Every finding on record at Phoenix Mountain Post Acute

Based on observations, record review, and interviews, the facility failed to ensure that menus provided alternate meal options for residents who refused the food offered. The census was 110, and the sample size was 22. The deficient practice had the potential to affect all residents in the facility by limiting resident choice and failing to meet individual nutritional preferences and needs. Findings include:An initial screening interview was conducted with Resident #106 on September 16, 2025 at 8:55 AM who stated that the facility had not provided other meal options for breakfast, lunch, and dinner. Resident #106 showed this surveyor their breakfast meal tray, which was still present on the resident's bedside table during the interview and appeared untouched. Resident #106 also stated that the facility menu had not always been limited. Resident #106 stated that about 6 months ago, the menus had changed and that they no longer included alternate options. Resident #106 stated that she had been able to request food items such as quesadillas and beef burgers if they did not prefer the meal options provided. Resident #106 stated that they were unsure of what options were available, as the provided menu did not state any other available options.An initial screening interview was conducted with Resident #10 on September 16, 2025 at 9:09 AM who stated that the facility had not provided other meal options for breakfast, lunch, and dinner. Resident #10 stated that they understand that their options could be limited due to an ordered weight loss diet. However, they stated that before the change in diet, they had shared their concerns regarding the alternative food options available and within their preferences for weight management. Resident #10 stated that the prepared meals would have included chicken, and had been chicken for days in a row.An interview was conducted on September 17, 2025, at 11:54 AM with the Dietary Supervisor (Staff #89) who stated that residents are given a menu on Friday's that will include the meal for the upcoming seven days and the residents can choose between two main entree items, and, then expected to return them to the dietary staff by the ed of the day Saturday so that their choice is accommodated. Staff #89 also stated that residents are able to choose a peanut butter and jelly sandwich or a grilled cheese sandwich upon request. Staff #89 stated that as dietary staff, they will rely on the resident's individual meal ticket as a tool to advocate preferences and advise the dietary staff if they do not want what is provided, so that an accommodation can be made. Staff #89 also stated that a count of residents who request an alternate meal is not documented, as the dietary staff who participate in the tray assembly line review the meal ticket during tray line assembly and will be able to confirm what meal is agreed on by the resident and their assigned meal ticket.At the time of the above interview, this surveyor completed an observation of the lunch tray assembly on September 17, 2025. During this observation, it revealed that a resident's individual meal ticket provided each resident with two entree items to pick, baked creamy garlic chicken or bot ties with Italian sausage, tomato, and cream; with a baked potato and sour cream, buttered corn, apple crisp, dinner roll, and a beverage. There were no other options or substitutions on a resident's individual meal ticket to choose from.Additional interviews were conducted with residents following this observation of the lunch tray assembly on September 17, 2025, and the following were stated:An interview with Resident #103 on September 17, 2025, at 2:30 PM, who stated that they did not eat their lunch. Resident #103 stated that they do not enjoy eating heavy starches such as potatoes and pasta. Resident #103 also stated that within the last seven days, they did not eat lunch for 5 of those days due to heavy starches such as potatoes and pasta. Resident #103 also stated that they were unaware of an alternate menu with other food options and had chosen not to eat due to the lack of meal options for lunch.An interview was conducted on September 17, 2025, with Resident #71 at 2:46 PM, who stated that there are never any options provided in their meal ticket. Resident #71 stated that their meal ticket provided two options for every meal and stated they do not know how to order any other meal options.An interview was conducted on September 17, 2025, with Resident #1 at 2:54 PPMM, who stated that they did not know there were other meal options provided and would pick and choose what to eat off the plate that is provided. Resident #1 stated that there are certain food items that he has to be mindful of due to receiving outside dialysis services, so if the facility provides food items, such as potatoes, he will not eat the food item and eat what he can eat from the provided meal tray.An interview was conducted with Staff #89 on September 18, 2025, at 2:31 PM, who stated that the alternate menu process begins on Fridays, where printed out menus of the upcoming week, Sunday through Saturday, are provided to each resident for individual review by Saturday's dinner so that the dietary staff is aware of which residents would prefer the alternate entree. If a resident does not like the two offered entrees, they are able to request a peanut butter and jelly sandwich or a grilled cheese sandwich. Staff #89 stated that residents are not able to write any other food option on their menu requests and meal tickets, and that they are only able to choose from the two alternate entree options or the two sandwich options. Staff #89 acknowledged that not providing residents with all of their options for meals could pose difficulty in respecting the preferences of residents. Staff #89 stated that the expectations regarding the two sandwich alternative meals were to advise the resident upon admission, and by staff throughout the day-to-day, should a resident question their meal options. Staff #89 also stated that if the meal tools provided to the residents for meal preferences and meal selections are not prepared in a way that benefits the residents, or do not provide preferences or options that they are agreeable with, the risk could be that residents choose not to eat, and can experience unmanaged and excessive weight loss. Staff #89 stated that if a resident refuses to eat what is provided, whether one of the two alternate entrees or one of the two alternate sandwich options, staff are encouraged to let the dietary staff know of the lack of meal intake so that a proper conversation with the resident can take place. Staff #89 also advised that another tool to determine if a resident chose to not eat the meal provided, floor staff is encouraged to rip the meal ticket in half as an indication to the dietary staff that that meal tray had been refused by that assigned resident in which the meal ticket had been placed on. However, Staff #89 stated that there is no set tool for residents to view when determining their meal options and alternatives, other than the weekly review of menus that takes place from Friday to Saturday.A facility policy titled 'Menu Planning', last edited in 2022, revealed that regular and therapeutic menus would be written to provide a variety of foods served on different days of the week. The policy also revealed that the facility's efforts should reflect the religious, cultural, and ethnic needs of the population served, as well as the input received from individuals and groups.

Based on observations, record review, interviews, and policy review, the facility failed to ensure that proper infection control practices were implemented according to professional standards for five residents (#6,11, 25, 67 and 99). This deficient practice could lead to the spread of infection.Based on observation, clinical record review, interviews and a review of policies and procedures, the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for four residents (#99, #6, #25, and #11). This deficient practice could result in an increased risk of pathogen transmission. Findings include: Based on the resident matrix and a review of resident records, Residents #25, #6, #99, and #11 were receiving catheter care. However, EBP signage was not present outside these residents' rooms on two consecutive days—September 16 and 17, 2025. In an interview with Infection Preventionist Staff #91 regarding this issue, Staff #91 stated that sometimes the signs fall off or are removed by residents. However, the staff member also noted that signage is only routinely checked every Friday. Staff #91 further explained that current facility practice requires nursing staff to wear gowns and gloves during high-contact care (e.g., brief changes, bathing, changing bed linens) for residents with EBP signage. Staff #91 also confirmed that residents with long-term intravenous (IV) use, indwelling devices such as catheters, nephrostomy tubes, peripherally inserted central catheters (PICC lines), or open wounds for 90 days or more with drainage are required to have EBP signage posted on their doors. Additionally, Staff #91 stated it is the expectation of the facility to adhere to this infection control policy. However, EBP signage was only observed outside the doors of the residents' doors starting on the third day of the survey and remained in place through the final day. Findings include: -Regarding Resident #67 Resident #67 was admitted to the facility on [DATE], with diagnoses that included aphasia, hydrocephalus, dysphagia, and contractures. A physician's order, dated April 6, 2024, instructed staff to employ Enhanced Barrier Precaution (EBP) every shift for the G-tube (gastrostomy tube). Medication administration was observed for Resident #67 on September 17, 2025, at 7:20 AM with a Licensed Practical Nurse (LPN/Staff #58). The LPN (Staff #58) explained that Resident #67 had a G-tube and would receive her medication through the tube. The LPN was observed sanitizing his hands, donning gloves, and preparing Resident #67's medicines at the medication cart. He was not observed to don a gown. An Enhanced Barrier Precaution (EBP) sign was observed next to Resident #67's room. The sign instructed staff to don gloves and a gown when performing care involving the resident's G-tube. Two unopened packages of gowns were observed in the resident's room above her sink. Staff #58 was observed to enter the Resident 67's room with his gloves on, set the resident's medications on a table next to the resident, and begin administering the following medications through the G-tube: - Water flush - Amlodipine 10 mg, one tablet crushed and mixed with water - Famotidine 2.5 milliliters (ml) and - Lactulose 10 ml - Water flush Staff member #58 was not observed wearing a gown during the administration of the medications through the G-tube. Following the administration, an interview was conducted with Staff #58, who stated that the EBP sign by Resident #67's door was used to inform people that the resident had a G-tube. The LPN (Staff #58) stated he did not need to wear a gown when manipulating Resident #67's G-tube. He stated gowns were only for residents who were on contact isolation. The LPN continued to explain that if staff needed to wear gowns, supplies would be available outside the resident's room. Staff #58 was asked to review the EBP sign by Resident #67's door. The nurse reviewed the sign and continued to state that gowns were not necessary when providing care to Resident #67's G-tube. An interview was conducted with the Director of Nursing (DON/Staff #200) on September 19, 2025, at 10:16 AM. The DON stated that she expected her staff to follow the EBP postings located outside the resident rooms. She explained that EBP would be used for residents who had indwelling catheters, wounds, feeding tubes, and other similar conditions. She stated that for feeding tubes in particular, she expected staff to wear gloves and gowns when starting or stopping the feeding, or manipulating the tube in any way, including administering medications. The DON stated that the risk of not following the EBP guidelines could be the spread of infection. A facility policy titled IPCP Precautions Policy and Procedure, revised and reviewed on April 2025, provides guidance on implementing infection control measures to prevent the spread of communicable diseases and conditions, states that EBP must be initiated for residents with: (i) wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers); and/or (ii) indwelling or implanted medical devices (e.g., central lines, ports, urinary catheters, feeding tubes, tracheostomy or ventilator tubes), even if the resident is not known to be infected or colonized with multidrug-resistant organisms (MDROs). Furthermore, guidance from the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality, Safety and Oversight Group—QSO-24-08-NH—states that EBP is recommended for residents with chronic wounds or indwelling medical devices during high-contact resident care activities, regardless of their MDRO status.

Number of residents sampled: 110Number of residents cited: 1Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that individualized activities were consistently offered to one resident (#9). The facility census consisted of 110 residents, and the target sample size was 22. The deficient practice could result in residents not consistently being provided with activities that meet their interests and support their physical, mental, and psychosocial well-being.Findings include:Resident #9 was admitted to the facility on [DATE], with diagnoses including: vascular dementia, unspecified severity, with other behavioral disturbance.During the initial pool conducted on September 16, 2025, at 11:12 a.m., resident #9 stated that she finds the activities juvenile and childlike and has no interest in them. Resident #9 stated she wished they would offer her more adult-like activities that she could participate in. A review of a Care Plan, initiated on February 20, 2023, revealed a focus on activities with resident #9, who was observed to be resting, unavailable, and requiring sensory/activity stimulation within her comfort zone. Resident #9 has a history of homelessness and wishes to be alone. Interventions included: 1:1 interaction will offer reminiscing and conducting interests. The sister will assist/offer correspondence as wished and tolerated. Will offer enrichment sensory activities, comfort foods, sounds of relaxation, provide 1:1 support in-room activities with supplies, conversation, and comfort. Will offer interaction with visiting & facility pets, will offer past interests: books, newspapers, magazines to read, card/word games, trivia, bingo, and puzzles. Will offer to go outside for 1:1 interaction, will offer to listen to music, watch news, shows, and movies. Review of the quarterly assessment dated [DATE], revealed that resident #9 can state her preferences. Diagnosed with Vascular Dementia with a history of homelessness, and prefers to be alone. Resident #9, on occasion, accepts 1:1 for short periods at a time. Resident #9 continues to enjoy a variety of TV programs, snacking on treats provided by familyA quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 03, which indicates severe cognitive impairment. Review of the activity participation task in Point Click Care revealed no documentation for the last 30 days for social activity, which includes the care planned pet visits, meal/food/snack social, bingo, and board games. There is no documented evidence that the activities were offered or that the resident refused to participate in he offered activities of interest. Review of the activity task for one one-on-one activity on August 29, 2025, and September 4, 2025, is documented as the resident refused. A review of the progress notes revealed no documented activity progress notes.An interview was conducted on September 19, 2025, at 2:38 pm with the Activity Director (Staff #79). Staff #79 stated the resident's program of activities and goals for resident #9 is a preference to be in the room and rest, sensory activities, and comfort, and wishes to be alone. Staff #79 stated the activity department provides one-on-one interventions twice per week, per the resident's care plan, and activities of choice. Staff #79 stated that if a resident refuses to participate, the refusal is documented in the resident's activity record or manually inputted on the resident activity attendance sheets. Staff #79 reviewed the resident's activity record for care planned activities. Staff #79 acknowledged there were two days, August 29, 2025, and September 4, 2025, that were documented as the resident refused within thirty days. Further review of the manually documented activities for resident #9 by staff #79. Per record review by the activity director, she acknowledged there was no documentation that the resident was offered activities per the resident's care plan for June, July, and August 2025. Staff # stated that the activity staff will encourage and offer residents the opportunity to participate in an activity of preference, and if they choose not to participate, then the refusal is documented in the resident's chart. Staff # stated her expectation for the activity staff is that they are documenting the offered activities and refusals. Staff #79 stated that the risk of not providing residents' activities or documenting their refusals or participation is that it gives the appearance that the offered activity did not occur, or risk for isolation.An interview was conducted on September 19, 2025, at 10:47 am with Registered Nurse (RN/Staff #67). Staff #67 stated that staff will assist the residents in participating in activities of choice, and if they are aware of a certain activity that a resident may enjoy, the activity staff will go around and ask for help in getting the residents to the activities. Staff #67 stated that nursing staff will follow up to ensure that the residents are attending. Staff #67 stated the activity department offers the residents activities daily and on weekends. Staff #67 stated that if a resident refuses to participate in activities, he will try to identify and address the reasons why. Staff #67 stated that he would start by asking the resident to identify the problem. If it turns out to be a persistent problem, we will notify the provider and document a change in behavior note in the resident's chart. An interview was conducted on September 19, 2025, with the interim Administrator (Staff # 201) and Administrator in Training (AIT/Staff # 204). Staff # stated that the activity department was offering the resident, but the resident is refusing the activities. Staff # stated he expects that all interactions with residents by the activity department are documented. Review of the facility policy titled Delivery of Activity Services, revised 07/2007, reviewed 07/2027, states, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate.Review of the facility policy titled Documentation and Charting, revised 7/2022, states that it is the policy of this facility to provide:1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure medications were administered within ordered parameters and according to accepted standards of practice for 1 of 5 residents reviewed for unnecessary medications (Resident #6). The census was 110, and the sample size was 22. The deficient practice had the potential to cause adverse drug effects and place residents at risk for harm from unnecessary medications that were not clinically indicated at the time of administration.Findings include:Resident #6 was admitted on [DATE], with the diagnosis of hypotension and unspecified dementia, unspecified severity, with anxiety.A physician's order dated July 1, 2024, revealed an order for Midodrine HCl Tablet 2.5 MG, one tablet three times a day for hypotension. The order also revealed that the medication is to be held if the systolic blood pressure (SBP) is greater than 120.A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment.A review of the Medication Administration Record (MAR) for August 2025 revealed that Midodrine HCl Tablet 2.5 MG had been administered out of ordered parameters at 10:00 AM on August 11, 2025 with the SBP of 134; August 15, 2025 with the SBP of 137; August 18, 2025 with the SBP of 143; and August 29, 2025 with the SBP of 133. As well as at 1:00 PM on August 20, 2025, with the SBP of 131, and on August 31, 2025, with the SBP of 142. And, as well as at 8:00 PM on August 1, 2025 with the SBP of 126; August 2, 2025 with the SBP of 128; August 3, 2025 with the SBP of 130; August 6, 2025 with the SBP of 122; August 7, 2025 with the SBP of 122; August 15, 2025 with the SBP of 137; August 17, 2025 with the SBP of 134; August 18, 2025 with the SBP 138; August 20, 2025 with the SBP of 131; August 26, 2025 with the SBP of 149; and August 29, 2025 with the SBP of 123.A review of the MAR for September 2025 revealed that Midodrine HCl Tablet 2.5 MG had been administered out of ordered parameters at 1:00 PM on September 7, 202,5, with the SBP of 141; September 14, 2025, with the SBP of 132; and September 17, 202,5, with the SBP of 128.An interview was conducted on September 18, 2025, at 11:25 AM with a Registered Nurse (RN/Staff #107), who advised that the hypotensive medication, Midodrine, is expected to be administered per the physician's orders, as it will require the administering nurse to confirm that the ordered parameters are being met. Staff #107 stated that the physician's order for Resident #6 stated to administer one tablet of Midodrine three times a day; however, to hold the medication if Resident #6's systolic blood pressure were to reach greater than 120. Staff #107 also advised that the risk of administering Midodrine outside the parameter of greater than 120 could cause a spike in the Resident's systolic blood pressure, induce cardiac arrest, or stroke.An interview was conducted on September 18, 2025, at 11:56 AM, with the Director of Nursing (DON/Staff #200) and a Clinical Resource (Staff #206), where Staff #200 stated that the facility expected nursing staff to administer medications per the physician's orders and stated parameters. Staff #200 reviewed August and September MARS for Resident #6 and reviewed the administration of Midodrine. Staff #200 confirmed that Resident #6 received Midodrine out of parameters at 10:00 AM on August 11, 2025, with the SBP of 134; August 15, 2025, with the SBP of 137; August 18, 202,5, with the SBP of 143; and August 29, 20,25, with the SBP of 133. As well as at 1:00 PM on August 20, 2025, with the SBP of 131, and on August 31, 2025, with the SBP of 142. And, as well as at 8:00 PM on August 1, 2025 with the SBP of 126; August 2, 2025 with the SBP of 128; August 3, 2025 with the SBP of 130; August 6, 2025 with the SBP of 122; August 7, 2025 with the SBP of 122; August 15, 2025 with the SBP of 137; August 17, 2025 with the SBP of 134; August 18, 2025 with the SBP 138; August 20, 2025 with the SBP of 131; August 26, 2025 with the SBP of 149; and August 29, 2025 with the SBP of 123. As well as in September at 1:00 PM on September 7, 2025, with the SBP of 141; September 14, 202,5, with the SBP of 132; and September 17, 2,25, with the SBP of 128. Staff #200 further stated that the risk of receiving Midodrine out of parameters could have the potential for possible hypertension concerns. Staff #206 advised that Resident #6's administration of Midodrine out of parameters had been addressed at the end of August during the routine Medication Regimen Review. Staff #200 and Staff #206 advised that administering medications out of parameters had been discussed during huddle meetings, with no documentation signed for education completion. Staff #200 confirmed that education on medications administered outside of parameters took place on September 11, 202bu ut, but was unable to provide documentation to support the education provided. Staff #200 also advised that the administration of Midodrine out of the ordered parameters for Resident #6 was not within the facility's expectations. A policy titled Physician Orders, with the last review date of September 2024, revealed that drugs or biologicals shall not be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses.

