Every finding on record at Pelican Pointe Health and Rehabilitation Center

Based on record review and interviews, the facility failed to report alleged violations of sexual abuse to the State Survey and Certification Agency in accordance with state law for two (#3 and #4) of two residents reviewed for abuse out of four sample residents. Specifically, the facility failed to ensure an incident of alleged sexual abuse between Resident #4 and Resident #3 was reported to the State Survey Agency.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/21/26, resulting in the deficiency being cited as past noncompliance with a correction date of 6/15/26.I. Incident of sexual abuse on 6/6/26 On 6/6/26 a certified nurse aide (CNA) reported Resident #4 was restless all night, constantly getting up and trying to wake up her roommate, Resident #3. The CNA placed a chair outside the residents' room with the door open, so when Resident #4 got up she could lay her back in bed. After assisting another resident down the hall, the CNA returned to the chair. When she returned to the chair outside the residents' room, she heard Resident #3 saying What are you doing? The CNA entered the residents' room and saw Resident #4 sitting on the edge of her Resident #3's bed with her hand inside the brief of Resident #3. The CNA asked Resident #4 to return to her bed.-However, the facility failed to report the allegation of sexual abuse to the State Agency. II. Facility plan of correctionA. Immediate action to correct the deficient practice The corrective action plan the facility implemented in response to the sexual abuse incident involving Resident #4 and Resident #3 on 6/6/26 was received from the nursing home administrator (NHA) on 7/21/26 at 9:00 a.m. The corrective action plan revealed that upon notification of the sexual abuse allegation involving Resident #4 and Resident #3 that occurred on 6/6/26, the facility immediately separated both residents. Resident #4 was moved to a different room. Resident #3 was assessed by a nurse and no signs or symptoms of trauma or injury were noted. Resident #3 remained at her mood and behavior baseline and had no evidence of physical or emotional injury.On 6/6/26, the NHA initiated an investigation that included 17 residents residing on the secured unit. Based on the staff and sample residents' interviews, the NHA unsubstantiated the allegation of sexual abuse.The facility policy and procedure requires that all allegations of abuse will be reported immediately to the appropriate state agency. On 6/10/26 the facility medical director reviewed the records of alleged sexual abuse between Resident #4 and Resident #3 and documented that there appeared to be no medical issue that needed to be worked up at this time. Staff had followed up appropriately and would continue to monitor. On 6/11/26, as Resident #3's representative was packing the resident's belongings for a planned transfer to another facility, a CNA informed her of the incident that occured with Resident #4 on the night of 6/6/26. The representative took Resident #3 to an emergency department (ED) at a local hospital for an evaluation. Resident #3's ED medical record revealed no vaginal injuries and the resident was discharged with a course of antibiotics for a urinary tract infection (UTI). The facility reported the alleged sexual abuse incident to the State Agency on 6/12/26 at 5:00 p.m.On 6/15/26, the NHA received one-on-one re-education on abuse investigations and reporting to the State Agency by a corporate operations manager.III. Facility policy and procedure The Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised December 2023, was provided by the NHA on 7/21/26 at 4:01 p.m. It read in pertinent part, If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal laws. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that all alleged violations involving abuse, neglect, exploitations or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury.IV. Resident #3 (victim)A. Resident statusResident #3, age [AGE], was admitted on [DATE] and discharged on 6/11/26. According to the June 2026 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance, anxiety disorder, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, and cognitive communication deficit.The 5/11/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent on staff assistance with toileting hygiene and bathing, required substantial assistance with all transfers, and used a wheelchair for mobility.The assessment indicated the resident had wandering behavior present on four to six days during the assessment look-back period. B. Record reviewResident #3's behavior care plan, initiated 9/9/24, revealed she demonstrated physical behaviors towards others, she was verbally aggressive, tearful, and voiced anxiety and distress at times. She had a history of seeing young children urinating on her bed. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalated the resident's behavior and documenting, Assessing and anticipating the resident's needs, such as food, thirst, toileting needs, comfort level, body positioning and pain.-Review of Resident #3's electronic medical record (EMR) revealed no progress notes regarding the incident with Resident #4 on 6/6/26. V. Resident #4 (assailant)A. Resident statusResident #4, age [AGE], was admitted on [DATE] and re-admitted on [DATE]. According to the June 2026 CPO, diagnoses included Alzheimer's disease, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety disorder and bipolar disorder.The 4/2/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15.She required substantial assistance with toileting hygiene, moderate assistance with bathing, transfers and walking with supervision.The assessment indicated the resident had wandering behavior daily during the assessment look-back period. B. Record reviewResident #4's behavior care plan, initiated 10/16/25, revealed she demonstrated physical & verbal behaviors towards staff, and wandered aimlessly into other residents' rooms. Interventions included, chores like sweeping, washing dishes, or folding, non-alcoholic [NAME] mix and sweets, allow her to call her daughter or husband on the phone, sound machine in room, take for walks, allow resident to sleep in as long as desired, and redirect her when she is encroaching on the personal space of peers. On 6/6/26 a social worker documented she met with Resident #4 about an alleged incident with another resident (Resident #3). Resident #4 was in the common area with other residents listening to music. Resident #4 did not recall the alleged incident. She was observed interacting with staff and peers as per her usual routine and was displaying no signs of psychosocial or physical distress.V. Staff interviewsThe NHA was interviewed on 7/21/26 at 8:45 a.m. The NHA said he immediately initiated an investigation of the incident on 6/6/26 involving Resident #3 and Resident #4 after it was reported to him. He said the investigation included interviews with all interviewable residents in the female memory care unit. The NHA said the investigation identified there were no concerns from others about Resident #4's inappropriate behavior. He said Resident #4 worked in a healthcare profession prior to her retirement. He said the CNA who reported the incident could not explain if she observed Resident #4 touching Resident #3 inappropriately in her bikini area or if she was just touching the undergarment/brief. The NHA said the facility completed a physical and emotional assessment on both residents immediately and identified no harm or injury to either resident, therefore he did not substantiate the allegation of sexual abuse and did not report the allegation to the State Agency. The NHA was interviewed again on 7/21/26 at 2:30 p.m. The NHA said after he learned the Resident #3's representative took the resident to the ED for evaluation related to sexual abuse, he contacted his clinical resource. He said on 6/12/26 the facility initiated re-education with all facility staff members that included abuse identification, prevention and reporting. The NHA said all residents on the secured units were interviewed and family members were contacted. He said the facility initiated a plan of correction for abuse and reporting. He said the interdisciplinary team (IDT) initiated reviewing the facility's 24-hour report for any behavior or abuse concerns for all facility residents. He said the plan of correction, the Abuse Reporting policy and the facility's grievance process had been reviewed in the QAPI meeting on 6/15/26. The NHA said Resident #4 was transferred to another nursing facility per her family's choice.Registered nurse (RN) #1 was interviewed on 7/21/26 at 12:49 p.m. RN #1 said she knew Resident #4 and Resident #3 very well. She said both residents wandered around the unit and occasionally encroached on other residents' personal space, which led to verbal disputes. She said Resident #4 exhibited attachment to some staff by hugging them. She said she had not observed any inappropriate sexual behaviors for either of the residents. CNA #1 was interviewed on 7/21/26 at 1:00 p.m. CNA #1 said she worked 12-hour day shifts and knew both Resident #4 and Resident #3. She said Resident #4 was a very lovely lady who was always around the staff and in the dining room, participating in activities. She said Resident #4 liked to hug staff, but there were no incidents of her being inappropriate.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#5) of six residents out of nine sample residents. Specifically, the facility failed to respond to Resident #5's failure to void following the removal of the resident's catheter in a timely manner, which delayed the resident's transfer to the hospital.Resident #5 was admitted to the facility on [DATE]. Resident #5 was sent to the emergency department on 4/30/26 and returned the same day with an indwelling (tubing placed in the bladder) catheter for urinary retention and an order for an antibiotic. On 5/12/26 at approximately 1:30 p.m. the resident's indwelling catheter was removed per the physician's orders.On 5/12/26 at 7:45 p.m. Resident #5 was sitting in the dining room and told the nurse he was not feeling well. Resident #5 was escorted to his room and his vital signs were checked and within normal limits. The nurse documented the catheter had been removed earlier in the day and Resident #5 had not voided. The nurse attempted to use a bladder scan (machine to measure volume of urine in the bladder), however the bladder scan was not functioning.Resident #5's representative arrived at the facility and voiced multiple concerns regarding Resident #5 not voiding after the catheter was removed and the green exudate (fluid) that was noted on the meatus (tip) of the resident's penis. The nurse provided reassurance that efforts were ongoing regarding the bladder scanner and the resident's voiding issues. The resident's representative was informed the physician would be notified regarding the abnormal drainage and edematous (swollen) penis and lack of voiding since the resident's indwelling catheter had been removed. However, Resident #5's representative wanted Resident #5 sent to the emergency room and did not want to troubleshoot the issues at the facility. On 5/12/26 at 11:24 p.m. (over nine hours after the resident's catheter was removed) Resident #5 was sent to the hospital by emergency medical transport for further evaluation per the resident's representative's request.At the hospital, Resident #5 was found to have a distended bladder, suprapubic cramping, a strong urge to void, and green discharge from the urethral meatus. An indwelling catheter was immediately placed with a urine output of 1300 milliliters (ml). Resident #5 was diagnosed with urethritis (inflammation of the tube that carries urine out of the body), urethral discharge and retention of urine. The resident was discharged back to the facility on 5/13/26 with a physician's order for an antibiotic.Findings include: I. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included cerebral infraction, Parkinson's disease and Alzheimer's disease.The 3/30/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment revealed the resident was dependent on staff for dressing, toilet hygiene, and personal hygiene. He was dependent on staff for transfers on and off the bed and on and off the toilet.The MDS assessment revealed the resident was incontinent of urine and did not have a catheter at the time of the assessment. B. Resident #5's representative interviewResident #5's representative was interviewed on 5/19/26 at 2:40 p.m. The representative said she was notified earlier in the day (on 5/12/26) , from their paid companion who sat with Resident #5 at the facility, of a discharge from Resident #5's penis. Resident #5's representative said she notified the director of nursing (DON) earlier in the day about the discharge and the DON told her that the discharge was normal. Resident #5's representative said she and her husband arrived at the facility at 7:30 p.m. She said Resident #5 was in his room and said he felt lousy and was holding his lower abdomen saying it hurt. Resident #5's representative said she asked the nurse to go to the room to look at Resident #5's penis because of the reported green discharge. Resident #5's representative said after they looked at the resident's penis, she asked for the resident to be sent to the hospital because his penis looked infected to her and her husband. She said the nurse told her the facility was able to manage his care. Resident #5's representative said she was told by the nurse that Resident #5's bladder had been scanned twice; however, when the nurse went to scan his bladder while they were there, the nurse said the bladder scan was not functioning. Resident #5's representative said she again requested that the resident be sent to the hospital because he had not voided or been checked in several hours and the resident was uncomfortable. She said she was told the resident did not need to go to the hospital because the facility could care for him in place. She said her husband then spoke with the DON and was told the laboratory (lab) work and a urine sample could be done at the facility. Resident #5's representative said the resident was acting like he needed to urinate and said he was cramping up. She said her husband took a urinal and with the help of a certified nurse aide (CNA), sat Resident #5 up at the edge of the bed but after five minutes, Resident #5 could not void. Resident #5's representative said she was provided with the option of the nursing staff performing a straight catheter (to drain the bladder) on Resident #5, but she said she did not want the facility to use a catheter at the facility due to the penis looking infected and the family wanted him at the hospital for the procedure. Resident #5's representative said she did not call the ambulance herself because she thought the facility had to make the call and have a physician's order for the transfer. She said a new nurse came into the resident's room after 11:00 p.m. (on 5/12/26) and agreed Resident #5 should go to the hospital and made the transfer arrangements. Resident #5's representative said during this time, from 7:30 p.m. until 11:00 p.m., she had asked for Resident #5 to go to the hospital but was told by the nurse and the DON that he could be treated at the facility, even after she declined to have a catheter done at the facility.C. Record reviewThe 5/12/26 nursing progress note, documented at 2:05 p.m., revealed Resident #5's indwelling catheter had been removed per physician's orders.Review of Resident #5's May 2026 CPO revealed a physician's order to discontinue the resident's catheter and perform post-void residuals every six hours for 24 hours. If greater than 400 ml of urine remained in the bladder after voiding or no voiding in 12 hours, staff were to notify the provider for new ordersThe 5/12/26 nursing progress note, documented at 7:45 p.m., revealed Resident #5 was sitting in the dining room and told the nurse he was not feeling well. Resident #5 was escorted to his room and his vital signs were checked and were within normal limits. The nurse documented the catheter had been removed earlier in the day and Resident #5 had not voided. The nurse attempted to use a bladder scan (machine to measure volume of urine in the bladder), however the bladder scan was not functioning.-There was no documentation to indicate the physician was notified regarding the resident's inability to void and the non-functional bladder scan machine.The 5/12/26 nursing progress note, documented at 9:00 p.m., revealed Resident #5's representative had arrived at the facility that evening and voiced multiple concerns regarding Resident #5 not voiding after the catheter was removed and the green exudate apparent on the meatus of the resident's penis. The nurse documented that she provided reassurance that efforts were ongoing regarding the bladder scanner, voiding issues, and all the rest and a call would be placed to the physician regarding the abnormal drainage and edematous (swollen) penis, and lack of voiding since the indwelling catheter had been removed. The 5/12/26 nursing progress note, documented at 10:40 p.m., revealed Resident #5's representative wanted Resident #5 sent to the emergency room and did not want to troubleshoot the issues at the facility. -However, the note was documented nine hours after the indwelling catheter had been removed and Resident #5 had not voided. Resident #5 had complained of not feeling well at 7:45 p.m., almost three hours prior.The 5/12/26 nursing progress note, documented at 11:24 p.m., revealed Resident #5 was sent to the hospital by emergency medical transport per Resident #5's representative request.A review of Resident #5's hospital records, dated 5/12/26, revealed the resident was admitted to the hospital at 11:49 p.m. and discharged back to the facility on 5/13/26 at 7:44 a.m. with the diagnoses of urethritis, urethral discharge and retention of urine. During the hospital exam, Resident #5 was found to have a distended bladder, suprapubic cramping, a strong urge to void and green discharge from the urethral meatus. An indwelling catheter was immediately placed and immediate urine output was 1300 ml. Resident #5 was discharged back to the facility with a physician's order for an antibiotic.II. Staff interviewsThe medical director (MD), who was Resident #5's physician, was interviewed on 5/19/26 at 9:30 a.m. The MD said he would have expected a straight catheterization would have been performed if the resident did not void all day. He said his office was not notified until that night (5/12/26) of Resident #5 not being able to void or of the green exudate discharge from his penis. He said he was not aware the bladder scanner was not working on that day.The DON and the clinical resource nurse were interviewed together on 5/19/26 at 11:30 a.m. The DON said Resident #5 had his indwelling catheter removed (on 5/12/26) and the physician's order said to check post-void residuals every six hours. The DON said when the nurse was going to use the bladder scan for Resident #5, the resident's representative had come to the facility and started to ask questions. The DON said the nurse informed the representative the bladder scanner was not working and the DON was trying to obtain a bladder scanner from another facility. The DON said the family had been offered in-house interventions but the family made it clear they did not want another catheter inserted at the facility. The DON said the family did not trust the facility to manage the resident. The regional clinical nurse said Resident #5's indwelling catheter was discontinued at 2:05 p.m. on 5/12/26, per the nurse's progress note, however; the DON said the indwelling catheter was pulled at 1:30 p.m., not at 2:00 p.m. per the nurse's correction. The DON and the regional clinical nurse said it could take up to an hour to get a resident ready to go to the hospital unless emergency services were called. III. Facility follow-upNursing home administrator (NHA) #1 provided additional documentation on 5/20/26 at 4:26 p.m. (after the survey exit). The additional documentation included the following:A physician's visit progress note, dated 5/20/26 at 3:52 p.m., documented that the night Resident #5 was transferred to the hospital (5/12/26), despite needing a straight catheterization for urinary retention, this was refused by the Resident #5's representative which led to a further delay in urinary retention until the resident was able to be treated adequately at the hospital. -However, Resident #5's representative said she had asked for Resident #5 to be sent to the hospital earlier in the evening, more than once, because she was concerned with the possible infection in Resident #5's penis and inserting a catheter. She said she was told by the nurse and the DON that the facility could handle Resident #5's medical issues, although the physician's office had not been notified until late that night (5/12/26) of Resident #5's condition (see resident representative's interview above).

Based on record review and interviews, the facility failed to ensure residents were free of significant medication errors for one (#5) of six residents reviewed for medications errors out of nine sample residents. Specifically, the facility failed to ensure Resident #5 received antibiotics for a diagnosis of a urinary tract infection (UTI) per the physician's orders.Findings include:I. Facility policy and procedure The Administration of Medications policy, dated July 2017, was provided by nursing home administrator (NHA) #1 on 5/19/26 at 4:08 p.m. The policy read in pertinent part, Medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. Medications must be given in accordance with the resident's service plan. Medications must be administered in accordance with the written orders of the attending physician. The nurse or medication technician administering the medication must record such information on the resident's medication administration record (MAR) before administering the next resident's medication. Should a drug be withheld, refused, or given other than at the scheduled time, the staff administering must indicate the reason on the medication administration record (MAR). For those utilizing electronic medication administration records (eMAR), the appropriate code must be entered with any follow up documentation as appropriate for the situation.II. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included cerebral infraction, Parkinson's disease, Alzheimer's disease and neuromuscular dysfunction (affects the nerves that control voluntary muscles) of the bladder.The 3/30/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment revealed the resident was dependent on staff for dressing, toileting hygiene, personal hygiene and transfers. The MDS assessment indicated Resident #5 was incontinent of urine and did not have a catheter at the time of the assessment. B. Record reviewA review of Resident #5's emergency room provider's note, dated 4/30/26, revealed the resident had been in the emergency room on 4/30/26, from 8:23 a.m. until 3:08 p.m.A review of Resident #5's electronic medical record (EMR) revealed the resident returned from the emergency room on 4/30/26 with a new physician's order for cephalexin capsule (antibiotic) 500 milligrams (mg), give one capsule by mouth three times a day for a urinary tract infection for seven days. -A review of Resident #5's April 2026 medication administration record (MAR) revealed the cephalexin medication was not on the MAR to be administered on 4/30/26. The 4/30/26 nursing progress note, documented at 8:55 p.m., revealed Resident #5 received the first dose of cephalexin 500 mg for the UTI.-However, the administration was not documented on the MAR (see above). The automatic medication dispensing system's transaction by item record, provided by NHA #1 on 5/19/26 at 11:23 a.m., revealed that on 4/30/26 at 8:54 p.m. one dose of cephalexin 500 mg capsule was dispensed and the quantity that remained available in the dispensing system was four capsules.A review of Resident #5's May 2026 MAR revealed Resident #5 received the ordered dose of cephalexin 500 mg capsule on 5/1/26 at 8:00 a.m.The automatic medication dispensing system's transaction by item record revealed one dose of 500 mg cephalexin capsule was dispensed on 5/1/26 at 7:38 a.m. and the quantity that remained available in the dispensing system was three capsules.A review of Resident #5's May 2026 MAR revealed Resident #5 received the ordered dose of 500 mg cephalexin capsule on 5/1/26 at 2:00 p.m.The automatic medication dispensing system's transaction by item record revealed one dose of 500 mg cephalexin was dispensed on 5/1/26 at 1:30 p.m. and the quantity that remained available in the dispensing system was two capsules.A review of Resident #5's May 2026 MAR revealed the 5/1/26 at 8:00 p.m. 500 mg cephalexin dose was not administered and was coded to see the progress note.The 5/1/26 medication administration progress note, documented at 7:35 p.m., revealed the 500 mg cephalexin capsule for Resident #5 was ordered.A review of Resident #5's May 2026 MAR revealed that on 5/2/26 at 8:00 a.m. the resident received a dose of 500 mg cephalexin capsule.The automatic medication dispensing system's transaction by item record revealed two doses of 500 mg cephalexin were dispensed on 5/2/26 at 9:06 a.m. and the remaining quantity available in the dispensing system was zero capsules.A review of Resident #5's May 2026 MAR revealed the resident received a dose of 500 mg cephalexin capsule on 5/2/26 at 2:00 p.m.A review of Resident #5's May 2026 MAR revealed the resident received a dose of 500 mg cephalexin capsule on 5/2/26 at 8:00 p.m.-However, according to the facility's automatic medication dispensing system's transaction by item record, there were no more 500 mg cephalexin capsules available for dispensing after the 5/2/26 9:06 a.m. transaction (see above). A review of Resident #5's May 2026 MAR revealed the resident received a dose of 500 mg cephalexin capsule on 5/3/26 at 8:00 a.m.-However, the automatic medication dispensing system's transactions by item record revealed that on 5/3/26 one dose of cephalexin 250 mg was dispensed at 8:40 a.m., which was only half the dose of the physician-ordered dose of 500 mg. A review of Resident #5's May 2026 MAR revealed the 5/3/26 2:00 p.m. dose was left blank and did not indicate if the resident received or did not receive the antibiotic administration.-However, the automatic medication dispensing system's transactions by item record revealed there were no more cephalexin capsules dispensed after the 250 mg cephalexin capsule at 8:40 a.m. on 5/3/26 (see above).A review of Resident #5's May 2026 MAR revealed the resident received a dose of 500 mg cephalexin capsule on 5/3/26 at 8:00 p.m.-However, the automatic medication dispensing system's transactions by item record revealed there were no more cephalexin capsules dispensed after the 250 mg cephalexin capsule at 8:40 a.m. on 5/3/26 (see above).A review of Resident #5's May 2026 MAR revealed the 5/4/26 at 8:00 a.m. 500 mg cephalexin dose was not administered and coded to see the progress note.The 5/4/26 medication administration progress note, documented at 7:13 a.m., revealed the 500 mg cephalexin capsule for Resident #5 was ordered. A review of Resident #5's May 2026 MAR revealed the 5/4/26 at 2:00 p.m. 500 mg cephalexin dose was not administered and coded to see the progress note. The 5/4/26 medication administration progress note, documented at 1:18 p.m., revealed the 500 mg cephalexin capsule for Resident #5 was ordered.A review of Resident #5's May 2026 MAR revealed the 5/4/26 at 8:00 p.m. 500 mg cephalexin dose was not administered and coded to see the progress note.The 5/4/26 medication administration note, documented at 8:54 p.m., revealed the facility was waiting for the delivery of the 500 mg cephalexin capsules from the pharmacy and the 500 mg cephalexin capsules were not stocked in the automatic medication dispensing system. A review of Resident #5's May 2026 MAR revealed the 5/5/26 at 8:00 a.m. 500 mg cephalexin dose was not administered and coded to see the progress note.The 5/5/26 medication administration progress note, documented at 8:09 a.m., revealed the 500 mg cephalexin capsule for Resident #5 was ordered.A review of Resident #5's May 2026 MAR revealed the 5/5/26 at 2:00 p.m. 500 mg cephalexin dose was not administered and coded to see the progress note.The 5/5/26 medication administration progress note documented at 1:06 p.m. revealed the 500 mg cephalexin capsule for Resident #5 was ordered. A review of Resident #5's May 2026 MAR revealed the resident received the 500 mg dose of cephalexin as ordered on 5/5/26 at 8:00 p.m., 5/6/26 at 8:00 a.m., 5/6/26 at 2:00 p.m., 5/7/26 at 8:00 p.m., 5/7/26 at 8:00 a.m., 5/7/26 at 2:00 p.m. and 5/7/26 at 8:00 p.m.A review of Resident #5's May 2026 MAR revealed the medication was discontinued on 5/7/26 (after the 8:00 p.m. dose), at seven days, as prescribed by the physician.-However, record review revealed Resident #5 missed 10 doses (out of 21 doses) of the physician-ordered cephalexin 500 mg capsules.-Review of Resident #5's EMR revealed no documentation to indicate that the facility had notified the physician regarding the resident's missed doses of antibiotics on 5/1/26, 5/3/26, 5/4/26 and 5/5/26.III. Staff interviews.The facility's medical director (MD), who was Resident #5's physician, was interviewed on 5/19/26 at 9:30 a.m. The MD said he would expect a call if a resident's medication was missed, especially an antibiotic. He said if he was notified, he would ask the nurse how the resident was feeling, what the resident's vital signs were and if the resident was stable. He said he would want to know when the facility expected the medication to be delivered in order to provide further instructions to the nursing staff, such as putting a hold on the medication until it was delivered or ordering another medication. The MD said he was not aware Resident #5 had missed so many doses of the prescribed antibiotic. He said the nursing staff should follow physician's orders and the physician should be notified of missed medications. The director of nursing (DON) and the clinical resource nurse were interviewed together on 5/19/26 at 11:30 a.m. The DON said she would expect the nursing staff to notify the physician if a resident missed a dose of medication in order to receive further instructions for that resident. The DON and the clinical resource nurse said it usually did not take several days for a medication to be delivered and could not explain why the 500 mg cephalexin was delayed for Resident #5. The DON said a blank in the MAR would indicate the medication was not administered to the resident. She said she expected her nursing staff to follow physician's orders. The DON was interviewed again on 5/19/26 at 5:15 p.m. The DON said the infection preventionist was responsible for tracking the culture and sensitivity (C&S) (a two-part laboratory (lab) procedure used to diagnose infections and to check which medications would be effective) results and tracking the antibiotic use in the facility.The pharmacy consultant was interviewed on 5/19/26 at 5:30 p.m. The pharmacy consultant said it was important for the nursing staff to follow physician's orders. She said if a medication was missed, the medication should be given as soon as possible and the physician should be notified of the missed medication. The pharmacy consultant said it was a joint effort between the medical provider and the facility to follow up on the C&S results in order to track if a resident was prescribed the correct antibiotic. She said the goal was for a resident to take all the doses of a prescribed medication.IV. Facility follow-upNHA #1 provided the following additional documentation on 5/20/26 at 4:26 p.m. (after the survey exit):Resident #5's 4/30/26 urine C&S lab results were retrieved on 5/19/26 at 6:04 p.m. The report documented the lab results were completed on 5/3/26 at 8:32 a.m. The urine C&S revealed the bacteria was enterococcus faecalis (class of bacteria) and revealed cephalexin, which was ordered for Resident #5, was not susceptible (effective) to the infection. -However, the facility did not obtain Resident #5's urine culture C&S report until after the concern for the resident's missed doses of antibiotics was brought to the facility's attention during the survey. The facility did not obtain the C&S report until after the survey exit and were not aware that the bacteria present in the resident's urine was not susceptible to the initial prescribed dose of antibiotics at the time of the survey investigation. There was no indication that the MD was made of the results.

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to ensure Resident #5's indwelling catheter bag was not touching the floor.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Proper Techniques For Urinary Catheter Maintenance , (4/25/24), retrieved on 5/26/26, from and https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. II. Facility policy and procedureThe Infection Control Policy/Procedure, dated April 2020, was provided by nursing home administrator (NHA) #1 on 5/19/26 at 4:08 p.m. It read in pertinent part, It is the policy of this facility to prevent the spread of bloodborne pathogens among healthcare workers by the direct or indirect contact with high risk of body fluids. Standard precautions are the basic level of infection control that should be used in the care of all residents all of the time. Applies to blood, all body fluids, secretions and excretions (except sweat) whether or not they contain visible blood; non-intact skin, and mucous membranes. Resident care equipment and devices - handle in a manner that prevents transfer of microorganisms to others and to the environment.III. ObservationsOn 5/18/26 at 11:50 a.m. Resident #5 was observed in the dining room with his catheter bag clipped to the underside of his wheelchair. The bottom of the catheter bag was sitting on the floor. There was approximately one to two inches of catheter tubing dragging on the floor. There was no privacy bag covering the catheter bag. On 5/18/26 at 12:15 p.m. Resident #5 was in his room. The resident's catheter bag was lying flat on the floor next to the bed. There was no privacy bag covering the catheter bag. On 5/18/26 at 1:44 p.m. Resident #5 was in his room. The resident's catheter bag had a privacy covering, however; the catheter bag was lying flat on the floor, next to the bed, with the top half of the catheter bag (where the catheter tubing entered the bag) out of the privacy bag and approximately three to four inches of the catheter tubing was lying on the floor. On 5/18/26 at 3:10 p.m. Resident # 5 was in bed with his catheter bag propped up against the bed. The bottom half of the catheter bag was out of the privacy bag and sitting on the floor mat next to the bed.IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 5/18/26 at 3:22 p.m. LPN #1 said catheter bags should be checked at least every shift. She said they should be stored below the bladder and if the resident was in bed, the catheter bag should be clipped to the bed and off the floor. She said residents' catheter bags should not be touching the floor or lying on the floor for infection control reasons. LPN #1 said catheter bags should be covered for infection control and dignity purposes.The director of nursing (DON) and the clinical resource nurse were interviewed together on 5/19/26 at 11:30 a.m. The DON said catheter bags should not be placed on the floor and should be clipped to the bed or a resident's wheelchair to prevent infections.

