident in immediate jeopardy. Findings Included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident was non-verbal, rarely or never understood, rarely or never understands others, had short and long term memory loss, and severely impaired cognition for daily decision making, required extensive staff assistance with eating, had no chewing or swallowing problems, no dental problems, and received no special diet. The admission Care Area Assessment (CAA) for nutrition, dated [DATE], stated the resident had dementia (a progressive mental disorder characterized by failing memory and confusion) and he/she would grab at other's food. The CAA stated staff assisted the resident with eating. The [DATE] care plan directed staff to serve the resident a regular diet, have one staff assist him/her at all meals, and the dietitian would evaluate the resident for food likes and dislikes. The [DATE] physician's orders [REDACTED]. The [DATE] at 6:41 AM, dietary note stated the resident received a regular consistency diet and required staff assistance with meals. Staff should wait to serve the resident's plate until available and provide the resident with the physician ordered diet. The [DATE] at 8:15 AM, dietary note stated the resident had a good appetite and consumed 100% of lunch and supper.The note stated the resident had no chewing or swallowing problems, and dietary should continue to provide him/her with a regular diet, as ordered by the physician. The [DATE] at 2:56 PM, dietician note stated the resident consumed 100% of his/her lunch and supper.The note stated the resident enjoyed snacking, usually slept through breakfast, his/her protein intake was adequate, and no dietary recommendations at this time. Review of the medical record indicated there were no dietary or dietician notes after the [DATE] at 2:56 PM note. The [DATE] at 1:10 PM, nurse's note stated the resident had a choking episode when attempting to swallow a piece of meat.The note stated the episode lasted for approximately 30 seconds, until the resident coughed up the piece of meat, and staff would continue to monitor. The physician's orders [REDACTED]. The [DATE] at 2:45 PM, nurse's note stated staff reported the resident recently choked on meat several times, and the physician ordered his/her diet changed to ground meat. The [DATE] at 12:00 PM, nurse's note stated at approximately 11:40 AM, staff called the nurse over to the resident's dining room table, due to staff stating the resident was going blue.The note stated the resident was blue around the lips, and coughing. The note stated staff stood the resident up and began the [MEDICATION NAME] maneuver, and the nurse called for another nurse from the other side of the facility. The note stated the resident's legs began to go weak, and he/she could no longer bear his/her own weight. The note recorded staff performed the [MEDICATION NAME] maneuver several times, without success, and then suctioned the resident. The note stated the resident still had a pulse, and after staff called the resident's name, he/she began to get his/her color back, but then took a deep breath, slumped over, was blue around the lips, and became unresponsive. The note stated staff performed a sweep of the back of the resident's throat 3 times, with no success, and the resident still had a pulse, but it was weakening. The staff notified the physician, and received an order to transport the resident to the hospital. At 12:00 PM, the resident had no pulse, and no signs of life. The clinical record lacked evidence staff had called (EMS) emergency medical services when the resident began choking. The [DATE] at 12:15 PM, nurse's note stated staff notified the physician of the resident's death. On [DATE] at 11:30 AM, Nurse Aide A, stated at the noon meal on [DATE], the resident's meal tray contained a whole corn dog on a stick. Nurse Aide A stated the resident was on a regular diet, as written on his/her dietary card that comes on the meal tray. Nurse Aide A stated he/she had not ever observed the resident served ground meat. On [DATE] at 9:00 AM, Nurse B, in a telephone interview, stated he/she worked as the charge nurse on [DATE] on a different unit than resident #1, and staff asked him/her to come to the east dining room on resident #1's unit. Nurse B stated he/she found staff with the resident, in a wheelchair, in a private room, performing the [MEDICATION NAME] maneuver on the resident. Nurse B stated he/she also performed the [MEDICATION NAME] maneuver, and then tried to suction the resident, without success. Nurse B stated Nurse E looked into the resident's mouth and performed a finger sweep, and could not see or find what was lodged in the resident's throat. Nurse B stated Nurse E left to notify the physician, and when he/she returned, the resident's