Based on clinical record review, facility documentation, staff interview, and policy review, the facility failed to ensure the Narcotic Log/count Q shift Monitoring sheet was accurately completed. The deficient practice could result in narcotics not being accounted for. During an observation conducted on September 17, 2025, at 9:58 AM of the medication cart 200 even numbered room, with License Practical Nurse (LPN/Staff #39) stated that the Narcotic Log/Count Q shift Monitoring was incomplete for the following days in September 2025: 10, 11, 13, 14, 15. She further stated that there was no day shift nurse signature for September 10th and 11th of 2025. She also stated that there was no night shift nurse signature for September 13th, 14th, and 15th of 2025An interview was conducted on September 17, 2025, at 10:16 AM with the Unit Manager (LPN/Staff # 117), who stated that the medication cart 200 Odd number room Narcotic Log, Count Q Shift Monitoring was incomplete for nursing signatures for the following dates in September 2025: 3, 7, 14, 15, and 16. He further stated that the section Quantity was incomplete for the 14th and 15th of September 2025. A further interview was conducted on September 18, 2025, at 2:59 PM with (LPN/Staff # 39), who stated that the facility's expectation for Narcotic Log/ Count Q Shift Monitoring is that at the start and end of the shift, the nurses would sign the log. He also states that nurses would be accepting responsibility and that nurses are saying that the narcotic count is accurate. He further stated that not filling out the Narcotic Log/ Count Q Shift Monitoring would not be accurate. He then stated that this can impact the resident because if there is a need for a medication, then that medication may not be available because of missing information on the Narcotic Log/count Q shift Monitoring. An interview was conducted on August 18, 2025, at 3:36 PM with the Director of Nursing (staff/# 200), who stated the Narcotic Log/count Q Shift Monitoring would have an On coming and Off coming nurse count the narcotic card to match the record. She also stated that the Narcotic Log/Count Q shift Monitoring would be signed at the same time by the two nurses who are counting. She then stated the sections: Quantity, and the Nurse's initial should be completed. (DON/Staff # 200) also stated that an incomplete Narcotic Log/Count Q Shift Monitoring can cause the narcotic count to be incorrect, and there would be a loss in pain control. A policy review on May 2025 titled Medication Administration revealed that At each shift change, a physical inventory of all controlled medication is conducted by two licensed nurses and is documented on an audit record.

Based on interviews, facility documentation and policy, the facility failed to ensure patient care equipment was maintained according to manufactures recommendations and kept in safe operating condition. The deficient practice could result in a resident not receiving basic life support with an Automated External Defibrillator (AED). Findings Include: An observation was conducted with the Executive Director (Staff # 07) on May 28, 2025 at 12:00 p.m. of the facility's Core Crash Cart. The defibrillator is stored in the bottom drawer of the Core Crash Cart with a blinking green light. The crash cart daily checkoff list is located on top of the cart. According to an invoice dated December 20, 2021, the facility acquired the AED machine. According to the user manual, version DAC-A580-EN-DL, the Operator's Checklist should be used as a basis for routine maintenance. The manual includes specific maintenance tasks that are recommended to be performed on a regular basis to ensure machine readiness. The 2024 Facility Assessment revealed ways of ensuring an adequate supply of equipment revealed the facility can also rent specialized or additional equipment on any given day through a variety of local vendors. The Phoenix Mountain Nursing Center Emergency Cart Checklist from April 2024 through June 2024 failed to support the presence of an AED on the list, and that daily checks on the machine were being performed. Facility documentation provided by the Assistant Director of Nursing (Staff # 43), undated, revealed the AED showed signs of malfunction on May 11, 2025, and that a confirmation email was received on May 15, 2024 instructing the facility to remove the AED from use until a new battery was available. An email dated May 28, 2025 at 12:42 p.m. addressed to the ADON, revealed the replacement of the battery pack and instructions was originally sent on May 15, 2024 at 1:48 p.m. The facility documentation failed to support the daily equipment check of the AED machine. The facility documentation also failed to support the use of the manufacturers recommended way to document the functioning of the defibrillator. Review of a complaint filed with the Arizona Department of Health on May 13, 2024 revealed Emergency Medical Services (EMS) arrived to assist a resident in cardiac arrest. The rescue team reported concern that the facility's AED was not in operational order. An interview conducted on May 28, 2025 at 1:22 p.m. with the customer service representative for the manufacturer revealed the date of contact for the malfunctioning AED was on May 15, 2025, and after troubleshooting a replacement battery was decided as part of the solution. An interview was conducted with a representative from the local Emergency Medical Services department on May 29, 2025 at approximately 3:02 p.m. The representative revealed appreciation for the investigation into this matter, and felt inoperable lifesaving equipment at a healthcare facility is definitely of concern. A panel discussion was conducted on May 30, 2025 at 12:28 p.m., with the Director of Nursing (Staff #01) and the ED. Both parties revealed that in August of 2024, the AED was added to the crash cart log checklist. They also explained that in February 2025, service for the AED was added to the monthly maintenance checklist. Both parties revealed that an AED is not a requirement in the nursing home, however the panel acknowledged the facility is responsible for maintaining patient care equipment in working order. The panel also agreed that the AED was intended for resident emergency use. A second interview was conducted on May 30 at 1:22 p.m. with the manufacturer's customer service representative. The representative re- verified that the manufacturer was not contacted until May 15, 2024 at 10:00 a.m. The representative explained that during customer calls, a ticket is immediately opened and timestamped in their system. The facility's Cardiopulmonary Resuscitation policy, revised December 2023, revealed Basic Life Support includes early cardiopulmonary resuscitation, and rapid defibrillation with an automated external defibrillator, if available. A crash cart policy was requested on May 28, 2025, but notice was given on May 28 2025 at 13:48 that there was not a corresponding policy. However, the procedure is for the night staff nurses check daily.

Based on clinical record review, observations, interviews, facility documentation and policy, the facility failed to ensure that one resident (#435) with an intellectual disability was properly groomed, and provided proper hygiene. The sample size was three residents. The deficient practice could result in the resident being ostracized and ridiculed at the facility, adversely impacting self esteem. Findings include:Resident # 435 was admitted to the facility on [DATE], with diagnoses that included unspecified intellectual disabilities, adjustment disorder with mixed anxiety and depressed mood, pyoderma gangrenosum (a rare, inflammatory skin disease where painful pustules or nodules become ulcers), and psoriasis vulgaris (a chronic inflammatory skin condition characterized by red raised patches, covered with silvery white scales).The Activities of Daily Living (ADL) care plan dated October 1, 2021, revealed that the resident required assistance with self-care and mobility. The care plan goal included the resident being clean and well-groomed. Resistance to Care was care-planned and initiated on January 31, 2024, with a goal of being open to feedback and coping mechanisms A progress note dated April 7, 2025, revealed the resident became upset with her about a shower, and for not allowing the resident to keep a urine-soaked blanket. The quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The assessment also revealed the resident has had no adverse behavioral symptoms or rejection of care over the lookback period. The Interim Self-Care assessment revealed the resident was capable of performing activities of independent living independently (requiring no assistance from a helper). An investigation of an anonymous complaint submitted to the Bureau of Long-term Care on June 17, 2025, revealed the complainant's disapproval of the resident being allowed to walk around the facility and dining area with her briefs always soaked. A request for the past three months of the resident's shower sheets was made on July 11, 2025. Repetitive refusals of bad baths/ showers were revealed throughout April 2025 to July 2025. Shower sheets or other documentation supporting the resident having a bath from June 28, 2025 to July 11, 2025, were not provided to the compliance officer before exit. The clinical record does not support the IDT's attempt to re-evaluate the resident's ability to maintain proper bowel and bladder management on a quarterly basis. On July 11, 2025, at approximately 1:25 p.m., the compliance officer, along with the Assistant Director of Nursing (ADON/Staff #43) observed the resident walking down the hallway in a disheveled, ungroomed, and malodorous state. The resident stopped to engage in small talk with the ADON. Upon closer evaluation, a substantial amount of skin flaking was present on clothes and in hair. The resident's clothing had staining, and the resident's walker had a brown dried substance near the hand-grip area. Upon leaving the facility on July 11, 2025, at 3:40 p.m., the compliance officer, along with the Clinical Resource Staff (Staff # 40), observed the resident standing in the facility lobby. The resident state was unchanged from the previous observation.An interview was conducted with Resident # 412 on July 11, 2025, at approximately 1:13 p.m., who voiced familiarity with the resident and stated they let her Resident # 435 walk around all day smelling like piss and sh--, and do nothing about it. It's disgusting! The resident continued that the staff should think about how they would feel if someone allowed their loved one to be walking around like that!. An interview was conducted on July 11, 2025, at approximately 1:25 p.m., with the ADON (Staff # 43), who revealed that the resident is oftentimes resistant to care. The ADON further explained that they work hard to meet the resident's demand, and respect her rights as to when and how she wants things done. The ADON explained that the resident is very independent and refuses to let others assist. After seeing the brown dried matter on the walker, the ADON stated she would instruct staff to assist the resident in getting cleaned up immediately.During an exit conference conducted on July 11, 2024, at approximately 3:30 p.m. with the Director of Nursing (DON/Staff # 01), the DON revealed that the facility is aware that the resident has a long history of being resistant to care, and will continue to find ways to accommodate to help the resident meet care needs. The facility's Dignity and Respect policy, revised September 2024, revealed that residents will be appropriately dressed in clean clothes arranged comfortably on their persons and be well-groomed. The facility's ADL (Activities of Daily Living), Services to carry out policy, reviewed August 2024, dictate that qualified staff will provide necessary services to ensure residents maintain good nutrition, grooming, toileting, and personal oral hygiene. The facility's Bowel and Bladder Management policy, revised July 2013, directs the Interdisciplinary Team (IDT) to re-evaluate on at least a quarterly basis, upon a change of condition, and at other times as appropriate or indicated by the circumstances.

Based on observations, clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (# 382) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new skin impairments. The sample size was three residents. The deficient practice could result in the development, or worsening of skin impairments.Resident # 382 was admitted to the facility on [DATE], with diagnoses that included paraplegia, neurogenic bowel and bladder (damaged nerves adversely affect bowel and bladder control), Type 2 Diabetes Mellitus, anxiety, and neoplasm of bone/soft tissue/ and skin. The resident's Activity of Daily Living (ADL) Self-care Performance Deficit care plan, initiated on October 19, 2019, goal for the resident to be clean and well-groomed through the review date. The resident's Pressure/Skin care plan, initiated on November 3, 2019, revealed the resident was to receive a low-air-loss mattress, mobility bars, and pressure-relieving/reducing device on the chair. A progress note dated January 3, 2022, revealed that an offloading mattress was included in the wound care orders.An order for a low-air-loss mattress was initiated on February 10, 2022. The Medication Administration Record (MAR)/Treatment Administration Record (TAR) did not support offloading mattress documentation from January 3, 2022, until February 9, 2022. The resident's shower sheets were reviewed for February 2022 through May 2022 and revealed the following:- No bathing activity occurred between February 2-7, 2022.- No bathing activity occurred between February 9-15, 2022. - No bathing activity occurred between February 17-21, 2022. - No bathing activity occurred between February 23-27, 2022.- Excluding the refusal on March 8, 2022, no bathing activity occurred between March 4, 2022 - March 14, 2022. - There is no clinical documentation supporting bathing activity that occurred during the month of April 2022.- No bathing activity occurred between May 4, 2022-May 8, 2022- No bathing activity occurred between May 10-17, 2022. A vascular clinic note dated April 19, 2022, revealed a positive prognosis for resident wound healing. The provider notes supported that the right and left lower extremity wounds had the capacity to heal. The resident's quarterly Minimum Data Set (MDS) assessment, dated April 23, 2022, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment indicated the resident required physical help with bathing. The assessment further indicated the resident had Moisture Associated Skin Damage (MASD) and required a pressure-reducing device for bed. The progress note dated May 16, 2022, revealed the following status of the resident's wounds:Wound #7 Left, Lateral Thigh is an Abrasion and has received a status of Not Healed.Wound #8 Buttock bilateral buttocks is a MASD and has received a status of Not HealedWound #9 Right, Plantar Foot is a Diabetic Ulcer and has received a status of Not Healed. Wound #12 Right, Posterior Heel is an Arterial Ulcer and has received a status of Not Healed. A shower sheet dated March 8, 2022, revealed the resident refused bathing. The clinical record does not reflect any other episodes when the resident requested showers less than twice a week. An interview was conducted with Licensed Practical Nurse (LPN/ Staff #2) on May 28, 2025, at 1:22 p.m. The LPN revealed that residents with severe incontinence are checked on hourly. The LPN further elaborated the importance of knowing your resident and their clinical diagnosis to anticipate needs. In addition, the LPN revealed that showers are scheduled twice a week, and if a resident requests more than that, the staff will provide the opportunity. In regard to skin assessments, those are documented in the electronic medical record weekly under the skin assessments tab. An interview was conducted with Resident #204, who voiced aggravation, stated, I don't appreciate having to sit and wait in my own piss for over an hour, the CNAs (Certified Nurse Assistant) never want to work! They will come into your room and turn off your call light, and tell you they will be right back, but they never do! It can be an hour or two when you put your light back on to remind someone to come change you. I am afraid of getting sores! Luckily, I move better than most here, otherwise I would have had one by now! An interview was conducted with the Wound Care Nurse (WCN/Staff # 92) on May 29, 2025, at approximately 9:20 a.m. The WCN revealed Incontinence Associated Dermatitis (IAD/ a form of MASD) is when the skin has prolonged contact with an incontinent episode. The WCN explained one of the best ways to minimize MSRD is by keeping the resident clean and dry and maintaining good hygiene practices. An interview was conducted with the Wound Care Physician (WCP/Staff#40) on May 30, 2025, at 8:40 a.m. The physician revealed that not keeping a resident clean and dry can lead to MASD. The physician continued is one of the best ways to keep a resident is supporting good hygiene practices, and making sure soiled and wet briefs do not allow prolonged contact time with skin. The facility's Activities of Daily Living policy, reviewed date August 2021, revealed bathing will be offered twice weekly (unless residents request more or less). In addition, the policy instructs staff to document ADL care in the medical record accordingly. The facility's Wound Management policy, reviewed date July 2021, revealed that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable. In addition, if the resident is incontinent, make sure that the skin remains clean and dry with regular peri care and toileting when appropriate.

