Every finding on record at Peterson Rehabilitation and Healthcare

Based upon record reviews and staff interviews, the facility failed to ensure proper documentation of medical procedures. Blood pressures were documented for the wrong locations of dialysis patients. This was true for two (2) of two (2) residents reviewed under the Dialysis Pathway throughout the Long-Term Care Survey Process. Resident Identifiers: #8 and #11. Census 131. Findings include: a) Resident #8 During record review, conducted on 06/25/2026, it was identified that blood pressures (BPs) were being documented as taken in the resident's right arm a total of nine (9) times between 03/30/26 and 06/25/26. Resident #8's orders specifically stated not to take blood draws (lab work) or BP in the right arm due to an A/V Fistula (dialysis access) being present at that location. During an interview with the Director of Nursing (DON) and the Administrator, on 06/25/2026 at approximately 11:30 AM, they confirmed the documentation error. We realized we had an issue when we did a mini audit and did staff education and training. We did a whole plan of correction. The plan of correction provided was dated for 06/22/26 and included a training for all nursing staff about BPs and proper documentation for dialysis patients. All medical staff signed the training between 06/22/26 - 06/23/26. During a subsequent interview, Resident #8 stated they don't allow staff to take their BP in that arm ever. I have not had BP's or anything else done to that arm. b) Resident #11 A record review of dialysis care revealed Resident #11 had a physician order for no blood draws / injections / blood pressures from right upper arm. A medical record review found documentation of blood pressures being obtained in the right arm. During an interview on 06/29/26 at about 9:10 AM Resident #11 stated that he would not allow anyone to take blood pressures from his right arm. He stated that he protects his right arm. During an interview on 06/29/26 at 9:15 AM, the Director of Nursing (DON) confirmed the documentation was inaccurate.

Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of a medication left at bedside unattended Resident Identifier #11. Facility census 131. a) Resident #11An observation, on 06/22/26 at 12:23 PM, found two (2) pills in a 30 ml medication cup at Resident #11's bedside, unsecured and unattended and allowing access to this medication by wandering residents, unauthorized staff, or visitors. During an interview on 06/22/26 PM at 12:29 PM , Licensed Practical Nurse (LPN) #120 verified the two (2) Renvela pills (a prescription phosphate binder used to lower high blood phosphorus levels in adults with chronic kidney disease) should not be left out in the room. LPN #120 removed the 30ml medication cup at this time.A medical record review revealed, Resident #11 did not have physician's order for medication self-administration.

Based on observation, resident interview, record review, and staff interview, the facility failed to ensure meals were palatable and served at a safe and appetizing temperature. This was found during the Long-Term Care Annual Survey Process and had the potential to affect more than a limited number of residents. Resident Identifiers, #2, #11, #13, #17, #18 ,#44 and #84. Facility census: 131. Findings included: a) Policy Review Review of the facility's policy for food temperatures, read in part, 8.15.4.d At the time of receipt by the resident, foods shall be at a temperature of no less than 120 degrees Fahrenheit (F) for hot foods and at no more than 50 degrees F for cold foods. b) Resident Council Minutes Review of resident council meeting minutes over the last year revealed six (6) of 12 months reviewed had complaints of cold foods. c) Test Tray Results On 06/24/26, tray line service began at approximately 12:05 PM. The meal cart left kitchen at approximately 1:15 PM. The meal cart arrived at Wing 600 at approximately 1:35 PM. Test tray temperatures were obtained by the Dietary Manager at around 1:55 PM. The food temperatures were:-Regular roast beef-101 degrees F-Puree roast beef-100 degrees F-Puree carrots-100 degrees F-Mashed potatoes-104 degrees F-Pudding- 60 degrees F Review of meal service temperatures identified the following dates that did not have documented temperatures:- 06/18/26 for breakfast and lunch- 06/23/26 for lunch The Dietary Manager, on 06/24/26 at approximately 1:35 PM, verified temperatures were not documented and reported, I will educate them. d) Resident Interviews During interviews on 06/23/26 at approximately 2:00 PM: -Resident #17 reported, The food is usually cold. Sometimes I have the gals warm it up, that helps.-Resident #13 reported, It takes a good bit to get our food, usually it's cold.-Resident #13 reported, The food is ok, cold a lot though.-Resident #84 reports, I think if we got our food earlier it would not be cold-Resident #2 reported, The food is usually cold when we get it.-Resident #11 reported, We get our food late usually. It is almost always cold; I have them reheat at times.-Resident #44 reported, The flavor was good today, but the food was cold.-Resident #17 reported, The meal would have been good if it was warm. I asked them to heat it back up, that helped. During interviews on 06/24/26 at approximately 2:30 PM:-Resident #13 reported, I liked the flavor, but it was cold.-Resident #84 reported, The meal was pretty cold today, the flavor was good though.-Resident #2 reported I would have liked it better if it was warmer.-Resident #11 reported, It was pretty cold today, I needed it re-heated.-Resident #18 reported, The meal was really cold, so I ordered something else.

Based on observation and staff interviews, the facility failed to distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure all equipment used for meal deliveries was clean, that hotel pans were not air dried prior to storage, and that proper hair restraints were being utilized. The facility also failed to ensure any plastic items with large chips were removed from service. This was found during the annual Long-Term Care Survey Process and had the potential to affect more than a limited number of residents. Facility census 131.Findings include.A) review of Sanitization policy Statement reads- The food service area is maintained in a clean and sanitary manner. Policy interpretation and implementation reads in part. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.7. Food preparation equipment and utensils that are manually washed are allowed to air dry12. Plastic ware, China, and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment cannot be repaired and is discarded.B) review of policy for preventing foodborne illness-Employee hygiene and sanitary practices. Statement reads - Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.Policy interpretation and implementation reads in part. Hair nets: Hair nets or caps and/or beard guard are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clan equipment, utensils and linens.C) Initial tour of kitchen revealed.On 06/22/2026 at around 12:00 PM tour of kitchen with dietary manager, observed in the dry stock room three (3) cases of oil on floor, Dietary Manager verified it should be up off the floorOn 06/22/2026 at around 12:00PM during initial tour of kitchen with Dietary Manager, observed in the dry stock room moderate amount of food and trash debris on the bottom shelves, dried food debris under the shelves, Dietary Manager verified the area needed swept and cleaned.On 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed in the reach in refrigerator that is located in the dry stock room,empty, however observed moderate amount of dried liquid debris on the inside of the refrigerator where empty milk crates were being housed. Dietary Manager verified needing cleaned. Reports, We only use this for overages from the walk-in.On 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed in the freezer walk- in, under the shelves that are placed against the wall, moderate amount of food debris, dried liquid, the shelves with build up of debris dried white, and crumbs, the fan with moderate amount of dust and debris blowing outward. Dietary Manager verified area needing cleaned and that Maintenance would be informed to clean fan.On 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed the food delivery carts six (6) of six (6) with dried liquid debris, on inside and dried food debris on outside at handle. Dietary Manager verified these carts were ready for service and that they did need cleaned.On 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed on the stove back splash having a moderate amount of dried,sticky debris, the tray under the stove top with moderate amount of debris. Dietary Manager verified needing cleaned, reporting They usually clean these at end of shift, however the backsplash does need deep cleaned to remove the greasy, sticky debrisOn 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed the can opener with moderate amount of thick build up dark brown debris, Dietary Manager verified it needed to be cleaned.On 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed the floor under the prep tables with moderate amount of build up dark brown debris and paper debris. Dietary Manager verified needing cleaned.On 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed wet nesting to eight (8) of (10)hotel pans. Dietary Manager verified they were wet when stored.On 06/22/2026 at around 12:00PM during the tour of kitchen with Dietary Manager observed moderate amount of food debris inside the clean hotel pans found true for four (4) of six (6) pans observed. Dietary Manager verified they were not clean and removed the pans, then instructed staff to ensure all items are air dried and or clean prior to putting up.On 06/24/2026 around 11:00 AM follow up rounds in kitchen observed Dietary aides (62) and (124) in food prep areas without beard guard, manager verified and instructed placement. Food Delivery carts six (6)of eight (8) per dietary aide (62) verified they were cleaned and ready for use, however, noted food debris, dried liquid substance on inside of doors, and along outside. Dietary aide(62) verified they needed to be wiped down again.On 06/24/2026 at around 12:30PM, during observation of meal service (28) of (125) bases with large cracked and missing pieces sharp edging. Dietary manager verified needing replaced.On 06/29/2026 at around 11:50 AM during follow up walk through of the kitchen wet nesting was observed observed in (22) of (22) soup bowls, Dietary Manager verified these were not allowed to be air dried, then removed them and instructed staff to wash and allow to air dry.On 06/29/2026 at around 11:50AM during follow up walk through of the kitchen, wet nesting observed in four (4) of eight (8) hotel pans. Dietary Manager verified and education given to staff.On 06/29/2026 at around 11:50AM during follow up walk through of the kitchen, observed the Ice machine having moderate amount of dried white debris on side, to lid a moderate amount of food debris, along the floor surrounding the ice machine and wall behind a moderate amount of debris build up, dark brown in color. Dietary Manager verified cleaning needed done.

Based on observations and staff interviews, the facility failed to establish and 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 with regards to resident hand washing, and unsanitary practices with trash storage. These were random opportunities for discovery. This practice had the potential to affect all residents that reside in the facility. Facility census: 131. Findings included: a) Soiled Utility An observation, on 06/22/26 at 12:37 PM, of the soiled supply rooms on 500 and 600 halls revealed three (3) large bags of trash on both wings laying on the floor. During an interview on 06/22/26 at 12:45 PM with the Assistant Director of Nursing (ADON) verified the bags of trash should not be stored on the floor. b) Lunch Pass Hand Sanitation for Residents On 06/22/26 at 1:16 PM, during observation of lunch pass on the hallways there was no hand sanitation being completed for residents. This affected Resident #59. Nursing assistant #162 verified not washing residents hands. c) Lunch Pass Hand Sanitation for Staff On 06/22/26 at 1:32 PM, there was no hand sanitation or hand washing being completed by Licensed Practical Nurse (LPN) #98. LPN #98 verified this by stating she had her own hand sanitizer, which was on the desk, and that she didn't normally help with trays, LPN #98 stated she was just helping real quick. This affected Resident #53. d) 100 Wing On 06/22/2026 at around 1:30 PM, during observation of meal services, no resident or staff hand hygiene was completed. Nursing Assistant #11 reported, We usually just wash their hands in their rooms, and we use hand wash or hand sanitizer. Resident #124, #126, and #122 were in the day room for 100 wing eating their meals.

Based on record review and staff interview, the facility failed to ensure a comprehensive, person-centered care plan was in place for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD), for a resident receiving comfort care, and a resent ordered to use plastic utensils. This deficient practice was true for three (3) out of 33 sampled residents throughout the Long-Term Care Survey Process. Resident identifiers: #12, #17, and #23. Facility census: 131. Findings included:Findings included: a) Resident #23, PTSD Diagnosis Review of Resident #23's diagnosis list, on 06/25/26, revealed the resident was diagnosed with Post-Traumatic Stress Disorder PTSD), Unspecified on 05/08/26. Review of Resident #23's care plan, on 06/25/26, revealed the care plan did not specifically address PTSD. During an interview on 06/25/26 at 9:07 AM, the Director of Nursing (DON) acknowledged PTSD and potential triggers were not addressed in care plan. b) Resident #12, Comfort Measures Review of Physician note, dated 06/17/26, revealed Resident #12 was placed on comfort focused care, that resident's family was aware and in agreement. Review of Resident #12's care plan, on 06/29/26, did not address comfort focused care. During an interview on 06/30/26 at 3:37 PM, the DON acknowledged physician ordered comfort measures had not been put into care plan but would be as of that date. c) Resident #17, Use of Plastic Utensils On 06/29/26 at approximately 11:30 AM. a review of physician orders/care plan progress notes revealed an order for Resident #17 to have plastic utensils for meals. No reason given. There were no care plan interventions as to use of plastic utensils during meals. During a subsequent interview, the Administrator reported, He gets the plastic utensils because he tries to cut the wander guard off. A review of progress notes and care plan was then conducted. There was no mention of plastic utensils being used. During an interview on 06/29/26 at 1:15 PM, the DON reported, He gets these due to he tries to cut the wander guard off. When questioned if the need for these utensils were reviewed, the DON reported, Yes, we review at care plan meetings and as needed. The State Agency (SA) requested copies of any care plan notes / progress notes were use of plastic utensils had been reviewed. Nothing was shared with the SA prior to completion of the survey process.

Based on medical record review and interview, the facility failed to revise a person-centered comprehensive care plan. The facility failed to revise care plans for behaviors. This practice affected one (1) of (33) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifier #110. Facility census: 131. Findings included:a) Resident #110On 06/22/26 an observation of Resident #110 found her sitting in the hallway eating lunch in a Styrofoam container with plastic utensils. A review of Resident #110's medical record showed the diet order, Styrofoam and plastic ware with all meals.A review of the current care plan showed there was an active care plan addressing the diet order for Styrofoam and plastic ware. There was no focus, intervention or behaviors noted for the use of plastic ware. On 06/23/26 at 12:39 PM, a second observation revealed Resident #110 eating in the hall out of a Styrofoam container with plastic ware.During an interview at 12:44 PM, Nurse Aide #165 stated that she was unsure why Resident #110 had to eat out of the containers and not allowed to have silverware.An interview on 06/24/26 at 11:45 AM with the Director of Nursing (DON) and Administrator, verified that Resident #110's care plan was not revised to reflect the resident's current status and behaviors of throwing dishes and silverware.

Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PASSAR) reflected pre-admission diagnoses for one (1) of two (2) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #26. Facility Census 131.Findings Included:a) Resident #26A record review of the resident's electronic medical record (EMR), the resident's most recent PAS, dated 02/06/26, indicated no level II not required. Section lll, Question #30 MI/MR Assessment indicated Anxiety and history of seizure diagnosis.The record also revealed indicated the resident had a diagnosis of schizophrenia on admission, 02/09/26, but did not receive a new PAS to address whether or not specialized services were needed. On 06/24/26 at 10: 00 AM, the Director of Nursing (DON) and Administrator verified Resident #26's PAS did not reveal his diagnosis of schizophrenia. The DON confirmed a new PAS was not completed.

Based on interview and record review, the facility failed to thoroughly investigate potential verbal and sexual abuse, failed to implement interventions to prevent further abuse and mistreatment from occurring while the investigation was in progress; and failed to take appropriate corrective action to ensure that the abuse or mistreatment would not recur. Resident Identifiers: Residents #5, #27, #46, #51, #75, #76, and #119. Facility Census: 137. Findings IncludeRecord review revealed that Resident #161 was no longer at the facility. a) Resident #5Record review on 10/06/24 at approximately 4:25 PM revealed the following: A note on 05/10/25 at 7:19 AM by LPN #131Resident repeatedly going into a female Residents room while they where sleeping. This nurse redirected resident to leave and go back to his floor. Explained that he can not be in female residents room. Supervisor made aware. A note on 05/14/25 at 6:30 AM by Director of Nursing (DON), which stated: Resident continuing to go into Female Residents rooms while they are sleeping. Redirected with effect Another note on 05/14/25 at 3:44 PM by the DON, which stated:social services notified about resident going into other residents rooms On 05/15/25 at 9:01 AM SW #304 documented a progress note which stated: SW spoke with resident in length on 5/14/25 about his entering other resident's room at night when residents are sleeping. This SW told [Resident] he is not permitted to enter other residents' rooms at any time unless he is given permission by the resident who occupies that room. SW explained that he was violating other resident's rights and privacy. [NAME] agreed that he would not go in and out of other resident's room. A note on 05/15/25 at 5:30 PM by RN #73 stated:Resident was observed entering room [ROOM NUMBER]. Bed 1 (Resident #5) was asleep and bed 2 (Resident #84) told him to leave. During a phone interview with LPN #131 on 10/07/25 at 11:14 AM, LPN #131 stated that Resident #161 would enter the female residents' rooms, and the staff would attempt to make him leave. She stated that she knew of two female residents' rooms that he went to. Resident #5 and Resident #27. She stated that every time she attempted to make him leave, he would curse at her and call her you [NAME] bitch.LPN #131 stated that she had submitted a report to her supervisor. b) Resident #27During an interview with Resident #27 on 10/07/25 at approximately 10:20 AM, Resident #27 stated that Resident #161 would try to be 'sexual' with her by rubbing her arms and legs. She said that she had made a complaint on 04/05/25, and the facility had investigated the incident. She stated that Resident #161 was no longer in the facility. A record review revealed that resident #161 had discharged himself from the facility on June 6, 2025. Upon being asked whether Resident #161 had raped or performed any sexual act on her, Resident stated that that did not happen!Further record review on 10/07/25 revealed that the resident had called 911 from her cell phone, and EMS had come in and taken her to the hospital for evaluation. Skin assessment revealed no redness, no bruises to the groin, buttocks, stomach, or breasts. Evaluation results showed an elevated blood pressure and Troponin level. During another interview on 10/07/25 at approximately 1:35 PM, upon being asked whether Resident #161 had touched her under her clothes, she stated, No, he touched my arms and legs. Upon being asked about the statement she had given on 04/05/25, Resident #27 stated that she did not say that she had been raped. She stated that she did not feel well and felt that there was something inside me that needs to come out. She further stated that the Nursing Assistant (NA) had told her that there was blood around the room. Resident stated that Resident #161 had been in her room, and she was aware that Resident #161 frequently hits his stumps while ambulating around in his wheelchair and bleeds.The resident was re-directed to the incident on 04/06/25 and asked why she had called 911. She stated that she had not felt well, and They were watching me. She also stated that They were trying to kill me, I felt there was something inside me and it needed to come out! Resident stated that after she visited the hospital, she felt better. Resident #27 is diagnosed with Huntington's Disease, Unspecified Mood (Affective) Disorder, Anxiety Disorder, Depression, Legal Blindness and Hypertension. During a phone interview on 10/07/25 at approximately 8:55 AM, with the resident's mother, who is her Medical Power of Attorney (MPOA), she stated that she lives about an hour and a half away from the facility. She went on to state that her daughter has paranoia and is also blind. Upon being asked whether Resident #27 had expressed any complaints or concerns, MPOA stated that her daughter had not mentioned anything to her. MPOA was aware of the incident at the facility, and that Resident #27 had 'panicked' and called 911 and had been taken to the hospital. MPOA stated that she usually tries to take her daughter home with her for at least a few days every other month. MPOA stated that if her daughter had any concerns, she would usually bring them up. Upon being asked whether Resident #27 had mentioned any residents or staff to her, MPOA stated that her daughter had not mentioned anyone specifically, but she was comfortable talking to SW #38Record review on 10/07/25 at 1:25 PM revealed an initial report had been submitted to the Office of Health Facility Licensure and Certification (OHFLAC) on 04/06/25 at 3:45 PM.Record review on 10/07/25 revealed the following note dated 04/08/25 at 3:56 PM by Social Worker (SW) #304, which stated:SW spoke to [Resident] this morning about the issues of him going into female resident rooms and touching them inappropriately. Staff have documented that [Resident] has these inappropriate behaviors. SW told [Resident] that that he was not permitted to enter another resident's room in the facility. SW was very clear with resident about above. SW explained that if he continues to have inappropriate behaviors such as touching other females resident that this could be grounds for a 30-day notice of discharge. Resident stated that he understood.During a phone interview with LPN #131 on 10/07/25 at 11:14 AM, LPN #131 stated that Resident #161 would enter the female residents' rooms, and the staff would attempt to make him leave. She stated that she knew of two female residents' rooms that he went to. Resident #5 and Resident #27. She stated that every time she attempted to make him leave, he would curse at her and call her you [NAME] bitch.LPN #131 stated that she had submitted a report to her supervisor.The five-day follow-up was submitted on 04/11/25 at 6:59 PM. Facility had performed an investigation and interviewed all female residents. The residents had stated that no one had entered their rooms or touched them. Resident #161 had admitted to visiting Resident #27 but had denied touching her. The facility had stated that the investigation was inconclusive. c) Resident #51A note on 04/17/25 10:15 PM by RN #158 stated:Resident observed propelling in hallway attempting to go to room [ROOM NUMBER]. (Resident #51 and Resident #75) Nursing Assistant (NA) informed resident he was not to be on wing 3 stated he is an adult and can do what he wants. NA redirected resident back to wing 7Record review on 10/07/25 at 9:45 AM revealed that the facility had not attempted to interview Resident #51 to ensure that she was safe and free of abuse or mistreatment. d) Resident #75A note on 04/17/25 10:15 PM by RN #158 stated:Resident observed propelling in hallway attempting to go to room [ROOM NUMBER]. (Resident #51 and Resident #75) Nursing Assistant (NA) informed resident he was not to be on wing 3 stated he is an adult and can do what he wants. NA redirected resident back to wing 7Record review on 10/07/25 at 9:45 AM revealed that the facility had not attempted to interview Resident #75 to ensure that she was safe and free of abuse or mistreatment. e) Resident #76Record review on 10/07/25 at 10:00 AM revealed a nursing note dated 30/17/25 22:54 by RN #301 which stated:Resident was seen by staff kissing Resident # 161 in this resident's room. A follow-up note on 03/18/25 at 11:07 AM by RN #144 which noted:(POA) was notified of incident with another resident. POA stated that resident behaviors are within her rights. No interventions needed at this time. During a phone interview with Resident's Power of Attorney (POA), who was a Case Manager from Adult Protective Services, regarding Resident #76, on 10/07/25 at approximately 8:59 AM, POA stated that she visits resident about once every two months. She also stated that resident likes men and makes her own decisions. A review of Resident #76's Care Plan on 10/07/25 at 9:25 AM revealed the following:FOCUSSexual behavior-seeking physical affection from male residents; related need for attentionDate Initiated: 01/25/2023Created by: (Unit Manager)Revision on: 01/25/2023Revision by: (Unit Manager)GOALWill only engage in sexual activity with consenting partnersDate Initiated: 01/25/2023Created by: (Unit Manager)Target Date: 01/25/2026INTERVENTIONSAvoid conversations/television/radio that could encourage or initiate inappropriate behaviorDate Initiated: 01/25/2023Created by: (Unit Manager) Provide privacy/remove to a private areaDate Initiated: 01/25/2023Created by: (Unit Manager)Supervise in social gathering/recreation programsDate Initiated: 04/05/2024Created by: [NAME] (Social Service Coordinator) During an interview with Resident #76 on 10/06/25 at approximately 1:24 PM, resident was observed sitting in the common area. Resident was pleasant but slurred her words while speaking. When asked about Resident #161, resident stated oh yeah! I When she was asked if Resident #161 had touched her anywhere, she smiled and said I liked him! Resident #76 did not say anythinh more. f) Resident #119 Record review on 10/06/25 at approximately 2:10 PM revealed the following note dated 11/27/24by RN #94 which stated:This patient (Resident #161) along with (Resident #53) sat outside the doorway of 704. Both patients yelling insults and curses into the room at 704-1 (Resident #119) This nurse overheard Waaaa, stick your finger up my A$$. Asked the patients to stop, unacceptable and no one wanted to hear such language. This patient threatened this nurse, Do you want to fight? Both patients refused to leave the spot outside the room, neither would move to a common area. Reported to charge nurse and social services. Will continue to monitor.Further record review revealed another note dated 12/11/24 at 4:49 PM by RN #94 which stated:Resident #161 exchanging inappropriate insults with roommate (Resident #119). During an interview wit Resident #119 on 10/06/25 at approximately 2:55 PM, when asked about the argument with Resident #161, he stated he is no longer here, and that he was an ass. A review of the Concern/grievance Log revealed that the incident was logged, but the facility did not recognize this as an instance of verbal abuse between residents and failed to report it to OHFLAC. In addition the facility failed to investigate and failed to take appropriate action to ensure that the abuse would not continue.