Based on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for one (#8) of five residents out of 37 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of side effects and adverse reactions were monitored and identified for Resident #8 while the resident was receiving prescribed antibiotics.Findings include:I. Professional referenceThe Centers for Disease Control and Prevention's (CDC) Antibiotic Prescribing and Usage in Hospitals and Long-term Care, dated 2019, was retrieved on 1/16/26 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html. It read in pertinent part,Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections.II. Facility policy and procedureThe Antibiotic Stewardship policy, dated September 2017, was received from nursing home administrator (NHA) #1 on 1/12/26 at 10:26 a.m. The policy read in pertinent part, It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. The team will review data, monitor and summarize antibiotic use from pharmacy data, such as the rate of new starts, types of antibiotics prescribed, or days of antibiotic treatment per 1,000 resident days. Summarize antibiotic resistance patterns based on laboratory data. Incorporate monitoring of antibiotic use, including the frequency of monitoring/review. Report on the number of antibiotics prescribed and the number of residents treated each month and assess residents for any infection using McGeer's criteria.III. Resident #8 A. Resident statusResident #8, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included obstructive uropathy (a condition where urine flow is blocked, causing a backup of urine into the kidneys), dementia, transient ischemic attack (TIA), epilepsy and spinal stenosis. According to the 11/24/25 minimum data set (MDS) assessment, Resident #8 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He was dependent on staff assistance and required two or more staff members for toileting hygiene, dressing and bathing. The MDS assessment revealed the resident was receiving an antibiotic medication and had an indwelling urinary catheter.B. Resident interview Resident #8 was interviewed on 1/13/26 at 1:30 p.m. Resident #8 said he did not eat by mouth because he had the gastrostomy feeding tube (G-tube) R said he had a catheter because he retained urine. Resident #8 did not think he had any infections but was aware he was taking an antibiotic medication. He said he did not know what side effects of the medication to watch for. C. Record review Review of Resident #8's January 2026 CPO revealed the following physician's order:Cefuroxime Axetil (antibiotic) oral tablet 500 milligrams (mg). Give one tablet by G-tube two times a day for urinary tract infection (UTI) for three days, ordered 1/13/26.Review of Resident #8's electronic medical record (EMR) revealed alert charting to monitor the resident's urinary tract infection. The monitoring included abnormal urine color, cloudy urine, hematuria (blood in the urine) and bladder spasms.-There was no documentation in the resident's EMR to indicate antibiotic side effects were consistently being reviewed and monitored. Resident #8's infection care plan revealed he had a risk for infection related to indwelling devices, including a suprapubic catheter and an internal feeding device (initiated 9/10/24). Interventions included enhanced barrier precautions, monitoring for signs and symptoms of infection, monitoring vital signs and educating the resident, family and caregivers regarding the importance of hand washing. -However, the resident's care plan revealed no specific interventions for caregivers to monitor for side effects related to the use of antibiotics. IV. Staff interviews Certified nurse aid (CNA) #8 was interviewed on 1/11/26 at 2:02 p.m. She said she worked at the facility through a staffing agency. She said the long-term hall residents required mechanical lifts, incontinence care, and fall risk monitoring. She said she did not do any monitoring for antibiotics for Resident #8 because that was not her role. She said if she noticed any behavior that was unusual for any residents, she would report it to the floor nurses. She said some days the nursing staff would work with not enough help. She said if she worked shorthanded, it would affect her ability to provide care and notice changes in the residents. \Licensed practical nurse (LPN) #2 was interviewed on 1/14/26 at 8:30 a.m. LPN #2 said the nurses were responsible for performing catheter care for the residents every shift. She said Resident #8 was on an antibiotic for a urinary tract infection. She said the nursing staff would monitor the resident to make sure the antibiotic was effective. She said the nursing staff would also monitor for side effects of taking the antibiotics. She said side effects of taking antibiotics included nausea, vomiting or upset stomach. She said the nurses would document the side effects of the antibiotic in the nursing progress notes.-However, there was no documentation in Resident #8's EMR to indicate side effects of the antibiotic medication were being monitored for the resident (see record review above). The infection preventionist (IP) and director of nursing (DON) #1 were interviewed together on 1/15/26 at 10:10 a.m. The IP said She is responsible for monitoring and tracking infection trends in the facility. The IP said every resident who has an indwelling urinary catheter would also have a care plan for catheter care to prevent urinary tract infection. The IP said if a resident was on antibiotics for an infection, the nurses would monitor for the effectiveness of the antibiotic, in addition to adverse reactions to the antibiotic. She said this monitoring would be documented in the residents' EMR. She said all residents who were taking antibiotics should have a care plan with interventions for the nursing staff to utilize. DON #1 said Resident #8 received an order from the physician for an additional three days of antibiotic therapy for his urinary tract infection. She said the nurses were aware of the need to monitor for and document adverse reactions while residents were receiving antibiotics. She said there was no monitoring documentation placed in Resident #8's EMR. She said she assumed that the nurses would document this information in the progress notes. She said she would make sure all residents who were on antibiotics had specific antibiotic adverse reaction monitoring documentation. DON #1 said it was always important to monitor when residents were taking short-term antibiotics to prevent unwanted side effects.

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four units. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene and gown changes while performing wound care for Resident #61; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care and transfers for Resident #70, who was on enhanced barrier precautions (EBP) for wounds.Findings include:I. Failed to ensure staff performed appropriate hand hygiene and gown changes while providing wound care for Resident #61A. Facility policy and procedureThe infection Control policy, undated, was received from nursing home administrator (NHA) #1 on 1/12/26 at 10:26 a.m. The policy read in pertinent part, It is the policy of this facility to prevent the spread of bloodborne pathogens among healthcare workers by direct or indirect contact with high risk body fluids. Hand hygiene is required following any resident contact, after touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves, and between resident contacts. Avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Remove gloves promptly after use and discard before touching non-contaminated items or environmental surfaces, and before providing care to another resident. Wash hands immediately after removing gloves.B. Resident interviewResident #61 was interviewed on 1/14/26 at 7:45 a.m. Resident #61 said she was admitted to the facility last month for wound care and recovery. She said her wound care involved a wound vac and it was done on Mondays, Wednesdays, and Fridays. She said the nursing staff would wear gloves and a mask when providing her with wound care. She said the nursing staff did not always wear gowns when doing her wound care. She said she did not know if the nursing staff were required to wear a gown during wound care.C. ObservationsOn 1/14/26 at 2:00 p.m. there was a sign on Resident #61's door that indicated she was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 1/14/26 at 2:12 p.m., during completion of wound care for Resident #61, the assistant director of nursing (ADON) touched the resident's dresser dresser drawer to retrieve barrier pads to use during wound care while wearing gloves. After touching the resident's dresser drawer with her gloved hands, the ADON proceeded with the resident's wound care without changing her gloves or performing hand hygiene. The ADON was immediately notified of the observations made of her contaminating her gloves by touching the resident's furniture. The ADON said she did not realize what she was doing at the moment and proceeded to remove the dirty gloves, perform hand hygiene with hand sanitizer and put on new clean gloves. On 1/14/26 at 2:14 p.m. an unidentified staff member donned gloves and a gown to assist the ADON with wound care for Resident #61. The unidentified staff member failed to change his gown after rubbing his face on his left arm twice during the wound care. The unidentified staff member was notified of the observation. He said he should not have rubbed his face on the clean gown because of the risk of spreading bacteria. The unidentified staff member proceeded to remove his gown and put on a clean new gown to continue assisting with the ADON with Resident #61's wound care.II. Failed to ensure staff wore the appropriate PPE when providing incontinence care and transfers for Resident #70, who was on EBP for open wounds on his left foot. A. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 1/18/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.B. Observations On 1/12/26 at 10:25 a.m. there was a sign on Resident #70's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 1/14/26 at 6:53 a.m. certified nurse aide (CNA) #7 was assisting Resident #70, with a toilet to chair transfer. CNA #7 had gloves on, but failed to don a gown while providing direct care to Resident #70. III. Staff interviews CNA #5 was interviewed on 1/13/26 at 8:47 a.m. CNA #5 said she picked up shifts often at the facility through a staffing agency. She said she did not receive any specific training from the facility regarding resident care or facility policy. She said it was typical not to receive any training from the facility as an agency CNA. She said she understood infection control precautions from previous training at other facilities. She said her understanding of EBP was that staff were to wear gowns and gloves when a resident had an indwelling foley catheter, open wounds, indwelling devices or other high contact care such as transferring, dressing and linen changes.CNA #7 was interviewed on 1/14/26 at 7:00 a.m. CNA #7 said she did not wear a gown while providing care for Resident #70 because she did not know he was on precautions. She said she did not recall receiving any specific education regarding EBP from the facility. She said she knew Resident #70 had wounds on his feet, but thought she was only required to wear gloves while providing care. Licensed practical nurse (LPN) #2 was interviewed on 1/14/26 at 8:30 a.m. LPN #2 said any resident with an indwelling foley catheter or open wound required gowns and gloves for nursing staff to perform care. The infection preventionist (IP) and director of nursing (DON) #1 were interviewed together on 1/15/26 at 10:10 a.m. The IP said she was responsible for monitoring and tracking infection trends in the facility. The IP said it was very important to adhere to infection control standards while providing care to residents to minimize the spread of bacteria. The IP said all nursing staff in the facility were provided education regarding EBP during new employee orientation. The IP said she also provided infection control education quarterly to all nursing staff. The IP said she would start to conduct more audits and education for the nursing staff regarding preventing the spread of bacteria through transmission based precautions.DON #1 said the ADON was very nervous while being observed performing wound care for Resident #61. DON #1 said she would immediately provide education to both the ADON and the unidentified staff member, along with the rest of the direct care nursing staff regarding infection control protocol with hand hygiene and gown changes. DON #1 said Resident #61 was at a high risk of getting an infection because she had a very complicated wound. DON #1 said the importance of maintaining strict transmission based precautions was critical to prevent Resident #61 and Resident #70 from acquiring an infection.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#10) of one resident reviewed for dialysis out of 37 sample residents. Specifically, the facility failed to consistently complete the communication form used for dialysis communication for Resident #10Findings include:I. Facility policy and procedureThe Dialysis (Renal), Pre and Post-Care policy and procedure, revised April 2025, was received from the regional consultant on 1/15/26 at 9:02 a.m. It read in pertinent part, Assist resident in maintaining homeostasis pre- and post-renal dialysis; assess and maintain patency of renal dialysis access; assess resident daily for function related to renal dialysis; participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Assess resident's blood pressure (in non-fistula arm) prior to being transported to the dialysis unit. Any staff concerns about resident's condition that may influence the dialysis treatment should be addressed prior to leaving skilled facility as the resident may need to be assessed in an emergency room. Dialysis access should be assessed upon return to the facility for patency, any unusual redness, swelling, or bleeding. Any significant change in medical condition should be reported immediately. Report any fever, unusual fatigue or weakness, shortness of breath, unusual pain, sleeplessness, chest pain, somnolence or any deviation from the resident's norm. The care of the resident receiving dialysis services will reflect ongoing communication, coordination and collaboration between the nursing home and dialysis staff. Documentation related to pre- and post-dialysis care will be placed in the clinical record and include: resident assessments, interventions, and any provided education. Assessment of renal dialysis access site, to include presence or absence and quality of a bruit and thrill for residents with an arteriovenous fistula. Communication between facility and dialysis staff or medical provider.II. Resident #10 A. Resident statusResident #10, age less than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included other disorders of electrolyte and fluid balance, end stage renal disease (abnormal kidney function), type two diabetes (abnormal glucose control). The 1/2/26 minimum data set (MDS) assessment revealed Resident #10 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. The MDS assessment revealed Resident #10 was dependent on staff for transfers, and lower body dressing and needed substantial to maximal assistance with upper body dressing, toileting, and bathing. The MDS assessment revealed Resident #10 had renal insufficiency, renal failure, or end stage renal disease (ESRD).B. Record reviewThe dialysis communication for Resident #10, from 12/23/25 (the date of the resident's admission to the facility) through 1/14/26, was provided by nursing home administrator (NHA) #3 on 1/14/26 at 2:16 p.m. Review of the communication revealed three dialysis communication forms, dated 1/1/26, 1/6/26 and 1/13/26.-The 1/1/26 dialysis communication form did not document what medications were administered to Resident #10 prior to dialysis treatment. -The 1/6/26 dialysis communication form did not document a pre-dialysis weight for Resident #10.The 1/13/26 dialysis communication form had all information documented completely on the form.-There were no further dialysis communication forms from 12/23/25 through 1/14/26 provided by the facility. On 1/16/26, after the survey exit, the facility provided additional dialysis communication forms for Resident #10 for 12/27/25, 12/30/25, 1/3/26, 1.8/26 and 1/9/26. The additional dialysis communication forms revealed the following:-The 12/27/25 dialysis communication form did not document what medications were administered to Resident #10 and was not signed by the nurse.-The 12/30/25 dialysis communication form did not document a pre-dialysis weight for Resident #10.-The 1/3/26 dialysis communication form did not document what medications were administered to Resident #10 prior to dialysis and was not signed by the nurse.-The 1/8/26 dialysis communication form did not document what medications were administered to Resident #10 prior to dialysis. -The 1/9/26 dialysis communication form did not document a pre-dialysis weight for Resident #10, did not document what medications were administered to the resident prior to dialysis and was not signed by the nurse.-Additionally, none of the dialysis communication forms provided after the survey exit included the information from the dialysis center on them. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 1/14/26 at 1:08 p.m. LPN #1 said the facility was using a communication sheet for dialysis communication instead of a notebook. She said the facility would send the communication sheet in a folder to dialysis with the resident. She said the facility filled out the top half of the sheet and the dialysis center filled out the bottom portion. LPN #1 said when the resident came back from dialysis, the medical records staff would upload the form into the resident's electronic medical record (EMR). The dialysis registered nurse (RN) was interviewed on 1/14/26 at 1:55 p.m. The dialysis RN said she had been working with Resident #10 since before she was admitted to the facility. She said communication with the facility was difficult. She said the facility did not get back to the dialysis center timely. She said the communication form was often not filled out completely. She said most of the time the facility would only fill out the resident's last vital signs and her diet. She said the facility should be completing the pre-dialysis weight, what medications were administered to the resident prior to dialysis, vital signs and if there was any change in condition for the resident. The dialysis RN said there was a transportation issue on 1/8/26. She said once Resident #10 was finished with her dialysis treatment, no one from the facility was there to pick her up. She said the facility refused to pick her up. She said it took calling the non-emergent paramedics and having them convince the facility to pick the resident up. She said Resident #1 was at the dialysis center for an extra hour and a half to two hours on 1/8/26 because of the transportation issue. She said that on 1/9/26 Resident #10's treatment was delayed two hours due to the facility forgetting to send her sling for transfers. She said the dialysis center had to call numerous times for the facility to pick up the phone. She said best practice for good communication had been having one point of contact, which was usually the transportation person unless it was high critical needs. RN #5 was interviewed on 1/15/26 at 10:21 a.m. RN #5 said the process for sending a resident to dialysis included administering medications to the resident, taking their vital signs and obtaining their pre-dialysis weight. She said the nurse would write down the resident's weight and vital signs on the dialysis communication sheet. She said that when the resident came back from dialysis, the nurse would take the resident's vital signs again and check the resident's dialysis access site. She said for Resident #1, she would check the resident's bruit and thrill as well). She said she was unsure if the nurses were supposed to obtain a post-dialysis weight when the resident came back from dialysis. Director of nursing (DON) #1 was interviewed on 1/15/26 at 1:07 p.m. DON #1 said staff knew who had dialysis because there was a physician's order with the resident's dialysis chair time, the days the resident went to dialysis and which dialysis center the resident went to. She said that when a resident went to dialysis, the facility would send the dialysis communication form with the resident. DON #1 said the communication form had the resident's vital signs and pre-dialysis weight documented on it and then the dialysis center would fill out their portion of the form and send it back with the resident. She said the resident's primary nurse for the day was responsible for filling out the dialysis communication form and the dialysis center was responsible for filling out their portion. She said the communication form was then uploaded into the resident's EMR upon the resident's return from the dialysis center. She said the dialysis center would talk to the charge nurse when they called or if the charge nurse was not available, the dialysis center would talk to the DON.DON #1 said she did hear about the transportation issue that had happened on 1/8/26 with Resident #10. She said when Resident #10 was living in the community, her family would cancel her rides, so the transportation company had canceled her service. She said the facility had been working on setting up a new transportation company but the facility van driver had been filling in until they got everything worked out. She said for the missing dialysis communication sheets for the days that Resident #10 went to dialysis, she said the dialysis center did not send the communication sheets back. She said when the dialysis center did not send the communication forms back, she would request the treatment details and they would send them over.

Based on observations, record review and interviews, the facility failed to ensure two (#78 and #70) of three residents reviewed for pressure injuries out of 37 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing or worsening.Specifically the facility failed to:-Ensure staff consistently offloaded Resident #78's heels; and, -Ensure staff consistently provided wound care to Resident #78 and Resident #70 in a timely manner, per physician's orders.Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019) retrieved on 1/20/26 from https://www.internationalguidelines.com/guideline, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that did not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk).Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle were not exposed. Slough may be present but did not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpableUnstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.II. Resident #78A. Resident statusResident #78, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included dementia, anxiety, hypothyroidism, pain and insomnia. According to the 12/5/25 minimum data set (MDS) assessment, Resident #78 was cognitively impaired and was not able to complete a mental assessment as indicated with a brief interview for mental status (BIMS) score of zero out of 15. She required substantial/maximal assistance of two staff members for showering/bathing, dressing and transferring. The MDS assessment documented that the resident was at risk of developing pressure ulcers and had an unstageable pressure ulcer on her right heel that was not present upon admission or reentry.B. ObservationsOn 1/14/26 at 9:15 a.m. Resident #78 was lying on her right side in bed. Two foam heel booties were observed in the resident's closet in her room. The resident was lying on an air mattress and did not have heel protection devices on either of her feet.-However, the resident's care plan indicated to float her heels as tolerated. Additionally, the resident's care plan was not updated to indicate the resident had an air mattress (see care plan below).On 1/14/26 at 9:20 a.m. Resident #78's wound care was observed with the assistant director of nursing (ADON) and certified nurse aide (CNA) #6. After the ADON removed the resident's socks, Resident #78 was noted to have a black necrotic area (dead tissue) on her right heel. There was no wound care dressing covering the resident's right heel when the ADON removed the resident's socks. -However, according to the resident's January 2026 CPO, Resident #78 should have a protective dressing on her right heel (see physician's orders below). C. Record reviewA skin assessment, dated 1/3/26, documented Resident #78 was admitted without any pressure injuries to her heels measuring a length of 0.5 centimeters (cm) and width of 0.4 cm. The skin assessment indicated the resident's right heel wound onset date was 11/23/25. Review of Resident #78's January 2026 CPO revealed the following physician's orders:Wound care for right heel: Cleanse right heel area, pat dry, apply hydrocolloid dressing. Change once weekly on Fridays and as needed if dislodged, ordered 12/12/25. -However, there was no dressing on Resident #78's right heel when wound care was performed (see observation above). Encourage resident to offload heels and side to side position while in bed, ordered 7/19/25.-However, Resident #78's heels were noted to be positioned directly onto her air mattress and not offloaded on 1/14/26 (see observations above). Resident #78's skin integrity care plan, initiated 11/14/24, revealed Resident #78 had potential for pressure ulcer development related to disease process and immobility. Pertinent interventions included floating heels as necessary, encouraging the resident to turn and reposition and providing assistance as needed and administering treatments as ordered and monitoring for effectiveness. -The staff failed to consistently implement the interventions on the care plan for protection of the resident's heels (see observations above). III. Resident #70A. Resident statusResident #70, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included hypertension, chronic kidney disease, anxiety, depression and transient ischemic attack. According to the 10/23/25 MDS assessment, Resident #70 was severely cognitively impaired and was not able to complete a mental assessment as indicated with a brief interview for mental status (BIMS) score of zero out of 15. He required substantial/maximal assistance of two staff members for showering/bathing, dressing and transferring. The MDS assessment documented that the resident was at risk of developing pressure ulcers and had an unstageable pressure ulcer that was not present upon admission or reentry.B. ObservationsOn 1/13/26 at 2:03 p.m. Resident #70's right heel wound care was observed with registered nurse (RN) #6. The wound dressing on the resident's right heel was dated 1/9/26, indicating wound care had not been provided to the resident for four days. -However, the physician's orders for wound care instructed the nursing staff to change the wound dressing daily (see physician's orders below). C. Record review Review of Resident #70's January 2026 CPO revealed the following physician's order:Wound care orders to right heel: Cleanse area to right heel, pat dry, cover wound bed with xeroform to fit and cover with bordered gauze daily and as needed, ordered 1/9/26.-However, the resident's dressing had not been changed since 1/9/26, a four-day period (see observations above).Resident #70's skin integrity care plan, initiated 11/5/25, revealed the resident had an actual impairment to skin integrity related to a stage 3 ulcer to right heel and an abrasion to left lateral malleolus (ankle bone). Pertinent interventions included administering treatments as ordered, enhanced barrier precautions, pressure reducing mattress and cushion and wound rounds to follow weekly as needed (initiated 11/12/25). IV. Staff interviews. RN #6 was interviewed on 1/13/26 at 2:10 p.m. RN #6 said Resident #70 had a physician's order for his wound care dressing to be changed every day during the day shift, or as needed. She said the resident's' dressing on his right heel should have been completed on the prior day shift (1/12/26) by the on-duty nurse. RN #6 said the resident often declined to wear his offloading boots. RN #6 said she typically did not have a problem completing wound care for the residents. She said there were plenty of staff members working during the day to help with wound care dressings if it were needed. CNA #6 was interviewed on 1/14/26 at 9:25 a.m. CNA #6 said Resident #78 was very weak and frail and was currently on hospice services. She said the nursing staff tried to make the resident comfortable by repositioning her and assisting her with eating and bathing hygiene. CNA #6 said the resident had dressings on her body to prevent her from acquiring worsening wounds. She said if she noticed any dressings that were missing, she was instructed to notify the nursing staff. CNA #6 said the resident should have her offloading boots on while in bed because the resident was unable to reposition herself.Director of nursing (DON) #1, the assistant director of nursing (ADON) and the regional consultant were interviewed together on 1/14/26 at 10:43 a.m. The ADON said she was not wound care certified, but worked as the wound care nurse for the facility on a full-time basis Monday through Friday. The ADON said her duties included conducting wound care audits, weekly skin check documentation audits of the nursing staff, completing resident admission documentation and completing weekly rounds with a wound care physician. The ADON said the nursing staff were responsible for completing daily dressing changes and skin assessments for the residents. The ADON said the dressing for Resident #70 should have been completed daily according to the physician's order. The ADON said Resident #78 should have had a dressing applied to her right heel. The ADON said Resident #78's heels needed to be off loaded in order to prevent the resident's heel wound from worsening. DON #1 said she would provide staff training regarding adhering to physician's orders, specifically regarding wound care. DON #1 said the nursing staff would often be extremely busy with other resident care duties. DON #1 said the reason why Resident #70 and Resident #78 did not have timely wound care completed could have been the result of the nurses being extremely busy. DON #1 said it was the nurse's responsibility to reach out for assistance to the administrative staff to get all nursing duties completed, including wound care. The regional consultant said it would be critically important for the nursing staff to follow the physician's orders regarding wound care to prevent infections or additional wound development. The regional consultant said Resident #70 was often non-compliant with his wound care dressing, and the facility failed to add this information to the resident's care plan. The regional consultant said she would update the resident's care plan today (1/14/26).

Based on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and personalized care for one (#9) of three residents out of 37 sample residents. Specifically, the facility failed to revise Resident #9's care plan to address catheter care interventions for the prevention of recurrent urinary tract infections (UTI).Findings include: I. Facility policy and procedureThe Care Planning policy and procedure, revised March 2020, was provided by the regional consultant on 1/15/26 at 2:42 p.m. It read in pertinent part, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Will complete an initial care plan within 48 hours of admission. A comprehensive care plan is developed within seven (7) days of completion of the Resident Minimum Data Set (MDS) Assessment.The Catheter Care policy and procedure, revised April 2021, was provided by the regional consultant on 1/15/26 at 2:42 p.m. It read in pertinent part, It is the policy of this facility to reduce the risk of catheter- associated urinary tract infection. Use standard precautions when handling or manipulating the drainage system. Maintain clean technique when handling or manipulating catheter, tubing, or drainage bag. Empty drainage bag every shift and as needed using a graduated cylinder to measure if indicated. Certified nurse aides (CNA) may also perform catheter care and notify the nurse.II. Resident #9A. Resident statusResident #9, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, Parkinson's disease (neurological disorder affecting movement), benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate causing urinary issues), unspecified urethral stricture, male, unspecified site ( narrowing of the male urethra) and bladder neck obstruction (blockage at the base of the bladder). The 12/5/25 minimum data set (MDS) assessment revealed Resident #9 had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. Resident #9 required partial to moderate assistance with oral hygiene, toileting hygiene, personal hygiene, and upper body dressing. Resident #9 was dependent on staff for lower-body dressing and needed substantial to maximal assistance with bathing. The assessment revealed Resident #9 had an indwelling catheter. B. Record reviewThe methenamine hippurate (non-antibiotic prescription antiseptic used for preventing UTI) care plan, revised 12/16/24, revealed the goal was for Resident #9 to be free from infection (revised 9/24/25 with a target date of 3/5/26). Interventions (revised 12/16/24) included educating the resident, family members and caregivers regarding the importance of handwashing, using soap and water and drying hands using disposable towels, encouraging fluid intakes and enhanced barrier precautions during close contact care, monitoring the resident for signs and symptoms of an active infection, obtaining and monitoring laboratory/diagnostic work as ordered and reporting results to the physician.The suprapubic catheter for obstructive and reflux uropathy care plan, revised 12/1/25, revealed the goal for Resident #9 was for the resident to show no signs or symptoms of urinary infection and remain free from catheter-related trauma (revised 9/24/25). Interventions included positioning the resident's catheter bag and tubing below the level of the bladder, changing catheter bag and tubing as ordered, discussing with resident/representative the risks and benefits of the use of a catheter, removal of the catheter when criteria for use was no longer present and the right to decline the use of the catheter, providing catheter care every shift and as needed, measuring urinary output, monitoring for signs and symptoms of discomfort on urination and frequency, urology appointments as needed and using enhanced barrier precautions. The 3/21/25 at 2:33 p.m. alert note documented Resident #9 required cues to encourage him from pulling on his catheter. The 10/16/25 at 2:40 p.m. nursing note documented Resident #9 was encouraged to not tamper with the catheter tubing.The 11/30/25 at 11:23 a.m. therapy note documented Resident #9 was being seen by speech therapy. Per IDT discussion, speech therapy would work on educating Resident #9 on catheter hygiene. The 12/1/25 at 11:14 a.m. IDT fall committee note documented part of the root cause analysis for the resident's fall was due to Resident #9's UTI. It was documented Resident #9 would often unhook and touch his catheter frequently throughout the day due to his impaired cognition and the resident did not recall staff education. The note further documented speech therapy would attempt to work on educating Resident #9 on appropriate catheter hygiene and care.The 12/2/25 at 3:30 p.m. IDT note documented barriers to Resident #9's UTI treatment were Resident #9's cognition and his frequent touching of the catheter tubing and his skin without proper hand hygiene and catheter care. The note further documented occupational therapy had done an evaluation and speech therapy was there to help with education and maintenance of hygiene and catheter care needs.The 12/4/25 at 11:49 a.m. nurse practitioner (NP) note documented Resident #9 was being seen for recurrent UTI and catheter pain. The note documented Resident #9 manipulated his catheter tubing. The 12/5/25 at 10:10 a.m. the condition follow-up note documented staff continued to assist with catheter care and reminding Resident #9 not to touch the catheter tubing and bag when witnessed.On 12/11/25 continued education was given to the staff for catheter care for Resident #9. The education provided was to continue to encourage Resident #9 to not touch his suprapubic catheter, continue to assist Resident #9 with handwashing, engage Resident #9 in activities, offer snacks to keep the resident's attention off of his catheter, encourage fluids and empty urination bag timely to prevent Resident #9 from trying to complete the task on his own.-However, Resident #9's UTI and catheter care plans failed to document the new interventions put in place to help prevent Resident #9 from touching his catheter tubing, leading to the resident's frequent UTIs (see care plans above). III. Staff interviewsCNA #3 was interviewed on 1/13/26 at 2:33 p.m. CNA #3 said Resident #9 had a catheter leg bag and CNAs would do catheter care for Resident #9 at least once every shift. She said CNAs would use alcohol swabs and clean the catheter away from his abdomen, because he had a suprapubic catheter. CNA #4 was interviewed on 1/13/26 at 3:46 p.m. CNA #4 said CNAs would do Resident #9's catheter care once a shift. She said they would use the peri care wipes to clean his tubing away from his abdomen. Registered nurse (RN) #2 was interviewed on 1/14/26 at 7:39 a.m. RN #2 said the nurses normally did the residents' catheter care. She said Resident #9 had chronic extended-spectrum beta-lactamase (ESBL), specifically E.coli. She said she normally did Resident #9's catheter care and the CNAs would do it as needed on top of what she did. The infection preventionist (IP) and director of nursing (DON) #1 were interviewed together on 1/15/25 at 10:10 a.m. The IP said she was responsible for monitoring and tracking infection trends in the facility. The IP said every resident who had an indwelling urinary catheter would also have a care plan for catheter care to prevent urinary tract infections. She said Resident #9 should have had a care plan with interventions for the nursing staff to utilize in order to prevent infections. DON #1 said all nursing staff were trained to do catheter care and used an alcohol wipe for cleaning. She said catheter care should be done at a minimum of once per 12 hour shift, or as needed. DON #1 said Resident #9 had chronic urinary tract infections because he had dementia and he continuously put his hands down his pants and touched his catheter. She said the facility encouraged staff to keep the resident's catheter bag empty, make sure Resident #9's hands were washed and clean and distract Resident #9 from putting his hands down his pants. DON #1 said all of these interventions were known by the nursing staff due to the education that was given to them. - However, the interventions were not updated on Resident #9's care plan (see care plans above).