Based on observations, clinical record review, interviews, and facility documentation and policy, the facility failed to ensure hospice services was contacted for a significant change in condition for resident #83. The deficient practice could result appropriate hospice services not being provided to the resident. Findings include:Regarding Resident #83:Resident # 83 was admitted to the facility on [DATE], with diagnoses that included hepatic encephalopathy (the loss of brain function when a damaged liver doesn't remove toxins from the blood), dementia, and anxiety. The resident was admitted to hospice on March 31, 2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. An observation on May 29, 2025, at 10:27 a.m. revealed the resident quietly lying in bed with his brief visible. In addition, a bowl of spilled cereal and milk, another bowl, and a cup were on the bed by the wall in the resident's bed. Crumbs were also present on the resident's gown. An observation was conducted on May 29, 2025, at 11:06 a.m. with the Assistant Director of Nursing (ADON/Staff #43) of the resident in the bed, brief still showing, food on clothing, bowl of spilled cereal and milk, and an additional bowl. A panel discussion was conducted on May 29, 2025, at 1:45 p.m. with the Director of Nursing (DON/ Staff # 01) and the Assistant Director of Nursing. The panel revealed if a resident has been determined to be dependent for eating, the facility's expectation during meals is that the resident is being assisted by staff. Some interventions that would be included in a care plan for a resident who requires total dependence on meals would include one on one assistance with meals, or some just says assistance, the intervention will depend upon the need. In regard to the resident being left in the state, found. With breakfast ending around 8:30 a.m. and the resident in the current state at 11:06 a.m., what dignity issues can arise? In the matter of dignity and safety, those are addressed throughout his care plan, so it is about the combative behavior with staff, then they will step away, and go back for it later. The facility expectation revealed if the resident was in a calmer they would finish the meal. expectation. The facility's expectation was to go back when the resident was calmer, try to finish the meal, and clean up the resident. The panel voiced being unable to locate documentation in the clinical record supporting the combative episode at breakfast. An interview was conducted with CNA staff # 99 on May 29, 2025, at 4:04 p.m., revealing that the resident was combative that morning and made a mess with the breakfast and dishes on the bed. We are encouraged to walk away and let the resident calm down before reattempting. The CNA revealed her supervising nurse was informed, and that housekeeping was contacted to clean up the mess. An interview was conducted with the resident's hospice Registered Nurse (RN) on May 30, 2025, at 10:59 a.m. The RN revealed that hospice was not contacted regarding the resident having a combative episode. The RN further explained that whenever there is a change, especially as the one described, the facility was supposed to let hospice know. The RN voiced great concern about this matter and will follow up immediately with the facility. The RN revealed that informing the hospice when a change of condition occurs is imperative to be able to collaborate with their team to help the resident. An order for a regular diet, mechanical soft was initiated on May 27, 2025.The Activities of Daily Living (ADL) Self Care Performance Deficit care plan-initiated April 30, 2025, encouraged the resident to participate to the fullest extent possible with each interaction. The admission Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was severely cognitively impaired. The Self-Care functional abilities score for eating is listed as Dependent.Documentation supporting the MDS change to eating alone or with minimal assistance was requested on May 30, 2025, at 13:00. The facility failed to fulfill the request. A request to view video surveillance of the resident's hall between 8:15 a.m. to 10:45 a.m. on May 29, 2025, was requested on 5/30/25 at 9:50 a.m. The facility was unable to fill the request.A request for documentation supporting the CNA's account of the combative episode was requested, however the facility was unable to fill the request. The facility's contractual agreement with the Hospice provider reveals the Hospice and facility intends to implement a collaborative relationship in compliance with all relevant state and federal laws which will facilitate access to Hospice care services. In addition, item 4.8 of the agreement revealed that the facility is to immediately notify Hospice if a significant change in a Hospice patient's physical, mental, social, or emotional status occurs. The facility's Change of condition reporting policy, reviewed 09/2024, revealed that all changes in resident condition will be communicated to the physician and resident representative and documented.The facility's End of Care; Hospice policy, reviewed 09/2024, revealed collaborating with Hospice will include processes for orienting staff to facility policies and procedures.

Based on review of the facility assessment, facility documentation, staff interviews, personnel files, and facility policy, the facility failed to ensure that one staff member (#65) had the competencies and skill sets necessary to provide nursing and related services to safely meet one resident's (#166) transfer needs. The deficient practice regarding resident transfer equipment could increase the risk for accident-related injuries. Findings include: Resident #166 was admitted to the facility on [DATE] with the diagnosis type 2 diabetes and muscle weakness. A care plan focus of self-care performance deficit with the initiation dated of August 29, 2019 revealed that Resident #166 requires a Hoyer lift for transfers. A quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed that Resident #166 had been dependent on helper assistance for chair to bed transfers, toilet transfers, and shower/tub transfers. Indicating that the resident relied on staff assistance to transfer in and out of their bed, and, into their wheelchair. A review of the facility's 2025 facility assessment revealed provided services include mobility and fall prevention with practices such as transfers. The assessment noted that in addition to required certification and licensure, all staff are oriented at the time of hire and receive all required training on an ongoing basis to meet the residents' needs, as identified, including the necessary competencies and skill sets. The assessment also revealed that the facility has identified competencies and trainings regarding transfers can include gait belts and mechanical lifting techniques. The assessment included factors that may affect the care provided by the facility, including staff competencies. On June 13, 2025 at 8:50AM, there was an observation of a CNA (certified nursing assistants/Staff #65) utilizing a Hoyer lift with Resident #166. There were no other staff members assisting Staff #65 with the usage of the Hoyer lift to transfer the resident. An interview was conducted with Staff #65 on June 13, 2025 at 10:48AM, where Staff #65 stated that the facility had provided training on Hoyer lift usage and the expectations regarding the utilization of mechanical lifts for transfers. Staff #65 stated that the usage of medical equipment is discussed during in-service trainings, and, as well as monthly meetings for CNAs. Staff #65 stated that the facility's expectation is to have two staff members present when utilizing a Hoyer lift. Staff #65 had also stated that they did not have a second staff present when utilizing the Hoyer lift with Resident #166 during the observation mentioned above. An interview was conducted with a CNA (Staff #17) on June 13, 2025 at 11:03AM, where Staff #17 stated that the usage of a Hoyer lift requires two staff to be utilized properly and to the facility's expectations. Staff #17 also advised that they facility had a recent training regarding how to utilize a Hoyer lift and that the requirement of two staff had been reiterated during that medical equipment training. An interview was conducted on June 13, 2025 at 11:20AM with an LPN (Licensed Practical Nurse/Staff #94), where Staff #94 stated that a Hoyer lift should not be used by any staff in the facility unless there are two staff present to utilize the mechanical lift. Staff #94 also stated that there should not be a problem to obtain a second staff member to complete a transfer with a Hoyer lift as CNA's are encouraged to ask staff such as a nurse or a therapy staff member. An interview was conducted with the DON (Director of Nursing/Staff #81) on June 13, 2025 at 1:08PM, where Staff #81 stated that the facility's expectations regarding the usage of a Hoyer lift requires two people to be able to utilize the equipment appropriately to meet the needs of a resident. Staff #81 also stated that the requirement of two staff members is important for the safety of the resident and as well as the staff members who utilize the equipment. Review of the facility policy, Resident Safety - Mechanical Lift, revealed that the policy is to help ensure the safety of the employees and the residents. The policy also revealed that the policy applies to all healthcare personnel involved in patient care and transfers within the facility. The policy also revealed that there should always be a minimum of two healthcare personnel during patient transfers with a mechanical lift, to ensure there is one person operating the equipment and one who assists the person operating the equipment.

Based on review of the clinical record, staff interviews, and review of policies and procedures, the facility failed to ensure clinical record documentation was accurately documented for one resident (#111) regarding medication administration. The deficient practice has the potential for clinical records to inaccurately and incompletely reflect the administration of medications to all residents. Findings include: Resident #111 was admitted to the facility on [DATE] with the diagnosis of Schizophrenia. An order dated November 28, 2023 revealed that a complete blood count with differential is to be completed every Monday for Clozapine monitoring, and, to fax the results to the pharmacy for review. An order dated December 6, 2023 an order of Clozapine 25 MG oral tablet one time a day for Schizophrenia. This ordered had been discontinued on February 20, 2024. A Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. A medication administration record for February 2024 revealed that the resident had been administered Clozapine 25 MG on February 9, 2024; February 14, 2024; and February 18, 2024. Indicating that from February 1, 2024 to February 20, 2024, Resident #111 did not receive Clozapine 25 MG on the days not listed above. An interview was conducted on June 11, 2025 at 11:19AM an LPN (Licensed Practical Nurse/Staff #12, where staff #12 stated what the facility's expectations are regarding the medication process. Staff #12 stated that if a medication is not available for a resident in their designated medication cart, that they will refer to the facility's additional medication storages to locate additional supply. Staff #12 also stated that if the medication is not present, they are to reach out to the provider and the pharmacy as soon as possible to determine the status of the order. Staff #12 also stated that a detailed description of what was done, who was contacted, and any directives given by either the provider or the pharmacy, and to notate that description into the progress notes of the resident's electronic health records. Although Staff #12 did not provide care to Resident #111, Staff #12 also stated that the completion of this process, in regards to Clozapine, is to prevent the risk of increased symptoms of anxiety, restlessness, confusion and behaviors. Staff #12 also stated that although medications can take time to get to the facility, there can be times where the medication may not be available for a few days and having accurate documentation of what was done to obtain a status is important. Another interview was conducted on June 11, 2025 at 12:01PM with an LPN (Staff #11), where Staff #11 stated that if a medication is not available that there is an emergency box where medications can be located. Staff #11 also stated that the pharmacy and as well as the provider would be contacted to determine where the medication is and the status of the order. Staff #11 also stated that they are to seek guidance from the provider as well to determine what to do for the resident. Staff #11 also stated that a progress note in the resident's electronic health record would be completed with the information of any updates and that the medication was not administered due to not being available. Staff #11 also stated that there may be times where family notification will need to be done and that is expected to be documented in the progress note as well. Staff #11 had been familiar to the behaviors Resident #11 exhibited, however did not provide direct care with the resident and did not directly administer medication to the resident. Staff #11 also stated that the completion of accurate administration and documentation of medications, in regards to Clozapine, can prevent to risk of signs and symptoms worsening. There was an attempted interview with the contracted Psychiatric Provider (Staff #158) who had been the provider at the time of the review of Resident #11 on June 12, 2025 at 11:12AM, who had been the Psychiatric Provider at the time of the review. However, it was unsuccessful. An interview had been conducted on June 12, 2025 at 1:04PM with the current contracted Psychiatric Provider (Staff #159) where Staff #159 stated that if a medication is unavailable for a resident, the facility can reach out to her to determine the status of the order. Staff #159 also stated that a delay in available medications would require adjustments and changes and with her role. Staff #159 stated that they were familiar to the care of Resident #111's psychiatric interventions. Staff #159 advised that when they had transitioned into their role, had been around the time where Resident #111 had been experiencing medication delays for Clozapine 25 MG. Staff #159 also stated that Resident #111 grew non-compliant with care and refused to completed lab work that had been required for the pharmacy to dispense the medications. Staff #159 also stated that although they do not see the documentation left by staff following conversations of unavailable medications or updates with medication status', that the expectation is to ensure there is documentation of any interaction pertaining to the unavailable medications and any recommendations that may be provided. An interview had been conducted on June 12, 2025 at 2:35PM with the DON (Director of Nursing/Staff #81) where correspondences to attempt to obtain updates on the status of the medications had been initiated. Staff #81 provided documentation that a new order of Clozapine 25 MG had been sent on February 20, 2024 with a new request for lab work. Staff #81 also stated that the administration of Clozapine 25 MG resumed on February 21, 2024. Staff #81 also reviewed medication administration record and the progress notes for February 1, 2024 to February 20, 2024, and stated that the only explanation for February 9, 14, and 18 of 2024 was that they were incorrect charting of the administration of the medication, as the medication had not been available at all. Staff #81 also stated that there can be times where medication is completely unavailable and if s situation were to arise, the expectation is that documentation is completed. Staff #81 stated that accurate documentation is crucial as the risk can include incorrect statements and documentation that do not accurately depict the resident's care. A facility policy titled, 'Documentation and Charting', revealed that the purpose of the policy is to provide a complete account of the resident's care and treatment, and, a source of guidance for providers when prescribing appropriate medications and treatments.