Based on interview and record review, the facility failed to identify potential incidents of abuse, report the alleged violations, and implement interventions to prevent further abuse and mistreatment from occurring Resident Identifiers: Residents #161 and #46. Facility Census: 137. Findings Include a) Resident #161 Record review on 10/06/24 at approximately 4:25 PM revealed that Resident #161 was no longer at the facility. Further record review revealed the following: A note on 05/14/25 at 6:30 AM by Director of Nursing (DON), which stated: Resident continuing to go into Female Residents rooms while they are sleeping. Redirected with effect Another note on 05/14/25 at 3:44 PM by the DON, which stated: social services notified about resident going into other residents rooms On 05/15/25 at 9:01 AM SW #304 documented a progress note which stated: SW spoke with resident in length on 5/14/25 about his entering other resident's room at night when residents are sleeping. This SW told [Resident] he is not permitted to enter other residents' rooms at any time unless he is given permission by the resident who occupies that room. SW explained that he was violating other resident's rights and privacy. [Resident] agreed that he would not go in and out of other resident's room. Resident #161 was observed attempting to enter Resident #5's room as evidenced by this note on 05/21/25 at 12:20 AM by RN #94 which stated: [Resident #161] sitting outside 707 where female patients were sleeping (Resident #76 and Resident #26). Aide stopped patient from entering and effectively redirected patient away from bedroom. Record review of the resident's care plan on 10/06/25 at approximately 4:20 PM revealed Resident #161's Care Plan notes that state the following: FOCUS: Resident has behaviors related to inappropriate sexual behaviors Date Initiated: 11/29/2024 Created by: (MDS Coordinator) Revision on: 06/09/2025 Revision by: (MDS Coordinator) Cancelled Date: 06/09/2025 GOAL: Resident will have no adverse effects related to behaviors through the next review. Date Initiated: 11/29/2024 Created by: (MDS Coordinator) Revision on: 06/09/2025 Revision by: (MDS Coordinator) Target Date: 08/04/2025 Cancelled Date: 06/09/2025 INTERVENTIONS/TASKS: Administer medications per physician order. Monitor for effectiveness and side-effects. Date Initiated: 11/29/2024 Created by: (MDS Coordinator) Revision on: 06/09/2025 Revision by: (MDS Coordinator) Cancelled Date: 06/09/2025 Approach resident in a calm manner to avoid frustration and behavior escalation; If resident becomes agitated and shows signs of escalation, re-approach later. Date Initiated: 11/29/2024 Created by: (MDS Coordinator) Revision on: 06/09/2025 Revision by: (MDS Coordinator) Cancelled Date: 06/09/2025 Record review on 10/07/25 revealed multiple reports by staff and the Social Worker, over a period of over six (6) months, stating that Resident #161 was indulging in sexually inappropriate behaviors with female residents, as evidenced by the following progress notes: A note on 11/27/24 by Registered Nurse (RN) #94, which stated: This patient (Resident #161) along with 706-2 (Resident #53) sat outside the doorway of 704. Both patients yelling insults and curses into the room at 704-1 (Resident #119). This nurse overheard Waaaa, stick your finger up my A$$. Asked the patients to stop, unacceptable and no one wanted to hear such language. This patient threatened this nurse, Do you want to fight? Both patients refused to leave the spot outside the room, neither would move to a common area. Reported to charge nurse and social services. Will continue to monitor. A note on 12/11/24 at 4:49 PM by RN #94, which stated: Patient (Resident #161) exchanging inappropriate insults with roommate (Resident #119). A review of the Concern/grievance Log revealed that the incident was logged, but the facility did not identify this as an instance of verbal abuse between residents, failed to report it to OHFLAC, and failed to take appropriate action to ensure that the abuse would not continue. A note on 04/04/25 at 10:45 PM by (RN) #305, which stated: Resident exhibiting inappropriate behaviors with another resident. A nursing note on 04/07/25 at 11:01 PM by Licensed Practical Nurse (LPN) #303, which stated: Resident asked by staff several times to leave female residents rooms. Resident becomes agitated with staff but does leave once requested. A note on 04/08/25 at 3:56 PM by Social Worker (SW) #304, which stated: SW spoke to [Resident] this morning about the issues of him going into female resident rooms and touching them inappropriately. Staff have documented that [Resident] has these inappropriate behaviors. SW told [Resident] that he was not permitted to enter another resident's room in the facility. SW was very clear with resident about above. SW explained that if he continues to have inappropriate behaviors such as touching other females resident that this could be grounds for a 30-day notice of discharge. Resident stated that he understood. Another note on 04/17/25 10:15 PM by RN #158 which stated: Resident observed propelling in hallway attempting to go to room [ROOM NUMBER]. (Resident #51 and Resident #75) Nursing Assistant (NA) informed resident he was not to be on wing 3 stated he is an adult and can do what he wants. NA redirected resident back to wing 7 A note on 04/26/25 at 1:25 AM by LPN #168, which stated: Pt holding hands with another female pt in the center core 2nd floor A note on 05/10/25 at 7:19 AM by LPN #131 Resident repeatedly going into a female Residents room while they where sleeping. This nurse redirected Resident to leave and go back to his floor. Explained that he can not be in female Residents room. Supervisor made aware. A note by Nurse Practitioner (NP) #306 on 05/14/25, which stated: History Of Present Illness: [Resident] alert and oriented known to our facility status post bilateral amputations. Patient was discharged independently to his own apartment was doing well however presented to the emergency room on 10/28 with increased weakness. It is noted that patient was evicted from his apartment due to deplorable conditions. Patient has a long history of diabetes bilateral BKA's A-fib on Eliquis CVA depression. Patient was admitted into the hospital with failure to thrive alteration of self-care positive morbid obesity with a BMI of 40 to 44.9%. Possible long-term care due to inability to care for himself At this time noted patient does have a history of CKD 3 is followed by nephrology along with uncontrolled diabetes. Last A1c was 13.6, questionable compliance at this time. patient returns back to facility due to homeless at this time review of A1c (10.3) and noted continues to be on humalog 10u ac meals, sliding scale and lantus 20u bid trulicity 3mg qwk increased this week and noted continues to have elevated blood sugars non compliant with oral intake and noted blood sugars fluctuate noted patient becomes inappropriate with female patients at times. needs redirected A note on 05/14/25 at 6:30 AM by Director of Nursing (DON), which stated: Resident continuing to go into Female Residents rooms while they are sleeping. Redirected with effect Another note on 05/14/25 at 3:44 PM by the DON, which stated: social services notified about resident going into other residents rooms On 05/15/25 at 9:01 AM SW #304 documented a progress note which stated: SW spoke with resident in length on 5/14/25 about his entering other resident's room at night when residents are sleeping. This SW told [Resident] he is not permitted to enter other residents' rooms at any time unless he is given permission by the resident who occupies that room. SW explained that he was violating other resident's rights and privacy. [Resident] agreed that he would not go in and out of other resident's room. A note on 05/15/25 at 5:30 PM by RN #73 stated: Resident was observed entering room [ROOM NUMBER]. Bed 1 (Resident #5) was asleep and bed 2 (Resident #84) told him to leave. On 05/15/25 at 1:37 PM SW #38 noted: QCC 5/15/25: In attendance were social services, nursing, and activities. (Resident #161) was in attendance as well. Code status discussed and may change. Funeral home reviewed. Diet discussed with [Resident]. Weight was discussed, as [Resident] has had a gain. Weight gain explained by nursing. Care plan reviewed and discussed. [Resident] stated he has no concerns or questions. A request was submitted to the facility on [DATE] at 10:15 AM for contact information for the following staff members: RN #73, RN #94, RN #305, and LPN #168. The facility submitted the requested contact information at 11:50 AM on 10/07/25. During an interview on 10/06/25 at approximately 4:11 PM with RN #73 stated that Resident #161 was 'social' and he would talk with female residents. She stated that he had probably gone into room [ROOM NUMBER] to speak to Resident #5. RN #73 stated that to her knowledge Resident #161 had not exhibited sexually inappropriate. Behaviors. During an interview with SW 38 on 10/07/25 at approximately 10:32 AM, he stated that he was currently responsible for submitting reports to OHFLAC and APS when necessary. He also stated that Resident #161 had been followed by SW 304, who was no longer at the facility, as she had retired about one month ago. SW #38 also confirmed that he was aware of complaints Resident #161 going into female resident's rooms and being inappropriate with them. He stated that SW #304, who had been the Director of Social Services at the time, had dealt with the complaints, and he assumed that she would have submitted a report to OHFLAC and APS if she had deemed it necessary. Upon being asked what he would have done about the complaints about Resident #161, SW #38 stated that he would have consulted with the Administrator and deferred to her judgment on filing a report. During a phone interview with LPN #131on 10/07/25 at 11:14 AM, LPN #131 stated that Resident #161 would go into the female residents' rooms, and the staff would go and try to make him leave. She stated that she knew of two female residents' rooms that he went to. Resident #5 and Resident #27. She stated that every time she attempted to make him leave, he would curse at her and call her you [NAME] bitch. LPN #131 stated that she had submitted a report to her supervisor. During another phone interview on 10/07/25 at approximately 4:00 PM, with RN #94, revealed that Resident #161 frequently went into female residents' rooms while they were sleeping. She stated that Resident #161 is a bilateral below the knee amputee who uses a wheelchair for ambulation. She also added that resident was a very 'bad driver' who frequently rammed into obstacles, injuring his limbs in the process. RN #94 then stated that she assumed that Resident #161 was looking for someone to talk to, when he went into residents' rooms. RN #94 also stated that all the staff were aware that they were to watch Resident #161, and re-direct him out of the female residents' rooms. During an interview with the Administrator on 10/08/25 at approximately 10:20 AM, she confirmed that the facility had not considered interviewing female residents, or investigating the incidents because no residents had submitted any complaints. In addition, the Administrator referred to the verbal altercation between Residents #161, #53, and #119 on 11/27/24, and stated that it was an argument, and not considered reportable. Despite these multiple incidents, the facility failed to report the incidents, failed to address Resident #161's actions during the Quality Assurance (QA) meeting, and failed to investigate and report potential resident abuse. b) Resident #46 -Family interviews: -On 10/06/25 at 2:30 PM, A telephone interview was conducted with Resident # 46's daughter, She stated her mother had spoken to the staff nurse r/t her father's complaint of pain on 08/06/25. - --Then on 08/08/25, Resident #46's daughter reported her father's lack pain and anxiety management to the DON. She said the DON stated she was unaware of her mother's complaint made on 08/06/25, but would check into it. -On 10/06/2025 at 2:45 PM, a telephone interview was conducted with resident #46's granddaughter, she stated she had reported her grandfather's high pain level to staff during a visit with him on 07/26/25 at approximately 2:30PM and waited several hours for staff to give him his PRN medication. She stated she knew he was allowed to have his pain meds every hour if needed. She stated she complained several times to staff while waiting. Record Review: -During a record review on 10/07/25 at 12:35 PM, It was found that License Practical Nurse(LPN) # 34, documented a progress note dated 08/06/25, which stated: Resident # 46 called his wife twice c/o pain in his penis and his wife called this facility each time and asked for him to be given Morphine. Once LPN # 34 checked Resident's foley was in working order. She noted she did adjust location of foley, placed a leg strap on R leg and attached the foley tubing. per patient still having pain. LPN # 36 gave him morphine and methocarbamol 500 mg. and was resting comfortably. -On 08/08/2025 at It was noted a progress statement from the Director of Nursing (DON), which stated: Family spoke to me today regarding, they don't think his pain or anxiety is being controlled, placed a call to hospice/waiting on a call back regarding these concerns of the family. -On 10/07/23 at 1:30 PM, a review of the facility's Abuse and Neglect policy revealed that an event may not be perceived by staff to constitute resident neglect; however, if a resident, family member, or visitor perceived the event to be neglect, the facility must report the event. -A review of the facility's reportable log, completed on 10/08/25 at 10:35AM, revealed the allegations of abuse on 08/06/25, 08/08/25, or 07/26/25 had not been entered on the Grievance/Concern log nor reported to appropriate state agencies. Staff Interviews: -During an interview on 10/08/25 with LPN #36, she stated she went to check on Resident #46 on 08/06/25 due to Resident #46's family member's phone call reporting Resident complaining of pain in his penis. On 10/08/25 at 11:40 AM, an interview was conducted with the DON. She acknowledged the complaints made on dates 08/06/25, 08/08/25 and 07/26/25 had not been logged on the concern/grievance logs, nor reported to the appropriate agencies.

Based on interview and observation the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident room [ROOM NUMBER]. Facility Census: 137.Findings Include a) room [ROOM NUMBER]During an interview with Resident #27 in room [ROOM NUMBER], on 10/07/25 at approximately 10:20 AM, the bathroom door was open and a 'pool noodle' was observed taped with orange tape, to the entire length of the water pipe leading to the commode. The flush handle too was covered with foam and tape. When asked about it, Resident #27 stated, It was there when I came to this room! During an interview with the Director of Nursing (DON), on 10/07/25 at approximately 11:00 AM, she stated that it had been installed when another resident occupied the room. DON confirmed that it was an infection control issue because it could not be properly sanitized. She stated, I'll get it removed immediately!

Based on interview, and record review, the facility failed to document the resident's grievance, and failed to make prompt efforts to resolve those grievances. Resident Identifiers: Resident #76. Facility Census: 137. Findings Include a) Resident #76During an interview on 10/07/25, at approximately 1:15 PM, the resident indicated that she had requested a room change due to difficulties sleeping at night. When asked about the reasons for her sleeplessness, Resident #76 mentioned that her roommate often makes a lot of noise during the night.When asked if she had informed the facility about her issues, the resident replied that she had notified both the nurse and the Director of Nursing (DON) about her complaint and had requested a room change in late August. While she could not recall the name of the nurse she had spoken to, she was confident that she had communicated with the DON. She mentioned that she was still waiting for a transfer to another room and that the DON had informed her that the facility was working on moving her as soon as a bed became available.A request for the Complaint and Grievance logs, on 10/07/25 at 10:35 AM revealed that the facility maintains documents titled Concern/Grievance logs . A review of the logs for the period 08/01/25 through 09/30/25 revealed no concerns or grievances noted for Resident #76.During an interview with the DON on 10/08/25 at approximately 9:55 AM, she stated that she was unaware of Resident #76's request. The DON confirmed that the facility was experiencing some difficulties with documentation and stated that they were actively working to train staff to ensure accurate documentation.