Based on record review and interviews, the facility failed to ensure one (#1) of five residents reviewed for psychotropic medications out of 37 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to:-Ensure Resident #1 had behavior monitoring in place for antipsychotic use; and,-Ensure consents were obtained prior to administration of psychotropic medications.Findings include:I. Facility policy and procedureThe Chemical Restraints and Psychotropic Medication Management policy and procedure, revised April 2025, was provided by the regional consultant on 1/15/26 at 2:42 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents are free from chemical restraints imposed for purposes of discipline or convenience or that are not required to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for the purpose of discipline or convenience. Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The licensed nurse shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors and related adverse side effects prior to verification of admission orders with the attending physician. The social services director (SSD) and/or nursing designee will be responsible for initiating the residents' individualized, person-centered psychosocial plan of care, based on their comprehensive initial admission assessment. Upon initial comprehensive assessment, the SSD designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotropic medications. The facility's interdisciplinary team (IDT) will review to ensure: psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record; not in excessive dosage; behavior is not related to delirium or other reversible conditions; monitoring for adverse consequences and effectiveness of medications are in place; PRN medications are within guidelines; informed consent was obtained prior to medication use; review of plan of care shows individualized, person-centered care approaches to manage behavior with non-pharmacological interventions; attempt/consider a GDR, if appropriate. II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included pneumonia, chronic obstructive pulmonary disease and dementia. The 12/26/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment revealed Resident #1 was dependent on staff for lower body dressing and needed partial assistance for upper body dressing and needed substantial assistance for toileting and bathing and was independent with eating. The MDS assessment further revealed Resident #1 did not have any behaviors of psychosis, verbal or physical aggression, or other behavioral symptoms such as pacing, exit seeking, rejection of care or sexual inappropriate behavior. The MDS assessment revealed Resident #1 had mild depression with a score of eight out of 27.The MDS assessment revealed Resident #1 received antidepressant, antianxiety and antipsychotic medications. B. Record reviewReview of Resident #1's January 2026 CPO revealed the following physician's orders: Citalopram Hydrobromide (Celexa, an antidepressant medication) 20 milligram (mg) tablet. Give one tablet by mouth one time a day for depression, ordered 12/22/25. Clonazepam (an antianxiety medication) 1 mg tablet. Give one tablet by mouth in the morning for anxiety, ordered 12/22/25. Quetiapine Fumarate (Seroquel, an antipsychotic medication) 100 mg tablet. Give 100 mg by mouth at bedtime for dementia, ordered 12/22/25. Review of Resident #1's electronic medical record (EMR) revealed a psychoactive medication evaluation, dated 12/23/25 for Seroquel 100 mg. The diagnosis listed for the medication was dementia. -The evaluation did not document any behaviors for Resident #1. Resident #1's potential for a psychosocial well-being problem care plan, referring to the resident's mild depression, initiated 12/22/25 and revised 1/2/26, documented social services offered mental health counseling services which Resident #1 accepted. The interventions included allowing time for the resident to answer questions and to verbalize feelings, perceptions, and fears, providing opportunities for family to participate in care, and when conflict arose, removing the resident to a calm safe environment and allowing the resident to vent/share feelings. -The care plan failed to document specific target behaviors to monitor for Resident #1 in order to justify the use of the resident's psychotropic and antipsychotic medications. Review of Resident #1's December 2025 and January 2026 medication administration records (MAR) revealed there was no documentation for mood or behavior tracking. Review of Resident #1's December 2025 and January 2026 MARs documented tracking of sleep and side effects for the resident's antidepressant medication; however, the MARs failed to reveal side effect tracking for the resident's antipsychotic and antianxiety medications. The pharmacy consultation report, dated 1/8/26, recommended for the facility to add behavior and side effect tracking to Resident #1's MAR for the medications clonazepam, citalopram and Seroquel. -Review of Resident #1's EMR did not reveal any documentation to indicate the facility obtained consent to administer the resident's psychotropic medications. III. Staff interviewsRegistered nurse (RN) #5 was interviewed on 1/15/26 at 10:21 a.m. RN #5 said Resident #1 was on Seroquel for dementia and clonazepam for anxiety. She said the facility was monitoring the resident's hours of sleep for her antidepressant. She said Resident #1 did not have any behaviors. Director of nursing (DON) #1 was interviewed on 1/15/26 at 1:07 p.m. DON #1 said staff knew what resident behaviors to monitor for because the behavior monitoring was on the behavior tracking care plan. She said it was then documented on either the treatment administration record (TAR) or the MAR. She said once the facility was able to determine triggers and non-pharmacological interventions through observations and interviews, all of the information would be documented on the resident's care plan. She said if a resident had a behavior, the interventions for the behavior were documented on the care plan and the Kardex (a reference tool that summarizes vital resident data). She said interventions that were used during a behavioral moment and if the intervention was effective or not were documented on the TAR or the MAR. She said for Resident #1, the facility was monitoring the resident's hours of sleep for a sleep aid, and she could not find a specific behavior for the resident's antipsychotic medication. She said the facility should have triggered antipsychotic behavior. She said the facility should have documentation of the psychotropic medication consents but sometimes, they did not upload them until they could get the physical signature. -However, during the survey process, the consents were requested and the facility did not provide documentation of them.

Based on observation, record review and interviews, the facility failed to create an environment that protected residents from resident-to-resident abuse. This affected six (#2, #3, #5, #6, #8 and #10) of 10 residents out of 12 sample residents residing on three of five units (Mountain View South, Sunrise South, and Mountain View North) in the facility. 1. Resident-to-resident abuse on the Mountain View South UnitResident #4, with severe cognitive loss, exhibited physical aggression toward four residents (#2, #3, #5, and #10), all of whom were cognitively impaired and resided with Resident #4 in the Mountain View South unit. Resident #4 was known to wander aimlessly and in and out of other residents' rooms, and to significantly intrude on the privacy of others. Record review revealed Resident #4 began displaying physically aggressive behavior toward his new roommate, Resident #2, on 5/14/25, which the facility failed to investigate, despite Resident #4 never having shown behaviors of physical aggression before. This failure contributed to an escalation of aggression toward Resident #2, along with physical aggression toward Residents #3, #5, and #10. -On 5/31/25, staff observed Resident #4 standing over his sleeping roommate, Resident #2, and holding his oxygen tubing in a threatening manner. While the facility provided immediate intervention to ensure resident safety after the incident (15-minute checks for 72 hours), the immediate intervention was ineffective in preventing Resident #4 from attempting to put his walker on the shoulders of Resident #3 later the same day. The facility failed to investigate Resident #4's aggressive behavior and develop interventions to identify and address the risks Resident #4 posed to the safety of the cognitively impaired residents on the unit, including to his roommate, Resident #2, and additional physically aggressive incidents by Resident #4 followed on 6/1/25, 6/3/25, and 6/30/25. -On 6/1/25, one day after Resident #4 was involved in two aggressive incidents with Resident #2 and Resident #3, Resident #4 entered the room of Resident #5 and pushed him to the floor. Resident #4's psychoactive medications were adjusted, and 15-minute checks were continued. However, the 15-minute checks had not been effective in preventing the incident on 6/1/25. -On 6/3/25, three days after the incident with his roommate, Resident #2, Resident #4 placed a table on Resident #2's chest while he lay in bed, punching him, and attempting to drag him out of his bed. Resident #4 was then moved to another room and provided one-on-one staff supervision for 72 hours. However, there was no evidence that the facility conducted comprehensive clinical assessments of Resident #4 to rule out clinical contributing factors for his aggressive behavior. No updated interventions or triggers were added to his plan of care or the abbreviated care plan the staff were to utilize to prevent recurrences. Additionally, the resident's new behavior of physical aggression was not added to Resident #4's behavior monitoring orders for staff. -On 6/30/25, Resident #4 approached Resident #10 in a hallway and pushed Resident #10's walker with his walker, causing Resident #10 to almost lose his balance. Resident #4 did not have any enhanced supervision - either one-to-one monitoring or 15-minute checks - in place, even though his room was down a hallway with limited staff visibility. 2. Resident-to-resident abuse on the Sunrise South and Mountain View North Units Residents #6 and #7 resided in the Sunrise South Unit. Review of a facility abuse investigation, dated 6/18/25, documented Resident #7 physically abused Resident #6 on 6/18/25 at 9:25 p.m. The investigation read that Resident #7 entered his room, got into a verbal altercation with his roommate, Resident #6, and Resident #7 picked up a coffee cup and threw it at Resident #6, hitting him in the face and causing a one-inch laceration above his left eyebrow.Staff interviews revealed that Resident #6 and Resident #7 had personality clashes when they were roommates, which led to issues between the two that escalated over time. However, review of Resident #6 and #7's progress notes revealed no documentation indicating staff assessed, monitored, or addressed the escalating conflict between Resident #6 and Resident #7.Residents #8 and #9 resided in the Mountain View North Unit. Review of a facility abuse investigation documented that staff witnessed Resident #9 push Resident #8 with an open hand on the shoulder while they were in the dining room/sitting area. Resident #9 told Resident #8 to move out of his way and then pushed Resident #8. The residents were separated and started on frequent checks. However, neither resident's record contained documentation of frequent checks.Specifically, the facility failed to:-Protect Resident #2, Resident #3, Resident #5 and Resident #10 from physical abuse by Resident #4;-Protect Resident #6 from physical abuse by Resident #7; and,-Protect Resident #8 from physical abuse by Resident #9.The facility's failure to develop and implement effective interventions to prevent repeated incidents of resident-to-resident physical abuse created the potential for serious harm if the situation was not immediately corrected. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Resident #4, with severe cognitive loss, exhibited physically aggressive behaviors toward four residents (#2, #3, #5, and #10), all of whom were cognitively impaired. Resident #4 attempted to physically harm Resident #2, his roommate, on 5 /31/25, standing over his sleeping roommate and holding his oxygen tubing in a threatening manner. And, attempted to harm him again on 6/3/25 by placing a bedside table on Resident #2's chest as he slept. Resident #4 attempted to harm Resident #3 on 5/31/25 by attempting to place his walker on Resident #3's shoulders. Resident #4 hit and pushed Resident #5 on 6/1/25, causing the resident to fall to the floor. And, Resident #4 pushed Resident #10 on 6/30/25 in the hallway, causing him to lose his balance Record review revealed additional incidents of resident-to-resident altercations on the Sunrise South and Mountain View North units. Resident #7 threw a cup at Resident #6, causing a facial laceration, and Resident #9 pushed Resident #8. There was no evidence that interventions to prevent repeat incidents of abuse were timely initiated. The facility's failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to Resident #4's physical abuse and attempts at physical abuse, as well as abusive incidents by Resident #7 and #9, created the potential for serious harm if the situation was not immediately corrected. On 7/14/25 at 7:05 p.m., the administrator in training (AIT), the regional clinical resource (RCR), and the director of nursing (DON) were notified that the facility's failure to develop and implement effective interventions to protect cognitively impaired residents from repeatedly being subjected to physical abuse and attempts at physical abuse created the potential for serious harm if the situation was not immediately corrected. B. Facility plan to remove immediate jeopardy On 7/15/25 at 10:25 a.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Immediate Action: Upon notification of the immediate jeopardy, one-to-one staff supervision was immediately initiated on 7/14/25 for Resident #4. Resident #4 remained on one-to-one staff supervision until the survey exit at 6:00 p.m. on 7/15/25. During the period from 7/14/25 to 7/15/25, all staff were provided education on prevention and de-escalation of behaviors with Resident #4. Resident abuse education for staff was initiated on 7/15/25 by the DON. The education is to be completed at the beginning of each shift until all staff were 100% educated by 7/22/25 and ongoing education is to take place prior to the start of shift for all contracted staff. Abuse education included: types of abuse, reporting allegations and reporting to abuse coordinator and safety interventions. An additional binder was created and located in the nurses’ station to provide education to agency staff on abuse expectations and procedures. Education was initiated on 7/15/25 with staff on all residents’ plan of care updates. A binder for resident specific resident behaviors, identified triggers and interventions was initiated on 7/15/25 and placed at every nurses’ station. On 7/14/25, Resident # 4's comprehensive care plan and abbreviated care plan were reviewed and updated by social services and nursing, with up to date triggers and non-pharmacological interventions. A facility wide audit was completed on 7/15/25 for all residents with a history of verbal and/or physical aggression by social services and nursing. The care plans were updated with person centered care interventions including triggers and non-pharmacological interventions. Monitoring: The DON, or designee, to complete audits on three random residents three times a week for twelve consecutive weeks. The audits will include: Observation: Observe for any concerns with resident interactions and observe for any concerns with roommate living situations. Staff Interview: Ensure the staff are aware of resident behaviors, triggers and interventions. C. Removal of immediate jeopardy On 7/15/25 at 4:55 p.m., the AIT was notified that, based on review of the facility plan and evidence of its implementation, the immediate jeopardy situation had been abated. However, deficient practice remained at an E level, with the potential for more than minimal harm at a pattern. II. Facility abuse policy On 7/14/25 at 7:14 a.m., the RCR provided the facility’s Abuse Policy, revised April 2025. It read in pertinent parts: The facility will engage in training and orienting its new and existing staff on topics which relate to the delivery of care and service in the post-acute setting. Topics of such training will include, but not be limited to: reporting abuse, neglect, exploitation, and misappropriation of resident property. Identifying, assessing, care planning for appropriate interventions, and monitoring residents with needs and behaviors that might lead to conflict or neglect, such as: Physically aggressive behavior, wandering into other rooms/space, and touching or rummaging through other's property. If the allegation of abuse, neglect, or exploitation involves another resident, the facility will continue to assess, monitor, and intervene as necessary to maximize resident health and safety.” III. Incidents of resident-to-resident abuse on Mountain View South A. Incident on 5/14/25 between Resident #4 and his roommate, Resident #2 1. A nursing progress note, dated 5/14/25, revealed that Resident #4 woke up from sleeping, went over to his roommate's side of the room (Resident #2), and pushed all of his belongings onto the floor. The two residents began to yell aggressively at each other, and the staff was able to intervene before it escalated to a physical altercation. Resident #2 was put into a different room for the night to resolve the situation. 2. Facility failure There were no notes in Resident #4's electronic medical record (EMR) to show a review by the interdisciplinary team (IDT) regarding Resident #4's behavior, although staff interview (see below) revealed Resident #4 did not exhibit physically aggressive behavior before Resident #2 became his roommate. B. Incidents on 5/31/25 between Residents #4 and #2, and Residents #4 and #3 1. Incident on 5/31/25 with an unidentified time between Residents #4 and #2 Facility investigation: The facility investigation read that the incident between Resident #4 and Resident #2 occurred in the room the residents shared. Resident #4 was observed by staff in the room, standing over Resident #2, who was sleeping in his bed, with oxygen tubing in his hands, extending it towards Resident #2. When stopped by the certified nursing assistant (CNA), Resident #4 stated, I haven't done anything to him yet. Resident #4 was removed from the room and placed on 15-minute checks. The residents were not interviewed until 6/2/25 (due to late reporting to the management by the unit staff), and neither resident could recall the incident due to cognitive impairment. The facility did not substantiate the incident, as no physical contact was made between the two residents. Staff interview: CNA #7 was interviewed on 7/15/25 at 3:11 p.m. She said she was present for the incident between Resident #4 and Resident #2 on 5/31/25. CNA #7 said she had never seen Resident #4 display any behaviors of aggression until Resident #2 moved into his room (census records showed that was on 5/5/25). CNA #7 said the residents did not like each other from the beginning, and both men had too many belongings for the space in the room. CNA #7 said on 5/31/25, Resident #4 had been agitated and wanted Resident #2 out of his room. She said the two residents were in their room together, and she decided to go into the room to check on them. CNA #7 said she saw Resident #4 standing over Resident #2, who was asleep in his bed. Resident #4 had his oxygen tubing pulled between both hands and was preparing to put the cord under Resident #2's neck in order to wrap it around. She said she was able to intervene and reported the incident to the nurse. 2. Second incident on 5/31/25 with an unidentified time, between Residents #4 and #3 Facility investigation: The facility investigation read that the incident occurred in the common area where both residents resided. Resident #4 was observed by staff walking toward Resident #3, picking up his walker, and trying to place it on the shoulders of Resident #3. The residents were separated, and Resident #4 continued with 15-minute checks. The residents were not interviewed until 6/2/25 (due to late reporting to the management by the unit staff), and neither resident could recall the incident due to cognitive impairment. The facility did not substantiate the incident, as no physical contact was made between the two residents. 3. Residents a. Resident #2 (victim) Resident #2, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician’s orders (CPO), diagnoses included dementia. The 6/4/25 minimum data set (MDS) assessment revealed the resident was unable to participate in the brief interview for mental status (BIMS) cognitive assessment due to severe cognitive impairments, and a staff interview had to be conducted. The staff interview revealed the resident had short-term and long-term memory deficits with severely impaired decision-making. He had a behavior of wandering. The comprehensive care plan, revised 6/4/25, revealed the resident had depression. Interventions, initiated 6/4/25, included monitoring for symptoms of depression and sad mood. b. Resident #3 (victim) Resident #3, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included dementia. The 6/4/25 MDS assessment revealed the resident had been unable to participate in the assessment due to cognitive impairments. A staff interview revealed Resident #3 had short-term and long-term memory deficits, he was only orientated to himself, and had severely impaired in decision-making. The resident's elopement care plan, revised 6/4/25, revealed that the resident had impaired decision-making and intruded on the privacy of others. Interventions, revised 6/5/25, included offering him his favorite candy and playing his favorite music. The July 2025 CPO revealed orders dated 11/26/24 for behavior monitoring for verbal and physical aggression. Interventions included to offer a back rub, redirect, approach in a calm manner, reposition, offer food/fluids, assess for pain, and provide a quiet environment. c. Resident #4 (assailant) Resident #4, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included dementia and paranoid schizophrenia. The 4/29/25 MDS assessment revealed the resident had a severe cognitive impairment with a BIMS score of four out of 15. He had a behavior of wandering. The assessment’s behavior section failed to reveal that Resident #4 had behaviors of verbal or physical aggression. The resident's elopement care plan, revised 11/14/24, revealed the resident wandered aimlessly and significantly intruded on the privacy of others. He would wander in and out of other residents' rooms. Interventions, initiated 11/14/24, included to distract the resident from wandering with diversional activities. The July 2025 CPO revealed orders dated 11/26/24 for behavior monitoring for verbal threatening, agitation, and wandering. Interventions included to offer a back rub, redirect, approach in a calm manner, reposition, offer food/fluids, assess for pain, and provide a quiet environment. 4. Facility failures The facility failed to comprehensively evaluate either incident on 5/31/25; there were no notes in Resident #4's electronic medical record (EMR) to show a review by the interdisciplinary team (IDT) regarding this change in Resident #4's behavior, which posed a risk to cognitively impaired residents on the unit. Further, there was no evidence that the facility conducted comprehensive clinical assessments of Resident #4 to rule out clinical contributing factors for his aggressive behavior. And, there was no evidence that the facility considered separating Resident #2 and Resident #4, despite the earlier incident on 5/14/25, the nature of the incident on 5/31/25, and staff knowledge that the residents did not get along. CNA #7, interviewed on 7/15/25 at 1:41 p.m., said she had never seen Resident #4 display any behaviors of aggression until Resident #2 moved into his room (census records show that was on 5/5/25). CNA #7 said the residents did not like each other from the beginning, and both men had too many belongings for the space in the room. No additional interventions were initiated on Resident #4's care plan until after several other aggressive actions by Resident #4 (see below). No updated interventions or triggers were added to his plan of care or the abbreviated care plan the staff were to utilize to prevent recurrences. Additionally, the resident's new behavior of physical aggression was not added to Resident #4's behavior monitoring orders for staff. C. Incident on 6/1/25 between Residents #4 and #5 Facility investigation: The facility investigation revealed the incident between Resident #4 and Resident #5 occurred in Resident #5's room. Staff heard yelling and found Resident #5 standing up and yelling at Resident #4 to leave the room. Resident #4 reached out and hit Resident #5 in the arms and then pushed him, causing Resident #5 to fall to the floor onto his buttocks. The registered nurse (RN) contacted the director of nursing (DON) to report the incident. The RN advised the DON that Resident #4 had been agitated more than usual the prior day and had to be redirected many times to prevent him from agitating other residents on the unit. Both residents were put on 15-minute checks for 72 hours. Resident #4's hospice team was notified, and an order for twice-daily Ativan (an antianxiety medication) was initiated for Resident #4. Both residents were assessed by the RN and found not to have injuries. Resident #4 was interviewed on 6/2/25 and was unable to articulate the events due to cognitive impairments, other than to make a punching gesture while being interviewed. Resident #5 was interviewed on 6/2/25 and was unable to recall the event due to cognitive impairment. The facility substantiated the abuse. 2. Residents a. Resident #5 (victim) Resident #5, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included unspecified dementia. The 5/7/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of eight out of 15. (Resident #5 was approached on 7/14/25 at 2:15 p.m. and was unable to recall the events of the incident.) The resident's behavior care plan, revised 6/6/25, after the incident on 6/1/25, revealed the resident had the potential to display verbally aggressive behaviors regarding others entering his room. Interventions, revised 6/6/25, were for staff to document observed behaviors and attempted interventions and place a stop sign across his doorway to discourage other residents from entering. b. Resident #4 (assailant) (see resident information above) 3. Facility failures The care plan for Resident #5 (see above) did not reflect the incident on 6/1/25 with Resident #4, and observations on 7/14/25 at 10:23 a.m. did not reveal a stop sign across Resident #5's doorway as care planned. There were no notes in Resident #4's electronic medical record (EMR) to show a review by the IDT regarding this change in Resident #4's behavior, which posed a risk to cognitively impaired residents on the unit. The behavior care plan and approaches for Resident #4, ordered on 11/26/24, were not updated to increase supervision of the resident, who was known to wander into residents' rooms. The medication administration records (MARs) and treatment administration records (TARs) reviewed for June 2025 and July 2025 failed to reveal that the resident had behavior monitoring established for physical aggression toward other residents. D. Incident on 6/3/25 at 8:46 a.m. between Residents #4 and #2 1. Facility investigation The facility investigation revealed that a third incident between Resident #4 and Resident #2 occurred in the room the residents shared. Resident #4 was observed by staff in the room, standing over Resident #2, who was lying in his bed, and he was pushing a bedside table down onto Resident #2's chest. Resident #2 was attempting to push the table off himself when staff intervened. Resident #4 was assigned one-on-one staff supervision and was moved to a private room. Both residents were assessed by the RN and found not to have injuries. Resident #4 was interviewed on 6/3/25 and was unable to articulate the events due to cognitive impairments. Resident #2 was interviewed on 6/3/25 and told staff he had woken up to a table on top of him, and Resident #4 wouldn't stop and leave him alone. The facility substantiated the abuse. Staff interview: CNA #7 was interviewed on 7/15/25 at 3:11 p.m. She said she was present for the incident between Resident #4 and Resident #2 on 6/3//25. CNA #7 said on 6/3/25, she heard noise coming from the room Resident #4 and Resident #2 shared, and she came in to see Resident #4 pushing a bedside table on Resident #2's chest. She said Resident #2 was lying in his bed and was trying to push the table off himself, but he was unable to until the CNA entered and distracted Resident #4. CNA #7 said that after Resident #2 was able to push off the bedside table, Resident #4 began punching him in the body, and Resident #2 began kicking Resident #4. She said Resident #2 was still lying in his bed, and Resident #4 grabbed his foot and tried to pull him out of his bed. CNA #7 said she had to put her body physically between the residents to stop them from fighting. She said she reported the incident to the nurse. 2. Residents Resident #2 (victim) (see resident information above) Resident #4 (assailant) (see resident information above) Review of Resident #4's record revealed a physician visit note, dated 6/3/25, that the physician had visited Resident #4 and made no changes to his plan of care. The note indicated the resident had a few altercations in the past couple of weeks and had a history of hallucinations and underlying psychosis. 3. Facility failures On 6/4/25, interventions were initiated to analyze Resident #4's behavioral events for key times, circumstances, triggers, and what de-escalation was effective, to address contributing sensory deficits, and to document behaviors and interventions. -However, these interventions were not resident-centered and failed to address enhanced supervision when one-to-one supervision or 15-minute supervision was not in place. On 6/6/25, three days after the third incident with Resident #2, orders for alert charting in the treatment administration records (TARs), dated 6/1/25 to 6/30/25, was ordered, and documented Resident #4 was being monitored for chronic obstructive pulmonary disease (COPD) exacerbation with increased agitation, confusion, and wandering. -However, the medication administration records (MARs) and TARs reviewed for June 2025 and July 2025 failed to reveal that the resident had behavior monitoring established for physical aggression toward other residents. On 6/17/25, a psychoactive medication meeting note revealed Resident #4 had been reviewed due to agitation, verbal, and physical aggression towards others. However, no recommendations were made, and there was no mention of a root cause analysis to determine the cause of the resident's behavior. E. Incident on 6/30/25 at 4:10 p.m. between Residents #4 and #10 1. Facility investigation The facility investigation revealed that an incident between Resident #4 and Resident #10 occurred in the common area of the unit. Resident #4 was observed by staff pushing his walker against Resident #10's walker, almost causing him to lose his balance and fall before staff could intervene. The residents were separated and assessed by the RN and found not to have injuries. Resident #4 was placed on frequent checks. Resident #4 was interviewed on 6/30/25 and could not recall the specifics of the incident, but said he could recall feeling ticked off and if he had a problem with another resident, he said he would handle it. Resident #10 was interviewed on 6/3/25 and was unable to recall the incident due to cognitive impairments. The facility did not substantiate the incident, as no contact was made between the two residents. 2. Residents Resident #10 (victim) Resident #10, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included unspecified dementia. The 4/30/25 MDS assessment revealed the resident had a severe cognitive impairment with a BIMS score of three out of 15. Resident #10 was approached on 7/14/25 at 4:05 p.m. and was unable to recall the events of the incident on 6/30/25 due to cognitive impairments. The resident's behavior care plan, revised 4/30/25, revealed that the resident used antipsychotic medications related to dementia. The resident had behaviors of hallucinations, delusions, and aggression. Interventions, initiated 9/11/24, included documenting behaviors. The elopement care plan, revised 4/30/25, revealed the resident had wandering behaviors and poor impulse control. Interventions, initiated 9/11/24, included documenting wandering behaviors and offering structured activities. Resident #4 (assailant) (see resident information above) 3. Facility failures Resident #10 was observed on 7/14/25 at 10:23 a.m., engaged in behavior that placed him at risk for harm from Resident #4. He walked down the hallway to Resident #4's room, walking into the rooms across the hall from Resident #4's room. Resident #10 then walked in and out of Resident #4's room three times, each time slamming the door behind him when he left. While Resident #10 was going in and out of the room, CNA #10 was less than four feet away and did not intervene. CNA #10, interviewed on 7/14/25 at 2:00 p.m., said that when Resident #10 was going in and out of Resident #4's room, she was unaware of the two residents' history with each other or the risk to their safety that Resident #10's behavior posed. CNA #9, interviewed on 7/14/25 at 1:41 p.m., said the room that Resident #4 currently lived in could not be visualized unless the staff were in his hallway, and any residents who went into his room could not be observed. The administrator in training (AIT), interviewed on 7/14/25 at 4:56 p.m., said the potential outcome for Resident #10 wandering into Resident #4's room on 7/14/25 could have been an incident of resident-to-resident physical abuse. G. Staff interviews Staff interviews revealed the facility had expectations that aggressive behavioral events would be reviewed in a risk management meeting, and the resident's care plan updated immediately with the displayed behaviors and non-pharmacological interventions. However, record review (see above) and staff interviews (see below) revealed that these expectations were not all completed or completed timely, such that all staff would be aware of and know how to recognize and respond to Resident #4's physical aggression. 1. CNA #9 was interviewed on 7/14/25 at 1:41 p.m. She said if there were an incident between residents, the staff would put the residents on 15-minute checks, notify the nurses, and the social services director (SSD). -CNA #9 said Resident #4 had behaviors of wandering into other residents' rooms, physical aggression towards other residents, and the interventions that staff used with him were to ensure he was wearing his oxygen and to redirect him. See below; an intervention to ensure the resident's oxygen remained full and to monitor for his removal of the oxygen tubing as needed was not added to the behavior care plan until 7/3/25. 2. CNA #10 was interviewed on 7/14/25 at 2:00 p.m. She said she had been working at the facility for three weeks as a contract employee, and the facility did not have a good process of communicating with contract staff about resident behaviors and interventions. CNA #10 said she was unaware of Resident #4's history of physical aggression, and she was not informed of his behaviors until earlier on 7/14/25, during the survey. She said she was only told by another CNA that Resident #4 did not work well with others. 3. Registered nurse (RN) #4 was interviewed on 7/14/25 at 2:10 p.m. She said she had worked as a contract employee at the facility for six shifts and had not received specific training about how to find resident-specific behaviors and individualized interventions in the electronic medical records (EMR). 4. CNA #11 was interviewed on 7/14/25 at 2:20 p.m. CNA # 11 said she had worked at the facility for 12 years. She said Resident #4 had behaviors of not keeping his oxygen on and becoming confused. CNA #11 said Resident #4 did not have behaviors of physical aggression and did not have any enhanced supervision, such as 15-minute checks, line of sight, or one-on-one supervision. 5. RN #3 was interviewed on 7/14/25 at 2:30 p.m. She said she had only worked at the facility for three months. RN #3 said she looked in the CPO behavior monitoring orders for behaviors and interventions. 6. The AIT, the regional clinical resource (RCR), and the DON were interviewed on 7/14/25 at 4:56 p.m. The AIT said if a resident showed aggressive behaviors, the facility would investigate, and if determined to be concerning, the residents would be separated. He said the interdisciplinary team (IDT) reviewed the incidents in a risk management meeting, and immediately updated the resident's care plan with the displayed behaviors and non-pharmacological interventions. The DON said the IDT conducted a root cause analysis to determine the circumstances of an incident, triggers, and prior interventions to develop new non-pharmacological interventions. She said new interventions were documented in the care plan, and staff were verbally educated on the interventions to use. The DON said the staff were trained to review the abbreviated care plan for behaviors and interventions. She said Resident #4 had behaviors of agitation related to exacerbations of his COPD when he failed to wear his oxygen, and this exacerbation c

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome was likely to occur. Findings include:I. Facility policy and procedureThe Quality Assurance Performance Improvement (QAPI) policy and procedure, revised December 2024, was provided by the director of nursing (DON) on 7/15/25 at 1:00 p.m. It read in pertinent part, It is the policy of this facility to develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, and to resolve identified problems. The primary purposes of the Quality Assessment and Assurance Plan are: To have an ongoing Quality Assessment and Assurance Committee that includes designated key members Director of Nursing Services, a physician, and at least three other members of the facility's staff); to meet at least quarterly; to identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans. The committee should maintain a record of the dates of all meetings and the names/titles of those attending each meeting. The primary goals of the QAPI Committee is the identification of quality deficiencies. Include information such as: open and closed record audits; facility logs and tracking forms; incident reports; and, consultant's reports. The committee responds to quality deficiencies and serves a preventative function by reviewing and improving systems. The facility's QAPI Committee, having identified the root causes which led to their confirmed quality deficiencies, must develop appropriate corrective plans of action. Action plans may include: revision of policy and procedures; training for staff concerning changes; plans to purchase or repair equipment; improve the physical plant; standards for evaluating staff performance; implementation of facility's action plans; staff training; deployment of changes to procedures; monitoring and feedback mechanisms; and, process to revise plans that are not achieving or sustaining desired outcomes.II. Cross-reference citationCross-reference F600: The facility failed to ensure all residents were free from abuse. The facility's failure to protect residents from resident-to-resident physical abuse put residents in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviewsThe medical director (MD) was interviewed on 7/15/25 at 11:19 a.m. He said he was in the building about twice per week. The MD said some of the roles he provided included rounding as an attending physician, attending QAPI meetings, psychopharmacology meetings and getting reports from the departments. The MD said he provided education to the staff when needed especially when he noticed something related to the clinical practice such as when monitoring weights or medications. The MD said he received and reviewed many reports such as from the registered dietitian (RD), QAPI reports from different departments and the emergency preparedness manual. The MD said he provided oversight and follow-up to any suggestions by communicating with the DON, who was currently serving as the temporary nursing home administrator (NHA). The MD said he would communicate with the DON and social worker via email regarding resident placements and discharges. The MD said he had not reviewed and made policy changes but was available for that if needed. The MD said he had been the medical director at the facility for approximately one and a half years. The MD said he was not informed by the facility yet that the survey team had called for immediate jeopardy for failure to prevent abuse. The MD said his thoughts regarding the nature of the immediate jeopardy situation was that the facility needed to better communicate with the staff and thought that was something the facility could fix and improve upon. The MD said he was not sure of his further recommendations for the facility's next steps since he was just finding out about this and would give it some thought. The MD said he would review the charts and cases and said he was aware that there were some resident altercations but did not realize it rose to this level and was not aware that things were this serious. The DON was interviewed on 7/15/25 at 12:30 p.m. The DON said she had a temporary emergency license as the NHA since April 2025. The DON said she had notified the MD of the potential immediate jeopardy yesterday via email but did not necessarily say it was related to abuse but said it was related to reportable occurrences.The DON said the facility QAPI committee met monthly on the third Tuesday of each month. The DON said the last meeting was 6/17/25.The DON said the QAPI committee included all the required members and they completed a sign in sheet. The DON said for every issue identified the committee would review that. The DON said they had standard items that they reviewed and also obtained information from their tracking and trending, resident council meetings and grievances. The DON said they had worked on one performance improvement plan (PIP) since she started employment at the facility 10/24/24. The DON said the PIP was in regards to falls and there had been some improvements but they were still monitoring it.The DON said standard items were reviewed during QAPI such as admissions, discharges, dietary, weight loss, falls, hospitalizations, infection control, recruitment/hiring and online continuing education. The DON said there was a standard section they reviewed monthly for reportable occurrences and incidents. The DON said they had not implemented a PIP related to the recent occurrences because the interventions that they had in place seemed to be effective. The DON said they had reviewed the medications for Resident #4 and completed the investigations and it appeared it was going to be effective since there were no abuse incidents since the last three, but then another incident happened. The DON said it did not come to their attention to audit the facility since the occurrences were with the same resident. The DON said that abuse had not been identified by the facility as a concern, just the normal and usual review of any reportable occurrences which was looked at monthly.