Based on resident, resident representative, and staff interviews and facility documentation, the facility failed to protect the resident's (#11) right to be free from sexual abuse by a staff. The deficient practice could result in residents' increase risk of further harm and abuse. Findings include: Resident #11 admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included Wernicke's encephalopathy, anxiety, post-traumatic stress disorder, migraines, major depressive disorder, and suicidal behavior. The care plan initiated on 09/25/2023 indicated she preferred a female caregiver relation to her risk of re-traumatization related to a history of intimate partner violence. On 02/01/2024, a goal was initiated for potential for a psychosocial well-being problem related to an inappropriate relationship with a non-caregiving associate as evidenced by Anxiety, depression, and suicidal ideation. Interventions included consultations with pastoral care, social services, and psychiatric services as well as monitoring and documenting residents' feelings related to posttraumatic stress disorder (PTSD) and the termination of the same inappropriate relationship. The Admission Minimum Data Set (MDS) assessment on 10/01/2023, she scored a 13 on her Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact. She did not exhibit any behaviors in the look back period. The physician order dated 11/28/2023 revealed an order for trazodone (anti-depressant) 50 mg (milligrams) for inability to fall and stay asleep related to depression. Resident #1 had orders for the following psychotropic medications: Escitalopram 10 milligrams (mg) for depression dated 10/27/2023 and increased to 20mg on 11/29/2023, trazadone 50mg for inability to fall and stay asleep related to depression dated 11/28/2023 increased to 100mg on 01/22/2024 and increased to 150mg on 02/09/2024, Lorazepam 0.5mg for anxiety dated 10/03/2023. The Quarterly MDS from 12/13/2023, her BIMS was 15 which indicated no cognitive impairment. The physician order dated 1/22/2024 revealed the order for trazodone was increased from 50 mg to 100 mg for depression. The psychiatric note dated 02/01/2024 revealed resident #11 was assessed for trauma regarding a potentially inappropriate relationship between the resident and non-caregiving staff member. Per the documentation, the resident had also reported this to leadership that day; and that, resident #11 told the provider that all the interactions with the staff member (#20) were entirely voluntary and consensual. The plan was for resident #11 to continue her psychiatric medications as currently prescribed and he would follow up with her in 1-2 weeks. A progress note dated 02/01/2024 by the Interdisciplinary Team (IDT) documented the discussion of concerns regarding an inappropriate relationship between the resident and a non-caregiving staff member. The skin assessment completed on 02/01/2024 documented light bruising to left upper inner thigh, but indicated the resident reported that she got it from her brief. The clinical record revealed that on 02/01/2024 the provider ordered a pregnancy test and labs for sexually transmitted diseases (STD) which included herpes (virus), hepatitis (virus), HIV (human immunodeficiency virus), and chlamydia (bacteria). The clinical record also revealed an order for change of condition related to psychosocial well-being dated 02/01/2024 with the instructions to monitor for increased anxiety/depression and potential for suicidal ideation. The facility self-report with a date of discovery of 02/01/2024 revealed that on 02/01/2024, the resident reported a relationship between her and a male staff member (staff #20) to the administrator and DON (Director of nursing). Per the report the resident reported that the relationship was consensual; and that, it had involved oral sex on two occasions. It also included that the resident denied engaging in intercourse with staff #20. The report included a summary of the two interviews conducted with resident #11 by the DON. The summary included that the resident reported exchanged phone numbers with staff #20 and they would often text message back and forth; the relationship progressed into kissing and touching a few weeks after the text messages started; the resident and staff #20 had oral sex (both her for him and him for her) on two separate occasions (once in the shower and once in the resident's room) both times during the overnight shift. The summary also included that staff #20 shared that he was having financial hardships and the resident offered him help; but the resident confirmed that she never actually gave him money. The summary included that the resident reported she was not forced to engage in this conduct and there were no threats or promises were made by staff #20 to her. Continued review of the facility self-report included a summary of a phone interview conducted with staff #20 by the DON and the administrator on 02/01/2024. Per the documentation, staff #20 admitted that he exchanged telephone numbers with the resident; and that, he and the resident talked via text message. The documentation included that staff #20 denied any physical contact including but not limited to oral sex; and denied speaking with the resident regarding any financial hardships. Further review of the facility self-report included that the facility concluded there were no patterns or instances of any other unprofessional or inappropriate relationships; and there were no staff interviewed had witnessed or were aware of any improper conduct or relationship as between staff and resident. It also included that while the facility determined that the relationship between the resident and the staff member was inappropriate and unprofessional, it did not constitute abuse as that term is defined in the State's Adult Protective Services statute. The labs results completed on 02/02/2024 revealed negative for STD. The psychiatric consultation note dated 02/08/2024 revealed Resident #11 told the provider her mood was even heavier and her anxiety had increased since her last visit; and, her sleep had been interrupted, causing her to wake several times per night and making her want to sleep more during the day. It also included that the provider increased her trazodone to address the insomnia as well as the increased depression symptoms. The psychiatric consultation note dated 02/15/2024 included that Resident #11 reported that she continued to experience feelings of sadness and was having thoughts that she would be better off gone. Another psychiatric consultation note dated 02/22/2024 revealed the resident reported that she was transferring to a different facility soon, was optimistic about the move; and that, she had a decrease in all behavioral symptoms. Review of the personnel file for staff #20 revealed that a job description dated 8/31/2023 and that staff #20 was a certified nurse assistant (CNA). Further, the telephone number on record matched the telephone number that was on resident #11's phone and text messages. It also included that staff #20 signed a job description for laundry staff on 01/05/2024. A review of punch details for October 2023 to February 2024 revealed that Staff #20 worked as a nursing assistant from 10/01/2023 through 12/25/2023; and, from 01/01/2024 through 01/31/2024, staff #20 worked as a housekeeping aide. The report submitted by the resident's family to the State Agency complaint portal on 5/13/2024 revealed that resident #11 still had times where she breaks down crying and had told the family member multiple times about the incidents of sexual abuse by an unlicensed caregiver. The report identified the staff involved by name (staff #20); and that, the resident had now frightening nightmares on what took place and had been disgusted with herself. Further, the report included that there had been attempts made by the director of nursing, her manager, and multiple staff to cover up the incident. The report also included that resident #11 battled depression, suicide, and anxiety and had become cautious about anyone who touches her; and that, staff #20 was given the choice to quit or be terminated from the facility. An interview with Resident #11 was conducted on 6/11/2024 at 10:55 a.m. The resident stated that the facility was going to do everything they can to cover up and make it seem like they [referring to the facility] did right by me. Throughout the interview, Resident #11, was not sure of the exact dates each event occurred and was only able to give general timeframes. She proceeded to say that her relationship with Staff #20 started around the end of October 2023 and that staff #20 was her assigned nursing assistant. She stated that Staff #20 first began to touch her during showers and brief changes; and, she began to notice that the touch changed and that he would caress her leg and she dismissed it as her imagination. She stated it escalated to rubbing her thighs to touching and rubbing her vagina; and, it was not something she and staff #20 had discussed, and she felt too vulnerable to stop him. The resident stated that Staff #20 further escalated to rubbing her breasts, kissing her, and oral sex; and, would tell her that he loved her, cared about her and that was why he was doing this. Resident #11 said that Staff #20 had stopped working with her and was transferred to laundry because staff #20 did not pass his CNA (certified nursing assistant) test. However, resident #11 said that staff #20 would still come to her room, but would be quick because he no longer had a valid reason to be in there. She stated that she spoke with another CNA (Staff #34) who told her they would report the situation. During an interview with resident #11 conducted on 6/11/2024 at 10:55 a.m. the resident provided copy of screenshots from the resident's cellphone that showed conversation between staff #20 and resident #11. The message sent by staff #20 included that daddy [referring to staff #20] love you and wants to be deeply inside of you to which the resident responded Can you hold me tight as you nut inside me daddy. Staff #20 responded, Yes baby I [referring to staff #20] sure will really tight. Further review the screenshots revealed that had incoming call from staff #20. The resident said that the Director of Nursing (DON/Staff #6), the Executive Director (ED/ Staff #47), and Clinical Resource (staff #52) spoke to her about the incident; and that, she showed all three of them the screenshots of the texts between her and Staff #20 she had on her phone. She stated that she was worried about what would happen if she reported the incident because everyone else goes home at the end of the day and she has to stay in the facility with the staff whom she accused. The resident said that after the report on 2/1/2024, Staff #20 told Resident #11 that he had been given a choice to quit or be fired; and that, Staff #20 messaged her that he was not sure how he was going to pay his rent. She asked her sister for a few hundred dollars, but her sister became suspicious and declined to give her the money. When she told Staff #20 that she could not get him the funds, he became very upset and a light came on for her that it had not been a real relationship, and he had manipulated her for sex. An interview was conducted on 06/11/2024 at 1:27 p.m. with a CNA (staff #34) who stated that she provided care for Resident #11 starting around December. The CNA stated that she cannot recall the exact date, but sometime after the new year, she was caring for Resident #11 in her room when the resident reported that Staff #20 sent the resident a message and the resident pulled up and showed the CNA the Facebook messages of staff #20 to the resident. The CNA stated that the messages did not say anything sexual but she definitely saw the Facebook profile and the back and forth messages between the resident and staff #20. The CNA stated that in one of the messages, staff #20 had said good morning, Beautiful and the messages were all in that vein. The CNA said that she reported it immediately and did not question the resident further; and that, she could not find the DON at the time, so she reported it to the staffing coordinator (Staff #73). Further, the CNA stated that she and the staffing coordinator then located the DON together and she reported the incident to the DON. The CNA stated that it was the facility's policy for staff to never text, direct message, or friend a resident on social media; and that, it was unprofessional and could lead to HIPPA (Health Insurance Portability and Accountability Act) violations. In an interview with a CNA (staff #82) who was a former staff conducted on 06/11/2024 at 2:55 p.m., the former CNA stated that he worked at the facility until end of December 2023; and, he recalled a moment where he and Staff #20 were in the room providing care to resident #11 together. The former CNA stated that Staff #20 boasted that Resident #11 knows he (referring to Staff #20) was the resident's favorite. The former CNA also stated that it was a little bit off thing to say; and, it was his personal opinion and also a facility policy that staff cannot exchange phone numbers with residents. An interview was conducted on 06/11/2024 at 3:28 p.m. with another CNA (Staff #59) who stated she used to work at the facility through December 2023. She stated that when Staff #20 worked as an aide at the facility, staff #20 would randomly come over on the bariatric hall (where Resident #11 resided) and would be in Resident #11's room for a really long time even though he was not scheduled to be on the unit. The CNA said that staff #20 would offer to help out on the bariatric hall a lot; and, every time Resident #11 needed a shower, Staff #20 would offer to be the one to do it. She stated that Staff #20 would flirt with Resident #11 and make dirty jokes with her all the time. She stated that she noted behavioral changes in Resident #11 and that, the resident would no longer engage in those kinds of jokes and banter with any staff. She stated that Staff #20 created a difficult work environment related to dating and flirting with female staff members. In an interview with the Staffing Coordinator (Staff #73) conducted on 06/11/2024 at 4:41 p.m. the staffing coordinator stated she had worked at the facility for approximately 2 years; and initially denied recalling Staff #20 or Resident #11. She stated she had no knowledge of the incident before surveyor had indicated which incident was being investigated. She stated that she did not recall any incident regarding resident #11 having messages on her phone from the staff member (#20); and that, she did recall a CNA reporting seeing messages from staff #20 on Resident #11's phone. The staffing coordinator stated that staff and residents needed boundaries. During the interview, the staffing coordinator retracted her statement and stated that the CNA pulled her to the side and reported that the CNA saw a message from staff member (#20) to the resident. The staffing coordinator said that she does not recall if the alleged staff (#20) was still employed at the facility; and, does not recall who the CNA who reported the incident to her and that the CNA came to her only because the CNA could not find the DON. She stated that she found the DON for the CNA and she left before any conversation took place. Further, the staffing coordinator said that she never saw any messages from staff #20 to resident #11; and she does not recall when this interaction took place, but said it was a long time ago and may have been at the end of last year, or maybe just after the new year began. The staffing coordinator stated she was unsure of any policy regarding staff engaging with residents over phone or social media. She stated that staff were not supposed to engage with residents in that way; and, it was a HIPPA violation to have residents phone numbers and contact information taken out of the facility. During an interview with the DON conducted on 06/11/2024 at 4:50 p.m., the DON stated that Resident #11 reported having a relationship with a staff member to the ED, who then brought the DON into the conversation. The DON said that Resident #11 met with the DON, ED, and Clinical Resource (Staff #52) in the DON's office and reported that on 02/01/2024, the resident and Staff #20 had a sexual relationship. The DON said that the resident could not say definitively when the relationship began but said that it was around October 2023; and that, the resident and staff #20 texted back and forth. The DON denied that Resident #11 had showed her any text messages and said she was not aware that any text messages existed. The DON stated she interviewed Staff #20 who denied ever giving Resident #11 his number and was appalled that the resident had alleged a sexual relationship. A review of the facility self-report for the incident was conducted with the DON who stated that Staff #20 actually had admitted to exchanging phone numbers with the resident but denied having sexual contact; and that, he never talked to the resident about needing money. The DON stated that Staff #20 crossed the line by exchanging phone numbers with the resident, but there was never anything inappropriate in the texts. She said that there was no specific policy about exchanging numbers with residents, staff boundaries and professional standards; but facility's legal department said it was not okay. The DON said that the legal department taught staff that this behavior was unprofessional and was discouraged; and that, a resident was not able to have a consensual relationship with a staff member. The DON further stated that if there was a previous relationship between a staff and resident prior to admission or hire, that would need to be disclosed to the management immediately; and, the resident and the staff could not continue while both were at the facility. Further, the DON stated that the risk would be an unequal power dynamic; and, she would never want a resident to not receive care or feel they are getting less. The DON said that this was not a message that she would ever want to be sent to anyone in the facility. In an interview conducted with the ED on 06/11/2024 at 5:06 p.m. the ED stated that Resident #11 reported consensual sexual relationship with staff #20 on 02/01/2024; and, the resident alleged that she and staff #20 had oral sex on two occasions. The ED denied ever seeing any text messages or screenshots of conversations between Staff #20 and Resident #11. He said that did not talk to Staff #20 but he was there when the DON interviewed staff #20 as part of the facility's investigation. The ED said that Staff #20 denied texting with the resident and that none of the allegations were true. The ED said staff #20 never came back to the facility and quit over phone during the investigative interview. During the interview, a review of the facility self-report investigation was conducted with the ED who retracted his earlier statement and said that Staff #20 had in fact admitted to exchanging numbers with resident #11. Further the ED stated that a relationship between staff and a resident can never be consensual; and, all staff was educated on boundaries through in-services. In an interview with clinical resource staff on 6/11/2024 at 5:53 p.m. he stated that the resident reported having a relationship with staff; but the clinical resources denied seeing the messages of screenshots of messages between the resident and staff #20, but he denies ever seeing and messages or screenshots. The clinical resource staff stated that the facility reported Staff #20 to State Board of Nursing. Review of the facility's employee handbook revealed while employees were encouraged to develop friendship with residents, it is important that the relationship remain professional at all times. Employees are not allowed to purchase items or borrow money from or become involved in any personal or business relationships with residents. The handbook included to see the supervisor or the Executive Director immediately if a resident asks the employee you to engage in behavior that the staff think may cross a professional boundary. Situations of actual or potential conflict of interest are to be avoided by all employees. Personal or romantic involvement with the resident which impairs an employee's ability to exercise good judgement creates and actual or potential conflict of interest and may be cause for discipline up to and including termination. Under no circumstances may the employee solicit a gift, loan, gratuity or any item of value from anyone conducting business with us nor should the employee show or imply favoritism toward a resident who provides for such a gift. Facility policy titled Resident Rights: Reporting Alleged Violations of Abuse, Neglect, Exploitation, or mistreatment last reviewed 09/2020 stated that it was their policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility Staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. The policy goes on to define exploitation as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.

Based on observations, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that walls were painted in 4 (#64, #154, #40, and #63) residents' rooms and blinds were not broken in two residents' (#64 and #154) rooms. The census was 104. The deficient practice may result in the facility not maintaining a safe/clean, comfortable and homelike environment. Findings include: -Resident #64 was admitted to the facility on [DATE] with diagnoses that included anxiety, morbid obesity, and diabetes. The census record revealed that the resident was transferred to room [ROOM NUMBER] on December 21, 2022. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the work orders revealed that the wall behind the bed had torn areas and that the work was completed on May 22, 2023. During an interview conducted on June 28, 2023 at 11:33 a.m. with resident #64, there were 9 places on the wall near the headboard of the bed and the light where plaster and/or paint was missing: under the light, behind the bed, to the right of the bed, and above the electric outlet. One of the blinds on window was broken and piece was missing. Resident #64 stated that maintenance said they would paint the wall approximately two weeks ago. She stated that the wall was damaged and the blind was broken when she came into the room. -Resident #154 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, and chest pains, and cervicalgia. The census record revealed that the resident was transferred to room [ROOM NUMBER] on June 27, 2023. The MDS dated [DATE] included a staff assessment for mental status indicating the resident was able to independently make reasonable decisions consistently. Review of the work orders revealed that the wall behind the bed needed painting, and that repair of scratches and large plaster spots was completed on June 26, 2023. During an interview conducted on June 28, 2023 at approximately 11:50 a.m. with resident #154, he stated that that the damage to the wall, missing paint, and the broken blinds on the window were there when he was admitted to the room. -Resident #40 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and hypothyroidism. The census record revealed that the resident was admitted to room [ROOM NUMBER] on July 1, 2021. Documentation of work orders did not reveal an order to repair the wall. The MDS dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. During an interview conducted on June 28, 2023 at 11:01 a.m., the wall by the bed was observed to be severely damaged. -Resident #63 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, chronic kidney disease, and an anxiety disorder. The MDS dated [DATE] included a brief interview for mental status score of 3 indicating the resident has a severe cognitive impairment. The census record revealed that the resident was admitted to room [ROOM NUMBER] on June 9, 2023. Documentation of the work orders did not reveal an order to repair the wall. During an interview conducted on June 28, 2023 at 11:13 a.m. with resident #63, a 4 x 4-inch area of the wall was observed to be missing dry wall and paint. An interview was conducted on June 30, 2023 at 8:26 a.m. with the maintenance supervisor (staff #170), who stated that he inspects the rooms when there are discharges and that the staff in admissions inspect the rooms prior to new admissions. He stated that if any repairs are needed, the staff from admissions would email him a list of repairs. He stated that housekeepers and Certified Nursing Assistants are supposed to report broken things as well. He stated that he has orders for fix paint and walls on the 600 hall, no orders for room [ROOM NUMBER], and they are currently painting the 200 hall. He stated that he inspects the rooms weekly, but the inspection doesn't include the walls and blinds. However, he would document repairs needed if he noticed the walls or blinds needed repair. During a second interview conducted on June 30, 2023 at 9:00 a.m. with staff #170, he stated that he was aware that the blinds were broken and the wall needing to be painted in #605. He stated he patched the wall in #607 and was waiting for it to dry before he could paint and he just became aware that the blinds were broken. He stated he observed the wall was damaged in #201 and acknowledged that plaster and paint was missing from the wall, and he was aware of the wall being damaged in #401. He stated that as far as he knows, he did not receive orders for repairs. During an interview conducted on June 30, 2023 at 11:59 a.m. with the Administrator (staff #180), he observed that the blinds were fixed and the wall was patched in room [ROOM NUMBER]. He stated that it was his expectation that maintenance has paint on hand. He stated that housekeeping should inspect rooms to ensure everything is in working order and had no damage. He observed that the blinds were still broken and the wall was damaged in room [ROOM NUMBER]. The resident was present in room [ROOM NUMBER] and stated that damage was present when he was admitted to the room. Staff #180 acknowledged that there was damage to the walls in rooms #201 and #401. Staff #180 contacted staff #170 via phone and staff #170 stated that he had paint for the walls and went to the store to have new blinds cut to fit the windows in room [ROOM NUMBER]. Staff #180 agreed that the paint was on hand to paint the walls and staff #170 was able to find the blinds. The facility's policy, Physical Environment, Facility Maintenance, dated May 2021, stated that it was the policy of the facility to establish procedures for routine and non-routine care of the facility/building to ensure that the facility remains in good working order for resident and staff safety.