Based on record review and interview, the facility failed to revise and update the resident's care plan, and implement interventions to ensure that residents at the facility were free from abuse. Resident Identifier: #161. Facility Census: 137.Findings Include a) Resident #161Record review on 10/06/24 at approximately 4:25 PM revealed that Resident #161 was no longer at the facility.Record review on 10/07/25 revealed multiple reports by staff and the Social Worker, over a period of over six (6) months, stating that Resident #161 was indulging in sexually inappropriate behaviors with female residents, as evidenced by the following progress notes:[Typed as Written]A note on 11/27/24 by Registered Nurse (RN) #94, which stated:This patient (Resident #161) along with 706-2 (Resident #53) sat outside the doorway of 704. Both patients yelling insults and curses into the room at 704-1 (Resident #119). This nurse overheard Waaaa, stick your finger up my A$$. Asked the patients to stop, unacceptable and no one wanted to hear such language. This patient threatened this nurse, Do you want to fight? Both patients refused to leave the spot outside the room, neither would move to a common area. Reported to charge nurse and social services. Will continue to monitor.A note on 12/11/24 at 4:49 PM by RN #94, which stated:Patient (Resident #161) exchanging inappropriate insults with roommate (Resident #119). A review of the Concern/grievance Log revealed that the incident was logged, but the facility did not identify this as an instance of verbal abuse between residents, failed to report it to OHFLAC, and failed to take appropriate action to ensure that the abuse would not continue. A nursing note on 04/07/25 at 11:01 PM by Licensed Practical Nurse (LPN) #303, which stated:Resident asked by staff several times to leave female residents rooms. Resident becomes agitated with staff but does leave once requested. A note on 04/08/25 at 3:56 PM by Social Worker (SW) #304, which stated:SW spoke to [Resident] this morning about the issues of him going into female resident rooms and touching them inappropriately. Staff have documented that [Resident] has these inappropriate behaviors. SW told [Resident] that he was not permitted to enter another resident's room in the facility. SW was very clear with resident about above. SW explained that if he continues to have inappropriate behaviors such as touching other females resident that this could be grounds for a 30-day notice of discharge. Resident stated that he understood. A note on 05/14/25 at 6:30 AM by Director of Nursing (DON), which stated: Resident continuing to go into Female Residents rooms while they are sleeping. Redirected with effect Another note on 05/14/25 at 3:44 PM by the DON, which stated:social services notified about resident going into other residents rooms On 05/15/25 at 9:01 AM SW #304 documented a progress note which stated: SW spoke with resident in length on 5/14/25 about his entering other resident's room at night when residents are sleeping. This SW told [Resident] he is not permitted to enter other residents' rooms at any time unless he is given permission by the resident who occupies that room. SW explained that he was violating other resident's rights and privacy. [Resident] agreed that he would not go in and out of other resident's room. Resident #161 was observed attempting to enter Resident #5's room as evidenced by this note on 05/21/25 at 12:20 AM by RN #94 which stated: [Resident #161] sitting outside 707 where female patients were sleeping (Resident #76 and Resident #26). Aide stopped patient from entering and effectively redirected patient away from bedroom. Record review of the resident's care plan on 10/06/25 at approximately 4:20 PM revealed that the facility was aware of Resident #161's sexually inappropriate behaviors since 11/29/24 as evidenced by the following notes:FOCUS:Resident has behaviors related to inappropriate sexual behaviorsDate Initiated: 11/29/2024Created by: (MDS Coordinator)Revision on: 06/09/2025Revision by: (MDS Coordinator)Cancelled Date: 06/09/2025GOAL: Resident will have no adverse effects related to behaviors through the next review.Date Initiated: 11/29/2024Created by: (MDS Coordinator)Revision on: 06/09/2025Revision by: (MDS Coordinator)Target Date: 08/04/2025Cancelled Date: 06/09/2025INTERVENTIONS/TASKS:Administer medications per physician order. Monitor for effectiveness and side-effects.Date Initiated: 11/29/2024Created by: (MDS Coordinator)Revision on: 06/09/2025Revision by: (MDS Coordinator) Cancelled Date: 06/09/2025Approach resident in a calm manner to avoid frustration and behavior escalation; If resident becomes agitated and shows signs of escalation, re-approach later.Date Initiated: 11/29/2024Created by: (MDS Coordinator)Revision on: 06/09/2025Revision by: (MDS Coordinator) Cancelled Date: 06/09/2025 A note on 05/15/25 at 5:30 PM by RN #73 stated:Resident was observed entering room [ROOM NUMBER]. Bed 1 (Resident #5) was asleep and bed 2 (Resident #84) told him to leave. On 05/15/25 at 1:37 PM SW #38 noted:QCC 5/15/25: In attendance were social services, nursing, and activities. (Resident #161) was in attendance as well. Code status discussed and may change. Funeral home reviewed. Diet discussed with [Resident]. Weight was discussed, as [Resident] has had a gain. Weight gain explained by nursing. Care plan reviewed and discussed. [Resident] stated he has no concerns or questions. During an interview with SW 38 on 10/07/25 at approximately 10:32 AM, he stated that he was currently responsible for submitting reports to OHFLAC and APS when necessary. He also stated that Resident #161 had been followed by SW 304, who was no longer at the facility, as she had retired about one month ago. SW #38 also confirmed that he was aware of complaints Resident #161 going into female resident's rooms and being inappropriate with them. He stated that SW #304, who had been the Director of Social Services at the time, had dealt with the complaints, and he assumed that she would have submitted a report to OHFLAC and APS if she had deemed it necessary. Upon being asked what he would have done regarding the complaints about Resident #161, SW #38 stated that he would have consulted with the Administrator and deferred to her judgment on filing a report. During an interview with the Administrator and Director of Nursing (DON) on 10/07/25 at approximately 1:30 PM, they confirmed that the resident's Care Plan had not been updated to reflect implementations to prevent further abuse of other residents.

Based on record review and interview, the facility failed to ensure that a licensed nurse completed a timely assessment and intervention in response to an acute change in condition for a resident identified as high risk for bleeding due to anticoagulant therapy. This verifies a complaint that the facility failed to provide care in noncompliance with 42 CFR S483.25 (Quality of Care - F0684).Entry: 10/06/2025 at 12:00 PMFacility Census: 137RE: FRI #2561221Status: Verified- The facility failed to ensure that a licensed nurse completed a timely assessment and intervention in response to an acute change in condition for a resident identified as high risk for bleeding due to anticoagulant therapy.Date Complaint Received: 07/12/2025 at 8:38 AMAllegation Date (per complainant): 05/12/15 at 5:38 PMAllegation Summary:Resident #160 experienced a prolonged nosebleed that was not promptly or properly treated.Staff allegedly provided only washcloths and ice.Complainant states the nurse could not respond due to excessive patient load.A staff member told the complainant that anything positive I've heard about the facility lied to me.Complainant expresses fear of the hospital returning the resident to the facility.Investigation Actions:Record review showed the resident was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, morbid obesity (BMI 65.8), muscle weakness, and atrial fibrillation. The resident was prescribed Rivaroxaban (Xarelto) 20 mg daily for atrial fibrillation, which placed her at increased risk for bleeding.The record showed the resident received intravenous fluids on 07/10/2025 and had a complete blood count and comprehensive metabolic panel (CBC/CMP) completed on 07/11/2025. On 07/12/2025 at 14:41, the facility generated a skilled nursing note documenting that the resident was receiving oxygen at 3 liters per minute via nasal cannula and had diminished lung sounds. Review of the facility Kardex for that date showed multiple routine CNA and nursing tasks listed as Canceled-Requires documentation.The facility's discharge summary was dated 07/12/2025 but was revised on 08/13/2025. The record did not contain contemporaneous nursing documentation or assessment corresponding to the family-reported episode of active nasal bleeding that began at approximately 17:38 on 07/12/2025. No change-in-condition assessment, vital signs, or licensed-nurse follow-up was documented related to this episode. Progress notes indicated the resident later contacted emergency medical services and was transported to the hospital.Review of the oxygen saturation log showed the resident's last documented reading was 97% on room air at 16:08 on 07/12/2025. No subsequent oxygen saturation readings or respiratory assessments were documented following the onset of the reported nosebleed at approximately 17:38. The facility failed to reassess and document the resident's oxygenation status following an acute change in condition involving active bleeding in a resident with a history of respiratory failure, while receiving oxygen therapy at three liters per minute via nasal cannula.Review of the physician order summary for 07/01/2025-10/31/2025 revealed no new orders were entered on or after 07/12/2025 related to the resident's reported nosebleed or subsequent hospital transfer. The last clinical order was for laboratory testing completed on 07/11/2025. The record contained no provider orders for nasal care, respiratory monitoring, or change-in-condition evaluation. The absence of any new physician orders during or following the reported acute event indicates the facility failed to assess, notify, and obtain medical direction in response to a significant change in condition for a resident at high risk for bleeding.Review of the Medication Administration Record (MAR) showed rivaroxaban (Xarelto) 20 mg administered on 07/12/2025 at 17:00 hours by LPN C. [NAME] for atrial fibrillation. The reported onset of epistaxis occurred at approximately 17:38 hours, less than one hour after the scheduled anticoagulant dose. No PRN medications for nasal hemostasis (e.g., oxymetazoline, saline gel), oxygen humidification, or change-in-condition interventions were documented during or after the bleeding episode. The MAR contained no documentation of vital-sign reassessment, physician notification, or new treatment orders following the event.The Order Summary (07/01/2025-10/31/2025) reflected no new provider orders entered on or after 07/12/2025, and the Discharge Summary contained no contemporaneous nursing assessment or documentation of the acute episode.At 16:01 hours, the facility Administrator stated to the surveyor that the resident was only here for four days - we didn't do a change of condition. The Administrator further explained that staff do verbal shift change and that there was no log for physician communication. When asked about the duration and severity of the bleeding, the Administrator stated, I don't think it was a bad nosebleed.The surveyor explained that according to the complainant, the resident's family reported active bleeding lasting approximately one hour and that the resident was receiving anticoagulant medication, which increases the risk for prolonged or uncontrolled bleeding. The Administrator did not provide documentation of any nursing assessment, physician notification, or change-of-condition report related to the incident. The administrator sighed and stated that she placed a call in to the nurse on duty on the evening of 07/12/2025 during the time of the event. During an interview conducted on 10/07/2025, RN #19 stated that she was assigned to a different wing than the resident on the evening of 07/12/2025. She stated that at approximately 17:38 hours, she was called to the resident's unit and informed that the resident was experiencing a nosebleed. RN #19 stated, someone ordered ice for the resident, and that care staff were holding ice on the bridge of the resident's nose. She stated that she then returned to passing medications on her assigned wing. Some time later, she was notified that the resident's nose was still bleeding and that the family wanted the physician to consult with the resident again. Shortly afterward, prior to the physician seeing the resident, RN #19 was informed that the family was not satisfied with the care being provided and had contacted EMS to transfer the resident to the hospital for evaluation.This surveyor asked RN #91 if the facility had been short-staffed on the evening of 07/12/2025. RN #91 stated that the facility was short-handed due to staff call-ins, and that it was common practice to pull nurses from other wings for coverage when call-offs occurred. The facility's staffing sheet for that date reflected an HPPD of 2.5, consistent with reduced licensed-nurse coverage.Attempts to reach the former resident via phone were unsuccessfully attempted on 10/6/2025 at 4:30 PM, 10/7/2025 at 10:00 AM, at 1:00 PM, and 3:30 PM. There was no means to leave a message. These findings demonstrate that the facility failed to assess, notify, and obtain treatment orders for an anticoagulated resident experiencing active bleeding.Conclusion:The facility failed to ensure that a licensed nurse completed a timely assessment and intervention in response to an acute change in condition for a resident identified as high risk for bleeding due to anticoagulant therapy. The absence of a documented change-in-condition assessment, vital signs, and provider notification during a reported episode of prolonged bleeding demonstrates the facility's failure to provide the necessary care and services to maintain the resident's highest practicable physical well-being, in noncompliance with 42 CFR S483.25 (Quality of Care - F0684).

Based on record review, and Interviews, the facility failed to ensure that PRN(as needed) pain management was provided timely for a resident who required such services, consistent with Physician Orders, and the comprehensive person-centered care plan. Resident Identifier: # 46 Facility Census:137 Findings included: a) Resident #46 and family Interviews: -During an interview on 10/07/25 at 2:10 PM, Resident #46 indicated at times he has had to wait a long period of time for staff to get his PRN Pain Medication to him. -During a phone interview with Resident #46's granddaughter, on 10/07/25 at 2:30 PM, she reported that during a visit with her grandfather on July 26, 2025 her grandfather told her he was hurting. She stated she asked staff for pain medication for him at approximately 2:30PM. After waiting over an hour, she reported to her mother and stayed on the phone with her for another couple of hours before the nurse gave her grandfather his pain medication. -During an interview with Resident #46's daughter on 10/07/25 at 250PM, She reported her father was often in pain but didn't feel the facility was giving him his pain medications when he needed them. She stated on 8/26/25 her daughter called her to report that Resident # 46 was in pain and requested pain meds for him. She stated it took at least another hour before the pain meds were given. b) Record Reviews:-During a record review on 10/07/25 at 1:20Pm, Physician ordered Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 1 hours as needed for SOB/pain Dated 07/17/25. Monitor: Pain Score every shift Other Active: 7/18/2025 19:00 - On 10/07/25 at 1:45PM, a record review of the Treatment Administration Request (TAR) document found the Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML was recorded administered at 18:19 PM on 08/26/25. -A record review, completed on 10/07/21at 3:00 PM, revealed Resident # 46 had the following diagnoses muscle spasms, FX 1st lumbar Vertebra, compression fracture of T11/T12, and Diabetes, muscles spasms, right hip pain. -A record review of resident #46's care plan, on 10/07/25 at 3:15PM indicated Resident # 46 has a terminal prognosis with hospice care r/t end-of-life dx Pain control the resident was at risk for pain related to end of life dx. Resident has potential for pain r/t FX 1st lumbar Vertebra, compression fracture of T11/T12, and Diabetes, muscles spasms, right hip pain. Encourage the resident to request pain medication before the pain becomes too intense or prior to activities that the resident knows there is a potential for increased pain c) Staff Interview:During an interview with the DON on 10/08/25 at 9:20 AM, she acknowledged that resident # 46 PRN pain medication was not administered timely upon resident's request 0n 08/26/25.

Based on resident interview, observation and staff interview the facility failed to ensure the grievance forms were within reach for each resident to enable to file grievance anonymously if they so choose. This was a random opportunity for discovery and was true for Resident #40. Facility Census: 132. Findings Include: a) Resident #40 Upon entrance to the facility on [DATE] an observation found the grievance forms were up too high for residents who could not stand up. If a resident is confined to the wheelchair they are unable to obtain a grievance form without asking staff or others to hand them the form. On 02/11/25 at 11:45 am Resident #40 indicated they were not able to reach the grievance forms nor the box provided to place the grievance forms without standing up from the wheelchair. On 02/11/25 at 11:50 AM, during and interview with Social Worker #147 it was confirmed the resident was unable to reach the forms or the box. She stated, residents could come to my office and ask for a form but resident's would not be able to file it anonymously if they could not stand up.