Based on record review and interviews, the facility failed to ensure professional staff was licensed, certified, or registered in accordance with applicable State laws.Specifically, the facility failed to ensure the acting nursing home administrator's (NHA) license was valid. Findings include:I. Entrance interviewOn [DATE] at 9:00 a.m. the entrance conference was conducted with the director of nursing (DON). The DON said she was acting as the NHA at the time of the survey. The DON said there was a nursing home administrator in training who was preparing to become the permanent licensed NHA.II. Record reviewOn [DATE] at 9:15 a.m. a review was conducted on the State licensing website. The website showed the DON had applied for a temporary NHA license for emergency situations. The original issue and effective date was [DATE] and the expiration date was [DATE]. The NHA temporary permit for emergency situations was listed as expired.On [DATE] at 2:10 p.m. the corporate operations director provided the license invoice information. It was reviewed and revealed the application and payment for the temporary license submission was dated [DATE]. III. Staff interviewsThe DON was interviewed on [DATE] at 1:23 p.m. She said she had applied for the temporary NHA license [DATE] and it had expired on [DATE]. The DON said she was going to apply again and each time she applied it was good for 90 days. The corporate operations director was interviewed on [DATE] at 1:26 p.m. He said he was unable to provide evidence that the State Survey Agency was notified of the change in NHA position because he thought the licensing and regulatory agency would notify the State Survey Agency. IV. Facility follow up On [DATE] at 3:39 p.m. the DON provided documentation that the NHA temporary permit for emergency situations became effective on [DATE]. -There was a lapse in NHA licensing from [DATE] to [DATE].

Based on record review and interviews, the facility failed to ensure residents and their representatives were provided prompt efforts by the facility to resolve grievances for one (#3) of eight residents reviewed for grievances out of 14 sample residents. Specifically, the facility failed to document and follow-up on grievances reported by Resident #3 regarding a missing cell phone and eye glasses. Findings include: I. Facility policy and procedure The Grievances policy, dated December 2024, was provided by the nursing home administrator (NHA) on 2/4/25 at 2:07 p.m. It read in pertinent part, It is the policy of this facility to establish a grievance process that allows residents a way to execute their right to voice concerns or grievances to the facility without fear of discrimination or reprisal. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the residents may have. The facility's grievance official is responsible for overseeing the grievance process and for receiving and tracking grievances and leading necessary investigations by the facility. The grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations. The grievance official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and misappropriation of resident property to the administrator and as required by state law. The grievance official responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken towards resolution. I. Resident status Resident #3, age 85, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included chronic kidney disease, dementia, hypertension (high blood pressure) and depression. The 10/25/24 minimum data set (MDS) assessment revealed Resident #3 had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. Resident #3 required partial to moderate assistance with personal hygiene and substantial to maximal assistance with transfers and walking short distances. He used a manual wheelchair for longer distances with partial assistance from staff. II. Resident and representative interview Resident #3 was interviewed on 2/3/25 at 10:15 a.m. Resident #3 said he wore his eye glasses when he could find them. He said they had been missing for a while. Resident #3's representative was interviewed on 2/3/25 at 9:46 a.m. The representative said Resident #3 had lost five cell phones and five pairs of eye glasses at the facility. She said she had tethered his last cell phone in his room so it could not be taken or lost. She said she did take the cell phone home a few months ago because Resident #3 did not understand how to use it anymore. She said the most recent pair of Resident #3's eye glasses were lost in December 2024 and replaced in early January 2025. She said the eye glasses went missing again two days after they were replaced and were still missing. She said she reported his missing items to the staff at the facility. III. Record review On 2/3/25 at 3:37 p.m. the social services director (SSD) provided the following grievance forms related to missing items for Resident #3: A grievance concern form, dated 1/31/24, was completed by the SSD and documented Resident #3 was missing a cellular phone, a television, a recliner, several items of clothing and a red blanket. It was noted on the form that the recliner was located and was missing again and the television was replaced by the facility. -There was no follow-up on the form for the other alleged missing items or what the facility was doing to safeguard the resident's items in the future. A grievance concern form, dated 12/5/24, was completed by the SSD and documented Resident #3's representative informed the facility that the resident was missing a pair of eye glasses that were delivered to the resident two weeks prior. The SSD documented a search of the resident's room was conducted on 12/6/24 and laundry/housekeeping staff were alerted to watch for the missing glasses. The glasses were confirmed to be lost, and on 12/12/24, the SSD requested the glasses be replaced. On 1/3/25 the grievance was resolved when new glasses were provided to Resident #3. -There was no documentation on the grievance form or in the progress notes indicating the resident representative was notified of the resolution or what measures were put in place to safeguard the resident's eye glasses. -There was no grievance form documented for the eye glasses that were currently missing at the time of survey (2/3/25). IV. Staff interviews The SSD was interviewed on 2/3/25 at 2:47 p.m. The SSD said she was in charge of the grievances at the facility. The SSD said she was aware Resident #3's eye glasses were currently missing and she had called his insurance to get approval for new ones. The SSD said she did not complete a grievance because did not think the glasses were stolen. The SSD said the eye glasses that were currently missing were the second pair of glasses that had been replaced in the past few months for Resident #3. The SSD said Resident #3 was also missing two cell phones. She said one was replaced and then it went missing and had been missing for quite some time. The SSD said she should have completed a grievance form on the second missing pair of eye glasses and cell phones. She said she did not have any follow-up documentation on the missing eye glasses or cell phones. The SSD said the recliner from the 1/31/24 grievance form for Resident #3 was found in another resident's room and the television was replaced. She said there was no follow-up documented on the form, but the facility offered to replace the other items. She said she was not in charge of grievances in January 2024. The NHA was interviewed on 2/3/25 1:50 p.m. The NHA said he was aware Resident #3's eye glasses were missing again. He said he did not know if a new grievance form had been completed because the SSD was in charge of the grievances. The SSD was interviewed again on 2/4/25 at 10:50 a.m. The SSD said when a resident reported a missing item, a concern form should be completed and it should be reported to the NHA or designee. She said the facility reviewed grievance concerns during the morning meeting. The SSD said if an item was reported missing, the facility conducted a search right away for the missing item(s). The SSD said the facility would document the investigation and follow-up on the concern form or in a progress note. The SSD said the facility had tried different things to safeguard Resident #3's items but he had not been agreeable. She said the facility offered to lock up his eye glasses at night but he did not want the staff to take them. The SSD said Resident #3 did not want a chain or cord on his eye glasses. The SSD said the family decided not to provide another cell phone and staff were to take the resident a facility phone if he wanted to call his family. The SSD said the facility had educated staff to check the trash and the laundry for personal items. -However, the SSD was unable to locate documentation regarding the current missing items, investigation or follow-up. The NHA provided an email on 2/5/25 at 3:39 p.m.,the day after the survey exit. In the email, the NHA said the facility held a care conference with Resident #3 and his representative on 2/5/25 at 1:30 p.m. The facility reviewed the concerns of lost glasses and the cell phone. The facility said the eye glasses would be replaced and when they were received, Resident #3 would be provided an eye glasses string holder so the eye glasses would be secure and not fall off his person. Staff would also monitor the eye glasses at night when the resident went to bed by putting the glasses in a case. The facility offered to replace the lost cell phone but the representative said Resident #3 was no longer physically able to use it so it was not necessary to replace it. -However, the facility did not address the above missing items for Resident #3 until after the missing items were identified during the survey (2/3/25 to 2/4/25).

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff performed hand hygiene with blood glucose checks; and, -Ensure glucometers were cleaned and disinfected with appropriate disinfectant contact time between uses. Findings include: I. Facility policy and procedure The Handwashing Hand Hygiene policy, revised August 2019, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents, before performing any non-surgical invasive procedures, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after contact with objects (such as medical equipment) in the immediate vicinity of the resident and aAfter removing gloves. The Cleaning and Disinfecting of Resident Care Equipment Items and Equipment policy, revised September 2022, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (such as respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. Semi-critical items are sterilized or disinfected in a central processing location and stored appropriately until use. II. Manufacturer's instructions for Sani-Cloth Germicidal Disposable Wipes The directions on the side of the purple top Sani-Cloth Germicidal Disposable Wipes container used by the facility for disinfecting glucometers read in pertinent part, Disinfects after two minutes. Ensure the surface remains visibly wet for at least two minutes for complete disinfection. III. Observations and interviews On 6/10/24 at 11:01 a.m. licensed practical nurse (LPN) #1 was observed as she checked the blood glucose level of Resident #3. After obtaining Resident #3's blood glucose level, LPN #1 wiped the glucometer with a purple top Sani-Cloth Germicidal Disposable wipe. LPN #1 wiped the front and back of the glucometer with the wipe. The surfaces of the glucometer remained wet for approximately nine seconds. -LPN #1 failed to allow the surfaces of the glucometer to remain wet for the two minutes recommended on the container label as the appropriate amount of time for proper disinfection. LPN #1 said she did not know what the dwell time for the wipes was. She said she had just been given the wipe this morning (6/10/24) and she had previously been cleaning the glucometers with an alcohol wipe. On 6/10/24 at 11:24 a.m. LPN #2 was observed as she checked the blood glucose level of Resident #5. At the medication cart down the hall from the resident's room, LPN #2 donned a pair of gloves. -LPN #2 did not perform hand hygiene before applying the gloves. LPN #2 took a glucometer, a test strip, an alcohol pad and two lancets to Resident #5's room. She placed the supplies on the resident's bedside table. She checked the resident's blood glucose level and then pulled the test strip, with blood on it, out of the glucometer. The test strip with blood on it fell on the floor. LPN #2 attempted for several seconds to pick up the test strip off the floor but said it was sticking. She retrieved the test strip off the floor, grabbed the glucometer and headed back to her medication cart, wearing the same gloves she had on to obtain the resident's blood glucose level and pick up the used test strip from the floor. -After returning to her medication cart, LPN #2 proceeded to open a container of purple top Sani-Cloth Germicidal Disposable wipes, without removing her gloves or performing hand hygiene. -The lid to the disposable wipes came off and, without removing her soiled gloves or performing hand hygiene, LPN #2 reached into the canister and pulled out several wipes. -LPN #2 proceeded to clean the front and back of the glucometer with the same soiled gloves and placed the glucometer on a paper towel to dry. The glucometer surfaces remained wet for approximately 10 seconds. -LPN #2 removed her gloves but did not perform hand hygiene. LPN #2 said the glucometer dried quickly. LPN #2 said she did not know what the dwell time was on the Sani-Cloth wipes. She said she had just been given the purple top Sani-Cloth Germicidal Disposable wipes this morning (6/10/24). LPN #2 said she had been using Sani-Hand Cloth wipes to clean the glucometers. She said it was better than nothing. On 6/10/24 at 11:38 p.m. registered nurse (RN) #1 was observed as he checked the blood glucose level of Resident #2. RN #1 went to the resident's room. He said the resident's glucometer was in his room. RN #1 said he did not know why Resident #2's glucometer was kept in his room and other residents' glucometers were kept in the medication cart. RN #1 applied gloves and checked the resident's blood glucose level. -RN #1 did not perform hand hygiene before donning gloves. -RN #1 did not disinfect Resident #2's glucometer after use. RN #1 removed his gloves and went back to his medication cart. -He did not perform hand hygiene after removing his gloves. RN #1 said he had been using the Sani-Hand wipes and not the purple top Sani-Cloth Germicidal Disposable wipes to clean the glucometers. IV. Director of nursing (DON) interview The DON was interviewed on 6/10/24 at 12:57 p.m. The DON said nurses should complete hand hygiene before and after donning gloves to check residents' blood glucose levels. The DON said the glucometers should be disinfected after each use. She said the nurses used to have the purple top Sani-Cloth disinfectant wipes to clean the glucometers. She said she did not know what happened to them but she said she gave the nurses new canisters of the wipes to use this morning (6/10/24). She said she had not provided education on the dwell time or contact time for the Sani-Cloth Germicidal Disposable wipes.

Based on observations, record review and interviews, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for four (#4, #7, #8 and #9) of five residents reviewed for accident hazards out of 10 sample residents. Specifically, the facility failed to: -Provide supervision to prevent the elopement of Resident #4; -Investigate how Resident #4, who had a wander prevention device, eloped from the facility in order to prevent a recurrence; -Complete accurate elopement risk assessments for Resident #7 and Resident #8; -Ensure Resident #8 and Resident #9's care plans were updated to include their wander risk and wanderguards; and, -Routinely check the function of wander prevention devices for Resident #7, Resident #8 and Resident #9. Findings include: I. Facility policy and procedure The Wandering and Elopement policy, dated 2/29/24, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, A Wander/Elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team (IDT) during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with change of condition. Nursing staff will address initial elopement risk concerns in the baseline care plan. If the resident is identified as an elopement risk, the following will be maintained: Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder. Implementing and care planning interventions to address safety and decrease risk of elopement. A Physical Restraint Use Consent shall be obtained from the resident's responsible party if an electronic device is utilized. A Physician order will be required for the use of monitoring the device. The order will include checking placement of the device every shift and checking function of the device daily. The care plan will be updated to include that an electronic alarm system is used for resident's safety. II. Resident #4 A. Resident status Resident #4, age 79, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia and diabetes mellitus. The 5/1/24 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He was independent with transfers and ambulation. Resident #4 required partial to moderate assistance with dressing and personal hygiene, and supervision with toileting. The assessment documented the resident wandered. B. Record review On 4/27/24 the Wander Elopement Risk Evaluation documented the Resident #4 ambulated independently, routinely wandered or paced, wandered or paced in a manner that placed his safety at risk and had a diagnosis of dementia impacting his decision making. The assessment further documented the resident was confused and wandered in halls independently but did not appear to be at risk for exit seeking. On 4/27/24 at 2:06 p.m. a nurse progress note documented the resident had a diagnosis of dementia and ambulated with a walker. A wanderguard was placed. On 5/19/24 at 1:03 p.m. a nurse progress note documented Resident #4 went out the front door without the wanderguard going off. He was redirected back to the building. He walked out when another resident opened the door. His wanderguard was replaced. On 5/22/24 a Special Care Unit Criteria (secure unit) review documented the resident met the criteria for the special unit due to dementia with exit seeking, walking in halls naked, and wandering. On 5/25/24 at 12:57 p.m. a nurse progress note documented the resident was found walking two blocks away from the facility. His wanderguard did not go off when the resident exited. It did go off when the resident came back to the building. There were no injuries. The family was notified and said they would come in and move him to the secure unit that afternoon (5/25/24). -The physician's orders were reviewed. There were no orders for a wanderguard or checking the function of a wanderguard. -There was no documentation the physician was notified of Resident #4's elopement on 5/25/24. A physician's order, dated 5/28/24, documented Resident #4 was to move to the men's secure unit. The elopement risk care plan, initiated 4/27/24, documented the resident's risk for leaving the facility unattended would be minimized through the review date. Interventions included identifying patterns of wandering, intervening as appropriate, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. The resident used a wanderguard for safety and staff were to check placement of the wanderguard every shift. The care plan indicated Resident #4 was moved to the secure unit on 5/25/24. C. Interviews and observation The nursing home administrator (NHA) was interviewed on 6/10/24 at 1:00 p.m. The NHA said Resident #4 had eloped on a weekend. He said he was informed in a group chat text. He said he did not have an investigation of how the resident eloped with a wanderguard bracelet on. The NHA said he thought maybe the maintenance director checked the doors to make sure they were working the following Monday, but he was not sure. He said he had not interviewed any of the staff and did not know who was involved. The NHA said he was not aware there were no physician's orders for the wanderguard device or documentation the bracelet was checked to ensure it functioned routinely. The NHA said maybe the door was already open and Resident #4 followed someone out. He said he did not know how long the resident had been gone from the facility or who found him. The NHA said he had not reported the elopement to the state agency. The director of nursing (DON) was interviewed on 6/10/24 at 1:07 p.m. She said she was notified Resident #4 eloped via a group text chat on the weekend from social services. She said she thought the NHA investigated the elopement. The DON said she did not know how long the resident was gone or who found him. She said social services could provide more information. The DON said Resident #4 did have a wanderguard but she did not see a physician's order for it or to check the placement and function of the device routinely. The DON said the wanderguard device should be checked every 24 hours for placement and function. She said there was no increased supervision or monitoring of the resident but there should have been prior to his elopement on 5/25/24. The regional vice president (RVP) was interviewed on 6/10/24 at 1:28 p.m . The RVP said an investigation should have been done of the elopement to determine the cause. The RVP said the facility was doing a house sweep (during the survey) of all residents and verifying all residents with wander guards had physician's orders to include routine checks of the wanderguard function and a care plan. She said she would provide a copy of the facility's plan to correct the issue with elopement and lack of investigation as to cause and IDT education. The maintenance director (MTD) was interviewed on 6/10/24 at 1:45 p.m. The MTD said he heard about Resident #4's elopement over the weekend from a group text chat. He said he did not come in to check the function of the doors over the weekend. He said he routinely checked the function of the alarms on doors Monday through Friday and the manager on duty (MOD) checked them on the weekends. He said the MOD did not document the door checks on the weekends but he documented his door checks Monday through Friday. The MTD said the nursing staff had reported concerns with the doors not alarming when a wanderguard device was in range but each time he checked the doors, they worked. The front door was checked for function with the MTD on 6/10/24 1:45 p.m The MTD put a wanderguard device in his pocket. The alarm sounded and the door locked when the MTD was about eight feet from the door. The door was then placed in the open position. The door alarmed when the MTD approached with the wanderguard device at approximately eight to nine feet. -Copies of the door checks for Monday through Friday were requested twice from the MTD and not received by the end of the survey on 6/10/24. Registered nurse (RN) #3 was interviewed on 6/10/24 at 2:44 p.m. RN #3 said she was on duty on 5/25/24 when Resident #4 eloped. RN #3 said she came out of the bathroom and a couple of certified nurse aides (CNAs) told her a man in a white van came to the door and said he thought one of the facility's residents was seen down the road a couple of blocks away. She said the CNs got in the white van and went with the man. RN #3 said the CNAs walked the resident back to the facility. RN #3 said she did not know how long the resident had been gone or when he had last been seen at the facility. She said she was notified by the CNAs sometime after lunch. RN #3 said she did not recall who the CNAs were who notified her. She said she notified the family but did not notify the physician. RN #3 said she did not see any injuries on Resident #4. RN #3 said she assumed Resident #4's wanderguard did not alarm when he went out of the building but she did not know. RN #3 said she thought social services notified the NHA. The social service assistant (SSA) was interviewed via phone on 6/10/24 at 3:10 P.M. The SSA said she was helping serve lunch on 5/25/24 and she saw CNAs walking with Resident #4 outside. The CNA's said he had been way down the street. The SSA said she assumed the door did not alarm when the resident went out. She said sometimes it did not alarm when a wanderguard went through the door. She said the door had not alarmed in the past when a wanderguard was near it. She said the maintenance director had been notified. The SSA said she did not know who the CNAs were or who notified the NHA of the elopement. She said the resident already had an assessment done that indicated he needed secure unit placement due to his exit seeking. She said the facility had not moved the resident yet because they were waiting for the family to come in and assist with the move. She said the family had requested to be present for the move to decrease the resident's anxiety. CNA #1 was interviewed on 6/10/24 at 3:18 p.m. CNA #1 said she was providing incontinence care on a resident and saw a man walking outside the window. She said she thought it looked like Resident #4. CNA #1 said she finished what she was doing with the other resident, which took about 15 minutes, and then notified the nurse that she thought she saw a man who looked like Resident #4 walking outside. CNA #1 said she went to see who the resident was. CNA #1 said he was not aware of Resident #4's elopement risk. She said he must have been a good walker because she found him a couple of blocks down the street near a school. CNA #1 said she walked him back to the facility. She said she did not know anything about a white van with a man who had seen the resident. III. Other residents with wanderguards On 6/10/24 at 1:07 p.m. the director of nursing (DON) provided a list of residents with wanderguard needs due to risk of elopement. The list included Resident #7, #8 and #9. A. Resident #7 1. Resident status Resident #7, age less than [AGE] years old, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included vascular dementia and multiple sclerosis (nerves become damaged and communication with the brain and other body parts is lost). The 4/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with transfers, ambulation, dressing, personal hygiene and toileting. The assessment documented he used a wander elopement device. 2. Record review On 4/24/24 the Wonder Elopement Risk Evaluation documented the resident was not at risk for elopement. -However, the resident had a wanderguard device. On 4/25/24 at 12:41 p.m. the social services summary documented the resident had a wanderguard. The care plan, initiated 8/24/22, documented the resident was at risk of elopement related to cognitive status, mobility status and assessment indicating risk for wandering and elopement. He had a wanderguard. The wanderguard was to be checked for proper function daily and placement every shift. On 5/31/24 at 4:15 p.m. the provider documented the resident displayed impaired thought production and problem solving. He had moderate deficits in memory complex attention concentration, word finding and orientation. He had dementia with behavioral disturbance including defecating in the hallways, sexually inappropriateness and poor impulse control. On 6/5/24 at 10:40 a.m. social services documented the resident was going to his wife's funeral with his family. The family was advised that the resident needed constant supervision during the time out of the facility. The June 2024 CPO was reviewed. The resident had a physician's order dated 6/7/24 for a wanderguard, check the placement visually daily. -However, there were no physician's orders to check the function of the device. B. Resident #8 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included loss of cognitive function and awareness and mental disorder due to physiological condition. The 5/7/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. He required limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene. -The assessment documented he did not use a wander/elopement alarm. 2. Record review The June 2024 CPO was reviewed. The resident had an order dated 5/15/24 to apply a wanderguard to prevent the resident from going out of the facility unassisted. Monitor the presence of the wanderguard every shift. -The order did not include checking the function of the wanderguard device. -The nursing progress notes were reviewed for May 2024 and June 2024. There was no documentation as to why the wanderguard was ordered on 5/15/24. -The care plan was reviewed. There was no care plan for elopement or wandering. C. Resident #9 1. Resident status Resident #9, age 84, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia and obesity. The 6/5/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. He required substantial to maximal assistance with transfers, toileting, dressing, and personal hygiene. The assessment documented he used a wander/elopement alarm daily. 2. Record review The June 2024 CPO was reviewed. On 6/10/24 (during the survey) a physician's order was written for a wanderguard device for Resident #9. The Wander Elopement assessment dated [DATE] documented the resident was at low risk for wandering or elopement. -However the assessment inaccurately documented the resident did not have dementia or a condition impacting decision making. -The care plan was reviewed. There was no care plan for wandering or elopement. On 6/10/24, during the survey, a wandering elopement care plan was initiated. The care plan documented risk for wandering and elopement was identified. The resident would not leave the facility unattended. The resident's safety would be maintained. Interventions included clearly identifying the resident's room and bathroom, providing care in a calm and reassuring manner, providing clear, simple instructions and Providing reorientation to surroundings and the environment. D. DON interview The DON was interviewed again on 6/10/24 at 3:08 p.m. The DON said Resident #7, #8 and #9 all required wander guards due to their risk of elopement. She said she was not aware the function of the wander guards was not being checked routinely. IV. Facility follow up On 6/10/24 at 2:35 p.m. (during the survey) the RVP provided an action plan titled Elopement Actions items. The plan documented in pertinent part, Wanderguard audit: -An audit will be completed on 6/10/24 to ensure all residents are accounted for and to check if they have a Wanderguard in place, where it is located, and if it is functional; and, -Once the Wanderguard is confirmed, an audit will be conducted to ensure all appropriate orders and care plans are in place. Completed 6/10/24 for Resident #7, #8, #9. Admission Process to identify Wandering/Elopement Risk -Ensure you have a solid process for new admissions deemed to be at risk to be kept safe in the event WanderGuards are not accessible; -Referrals to be reviewed for risk of wandering/elopement prior to facility acceptance; -Residents identified of risk prior per Elopement to admission staff education to be completed on specific resident to ensure education on wandering/elopement and processes in place for: -15 minutes checks first 24 hours after admission; -Interventions to engage residents in purposeful activities; -IDT to review new admissions the next day to review orders, diagnosis, assessments at the clinical meeting; -Comprehensive, accurate assessment of each resident's needs to be completed no later than 14 days after the admission and at least every three months thereafter, unless there is a significant change in the resident's physical or mental condition; -If significant change resident to be placed on 15-minute checks; and, -If identified as exit seeking to be placed on one and one with IDT review for changes/updates to care plan After admission, facility will follow Elopements and Wandering Residents Policy. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; -The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; - Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff; -Adequate supervision will be provided to help prevent accidents or elopements; -Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly; and, -The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Wandering/Elopement Binders -Ensure information for all residents identified to be at risk are placed in an elopement binder at every nurse's station and front desk in the lobby to include a current photo, their room number, and face sheet, and Elopements and Wandering Residents Policy. Maintenance Assessment of WanderGuard and Egress Doors -If not already in place, ensure Maintenance is assessing every egress door accessible to a resident for either the WanderGuard or alarming functionality daily; -The Maintenance Director tested all WanderGuard doors, and egress exit doors to ensure they were functioning properly and alarmed when opened. All exit doors are currently functioning properly as of 6/10/25; -Maintenance Director to assess every egress door accessible to residents Monday - Friday; and, -Manager on Duty to assess every egress door accessible to residents Saturday - Sunday. All Staff Education in Wandering/Elopement Conduct All Staff education on Elopement. Education should include: -What makes a resident at risk; -Actions to take if a resident is exit-seeking; -The locations of your elopement binders; -The process for a missing resident (refer to the Disaster Plan); and, -If a resident does not come out for meals, is not available for medications, is not in usual activities, validate their location; What to do if a door alarm sounds: -Do not just deactivate the alarm; -Look for the resident outside; -Refer to the elopement book to ensure all residents who are at risk are accounted for; and, -Staff training has been initiated 6/10/24 and is ongoing till all staff has received training. All Staff Meeting meeting to be conducted in June and Wandering/Elopement Education to be reviewed. RDO (regional director of operations) completed education with NHA and DON on 6/10/24 regarding expectation for notifying the RDO and Nurse Quality Mentor (NQM) immediately for an elopement event. In case of an elopement event, the RDO, NQM will give guidance on investigation steps and documentation. Conduct Quarterly Elopement Drills Maintenance is responsible for conducting the drills. Facility to use as validation of staff education. Can include setting off a door alarm and seeing if staff respond appropriately on every shift. Elopement drill to be conducted by 6/30/24.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#1, #3 and #5) of three residents reviewed out of 10 sample residents. Specifically, the facility failed to: -Ensure Resident #1, Resident #3 and Resident #5, who were dependent on staff for bathing, received their scheduled showers; and, -Ensure resident #5, who was dependent on staff for ADL care, received assistance with shaving. Findings include: I. Facility policy and procedure The Supporting Activities of Daily Living (ADL) policy, revised March 2018, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). II. Resident #1 A. Resident status Resident #1, age 65, was admitted on [DATE] and discharged on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included debility, congestive heart failure, peripheral vascular disease (poor circulation to extremities), and surgical incision to the right groin. The 5/24/24 MDS assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. She required maximal, substantial assistance with bathing. B. Record review Review of Resident #1's June 2024 CPO revealed the following physician's order: Wound Care for the right groin incision, daily showers, clothing and bedding changes, ordered 5/23/24. The bathing records from the electronic medical record (EMR) were provided by the director of nursing (DON) on 6/10/24 at 1:00 p.m. -The documentation revealed the resident had not received showers on 5/28/24, 5/29/24, 6/3/24, 6/4/24, 6/5/24, 6/7/24 or 6/8/24 as ordered. The showers on those days were documented with a N or NA. III. Resident #3 A. Resident status Resident #3, age 84, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included debility, congestive heart failure, diabetes mellitus and obesity. The 4/15/24 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score of 13 out of 15. She required maximal, substantial assistance with bathing. B. Resident interview Resident #3 was interviewed on 6/10/24 at 12:34 p.m. Resident #3 said she was supposed to get bed baths during the day shift on Tuesdays and Fridays. She said she was too big to go in the shower or bath and therefore she had to have bed baths. Resident #3 said she frequently did not get a bed bath because the staff told her they were too busy or did not have enough staff. C. Record review The certified nurse aide (CNA) bathing record tasks for the last 30 days (from 5/11/24 through 6/10/24) was reviewed in the EMR on 6/10/24 at 12:45 p.m. The bathing task record documented the resident preferred baths on Tuesdays and Fridays. -There was no documentation in the CNA task record to indicate Resident #3 had received a bed bath from 5/11/24 through 6/10/24. Paper records of baths for Resident #3 from 5/11/24 through 6/10/24 were requested from the DON on 6/10/24 at 1:00 p.m. The records were provided at 1:30 p.m. The paper bathing records documented the following: Resident #3 received a bed bath on 5/16/24 (Thursday), 5/28/24 (Tuesday), 5/31/24 (Friday), 6/4/24 (Tuesday) and 6/10/24 (Monday). -There was no shower documentation for the week of 5/19/24 through 5/25/24. -The resident did not have a bed bath on 6/7/24. The paper shower record documented could not shower due to short staffing. The paper record documentation provided by the DON indicated Resident #3 received a bed bath, was shaved, and had no skin concerns on 6/17/24 and 6/23/24. -However, the information was provided on 6/10/24 and 6/17/24 and 6/23/24 had not occurred yet. IV. Resident #5 A. Resident status Resident #5, age 84, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included diabetes mellitus, cerebral vascular accident (stroke) and multi drug resistant organism (MDRO). The 4/25/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. She required maximal, substantial assistance with personal hygiene including shaving. B. Observation and interview Resident #5 was observed in her room on 6/10/24 at 11:24 a.m. She had long, thick, white facial hair across her entire upper lip, chin and below her chin. She said she would like to be shaved. C. Record review The resident's bathing records were reviewed in the EMR. The CNA task bath record documented the resident preferred baths on Wednesdays and Saturdays. -There was no documentation in the CNA task record to indicate Resident #5 had received a bed bath from 5/11/24 through 6/10/24. Paper records of baths for Resident #5 from 5/11/24 through 6/10/24 were requested from the DON on 6/10/24 at 1:00 p.m. The records were provided at 1:30 p.m. The paper bathing records documented the following: -The resident had a shower on 5/1/24 (Wednesday), 5/8/24 (Wednesday), 5/11/24 (Saturday), 5/15/24 (Wednesday), 5/18/24 (Saturday), 5/22/24 (Wednesday), 5/25/24 (Saturday), 5/27/24 (Monday) and 5/29/24 (Wednesday). -The resident did not receive a shower on 5/4/24. -The resident received a shower on 6/5/24, seven days after her last shower on 5/29/24. -The paper bathing records documented Resident #5 was not shaved on 5/29/24 or 6/5/24. V. Interviews The DON was interviewed on 6/10/24 at 1:40 p.m. She said when the CNAs documented N in the CNA bathing task record it meant the care was not done. She said NA meant not applicable. She said if a resident refused a bath or shower, the CNA would document RR for the resident refused. The DON said she did not know why the showers were not done daily as ordered by the physician for Resident #1 to prevent infection of her groin incision. She said she was not aware the showers had not been done. The DON said showers were documented in the residents' EMR and on paper. She said she had provided the EMR record (as above) and had no further paper records of showers for Resident #1, #3 or #5. The DON said the orders for Resident #3's baths had been put in the EMR incorrectly and therefore there was no documentation of her bed baths. She said she was not aware the resident had no record of baths the week of 5/19/24 through 5/25/24 or that she had not received a bath due to short staffing. The DON said residents were supposed to be shaved on bath days and as needed. She said did not have any further bathing records for June 2024 for Resident #5 or documentation to indicate why she had not been shaved. She said she would have the resident shaved. The DON was interviewed again on 6/10/24 at 4:18 p.m. The DON said she had provided education to the nursing staff in the past about ensuring showers and baths were given and documented. She said she had no current system for monitoring to ensure showers and baths were given and documented.