Based on documentation, staff interviews, and facility policy and procedures, the facility failed to notify two residents in writing (#10 and #24) of the reason for transfers. The sample size was 27. The deficient practice may result in residents and/or their representatives not being notified of the rationale for resident transfers. Findings include: -Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute gastric ulcer with perforation, unspecified asthma. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. Review of the progress notes dated May 31, 2023 at 7:20 a.m. included that a DuoNeb treatment was administered, and was ineffective. According to the note, the resident's oxygen saturation decreased to 71% after nebulizer treatment and [the resident] continued to present with respiratory distress. Findings were reported to the nurse practitioner and an order was received to send the resident to the emergency department for further evaluation. Review of the Nursing Home to Hospital Transfer form dated May 31, 2023 revealed that the resident was transferred to the hospital for respiratory arrest. The Notice of Proposed Transfer/Discharge form dated May 31, 2023 revealed that the resident/representative was notified on May 31, 2023 regarding reason for transfer, which was respiratory distress with possible pulmonary embolism (PE). However, the form was not signed or dated by the resident/representative and did not demonstrate that the form had been mailed to the resident/representative. Further review of the progress notes did not reveal that the resident/representative was notified in writing regarding the reason for transfer to the hospital. -Resident #24 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and morbid obesity. The MDS assessment dated [DATE] included a BIMS score of 11, indicating the resident had a moderate cognitive impairment. A progress note dated May 17, 2023 at 3:30 a.m. revealed that the nurse contacted the nurse practitioner (NP) to give an update regarding the resident's worsening condition. The NP stated to send the resident to the hospital. A progress note dated May 17, 2023 at 4:50 a.m. included that the resident was sent out to the hospital for further evaluation. The note indicated that the medical power of attorney and the Director of Nursing were to be notified. Review of the Nursing Home to Hospital Transfer form dated May 17, 2023 revealed that the resident was transferred to the hospital for respiratory arrest. The Notice of Proposed Transfer /Discharge form dated May 17, 2023 revealed that the resident/representative was notified on May 17, 2023, regarding reason for transfer, which was respiratory distress. However, the form was not signed or dated by the resident/representative and indicated that the form was not mailed to the resident/representative. Review of the progress notes did not reveal that the resident/representative was notified in writing regarding the reason for transfer to the hospital. An interview was conducted on July 5, 2023 at 11:41 a.m. with a case manager (staff #71) with the Social Services Manager (SS/staff #40) present. Staff #71 stated the nurse who discharged the resident to the hospital would complete all the paperwork and documentation in the medical record and notify the Ombudsman. She stated she did not know who was responsible to notify the resident in writing regarding the reason for transfer to the hospital. An interview was conducted on July 5, 2023 at 1:46 a.m. with Medical Records Supervisor (staff #146), who stated that she notified the Ombudsman of transfers once a month, but that she does not notify the resident or family in writing regarding the reason for the transfer. She stated that the nurse completed the notice of transfer, which goes into an envelope and is handed to the emergency medical transport as a packet. During the interview, she contacted admissions office and was told that they do not notify the resident/representative in writing regarding the reason for transfer to the hospital. An interview was conducted on July 5, 2023 at 11:55 a.m. with a licensed practical nurse (LPN/staff #2), who stated that she has worked at the facility for 2 years. She stated that the nurse completes the discharge paperwork, contacts the physician, but that the nurse doesn't give the resident/representative the reason for transfer in writing. An interview was conducted on July 5, 2023 at 12:04 p.m. with the Director of Nursing (DON/staff #181), who stated that resident #10 was transferred to the hospital on May 31, 2023 and Notice of Proposed Transfer /Discharge form was put into a packet and given to the EMT and not given to the resident. The Resident Rights policy, reviewed May 2022, included that the resident is to be fully informed in a language he or she understands of his or her medical condition and health status. The resident is to receive appropriate advance notice (usually thirty days written notice) or any involuntary transfer or discharge from the Nursing Center as required by law including the transfer or discharge is necessary for the resident's welfare because his or her needs cannot be met in the Nursing Center.

Based on documentation, staff interviews, and facility policy and procedures, the facility failed to provide two residents (#10 and #2) with the bed-hold policy prior to being transferred to the hospital. The sample size was 27. The deficient practice may result in residents and/or their representatives not being informed of the bed-hold policy. Findings include: -Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute gastric ulcer with perforation, unspecified asthma. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the progress notes dated May 31, 2023 at 7:20 a.m. included that a DuoNeb treatment was administered, and was ineffective. According to the note, the resident's oxygen saturation decreased to 71% after nebulizer treatment and [the resident] continued to present with respiratory distress. Findings were reported to the nurse practitioner and an order was received to send the resident to the emergency department for further evaluation. Review of the Nursing Home to Hospital Transfer form dated May 31, 2023 revealed that the resident was transferred to the hospital for respiratory arrest. The Notice of Proposed Transfer /Discharge form dated May 31, 2023 revealed that the resident/representative was notified on May 31, 2023, regarding reason for transfer, which was respiratory distress with possible pulmonary embolism (PE). However, review of progress notes did not reveal that a bed-hold notification had been provided to the resident and/or representative prior to transfer to the hospital. In addition, review of the resident's clinical record did not reveal a bed-hold policy. -Resident #24 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and morbid obesity. The MDS assessment dated [DATE] included a BIMS score of 11, indicating the resident had a moderate cognitive impairment. A progress note dated May 17, 2023 at 3:30 a.m. revealed that the nurse contacted the nurse practitioner (NP) to give an update regarding the resident's worsening condition. The NP stated to send the resident to the hospital. A progress note dated May 17, 2023 at 4:50 a.m. revealed that the resident was sent out to the hospital for further evaluation. The medical power of attorney and the Director of Nursing were to be notified. Review of the Nursing Home to Hospital Transfer form dated May 17, 2023 revealed that the resident was transferred to the hospital for respiratory arrest. The Notice of Proposed Transfer /Discharge form dated May 17, 2023 revealed that the resident/representative was notified on May 17, 2023, regarding reason for transfer, which was respiratory distress. However, review of the progress notes did not reveal that a bed-hold notification had been provided to the resident and/or representative prior to transfer to the hospital. Additional review of the clinical record did not reveal a bed-hold policy. An interview was conducted on July 5, 2023 at 12:04 p.m. with the Director of Nursing (DON/staff #181), who stated that the resident signs the bed-hold policy when admitted to the facility and staff go over the bed-hold policy when the resident is transferred to the hospital with the resident/responsible party, but we wouldn't have a progress note. She stated that she was not able to find a bed hold policy for resident #10 or #24. The facility's policy titled, Admission/Discharge/Transfer, Bed Hold, dated July 2022, stated that it was the policy of this facility to inform the resident, or the resident's representative, in writing, of the right to exercise the bed hold provision, upon admission and before transfer to a general acute care hospital or before the resident goes on therapeutic leave.

Based on observations, staff interviews, clinical record review and policy, the facility failed to ensure two residents (#23, #79) received catheter care and services in accordance with professional standards of practice. The sample size was 2. The deficient practice may increase the risk for urinary tract infections (UTI). Findings include: -Resident #23 was admitted on [DATE] with diagnoses that included Escherichia coli, hydronephrosis and neuromuscular dysfunction of bladder. Review of Nurse Practitioner (NP) and Internal Medicine (IM) Progress notes January 2023 through June 2023 revealed that a Foley catheter was placed by urology and would remain in place to promote perineal wound healing. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also included the presence of an indwelling catheter. An indwelling catheter care plan initiated on January 16, 2023 related to neurogenic bladder had a goal to remain free from catheter-related trauma. Interventions included to provide catheter care every shift and as needed, and to monitor/record/report to medical doctor for signs or symptoms of UTI. Review of the physician's orders included: -Indwelling catheter care, every shift; beginning January 13, 2023. -Change catheter drainage bag as needed if soiled or leaking; beginning January 13, 2023. -Ciprofloxacin tablet (antibiotic) 500 milligram (mg) tablet. Give by mouth every 12 hours for UTI for 7 days; beginning January 17, 2023 through January 24, 2023. -May change catheter as needed (PRN) for malfunction or dislodgement dated April 26, 2023. -Indwelling catheter care every shift, dated April 26, 2023 through May 18, 2023. -Indwelling catheter #16 FR/10 ml to closed drainage system for neurogenic bladder dated April 27, 2023. -Cephalexin tablet (antibiotic) 500 mg by mouth every 12 hours for UTI, cystitis for 7 days; beginning May 30, 2023 through June 6, 2023. -Ciprofloxacin tablet 500 mg tablet by mouth two times a day for UTI for 10 days; beginning May 31, 2023 through June 10, 2023. -Change catheter drainage bag and urinary cylinder as needed dated June 18, 2023 The February 2023 Treatment Administration Record (TAR) included catheter care was provided in accordance with the physician's orders. The TAR dated March 2023 revealed catheter care was provided as ordered. Further review of the April 2023 TAR included evidence that catheter care was not provided as ordered on 3 shifts during the month. Review of the May 2023 TAR revealed that catheter care was not provided as ordered on 1 shift during the month. Review of the Medication Administration Record revealed: -May 2023: change of condition monitoring for UTI every shift- completed as ordered on May 31, 2023. -June 2023: change of condition for UTI completed every shift on June 1, 2023 and June 2, 2023. Review of the June 2023 TAR revealed evidence that catheter care was not provided as ordered on 1 shift during the month. A catheter care observation was conducted on June 30, 2023 at 1:08 PM with a certified nursing assistant (CNA/staff #24), a facility Assistant Director of Nursing (ADON/staff #124) was in attendance. The ADON was standing adjacent (approximately 5 feet) back and from the head of the bed, with a bedside table placed between her and the bed. The CNA washed his hands in the sink, dried his hands and then donned gloves. He placed a barrier pad (chucks) on the bedside table, stating that it had been sanitized with bleach earlier. The resident's bed was observed to be in the lowest position, the CNA knelt next to the bed and proceeded to pull back the resident's blanket and sheet. He then pulled up the resident's gown and unclamped the catheter, removed a cleansing wipe from the container on the bedside table and proceeded to dab the urethra with the wipe horizontally in one area. The CNA was not observed to wipe away from the urethra in downward motions or to wash around the entire urethra. The CNA held the tubing with one hand, and with the other, proceeded to surround the catheter tubing with the same wipe, holding the wipe with the index finger and thumb, wiped down the tubing in one motion. The CNA was then observed to re-clamp the tubing, pull down the resident's gown, and recover the resident with the sheet and blanket. It was not observed that he removed the gloves after removing the blanket and sheet, prior to starting the catheter care. Further observation revealed that the same gloves were not removed after the catheter care prior to replacing the gown, blanket and sheet. An interview was conducted on June 30, 2023 at 01:18 PM with CNA (staff #24) directly after the catheter care observation, the Assistant Director of Nursing (ADON/staff #124) was present. The CNA stated that catheter care is completed once every shift, and as needed. He also stated that the facility policy is to remove gloves after removing the blanket/sheet from the resident and donning new gloves prior to starting the catheter care. He also stated that he should have removed the gloves after completing catheter care, and prior to replacing the gown and blanket back over the resident. He further stated that the blanket/sheets would be considered dirty, and that bacteria could have been introduced onto the catheter/urethra from the gloves after removing the sheets. He also stated that the way he held the wipe around the catheter tubing, it cleaned all sides at the same time. During an interview conducted on June 30, 2023 at 02:01 PM the Director of Nursing (DON/staff #181) she stated that her expectation for catheter care is that staff follow the policy, make the resident comfortable, set up equipment, introduce self to the resident, complete hand hygiene prior to catheter care, and apply gloves. She also stated that the expectation is that the CNA would have changed the gloves after removing the blanket, prior to starting catheter care. She further stated that she would expect the urethra would be cleaned on all sides. The DON stated that they have annual skills fair that included infection control hand washing and catheter care, and the competency check list is completed on orientation and annually. -Resident #79 was readmitted on [DATE] with diagnoses that included quadriplegia, neuromuscular dysfunction of bladder, depression anxiety and need for assist with personal care. Review of physician's orders revealed the following: -Indwelling catheter care every shift, dated May 16, 2022. -Cephalexin oral capsule 500 mg capsule by mouth every 8 hours every 5 days for urinary tract infection, dated March 16, 2023 -Cephalexin oral capsule 500mg, give 1 capsule by mouth every 8 hours for urinary tract infection dated March 18, 2023. -Change of condition for catheter change every shift for 3 days dated March 22, 2023. -Indwelling catheter #16 FR/10 ML to closed drainage system r/t neurogenic bladder as evidenced by urinary retention, dated May 18, 2022. -Nitrofurantoin macrocrystal oral capsule (antibiotic) 100mg, give 1 capsule by mouth two times a day for UTI with Escherichia coli for 7 days, dated 5/25/2023. -May change catheter as needed for malfunction or dislodgement PRN, dated July 3,2023. Review of progress notes revealed: -March 15, 2023 2:14 PM: resident found profusely sweating and shaking, abdominal pain. NP notified, resident transferred to the emergency room (ER). -March 16, 2023 6:39 PM: resident returned form ER with diagnosis of UTI and obstructed Foley with sediment likely caused the UTI. -May 26, 2023 10:20 AM: UTI with Escherichia coli Review of the April 2023 TAR revealed that catheter care every shift was conducted on every shift for the month except 1. Review of an indwelling catheter care planned area of focus initiated on May 16, 2022, which indicated the presence of an indwelling catheter, and to provide catheter care every shift and as needed. Review of the May 2023 TAR revealed that catheter was provided as ordered every shift except for 3 shifts. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 14, which indicated intact cognition. The assessment also revealed the presence of a urinary catheter. Review of June 2023 TAR revealed that catheter was provided every shift as ordered. A Catheter Care observation was conducted on July 3, 2023 at 1:27 PM with a CNA (staff #102), with Licensed Nursing Assistant (LNA/staff #31) in attendance. The CNA washed his hands in the sink, donned gloves, opened the bedside table and looked inside then asked the LNA to get a wipe package. The CNA raised the bed, opened the brief, removed his gloves, re-gloved, removed multiple wipes from the package and cleaned around the resident's scrotum. He then used another wipe and wiped around the meatus, wiping upwards from the catheter insertion site, up towards the meatus. He stated that there was some blood, and that he would notify the nurse. The CNA removed another 2 wipes from the package, wiped down the catheter tubing (while holding the tubing with his other hand) using the 2 wipes, discarded the wipes in a trash can. He then removed his gloves, donned another pair of gloves, turned the resident on his left side, cleaned the resident, and replaced the brief, then repositioned the resident. During an interview conducted with the DON (staff #181) on July 3, 2023 at 8:31 AM, the DON stated that she reviewed the catheter care policy, step-by-step instructions, watched the video of the training and policy, and steps all match up and agrees with the training instructions provided. When if touching a dirty area with a gloved hand and then performing catheter care would meet professional standards of practice, she stated that she is following the directions/policy of the facility and this is the way they are teaching their staff. The DON also stated the CNA followed their policy when he removed the blanket and linen then started catheter care without changing gloves. She stated that she had no comment when asked if there would be a problem with introducing bacteria following that process. She stated that she would not comment if the policy and the training video was correct with infection control. An Interview was conducted on July 3, 2023 at 1:05 PM with a CNA (staff #80), who stated that catheter that catheter care was provided every shift and PRN. She also stated the process included informing the resident of the treatment to be performed, donning gloves, getting supplies, removing the blanket or sheet, pulling up the gown, undoing the brief, pulling back the foreskin and cleaning around the area using a wipe, in a circular motion, then cleaning around the scrotum. She also stated that the wipe or washcloth would be folded back to use a new area every time. She further stated that she would wipe in a downward motion from the meatus a couple of times, then wipe down the catheter tubing, folding the wipe and repeating. She stated that she would replace the blanket/sheet, reposition the resident and discard the gloves, and sanitize her hands. The CNA stated that she has received catheter training throughout the year, by video, and at a skills fair. During an interview conducted on July 3, 2023 at 1:15 PM with a Licensed Practical Nurse (LPN/staff #111), who stated that he was trained in school as well as facility in-services on the catheter care process. He stated that the steps for catheter care included the following: -Sanitize hands before entering room and put on gloves. -Makes sure the resident is in bed in a comfortable position, and ensures that they are undressed from the waist down so he does not tug on the catheter. -Removes gloves and sanitize hands again. -Donns a new set of gloves and ensure that he has a clean working area. -Utilizes soap and water to gently clean in a downward motion to ensure that the whole circumference of the urethra has been wiped clean to include the edges of the urethra, using gauze or wash cloth, etc. -Empties the catheter drainage bag and records the output. -Assists the resident back into a comfortable position, making sure that the catheter bag is below the level of the bladder so that there is no back flow. -Ensures that there is a privacy bag [over the drainage bag] and that it does not touch the floor. Review of Catheter Care training skills check list revealed the following steps for catheter care: -Perform hand hygiene. -Explain the procedure. -Provide privacy. -Puts on gloves. -Lifts resident's gown to expose catheter area. -Using washcloth with soap and water carefully wash around the catheter where it exits the urethra. -Hold catheter where it exits the urethra with one hand. -While hold the catheter tubing with fingers were it exits the urethra, clean 2-3 inches down the catheter tube. -Clean with stroke(s) only away from the urethra. -Use a clean portion of a washcloth for any strokes. -Replace top cover over resident. -Empty drainage bag. -Record output on recording form. -Remove gloves and dispose of in trash can. -Wash hands. Review of the facility policy titled, Catheter Care, revised 5/2023, included that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling, to promote hygiene, comfort and decrease risk of infection. Use washcloth/disposable wipes, clean the catheter insertion in a downward motion. Use each gauze (or disposable wipes) for on cleansing motion. Clean the length of the Foley catheter 4 inches (from resident toward the bag). Repeat the procedure using wipes to rinse as needed.