Based on results of State inspection, The facility failed to ensure the most recent survey results were located in prominent areas and readily accessible to residents and public. This deficient practice had the potential to effect more than a limited number of residents. Facility census: 132 Findings include: a) During the resident council meeting on 02/10/25 at 11:30 AM, Resident Council President , (Resident #1), stated she knew there were survey results available for the residents to see but was not sure where they were recently located. Resident #19, #40, and # 64 were also in attendance and stated they did not know survey results were available to them nor where they were located. Based on record review of Section C of the most recent MDS record Residents #1, #19, # 40, and #64 had capacity and were cognitively intact. c) During an interview with theAdministrator, on 2/11/24 at 12:25 PM, she verified the facility failed to post notice of the availability of the results of the most recent survey in prominent areas in the facility and make accessible to all residents.

The facility failed to provide an environment that was free from accident hazards over which it had control. This was a random opportunity for discovery. Water temperatures were found to be above 120 degrees Fahrenheit (F). This deficient practice had the potential to negatively effect more than a limited number of residents. Facility census: 132. Findings included: a) State Operations Manual Appendix PP Review of the State Operations Manual Appendix PP found in the interpretive guidelines for F689 the following concern regarding water temperatures: - Water temperature of 124 degrees Fahrenheit will cause a 3rd degree burn in 3 minutes. - Water temperature of 120 degrees Fahrenheit will cause a 3rd degree burn in 5 minutes. - Burns can occur even at water temperatures below those identified, depending on an individual's condition and the length of exposure. -Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. b) On 02/09/25 at 1:13 PM, the water temperature of the sink in room [ROOM NUMBER] was tested by surveyors feeling very hot. Surveyors requested the water temperatures be tested via thermometer. Maintenance Supervisor #73 tested the water temperature was tested by inserting the stem of the thermometer into the stream of running water, so that the sensor was fully immersed. A water temperature of 126 degrees Fahrenheit was reached. c) Water Temperatures in Shower Rooms Date and Time - Shower room wing 1 had a water temperature of 126 degrees Fahrenheit. - Shower room wing 2 had a water temperature of 121.6 degrees Fahrenheit. - Shower room wing 7 had a water temperature of 122.5 degrees Fahrenheit. d) During an interview with Maintenance Supervisor #73, on 02/09/25 at 1:21 PM, He stated the water temperatures were tested on ce every week. He said the temperatures averaged around 113 degrees Fahrenheit. e) Number of Residents that go to the shower rooms by wings: Wing 1 - 20 of 20 Wing 2 - 16 of 18 Wing 7 - 20 of 21 f) During an interview, on 02/09/25 at 3:10 PM, the Nursing Home Administrator confirmed that the maintenance director would ensure all water temperatures would be 110 degrees Fahrenheit or below.

Based on observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of two (2) wings tested for food tray temperatures throughout the Long-Term Care Survey Process. Facility census: 132. Findings included: a) Wing 1 Lunch Time Meal Observation During an observation on 02/12/25 at 12:53 PM, it was noted that a food truck was brought out of the kitchen with all resident lunch trays for residents on the 100 Wing. Staff members immediately began to deliver the trays to the residents' rooms. At 1:03 PM, when four (4) trays were left on the food truck, the Surveyor requested that CNA #135 select one tray that would be served last. CNA #135 selected Resident #45's tray and stated that she was actually getting ready to go out to eat with her family member and would not need her lunch tray. Registered Nurse (RN) #62 was asked to call the kitchen and ask them to come to the wing in order to temp the last tray on the food cart. On 02/12/25 at 1:07 PM, Dietary Aide #300 tested the temperature of Resident #45's lunch tray with the following results: -Hamburger: 116.5 degrees Fahrenheit (F) -Carrots: 112.2 degrees F -Ham: 104.0 degrees F Dietary Aide #300 agreed the food temperatures obtained were not considered to be the appropriate desired temperature for the point of delivery to the residents. Dietary Aide #300 stated temperatures should be 120 degrees F or above for all hot food.

Based on observation, staff interview, and equipment manual review the facility failed to keep the ice machine in safe operating condition. This had the potential to affect all Residents who get their nutrition from the kitchen, and residents who attend food related activities. Facility Census: 132. Findings Included: a) Ice Machines On 02/13/25 at 12:40 PM a tour with the Maintenance Director found the ice machines located in the Kitchen area had a drainpipe running on the floor to a drain. Nutrition rooms on units one (1) and three (3) had no required air gap on the ice machine drains. The drainpipes were touching the drains. Continued tour found unit one (1), five (5) and six (6) had no required filter on the ice machines. On 02/13/25 throughout the tour, the Maintenance Director confirmed the drainpipes should not be touching the floor or drain and all the ice machines should have a filter.

Based on record review and staff interview, the facility failed to protect Resident #39's right to be free from sexual abuse. This was true for one (1) out of five (5) resident-to-resident altercations reviewed during the complaint process. Facility census: 135. Resident identifiers: #39 and #137. The facility's failure to follow their abuse policy and recognize the incident as an occurrence of resident-to-resident sexual abuse placed an unlimited number of residents currently residing in the facility at risk for possible abuse. The state agency determined this was an immediate jeopardy (IJ) situation. a) An electronic medical review, completed on 05/21/24 at 9:45 AM, revealed the following details: -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 9:04 AM, At 0150 [1:50] this AM, Staff entered resident's room and observed Resident [#137] on top of roommate [Resident #39] naked, making humping motion, and attempting to remove roommates [roommate's] gown and incontinence brief. -RN Unit Manager #28 documented in nursing note, dated 02/14/24 at 6:59 AM, Aide alarmed this nurse about resident being sexually inappropriate with resident in room. The note also indicated written statements by aides would be given to supervisor on duty. -The only written statement on file was from Nurse Aide (NA) #6 who reported NA #210 requested help in the resident room. NA #6 stated she saw Resident #137 was completely nude and was trying to rip Resident #39's brief off. She also documented she changed Resident #39's bed sheets because Resident #137 had peed on his top sheet. -Review of Resident #137's care plan reflected the facility did not address inappropriate sexual behaviors. -Review of Resident #39's care plan reflected the facility did not address possible trauma from the experience. A record review was completed on 05/21/24 at 9:22 AM. The facility noted the date and time of the incident as happening on 02/14/24 at 1:50 AM. The facility provided the following description of the incident: Resident #137 was observed being sexually inappropriate with roommate (Resident #39). Residents were separated. Resident #39 was moved to a different wing. The facility's five (5) follow-up report outlined the following investigative details: -Resident #137 [the perpetrator] was an [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Dementia, Paranoid Personality Disorder, Hallucinations, Depression, and anxiety disorder. He had a Brief Interview for Mental Status (BIMS) score of 09 which is indicative of moderate cognitive impairment. -Resident #39 [the victim] was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Dementia, and Depression. He had a BIMS of 01 which is indicative of severe cognitive impairment. -It was reported on 02/14/24 at approximately 2:00 AM a staff member noticed movement in the residents' room. Upon entering the room, the staff member found Resident #137 on top of Resident #39 and appeared to be trying to have sex with him. Resident #39 was dressed in a hospital gown and had an adult brief on. The staff immediately told Resident #137 to get off of him and that it was inappropriate. Staff assisted Resident #137 in getting dressed and removed him from the room to the nurses' station where he could be monitored. -Resident #39 was assessed, and no injuries were found. He showed no signs of emotional distress. -Upon completion of the investigation, the facility did not substantiate abuse occurred because of the incident due to Resident #137 did not have the capacity for intent. Interview with Social Worker -During an interview, completed on 05/21/24 at 10:58 AM, Social Worker #59 when asked to describe sexual abuse described it as, Anything that is uninvited. When asked if he had ever been trained to use the reasonable person concept when investigating complaints, Social Worker #59 stated he had not. By definition, a reasonable person concept would involve a case where a resident was unable to speak for themselves. The investigative team should assess how most people would react to the situation in question. Additionally, Social Worker #59 agreed there could be situations of abuse that do not result in an observable physical injury, or the psychosocial effects of abuse may not be immediately apparent. The social worker agreed that Resident #39 had a BIMS of 01 which would make it unlikely he would be able to speak about how the incident affected him. A resident with such severe cognitive impairment cannot usually recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Social Worker #59 agreed that neither physical marks on the body nor the ability to respond and/or verbalize was needed to conclude that sexual abuse/assault had occurred. During an interview, at approximately 11:20 AM on 05/21/24, the Administrator stated the facility did not substantiate resident-to-resident sexual abuse occurred as a result of the incident due to the fact Resident #137 did not have the capacity for intent. When explaining if there was an instance where a resident did not wish to engage in sexual activity with another resident that the facility must respond to it as an alleged violation of sexual abuse, the DON questioned how the facility would know if it was unwanted since they had no way of knowing Resident #39's sexual preference prior to his cognitive decline. The Surveyor explained that the expectation was if the resident did not have capacity to consent to sexual activity, the facility should always respond to it as an alleged violation of sexual abuse. Using a reasonable person concept, it could be assumed that a nude person climbing on top of you in the middle of the night, humping you, and attempting to remove your clothing would be considered sexually inappropriate and would reasonably cause anyone to have psychosocial harm. The Administrator and DON confirmed that neither resident's care plan had been updated to reflect the need to monitor Resident #137 more closely or to offer Resident #39 any trauma services. The resident-to-resident sexual abuse occurred on 02/14/24 at 1:50 AM. The facility was notified of the IJ on 05/21/24 at 12:10 PM. The State Office approved the facility's Plan of Correction (POC) at 5:54 PM on 05/21/24. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 1:00 PM on 05/22/24. The IJ started on 2/14/24 at 1:50 AM and ended on 05/22/24 at 1:00 PM. The facility's approved abatement POC consisted of the following: On 05/21/24 at 1:45 P.M. one on one education for staff present and via phone call for staff not present was provided related to the facility abuse policy, which included what abuse was and reporting requirements, including sexual and verbal abuse was initiated by the Director of Education for all 175 employees. The education consisted of the different types of abuse, whether it is physical and what this entails (hitting, slapping, punching, pinching, etc.), sexual and what that entails (unwanted physical touch, groping of private areas of the body, attempted intercourse, unwanted advances), emotional/verbal (making fun, degrading jokes, putting someone down, derogatory comments, yelling, cursing). A plan for any staff member not educated to not work until education was completed and implemented. On 05/21/24 from 1:45 P.M. to 3:30 P.M. interviews were completed by Management staff comprised of the Social Work, Social Service Designee, Business Office Manager, Assistant Business Office Manager, Human Resource Director, and the Admissions Director for 48 residents who have capacity using the Resident Ause Questionnaire with questions consisting of: How are you doing today?, How is your care?, Do you feel safe here?, Have you ever felt threatened by another resident or uncomfortable?, Do you have any issues with staff here?, Have staff ever made you feel afraid? No new concerns were identified by the facility following these interviews. On 05/21/24 from 1:45 P.M. to 3:15 P.M. skin inspections were performed by RN Unit Manager #1, RN Unit Manager #1, RN Skin Nurse, and ADON for 87 residents who do not have capacity. No abnormalities were found by the staff completing the inspections. On 05/21/24 at 2:03 P.M. the Chief Operating Officer for [NAME] Rehabilitation and Healthcare Center re-educated the Administrator and Director of Nursing on the facility abuse policy, including reporting and substantiating allegations of abuse regardless of capacity of the residents involved. On 05/21/24 at 2:40 P.M. the Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and Director of Nursing regarding incident of abuse involving Resident #39 and Resident #137 which occurred on 02/12/24 and what corrective action measures were being taken. On 05/21/24 at 2:25 P.M. to 3:10 P.M. the Registered Nurse Assessment Coordinator #1 and Registered Nurse Assessment Coordinator #2 completed an audit of resident care plans and identified those who exhibited possible inappropriate sexual behaviors. These were reviewed and updated to ensure that appropriate interventions are in place. Beginning 05/22/24, during the morning Interdisciplinary team (IDT) meeting the facility will discuss if any new allegations or concerns of abuse have been brought to anyone staff members' attention as well as reviewing the 24-hour report. The facility will ensure any/all allegations will be thoroughly investigated, and actions will be taken to ensure the facility is following the abuse policy. The facility identifies the deficient practice occurred related to a failure to identify the potential psychosocial harm from the occurrence and the failure to identify the incident as sexual abuse regardless of capacity. Beginning 05/22/24 the Administrator or her designee will forward any new reportable allegations to the Chief Operating Officer to review to ensure that the facility conducts a thorough investigation with accurate conclusions. Beginning 05/22/24 the Director of Nursing or her designee will conduct an audit of 10 residents using the Resident Abuse Interview Tool and skin assessment. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Beginning 05/22/24 the Director of Education or her designee will conduct an audit of 10 employees using the Staff Abuse Questionnaire. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Review of the facility's Abuse/Neglect policy revealed the following details regarding the definition of sexual abuse: -Sexual abuse was defined as, but was not limited to, non-consensual sexual harassment, sexual coercion, contact, or sexual assault. -Anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse.