Based on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss timely in one (#54) of seven residents out of 40 sample residents. Resident #54, who was identified as being at increased nutritional risk related to decreased oral intake and Alzheimer's disease, experienced a significant weight loss of 10.25% in a one month period of time and 12.42% in a three month period. The facility failed to ensure effective and timely interventions were in place to monitor, identify and prevent Resident #54's significant weight loss. The facility failed to monitor weekly weights, failed to consistently monitor meal intakes and failed to offer snacks when the resident refused or slept through meals. Additionally, the facility failed to implement new nutritional supplement interventions until 11/21/23, after the significant weight loss was identified. Due to the facility failures, the resident sustained a significant weight loss of 10.25% in one month and 12.42% in three months. Findings include: I. Professional reference Roigk. P. (2018) Chapter 8: Nutrition and Hydration. In K. [NAME] and J. [NAME]-[NAME] Eds. Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient (Internet). [NAME] Publishing. https://www.ncbi.nlm.nih.gov/books/NBK543833/ retrieved on 12/12/23 at 1:37 p.m. According to the North American Nursing Diagnoses Association ([NAME]) malnutrition is: 'Intake of nutrients insufficient to meet metabolic needs'. The criteria for malnutrition are: Body mass index (BMI) < (less than) 18.5 kg (kilograms)/m2 (height in meters squared), unintended weight loss > (greater than) 10% in the last 3-6 (three to six) months, BMI < 20 kg/m2 and unintended weight loss>5% in the last 3-6 (three to six)months, fasting period >7 (seven) days. II. Facility policy and procedure The Food and Nutrition Services policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 12/11/23 at 10:47 a.m. It read in pertinent part, The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional and psychosocial doctors that affect eating and nutritional intake and utilization. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for significant nutritional problems. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian. III. Resident #54 A. Resident status Resident #54, age over 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anemia and gastroesophageal reflux disease (GERD). The 11/17/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He required substantial or maximal assistance with dressing, partial to moderate assistance with toileting and personal hygiene and supervision or touch assistance with bed mobility, transfers and eating. The MDS assessment did not indicate the resident was at risk for malnutrition or had a weight loss of 5% or more in one month or 10% or more in 6 months. B. Observations On 12/5/23 at 11:00 a.m., Resident #54 was observed lying in bed on his right side sleeping with an untouched meal tray sitting at his bedside. On 12/5/23 at 12:00 p.m., Resident #54 was observed standing at his bedside and picking through the food on his tray. The resident did not attempt to eat anything on his tray. C. Record review The nutrition care plan, initiated on 12/23/21 and revised on 11/21/23, indicated that Resident #54 had a nutrition problem related to decreased oral intakes with a history of Alzheimer's, anemia and GERD. Interventions included fortified mashed potatoes with lunch and dinner, monitor oral intake, monitor skin integrity, monitor labs, monitor weights, monitor for malnutrition and significant weight loss, honor food/beverage preferences, obtain weekly weight for close weight monitoring, off snacks, provide diet as ordered and provide supplements as ordered. A comprehensive review of the care plan indicated Resident #54 had a prior history of significant weight loss in December 2022 and February 2023. The resident's weights were documented as follows: -8/20/23 124 pound (lbs); -8/30/23 122 lbs; -11/1/23 121 lbs; -11/6/23 112.6 lbs; and, -11/21/23 108.6 lbs. A comprehensive review of the resident's weights revealed a weight loss of 10.25% in less than one month ( between 11/1/23 to 11/21/23) and a loss of 12.42% in three months (between 8/20/23 to 11/21/23). The December 2023 CPO indicated weekly standing weights every Monday or Tuesday, ordered on 8/17/23. -There were no weekly weights documented for Resident #54 from 8/30/23 until 11/1/23. -There were no weekly weights documented for the resident from 11/6/21 until 11/21/23. A comprehensive review of Resident #54's physician orders revealed the following diet and supplementation orders: -Magic cup in the evening for a low body mass index (BMI) of 18.3, ordered 8/5/22; -House nourishment twice a day, ordered 2/10/22 and discontinued 11/21/23; -Regular, dysphagia advanced texture diet with regular thin consistency, ordered 1/5/23; -Offer snacks if the resident slept through the meal, ordered 2/10/23; and, -House nourishment after meals for weight loss offer 4 ounces (oz) shake if less than 50% of the meal consumed, ordered 11/21/23. -There was no documentation in the resident's electronic medical record (EMR) for snacks being provided to the resident for October 2023, November 2023 or December 2023. -New interventions were not put into place until 11/21/23 when a weight loss of 10.25% in one month time and 12.42% in three months was identified. The 8/31/23 nutrition progress note documented the resident's BMI was 20.3 with house shakes ordered twice a day, Magic cup once a day and snacks as needed. The progress note documented that the resident had variable intakes and no new interventions were ordered. The 11/7/23 nutrition progress note documented a weight of 112.6 lbs, which was a decrease of 6.9% in less than one week. A reweight was requested. -There was no documentation in the resident's EMR of a reweight being obtained until 11/21/23. The 11/21/23 nutrition progress note documented a weight of 108 lbs with nursing reporting the resident was not eating much and sleeping more. Interventions were to increase house shake to three times a day and to offer snacks when less than 50% of the meal was consumed. The 11/17/23 nutrition quarterly assessment indicated the resident had a weight loss of 6.9% in less than 30 days (11/1/23-11/6/23) and a reweight was requested. -There was no documentation of a reweight being done until 11/21/23. -A comprehensive review of the nutrition progress notes did not indicate any further documentation between 8/31/23 and 11/7/23. A comprehensive review of meal intakes for Resident #54 revealed inconsistent documentation of the resident's food intake. There were multiple days when staff failed to record the resident's meal intake including: -On 11/7/23, there was no documentation of intake for dinner; -On 11/8/23; documentation of 50% or less for lunch and there was no documentation of intake for dinner; -On 11/9/23; there was no documentation of intake for dinner; -On 11/10/23; there was no documentation of intake at breakfast or lunch; -On 11/11/23; there was no documentation of intake for dinner; -On 11/13/23; documentation of 50% or less for for lunch; -On 11/14/23; there was no documentation of intake for dinner; -On 11/15/23; there was no documentation of intake for breakfast or lunch; -On 11/16/23; there was no documentation of intake for dinner; -On 11/17/23; documentation of 50% or less for lunch and there was no documentation of intake for dinner; -On 11/18/23; there was no documentation of intake for breakfast or lunch; -On 11/19/23; there was no documentation of intake for breakfast, lunch or dinner; -On 11/21/23; documentation of 50% or less for dinner; -On 11/22/23; there was no documentation of intake for breakfast or lunch; -On 11/23/23; documentation of 50% or less for breakfast and there was no documentation of intake for lunch or dinner; -On 11/24/23; there was no documentation of intake for breakfast; -On 11/25/23; there was no documentation of intake for breakfast, lunch or dinner; -On 11/27/23; there was no documentation of intake for dinner; -On 11/28/23; there was no documentation of intake for dinner; -On 12/1/23; there was no documentation of intake for breakfast or lunch; -On 12/2/23; there was no documentation of intake for breakfast or lunch; and, -On 12/3/23; there was no documentation of intake for breakfast, and documentation of 50% or less for lunch and dinner. -Review of Resident #54's EMR revealed there was no documentation of snacks being provided when the resident refused or slept through meals or had an intake of 50% or less. IV. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 12/7/23 at 11:50 a.m. She said all residents needed to have their meal intakes documented and all CNAs were responsible for documenting meal intakes. She said that residents with nutrition and weight loss issues should have a weekly weight done. Licensed practical nurse (LPN) #1 was interviewed on 12/6/23 at 10:40 a.m. She said the CNAs documented meal intakes on the resident's record and provided meal assistance. She said residents with weight loss and nutrition issues had weekly weights ordered. She said Resident #54 was identified recently as declining with weight loss and said he should have weekly weights and meal intakes documented. The registered dietitian (RD) was interviewed on 12/7/23 at 11:50 a.m. She said all residents, especially those with identified weight loss, needed to have their meal intakes and weekly weights documented. She said Resident #54 was identified as losing weight on 11/1/23. She said there was a gap in the documentation for weights between August 2023 and November 2023 and that his meal intakes had been documented as variable at times. She said she had recently increased his house supplement to three times a day with meals. The director of nursing (DON) was interviewed on 12/11/23 at 2:30 p.m. She said CNAs could provide meal assistance to residents and were responsible for documenting meal intakes. She said that agency CNAs were given access to the documentation system in their orientation packet to the facility. She said weekly weights were to be completed on Resident #54 and all residents who had been identified with significant weight loss.

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure The Facility Assessment policy, dated October 2018, was provided by the nursing home administrator (NHA) on 12/11/23 at 4:38 p.m. It revealed in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The facility assessment includes a detailed review of the resident population. The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation. II. Record review The facility assessment was last reviewed in November 2023 by the NHA and the interdisciplinary team. The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff; -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population; and, -Identify facility resources needed and equipment to provide competent resident support during day-to-day operations and emergencies. III. Staff interviews The NHA was interviewed on 12/11/23 at 12:05 p.m. The NHA said the interdisciplinary team reviewed the facility assessment in November 2023 during the Quality Assurance and Performance Improvement (QAPI) meeting. The NHA said the facility assessment had many missing components. The NHA said the facility assessment had several areas that were missing and said fill in the blank. The NHA said the facility assessment did not include trainings needed for staff, the staffing plan, the secured unit or the bus and shuttle the facility had. The NHA said the emergency preparedness portion of the facility assessment had missing components such as a facility map. The NHA said he needed to review the facility assessment again to ensure it included all of the necessary items. The NHA said it was his first time completing a facility assessment and realized it needed to be a lot more thorough.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to: -Obtain committee feedback; collect data; monitor adverse events; identify areas for improvement; prioritize improvement activities; implement corrective and preventative actions; and conduct performance improvement projects related to problem-prone areas identified; and, -Address concerns related to the facility's failure to provide pneumonia vaccines as requested and per physician's orders. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) policy, dated 9/29/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 9:30 a.m., it read in part: Purpose: (facility name) have an ongoing Quality Management and Quality Assurance and Performance Improvement (QAPI) Program designed to objectively and systematically monitor and evaluate the resident's care and health care services. The comprehensive program is designed to provide care that is optimal within available resources and is consistent with the achievable goals for (facility name). Policy: To ensure that monitoring quality of residents' care is performed systematically and continuously. To identify the organizational components responsible for Quality Management and QAPI Program functions and to delineate the components which include the line of authority, responsibility, and accountability. To ensure communication among all departments in improving resident care and identifying problems through the use of ongoing monitors by focusing on the identification, analysis, and resolution of problems. To evaluate the results of actions taken by each department and maximize the use of resources available within the facility. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F883 Influenza and pneumococcal immunizations During the survey conducted between 12/4/23 and 12/11/23 failure to provide pneumococcal vacancies as requested and as required; it was cited at a scope and severity of substandard quality of care. Cross-referenced to F883. III. Other cross-reference citations Cross-reference F692 nutritional parameters: During the survey from 12/4/23 to 12/11/23, the facility failed to provide consistent and effective nutritional care to prevent a resident from experiencing signifying weight loss, which was cited at a G scope and severity, harm that was isolated. Cross-reference F600 free from abuse and neglect: During a recertification survey on 8/25/22, F600 was cited at a G scope and severity, which was harm. During the survey from 12/4/23 to 12/11/23, the facility failed to prevent resident-to-resident physical altercations, was cited at a D scope and severity, with the possibility of more than minimal harm. IV. Staff interviews The NHA was interviewed on 12/11/23 at 4:36 p.m. The NHA said he was new to the facility and had only been to one QAPI meeting. The NHA said that all department managers attended QAPI meetings. In addition, the medical director and pharmacy consultant attended meetings. The NHA said the committee reviewed resident grievances and presented concerns from each facility's department leaders, and staffing issues. Once the committee identified concerns they developed a plan of action to address the concern. Each identified concern was referred back to the leadership member/department in charge of the concern area and the department worked on the improvement plan and presented results back to the committee at each month's meeting. Each identified concern was followed by QAPI until the concern was considered resolved.

Based on record review and interviews, the facility failed to take effective steps to prevent inappropriate sexual behavior that involved three of five residents (#49, #225, and #35), all cognitively impaired, who resided on the facility's all male secure unit. Specifically, the facility failed to implement measures to prevent inappropriate sexual behavior between Resident #49 and Resident #225, inappropriate sexual behavior between Resident #49 and Resident #35, and the potential for inappropriate sexual behavior among other residents on the unit. Resident #225 was admitted to the facility's all male secure unit from a sister facility where he had exhibited sexually inappropriate behaviors toward female residents. An admission assessment by the medical director documented that the resident was not capable of understanding the nature of his behavior, accepting it, using any kind of internal restraint. The plan, per the medical director's discussion with the nursing home administrator (NHA), was to increase staff on the unit to monitor his behavior. However, the facility failed to have evidence it implemented increased staff on the unit or implemented any other preventive measures to deter Resident #225 from engaging in sexually inappropriate behavior with facility residents. And, on 6/12/22, four days after his admission, Resident #225 was observed engaged in sexually inappropriate behavior with Resident #49. Further, the facility failed to take effective steps after the 6/12/22 incident to implement measures to prevent a another incident of inappropriate sexual behavior involving Resident #49 and Resident #35 on 6/20/22. Cross-reference F744 for dementia services and care. Findings include: I. Facility policy and procedure A copy of the facility's The Abuse, Neglect, and Exploitation policy dated 8/24/21 was provided by the NHA on 8/23/22. It read in pertinent part, Screening: Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. Prevention of abuse, neglect, and exploitation: Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Protection of residents: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, and revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. II. Residents #225, #49 and #35 A. Resident #225 Resident #225, age 70, was admitted on [DATE] and discharged to a sister facility on 6/28/22. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/14/22 minimum data set (MDS) assessment documented that the resident had severe cognitive impairment with the brief interview for mental status score (BIMS) of three out of 15. The assessment documented the resident had verbal and physical behavioral symptoms directed toward others one to three times a week that put other residents at a significant risk of physical injury. He significantly intruded on the privacy and activities of others. Record review revealed a 6/11/22 admission summary by the medical director (MD). -The summary read in part, [AGE] year-old male who was sent to (this) nursing home because of inappropriate sexual behavior at his previous facility . I am told that he was transferred to our facility because it was all male and at that time he only made advances on females. -The MD wrote an inappropriate sexual contact with another resident was reported to him and it was clear the contact was not between two individuals who were capable of consent. He documented, Resident #225 does not understand the nature of his behavior and would be fair to say that he is not capable of even understanding the nature of his behavior, accepting it, using any kind of internal restraint. -The MD wrote the matter was discussed with the administrator of the facility and was told they were going to increase staff on the unit to monitor his behavior. The MD was contacted by phone on 8/24/22. He did not return the call by the time of the survey exit. However, interview with the physician assistant (PA #1) on 8/24/22 around 1:30 p.m. revealed Resident #225 was admitted to an all male unit under the assumption that his inappropriate sexual behaviors, previously with female residents, would stop on an all male unit. She said during his stay, Resident #225 was placed on medication to reduce his behaviors and it was unclear if medication had an effect prior to discharge. She said she did not know the resident very well, but based on his history, it was very unlikely that his behavior would change. B. Resident #49 Resident #49, age 69, was admitted on [DATE]. According to the August 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/15/22 minimum data set (MDS) assessment documented that the resident had severe cognitive impairment with the brief interview for mental status score (BIMS) of zero out of 15. The resident was wandering regularly in the unit. He did not reject care and did not have any physically or verbally aggressive behaviors. The comprehensive care plan was initiated on 2/21/22, and revised on 7/8/22. It identified the resident was at risk for harm due to his poor understanding of personal boundaries when relating to other residents. The resident was wandering in and out of other resident's rooms and demonstrated poor judgment and safety awareness. He was oriented to self only and required a consistent environment and staff reminders regarding safety. Certified nurse aide (CNA) #1, who regularly worked on the all male secure unit, was interviewed on 8/23/22 at 12:50 p.m. She said Resident #49 did not recognize other people's space and would intrude, requiring redirection. Redirecting him from other's personal space was the most frequent behavior and he was usually compliant with being redirected. The social services designee (SSE), who worked under the supervision of the social services director and who was responsible for assessments and care plans on the memory unit, was interviewed on 8/23/22 at 2:00 p.m. She said Resident #49 was not able to verbalize himself and was constantly wandering. He was unaware of others' personal space. C. Resident #35 Resident #35, age 80, was admitted on [DATE]. According to the August 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/6/22 minimum data set (MDS) assessment documented that the resident had moderately impaired cognition with the brief interview for mental status score (BIMS) of eight out of 15. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Within the lookback period captured in MDS, the resident was documented as having behaviors four to six days 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). Wandering behaviors also occurred during this period four to six days. The comprehensive care plan initiated on 10/12/21 and revised on 5/31/22, identified that Resident #35 had behaviors of sitting on the floor purposefully in order to receive attention from staff. He also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He had the potential for physically or verbally abusive behaviors related to dementia and poor impulse control. II. Incident 6/12/22 involving Residents #225 and #49 A. Summary of incident and facility response The facility investigation of an 6/12/22 incident between Residents #225 and #49 was provided by the nursing home administrator (NHA) on 8/23/22. The 6/12/22 investigation documented: -On 6/12/22 CNA walked around the corner, seeing two residents at the back door. Resident #225 was holding Resident #49 left arm in his right hand. Resident #49's penis was pulled out from his pants and Resident #225 appeared to be rubbing it. Shortly thereafter in the hallway, (the) same CNA walked around the corner, seeing that Resident #49 was walking down the hallway with his pants down. Shortly after (this) incident (the) same CNA walked in, saw Resident #49 standing with Resident #225 sitting in his wheelchair in front of him, rubbing Resident's #49's pants at the crotch area. Immediate actions included: At the first incident, residents were immediately separated. Then, after the second incident, Resident #225 was put on 15-minute checks. Now, Resident #225 is on line-of-sight supervision. Staff did observe Resident #49 and Resident #225 in compromising positions where Resident #49 had his penis exposed (and) Resident #225 stated he was helping Resident #49 and appeared to be touching the groin area. Staff were unable to definitively say whether Resident #49 was being touched. Resident #49 voiced no concerns, no change in mood/behavior noted. Following interventions were put in place: continuous line of site observation, frequent checks to monitor behaviors for 72 hours, medication review. Resident #225 was started on [MEDICATION(S)] per review. Staff education provided and Resident #225 was moved to a private room in a separate hall from the alleged victim. Resident #49 was placed on 15 minute checks for 72 hours. Staff monitor Resident #49 for change in mood/behavior and intervene if concerns are noted. B. Failure of the facility to prevent the incident on 6/12/22. Although the facility investigation revealed the facility took steps after 6/12/22 to prevent another incident between Resident #225 and #49, record review and interviews revealed the facility failed to take timely and effective steps prior to 6/12/22 to prevent the incident. 1. The medical director (MD)'s admission assessment revealed the administration's plan to increase staff on the unit after Resident #225's admission. However, there was no documentation that this plan was implemented. Review of the staff schedule log for June 2022 revealed that staffing numbers were the same during June 2022 as during May 2022 or July 2022. No additional staff members were documented as assigned to the unit during Resident #225's stay. The scheduler (SCH) was interviewed on 8/24/22 at 1:45 p.m. She said she was in charge of completing the monthly schedule for staff. She provided schedule records from June 2022 to August 2022. She said the staffing goal for the secure male unit where 15 residents resided was two CNAs and one nurse during day shift and one nurse and one CNA during the night shift. She said they were able to meet this goal consistently. Initially, she said she did not recall any special schedule adjustments made in June 2022. Later, she corrected herself and stated that during Resident #225's stay on the secure unit, the managers of other departments were assigned regularly to the unit to provide additional assistance with behavior management. However, she said she did not have any written list of the staff members who participated in the behavior management rotation in June 2022 or how consistently they were assigned to the unit. 2. Staff reported knowledge of and monitoring for inappropriate sexual behaviors; however, there was no direction to staff on the nature of Resident #225's behaviors and no direction on the level of monitoring he required. Record review failed to confirm the nature of the resident's behaviors was communicated to staff and monitored. a. Failure to communicate the nature of Resident #225's inappropriate sexual behavior. In-service education for staff on the secure unit provided by the social service designee (SSE) on 8/25/22, revealed in-service education was provided to staff working with Resident #225 on 6/10/22. However, while the education went over interventions if the resident became inappropriate, it did not explain what the inappropriate behavior was or how to address inappropriate behaviors toward other residents on the unit. Rather, specific interventions were related to the resident's past interests and hobbies. Registered Nurse (RN) #1, who regularly worked on the all male secure unit, was interviewed on 8/23/22 at 1:15 p.m. She shared a binder at the nurses' station that included a summary of every resident's history, their likes and dislikes. The binder also included a page of education to staff regarding inappropriate sexual behavior which was undated. Further, RN #1 did not state that Resident #225's history at his prior facility and the MD's admission assessment of the resident's inability to understand his behavior had been included in the binder. The social service designee (SSE) was interviewed on 8/23/22 at 2:00 p.m. She was aware the resident was admitted from another facility due to inappropriate behavior toward female residents. She said she had no evidence of formal education provided to staff prior to Resident #225's admission. She said the understanding was that his behaviors were only toward female residents until the incident on 6/12/22. The social service director (SSD) was interviewed in the presence of the social service designee (SSE) on 8/24/22 at 2:30 p.m. The SSD said she recalled having a conversation with the team prior to Resident #225's admission. She said they discussed his behaviors and the plan was to monitor his behaviors on the unit once he was admitted . She did not know if any formal education was provided to the staff on the unit prior to Resident #225's admission and was unable to provide any records of education specific to Resident #225. Further, review of Resident #225's care plan revealed it failed to inform staff of the nature of Resident #225's behaviors and direct staff on the level of monitoring he required to prevent the resident from engaging in inappropriate sexual behavior on the unit. Specifically, the resident's care plan for behaviors, initiated on 6/10/22, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Explain to him that his behavior is inappropriate. Use two staff members, as needed. Maintain consistent, firm boundaries. However, according to the MD's admission assessment (see above), Resident #225 was not capable of understanding the nature of his behavior; therefore, explaining to him that his behavior was inappropriate was not an effective intervention. Further, as noted in the investigation summary, the interventions to monitor the resident by way of frequent checks for 72 hours and continuous/line of sight observations, were not instituted and added to his care plan until 6/12/22, following inappropriate sexual behavior with Resident #49. The resident's other care plans, for aggressive behaviors (identifying poor impulse control and sexual and verbal agression due to dementia) and dementia, were imitated and/or revised after the resident's discharge and, therefore, not effective in preventing his inappropriate behaviors. b. Failure to have documentation that the resident's inappropriate sexual behaviors were monitored. CNA #1 who regularly worked on the all male secure unit was interviewed on 8/23/22 at 12:50 p.m. She said she was familiar with the Resident #225. She said Resident #225 was making daily sexually inappropriate comments to female staff members. She said they monitored him for such behaviors and reported it to the nurses. RN #1, interviewed on 8/23/22 at 1:15 p.m., said Resident #225 made several inappropriate sexual comments to staff on the unit. She said he was redirected all the time and observed for his behaviors. She said behaviors were documented under progress notes. The SSD, interviewed 8/24/22 at 2:30 p.m., also said she believed behaviors were monitored by nurses and CNAs in progress notes. However, review of progress notes from the resident's admission 6/8/22, until the incident 6/12/22, revealed his behavior was mentioned twice, although reported by staff as having occurred all the time and/or daily. In addition, review of the resident's medication and treatment administration records (MAR and TAR) for June 2022, failed to reveal evidence the resident's behaviors were monitored prior to 6/12/22. 3. The nursing home administrator (NHA) was interviewed on 8/25/22 at 2:05 p.m. She said Resident #225 was admitted to the facility from a sister facility where he resided in a mixed male/female secure unit. Resident #225 displayed sexually inappropriate behavior toward female residents on the unit prior to his admission to the facility. She said the resident was admitted to the male only secured unit under the assumption that he would not display inappropriate behaviors toward male residents. She did not indicate there was additional monitoring of Resident #225 prior to 6/12/22, stating, rather, that the resident was monitored for his behaviors as much as any other resident on the secure unit. Regarding the plan to increase staffing on the unit, documented by the MD in the 6/11/22 admission assessment, NHA said she did not recall having a conversation with the MD regarding increasing the number of staff working on the secure unit. She believed the resident was monitored appropriately for his behavior and it was a new behavior that occurred on 6/12/22. IV. Second incident of inappropriate sexual behavior A. Summary of investigation of incident involving Residents #49 and #35 and facility response An investigation of an incident between Residents #49 and #35 was provided by the NHA on 8/23/22. The 6/20/22 investigation read: On 6/20/22 Resident #49 was observed in Resident #35's room. Upon entering the room, CNA observed Resident #49 had his hand inside Resident #35's pants. Resident #49 had a firm grip on his penis and it was difficult for the CNA to remove Resident 49's hand. The investigation summary read that the residents were separated and placed on 15 minute checks. Resident #49 was placed on in line of site observations. Education to staff (was) provided regarding resident's behavior. A nursing progress note, dated 6/20/22, in Resident 35's record read that during a skin check, he told the nurse that he was being nice to the other resident (Resident #49) and the other resident must have taken it the wrong way. Interviews with staff revealed Resident #49 remained on line of sight supervision and staff were aware of the incident involving Resident #49 and #35 on 6/20/22. -CNA #1 was interviewed on 8/23/22 at 1:40 p.m. She said Resident #49 was kept in line of sight at all times. She said Resident #49 was wandering during the day and sometimes entered other residents' rooms. She said he recently had sexually inappropriate behavior with Resident #35 and they made sure he was in line of sight all the time. -RN #1 was interviewed on 8/23/22 at 1:15 p.m. She said Resident #49 required line of sight supervision due to inappropriate behaviors with another resident on 6/20/22. Resident #49 was unaware of others' personal space and would grab onto staff but not usually other residents. She said she was aware of (a) sexually inappropriate occurrence (6/20/22) and said Resident #49 had been in the wrong place at that time and it was a one-time incident. She said that he had wandered into the other resident's room and what had occurred on 6/20/22 had been an accident. B. Facility failures 1. The facility failed to provide specialized services to Resident #49 following 6/12/22 to ensure there was no need for support or services to meet his needs following the incident. Specifically: -A social service progress note dated 6/13/22 stated that a nurse on duty left a voicemail for the resident's brother regarding an incident that occurred 6/12/22. Another progress note on 6/14/22 stated the facility contacted the resident' sister and notified her of the incident. -A nursing progress note dated 6/14/22 documented the resident continued on 15 minute checks by staff related to a resident-to-resident incident that occurred 6/12/22. It was documented that the resident acted appropriately and had not shown behaviors of fear or being withdrawn. A follow-up progress note 6/15/22 stated the resident remained on 15 minute checks and was calm and content with no evidence of fear or facial grimacing. There were no further notes from social services or nursing staff regarding psychosocial wellbeing of the resident. However, interview with the SSE on 8/23/22 at 2:00 p.m. revealed Resident #49 had not displayed sexually inappropriate behavior before the incident on 6/20/22 and a physician note, dated 6/24/22, stated the reason for the visit was due to a report of inappropriate sexual contact. Physician states that Resident #49 saw another resident's penis and grabbed it tightly. Staff reported to physician that they were unsure if it had been an episode of aggression or of sexual behavior. Recently another resident was admitted with sexual issues (Resident #225) and the staff questioned whether this admission may have been a catalyst for Resident #49's behavior. Although the SSE, during an interview on 8/23/22 at 2:00 p.m. had indicated Resident #49 was being tracked for any changes in mood and behavior, record review revealed no documentation of behavior tracking for Resident #49 and no reference regarding his well-being after 6/15/22 (see above). Review of the resident's treatment administration record (TAR) for August 2022 showed behavior monitoring for physical aggression toward staff and residents initiated on 8/22/22 (after the incident). There was no behavior monitoring prior to this date. Further, psychoactive medication evaluation meeting notes dated 7/15/22 for antipsychotics made no mention of the 6/12/22 or 6/20/22 incident. Finally, a social services assessment dated [DATE] (during survey) showed behaviors of poor understanding of personal boundaries when relating to other residents and of being the recipient of inappropriate behaviors from other residents. Resident #49 also had the behavior of grabbing onto other people's wheelchairs, personal items, hands, etc. and it was difficult to get him to release grip. However, it did not address the resident's involvement in or response to the inappropriate sexual behaviors he had been involved in in the last quarter. 2. The facility failed to timely and adequately educate staff in order to prevent further incidents of inappropriate sexual between residents on the unit. Review of the education log provided by the SSE on 8/25/22 revealed insufficient training to protect residents from abuse after the incident 6/12/22 and again, after the incident 6/20/22. Specifically: -Education was provided to staff working with Resident #225 on 6/15/22 but not staff working with Resident #49. The in-service topic was line of sight supervision for Resident #225. -Education was provided to staff working on male memory care unit for inappropriate sexual behaviors on 6/23/22, after the second incident involving Residents #49 and #35. The in-service topic was how to handle inappropriate sexual behavior with people who have dementia. Education covered how to prevent or discourage behaviors directed towards staff, not residents, and how to redirect. The section pertaining to inappropriate behaviors toward others advised staff to keep others safe, but did not provide instruction on how to keep others safe or how to disengage residents engaging in sexual behaviors. The staff new hire general orientation packet was provided by NHA on 8/24/22. Included in orientation is training on stages of dementia, challenging behaviors and de-escalating a crisis. The packet did not reference resident-on-resident sexual abuse and how to manage hyper- sexual behaviors in residents with dementia.