Based on clinical record review, resident and staff interviews, facility records, and the facility assessment, the facility failed to ensure that there was sufficient nursing staff to meet the needs of residents 6 residents (#8, #72, #49, #52, #94, and #64). The census was 104. The deficient practice could result in resident's care needs not being met. Findings include: During the initial phase of the survey 6 out of 27 residents identified concerns of not having enough staff. The resident interviews were as follows: -Resident #8 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS revealed that the resident was extensive assist with bed mobility, dressing, toilet use and personal hygiene. During an interview conducted with the resident on July 3, 2023 at 1:00 PM, he stated that he has voiced concerns about staffing issues especially at night. He further stated that they are so short staffed that it takes about 1 hour to have his call light answered. He stated that he told the nurse on duty and she told him that they are doing what they can. -Resident #72 was admitted on [DATE] with diagnoses that included Parkinson's disease, dementia, type 2 diabetes mellitus, need for assistance with personal care, muscle weakness and dysphagia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed that the resident required extensive physical assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. During an interview conducted with the resident on June 28, 2023 at 11:16 AM, the resident stated that there was not enough staff to properly take care of him, and when he pushed the call light it took a long time for someone to come and check on him. -Resident #49 was admitted on [DATE] with diagnoses that included chronic kidney disease, stage 3, muscle weakness and need for assistance with personal care. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed that the resident required extensive physical assistance with bed mobility, and limited assistance with transfer, dressing, eating and personal hygiene. During an observation conducted with the resident on June 28, 2023, the resident was observed to be calling for help and stating to a nurse that he was sick of waiting for staff to came and change him. The nurse apologized and provided care. -Resident #52 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, difficulty in walking and weakness. Review of the quarterly MDS assessment dated [DATE], revealed the resident scored 15 on the BIMS assessment, which indicated intact cognition. The MDS revealed that the resident required extensive physical assistance with bed mobility, transfer, dressing, eating and personal hygiene. During an interview conducted on June 28, 2023 at 11:20 AM, the resident stated that when she utilizes the call light it can take a long time for staff to respond since she is at the end of the hallway. -Resident #94 was admitted on [DATE] with diagnoses that included dysphagia, morbid obesity, and need for assistance with personal care. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed that the resident required extensive physical assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. On June 28, 2023 at 11:08 AM resident #94 stated that her call light had been on for approximately 15 minutes. Resident #94 also stated that she has had to wait for up to an hour, stating that the way the rooms were configured the CNAs could not see that her call light was on. She stated that she needed someone to change her brief. The resident also stated that sometimes there is only one CNA working on the hall. Observation of the call light revealed that it was operational and on. Further observation conducted on June 28, 2023 at 11:14 AM, revealed that staff came to answer the call light after 21 minutes, and then left the room to get a sheet. -Resident #64 was admitted on [DATE] with diagnoses that included malignant neoplasm of central nervous system, morbid obesity and cognitive communication deficit. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed that the resident required extensive physical assistance with bed mobility, dressing, toilet use, and personal hygiene. On June 28, 2023 at 11:24 AM an interview was conducted with the resident, who stated that she has waited up to 3 hours for the call light to be answered and have a brief change. When also she stated that, staff #122 (CNA) told her that she has 16 other residents to take care of. The resident further stated that around 10:00 AM there was a problem, they need two CNAs at all times and were always understaffed and only have one CNA. Review of the facility assessment revealed the average daily census is 116, and that the facility averaged 70 admissions and discharges per month. The staffing assessment plan included that staff work 8 hour shifts and included the following: - (1) Restorative CNA (Certified Nursing Assistant), FT days - (5) RN/LPNs (Registered Nurse/Licensed Practical Nurse) scheduled to be in the facility 6:30 AM - 3:00 PM and 2:30 PM to 11:00 PM - (3) RN/LPNs scheduled to be in the facility 10:30 PM to 7:00 AM - (11-12) CNAs scheduled to be in the facility 6:30 AM - 3:00 PM and 2:30 PM to 11:00 PM - (5-6) CNAs scheduled to be in the facility 10:30 PM to 6:30 AM However, per the review of the Daily Staff Posting, staff sign in sheets and the punch details, the following dates were identified as having less than the required number of CNAs to care for the residents on the night shift: -June 5, 2023 (census 108) - 2 CNAs at approximately 8 hours, 2 CNAs at approximately 6 hours and 1 CNA at 2 hours. This was equal to 3.75 CNAs. -June 6, 2023 (census 112) - 2 CNA's worked approximately 8 hours, and 2 worked a partial shift (approx. 6 hours) for a total of 28.78 hours. This was equal to 3.5 CNA's. -June 7, 2023 (census 112) - 4 CNAs worked approximately 8 hours for a total of 31.16 hours. -June 9, 2023 (census 113) - 2 CNAs worked approximately 8 hours, 1 CNA worked 7.5 hours, and 1 CNA worked 6.64 hours for a total of 30.60 hours. This was equal to 3.75 CNA's. -June 10, 2023 (census 114) - 2 CNAs worked approximately 8 hours, and 1 CNA worked 7.5 hours for a total of 25.18 hours. -June 11, 2023 (census 113) - 1 CNA worked 8.5 hours, 1 CNA worked 7.75 hours and 1 CNA worked 4 hours. This is equal to 2.5 CNA's. Review of the Facility Quality Assessment and Performance Improvement (QAPI) Plan for Staffing challenges started January 2023, and reviewed at QAPI February, March, April, May and June, included a problem regarding staffing challenges. The goal was to ensure sufficient staffing according to the facility daily census need. The plan revealed the elimination of registry as of January 28, 2023, hiring hospitality aides and putting through the facility CNA program and resident interviews. An interview was conducted on July 5, 2023 at 9:34 AM with the Staffing Coordinator, Certified Nursing Assistant (CNA/staff #51), who stated that staffing levels were determined by PPD (per patient day), acuity, and the census. She stated that 110 or more residents would be staffed with 6 CNAs on the night shift. She also stated that for a lower census (109- below) would be staffed with 5 CNAs on the night shift. She further stated that she re-assesses the staffing schedule daily, and adjusts the schedule daily taking into consideration any staff that may call off. Staff #51 stated that she would make sure that there was enough staff to ensure residents received the care they require. She also stated that she would expect there to be 6 CNAs in the facility on the night shift for the whole facility. She stated that she would go in and assist if needed. She stated that when she does this she punches in as a CNA on her time card. She reviewed the Staff Daily Posting and staff sign in sheets for June 5, 2023 through June 11, 2023 and stated that they had less than the required number of CNAs on the evening shifts on all of the days except for June 8, 2023. She also stated that hospitality aides were in the facility on those dates but they did not count as direct care staff, and were not allowed to complete patient care. Staff #51 stated that the risk of not following the facility assessment for the number of staff working could result in the risk of patient care not being completed. An interview was conducted with the Director of Nursing (DON, staff #181) and the Administrator (staff #180), who stated that the facility assessment staffing plan included 5-6 CNAs on the night shift based upon the census. She stated that the Daily Staff Posting was completed by the Staffing Coordinator and the Administrator. She also stated that they have had problems with staffing and were working on this as a quality assurance item. She further stated that as part of this process they stopped registry and had started a CNA program in January or February 2023. She also stated that they knew they were staffing challenged on the night shifts. An interview was conducted on July 3, 2023 at 10:14 AM with an LPN (staff #135) who stated that there was one CNA scheduled on her unit on the night shift. She stated that she has heard complaints from residents that it took longer to answer the call light, and some residents have said that it took them so long because they must be short-staffed. She further stated that there has been no agency staff that she is aware of for the past 4 months. An interview was conducted with a CNA (staff #28) on June 3, 2023 at 10:07 AM, who stated that the facility staffs by the number of residents. He also stated that there is one CNA for every hall at night, and that they have 6 halls. A follow-up interview was conducted with the Administrator (staff #180) on June 5, 2023 at 11:21 AM who stated that he had reviewed the staff daily postings, sign in sheets and punch detail for June 5, 2023 through June 11, 2023 and that on the days there were 3-4 CNAs on the schedule, they also had hospitality aides in the facility. He also stated that the hospitality aides were not yet certified and trained, and were not able to cover for the CNAs, but were there to assist. An interview was conducted on July 5, 2023 at 2:07 PM with the Director of Nursing (DON/staff #181) and the Administrator (staff #180). The DON stated that they have possibly had a nursing shortage related to no longer using registry that started before January and was gradual. She also stated that they do a daily staffing meeting to discuss shortage, challenge, staff on call, and who will help. She stated that the Staffing Coordinator and managers do not have a time sheet, so there is no way to show that staff were there. She also stated that Hospitality aides were present to help assist on the nights that had been identified as short staffed. Review of the facility policy titled, Staffing, reviewed 10/2021, revealed that it was the policy of the facility to provide services by sufficient number on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans to meet each resident's needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being. Review of the Hospitality Aide Job Description, revealed that the primary purpose is to work alongside the nursing department to provide non-nursing/non-direct care for the residents.

Based on observations, facility documentation, staff interviews, policy review, and the glucose control solution instructions, the facility failed to ensure that 2 bottles of glucometer control solutions were dated when opened on 2 out of 3 medication carts observed. The sample size was 27. The deficient practice could result in inaccurate blood glucose test results. Findings include: An observation was conducted on June 28, 2023 at 11:00 a.m. of 1 of three medication carts near the central nurse's station with a Licensed Practical Nurse (LPN/staff #182). An opened glucose control testing solution was identified as not have an opened date on it. An observation was conducted on June 28, 2023 at 12:15 p.m. of 2 of 3 medication carts near the central nurse's station with Registered Nurse (RN/staff #151). One opened glucose control testing solution was noted without an opened date on it. An interview was conducted on June 28, 2023 at 12:15 p.m. with the RN (staff #151). The nurse examined the bottle of glucose control testing solution and stated that the bottle of did not have an opened date on it. She could not state the purpose or reason why opened bottles needed to be marked with the date the bottle of glucose control testing solution was opened. An interview was conducted on June 28, 2023 at 12:54 p.m. with the Director of Nursing (DON/staff #181). She stated that glucose control testing solution was not marked with the open date because the facility uses the order date from the medical supply order transaction date to base the manufacturer's recommendation of discarding unused portions of the glucose control solution after 90 days after opening or after expiration date. The DON explained that per the manufacturer's instructions, the glucose control solution must be used within 90 days of the bottle being opened or before the expiration date. Review of the manufacturer's glucose control solutions instructions revealed that newly opened bottles of control solutions must be marked on the space provided on the control solutions label with the date that it was opened. For storage and handling, discard any unused control solution 90 days after first opening or after expiration date.

Based on observations, interviews, and record review, the facility failed to ensure that dishes and utensils were cleaned under sanitary conditions and that spoiled and/or unpalatable refrigerated and frozen foods were available to be served to residents. The census was 104. The deficient practice could result in residents becoming ill. Findings include: -Regarding dish/utensil sanitation: On June 28, 2023 at 8:29 a.m., a brief kitchen inspection was conducted with the Dietary Supervisor (staff #126). The dishwasher was observed to be running and staff #126 stated that it was a low-pressure dishwasher which runs at 120 degrees Fahrenheit. During this time, she conducted a litmus test to determine the sanitation level and stated that the test had to achieve 50 parts per million (pmm). She utilized a litmus strip and the test result was 10 pmm, which she stated was low. She stated there was a risk of residents becoming ill if the dishes and utensils were not sanitized properly. She stated that her dishwashers were responsible for testing the sanitation level on a daily basis, but did not require the results to be documented. On June 28, 2023 at 9:45 a.m. a second load of dishes and utensils was observed to be washing. The cook (staff #138) stated that he tested the sanitary level of the dishwasher on a regular basis. Staff #138 was observed using the wrong litmus test strip to test the sanitary level. The Dietary Supervisor (staff #126) had to go and look for the correct litmus test strips and then she tested the sanitary level, which tested at 200 pmm, which she stated was okay. The facility's policy, Dietary Services, Dish Cleaning, dated June 2022 stated that it was the policy of the facility to ensure dishes for use in preparing, storing, serving, and consuming food are cleaned appropriately. Sanitary dishwashing procedures and techniques as recommended by the food service industry will be followed. Review of the Product Technical Fact Sheet - Product Description: Chlorine Test Papers 0-200 ppm stated that the 0-200 ppm chlorine test paper is used for testing sanitization and disinfecting levels of total available chlorine in water. The chlorine test papers can be used in facilities where food preparation areas, equipment, and general disinfection are strictly controlled. The 145 chlorine paper test strips are primarily used for monitoring restaurant and kitchen sanitizing solutions where the target ppm level is between 100-150 ppm. Regarding spoiled and/or unpalatable foods: -During the brief kitchen inspection conducted on June 28, 2023 at 8:29 a.m. with the Dietary Supervisor (staff #126) the following were identified: -6 chef salads were observed in the smaller refrigerator that were prepared by the kitchen on June 26, 2023 with no use-by date and wrapped in clear plastic wrap. One salad had lettuce that appeared dark and moist in color. Staff #126 stated that she would not serve this salad to a resident because it did not appear fresh and could possibly make a resident ill. -1 container of chopped lettuce in the smaller refrigerator dated June 22, 2023 had a use-by date of July 5, 2023. The lettuce was noted to have dark brown spots, appeared dry and wilted in some areas. Staff #126 stated that she would not serve the chopped lettuce to the residents. -8 heads of Romaine lettuce in a large brown cardboard box appeared to be wilted, brown and dark in some areas, and moist. The box was dated June 21, 2023 and there was no use-by date. -1 large unsealed bag of frozen scrambled eggs in a brown cardboard box. Staff #126 stated that the bag originally contained 120 and left unsealed could possibly affect the flavor and cause frost bite. -15 frozen sausages were observed in an unsealed bag. Staff #126 acknowledged that the bag was open. -25 frozen beef patties were observed in an unsealed plastic bag in a large brown cardboard box. The facility's policy and procedure manual, Food Storage, dated 2021 states that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. All refrigerated foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. All frozen foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