Based on record review and interview the facility failed to keep Resident #38 free from a chemical restraint imposed for purposes of discipline when an antipsychotic medication was given without a physician order. The deficient practice put all one (1) resident that exhibit behaviors currently residing in the facility at risk for serious injury, serious harm, serious impairment, or death. Resident identifier: #38. Facility Census: 135. Findings included: a) Resident #38 During a complaint survey a review of Resident #38's nursing progress notes found: Nursing note dated 05/5/24 4:35 AM Came onto wing at 2:20, patient (pt) came out screaming and chasing the staff down the hallway because they wanted a regular diet, was told to go back to their room, patient went into the room and laid down on the bed. Patient was held down and given 5mg/1ml IM shot of haldol. pt came back out and charged at staff again. pt charged at nurses station and fell into soiled room door. pt tried to get up and attack nurses again but wasn't able to get up. pt scooted into their room. pt came back out, charged at the nurses desk again. pt was trying to grab this nurse, this nurse held his hands and tried to get him off me. supervisor helped him back off of this nurse and he fell on the floor and laid there as the cops and the ambulance came to take him to the hospital. During a confidential interview (CI) #1, on 05/22/24 with an individual present on the day noted, the nurse administering the IM injection, was unable to readily report the dose given. CI #1 stated Licensed Practical Nurse (LPN )#1 discarded the Haldol bottle, and she provided medication from a zip lock bag. Continued record review of Resident #38's Physicians orders found there was no active order for Haldol on 05/05/24. The facility was notified of the Immediate Jeopardy (IJ) at 3:10 PM on 05/22/24. The facility submitted their first abatement plan of correction (POC) at 5:44 PM on 05/22/24. The abatement POC was accepted by the state agency at 6:00 PM on 05/22/24. After observation of the implementation of the abatement POC, the IJ was abated at 11:40 AM on 05/23/24. The IJ started on 05/22/25 and ended on 05/23/24. The facility's approved abatement POC consisted of the following: Correction action for area of concern- On 05/22/24 at 3:21 PM one on one education for licensed nursing staff present and via phone call for staff not present was provided related to the facility medication administration policy, the six rights of medication administration, and not administering a medication without an order was initiated by the Director of Education for all 39 licensed nurses. The education consisted of the right patient, the right drug, the right time, right dose, right route, and right documentation. It also consisted of verifying the order prior to administering the medication. A plan for any staff member not educated to not work until education was completed and implemented. On 05/22/24 at 3:25 PM the Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and Director of Nursing regarding incident administering a medication without an order to Resident #38 which occurred on 05/05/24 and what corrective action measures were being taken. On 05/22/24 from 3:35 PM to 5:00 PM an audit of PRN (as needed) medications given for the last seven days for all 136 residents were performed by RN Unit Manager #1 and the DON. The audit will ensure that any PRN medications that were given had a reason and the effectiveness of the medication was documented. This report was then audited against the nursing documentation for the last seven days to ensure that no PRN medication was given without an order. Any discrepancies found were corrected and if needed provider notified and new orders obtained if given. On 05/22/24 at 3:45 P.M. the Six Rights of Medication Administration signs were made and laminated and then secured to the seven medication carts in the facility as a visual reminder to the licensed nursing staff. On 05/22/24 from 4:00 P.M. to 5:00 P.M. an audit of the medication carts were conducted by RN Unit Manager #2, RN Wound Nurse, and the ADON to ensure that any discontinued PRN medication were not on the carts. If any were found they were removed and disposed of according to policy. Beginning 05/23/24, during the morning Interdisciplinary team (IDT) meeting the facility will review the PRN medication administration report from the previous day and review the 24-hour report to ensure that no PRN medications were given without an order. The facility will run a report of discontinued medications and ensure that the medications have been removed from the medication carts. The facility identifies the deficient practice occurred related to a medication being administered without an order, as the medication was a PRN. order that had previously been in place but had ended on 04/29/24 and not pulled from the medication cart. Beginning 05/23/24 the Director of Nursing or her designee will conduct an audit of 10 residents using the Unnecessary Drug Review audit to ensure that no residents are receiving medications without an order. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Beginning 05/23/24 the Director of Education or her designee will conduct an audit of 10 employees using the Medication Administration Audit tool to ensure that the licensed nursing staff are following the six rights of medication administration. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee. During an interview, with LPN #1 on 05/21/24 at 9:24 AM via phone, she stated, resident was so aggressive he was chasing staff down the hall multiple times. She stated, she administered an intermuscular Haldol 5ml per 1 ML in Resident #38's arm. She stated, she did try to administer the injection in the back of his arm, but it was administered in the middle of his arm due to him swinging his arms. She stated that five (5) staff members were present at this time. During an Interview on 05/22/24 at 1:48 PM, Nurse Practitioner #211 confirmed, she did not authorize an order for Haldol 5ml per 1 ML until 05/06/24 after he returned from the emergency room . During an Interview on 05/22/24 about 2:10 PM the director of Nursing verified Resident #38 did not have an active Haldol order when he was administered the drug.

Based on observation and staff interview the facility failed to ensure the residents environment over which it had control was free from accident hazards related to Resident # 27 received a burn after spilling reheated hot coffee on herself. The deficient practice put all residents that drink coffee currently residing in the facility at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #27. Facility census: 135. Findings included: a) Hot Liquids Review of facility documentation during a Facility reported Incident investigation (FRI) showed a reportable dated 10/30/23. The incident occurred on 10/30/23 when Resident # 27 sustained a burn injury to the right side of her abdomen after spilling coffee on herself that had been reheated. Continued review revealed a physician treatment order for Silvadene External Cream to be applied to the right side of the abdomen topically every day for burn. A care plan dated 04/23/20 with a revision date of 09/13/22 review found: A focus area for potential safety concerns and injury from hot liquids. The goal was to Minimize risk for injury from hot liquids. Interventions included: Encourage resident to be out of bed and in sitting position for consumption of hot liquids. Initiated 04/23/20. Temp of liquids not to exceed 180 degrees. Initiated 07/06/21. Subsequent review of the 10/30/23 statement from Nurse Aide #202 found: Resident #27 requested her coffee to be re-heated with most meals. Resident #27 was in bed. The coffee was in regular coffee cup with no lid or straw. The five (5) day follow up found Incident reported as failure to follow plan of care resulting in injury, the whole house education completed on hot liquid safety and observation audits to be completed of staff reheating foods/liquids to ensure instructions are followed, temperature of item is checked and verified temperature is within range and properly logged. Review of in- serviced/educated on Safety of Hot Liquids date 10/30/23 found only NA #202 was educated. During an interview with Staff Development #27 it was revealed that Resident #27 had at least two (2) burns from hot coffee at different times. Also, she confirmed that only one staff member was educated after the 10/30/23 burn on Resident #27. Interviews on 05/21/24 at12:10 PM with Registered Nurse #120, Helping Hands #74 and Licensed Practical Nurse #58 revealed they were unaware of the facility policy/ procedure for reheating food and liquids. The facility was notified of the Immediate Jeopardy (IJ) at 4:37 PM on 05/21/24. The facility submitted their first abatement plan of correction (POC) at 5:41 PM on 05/21/24. The abatement POC was accepted by the state agency at 6:12 PM on 05/21/24. After observation of the implementation of the abatement POC, the IJ was abated at 1:00 PM on 05/22/24. The IJ started on 05/21/25 and ended on 05/22/24. The facility's approved abatement POC consisted of the following: Correction action for area of concern- On 05/21/24 at 4:53 P.M. one on one education for staff present and via phone call for staff not present was provided related to the facility Safety of Hot Liquids policy and that if food needs to be reheated, it will be discarded and the kitchen will send up new as well as after-hours things can be reheated in one central location and temperatures are to be taken and recorded and no higher than 140 degrees was initiated by the Director of Education for all 175 employees. A plan for any staff member not educated to not work until education is completed and implemented. On 05/21/24 from 4:55 P.M. to 6:00 PM Hot liquid risk screening tool were completed by RN Unit Manager #1 and RN Unit Manager #2 on all residents and care plans updated as needed to reflect the assessment. On 05/21/24 at 5:00 P.M. Maintenance Man #1 removed microwaves from the unit pantries. One microwave will be kept in the conference room area in the event that something needs to be heated after hours. A sign will be placed there to instruct staff how to heat food and beverages, including taking the temperature and recording. The liquids are to be no hotter than 140 degrees. On 05/21/24 at 5:05 P.M. the Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and Director of Nursing regarding incident of Accident Hazard involving Resident #27 which occurred on 04/06/23 and again on 10/30/23 and what corrective action measures were being taken. On 05/21/24 at 5:30 P.M. the physician was notified, and orders received for Occupational Therapy evaluation. Beginning 05/22/24, during the morning Interdisciplinary team (IDT) meeting the facility will discuss if any new injuries have occurred related to hot liquids through reviewing the risk as well as reviewing the 24-hour report. Any new injuries from hot liquids will be investigated and new interventions in place to prevent future episodes. The facility identifies the deficient practice occurred related to a staff member not following the resident's plan of care and adhering to the facility policy as it relates to hot liquids. Beginning 05/22/24 the Administrator or her designee will forward any new reportable allegations to the Chief Operating Officer to review to ensure that the facility conducts a thorough investigation with accurate conclusions. Beginning 05/22/24 the Director of Nursing or her designee will conduct an audit of 10 residents using the Resident Skin Assessment tool. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance. Beginning 05/22/24 the Director of Education or her designee will conduct an audit of 10 employees using the Staff Questionnaire as it relates to how to reheat liquids and by demonstration. The audit will be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Improvement Committee for ongoing compliance.

Based on record review, and staff interview, the facility failed to ensure one (1) of three (3) residents had a person-centered comprehensive care plan implemented to meet his/her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Failure to implement Resident #72's care plan resulted in her sustaining a burn to her abdomen which required physician intervention. Resident #72 sustained actual harm due to the facility's failure to implement her care plan. Resident identifiers: #27. Facility census: 135. Findings included: a) Resident #27 Review of facility documentation during a Facility Reported Incident (FRI) investigation showed a reportable dated 10/30/23. The incident occurred on 10/30/23 when Resident #27 sustained a burn injury to the right side of her abdomen after spilling coffee on herself that had been reheated. Continued review revealed a Physician treatment order for Silvadene External Cream to be applied to the right side of the abdomen topically every day for burn. A care plan review found a care plan focus area initiated on 09/23/22 and revised on which included a potential for safety concerns and injury from hot liquids. A care plan goal initiated on 04/23/20 and revised on 09/13/22 included Minimize risk for injury from hot liquids. Interventions included: Encourage resident to be out of bed and in sitting position for consumption of hot liquids. Temp of liquids not to exceed 180 degrees. Initiated 07/06/21. Subsequent review of the 10/30/23 statement from Nurse Aide #202 found: Resident #27 requested her coffee to be re-heated with most meals. Resident #27 was in bed. Coffee was in a regular coffee cup with no lid or straw. The five (5) day follow up found incident reported as failure to follow plan of care resulting in injury, the whole house education completed on hot liquid safety and observation audits to be completed of staff reheating foods/liquids to ensure instructions are followed, temperature of item is checked and verified temperature is within range and properly logged. During an interview with Staff Development #27 it was revealed, Resident #27 had at least two (2) burns from hot coffee at different times. Also, she confirmed the care plan was not followed during the 10/30/23 incident that contributed to Resident #27 getting burned.