Based on observations, record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#6) of six residents reviewed out of 15 sample residents. Resident #6 was on hospice services. The resident's minimum data set (MDS) assessment dated [DATE] revealed the resident required extensive staff assistance for transfers, requiring two plus persons' physical assistance. The resident had severe cognitive impairment. The care plan intervention dated 6/7/21 revealed the resident required a mechanical lift (Hoyer) with two staff assistance for transfers. The resident was inappropriately transferred by two staff members without the use of a mechanical Hoyer lift. This transfer resulted in the resident experiencing pressure to her chest area and sustaining a large two-inch by 10-inch bruise to the left breast which later infiltrated to the left axilla (armpit) and shoulder area. Findings include: I. Facility policy and procedures The Safe Resident Handling/Transfers policy, copyright date of 2021, was provided by the nursing home administrator (NHA) on 2/22/22 at approximately 6:00 p.m. The policy revealed in pertinent part that the facility was to ensure residents were handled and transferred safely to prevent or minimize risks of injury. The facility would provide and promote a safe, secure, and comfortable experience for the residents while keeping employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual lifting techniques might be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts were a safer alternative and should be used. -Mechanical lifting equipment or other approved transferring aids would be used based on the resident's needs to prevent manual lifting except in medical emergencies. -Mechanical lifts might include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts (any others that might apply). -The facility would ensure that there were appropriate amounts of varying sizes of slings to accommodate residents and that residents would be measured correctly as per the manufacturer's instructions on proper sling sizing. -Staff members were expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. -Resident lifting and transferring would be performed according to the resident's individual plan of care. II. Resident observations The resident was observed on 2/16/22 at 12:58 p.m. The resident was lying in a low bed. The head of the bed was elevated. The resident had her eyes closed and bed covers were pulled to her chest. There was a fall mat on the floor next to the bed and the door to the room was open. The resident was not in any discomfort or pain. III. Resident status Resident #6, age 72, was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included dementia with behaviors, intracranial injury, muscle weakness, lack of coordination, restlessness and agitation. The 12/29/21 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 00 out of 15 with no behaviors. The resident required extensive staff assistance for transfers, requiring two plus persons' physical assistance. IV. Record review A physician's order (PO) dated 3/11/2020 at 10:14 a.m. revealed to consult hospice services for general decline and an increase in falls. The resident started receiving services on 3/13/2020. The PO dated 3/25/21 at 12:36 p.m. revealed to keep the resident's bed in the lowest position with a fall mat at the bedside. The PO dated 2/8/22 at 6:38 p.m. revealed to monitor a large bruise to the resident's left breast and surrounding area until healed. Document in progress notes every shift for monitoring and assessment. The PO dated 2/13/22 at 2:48 p.m. revealed there must be a nurse to witness and/or help with any transfers for proper technique and reduce possible injury. The care plan for activities of daily living (ADL) self-care performance deficit related to a diagnosis of dementia was initiated on 10/18/16. The plan also revealed the need to coordinate all care with hospice services. The pertinent intervention revealed the resident required a mechanical lift (Hoyer) with two staff assistance for transfers; initiated on 6/7/21. The treatment administration record for February 2022, revealed the resident had no pain on the day or night 12-hour nurse shifts for 2/8, 2/9, 2/10 and 2/11/22. A situation, background, assessment and recommendation (SBAR) communication form dated 2/7/22 at 8:42 p.m. revealed a large long bruise to the resident's left breast that started on 2/7/22. A certified nurse aide (CNA) alerted this nurse of the new large bruise on the resident's left breast. The bruise was dark in color and quite long and narrow. The bruise measured two inches by 10 inches long. It was the opinion of this nurse that the bruise resembled a gait belt, however that was purely conjecture. The bruise was of unknown origin, and appeared not to be new. This bruise was not noted on the resident's last skin check on 2/5/22. A nurse note dated 2/8/22 at 4:18 a.m., by a licensed practical nurse (LPN), revealed a CNA alerted this nurse to a new large bruise to the resident's left breast. The bruise was dark purple in color, quite long and narrow. It measured approximately two inches wide and 10 inches long. It was the opinion of this nurse that the bruise resembled a gait belt, however this was purely conjecture. The bruise was of unknown order. A weekly non-pressure skin assessment dated [DATE] at 6:03 a.m. revealed a large rectangular bruise approximately two inches by 10 inches to the resident's left breast. The onset date of the bruise was 2/7/22. A physician progress note dated 2/10/22, electronically signed by the MD on 2/17/22 at 1:34 p.m., revealed the resident had a hematoma of the chest wall. It did not appear like a strap (injury) but it was difficult to tell. There was no pattern of abuse. No other signs of trauma. There was no documentation of a fall. The resident had severe dementia and was unable to explain what happened. An SBAR communication form dated 2/12/22 at 12:00 noon revealed a CNA observed a problem with the resident's left shoulder. An assessment revealed an area of about four inches in the front of the left shoulder and bruising to the left armpit. The hospice nurse was called. This problem was not observed this morning and the resident has not had any recent falls. A nurse note by LPN #2 at 2/12/22 at 1:00 p.m. revealed this morning a raised area to the resident's left shoulder and upper chest area was observed. The area measured approximately four inches in diameter. A small bruise was also observed on the lateral area of the shoulder. Hospice services were notified and a nurse was sent to assess the resident. It was unknown when this started, since the resident was up in her wheelchair before 6:00 a.m. A hospice physician changed some of the resident's medications and an ice pack was applied to the area. A nurse note by a registered nurse (RN) on 2/13/22 at 2:24 p.m. revealed the resident was resting well. The nurse would continue to monitor the bruise to the resident's left breast and left shoulder. A nurse note by LPN #2 on 2/13/22 at 11:44 a.m. revealed the medical director (MD) was contacted at approximately 8:00 a.m. He was notified that the hospice was reluctant to get an x-ray of the resident's left shoulder. The MD said he had just observed the resident a few days ago for bruising to the left side of her chest. The MD was notified that the area was now a little higher and might involve the shoulder. The MD said he thought an x-ray had already been taken and he ordered a stat (immediate) anterior/posterior x-ray. A call was made to x-ray services and was told the x-ray should occur today, however they were experiencing problems at this time. A nurse note by LPN #2 on 2/13/22 at 5:23 p.m. revealed the x-ray service contractor called and stated the x-ray machine was non-functional. The x-rays would not be taken today. A radiology report dated 2/14/22 at 2:44 p.m. revealed no acute fractures or dislocations. The osseous structures appeared intact. The joint spaces were narrowed and the soft tissue was unremarkable. The conclusion was no acute findings or [CONDITION(S)] changes. The x-ray of the resident's left shoulder was completed on 2/14/22 in the morning. A nurse note dated 2/15/22 at 11:52 a.m., by an LPN, revealed the x-ray results were received and there was no acute fracture or dislocation. The osseous structures appear intact. Joint spaces are narrowed. Soft tissues are unremarkable. The results were discussed with a hospice nurse and a new order was received to discontinue the current [MEDICATION(S)] dosage and start [MEDICATION(S)] 0.25 milliliters every four hours. The Kardex (electronic file that contained a brief overview of a resident) dated 2/16/22 revealed the resident required a mechanical Hoyer lift with two staff assistance for transfers. Each time the Kardex was opened, it would populate to the date it was opened. The Kardex prior to 2/7/22 was unavailable. A physician progress note dated 2/17/22, electronically signed by the MD on 2/20/22 at 6:34 a.m., revealed this was the second visit with the resident regarding a change in the character of her hematoma. The hematoma was large and extended to the end of her pectoralis muscle. It was fluctuant (moveable) and did not seem to illicit a reaction when palpated. The assessment diagnosis was a hematoma of the chest wall with a possible rupture of the pectoralis muscle. V. Staff interviews LPN #2 was interviewed on 2/16/22 at 1:02 p.m. He said initially the resident had a bruise to the left side of the rib cage area from an unknown cause. He said a few days later, there was also bruising to the axilla region of the left shoulder with swelling to the shoulder. He said there were no falls reported for this resident. He said none of the staff admitted the resident had been dropped. He said he was unsure how the bruise occurred. He said staff were to use a mechanical Hoyer lift for transfers. He said currently he had to watch each transfer of the resident during his shift. He said the resident was on hospice services and was declining. The director of nursing (DON) was interviewed on 2/16/22 at 1:15 p.m. She said an agency nurse discovered the bruise to the resident's left chest area on 2/7/22 during the night shift. She said the facility did not know how the bruise occurred. She said she first learned of the bruise on the morning of 2/8/22 at approximately 9:00 a.m., by reading the 24-hour reports. She said she was not notified by the agency nurse when the bruise was first discovered. She said an investigation was started immediately after the morning meeting. She said the speculation after the investigation was completed on 2/9/22, was that staff were not using a mechanical Hoyer lift during transfers as directed by the care plan. She said a mechanical Hoyer lift with two staff members should have been used to transfer the resident. The staff transferred her inappropriately. She said one CNA stated there were no small slings for the mechanical Hoyer lift. She said when she looked in the storage room where slings were kept, she discovered four small slings. She said one sling was immediately placed in the resident's room and one was placed at the nurse's station. The DON said she talked with the RN that worked in the facility on 2/7/22. The RN thought the bruise was not related to physical abuse and did not report the bruise as soon as it was observed. The RN felt the bruise did not need to be reported. The DON said on the afternoon of 2/8/22 she looked at the bruise. She said the resident was already up in her wheelchair and she had to wait for the resident to be placed in her bed, before she could look at the bruise. She said when she observed the bruise there were no shoulder problems or raised/red areas to the axilla and or the front part of the shoulder/deltoid. She said to her knowledge the resident did not have a fall and was not dropped during a transfer. The DON said she was contacted on 2/13/22 by the NHA. The NHA told her that during the course of the investigation, she found a new progress note by the day shift nurse dated 2/12/22 regarding a new bruise and swelling to the resident's left shoulder area. She said neither she nor the NHA were notified of this new concern. She said staff were to notify her immediately of any bruise of unknown origin. She said to her knowledge the resident did not have any falls or had not been dropped during transfers. She said it was assumed that staff were not using a mechanical Hoyer lift during transfers with this resident and this was an inappropriate transfer for this resident. The NHA was interviewed on 2/16/22 at 1:48 p.m. She said the resident's bruise was reported during the 2/8/22 morning meeting at approximately 9:00 a.m. The resident had a large bruise of unknown origin that measured two inches by 10 inches across her left breast that was dark in color. She said the nurse that wrote the initial note did not contact her or the DON; they just wrote a note. She said the nurse thought the bruise might be due to the use of a gait belt during a transfer. The NHA said after the morning meeting she went and started asking staff how they were to transfer the resident. She said the resident was not transferred according to her care plan. She said staff were doing two-person transfers without the use of a mechanical Hoyer lift. She said the facility had sufficient quantities of mechanical Hoyer lifts. She heard from staff that they had to go look for small slings for the mechanical Hoyer lift. She said there were plenty of small slings in the facility. She said she located two small slings, one small sling was placed in the resident's room and one was placed at the nurse's station. She said none of the staff said they used a gait belt with two persons to transfer the resident. She said staff could look at the resident's care plan and the Kardex to find the transfer status of the resident. She said staff knew where to look for the resident's transfer status. The NHA said the investigation was unable to verify if the resident was transferred inappropriately. She said the resident's roommate told her that staff did not use a mechanical lift with the resident. She said the MD felt that the initial bruise and the second bruising in the shoulder area were related and not two separate issues. The minimum data set coordinator (MDSC) was interviewed on 2/17/22 at 9:25 a.m. She reviewed the resident's MDS dated [DATE]. She acknowledged the resident was coded as extensive staff assistance and required two plus persons' physical assistance for transfers. She said the resident actually needed the use of a mechanical Hoyer lift with two persons and should have been coded as total staff assistance. She explained during the seven-day assessment period, some of the CNAs charted incorrectly in the computerized point click care (PCC) system. She said the incorrect charting by the CNAs would cause the MDS to default to how they charted on the resident. The resident should have been a total staff assistance instead of an extensive staff assistance. She acknowledged the resident's transfer care plan was correct. A certified nurse aide (CNA) #2 was interviewed on 2/17/22 at 9:43 a.m. She said she was an agency CNA and had worked in the facility for seven weeks. She said she had worked with the resident and during transfers she always used a mechanical Hoyer lift with a second staff member. She said she learned about changes in residents' transfer status prior to the starting of her shift. She reviewed the resident's care plan and Kardex. She acknowledged they both documented the use of a mechanical Hoyer lift with two staff members. She said she reviewed resident care plans every two days for residents that had changes in their status. The DON was interviewed on 2/17/22 at 11:00 a.m. She acknowledged the resident's care plan for transfers revealed the resident required a mechanical Hoyer lift with two staff assistance for transfers. She said the Kardex had the same information as the resident's care plan for transfers and each time it was opened it would be populated to the date it was opened. She said CNAs should be reviewing resident care plans routinely to know how to safely and correctly transfer the resident. She said if there were any changes in a resident's transfer status, they should be told about the change during the start of their shift. She said ideally the CNAs should review a resident's Kardex or care plan before the start of their shift. The medical director (MD) was interviewed on 2/17/22 at 12:05 p.m. He said the last time he was in the facility, he was told by the nurses that the resident had a big bruise across her chest. He said he examined the bruise and it looked like it occurred from pressure placed on the area. He said it did not look like it was the result of using a mechanical lift. He said it probably was the result of tightening across the chest, like the use of a gait belt or possibly someone transferred the resident from behind and placed pressure on the area. He said a couple nights later, he was notified by a nurse that the resident had another bruise. He looked at the bruise and believed the new bruise was the discolored fluids from the initial bruise traveling upward toward the shoulder. He said he based this decision on the way the resident lay in bed. He said he did not believe it was any malicious or abusive type injury. The DON was interviewed on 2/22/22 at 5:10 p.m. She said staff should have used a mechanical Hoyer lift during transfers. She said it was assumed the bruise was the result of staff using a gait belt under her arms. She said this was an inappropriate transfer for the resident. VI. Follow-up The in-service education was provided by the NHA with the policy of Safe Resident Handling/Transfers with 20 staff members that signed a sheet from 2/8/22 to 2/11/22.

Based on interviews and record review, the facility failed to ensure eight (#2, #3, #6, #9 #13, #42 #49 and #27) out of 45 residents were treated in a respectful and dignified manner. Specifically, the facility failed to ensure residents experienced a dignified living experience by having enough staff to care for everyone, answering the call lights timely and to follow up with the residents as to the plan to ensure the facility had enough staff to care for everyone. The feeling of dehumanization, and treated in an undignified manner is evidenced by the residents' interviews. Cross-reference F725 for failure to maintain sufficient staffing; and Cross-reference F744 dementia care Findings include: I. Resident #3 A. Resident status Resident #3, age 83, was admitted to the facility on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/4/21 quarterly minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required limited assistance with one person physical assistance for bed mobility, toileting, and personal hygiene. She required extensive assistance and one person physical assistance with transfers and dressing. B. Resident interview Resident #3 was interviewed on 6/14/21 at 2:00 p.m. Resident #3 said there had been times when she had waited so long for staff to assist her to the bathroom that she had an accident. She said that it made her feel degraded and stupid. II. Resident #6 A. Resident status Resident #6, age 73, was admitted to the facility on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/28/21 quarterly minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision and setup help only with bed mobility, transfers, walking, eating, toileting, dressing, and personal hygiene. The resident was not coded as having any refusal of care. B. Resident interview Resident #6 was interviewed on 6/8/21 at 10:07 a.m. Resident #6 said the younger staff, particularly the nursing aides, could be very rude. He said when he went to sleep at night he would turn on his call light so staff could turn off the lights in his room. He said the staff acted like the request was a huge chore for them and would sometimes leave the room without even turning off the light as he had requested. He said he was not afraid of staff but was tired of the attitudes that some staff had when they came to assist him. III. Resident #13 A. Resident status Resident #13, age 75, was admitted to the facility on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/23/21 quarterly minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required supervision and setup help only with bed mobility, transfers, walking, eating, toileting, dressing, and personal hygiene. B. Resident interview Resident #13 was interviewed on 6/14/21 at 2:00 p.m. Resident #13 said that sometimes there were not enough staff available to get help when needed. He said that some of the staff would not help him with his care needs and would leave him to do it himself. He said that when he asked the staff to help him with something they would often tell him they would have to get back to him and then they would never come back or he would never get an answer. He said that when staff refused to help him or did not follow up with him he felt lousy. IV. Resident #49 A. Resident status Resident #49, under the age of 70, was admitted to the facility on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/9/21 quarterly minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was independent and required no help from staff with bed mobility, transfers, walking, eating, toileting, dressing, and personal hygiene. B. Resident interview Resident #49 was interviewed on 6/14/21 at 2:00 p.m. Resident #49 said that he did not feel that staff treated him with dignity and respect as he was only required supervision with activities of daily living, when he requested help with a task, the staff would respond in a way which made him feel he was bothering them. V. Resident #27 A. Resident status Resident #27, over the age 85, was admitted to the facility on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/22/21 quarterly minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with one person physical assistance for bed mobility, transferring, and dressing. He required limited assistance with one person physical assistance for toileting and personal hygiene. B. Resident interview Resident #27 was interviewed on 6/14/21 at 2:00 p.m. Resident #27 said staff complained about helping him with personal hygeine when help was requested. VI. Women's secured unit 1. Resident #9 A. Resident status Resident #9, age 73, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/18/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of 0 out of 15. She required extensive assistance with two persons physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required total dependence of one person for bathing. She required supervision and one person assistance for locomotion on/off unit in a wheelchair. She required supervision and setup help only with eating. Rejection of care occurred for one to three days. Behaviors occurred one to three days for physical and verbal symptoms directed toward others. B. Observations On 6/7/21 at 5:30 p.m., Resident #9 was observed to eat her meal. The resident ate with her fingers and hands. The resident consumed the entire 240 cc of juice, however, was not offered any refills. No refills of drinks offered in the dining area. Resident #9 finished her fruit cup and the caregiver asked if she was done eating. Resident #9 spoke, however, it was not understood, the CNA walked away and did not ask the resident to repeat. Resident #9 reached her hand out to the CNA, however, the CNA walked by her and did not address the resident. Resident #9 was observed to pick up the empty fruit cup and was using her fingers she was putting her fingers into the cup, and licking her fingers, although, although the bowl was empty. Resident #9 did not wear a clothing protector during the meal and had food on her shirt. On 6/9/21 at 11:10 a.m., the lunch cart arrived. Resident #9 was served at 11:25 am. Resident #9 ate turkey, stuffing, mashed potatoes and green beans with her hands and fingers. The resident was not offered a clothing protector, and therefore, she was dropping food onto her clothes. 2. Resident #42 A. Resident Status: Resident #42, age 80, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/4/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of 0 out of 15. She required extensive assistance with one person for bed mobility, transfers, toilet use, and personal hygiene. She required extensive assistance with two persons for dressing. She walks in the corridors with supervision and requires supervision with setup help only for eating. She is totally dependent for bathing. She has physical and verbal behavioral symptoms directed toward others one to three days. She had rejection of care behavior one to three days. She has wandering behavior four to six days but less than daily. B. Observations On 6/8/21 at 11:44 a.m., Resident #42 was observed to eat her meal on a rolling table with her hands and fingers from multiple bowls of food. She wore no clothing protector, and no meal assistance was provided beyond set up. Resident #42 dropped a bowl of food on the floor and her dinner roll was on her lap. She picked up the food pieces off the table/TV tray. Resident#42 started to pick up the dinner roll off of her lap and then it fell on the floor. Resident #42 said oh in a disappointed tone. She continued to pick up leftover pieces of food from the table. The resident was not provide any assistance, and was not given another dinner roll. The CNA approached the resident and asked if she could wash her hands, although the resident respond yes, Resident #42 continued to eat her food with her hands as her hands were being washed. The CNA proceeded to remove the rolling table, however, the resident said, no,no, no. The CNA proceeded to wash her hands and face, and cleaned the food off of her lap. The resident did not have a clothing protector and the resident's clothes were soiled with the meal, as the resident began to walk away. On 6/9/21 at 11:10 a.m., Resident #42 had 5 small bowls of food in front of her. A spoon was on the tray, however, the resident used her hands and fingers to eat. No clothing protector was used. The CNA sat to help the resident for a minute however, got called away to help pass out drinks. Resident #42 started to eat a paper napkin. The CNA noticed after a few minutes and removed the napkin from the resident. VII. Additional interviews The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 6/15/21 at 4:41 p.m. The DON recognized that the residents had complaints of not enough staff to take care of everyone. She said that the facility was actively recruiting nursing staff. The DON said the residents should always get the care which they need and request, without feeling disrespected. The call lights should be answered timely.