Based on observation, clinical record review, interviews and policy review, the facility failed to ensure an alternate food choice during meals was provided to one out of two residents reviewed (#12). The deficient practice could result in not honoring the choices that are significant to the resident. Findings include: Resident #12 was admitted on [DATE], with diagnoses of dementia with other behavioral disturbance, generalized muscle weakness and need for assistance with personal care. The nutritional problem/increased nutrition needs care plan initiated on March 30, 2023 related to underweight status and history of poor meal intakes had a goal to maintain adequate nutritional status as evidenced by maintaining weight, with no signs or symptoms of malnutrition. Interventions included to honor the resident's right to make personal dietary choices. The admission Minimum Data Set (MDS) assessment April 6, 2023 included a Brief Interview for Mental Status score of 3 which indicated resident had severely impaired cognition. The assessment included that the resident required extensive 1-person physical assistance for eating. Review of a significant change MDS dated [DATE] revealed the resident had weight loss of 5% or more in the last month. On June 28, 2023 at 12:54 p.m. an observation of lunch service was conducted in the dining room of the secured unit. Resident #12 was hitting her fork on the food tray and complained to a staff that the food was awful. The staff told the resident that she would let the nurse know, walked away from the resident and began assisting other residents. Further observation of the lunch service revealed the staff offered a spoonful of the same food to resident #12 who continued to refused and say no. The staff stopped, waited for a few minutes and again began to feed the resident the same food from her tray. Per observation, the staff did not notify the nurse that the resident did not want the food that was served and/or did not offer the resident any alternate food choice. An interview was conducted on July 3, 2023 at 3:35 p.m. with a certified nursing assistant (CNA/staff #70) who stated that she will offer an alternate food choice when residents complain about their meal. She also stated that the risk of not offering alternate food choices could result in the resident not eating her meal and not receiving proper nutrition. In an interview with a hospitality aide (staff #133) conducted on July 3, 2023 at 3:42 p.m. she stated that when a resident complains that the food was awful, staff should offer an alternative. During an interview conducted on July 3, 2023 at approximately 4:00 p.m. with the Director of Nursing (DON /staff #181) she stated that if a resident complains about the food a substitute will be offered. The DON also stated that they follow the care plan when resident say food was awful. An Interview was conducted on July 5, 2023 at 8:30 am with Licensed Practical Nurse (LPN/staff # 22). She stated that when residents complain about food, they offer an alternative. She stated that risk of not offering an alternate food choice could result in the resident becoming tired and sick. She also stated that the policy requires offering alternative food and reporting to the nurse when a resident refuses food. She further stated this is documented in the clinical record. An Interview was conducted on July 5, 2023 at 8:40 am with a CNA (staff # 6), who stated that when a resident complains about the food, they would offer an alternative choice. She further stated that she will apologize to the resident and notify to the nurse. She also stated that this is documented in the clinical record. The facility's policy titled Resident Rights, reviewed 5/2022, included that the resident has the right to be treated with consideration, respect, and with dignity and individuality.

Based on clinical record review, staff interviews, hospital documentation and policies and procedures, the facility failed to ensure that one sampled resident (#24) maintained sufficient fluid intake to maintain proper hydration and health. The deficient practice resulted in a lack of interventions to address ongoing low fluid intakes and administering an as needed diuretic. The resident was subsequently hospitalized . Findings include: Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS included the resident had the ability to express ideas, wants and understood verbal content, responding adequately to simple, direct communication. The resident ate and drank with encouragement or cueing and required set-up assistance. No issues with swallowing were identified in the assessment and the resident did not have any natural teeth. A care plan for cognition related to advanced dementia dated April 22, 2019 included a goal for the resident to have positive experiences in daily routines. Interventions were providing cues and supervision with activities of daily living needs. A care plan related to a potential for increased nutritional risk associated with dementia, Alzheimer's and fluid shifts due to diuretics was initiated on April 26, 2019. The goal was for the resident to maintain adequate nutritional status, as evidenced by consumption of more than or equal to [AGE] percent of meals. Interventions were to encourage the resident with fluid intake, monitor intake, recording every meal, assist with meals as needed and provide supplements as ordered. The quarterly MDS assessment dated [DATE] included a BIMS score of 3, which indicated severe cognitive impairment. Per the MDS, the resident required extensive assistance with activities of daily living. Review of the physicians orders for October 2019 revealed the following: -Regular diet, pureed texture, thin liquids consistency -Pro-Mod two times daily, give 30 milliliters (ml) by mouth. -[MEDICATION NAME] ([MEDICATION NAME]/a diuretic) 20 milligrams by mouth every 24 hours as needed for [MEDICAL CONDITION]. A nursing summary dated October 7, 2019 included the resident required assistance with eating including set-up, cueing and encouragement to eat. Per the note, the resident was eating 50% or less intake of meals and was only eating 1 meal on some days. Review of the Documentation Survey Report for Fluid Intake and the MAR from October 10 through October 18, 2019 revealed the resident received the following amounts of fluid per day: October 10: daily fluid intake total was 14[AGE] ml October 11: daily fluid intake total was 13[AGE] ml October 12: daily fluid intake total was 1410 ml October 13: daily fluid intake total was 13[AGE] ml October 14: daily fluid intake total was 15[AGE] ml October 15: daily fluid intake total was 1420 ml October 16: daily fluid intake total was 15[AGE] ml October 17: daily fluid intake total was 1590 ml October 18: daily fluid intake total was 1540 ml According to a Nutrition Interdisciplinary Team update assessment dated and signed October 18, 2019, the resident required 2010 ml per day of fluids and consumed an average of [AGE]% of her meals and was currently meeting per day caloric needs. Per the assessment, the resident was at risk for further weight loss related to her advanced age, dementia, dysphagia and having a wound. Further review of the Documentation Survey Report for Fluid Intake and the MAR indicated [REDACTED] October 19: daily fluid intake total was 13[AGE] ml. October 20: am fluid intake amount was 890 ml; pm fluid intake amount was 150 ml and night fluid intake amount was 120 ml. The daily total fluid intake amount was 11[AGE] ml. October 21: am fluid intake amount was [AGE]0 ml; pm fluid intake amount was 398 ml; and night fluid intake amount was 120 ml. The total daily fluid intake amount was 1408 ml. A nutrition quarterly evaluation dated October 21, 2019 included the resident had her own teeth, feeds herself with set-up, and was at risk for weight fluctuations. These fluctuations were related to fluid shifts, as evidenced by diuretic treatment. The evaluation included that the resident's current nutritional interventions were appropriate. The evaluation also included that the resident required a total of 2010 ml of fluids per day. A mini nutritional assessment was completed on October 21, 2019 and revealed the resident was at risk for malnutrition. Continued review of the Documentation Survey Report for Fluid Intake and the MAR indicated [REDACTED] October 22: am fluid intake amount was 990 ml; pm fluid intake amount was 430 ml and night fluid intake amount was 0. The total daily fluid intake amount was 1420 ml. October 23: am fluid intake amount was 1010 ml; pm fluid intake amount was 510 ml and night fluid intake amount was 240 ml. The total daily fluid intake amount was 17[AGE] ml. October 24: am fluid intake amount was 1010 ml; pm fluid intake amount was 430 ml and night fluid intake amount was 120 ml. The total daily fluid intake amount was 15[AGE] ml. October 25: am fluid intake amount was 442.5 ml; pm fluid intake amount was total intake 422.5 ml and the night fluid intake amount was 120 ml. The total daily fluid intake amount was 9[AGE] ml. October 26: am fluid intake amount was 30 ml; pm fluid intake amount was 390 ml and the night fluid intake amount was 120 ml. The total daily fluid intake amount was 540 ml. October 27: am fluid intake amount was 270 ml; pm fluid intake amount was 0 and the night fluid intake amount was 0 ml. The total daily fluid intake amount was 270 ml. A review of the October 2019 Medication Administration Record [REDACTED]. According to the Documentation Survey Report for Amount Eaten revealed the resident was provided [AGE] meals in October 2019. Forty-nine meals were documented as being 76-100% consumed, 25 meals were documented as being 51-[AGE]% consumed and 5 meals were documented as being 26-50% consumed. Despite documentation that the resident required a daily fluid intake amount of 2010 ml, there were no interventions to address the resident's low fluid intake for 2 1/2 weeks prior to being hospitalized (on October 27). A nursing note dated October 27, 2019 at 1:56 p.m. by a Licensed Practical Nurse (LPN/staff #147) included a change in the resident's condition. The resident was in the dining room prior to lunch, when a CNA found the resident unresponsive. The LPN called 911 and the resident was transported to the hospital. A history and physical from the hospital dated October 27, 2019 included the resident had lethargy and altered mental status. The resident's heart rate was 132 beats per minute and blood pressure was 81/46. The resident was found to have severe dehydration, pyuria (pus in the urine) and [MEDICAL CONDITION] with rapid ventricular response in the ER. Under Assessment and Plan, the documentation included the resident had acute metabolic [MEDICAL CONDITION] due to severe [MEDICAL CONDITION], acute non-traumatic kidney injury due to hypovolemia with dehydration, and [MEDICAL CONDITION] on presentation due to hypovolemia [MEDICAL CONDITION]. The ER laboratory results revealed the following: -[MED] 161 milliequivalents per liter (mEq/L) (normal range 135 to 145 mEq/L) -Chloride 128 mEq/L (normal range 96 and 106 mEq/L) -BUN 81 milligrams per deciliter (mg/dL) (normal range 7 to 20 mg/dL) -Creatinine 1.[AGE] mg/dL (normal range 0.5 to 1.1 mg/dL) -Osmolality 363 milliosmoles per kilogram (normal range 2[AGE] to 295 milliosmoles per kilogram) -Lactic Acid 2.2 milliosmoles per Liter (mmol/L) (normal range 0.5-1 mmol/L) A nursing note dated October 28, 2019 at 1:35 a.m. by a LPN (staff #149) included the resident was admitted to the Intensive Care Unit with a UTI, A-Fib, acute metabolic [MEDICAL CONDITION], and acute kidney injury due to severe dehydration. Per the clinical record, the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nutrition/Hydration Risk Evaluation completed on November 4, 2019 by a LPN (staff #29) revealed the resident had a daily fluid intake of 50-1000 ml a day. The evaluation indicated that the resident was at high risk. An interview was conducted with a Registered Nurse (RN/staff #129) on January 17, 2020 at 10:38 a.m. She stated the resident always sat at the assistance table for meals and required cuing and extensive assistance for fluid intake. She stated the resident would not usually just pick up a drink on her bedside table, as she needed cuing. She stated that the nurses document fluids on the MAR indicated [REDACTED] An interview was conducted with a Certified Nursing Assistant (CNA/staff #23) on January 17, 2020 at 12:13 p.m. She stated that the resident has a pitcher of water on her bedside table, but needs cuing to drink. She stated that once you give her water and cue her, she will drink but needs to have a little bit of instruction. The CNA stated the resident doesn't usually reach for a glass of water on her own, but will drink everything you give her. An interview was conducted with the Director of Nursing (DON/staff #145) on January 17, 2020. The DON stated that it is her expectation that the staff follow facility policy in the care of a resident at risk for dehydration. She stated the dietary department assesses the resident's needs upon admission, quarterly, and as needed to identify any potential risks to the resident. She stated the CNA's monitor fluids ingested during meals and additional fluid intake in the task tab in the EMR. The DON said that the nurses chart meal supplements, like Pro-Mod, in the MAR but the volume would not be reflected in the intake under the Task tab. She stated that unless the resident is on strict intake and output, there is no way to accurately know the total fluid intake or output. An interview was conducted with a Registered Dietitian (staff #150) on January 17, 2020 at 3:30 p.m. She stated the resident is provided over 3000 milliliters in liquids per day. However, she said there is not an accurate method of tracking if the resident actually consumes what she is given. She stated that unless the resident is on a strict intake and output order there is no way to monitor if she actually ingests everything she is offered. A policy and procedure titled Nutrition included it is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible. Evaluations of the residents include percentage of food eaten that may impact weight gain or loss. Once the resident has been evaluated for nutrition status, the registered dietitian, dietary technician and/or designee will determine if there is a significant change in the resident's condition. Nutritional assessment may include oral intake of food, fluids, and functional status including the need for cues and assistance. A policy and procedure titled Hydration revealed that this facility will provide each resident with sufficient fluid intake to maintain proper hydration and health. The purpose of this policy is to ensure that the resident receives a sufficient amount of fluids based on individual needs to prevent dehydration. The definition of sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. Risk factors for dehydration include functional impairments that make it difficult to drink fluids and dementia, in which the resident forgets to drink or forgets how to drink. A policy and procedure titled Food and Fluid Intake Documentation stated that it is the policy of this facility that a record of food and fluid intake shall be maintained for all residents receiving oral nourishment. The purpose of this is to record the oral intake for residents and utilized when accessing nutritional state. If a pattern of low food or fluid intake exists, the Charge Nurse will notify the resident's physician. The Charge Nurse will document this evaluation and steps taken in progress notes and will adjust the care plan appropriately.