Based on medical record review, staff interviews, family interview, resident interview, and review of facility policy and procedures, facility failed to operationalize policies and procedures for the prevention, identification and investigation of abuse allegations. The facility failed to ensure a reported allegation of abuse for Resident #104, a cognitively impaired resident, who was reportedly inappropriately touched by Resident #147 was investigated and reported. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficiency may have had on a reasonable person in the resident ' s position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance). Based on the application of the reasonable person concept as identified in Appendix P of the SOM, a determination of actual harm was made for Resident #104, a cognitively impaired resident. A reasonable person, if touched inappropriately, fondled, and/or kissed without consent in one's residence, would feel fear, humiliation, anxiety, and/or stress. This affected one (1) of three (3) residents reviewed for abuse. Resident identifiers: #104 and #147. Facility census: 128. Findings include: a) Resident #104 Review of the clinical record for Resident #104, on 12/17/15 at 2:05 p.m., revealed the resident was severely impaired in cognition, required extensive assistance of two (2) staff members for activities of daily living, and the use of wheelchair. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. On 12/16/2015 at approximately 9:00 a.m., review of a progress noted dated 12/15/2015 at 7:13 p.m., revealed Social Service Supervisor #107 documented attempted to reach the resident's daughter to inform her of an incident with happened at approximately 6:10 p.m. this evening in the lounge, where Resident #147 put his hand down Resident #104's shirt. Social Service Supervisor #107 did speak with Resident #104 who did not appear upset or concerned in any way after the incident took place. Resident #104 stated they were always hungry and just wanted to eat all the time. They discussed the resident's feelings and the resident did not indicate any feelings of distress or worry. Reassurance and support provided. Interview with LPN #38, on 12/16/15 at 4:00 p.m., verified she documented the incident that occurred on 05/31/15. She stated, on 05/31/15 at 10:03 p.m., Resident #147 was in the day room with his hand down the shirt of Resident #104. At that time, Resident #104 was removed from the day room and did not present in any distress at that time. After removing Resident #104, LPN #38 stated Resident #147 was informed that Resident #104 did not give to be touched in a sexual manner. When queried further LPN #38 stated to her knowledge Resident #147 had not exhibited this type of behavior before or after the 05/31/15 incident. At that time, she reported the inappropriate touching to the charge nurse. LPN #38 could not remember the name of the charge nurse. b) Resident #147 Review of the clinical record for Resident #147, on 12/15/15 at 6:40 p.m., revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. A progress note, dated 05/31/15 at 10:03 p.m., included, . observed patient touching women patients on wing inappropriately, also kissing female patients, patient was asked to stop and to stay away from the female patients but he continues to touch them inappropriately. reported to charge nurse. Section C1000 of the significant change Minimum Data Set (MDS) assessment, dated 11/01/15, revealed Resident #147 had moderately impaired cognition, and was oriented to location, and staff names and faces. Section E of the MDS indicated behavioral symptoms were not exhibited. Section G0400 of the MDS indicated the resident had upper extremity impairment on one side, and no lower extremity impairment. The care plan initiated, on 10/03/14, included the following focus/problem: --Resident has mood and behavior deficits. --Behavior symptoms: Behavior intrudes on the privacy or activity of others. --Staff have noted that the resident is making sexual advances toward confused female patients. --On 05/20/15, staff have not reported this to be a problem at this time. The goal of the care plan, initiated on 10/03/14, and revised on 11/23/15, for the focus/problem of Resident #147 making sexual advances toward confused female patients included: -- (Resident ' s first name) episodes of behavioral occurrences will not increase through the next review. The interventions of the care plan, initiated on 10/24/14, for the focus/problem of Resident #147 making sexual advances toward confused female patients included: --Refer to task (date initiated 01/23/15) --Behavior Occurrences: Did you observe any unusual behavior for this resident? (You MUST notify the charge nurse of any unusual behavior observations.) Any sexual advances toward female patients. (date initiated 10/24/15) The care plan did not include interventions to prevent the known behavior of being sexually inappropriate with female residents. Interview with Care Plan Nurse #27, on 12/17/15 at 3:07 p.m., revealed she did not know why the care plan was initiated on 10/03/14. She further verified the clinical record did not contain documentation to support the development of the care plan at that time. A progress note, dated 12/12/15 at 11:14 a.m., included the resident, propels self throughout facility in wc (wheelchair). On 12/15/15 at 5:55 p.m., a family member alerted Nurse Aide (NA) #95 and this surveyor that Resident #147 placed his hand down the front of the shirt of Resident #104. The residents were in the lounge at the end of the hall. No staff members were present in the lounge at that time. NA #95 went into the lounge and found Resident #147 sitting beside Resident #104. Resident #147's hand was not down the other resident's shirt at that time. NA #95 moved Resident #147 to another table across the hallway, and reported the incident. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. During an interview, on 12/15/15 at 6:15 p.m., NA #95 stated he/she was not aware of Resident #147 exhibiting this type of behavior and was not aware of any behavioral interventions in place to prevent this type of occurrence. During an interview, on 12/15/15 at 6:20 p.m., Licensed Practical Nurse (LPN) #105 stated he/she was not aware of the resident exhibiting such behaviors and was not aware of any interventions in place to prevent this type of occurrence. During an interview, on 12/15/15 at 6:45 p.m., the family member who reported the inappropriate action of Resident #147, stated this was not the first time he/she had observed Resident #147 put his hand down the front of Resident #104's shirt. Approximately 6 months ago (05/31/15), this family member observed Resident #147 put his hand down the front of Resident #104's shirt, and stated it was reported to staff at that time. The family member further stated Resident #147 seemed to always place himself close to Resident #104. Review of Complaint/Grievance Report, dated 12/17/15, found, Social worker spoke to resident about behavior that took place in Dayroom Wing 8, called resident's wife, and notified her of behavior. Following the 12/15/15 incident, the facility put the following interventions in place from 12/15/15 through 12/16/15: --A one on one staffing ratio for the resident until 11:00 p.m. --After 11:00 p.m. observation every hour during bedtime hours. Additional interventions were: --Resident #147 ' s care plan was updated on 12/15/15. --A care conference scheduled for 12/16/15, including the resident and his wife. --A behavior plan developed and scheduled for implementation on 12/17/15. Review of Resident #147's Behavior Management Support Plan, dated 12/17/15, revealed the following current issues: -- Resident #147 has been in his room since the fall and [MEDICAL CONDITION] at the end of October. -- The resident recently is up and in his wheelchair and ambulating freely throughout the second floor environment. -- The resident's spouse is a good support for the resident and visits the resident frequently, taking the resident to, and participating with, the resident in activities. -- Due to the history [MEDICAL CONDITION] and the resident's [MEDICAL CONDITION], it is difficult to determine the resident's cognitive ability concerning right from wrong along with the resident's brain damage as it relates to his impulse control. -- Due to these reasons and the resident's most recent incident of inappropriate touching of a female resident this plan was initiated. Proactive intervention strategies for Resident #147, include: -- Continue to encourage spouse to visit and participate with Resident #147 in the resident's life in the facility. -- Provide time alone time for Resident #147 and his spouse, if this is to be in the facility or on an outing. -- Resident #147 should never be left alone in any of the day rooms. -- Staff should be aware of Resident #147's whereabouts at all times, making sure he is not alone. The resident should be either with his spouse or involved in a social gathering or activity. Reactive intervention strategies for Resident #147 include: -- The resident should never be left alone with female residents. -- In social settings do not isolate the resident, but staff should try their best to have the resident around other male residents. -- In a social setting, participating in a facility activity, staff should be aware of his presence and if the resident makes any gestures of inappropriate touching toward a resident, staff are to without saying anything to the resident remove them from the immediate area. Once out of the area let him know the reason he was taken out of the area. Escort them back to his wing and inform the wing nurse. The wing nurse should inform the charge nurse and the incident should be documented and investigated. Interview with Nurse Aide (NA) #71, on 12/16/15 at 6:15 a.m., revealed she was aware of the 12/15/15 incident between Resident #147 and Resident #104. NA #71 stated he/she was aware of Resident #147 inappropriately touching other residents and the need to monitor the resident for such behaviors a month or so ago, but was unaware of interventions to prevent such occurrences. During an interview on 12/16/15 at 8:00 p.m., Licensed Practical Nurse (LPN) #51 said she had not observed Resident #147 engage in inappropriate behavior in the past, however they had been suspicious of the resident being inappropriate with other female residents due to the resident propelling himself in order to be in close proximity of the female residents. She stated the resident was able to propel himself when up his wheelchair. Observation of Resident #147, on 12/16/15 at 8:35 a.m., revealed him propelling himself in a wheelchair in the lounge at the end of the hallway. The resident was under the direct supervision of a staff member seated in the lounge. During an interview with Registered Nurse (RN) #132 and Care Plan Nurse #27, on 12/16/15 at 9:15 a.m., they verified the care plan in place at the time of the 12/15/15 incident did not include interventions to prevent the behavior of being sexually inappropriate with female residents. They both stated they were not aware of the documented occurrence on 05/31/15 where Resident #147 was sexually inappropriate with a confused female resident and verified the care plan was not updated at that time. Interview with Licensed Social Worker (LSW) #107, on 12/16/15 at 9:20 a.m., verified the care plan in place at the time of the 12/15/15 incident did not include interventions to prevent the behavior of being sexually inappropriate with female residents. She further verified she was not made aware of the documented incident on 05/31/15 where Resident #147 was sexually inappropriate with a confused female resident and verified the care plan was not updated at that time. Interview with LPN #38, on 12/16/15 at 4:00 p.m., verified she documented the incident that occurred on 05/31/15. She stated, on 05/31/15 at 10:03 p.m., Resident #147 was in the day room with his hand down the shirt of Resident #104. At that time, Resident #104 was removed from the day room and did not present in any distress at that time. After removing Resident #104, LPN #38 stated Resident #147 was informed that Resident #104 did not give permission to be touched in a sexual manner. When queried further LPN #38 stated to her knowledge Resident #147 had not exhibited this type of behavior before or after the 05/31/15 incident. At that time, she reported the inappropriate touching to the charge nurse. LPN #38 could not remember the name of the charge nurse. Review of progress notes from 04/01/15 to date, on 12/16/15 at 10:00 a.m., did not include documentation indicating the 05/31/15 incident as reported by the family member. LPN #38 stated she observed Resident #147 propel his wheelchair up to female residents and stopping, and once the resident realized someone was watching, the resident would move away from the female residents. LPN #38 stated she believe Resident #147 was aware of what he was doing when approaching the female residents. In addition, LPN #38 stated she never read Resident #147 ' s care plan. Licensed Practical Nurse #38 further clarified the progress note, dated 05/31/15 at 10:03 p.m., did not pertain to any other female residents other than Resident #104. c) Review of the Facility's Abuse Prevention Policy and Procedure Review of the facility's undated Abuse Prevention Policy and Procedure, on 12/17/15 at 1:13 p.m., revealed the following: --The facility will assure that every resident is free from sexual abuse by implementing written policies and procedures that prohibit mistreatment. This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. --Staff will ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the state survey agency and other appropriate agencies including Adult Protective Services and the State Ombudsman). --The Administrator and other health care professionals must ensure that all alleged violations are reported to the state survey agency following their initial assessment via fax reporting within 24 hours after the facility receives knowledge of the occurrence. Resident abuse is considered a most serious violation of resident care and resident rights. --The definition of sexual abuse is contact that results from threats, force or inability of the person to give consent, including, but not limited to assault, rape and sexual harassment. Examples of sexual abuse included inappropriate touching or fondling. The facility could not produce any records the 05/31/15 incident was investigated according to the facility ' s Abuse Prevention Policy and Procedure. The facility ' s policy requires: --All reports of resident abuse . shall be promptly and thoroughly investigated by the Administrator or designee. --The Administrator or designee will conduct an investigation into the allegations and complete the Office of Health Facility Licensure and Certification (OHFLAC) 225 for immediate reporting. --The facility will report to the OHFLAC Field Office all allegations of abuse . within 24 hours of initial knowledge . The five day follow up report for allegations . must be submitted . within five (5) working days of completion of the facility ' s investigation. --The resident ' s physician will be notified of the suspected abuse. The facility medical director will also be notified when appropriate. --Any resident, family member or staff member who reports abuse . will receive a response from the investigating individual. The report will include the resolution of the complaint. --If the alleged abuse involves another resident, the accused residents representative and attending physician will be informed of the alleged abuse incident and that there may be restrictions to the accused residents ability to visit other resident rooms unattended. --Peterson Rehabilitation Hospital & Geriatric Center will retain documentation that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. d) Interviews with the Administrator and Director of Nursing Interview with the Administrator #88, on 12/16/15 at 6:00 p.m., verified the 05/31/15 incident had not been reported as per their Abuse Prevention Policy and Procedure and an investigation had not been conducted at that time. During an interview with the Director of Nursing #53, on 12/17/15 at 11:00 a.m., she was asked about the status of reporting the incidence of abuse that occurred on 12/15/15 to the state survey agency. She stated it did not rise to the level of a reportable incident since it was a resident to resident situation. The Director of Nursing #53 was prompted by the team to review requirements for reportable incidents. Interview with the Administrator #88, on 12/17/15 at 12:30 p.m., revealed the incident of alleged abuse was reported the state survey agency and produced a facsimile dated 12/17/15 at 11:35 a.m.