Based on record review, observations and interviews, the facility failed to provide adequate supervision for the secured unit where two out of 30 sample residents (#130, #127) resided and ensure the resident environment was free of accident hazards. Specifically: 1. Resident #130 and #127 resided on the same secured unit for male and female residents with cognitive impairments. Both residents were new admissions; resident #130 had a history of [REDACTED]. On 6/9/13, in the early morning hours, no staff was on the residents' unit when resident #130 was heard by staff on the all male unit yelling at a male resident to 'Get away, get away, get away! and her roommate yelling, "Get out!" Resident #130 was naked and she was pointing at resident #127 who was in bed with her, telling him to 'get away and go away.' The facility did not initiate an investigation and did not take steps to protect resident #130. Staff continued to leave the unit unattended at night (cross-reference F225 and F353). 2. The facility failed to ensure medications were not found on the floor in the facility. 3. The facility failed to ensure the security gate door on the Mixed Secure Unit remained locked. 4. The facility failed to ensure two of three suction machines were functional and easily accessible in case of emergency. 5. The facility failed to ensure discarded cigarette butts were placed in an approved container, and 6. The facility failed to ensure the Men's Secure Unit Courtyard Area was free of holes in the terrain, debris, tools, broken furniture, exposed nail heads, rough unpainted/splintered wood fences and outdoor furniture. The findings include: An onsite survey was conducted on 6/11/13 through 6/18/13. 1. Facility Policy According to the facility's Abuse and Neglect Prohibition Policy, in pertinent part: "The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law ...The facility will protect residents from harm during the investigation." 2. Resident #130 and Resident #127, identified with cognitive impairments, resided on the secured unit and were newly admitted to the facility: Resident #130 According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. No diagnoses were listed on the face sheet. As the resident was newly admitted , Minimum Data Set information was unavailable. The communication care plan, dated 6/11/13, showed the resident had communication problems related to dementia and had difficulty understanding information communicated to her related to her dementia. Approaches included: --Speak directly to the resident with a calm voice. --Make sure the noise level is down when trying to communicate with the resident. --Wait for a response to the message each time. --Staff will anticipate resident needs. The memory/dementia care plan, dated 6/11/13, showed the resident had a loss of short-term and long-term memory related to her dementia and behaviors and was oriented to herself and her family but not place and time. Approaches included: --Allow for as many choices as possible. --Provide assistance in choosing appropriate clothing. --Allow making as many simple decisions regarding ADLs (activities of daily living) as possible. The hospital history and physical, dated 5/17/13, revealed in pertinent part: "...She was in her usual state of health when she developed aphasia, confusion on 4/26/13. She was admitted to (the hospital) and noted to have a cerebrovascular accident in the right temporoparietal area ...After that hospitalization , she went home to live with her daughter. At home, she was refusing her medications, refusing to eat and drink well, and developed hyperglycemia and was brought to the emergency roiagnom on [DATE]. She was admitted to the general medical floor and treated for [REDACTED]. She tried to run off the ward several times despite being on one-to-one supervision. The daughter stated that she was unable to manage her mother at home and requested nursing home placement. She is admitted to the inpatient psychiatric unit for agitation and aggressive behavior after a (CVA) and resulting aphasia and dementia ... Social History: ...There has been significant domestic violence in their home. There was a restraining order against her husband and when he came into her home the police picked him up and he was taken to jail just prior to this admission. Mental Status Examination: ...Her affect is somewhat odd smiling and laughing but not at the response of others. She cannot answer questions of memory. She cannot name objects presented visually. She cannot repeat words or sentences presented verbally ...Her insight is impaired. Her judgment is extremely impaired." The nursing admission assessment, dated 6/7/13, showed the resident's admitting diagnoses were syncope, Cerebrovascular accident (CVA), diabetes mellitus type two, hypertension, [DIAGNOSES REDACTED], dementia, and [DIAGNOSES REDACTED]. The admitting nurses' note documented, "Patient arrived via transport service. Patient walked independently into facility. Patient is pleasantly confused and tried to leave with transport driver. Patient was redirected to room. Patient followed CNA (certified nurse aide) around and became anxious when left alone. Patient eventually calmed down after staff reassured her. Patient did refuse to take off her clothes for her skin assessment ...Will continue to monitor." The resident's nursing notes were reviewed back to her admitted . Resident #127 Resident #127, an [AGE] year-old male, was transferred from another long term care facility to this facility on 5/31/13 with documented diagnoses that included dementia, hypertension, [DIAGNOSES REDACTED], post-traumatic stress disorder and altered mental status. He was admitted to the Mixed (both men and women) Secure Unit in the facility. As the resident had been in the facility less than 14 days, an admission Minimum Data Set had not been completed. The 5/31/13 Admission Nursing Assessment reported that resident #127 was six feet tall and weighed 148 pounds, was ambulatory and independent with activities of daily living except bathing, was incontinent of bowel and bladder, wandered and was combative with cares. The assessment did not assess his cognitive status. The relevant Admission Physician order [REDACTED]. All further telephone orders were reviewed and there were none related to resident's behaviors. His Care Plans included the following: -"Wandering 6/2/13 Problem: At risk related to new environment, resistance to long term care admission and dementia. Approaches: Evaluate resident for placement of . . . secure unit, reorient and redirect resident as needed, observe for increased safety risks, wandering into other rooms . . ." -"Behavior symptoms 6/2/13 Problem: Exhibition of Behavioral Symptoms as evidenced by socially inappropriate/disruptive related to [DIAGNOSES REDACTED]. further evaluation and possible medication adjustment as well as a referral to the community as well as a referral to the community mental health center, notify MD (medical doctor) as needed, monitor interactions with other residents." There were other problems and approaches added on 6/11/13 after survey team identified issues. There was an additional, separate "Behavior Management" plan dated 6/4/13 that included: "Behaviors: 1. Can be physically and verbally aggressive during cares . . . 3. Is verbally aggressive towards resident and staff. Will use foul language towards others . . . 6. Resident has PTSD (post traumatic stress disorder) and needs to be placed where he can see others. Attempt to place resident with his back against the wall. He can be easily startled. Approaches: 1 . . . 3. Provide verbal and non-verbal cues/reminders prior to initiating care. Position yourself to provide safety for yourself and (resident) . . . 5. Be aware that (resident) was in the military and is not used to taking direction from women. . . . 7. Give (resident) time to express thoughts and to understand what is being said. Watch (resident) for non-verbal communication. 8. During interaction watch for non-verbal signs of anger such as defensive positioning, change in the eyes, widening of the eyes, heavy breathing. Back away if he seems to be distressed by you. 9. When (resident) is upset, provide reassurance, leave and return later if (resident) continues to be frustrated or upset. Do not push (resident.) 10. When (resident) is upset remove others away from him. Do not attempt to move (resident.) Monitor interactions with others. 11. When (resident) is resisting cares reproach {sic} at a later time . . ." --On the medication administration record (MAR) for behavior monitoring, a target behavior of "verbal aggression" was identified and being monitored. --The Nursing Daily Skilled Summary notes were reviewed from 6/1/13 through 6/10/13 and included in pertinent part: "6/1/13 6:00 a.m. Resident finally let us check his skin this time . . . 6/2/13 no time Intrusive into peers rooms while cares being given. Becomes agitated when asked to leave area . . . 6/6/13 no time Restless in morning, manifested only by ambulation in halls and fidgeting in chair . . . 6/7/13 6:00 p.m. Alert, up ambulating independently, wandering into other residents' rooms - redirectable . . . (Incident) 6/9/13 3:00 a.m. Resident had been laying on couch in LR (living room) All staff were with other residents. Residents (female) in room 202 were heard yelling "get out" and "go away." Staff entered room 202 to find (resident) in bed with 202B. (Resident) was re-directed back to his own room . . . Per day shift (resident) has been overly friendly with resident 202B. He has been found in her room multiple times. They have been holding hands, hugging, sitting on her bed. All day shift activities have been reported to the social worker. 6/10/13 no time Alert/confused. Med compliant. W (wandering) decreased . . . Continue to monitor." --Notes from 6/1/13 to 6/11/13 were reviewed and the following documentation was included in pertinent part: "6/1/13 6:00 p.m. During . . . At 5:40 p.m. he wandered into resident (female) room while she was being helped to the bathroom. He was asked to move and pushed the CNA. No harm. He wandered into dining room . . ." --The Social Progress Notes were reviewed from 6/2/13 to 6/11/13 and documented in pertinent part: "6/2/13 Admissions Assessment - (Resident) was admitted . . . He resides on our mixed secure unit due to history of verbal aggression and wandering . . . Resident has a history of being verbally aggressive with cares but is not physically aggressive . . .He does tend to wander throughout the day and into other residents rooms . . ." After the 6/9/13 incident (see below), social services documented on 6/11/13 no time, "I have been observing (resident) since Sunday morning . . . He at times likes to hold hands with a particular lady (resident) and enjoys spending time with her. (Resident) seems to be content with this particular lady and the other residents . . . (Resident) tends to wander in and out of residents rooms but does not seem to be targeting any particular room . . ." --A 4/15/13 social service progress note at the resident's former facility documented, "Behaviors noted during assessment period include physical/verbal aggression, pacing, wandering into other resident's rooms, attempts to lie in other residents' beds, and rejections of care." -- Review of behavior monitoring forms, from the previous facility, were reviewed back to January 2013 (1/19/13 - 5/12/13). Documented behaviors included wandering into other resident rooms at different hours, removing a blanket off another resident while they were in bed, attempting to sit on another resident while they were in bed, exit seeking and looking for a female, physical aggression towards staff, cursing, wanting to get into a bed occupied by a resident and then attempting to pull them out of bed, verbally threatening, and sitting on his roommate/other residents when they were sleeping or in bed. On 6/17/13 at 2:21 p.m., the assistant director of nursing (ADON) at a facility resident #127 discharged from on 5/31/13 was interviewed. She stated the resident had to be transferred because their VA contract had ended. She stated the resident resided on an all male secured unit at their facility. She said, "He came in needing secure placement because of his aggressive behaviors. He had a history of [REDACTED]. Facility Failures The facility failed to timely identify, adequately assess, devise appropriate care plan, implement interventions and sufficiently monitor/supervise the resident for behaviors ( i.e. crawling into female residents beds, wandering in and out of female residents' rooms, and intimidating other residents and staff), that he exhibited soon after his admission to the mixed unit. These failures contributed to the incident that occurred during the early morning hours of 6/9/13. 3. Incident Two days after #130's admission, the following event occurred (cross-reference tag 353 insufficient staffing and the secured unit was unattended during this event): --As documented in resident #130's medical chart: On 6/9/13 at 4:30 a.m., a note was recorded, "Male res(ident) (#127) was found in bed with (resident). At the time, (resident) was asking male to leave. Male was redirected to his own room. This res went to sleep. At 0630, this RN asked (resident) if she was fearful or uncomfortable. Res gave no verbal response. Will cont(inue) to monitor ...DON (director of nursing) called re(garding) above issue. This RN was advised to interview (resident #130) only. No incident needed at this time. No need to notify MD or POA (power of attorney)." Following this incident, there was no evidence located in the documentation that a physical assessment was done to ensure the resident was not assaulted. On 6/11/13, a late entry for 6/9/13 was entered into the nurses' notes by the director of nursing. The note documented, "This nurse/DON received call on Sunday AM regarding a male resident being in this resident's bed. There was no evidence or witness of the male resident touching this resident inappropriately. I advised this nurse to interview female resident for any fear or anxiety related to this situation. It was reported to me that this resident was non-verbal with questions but did not show any signs of fear of anxiety. Later in the afternoon, I spoke with nurse who stated the two residents were going about their routines per normal. This female resident was seeking out male resident was still not exhibiting any fear or anxiety. Will cont (inue) to monitor." --As documented in resident #127's medical chart: On 6/9/13 at 3:00 a.m., the nurse documented "Resident had been laying on couch in LR (living room?) All staff were with other residents. Residents (female) in room 202 were heard yelling "get out" and "go away." Staff entered room 202 to find (resident) in bed with 202B. (Resident) was re-directed back to his own room . . . Per day shift (resident) has been overly friendly with resident 202B. He has been found in her room multiple times. They have been holding hands, hugging, sitting on her bed. All day shift activities have been reported to the social worker." -Observations of the residents during survey: On 6/11/13 at 4:25 p.m., resident #130 was observed sitting on her bed holding a photograph. Her daughter was visiting and was seated in a chair next to the bed. The resident did not respond to attempts to interview her. Her affect was flat and she stared straight ahead. During this observation, resident #127 walked into the resident's room and sat on the resident's roommate's bed. He remained there until a staff member redirected the resident out of the room approximately three minutes later. The following observations were made of resident #127: On 6/12/13 at 10:11 a.m., the resident was walking in hallway. He wore a dark green shirt and black pants. A CNA was walking by his side. On 6/12/13 at 6:09 p.m., the resident was in the dining room. He was sitting at a table with three female residents. He was feeding himself. He was rocking back and forth and mumbling to himself. On 6/13/13 at 8:02 a.m., the resident was sitting in dining room. A CNA was cueing him to eat. On 6/13/13 at 9:42 a.m., the resident was lying on his bed in his room. A CNA was sitting outside of the door to his room. During an interview at 9:45 a.m., with the RN she said that he had kicked a female resident and was now under one-on-one monitoring. On 6/13/13 at 12:06 p.m., the resident was sitting at dining room table with three female residents. The one sitting directly to his left had turned her chair sideways and had positioned herself with her back on a diagonal towards him. He was mumbling to himself. 4. Facility actions after the 6/9/13 incident: Staff Interviews revealed the mixed unit was left unattended during this 6/9/13 incident and upon the staff member's return to the unit, resident #130 was yelling for resident #127 to "get away" and "get out." -An investigation had not been initiated to ensure resident safety or needs were assessed. Interviews: -On 6/11/13 at approximately 11:00 a.m., the licensed nurse assigned to work on the secured unit stated she was not aware of the above incident and it had not been passed onto her in report. -On 6/11/13 at approximately 11:05 a.m., a CNA working on the secured unit stated she had heard about it but was not instructed to complete any extra monitoring or supervision of the residents. -On 06/11/13 at 1:08 p.m., the Social Services Assistant (SSA) stated she was responsible for coverage of both secure units. She stated, "I knew about the event (between resident #127 - male and resident #130 - female). The SSA stated she interviewed resident #130 (the female), but made no documentation. He was very confused and when asked questions, he made sounds and shrugged shoulders but did not answer yes or no. She asked if they were holding hands, if he knew who resident #130 was, and if he was in bed with her. The SSA during an attempt to interview resident #130, she (#130) focused on the room door and when asked, played with the door knob. When asked if she was in bed with (resident #127) she only pointed at the door. No documentation was again made. The SSA said on Monday (6/10/13) during the scheduled morning meeting a discussion was held about this event. The DON, Regional Clinical Nurse and Nursing Home Administrator (NHA) made a decision to talk with an outside entity before calling the families or physicians. The SSA said with the residents holding hands earlier in the day, it was thought that laying in bed together was consensual. The SSA stated after the event (resident #127) was not put on direct supervision. -The nursing home administrator (NHA) was interviewed at 1:14 p.m. on 6/11/13. The NHA defined reportable physical abuse as "physical altercation with injury" and that any staff suspecting abuse "should immediately report it to their supervisor." The NHA made the following comments, "Yes, I did hear about that (the incident on 6/9/13.) They were in her room and she was naked and they were kissing on the bed. Monday morning I found out. Our DON found out about it over the weekend. No one else was involved . . . An incident report was made out I think. We notified an outside entity and got some guidance. I believe the MD was notified. I don't believe family members were notified. . . Yes I think they both were consenting ... We just made sure staff knew to make sure it was consensual but not to let it happen in front of other residents. No, nothing like get off me was mentioned. I was not aware of that. She does have a room . . . Yes; there is another female resident in with her. We have one empty room back there to give them privacy . . . No; they are not their own power of attorney. They have to have oversight to go on the unit. With a dementia [DIAGNOSES REDACTED]. . ." The NHA acknowledged being aware of the resident's history of domestic violence. "We, the Director of Nursing (DON), SSD (social service director) and IDT (interdisciplinary) team discussed it. We talked about resident rights . . . Our plan? We would keep an eye on them - to make sure that someone wasn't doing anything unwillingly and it wasn't forced . . . No set times to monitor him. There was no injury and we didn't feel anyone was a victim in this." -On 6/11/13 at 1:17 p.m., the DON stated, "There's a couple on the secured unit who have been holding hands and following each other around. They were both consenting to holding hands. He was found in her bed and her roommate was saying get out." The DON said an incident report was not completed because the resident did not show any signs of distress. The DON was not aware it was documented the resident was asking the male resident to leave and as well as her roommate. She added, "Staff have been monitoring in public areas and I've told the staff not to allow him in her room. She seeks him out and he seeks her out." The DON stated she expected documentation of the additional monitoring to be present in resident #127's medical record. -On 06/11/13 at 1:54 p.m., the Director of Social Services stated if resident #130 said for resident #127 to get away then the event was not consensual. She stated she did not do an investigation and she has no documentation of the event. -On 6/12/13 at 9:00 a.m., the Certified Nurse Aide (CNA) who worked with resident #127 and #130 on 6/9/13 stated, "Earlier in the day, they were holding hands and he was rubbing her shoulder. She was just sitting there. I went and talked to the social worker about it. The social worker told me if they wanted to be friendly, I had to respect that and if they both consent to it, I have to leave them alone." The CNA continued, "That night, the girl (the CNA) from the men's unit hollered at me because a resident was trying to get out of bed and I ran over there to help. (Resident #127) had fallen asleep on the couch and when I got back, I heard (resident #130) yell, "Get away, get away, get away!" and her roommate was yelling, "Get out!" I ran to the room because I thought they were having a fight. (Resident #130) was naked and she was pointing at him and telling him to get away. Her nightgown was on the floor. I was shocked to see him in her bed. I hollered to the CNA on the men's unit because he's really big and he can get aggressive. He was being resistive and it took two of us to redirect him back to his room." The CNA described resident #130 as being "upset" after the incident because she kept saying "get away, get away!" -On 6/12/13 at 12:25 p.m., a registered nurse (RN) who worked the night shift on 6/9/13 was interviewed. She said, "that night I had to go up front and do the narcotic count and then I got back and the two CNAs had told me they had been on the men's side helping a resident that was pretty combative. They came back and a resident was telling one of the men residents to get out and go away. I was told (resident #130) was naked and he (#127) had his clothes on. They redirected him out of the room." The RN said she was gone from the Mountain View units for approximately 20 minutes. She continued, "At 7:00 a.m. I called the DON and because one of the CNAs said this had been going on throughout the day and she had talked to social services and I guess what was said to her was that the residents had the right to determine who they wanted to have relationships with. I wasn't sure if this was an incident or if I wasn't supposed to write it up. I told her (DON) what was going on she said it does not need to be written up unless (resident #130) told me she was scared or if she didn't want him in the room. She has dementia and she doesn't speak really good English." The RN said when the resident was saying "get away", it was an indication to her the resident did not want that male in her room at that particular time." -A licensed practical nurse (LPN), who provided care on both evening and night shifts on the secure units, was interviewed at 4:16 p.m. on 6/12/13 and said, "He (resident #127) needs a lot of redirection, he wanders. After hearing about that (the incident on 6/9/13) about his sexual inappropriateness from the social worker, I suggested moving another resident in a wheelchair onto the mixed (men and women) unit and moving him over here (just men's unit) . . . I believe they are working on trying to get that to happen." -A certified nurse aide (CNA) who provided care on the secure units' day shift was interviewed at 4:50 p.m. on 6/12/13 and said, "One of our jobs is to stop them (residents) from hurting each other . . . I heard about what happened on Saturday night. They both just got here so we didn't really have anything in place for him. Now we are just watching out for him more; keep him busy and stuff." -Another CNA who provided care on the mixed unit was interviewed at 6:05 p.m. on 6/12/13 and stated, "I do think some of the residents are afraid of him; they stay out of his way . . . The only thing I ever see is that he was holding hands with the other lady. They were walking in the hallway. They do talk with each other. I think it is hard to understand both of them . . . No, I have not heard about anything this week. I heard a lot of stuff but I don't believe it; you can't take everybody's word for it. It would be nice to hear about it from a supervisor so they could tell us what to do if it happens again." -A third CNA who provided care on the mixed unit was interviewed at 6:15 p.m. on 6/12/13 and said, "I did hear about one of them crawling into bed with the other . . . a night shift CNA told me about it in report that morning . . . I haven't seen them together . . . Afraid of him? Not usually but I have asked another CNA to come help me with him a couple of times when he was upset." -On 6/12/13 at approximately 7:00 p.m., the same registered nurse stated she attempted to visualize the resident's vaginal area for signs of trauma to the best of her ability, but the resident was sitting up. -On 6/13/13 at 11:30 a.m., a certified nurse aide (CNA) working on the mixed secured unit stated she usually worked the evening shift. She said, "(Resident #127) gets antsy and one night he was saying sexually inappropriate comments. He looked at another resident and told her, "I could eat that up," and she said, "Oh no you won't!" -On 6/13/13 at 11:44 a.m., the medical director (MD) was interviewed. He stated, "I have not been notified about this particular event." The MD stated he expected the facility to notify him of "adverse events." The MD said, from what was described to him, the incident between resident #127 and resident #130 would be an adverse event. He continued, "For an event like that I would expect some explanation of what was going to be done. Was a physical assessment done? That would be my response. Do we need to send her to the ER and at least have someone do a physical assessment?" -On 6/13/13 at 12:05 p.m., the DON said, "To my knowledge, a physical assessment was not done. I know she's very non-verbal and she gives very short answers. I know from them talking to her daughter she does understand some English." The DON stated residents are placed on the men's secured unit if they have a history of physical behaviors and aggression. Male residents can be placed on the mixed unit (where resident #127 and resident #130 resided), if there is no history of physical or sexual aggression towards others. 5. Follow up during the survey, after it was brought to the facility's attention: For Resident #127 On 6/12/13, after concerns were identified by survey team, the behavior monitoring had been modified and the new target behaviors included: "expressing unwanted sexual attention from other residents and making unwanted sexual advances to other residents." On 6/11/13, the nurse documented, "Late Entry for 6/9/13 This Nurse/DON (director of nursing) was notified by night nurse that this resident was noted to be in another female resident's room. Upon entering room staff noted this resident was fully dressed and female resident was naked. (See note of 6/9/13 above) There was no observation of this resident inappropriately touching female resident. This resident was re-directed by nursing staff and taken out of room." (As cross-referenced in Tag 353 - no staff were on the unit to monitor resident actions or address safety concerns/needs). 2. Medication Found on Facility Floor Nursing Professional Standards- According to "Fundamentals of Nursing," by Harkreader & Hogan, 2nd Edition, (2000), page 414, "Make sure the client has swallowed all medications by questioning him or checking his mouth. Stay with the client until all medications have been taken." According to "Clinical Nursing Skills & Techniques," by Perry & Potter, 5th Edition, (2004), page 456: "Prepare medications for one client at a time." The same reference states on page 460: "Stay until client has completely swallowed each medication. Ask client to open mouth if uncertain whether medication has been swallowed. Rationale: Nurse is responsible for ensuring that client receives ordered dosage. If left unattended, client may not take dose or may save drugs, causing risk to health." A. On 6/13/13 at 10:06 a.m., observations documented one round white tablet lying on the floor beside the fire door near room #412. A Licensed Practical Nurse (LPN) was immediately notified. The LPN put on a glove and picked the tablet from off the floor. The LPN stated the medication should not have been found lying on the floor. The LPN was asked to put the tablet in a clear plastic crush tube and give it to the Director of Nursing (DON) to be identified. On 6/13/13 at 10:25 a.m., the DON stated the medication found on the floor was Zyprexa 5 milligrams (antipsychotic). The DON stated the medication should not have been found on the floor. The DON stated it was her expectation nursing staffs remain with residents until medications are swallowed. On 6/13/13 at 10:44 a.m., the DON provided the facility policy on Medication Administration SSP 0603.00 (revised June 2008). The policy documented in pertinent part: 7. Observe that the resident swallows oral drugs. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication. The DON stated it was her expectation nursing staffs follow facility policies. The policy did not address discarded medications. 3. Unlocked Security Gate Door on Mixed Secure Unit On 6/18/13 at 12:25 p.m., observations documented an unlocked security gate door on the Mixed Secure Unit Courtyard Area. The gate door opened outward to the exterior of the facility. The city street was approximately 75 feet in distance from the gate. There were four female residents sitting with a staff member in the courtyard area under the awning outside the sliding glass door of the dining room area. At 12:28 p.m., a Certified Nurse Aide (CNA) was immediately notified. The CNA observed and agreed the gate door was unlocked. The CNA stated she was not aware the security gate door was unlocked. The CNA stated she thought the gate door locked automatically. The CNA stated the gate door opened onto the outside of the facility and into the public area. At 12:32 p.m., the Maintenance Director (MD) stated he did not know the security g

Based on observation, interviews and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for four of 20 sample residents (#69, #96, #151 and #20). Specifically: -The facility failed to assess and monitor the resident's skin condition. The findings include: Resident #151 Resident #15,1 a [AGE] year old male, was admitted to the facility on [DATE]. According to the resident October 2012 computerized physician orders [REDACTED]. According to the most recent minimum data set assessment, dated 9/25/12, the resident scored a 15/15 on his brief interview for mental status and demonstrated no cognitive deficit. He required extensive assistance for activities of daily living. Resident had multiple [MEDICAL CONDITION] and skin tears, but no pressure sores. Observation: On 10/10/12 at 1:00 p.m., the resident's permission was obtained to look at his lower leg. The resident had a pencil eraser size wound on the lateral side of his left leg and below his knee. The wound was scabbed over but there was bruising and redness observed around the wound and above the wound. The area was reddened and appeared swollen. The resident denied any pain. The wound was not covered and was left open to air. Record Review: -Review of the resident record, on 10/10/12 at 10:39 a.m., revealed the current skin treatment orders were: apply [MEDICATION NAME] cream to all trauma areas on skin twice a day, monitor skin and leave right toe open to air-No dressing, apply ACE wrap to bilateral legs-On in the AM and off at night for [MEDICAL CONDITION], and cleanse skin tear left posterior forearm twice daily- apply triple antibiotic ointment and cover as needed- monitor for signs and symptoms of infection. -An order on the resident treatment administration record (TAR) read to monitor skin: -Weekly head to toe skin assessment += intact, -= Not intact. (10/1/12) -Apply Ace wrap to bilateral legs-on in the AM and off at night for [MEDICAL CONDITION]. (10/1/12) -Clean and change dressing on lower leg- use non-adherent bandage and Karle dressing. (10/4/12) -Care plan non-pressure ulcer skin impairment care plan last updated 10/8/12 documented: Problem: left calf area; Goal: resident will be free of further skin impairment related to risk factors through next review: 92 days; Approaches; observe skin weekly and document findings as indicated, document observation of any non-pressure related skin impairments on facility non-pressure ulcer wound documentation form, observe for safety needs with transfers, geri-sleeves as indicated, wound care as ordered, chart any changes, refer to registered dietician or therapy services as needed and monitor site daily for changes, sign/symptoms of infection and continue wraps. Collaborative Practice Orders Review of the collaborative practice orders for skin care received from the Director of Nursing on 10/10/12 at 4:38 p.m. stated in pertinent part;..."Skin Care: Notify facility wound care of all wounds. Notify provider for non-healing or worsening wounds. 1. Skin Tears: Non-Draining: Cleanse with NS (normal saline), approximate edges with sterile applicator or gauze, cover with [MEDICATION NAME] or opsite. NO [MEDICATION NAME]. Change PRN (as needed). Draining: Cleanse with NS, apply triple antibiotic ointment, cover with oil [MEDICATION NAME] dressing to prevent dressing adhering to wound, and then apply gauze dressing. Change daily and PRN. NO [MEDICATION NAME]." Incident Report -Review of the incident on 10/10/12 at 4:32 p.m. revealed that on 10/4/12 at 1 p.m. the resident had a bleeding spot on the calf of his left leg, which started while his legs were being wrapped. The resident's vital signs were blood pressure 146/79, heart rate 74, respirations 16, temperature was 96.4 and pulse oximetry 96%. The physician and family member were notified and the spot was bandaged. -Follow-up investigation stated that the resident was found to have a bleeding spot the size of a pin hole on the lower legs while dressing his legs. The resident denied fear or abuse. The resident has two plus [MEDICAL CONDITION] and fragile skin and as the dressings were being applied the resident began bleeding. The recommendations were to apply dressing, change every shift, chart any changes and use non-stick dressing with Karle. The site was to be monitored daily for changes and signs/symptoms of infection and to continue wraps as ordered. Change of Condition -A change of condition form completed on 10/4/12 at 5:00 p.m. documented that the resident had a bleeding spot. The resident's vital signs were blood pressure 146/79, heart rate 74, respirations 16, temperature was 96.4 and pulse oximetry 96%. The resident has end stage [MEDICAL CONDITION], fragile skin and [MEDICAL CONDITION]. The nurse notified the resident's physician by fax. There was no further documentation. Nurse's Notes Review: -There was no 10/4/12 corresponding nurse's note regarding the resident's change of condition or incident report for the bleeding pin hole spot on his left calf. Head to Toe Skin Checks: Head to toes skin check sheets provided by the facility had an illustration of a person from four sides and stated to mark the locations of skin conditions/ wounds on illustration. The following questions were included on the weekly skin checks: Skin intact: yes or no and if no please specify Bruises: yes (specify) or no Skin tear: yes (specify) or no Abrasions: Yes (specify) or no Rashes: Yes (specify) or no Previously identified areas: Yes or no Preventative measures in place: Yes or no Nails cleaned and trimmed: Yes or no Nurse signature: Review of the resident head to toe skin checks that were to be performed weekly (see TAR order above) revealed that: 9/23/12- The form read skin intact, "no, see admit assessment 9/18/12". There were multiple markings on the resident's arms, shoulders, back and belly. There were two marks on the resident's right lower leg on his knee and shin and one mark on the left great toe. It also stated that the bruises were "yes- TNTC (too numerous to count), skin tears "yes- see individual skin sheets", abrasions was checked as "yes" with no documentation, rashes "yes- groin excoriation." There was nothing documented under previously identified areas, preventative measures in place and nails cleaned and trimmed. 10/6/12- The form read skin intact, "no, numerous old skin tears and a few new". There were no markings on the diagrams. It also stated that the bruises were "yes-on admit TNTC (too numerous to count), skin tears "yes- see skin sheets", abrasions and rashes were checked, "no". The form documented "yes-previously identified areas, and preventative measures in place". There was nothing checked regarding the resident's nails being cleaned and trimmed. Non-Pressure Skin Condition Record: The non-pressure skin condition record provided by the facility had an illustration of a person from four sides and stated to mark the locations of skin conditions/ wounds on illustration. -10/4/12-The form read first observed on 10/4/12 on the left lower leg. There was a small "X" noted on the left lateral leg below the resident's knee. The measurement was "pin hole size", skin intact, wound bed was normal, small amount of serous exudate, progress revealed improved and to continue treatment. The summary documented, "Resident started bleeding out hole in leg when legs were being wrapped." There was no further documentation noted. Staff Interviews: On 10/10/12 at 1:30 p.m., the DON stated that with the skin sheets it was her expectation that if there was a new skin issue she would expect them to identify it on the weekly skin sheets and the head to toe assessment. She discussed that resident #151 had numerous skin issues and he had so many it was hard to identify new ones as the old ones may have been re-opening. She stated any old wound re-opening needed to be treated like a new wound, an incident/accident report needed to be completed, the physician needed to be notified to get new orders. She stated that the incident/accident forms were a quality assurance document and would be reviewed by the interdisciplinary committee (IDT) by the next business day or 24-48 hours depending on if it was a weekend or holiday. The care plan was usually updated within 24-48 hours as well. She discussed that the physicians allowed the IDT team to write orders for basic wound care and the order would need to include the frequency and specifics regarding what was needed. She stated that she did not see in the skin documentation or notes where the nurse had clarified the frequency or specifics for the wound care. The DON further discussed that if a resident did not have an order for [REDACTED]. On 10/10/12 at 1:54 p.m., the nurse stated when preparing to do a wound treatment she would check to see the doctor's order, make an assessment and do the treatment. If there was something different or she did not feel the treatment was appropriate she wound have the wound care team advice on treatment and get a new order if needed. The nurse reviewed the change of condition form and stated based on the documentation she suspected an open area, stated she did not get much from the nurses notes, and the skin sheet documented, pin hole in size, and below the left knee. The nurses stated that since this was the 10th of the month and it had been six days she would hope that the wound was healed. She stated that the practice is after a change of condition nursing should be charting every shift for the first 72 hours on the injury. She stated that the treatment was to clean and change dressing to the lower leg, using non-adherent bandage and [MEDICATION NAME] dressing. She stated that the care plan was not clear. On 10/10/12 at 2:30 p.m., the nurse stated she had completed the resident's wound care and discussed that based on the last documentation in the chart, she did not think the wound was infected but it was scabbed over. His lower leg was cool to the touch, he had two plus [MEDICAL CONDITION] and fragile paper thin skin. She stated that according to the measurements this week the wound was worse, and her measurements were a big difference from a pin hole, and the surrounding area was not previous documented, there was clearly bruising and [MEDICAL CONDITION] around the wound now. On 10/10/12 at 4:30 p.m., the nurse practioner stated that the facility and her company have a book that is kept at every nurse's station and the nurses could find standing orders for skin treatment and implement any of the standing orders, or obtain a new order. She stated that if nursing was using one of the standing orders they must call by the next business day to get a clarifying order. On 10/10/12 at 4:35 p.m., the nurse providing care to resident #151 stated that she was not aware of the collaborate standing orders and usually called the physician for the order. On 10/10/12 at 4:45 p.m., the DON stated that she had not previously been aware of the collaborate orders and only became aware of them when making a copy for the survey team. Follow-Up on Survey A nurse's note dated, 10/10/12 at 3:50 p.m. documented, treatment done-measured area on left calf 0.7X0.6 cm scabbed skin tear with bruising surrounding area. Skin was cool to the touch, two plus [MEDICAL CONDITION]. The nurse documented that she spoke with the assistant director of nursing who stated that it has decreased in swelling, the sore is larger, no signs/symptoms, physician assistant visited, obtained new treatment orders. A 10/10/12 treatment order documented, left leg/calf-cleanse wound with cleanser daily. Wrap with ace wrap as ordered. The non-pressure skin condition report documented on 10/10/12, [MEDICAL CONDITION] cm, depth unknown due to scab, no exudate, improved progress and continue treatment. It also documented that the resident had pain associated with the wound. The progress note documented, left calf wound measured, no drainage, scabbed with noted bruising surrounding the area. The skin was cool to the touch, two plus [MEDICAL CONDITION] and bilateral lower extremities wrapped with ace wrap. FACILITY POLICY Facility policy titled, 'skin management,' provided by the facility on 10/10/12 at 2:42 p.m. read in pertinent part: Residents admitted with skin impairments will have: Appropriate interventions implemented to promote healing; A physician's orders [REDACTED]. In addition, the following forms are completed and placed with the resident's treatment record: Pressure ulcer: Weekly pressure ulcer record; Low extremity ulcer: Non- Pressure skin condition Record; Skin tears and all other significant skin impairment; Non- Pressure skin condition record. The Licensed Nurse will document daily monitoring of all pressure ulcers on the treatment administration record (TAR). A physician's orders [REDACTED]. The licensed Nurse will record: A plus sign if there are no observed abnormalities or changes to the dressing, skin or pain associated with the wound: Minus sign if abnormalities or changes to the dressing, skin or pain associated with the wound are present/observed. If any abnormalities are observed, document a descriptive note of findings and the licensed nurse's response in the nurses' notes section of the resident's medical record. Skin assessments: "Weekly skin check," will be transcribed onto the treatment record including the day and shift on which the check will be conducted; Completion of the weekly skin assessment will be noted on the TAR with the licensed nurse's initials; skin assessment findings will be documented weekly on the Head to toe skin check form. Note: Alterations or changes in skin integrity, any break in the resident's skin, including skin tear, bruises, abrasions, ulcers, rash, surgical wounds etc, are to be recorded on the Head to toe skin check form. A Change of condition form is to be completed and new physician's orders [REDACTED]. Findings and follow-up, if needed, are to be documented in the nurses' notes. The nurse will assure treatments, interventions, care plan, and the appropriate skin documentation records are initiated in a timely manner according to practice guidelines. Pressure ulcers are measured and staged weekly in accordance with the Practice guidelines. The DON/designee will distribute follow up assignments to the IDT following the at risk review meeting. The assigned IDT member will ensure communication to other staff of the results of the review and any changes to the plan of care. Lower extremity ulcers Resident, family and attending physician are notified of the development of the vascular ulcer. Etiology of the ulcer is determined as well as the treatment plan. This is achieved via the attending physician. Care plan is updated to reflect the new problem and interventions with evaluation and revision documented on an ongoing basis. Ulcers will be assessed weekly and status/progress documented on the non-pressure skin condition record. Resident is assessed for pain, and appropriate interventions implemented and care planned. Resident is added to 24 hour report. Care is actively planned and discussed during shift report with all members of the nursing team (include direct care staff). Monitor the area closely during treatment to evaluate appropriateness of treatment regime. Monitor placement of the affected limb to prevent further injury. This is especially important if [MEDICAL CONDITION] is a factor. Consult with rehab for evaluation and options for treatment intervention and options for treatment, especially for [MEDICAL CONDITION] management. Consultation with certified wound care nurse or surgeon may be appropriate. Begin resident teaching. WEEKLY HEAD TO TOE SKIN CHECKS Head to toes skin check sheets provided by the facility had an illustration of a person from four sides and stated to mark the locations of skin conditions/ wounds on illustration. The following questions were included on the weekly skin checks: Skin intact: yes or no and if no please specify Bruises: yes (specify) or no Skin tear: yes (specify) or no Abrasions: Yes (specify) or no Rashes: Yes (specify) or no Previously identified areas: Yes or no Preventative measures in place: Yes or no Nails cleaned and trimmed: Yes or no Nurse signature: RESIDENT #69 Resident #69, age 58, was admitted to the facility on [DATE]. The Face Sheet documented the resident [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/18/12, documented the resident had a BIMS (cognition) score of 11, which indicated the resident was moderately impaired. The resident did not have any short- or long-term memory problems. The resident was independent in bed mobility, transfers, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, toileting, personal hygiene and bathing. The resident has two unstageable pressure ulcers due to coverage of wound bed by slough or eschar tissue. The measurements of the unhealed pressure ulcer were 2.0 cm (centimeters) x 2.0 cm x 0 cm. The resident had ulcer treatments consisting of pressure reducing device for his bed, pressure ulcer care and applications of ointments/medications other than the foot. The resident's last MDS available in the chart was 6/18/12. RECORD REVIEW: -Review of the resident record on 10/10/12 at 8:39 a.m. revealed that the current wound order was: monitor all wounds for changes or abnormalities to surrounding skin or pain associated with wound + for no change and - for changes and chart in nursing notes daily. Right heel and lateral foot wounds- clean with saline, apply a thin mixture of 1:1 santyl/[MEDICATION NAME] oint topically to open wounds then cover with [MEDICATION NAME] and gauze and kerlix and coban dressing daily start date 9/18/12, but order was originally written on 9/11/12. -An order on the resident treatment administration record (TAR) read to monitor skin: Weekly skin check 6-2 Fridays. I= intact, P= Problem. -Care plan ulcers care plan last updated 9/29/12 stated: Refuses to wear blue booties and to float heels, -9/24/12 care plan updated 9/24/12 stated actual infection related to wound heel, goal read. 9/21/12 bactrim DS oral bid for 20 days. Under approaches it stated hand washing before and after delivery of care, monitor resident for signs and symptoms of infection including fever chills nausea, vomiting, pain/ discomfort every shift, educate resident regarding infection prevention, administer medications as ordered, monitor site for signs and symptoms of infection, redness tenderness, drainage every shift, and monitor lab values as ordered. -The resident care plan titled, "Pressure ulcers- potential." Stated under approaches to measure and stage wound weekly using the pressure ulcer healing assessment form, and complete a full body check weekly and document. Wound Care Consults -9/18/12- Dressing change instructions: [MEDICATION NAME] and Coban to secure toes to knee. Cleanse Right heel and right lateral foot wound with saline. Apply thin layer of 1:1 santyl and Poly sporin to open wounds cover with nonadherent gauze, cover heel wound with foam, lateral foot wounds with 2x2 gauze. Secure with [MEDICATION NAME] gauze roll and coban gentle compression from toes to knee. Culture of right heel tissue. -9/21/12, bactrin ds ordered by wound clinic for 20 days bid. -10/2/12, wound clinic note written total contact cast applied to r leg/ must remain on at all times. -10/9/12, wound clinic note stated total contact cast/ continue Bactrim orally twice daily until next visit. (Do not stop) If cast requires removal cut down sides and chevron as usual (not anterior, as with Tcc system). Nurse's Notes Review: 9/18/12- Resident was seen by wound clinic this morning he came back with his foot dressed and no change to treatment order. He had taken his dressing off this morning and refused to let me put anything on it. 9/18/12- Resident got [MEDICATION NAME] (pain medication) routinely now and it was given he denies having pain. He was lying in bed and had not gotten up. However when he did get up later he was not limping and said he was okay. 9/21/12- Resident started on antibiotics for foot wound, pt has taken his dressing off and running around with his slipper on. He has taken his pain meds and in walking ok and said he did not have pain, NP was in and seen him (illegible) ordered and wound clinic called about the culture they did on her heel and ordered ab(antibiotics). 9/23/12- Resident continues on antibiotic for heel wound and no adverse reaction. Pt(patient) taking [MEDICATION NAME] for pain routinely and said it helped. He does not have pain when he takes it. Pt limps badly when he don't take it but walks much better after taking the med(medication). 9/23/12- continues on ATBs no s/ss (signs or symptoms) of adverse reaction. Dressing remains on at this time to heel. 9/24/12- T97.4 cont on ATB. Dressing to heel d/I (dry and intact) sleeping without problem or c/o (complaints of). Will cont to monitor. 9/24/12- 1420- Call placed to notify - proxy of resident (about) order for foot wound. (Continued) on ABT with no adverse reaction. Afebrile. Dressing off heel states he took it off, has refused to allow this nurse to replace it this shift will cont to monitor. 9/24/12- T-98.2 (continue) on ABT for feet- no dressing has socks slippers on. No c/o pain collected ua(urinary analysis). 9/25/12- T- 97.4- (continued) on ATB without problem no c/o pain. Sleeping without complaint of this noc(night). No drsg (dressing) will cont to monitor. 9/21/12- late entry; resident started on ATB for foot wound. (Proxy) called and message left on his answering machine as to pt being started on ATB and progress of heel. 9/25/12- Resident continues on ATB for heel wound. No adverse reaction noted. pt continues to take dressing off after about an hour. I asked him why and he said it makes his leg itch. 9/26/12- refused dressing 9/28/12- refused dressing 10/2/12- went to wc (Wound care) clinic today cast to foot see to this date. 10/9/12- went to wcc (wound care clinic) today will continue on ABT until next appointment 10/16/12. HEAD TO TOE SKIN CHECKS Head to toes skin check sheets provide by the facility had an illustration of a person from four sides and stated to mark the locations of skin conditions/ wounds on illustration. The following questions were included on the weekly skin checks: Skin intact: yes or no and if no please specify Bruises: yes (specify) or no Skin tear: yes (specify) or no Abrasions: Yes (specify) or no Rashes: Yes (specify) or no Previously identified areas: Yes or no Preventative measures in place: Yes or no Nails cleaned and trimmed: Yes or no Nurse signature: Review of the resident head to toe skin checks that were to be performed weekly (see TAR order above) revealed that: 10/3/12- The form stated that the skin intact, "no," but no detail was given. There was no detail on the illustration. It also stated that there were no skin tears abrasions, rashes or bruises and he had previously identified areas, preventative measures in place and nails cleaned and trimmed. A head to toe skin check provided by the facility after exit showed an assessment completed on 10/12/12 which stated that the skin intact, "no," but no detail was given. There was no detail on the illustration. It also stated that there were no skin tears abrasions, rashes or bruises and he had previously identified areas, preventative measures in place and nails cleaned and trimmed. The interview with the DON (see below) indicated that if a boot were on the resident it should be documented; however, the illustration and area for specifics had no detail and no mention of a boot/cast or any wounds. WEEKLY PRESSURE ULCER RECORD REVIEW Review of the weekly pressure ulcer record revealed that the resident had measurements for a right 5th metatarsal pressure ulcer. Measurements were available from the time of the resident acquiring the wound (9/13/12) until 10/3/12 which stated that resident attends wound clinic and now a cast on RLE (right lower extremity), no measurements available at this time. No indication was drawn on the illustration noting where the resident's wound was on the 5th metatarsal. No additional progress notes were made for 10/10/12 when the next wound documentation would be due. Review of the weekly pressure ulcer record revealed that the resident had measurements for his right heel. No notation was made on the illustration and measurements were available on a weekly basis through 10/3/12 which stated that resident attends wound clinic and now has cast on RLE no measurements available at this time. No additional progress notes were made for 10/10/12 when the next wound documentation would be due. Review of the record revealed that the weekly pressure ulcer record, nurses' notes, head to toe skin checks all did not have any mention or note of the resident having a wound or cast on from 10/6/12 to 10/13/12. On 10/10/12 review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no mention of monitoring of boot site. The resident TAR provided by the facility on 10/11/12 at 8:02 a.m. revealed that he had an order written [REDACTED]." There was no signature indicating the cast or leg had been checked on 10/10/12 for the 6:00 a.m. shift and the 2:00 p.m. shift. There was also no note of it being checked for the same shifts on 10/11/12. (The additional documents sent by the facility on 10/12/12 showed that the 10/11/12 signatures had been obtained but no documentation on a late entry was noted.) It showed that a nurse had signed off on monitoring of the cast on 10/12/12 in the morning shift, it was not documented as being monitored on the evening shift, but it was documented as being monitored on the evening shift which started at 10:00 p.m.; however, the document was faxed on 10/12/12 at 5:19 p.m. prior to the start of the shift that had already been documented on. INTERVIEWS: -Interview on 10/10/12 at 10:40 a.m., with the licensed practical nurse (LPN) on the unit revealed that no one on the hall or in the building that he knew of was on any type of precautions for infections. When asked if he took care of resident #69 he stated that he did and he assessed the cast every shift. When asked where he documented that he stated that he just assessed the cast but did not document it. Interview with the DON on 10/11/12 at 9:30 a.m., revealed that she would expect the resident's cast on his right leg to be noted on the head to toe weekly skin assessment and that she had already reviewed the resident recorded and noticed that it was not recorded appropriately. She stated that the monitoring of the resident wearing slippers was from before he had the boot on and they just had not updated the monitoring sheet. When asked if they were documenting monitoring of the boot she stated that she knew that they were looking at the boot daily, but did not know of any documented monitoring. She stated that they had updated the care plan for the resident's wound infection, but when asked if they had updated the care plan with any approaches for the cast she stated that they had put the cast on the care plan for wounds, but had not put any approaches to monitor or care for the cast. Resident #96 Resident #96 was an [AGE] year old female admitted to the facility on [DATE] and according to her resident face sheet her [DIAGNOSES REDACTED]. Her most recent MDS assessment, dated 8/19/12, read the resident was unable to participate in a brief interview for mental status (BIMS) as she was unable to complete one or more questions in the interview. RECORD REVIEW A care plan dated 10/9/12 stated that resident had bilateral breasts bruising, and under approach it stated document occurrence in resident chart notify md (physician) and family, keep area clean and dry, tx (treatment) per md orders, observe for s/s (signs or symptoms) of infection and notify md as noted, and provide as safe an environment as possible 10/9/12 added in pen- monitor (resident) for s/s fear, anxiety, and change in mood behavior, 10/9/12 monitor bruise for changes, staffed assist (resident) to lie down. The resident had weekly head to toe skin checks in her MAR indicated [REDACTED]. Both head to toe skin checks indicated that there were no bruising, skin tears, abrasions, rashes previously identified areas, and no preventative measures in place. The illustrations had no indications or markings to indicate any skin issues. Non-pressure skin condition records for the resident dated 10/8/12 documented a left and right breast quarter size bruise. Change of condition dated 10/8/12 stated bruise to breast-bilateral started 10/8/12 - 7:00 a.m. monitor, change in skin bruise to each breast monitor vital signs and observe. Physician and family notified. During getting up-CNAs noted bruise to each breast undetermined cause. An incident/Accident report dated, 10/8/12 at 7:00 a.m., revealed that the resident was discovered to have bruises on bilateral breasts. It stated under finding that CNA assisted resident to get dressed this morning and noted a bruise on each breast. Cause undetermined. Denies pain, no fear observed, none voiced. A follow up investigation form dated 10/9/12, revealed that the assistant director of nursing had examined bruises, stated that they were round, did not appear to be finger prints, and that they were fading yellow bruises on bother upper breasts that were quarter sized; however, the head to toe skin assessment on the same day showed no skin issues on the resident. 10/9/12 was the only nurse's note since the date of discovery of the bruises which stated that patient's bruises on bilateral breast intact and heeling no c/o pain no verbalization of fear or anxiety expressed r/t bruises, Will continue to monitor. INTERVIEW Interview with the director of nursing on 10/10/12 at 2:45 p.m. revealed that per the facility policy and her expectations she would expect each area of skin breakdown or abnormality to be documented on the weekly head to toe skin checks. She stated that the wound measurements and specifics would be noted on the wound sheets that they did wound rounds with the nurses but that the nurses would have to document generally the issues that were present weekly. Interview with the DON on 10/11/12 at 9:30 a.m., revealed that the resident was assessed by the ADON on 10/9/12 and the resident was noted as having bruising. She stated that the weekly head to toe skin assessment was incorrect and that she had not seen it. She stated that they did do education on the skin assessment but they went over the entire policy and they did go over the need to reflect any skin issues on the resident on the weekly head to toe wound assessment. Resident #20 Resident #20 was a [AGE] year old female admitted to the facility on [DATE] and according to the resident face sheet the resident's [DIAGNOSES REDACTED]. According to the admission minimum data set (MDS), dated [DATE]; the resident was cognitively intact, scoring 13 out of 15 possible points on the Brief Interview for Mental Status (BIMS). The resident require