Based on observations, clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to protect three residents (#9, #10 and #58) from one resident (#56), who displayed known sexually inappropriate behaviors. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The facility also failed to protect one resident (#204) from verbal abuse by a staff member. Findings include: On (MONTH) 5, (YEAR) at 10:20 a.m., the Administrator (staff # 81) was informed that resident #9 reported to a surveyor that while resident #56 was shaking her hand in the hall, he stated that he was going to f--- her. Resident #9 reported that this incident occurred on (MONTH) 2, (YEAR). Two additional reports of sexually inappropriate behaviors by resident #56 were also received on (MONTH) 5, (YEAR) from resident #10 and resident #58. In addition, it was identified that staff members were aware of some of the sexually inappropriate behaviors of resident #56 and did not report these behaviors to administration or implement measures to protect the other residents. As a result, the Condition of Immediate Jeopardy and Substandard Quality of Care (SQC) were identified on (MONTH) 5, (YEAR) at 5:00 p.m. The Administrator was informed of the facility's failure to protect residents from resident #56, who exhibited sexually explicit and inappropriate behaviors. The Administrator presented a plan of correction on (MONTH) 5, (YEAR) at 6:47 p.m. The Administrator was informed that the plan of correction did not include all of the necessary components to ensure the safety of residents and provide care to those residents, who may have been affected by resident #56's sexually inappropriate behaviors. At 7:35 p.m., a revised plan of correction was presented and accepted. Observations were conducted on (MONTH) 5, (YEAR) at 7:40 p.m. of the facility implementing their plan of correction. Staff in-services were being conducted regarding abuse and sexually inappropriate behaviors. The facility also implemented 1:1 monitoring for resident #56. Additional observations were conducted on (MONTH) 6, (YEAR), of the facility continuing to implement their plan of correction. Staff in-services continued to be conducted and staff interviewed were knowledgeable of the different kinds of abuse, the reporting process, and of the measures which were being implemented to protect the residents. Resident #56 also remained on 1:1 monitoring. As a result, the Condition of Immediate Jeopardy was abated on (MONTH) 6, (YEAR) at 10:39 a.m. -Resident #56 was admitted to the facility on (MONTH) 20, 2012, with [DIAGNOSES REDACTED]. Review of the nursing monthly summaries dated (MONTH) 27, (MONTH) 24, and (MONTH) 11, (YEAR), revealed that resident #56 had moderate cognitive impairment, delusions, hallucinations, wanders in the facility, uses a wheelchair and displays sexual behaviors toward female staff. A nursing monthly summary dated (MONTH) 11, (YEAR) included that resident #56 had severe cognitive impairment, uses a wheelchair, continues to be sexually inappropriate and makes inappropriate comments to female staff and visitors. A nursing monthly summary dated (MONTH) 10, (YEAR) revealed that resident #56 has disorganized thinking and memory problems, uses a wheelchair, and is sexually inappropriate with female staff and is redirected. Review of a nursing monthly summary dated (MONTH) 10, (YEAR) revealed the resident had severe cognitive impairment, memory problems, uses a wheelchair, and that behavior monitoring is in process for sexually inappropriate behaviors at times. According to the annual Minimum Data Set (MDS) assessment dated (MONTH) 30, (YEAR), the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS included the resident required extensive assistance of one person with transfers, bed mobility, bathing and eating and was able to use a wheelchair for locomotion. Under the behavior section, the documentation included that the resident did not have any physical or verbal behaviors, and did not have any behaviors which were directed toward others; such as public sexual acts. Review of an activity care plan dated (MONTH) 2, (YEAR) revealed that resident #56 was unable to complete simple program tasks and has little speech during activities, with the exception of episodes of inappropriate sexual remarks. Interventions included the following: quickly redirect at the first show of behaviors and be aware of the surroundings or seating of resident #56 related to the potential for inappropriate verbal behaviors with other residents. A care plan dated (MONTH) 3, (YEAR) included the resident has long and short term memory deficits, with poor cognitive decision making abilities related to Alzheimer's. The care plan included the resident makes sexually inappropriate gestures and comments towards female staff. Interventions were as follows: attempt to redirect the resident when sexually inappropriate gestures or comments are made towards staff by talking with him about his family, assign consistent caregivers whenever possible, and approach the resident in a calm manner. Review of a care plan dated (MONTH) 3, (YEAR) revealed the resident has a [DIAGNOSES REDACTED].e. grabbing genitals) and comments (advances for oral sex) toward female staff. Interventions listed included the following: Do not respond or react to inappropriate comments, instead distract to more appropriate conversation, if the behavior continues offer reminders of respectful talk or use sterile attention, reinforce with staff that firm and clear limits are healthy and required when the resident makes inappropriate gestures or statements, when resident #56 engages in inappropriate gestures (grabbing genitals) distract him and engage in an activity, offer a snack to occupy his hands, or escort him to his room if safe. Review of the resident assessment change of condition-alert charting dated (MONTH) 6, (YEAR), revealed documentation that the physician stated that resident #56 made sexual inappropriate comments to her, during her visit with him. A physician progress notes [REDACTED]. The physician questioned resident #56 regarding his behaviors in his room and in common areas to see if he knows right from wrong, but made sexually inappropriate comments to the female physician instead. The documentation included that the resident was alert, but was not appropriate in conversation or behaviors. -Resident #9 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 6, (YEAR) revealed that resident #9 had a BIMS score of 12, indicating moderate cognitive impairment. The MDS included that resident #9 walks independently with her walker. An interview was conducted on (MONTH) 5, (YEAR) at 9:26 a.m. with resident #9, who stated that last week either Thursday or Friday (November 1 or (MONTH) 2), a man (resident #56) was sitting in his wheelchair in the hallway and held out his hand to her. Resident #9 stated she thought he was being friendly and went to shake his hand, but he grabbed her hand and pulled it toward his chest and stated I'm going to F--- you. Resident #9 stated that there was a nurse in the hall at the time (staff #115) and believes the nurse witnessed the incident. Resident #9 stated that resident #56 wanders that hall in his wheelchair and has wandered into her room on multiple occasions. She stated that she now uses her wheelchair and walker to build a fence around her bed at night to feel safe. An interview was conducted on (MONTH) 5, (YEAR) at 10:20 a.m., with the Administrator (staff #81). Staff #81 stated that he became aware of the incident this morning when interviewing resident #9, and that resident #9 said she was fine. Staff #81 was informed that resident #9 felt that the incident was abuse. Another interview was conducted on (MONTH) 6, (YEAR) at 9:31 a.m., with resident #9. The resident stated that she began barricading herself in bed the night after the incident with resident #56, when he made the sexual comment to her. Resident #9 stated that she was not afraid of him prior to the incident, even though he has wandered into her room multiple times in the past. Resident #9 stated the comment that resident #56 said to her has now made her afraid of him, so she sets up her wheelchair and walker by her bed to ensure he does not come near her, while she is sleeping. An interview was conducted on (MONTH) 6, (YEAR) at 3:02 p.m. with a LPN (staff #115), who was on the hallway at the time of the incident on (MONTH) 2. Staff #115 said that she turned around and saw resident #56 holding the right forearm arm of resident #9. Staff #115 stated that she thought resident #9 was trying to pull her arm away. She said that she did not hear anything verbally, as she was standing at her medication cart which was down the hallway. She stated that she was orienting a student nurse and sent the student over to the residents, but she also went with the student. She said that resident #9 told her that she was fine, walked away and laughed. Staff #115 stated that she informed the social worker (staff #43), because she saw resident #56 holding the arm of resident #9, but she did not feel that abuse had occurred. On (MONTH) 8, (YEAR), the Administrator provided a review of the video recording of the incident which had occurred on (MONTH) 2, (YEAR) at approximately 7:27 a.m. in the 400 hallway, between resident #9 and resident #56. Per the video, resident #9 was walking down the hallway with her walker and resident #56 was sitting in his wheelchair in the hallway holding his hand out. Staff #115 was standing at the far end of the hallway by her medication cart with a student nurse. As resident #9 reached resident #56, the two residents shook hands and resident #56 pulled resident #9 close to him and talked to her. Staff #115 remained at the medication cart and the student nurse walked toward the two residents, and within a few seconds the resident's released their hands, without any staff intervention. An interview was conducted on (MONTH) 9, (YEAR) at 11:36 a.m. with Social Services (staff #43). Staff #43 stated the resident approached him Friday morning (November 2, (YEAR)) and wanted to talk with him. Staff #43 said that resident #9 stated that when she was walking past resident #56, he reached out to shake her hand and then took her hand and pulled her close to him stating I want to f--- you. Staff #43 said that resident #9 originally said she was shocked about the incident, but said no when asked if she felt abused or assaulted. Staff #43 stated that he told her if she changed her mind, the facility will need to report it and call the police. Staff #43 stated that resident #9 replied Well that's just (resident #56), but if it happens again, she would file a police report. Staff #43 stated he was surprised that the incident occurred and the language used by resident #56, but did not think any more about it. Staff #43 stated that he did not consider the incident to be abuse, because resident #9's skin was intact, and she did not seem to be offended. He said that he is aware of the care plan for resident #56 regarding comments toward staff, but has never heard anything regarding comments or actions toward peers. Staff #43 stated he informed his supervisor (the Social Service Manager/staff #8), who told him to inform the Director of Nursing (DON/staff #38) right away, which he did. Staff #43 stated he had been educated on the types of abuse and the steps of reporting abuse. He said that sexual abuse would be unwanted physical contact or innuendos, things like that. He said looking back on the incident between resident #9 and resident #56 and based on his definition of sexual abuse, that incident would be considered sexual abuse. -Resident #58 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 1, (YEAR) revealed the resident has a BIMS score of 15, which indicated intact cognition. The MDS included the resident required one person extensive assistance with transfers, bed mobility, bathing, dressing and was independent in her wheelchair. An interview was conducted on (MONTH) 5, (YEAR) at 3:29 p.m. with resident #58, who stated that there is a male resident (resident #56) who has been sexually inappropriate for a long time. Resident #58 stated that approximately three weeks ago, resident #56 was in the dining room during meal time, when he started to remove his shirt and started masturbating. Resident #58 stated that she had to get the attention of a staff member, who removed resident #56 from the dining room. She said that resident #56 has behaved like this for a long time and she tries not to look when he does it because it's not something she wants to see. Another interview was conducted on (MONTH) 6, (YEAR) at 9:03 a.m. with resident #58, who stated that at the time of the incident approximately three weeks ago, there were multiple female residents who were present in the dining room, when he was masturbating. Resident #58 stated that she was the one who notified a staff member, because she thinks the other female residents have dementia and are not very with it and are unable to speak for themselves. Resident #58 stated that resident #56 displays this behavior often and she wishes not to see it, so when it happens in a public area, she will take herself elsewhere. Resident #58 also recalled an incident when resident #56 was sitting close to the nurses station in his wheelchair masturbating. She could not recall the date, but stated that there were multiple staff members who saw resident #56 masturbating and they did not do anything about it, until she intervened and asked resident #56 to stop. Resident #58 stated it was only then that a staff member removed resident #56 from the nurses station area. Resident #58 stated that she feels like the staff do not care about his behavior in public, because they do not do anything to help or stop the behavior from happening. -Resident #10 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated (MONTH) 7, (YEAR) revealed that resident #10 had a BIMS score of 14, indicating intact cognition. The MDS also revealed that resident #10 required one person limited assistance with walking and bathing, and required supervision and/or was independent with eating, transfers and bed mobility. The MDS also included that resident #10 required extensive assistance of one person while going on and off the unit. An interview was conducted on (MONTH) 5, (YEAR) at 12:53 p.m. with resident #10, who stated that approximately one month ago she was walking down the hallway going back to her room, and resident #56 was sitting in his wheelchair in the door way. Resident #10 stated that resident #56 yelled out to her that he wanted to see her tits. Resident #10 stated that she has seen resident #56 touch the nurses inappropriately and that he has behaved this way for a long time. An interview was conducted on (MONTH) 5, (YEAR) at 3:14 p.m. with a Certified Nursing Assistant (CNA/staff #18), who stated that she has witnessed resident #56 display behaviors. Staff #18 stated there was an incident in the dining room where resident #56 was saying inappropriate things and that she told resident #56 it was not okay to do that. An interview was conducted on (MONTH) 5, (YEAR) at 3:21 p.m. with a CNA (staff #82), who stated that she has worked with resident #56 for a year and he is confused and that he wanders into other resident's rooms. Staff #82 stated that some residents are fearful, because resident #56 will park himself in his wheelchair at the doorway to their rooms. Staff #82 stated that resident #56 is sometimes sexually inappropriate and will use the F word or will say to other residents come touch me. Staff #82 stated that resident #56's sexually inappropriate behaviors are directed to both staff and other residents. An interview was conducted on (MONTH) 5, (YEAR) at 4:07 p.m. with the Administrator, who stated that he had no knowledge of resident #56's sexually inappropriate behaviors. He stated that now there is a staff member with resident #56 at all times. An interview was conducted on (MONTH) 5, (YEAR), with the Director of Nursing (DON/staff #38). Staff #38 stated that she recently became aware that resident #56 had inappropriate behaviors, but did not investigate what the inappropriate behaviors consisted of. An interview was conducted on (MONTH) 5, (YEAR) at 4:47 p.m., with a LPN unit manager (staff #90). Staff #90 stated that resident #56's behaviors consist of being verbally and sexually inappropriate during care and would use phrases such as I want to F--- you or hold my privates. Staff #90 stated that last week she sat with resident #56 at the nurses station for a 1:1 and that he stated to her Let me hold your hand, take my c---. Staff #90 stated that resident #56 has been sexually inappropriate since admission to the facility in 2012. She further stated that she does feel the other residents in the facility have the right to be free from sexual verbal comments or gestures. An interview was conducted on (MONTH) 6, (YEAR) at 9:25 a.m. with a CNA (staff #93), who stated that resident #56 does say sexual comments, such as I want to touch you. She said these behaviors have been occurring for the two years that she has worked at the facility. An interview was conducted on (MONTH) 7, (YEAR) at 8:17 a.m. with a CNA (staff #119), who stated that resident #56 has displayed sexually inappropriate behaviors mostly verbal, but will occasionally start to masturbate while in the dining room and at the nurses station. Staff #119 said that she will place a blanket on his lap with his hands outside of the blanket to try and prevent this behavior from occurring. A later interview was conducted on (MONTH) 7, (YEAR) at 9:51 a.m. with staff #119. She said there was an incident approximately three weeks ago where resident #56 was in the dining room and she was assisting him to eat. She said that resident #56 yelled out F--- me and suck my c----, then proceeded to remove his shirt and brief and pulled his private parts out. She said that she immediately covered resident #56 with a blanket and removed him from the dining room. Staff #119 stated that she reported this to the nurse (staff #115), but did not report the incident to anyone else. Staff #119 stated that resident #56 has had behaviors such as masturbating in public areas and has made inappropriate sexual comments for a long time. -Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to Hospice. Review of a quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Review of the facility's investigative summary included that on 2/01/18 at approximately 9:30 a.m., three staff (CNA/staff #132, CNA/staff #187, housekeeper/staff #131) and a visitor, witnessed a Licensed Practical Nurse (LPN/staff #188) yell at resident #204 saying at least three times You can go to hell. The incident was reported to the Director of Nursing and the Administrator. Staff #188 was suspended immediately. According to the summary, staff #187 reported that she was taking the resident down the hall, when he started cursing at staff. Staff #187 reported that immediately staff #188 started yelling at the resident saying not to talk to her like that and that he is an educated man and should start to behave like one. The documentation included that the visitor who witnessed the incident reported that the nurse came up the hall saying, You don't treat people that way, I an not putting up with it and this if f--- BS. A statement by staff #131 included that staff #188 yelled at resident #204 saying, You go to hell, you go to hell. I thought you were more intelligent than that. Per the report, a statement by staff #188 included that staff #187 was taking resident #204 down the hall, when he started using profanity and she replied, Please Mr. (resident's name) you are a fine educated gentleman, so please do not speak that way to me or my staff. She said that she repeated this three times and then the resident calmed down and stopped using profanity. Review of an e-mail dated 2/1/18 at 10:29 a.m. written by the Business office Administrator (staff #54) to the Director of Nursing (DON/staff #38) and Administrator (staff #81), revealed documentation that staff #131 came to her office on 2/1/18 around 10 a.m. to report that staff #187 was taking resident #204 by the station, and the resident told staff #187 to go to hell. Staff #188 followed them and then told resident #204 to go to hell, you are a more educated man than that. The documentation included that a family member of another resident heard the encounter. In a telephone interview on 11/06/18 at 2:13 p.m. with CNA (staff #134), she stated that resident #204 was being very loud and very disrespectful and the nurse (staff #188) lashed out and yelled at him. Staff #134 stated everybody heard it, but she did not recall the exact words said by the resident or the nurse. She said she was shocked by what the nurse had said to the resident. She said that resident #204 was very upset and he started to shake. Staff #134 stated the staff then had to comfort the resident to get him to relax. She further stated that she did witness abuse when the nurse lashed out and was disrespectful to the resident and that is wrong. An interview was conducted on 11/06/18 at 2:33 p.m. with staff #131, who stated that she was on the 300 hall buffing the floor on 2/01/18 at approximately 9:30 a.m. She stated that resident #204 was sitting on one side of her saying some things, when the nurse on the unit took her finger and pointed it at him and said, Who do you think you are. You don't F------ talk to anybody like that. You can F------ go to hell. Staff #131 stated the resident felt bad, as his head went down. Staff #131 also said that there was a family member in another room who heard the whole thing. Staff #131 stated at that point she knew she had to report it because it upset her. An interview was conducted on 11/07/18 at 8:46 a.m. with staff #54, who stated that staff #131 came to her office on 2/01/18 and reported that staff #188 had said something to resident #204. Staff #54 stated she sent an e-mail to the DON and the Administrator, but the DON never had her e-mail set up to her phone, and that she had entered the Administrator's e-mail address incorrectly, so neither of them received the e-mail. Staff #54 stated she didn't see it as abuse, but thought it was more like a dignity thing. Staff #54 stated she now knows it was abuse and that it should have been reported immediately. An interview was conducted on 11/07/18 at 8:44 a.m. with the DON, who stated that she was not notified immediately, but found out the next day (2/02/18) when she received the e-mail from staff #54. She stated that staff #188 was suspended while the investigation was completed, and after the allegation was substantiated, staff #188 was terminated. However, according to the time sheet punches, staff #188 worked her entire shift until 3:25 p.m. on 2/01/18, and was not removed from further contact from residents on the day of the verbal abuse incident with resident #204. An interview was conducted on (MONTH) 8, (YEAR) at 12:36 p.m. with the Administrator (Abuse Prohibition Officer/staff #81), who stated that part of new hire orientation and prior to staff working with residents, they receive training on abuse, abuse prevention, types of abuse and the reporting process to ensure they are keeping residents safe. Staff #81 stated if a staff member witnessed or was informed of abuse, they should protect the resident and report it immediately. Staff #81 said if a staff member is involved then that person is suspended, pending completion of the investigation. Staff #81 further stated that a report should be made to the State Agency, APS and the police. Review of the facility's policy titled, Resident Abuse Definitions and Report revealed that residents have the right to be free from mental, physical, sexual, and verbal abuse .and prohibits staff from engaging in any such conduct, as well as sets forth procedures for reporting complaints, concerns, or incidents. The policy included that Emotional/Psychological Abuse includes, but is not limited to harassment, deprivation or conduct that is demeaning, humiliating or threatening .Sexual Abuse includes: Any non consensual sexual contact of any type with a resident and includes but is not limited to sexual harassment, sexual coercion, sexual assault, sexual contact, sexual intercourse, sexual penetration with a foreign object, sexual assault or sodomy. The policy further included that verbal abuse included the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance, regardless of their age, ability to comprehend or their disability. Examples of verbal abuse include, but are not limited to threats of harm, saying things to frighten a resident or cursing at them.