Based on medical record review, staff interviews, family interview, resident interview, observations, and review of Appendix P of the State Operations Manual (SOM), the facility failed to ensure Resident #104, a cognitively impaired resident, was not inappropriately touched by Resident #147, who had a history of [REDACTED]. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficiency may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance). Based on the application of the reasonable person concept as identified in Appendix P of the SOM, a determination of actual harm was made for Resident #104, a cognitively impaired resident. A reasonable person, if touched inappropriately, fondled, and/or kissed without consent in one's residence, would feel fear, humiliation, anxiety, and/or stress. This affected one (1) of three (3) residents reviewed for abuse. Resident identifiers: #104 and #147. Facility census: 128. Findings include: a) Resident #104 Review of the clinical record for Resident #104, on 12/17/15 at 2:05 p.m., revealed the resident was severely impaired in cognition, required extensive assistance of two (2) staff members for activities of daily living, and the use of wheelchair. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. On 12/16/2015 at approximately 9:00 a.m., review of a progress noted dated 12/15/2015 at 7:13 p.m., revealed Social Service Supervisor #107 documented attempted to reach the resident's daughter to inform her of an incident with happened at approximately 6:10 p.m. this evening in the lounge, where Resident #147 put his hand down Resident #104's shirt. Social Service Supervisor #107 did speak with Resident #104 who did not appear upset or concerned in any way after the incident took place. Resident #104 stated they were always hungry and just wanted to eat all the time. They discussed the resident's feelings and the resident did not indicate any feelings of distress or worry. Reassurance and support provided. Interview with LPN #38, on 12/16/15 at 4:00 p.m., verified she documented the incident that occurred on 05/31/15. She stated, on 05/31/15 at 10:03 p.m., Resident #147 was in the day room with his hand down the shirt of Resident #104. At that time, Resident #104 was removed from the day room and did not present in any distress at that time. After removing Resident #104, LPN #38 stated Resident #147 was informed that Resident #104 did not give to be touched in a sexual manner. When queried further LPN #38 stated to her knowledge Resident #147 had not exhibited this type of behavior before or after the 05/31/15 incident. At that time, she reported the inappropriate touching to the charge nurse. LPN #38 could not remember the name of the charge nurse. b) Resident #147 Review of the clinical record for Resident #147, on 12/15/15 at 6:40 p.m., revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. A progress note, dated 05/31/15 at 10:03 p.m., included, . observed patient touching women patients on wing inappropriately, also kissing female patients, patient was asked to stop and to stay away from the female patients but he continues to touch them inappropriately. reported to charge nurse. Section C1000 of the significant change Minimum Data Set (MDS) assessment, dated 11/01/15, revealed Resident #147 had moderately impaired cognition, and was oriented to location, and staff names and faces. Section E of the MDS indicated behavioral symptoms were not exhibited. Section G0400 of the MDS indicated the resident had upper extremity impairment on one side, and no lower extremity impairment. The care plan initiated, on 10/03/14, included the following focus/problem: --Resident has mood and behavior deficits. --Behavior symptoms: Behavior intrudes on the privacy or activity of others. --Staff have noted that the resident is making sexual advances toward confused female patients. --On 05/20/15, staff have not reported this to be a problem at this time. The goal of the care plan, initiated on 10/03/14, and revised on 11/23/15, for the focus/problem of Resident #147 making sexual advances toward confused female patients included: -- (Resident ' s first name) episodes of behavioral occurrences will not increase through the next review. The interventions of the care plan, initiated on 10/24/14, for the focus/problem of Resident #147 making sexual advances toward confused female patients included: --Refer to task (date initiated 01/23/15) --Behavior Occurrences: Did you observe any unusual behavior for this resident? (You MUST notify the charge nurse of any unusual behavior observations.) Any sexual advances toward female patients. (date initiated 10/24/15) The care plan did not include interventions to prevent the known behavior of being sexually inappropriate with female residents. Interview with Care Plan Nurse #27, on 12/17/15 at 3:07 p.m., revealed she did not know why the care plan was initiated on 10/03/14. She further verified the clinical record did not contain documentation to support the development of the care plan at that time. A progress note, dated 12/12/15 at 11:14 a.m., included the resident, propels self throughout facility in wc (wheelchair). On 12/15/15 at 5:55 p.m., a family member alerted Nurse Aide (NA) #95 and this surveyor that Resident #147 placed his hand down the front of the shirt of Resident #104. The residents were in the lounge at the end of the hall. No staff members were present in the lounge at that time. NA #95 went into the lounge and found Resident #147 sitting beside Resident #104. Resident #147's hand was not down the other resident's shirt at that time. NA #95 moved Resident #147 to another table across the hallway, and reported the incident. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. During an interview, on 12/15/15 at 6:15 p.m., NA #95 stated he/she was not aware of Resident #147 exhibiting this type of behavior and was not aware of any behavioral interventions in place to prevent this type of occurrence. During an interview, on 12/15/15 at 6:20 p.m., Licensed Practical Nurse (LPN) #105 stated he/she was not aware of the resident exhibiting such behaviors and was not aware of any interventions in place to prevent this type of occurrence. During an interview, on 12/15/15 at 6:45 p.m., the family member who reported the inappropriate action of Resident #147, stated this was not the first time he/she had observed Resident #147 put his hand down the front of Resident #104's shirt. Approximately 6 months ago (05/31/15), this family member observed Resident #147 put his hand down the front of Resident #104's shirt, and stated it was reported to staff at that time. The family member further stated Resident #147 seemed to always place himself close to Resident #104. Review of Complaint/Grievance Report, dated 12/17/15, found, Social worker spoke to resident about behavior that took place in Dayroom Wing 8, called resident's wife, and notified her of behavior. Following the 12/15/15 incident, the facility put the following interventions in place from 12/15/15 through 12/16/15: --A one on one staffing ratio for the resident until 11:00 p.m. --After 11:00 p.m. observation every hour during bedtime hours. Additional interventions were: --Resident #147 ' s care plan was updated on 12/15/15. --A care conference scheduled for 12/16/15, including the resident and his wife. --A behavior plan developed and scheduled for implementation on 12/17/15. Review of Resident #147's Behavior Management Support Plan, dated 12/17/15, revealed the following current issues: -- Resident #147 has been in his room since the fall and [MEDICAL CONDITION] at the end of October. -- The resident recently is up and in his wheelchair and ambulating freely throughout the second floor environment. -- The resident's spouse is a good support for the resident and visits the resident frequently, taking the resident to, and participating with, the resident in activities. -- Due to the history [MEDICAL CONDITION] and the resident's [MEDICAL CONDITION], it is difficult to determine the resident's cognitive ability concerning right from wrong along with the resident's brain damage as it relates to his impulse control. -- Due to these reasons and the resident's most recent incident of inappropriate touching of a female resident this plan was initiated. Proactive intervention strategies for Resident #147, include: -- Continue to encourage spouse to visit and participate with Resident #147 in the resident's life in the facility. -- Provide time alone time for Resident #147 and his spouse, if this is to be in the facility or on an outing. -- Resident #147 should never be left alone in any of the day rooms. -- Staff should be aware of Resident #147's whereabouts at all times, making sure he is not alone. The resident should be either with his spouse or involved in a social gathering or activity. Reactive intervention strategies for Resident #147 include: -- The resident should never be left alone with female residents. -- In social settings do not isolate the resident, but staff should try their best to have the resident around other male residents. -- In a social setting, participating in a facility activity, staff should be aware of his presence and if the resident makes any gestures of inappropriate touching toward a resident, staff are to without saying anything to the resident remove them from the immediate area. Once out of the area let him know the reason he was taken out of the area. Escort them back to his wing and inform the wing nurse. The wing nurse should inform the charge nurse and the incident should be documented and investigated. Interview with Nurse Aide (NA) #71, on 12/16/15 at 6:15 a.m., revealed she was aware of the 12/15/15 incident between Resident #147 and Resident #104. NA #71 stated he/she was aware of Resident #147 inappropriately touching other residents and the need to monitor the resident for such behaviors a month or so ago, but was unaware of interventions to prevent such occurrences. During an interview on 12/16/15 at 8:00 p.m., Licensed Practical Nurse (LPN) #51 said she had not observed Resident #147 engage in inappropriate behavior in the past, however they had been suspicious of the resident being inappropriate with other female residents due to the resident propelling himself in order to be in close proximity of the female residents. She stated the resident was able to propel himself when up his wheelchair. Observation of Resident #147, on 12/16/15 at 8:35 a.m., revealed him propelling himself in a wheelchair in the lounge at the end of the hallway. The resident was under the direct supervision of a staff member seated in the lounge. During an interview with Registered Nurse (RN) #132 and Care Plan Nurse #27, on 12/16/15 at 9:15 a.m., they verified the care plan in place at the time of the 12/15/15 incident did not include interventions to prevent the behavior of being sexually inappropriate with female residents. They both stated they were not aware of the documented occurrence on 05/31/15 where Resident #147 was sexually inappropriate with a confused female resident and verified the care plan was not updated at that time. Interview with Licensed Social Worker (LSW) #107, on 12/16/15 at 9:20 a.m., verified the care plan in place at the time of the 12/15/15 incident did not include interventions to prevent the behavior of being sexually inappropriate with female residents. She further verified she was not made aware of the documented incident on 05/31/15 where Resident #147 was sexually inappropriate with a confused female resident and verified the care plan was not updated at that time. Interview with LPN #38, on 12/16/15 at 4:00 p.m., verified she documented the incident that occurred on 05/31/15. She stated, on 05/31/15 at 10:03 p.m., Resident #147 was in the day room with his hand down the shirt of Resident #104. At that time, Resident #104 was removed from the day room and did not present in any distress at that time. After removing Resident #104, LPN #38 stated Resident #147 was informed that Resident #104 did not give permission to be touched in a sexual manner. When queried further LPN #38 stated to her knowledge Resident #147 had not exhibited this type of behavior before or after the 05/31/15 incident. At that time, she reported the inappropriate touching to the charge nurse. LPN #38 could not remember the name of the charge nurse. Review of progress notes from 04/01/15 to date, on 12/16/15 at 10:00 a.m., did not include documentation indicating the 05/31/15 incident as reported by the family member. LPN #38 stated she observed Resident #147 propel his wheelchair up to female residents and stopping, and once the resident realized someone was watching, the resident would move away from the female residents. LPN #38 stated she believe Resident #147 was aware of what he was doing when approaching the female residents. In addition, LPN #38 stated she never read Resident #147 ' s care plan. Licensed Practical Nurse #38 further clarified the progress note, dated 05/31/15 at 10:03 p.m., did not pertain to any other female residents other than Resident #104.

Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of twenty-one (21) sampled residents, to ensure that care and services were provided for a resident who was experiencing unrelieved pain and nausea. This caused physical and emotional harm to Resident #13. Resident identifier: #13. Facility census: 138. Findings include: a) Resident #13 1. During an initial tour of the facility on 08/17/09 at 1:00 p.m., observation found Resident #13 lying in bed with facial grimacing and guarding. A meal tray was observed on the bed side table set up, but the food was not touched. When interviewed at this time, Resident #13 reported, "I am so sick at my stomach." When was asked if she had pain, and she reported having intermittent stomach pain and pain in her breast, pointing to her right breast. When asked if they were giving her medications, she said yes but reported the pain and nausea medications were not working. On 08/17/09 at 2:00 p.m., medical record review revealed Resident #13 had been diagnosed with [REDACTED]. In July 2009, she was admitted to the hospital and had surgery on her breast, for which a drain was placed. The medical record also noted she had an abscess of the breast, and the [MEDICAL CONDITION] treatments had left [MEDICAL CONDITION] her breast, abdomen and back. The orders for [MEDICAL CONDITION] and [MEDICAL CONDITION] were placed on hold. She returned to the facility on [DATE] and, since then, the [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments have remained on hold. The medical record indicated that, on 07/30/09, the attending physician was notified the medication [MEDICATION NAME] was not effective in relieving the resident ' s pain. On 07/30/09, an order was received to increase the frequency of the [MEDICATION NAME] from every six (6) hours to every four (4) hours for pain. On 08/14/09, her attending physician was notified the medication [MEDICATION NAME] was not effective in relieving the resident ' s nausea. The attending physician increased the frequency of [MEDICATION NAME] from every eight (8) hours to every four (4) hours for nausea. -- According to <http://www.rxlist.com/[MEDICATION NAME]-drug.htm>, [MEDICATION NAME] is indicated for use for the following: - Prevention of nausea and vomiting associated with highly [MEDICAL CONDITIONS], including cisplatin ? 50 mg/m?. - Prevention of nausea and vomiting associated with initial and repeat courses of moderately [MEDICAL CONDITIONS]. - Prevention of nausea and vomiting associated with radiotherapy in patients receiving either total body [MEDICAL CONDITION], single high-dose fraction to the abdomen, or daily fractions to the abdomen. - Prevention of postoperative nausea and/or vomiting. As with other antiemetic, routine [MEDICATION NAME] is not recommended for patients in whom there is little expectation that nausea and/or vomiting will occur postoperatively. In patients where nausea and/or vomiting must be avoided postoperatively, [MEDICATION NAME] Tablets, [MEDICATION NAME][MEDICATION NAME](orally disintegrating tablets), and [MEDICATION NAME] Oral Solution are recommended even where the incidence of postoperative nausea and/or vomiting is low. The facility failed to contact the resident's oncologist in order to inform him that the [MEDICATION NAME] was not effective for nausea, especially since this medication is specific to use in conjunction with [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments, which had been placed on hold. -- According to <http://www.rxlist.com/[MEDICATION NAME]-drug.htm>., for [MEDICATION NAME] indications and dosages: - Dosage should be adjusted according to the severity of the pain and the response of the patient. However, it should be kept in mind that tolerance to [MEDICATION NAME] can develop with continued use and that the incidence of untoward effects is dose related. - The usual adult dosage is one (1) or two (2) tablets every four (4) to six (6) hours as needed for pain. The total daily dosage should not exceed eight (8) tablets. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 08/17/09 at 3:00 p.m., a licensed nurse (Employee #119), when interviewed at the nursing station, identified that Resident #13's [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments had been on hold for approximately two (2) weeks, and confirmed that Resident #13's was receiving two (2) [MEDICATION NAME] tablets every four (4) hours for pain, she had not been eating much, and Employee #119 was not sure if the [MEDICATION NAME] was causing Resident #13's nausea. The facility failed to contact the attending physician when Resident #13 was experiencing unrelieved pain and nausea following the 07/30/09 and 08/14/09 orders. 2. On 08/17/09, following surveyor intervention, the oncologist was called and the nausea medication was changed to [MEDICATION NAME] 10 mg by mouth three (3) times a day. When interviewed on the morning of 08/18/09, Resident #13 related that the new nausea medication was working and this was the first time in days she was not nauseated. 3. On the morning of 08/18/09, facility management staff (Employees #138 and #139) were questioned about the high dosage of [MEDICATION NAME] with unrelieved pain and the possibility that the [MEDICATION NAME] may have been causing or contributing to the resident's nausea. The attending physician was notified, and Resident #13 was started on a [MEDICATION NAME] 25 mg pain patch and [MEDICATION NAME] sulfate liquid medication for pain. On 08/19/09, following an outside appointment, observation found Resident #13 resting quietly in bed with no grimacing, guarding, or nausea noted.