Based on observation, record review, and resident/staff interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being, of three of 43 sample residents (#91, #29 and #20). Specifically, the facility failed to ensure residents' pain was assessed and managed. Resident #91, per interview, expressed unrelieved pain. The facility also failed to ensure skin was properly assessed. Findings include: I. Pain Management A. Facility Policy The facility Pain Management policy dated 7/10, read in pertinent part, "Residents will be screened for pain by using the monthly summary and pain evaluation quarterly, annually and with a significant change and/or onset of pain. A. Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. B. These evaluations will be used by the IDT (interdisciplinary team) to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmacological techniques. Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain, or identified through the RAI (resident assessment) process or otherwise will have a full evaluation of the pain conducted using the pain evaluation form. Following the pain evaluation, notify the physician of the findings and document on the change of condition. Implement new orders as received ...The licensed nurse will communicate any new onset of resident pain or change in resident pain through the 24 hour report process ..." B. Resident Failures 1. Resident #91, age 81, was admitted to the facility on [DATE]. According to the Computerized Physician order [REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], the resident had no cognitive impairments. She required limited assistance with ambulation, bed mobility and transfers and personal hygiene. The resident was coded as not having any behavior symptoms. The MDS indicated the resident had experienced pain within five days of the completion of the assessment and that she had received both scheduled and as needed pain medications. The resident was coded as having pain occasionally and that the pain had limited her day to day activities. a. Record Review (1) Orders Review of the resident's CPO and telephone orders revealed the following orders for Pain Management: -Current CPO for pain control included [MEDICATION NAME] 5 mg-500 mg three a day for pain, Tylenol 650 mg one tablet every four hours as needed for pain, and [MEDICATION NAME] 5 mg PO every 6 hours as needed. An 8/2/12 physician's telephone order documented [MEDICATION NAME] extended release (ER) 15 mg one tablet every eight hours for pain. -The CPO included an order for [REDACTED]. Review of the as needed (PRN) pain medication administration record documented "0 = no hurt; 1-2 = hurts little bit; 3-4 =hurts little more; 5-6=hurts even more; 7-8= hurts whole lot; 9-10= hurts worst." (2) Pain Assessments -The 5/14/12 quarterly Pain Evaluation (PE) documented the resident had frequent pain in the last 5 days. The PE also documented the resident's pain made it hard to sleep. The resident stated on the PE the pain was generalized, legs, feet, back and emotional. The potential underlying cause was documented as "mental illness." The resident stated on the PE that the goal for managing her pain or hurting was a "0" (no hurt). -The most recent PE was completed on 8/12/12 identifying the [DIAGNOSES REDACTED]. The PE documented the resident had almost constant pain in the last 5 days. The PE also documented the resident's pain limited her day to day activities because of pain. The PE documented the resident ' s present pain/hurting rating was "10" (hurts worst). The PE documented the best the pain/hurting gets was a 4 (hurts alittle more than a bit). The resident stated on the PE that the goal for managing her pain or hurting was a 3-4. The PE documented the pain interfered with her sleep, mood, and ability to concentrate. The PE documented the location of the pain/hurting was legs, bladder, vagina, rectum and GI (gastrointestinal). The potential underlying cause of pain was documented [MEDICAL CONDITION]. (3) Physician note A physician visit note, dated 8/2/12, documented the reason for the visit was pain. The note documented the pain had returned since her [MEDICATION NAME] was stopped ([MEDICATION NAME] 100 mg three times a day was discontinued on 7/30/12). The resident stated the pain comes and goes, sitting worsens it. The note documented the resident's [MEDICATION NAME] ER 15 mg was increased to three times a day from twice a day. The note documented the resident had slurred speech. (4) Medication Administration Record Review of the resident's Medication Administration Record (MAR) revealed frequent elevated levels of pain at the time routine [MEDICATION NAME] was administered. While post administration assessments indicated the medication had an effect, the effect was not always at the resident's acceptable level of pain. -MAR review also revealed that by the next routine administration, the resident's pain level had again increased beyond an acceptable level. -MAR review revealed the resident rarely received prn Oxycondone more than once a day. -MAR review revealed the resident never received prn Tylenol. Review of the resident's MAR, dated 8/12, revealed the resident received [MEDICATION NAME] 5/500 three times a day at 8:00 a.m., 2:00 p.m., and 10:00 p.m. The resident's pain level was assessed both before and after the administration. The results were as follows: 8/1/12: -8:00 a.m. before medication 7 and after 7. -2:00 p.m. before medication 7 and after 7. -10:00 p.m. before medication 8 and after 3. 8/2/12: -8:00 a.m. before medication 7 and after 4. -2:00 p.m. before medication 10 and after 6. -10:00 p.m. before medication 10 and after 5. 8/3/12: -8:00 a.m. before medication 10 and after 7. -2:00 p.m. before medication 5 and after 1. -10:00 p.m. before medication 7 and after 4. 8/4/12: -8:00 a.m. before medication 8 and after 3. -2:00 p.m. before medication 6 and after 4. -10:00 p.m. before medication 8 and after 3. 8/5/12: -8:00 a.m. before medication 8 and after 4. -2:00 p.m. before medication 6 and after 4. -10:00 p.m. before medication 7 and after 3. 8/6/12: -8:00 a.m. before medication 8 and after 4. -2:00 p.m. before medication 6 and after 4. -10:00 p.m. before medication 8 and after 3. 8/7/12: -8:00 a.m. before medication 8 and after 3. -2:00 p.m. before medication 6 and after not assessed. -10:00 p.m. before medication 7 and after 3. 8/8/12: -8:00 a.m. before medication 10 and after 6. -2:00 p.m. before medication 6 and after 1. -10:00 p.m. before medication 5 and after 2. 8/9/12: -8:00 a.m. before medication 8 and after 4. -2:00 p.m. before medication 6 and after 1. -10:00 p.m. before medication 5 and after 2. 8/10/12: -8:00 a.m. before medication 5 and after 1. -2:00 p.m. before medication 4 and after 1. -10:00 p.m. before medication 7 and after 2. 8/11/12: -8:00 a.m. before medication 4 and after 1. -2:00 p.m. before medication 4 and after 1. -10:00 p.m. before medication 6 and after 2. Review of the resident's MAR, dated 8/12 revealed the resident received [MEDICATION NAME] ER 15mg every 8 hours (ordered 8/2/12) and it was administered as ordered 8/3 - 8/13/12. No pain levels were recorded on the MAR Review of the resident's MAR, dated 8/12 revealed the resident did not receive any of the PRN Tylenol. The resident received PRN oxycodnone 5 mg as follows: -On 8/2/12 the resident received one dose of 5 mg of [MEDICATION NAME] at 12:35 p.m. for complaint for pain at a level 10. The MAR documented the post administration was a 6. -On 8/2/12 the resident received one dose of 5 mg of [MEDICATION NAME] at 8:00 p.m. for complaint for pain at a level 8. The MAR documented the post administration was a 7. -On 8/5/12 the resident received one dose of 5 mg of [MEDICATION NAME] at 11:00 a.m. for complaint for pain at level 8. The MAR failed to document if the medication was effective. -On 8/6/12 the resident received one dose of 5 mg of [MEDICATION NAME] at 10:30 a.m. for complaint for pain at a level 9. The MAR documented the post administration was a 4. -On 8/9/12 the resident received one dose of 5 mg of [MEDICATION NAME] at 2:00 a.m. for complaint for pain at a level 7. The MAR documented the post administration was a 4 -On 8/9/12 the resident received one dose of 5 mg of [MEDICATION NAME] at 5:15 p.m. for complaint for pain at a level 7. The MAR documented the post administration was a 2. -On 8/10/12 the resident received one dose of 5 mg of [MEDICATION NAME] for complaint for pain at a level 8. The MAR documented the post administration was a 3. -On 8/11/12 the resident received one dose of 5 mg of oycodone for complaint for pain at a level 6. The MAR documented the post administration was a 1 -On 8/12/12 the resident received one dose of 5 mg of oycodone at 5:30 p.m. for complaint for pain at a level 6. The MAR documented the post administration was a 3. (5) Assessments There was no documentation of assessments of the resident's rectum or buttocks in the record for 8/12. b. Observations and Resident/Roommate Interview and MAR review (1) 8/6/12 On 8/6/12 at approximately 9:45 a.m., the resident was interviewed. She said that she was in pain and that she had told a volunteer; she could not remember how long ago she'd told the volunteer of her pain, but stated she had told the volunteer that she was in pain and needed a pain medication. She said that she [MEDICAL CONDITION] and that her bottom 'always hurts.' The resident stated that she had recently gone onto hospice and hospice was supposed to help with her pain control. The resident stated that it must not be time for her medication as she had not received it since asking the volunteer. The licensed practical nurse (LPN) was interviewed on 8/6/12 at approximately 10:00 a.m. The LPN stated that she had ben informed the resident was having pain. She said she would go and see the resident. Review of the resident's medication administration record (MAR) revealed the resident received one dose of 5 mg of prn [MEDICATION NAME] at 10:30 a.m. for complaint for pain at a level 9. The MAR documented the post administration pain level was a 4. Further MAR review revealed the resident had received routine [MEDICATION NAME] (scheduled for 8:00 a.m., 2:00 p.m., and 10:00 p.m.) at 8:00 a.m. At that time, pain was recorded at 8 level. Post administration, pain was documented at 4. She also had received her routine [MEDICATION NAME]. (2) 8/8/12 On 8/8/12 at approximately 2:00 p.m., the resident was observed sleeping in bed. The resident was curled up with the blanket up over her head. The resident's roommate stated that "(resident #91's) (bottom) was really hurting today." Review of the resident's medication administration record (MAR) for 8/8/12 revealed the resident received no doses of 5 mg of prn [MEDICATION NAME]. Further MAR review revealed the resident had received routine [MEDICATION NAME] at 8:00 a.m. for a pain level of 10 (post-administration level of pain was 6) and at 2:00 p.m. pain level 6 (post-administration pain level was 1). She also had received her routine [MEDICATION NAME]. (3) 8/9/12 On 8/9/12 at 5:03 p.m., the resident was observed lying in bed. The resident stated that her current pain level was a 10 out of 10 (10 being the worst pain). She stated that her rectum hurt. The resident stated that she was given a clear like cream (she described as vasoline) to put on her bottom and that when she did, it burned really bad. She said that sometimes she did not eat or go to activities because the pain was so bad. The resident's voice quivered as she talked and her face had a grim expression. Review of the resident's medication administration record (MAR) revealed the resident received a dose of 5 mg of prn [MEDICATION NAME] at 5:15 p.m. for complaint for pain at a level 7. The MAR documented the post administration pain level was 2. Further MAR review revealed the resident's pain level at 2:00 when routine [MEDICATION NAME] was administered had been a 6 level, reduced to a level 1 with the medication and her routine [MEDICATION NAME] as ordered. (4) 8/13/12 On 8/13/12 at 1:05 p.m., the resident was observed lying in bed. The resident stated her pain level was between a 6-8 out of 10. As the resident talked, she started to cry and her voice shook. The resident stated that she was in pain. The resident stated that she had received her medication; however, she was waiting for the medication to start working. The resident stated that she hurt all over. The resident stated that the nurse had looked at her bottom 'for the first time' as she has been complaining that her bottom hurt. The 8/13/12 MAR documented she received one [MEDICATION NAME] 5 mg prn at 6:30 a.m., with a pain level of 6, reduced to a level 2 with the medication. Routine [MEDICATION NAME] was initialed for 8:00 a.m; however, there were no pain level scores. Routine [MEDICATION NAME] also was given that morning. c. Interviews The resident's LPN was interviewed on 8/7/12 at approximately 11:00 a.m. The LPN stated the resident was involved with hospice and they were working with the resident in controlling her pain level. The director of nurses (DON) was interviewed on 8/9/12 at 6:34 p.m. The DON was notified the resident was having 10 out of 10 pain level. The DON stated the resident [MEDICAL CONDITION] and that she was recently placed on hospice. She stated that the resident has had an increase in pain. The DON stated the resident was receiving [MEDICATION NAME] three times a day and [MEDICATION NAME] three times a day. The certified nurse aide (CNA) was interviewed on 8/12/13 at approximately 1:00 p.m. The CNA stated the resident was curled up in a ball today with covers over her head and did not want to deal with the world. She stated the resident had complained of her bottom hurting. The DON was interviewed again on 8/13/12 at 9:20 a.m. The DON stated she had reviewed the resident's medical record. -The DON stated that the resident was admitted in 12/11, she had general complaints of leg pain. She stated that the resident was seen by a proctologist and that the resident may have a mass which was possibly causing the pain. The DON stated the resident and family decided to not proceed with any further treatment. -The DON stated the [MEDICATION NAME] was increased (8/2/12) to help cover the pain. She stated that the goal was to have the pain at a tolerable level; tolerable means "a good quality of life." She stated that she was unsure of what the resident's pain goal was. -The DON said pain assessments should be completed quarterly, on admission and with any change of condition. The DON indicated a pain assessment should have been completed when resident had begun experiencing increased pain. -The DON stated the topical cream did not work well for the resident to help control her pain. -The DON stated that the doctor should be notified if the pain level is not being controlled. and she did not think the resident's pain was under control. She said the resident was admitted to the hospice program to help to provide assistance with managing her pain level. -The DON confirmed the resident's last pain medication change occurred on 8/2/12 and based on the MAR entries above, the resident's physician should have been notified that the resident's pain was not being adequately managed. Another LPN was interviewed on 8/13/12 at approximately 10:00 a.m. The LPN stated the resident was on hospice and that he communicated with the hospice nurse when changes occurred. The LPN stated that the resident complained of generalized pain and the resident received [MEDICATION NAME] and [MEDICATION NAME]. The LPN stated that when he gives medication to the resident's roommate, he will ask the resident how she was. The LPN stated that he did not routinely offer the PRN medication as the resident was able to ask for the medication. The LPN stated that the resident complained about her rectum hurting related to [MEDICAL CONDITION]. He stated that the resident's rectum was not assessed routinely. The DON was interviewed again on 8/13/12 at approximately 2:00 p.m. The DON stated the resident's bottom was assessed by the assistant director of nurses (ADON) and that it was tender, but no excoriation. The DON also stated that she reviewed the 24 hour report and the level 10 pain from the pain assessment (on 8/9/12 at 5:03 p.m.) was not entered on the 24 hour report. The hospice nurse was interviewed on 8/13/12 at 4:50 p.m. -The hospice nurse stated the resident was in pain and that the resident had told her the pain level was at an 8. She stated that she had spoken with the resident today and the resident had voiced she wanted her pain controlled and that she was ok to have the medication make her sleepy. She stated that the resident also had some emotional pain due to her recent losses. The hospice nurse stated she was going to inquire about an [MEDICATION NAME]. The goal was for the resident to be comfortable and to have controlled pain. -The hospice nurse stated she had not been informed before today that the resident's pain was not managed with her current medication regimen. 2. Resident #29, age 67, was admitted to the facility on [DATE]. According to the facility admission record, his [DIAGNOSES REDACTED]. a. Record Review Review of the care plan dated 2/28/12 revealed the resident had actual pain related to: [MEDICAL CONDITION], Hep(atitis) C and a fracture (which was added 3/9/12). The approaches included: -positioning/support -relaxation -counseling/support via psychology -administer [MEDICATION NAME] as ordered -see physician orders -implement pain management flow sheet -observe resident for signs and symptoms of pain, including verbal expression, (facial grimacing, bracing, restlessness, rubbing, other) -notify physician if interventions are not consistently effective. -medicate resident for pain prior to treatments and therapy, if indicated Review of the Interdisciplinary Post Fall Review dated 3/8/12 revealed the resident was found on the floor at 2:15 a.m. Review of the nurses notes (NN) dated 3/9/12: -at 9:00 a.m. the NN read in pertinent part that the resident was very uncomfortable and moaning during ADLs (activities of daily living). Upon examination, the resident had intense pain to his left hip, the physician was notified and an order for [REDACTED]. -at 3:00 p.m. the NN read in pertinent part that the resident's x-ray results confirmed a left [MEDICAL CONDITION], providing pain medication and positioning for comfort at this time. There were no NN between 9:00 a.m. and 3:00 p.m. and there was no additional documentation regarding the resident's noted intense pain at 9:00 a.m. According to the telephone orders dated 3/9/12: -at 10:00 a.m. the resident received an order for [REDACTED]. -at 3:00 p.m. the resident had an order for [REDACTED]. According to the March 2012 Medication Administration Record (MAR), the resident received the PRN [MEDICATION NAME] 5/500 on 3/9/12. There was no documentation indicating what time the medication was given or whether it was effective in addressing the resident's "intense pain." However, according to the Controlled Drug Administration Record for [MEDICATION NAME] 5/500, six tabs were taken from the E-kit (emergency kit) for resident #29; the first dose signed out was on 3/9/12 at 12:00 p.m., three hours after the resident had reported "intense pain." Interviews: On 8/8/12 at approximately 11:30 a.m. the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed. -The NHA indicated that he felt that three hours was an acceptable amount of time for a resident with intense pain to wait for pain medication with everything else that staff has to do. -The DON indicated that she would not really expect any additional follow up related to the resident's pain, such as nurses doing follow up calls to the physician or the pharmacy to treat the resident's intense pain. Nor would she have expected the nurse to provide any other interventions like an over the counter (OTC) medication, heat, or any other interventions because the goal was just to get the [MEDICATION NAME] on board to treat the pain. On 8/9/12 at approximately 10:00 a.m. the DON was interviewed again. She indicated that she would expect the nurse to chart on the resident's status related to his intense pain, what had been done to keep him comfortable, and whether or not it was effective. 3. Resident #20, a [AGE] year-old female, was admitted to the facility on [DATE]. According to the face sheet, her [DIAGNOSES REDACTED]. According to the admission minimum data set ((MDS) dated [DATE], the resident was cognitively intact, scoring 13 out of 15 possible points on the Brief Interview for Mental Status (BIMS). The resident required limited assistance with bed mobility, transfers, walking, toilet use, and personal hygiene. a. Resident Observation On 8/2/12 at 2:59 p.m., the resident was observed in her room. She was sitting up in bed. The resident's right arm was visualized. She had three dark bruises (approximately one inch in size and purple) in close proximity on her right forearm. b. Record Review - Failure to assess According to the pressure ulcer care plan dated 7/12/12, the resident was at risk for pressure ulcers related to moisture/incontinence, decreased activity, impaired mobility, co-morbid conditions, and nutrition/hydration risks. Approaches included a complete full body check weekly and document. According to the August 2012 computerized physician orders, as of 3/19/12, the resident was to have a weekly head to toe skin assessment on Thursdays. The resident's 7/12/12 skin assessment was reviewed. It showed the resident had multiple bruises on her extremities. The resident had no further documented skin assessments for the remainder of July 2012. The resident's 8/2/12 skin assessment was reviewed and no bruises were noted on the assessment. c. Staff Interview On 8/8/12 at approximately 2:00 p.m., the director of nursing (DON) was asked about the bruises on the resident ' s forearm. She said she would look into it. On 8/9/12 at 4:45 p.m., the DON said, " We did complete an investigation on the bruises. They had not been noted until it was brought to our attention. The floor nurse saw them but thought it was a vascular area. " d. Facility Follow-up A change of condition form was initiated on 8/8/12 (during survey) for, "3 small bruises to bilat(eral) forearms." A progress note showed, " Res(ident) noted to have 3 small bruises to bilat forearms. Res interviewed and states, " Of course I have bruises, I have vasculitis! " Res states no fear of staff or other residents. Res states, " I bruise easily. " Res also receives [MEDICATION NAME] therapy per doctor orders. Will cont(inue) to monitor res for additional s/s (signs or symptoms). Will report accordingly to MD. Will cont to monitor for any s/s frear/anxiety and changes in mood/bx (behavior). Non-pressure skin condition records were also initiated on 8/8/12 for two bruises on the right forearm and one bruise on the left arm.