plus and respirations had ceased. On [DATE] at 10:50 AM, Nurse Aide C verified he/she assisted the resident with his/her noon meal on [DATE], which consisted of a whole corn dog, macaroni and cheese, and peas. Nurse Aide C stated the resident was eating the corn dog, taking small bites, and when he/she turned to assist another resident, Nurse Aide A asked if the resident was ok. Nurse Aide C stated when he/she turned back to the resident, he/she was not breathing, and was turning blue. Nurse Aide C called for the nurse, and then stood the resident up and performed the [MEDICATION NAME] maneuver. Nurse Aide C stated staff placed the resident into a wheelchair, moved him/her to a private room, and continued the [MEDICATION NAME] maneuver, before the charge nurse from the other side of the facility came to help. Nurse Aide C stated Nurse E looked inside the resident's mouth, used his/her fingers to feel inside his/her mouth, and continued the [MEDICATION NAME] maneuver, without success, for approximately ,[DATE] minutes. On [DATE] at 11:15 AM, Dietary Staff D, verified the resident had been served a regular diet instead of a ground meat diet by mistake. Dietary Staff D verified the resident's dietary card the cook used when filling the plates, stated the resident received a regular diet. Dietary Staff D stated on [DATE], the dietary department received an order from nursing, to change the resident's diet to regular with ground meat, but the order was never processed by the kitchen. On [DATE] at 12:10 PM, Nurse E verified staff served the resident a whole corn dog for lunch on [DATE], and to his/her knowledge, the resident was on a regular diet. Nurse E said the resident choked, and staff performed the [MEDICATION NAME] maneuver several times, suctioned the resident, and he/she did a visual and finger sweep of the resident's mouth 3 times, without success. Nurse E stated none of the interventions were successful and the resident died . On [DATE] at 10:15 AM, Physician H stated he/she admitted the resident to the facility on [DATE], and at that time the resident was to receive a regular diet. Physician H stated staff notified him/her the resident had problems with choking on meat, and on [DATE], he/she ordered the staff to serve the resident a regular diet with ground meat due to the risk of choking. On [DATE] at 12:25 PM, Dietary Staff F verified he/she was the cook on [DATE], and he/she served the resident a regular diet of a whole corn dog, macaroni and cheese, and peas. Dietary Staff F stated he/she uses the diet cards to know what diet a resident was on, and the resident's diet card recorded he/she was on a regular diet. Dietary Staff F stated he/she was never told the resident's diet changed to ground meat, and he/she never saw an order to change the diet. Dietary Staff F stated the dietary manager was the one who changed the orders on the diet card. On [DATE] at 1:45 PM, Administrative Nurse G verified the resident's diet card said the resident was on a regular diet. Administrative Nurse G verified the physician changed the resident's diet from regular consistency, to regular with ground meat, on [DATE], but the order never got changed in the dietary department. Administrative Nurse G stated the resident received a regular consistency diet, choked on a whole corn dog, and died in the facility on [DATE]. On [DATE] at 4:25 PM, Medical Examiner I verified on [DATE], he/she performed the autopsy on the resident, and he/she found part of a hot dog lodged in the resident's larynx (a tube-shaped organ in the neck that contains the vocal cords) and esophagus (an organ that carries food, liquids, and saliva from the mouth to the stomach). Medical Examiner I stated in his/her opinion, the resident's death was accidental from choking, and preventable. The facility's diet order policy, dated [DATE], stated all diet order changes were obtained from the physician prior to initiation.The policy stated all orders were written on the duplicate telephone order, or written by the physician on the order form when he/she was in the facility.The policy stated a copy was sent to the kitchen, and the dietary manger was responsible for updating the diet card for that resident,with the new order. The facility failed to ensure staff provided the physician ordered ground meat diet to Resident #1, who was at risk for choking. Staff served the resident a whole corn dog on [DATE], choked, became unresponsive, and died . This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 4:50 PM, when they completed the following: All staff educated by administrative staff/designee of the facility's [DATE] Diet Order Policy, to ensure all residents are served the appropriate diet, as physician ordered. The deficient practice remains at a scope and severity of G. .