Every finding on record at Pleasant View Home

The facility identified a census of 79 residents, with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to ensure staff responded appropriately with adequate supervision to prevent potential abuse and/or mistreatment of Resident (R) 1, a cognitively impaired resident. This placed R1 at risk for potential abuse and/or mistreatment. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), weakness, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognitive function. The MDS documented R1 had no behaviors during the look back period. The MDS documented R1 required moderate staff assistance with dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 required substantial staff assistance with bathing and donning footwear. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated [DATE], documented R1 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R1 had no behaviors during the look back period. The MDS documented R1 required moderate staff assistance with toileting hygiene, bathing, and dressing. The MDS documented R1 required supervision or touching assistance with all of her other activities of daily living. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/19/24, documented R1 had orientation, memory, and recall deficits. The CAA documented R1 had dementia, a change in mental status, and short and long-term memory loss. The Communication CAA, dated 06/19/24, documented R1 had difficulty understanding others and being understood by others. The CAA documented R1 suffered from cognitive loss and aphasia (a condition with disordered or absent language function). R1's Care Plan documented R1 had the potential for side effects related to the use of aspirin (a non-steroidal anti-inflammatory drug used to treat fever, pain, inflammation, and as an antithrombotic {medications used to prevent or treat blood clots}) and may be prone to bruising of unknown origin and directed staff to observe R1 for bruising (03/11/25). The care plan documented R1 had a bruise to her chest (07/18/24), a bruise to right lateral forearm (07/11/24), a bruise to her forehead (09/13/24), a bruise to her right wrist (10/08/24), a bruise to her forearm (12/13/24), a bruise to her right upper arm (01/29/25), two bruises to her right outer lower extremity (02/25/25). The care plan documented R1 had experienced traumatic events. R1 reported her husband had twisted her arm which led to bruising and this event happened over a month ago. The care plan directed staff not to discuss traumatic events with R1 as R1 was concerned about others knowing of her traumatic events (03/11/25). The Progress Note, dated 01/09/25, documented R1 often called her husband her brother. The Progress Note, dated 01/28/25, documented R1 continued to have multiple bruises from a fall on 12/30/24. The Progress Note, dated 01/29/25, documented nursing staff was helping R1 get dressed for the day and noted a new bruise on her right upper arm. The bruise measured 6.0 centimeters (cm) by 4.0 cm with a small, reddened area in the middle. When nursing staff assessed the area, R1 reached over and scratched the area. The bruise and small reddened area were consistent with R1 scratching her arm. The Progress Note, dated 02/04/25, documented the weekly skin assessment had been completed. R1 had multiple areas of bruising in various stages of healing. The Progress Note, dated 02/25/25, documented R1's skin assessment was completed that afternoon. Staff noted two small bruises next to one another on R1's right outer extremity. Bruises were reddish/purple and measured 2.5 cm by 2.0 cm and 1.5 cm by 1.0 cm. R1 communicated to staff she did not want staff to fuss over it. The administrator, director of nursing, R1's responsible party, and R1's primary care physician were notified of the bruising. The location of the bruising was consistent with wheelchair foot pedals or a walker during ambulation. The Progress Note, dated 04/01/25, documented bruising was noted to R1's right hand during her bath. The bruising measured 4.0 cm by 5.0 cm. R1 stated, Oh, that has been there a long time. When R1 was asked what happened, R1 stated, I probably swung my hand too fast and bumped it on something. R1's responsible party, administration, unit coordinator, and R1's primary care physician were notified of bruising. The edited Progress Note, dated 04/02/25 at 08:45 PM was documented as being a late entry (04/03/25 at 11:19 AM), edited on 04/03/25 at 11:23 AM, documented R1's husband visited R1 on 04/02/25 at approximately 08:45 PM. R1's husband reported he assisted R1 with getting ready for bed and while helping R1 get undressed, R1's arm got stuck in her sweater so he grabbed R1's arm to help pull her arm out of the sleeve. Evening staff reported a large bruise on R1's left forearm after R1's husband left her room. The bruising was dark blue/black in color with mild swelling noted to the area. R1's husband in to visit R1 again on 04/03/25, and LN H educated R1's husband to be cautious when assisting R1, as R1 bruised easily. LN H educated R1's husband staff would assist R1 to get ready for bed as R1 allowed. R1's primary care physician, administration, and R1's responsible party were notified of the new bruise. The EMR lacked any further documentation regarding the large black/purple bruise on R1's left forearm. LN G's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at approximately 08:45 PM, CNA M called LN G up to R1's living unit due to a bruise on R1's left forearm. LN G stated she went into R1's room and noted a bruise, dark in color, and edematous (swollen) on R1's left forearm. LN G stated she asked R1 what happened, and R1 replied, My brother got mad at me and twisted my arm! He gets mad a lot. CNA M told LN G R1 referred to her husband as her brother. LN G stated she reassured R1 she was okay. LN G stated she headed to the nurse's office to notify Administrative Staff A and told CNA M and CMA R to fill out witness statements when CMA R told LN G R1's husband had stopped by her medication cart when he was leaving and told CMA R he had lost his temper. LN G stated she called Administrative Staff A and informed her of the bruise and what the staff had reported. Administrative Staff A said, I don't believe that. Don't write up or chart anything, and I will have LN H (unit manager) follow up in the morning. LN G stated she told CNA M and CMA R what Administrative Staff A had said and told them to write a report and keep it with them. R1 was safe at that time, and her husband was gone. CMA R's Notified Witness Statement, dated 04/08/25, documented on 04/02/25 R1's husband came to visit R1 in her room. CMA R stated she checked on R1, and her husband was attempting to dress R1. CMA R stated she went back to her medication cart, and R1's husband stopped at her cart and asked if R1's condition was worsening. CMA R told R1's husband no R1 was about the same. CMA R stated that R1's husband said he lost his temper, and maybe he shouldn't have, and then left. About five to ten minutes later, CNA M came and told CMA R she had found a bruise on R1's left wrist, and R1 stated it came from her husband. CMA R stated she and CNA M called LN G to the unit to do an assessment. LN G called Administrative Staff A, and we were instructed not to report and not to do incident reports. CNA M's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at around 08:30 PM, R1 called CNA M into her room and asked CNA M if she could cover her new bruise. CNA M asked R1 how it had happened, and R1 said her husband had done it because he got mad. R1 stated her husband had grabbed her arm and applied pressure. CNA M stated she and CMA R reported the bruise to LN G, and LN G measured the bruise and called Administrative Staff A. Administrative Staff A said not to report it or make witness statements and that she would talk to LN H, the unit coordinator, and R1's husband the next day. R1's husband said it happened when he was taking R1's sweater off for bed, so they made that report of that statement because Administrative Staff A said she did not believe the first story, and R1's husband wouldn't do that. LN H's Notarized Witness Statement, dated 04/08/25, documented LN H had received a phone call on 04/02/25 in the evening from CMA R at approximately 08:52 PM. CMA R reported an incident regarding R1 and her husband. CMA R reported to LN H that R1's husband had come up to her before leaving and stated he should not have lost his temper. Staff went in to assess R1 and located a large bruise developing on R1's left forearm. CMA R reported R1 stated her husband had grabbed her arm. CMA R reported to LN H she had reported the incident to LN G. CMA R told LN H, LN G had reported the incident to Administrative Staff A and was told Administrative Staff A did not believe that is what happened, and to not make a report until Administrative Staff A and LN H were back in the office in the morning to investigate. CMA R reported to LN H that Administrative Staff A had told them not to document anything at that time, including witness statements. On the morning of 04/03/25, Administrative Staff A told LN H to investigate the incident. LN H noticed a very large bruise to R1's left arm. LN H asked R1 what had happened, and R1 stated her brother was in her room and grabbed her arm. LN H questioned R1 further, and R1 stated it was her husband who grabbed her arm. R1's husband was visiting R1 later that morning, and LN questioned R1's husband about what had happened. R1's husband reported he was getting R1 ready for bed, and her arm got stuck in her sweater, so he grabbed R1's arm to help remove her arm from the sweater. LN H told R1's husband that staff reported he had made a comment when he left the room; he shouldn't have lost his temper with R1. R1's husband did not say anything to LN H's statement. LN H educated R1's husband that staff would assist R1 get ready for bed, and if he felt himself getting irritated or angry in R1's presence, he needed to leave immediately, as this would not be tolerated. LN H informed R1 and her husband that R1's door would remain open while R1's husband visited, and staff would peek in on them frequently. LN H called R1's responsible party, her son, to discuss the incident. R1's responsible party agreed that staff should assist R1 with her bedtime routine and not her husband. Following the interviews, LN H reported her findings to Administrative Staff A. LN H told Administrative Staff A this incident should be reported, and Administrative Staff A told LN H it was outside of the reporting window and LN H needed to drop it. LN H stated she was concerned this was physical abuse due to the bruising that was left, and the statements made by R1 and her husband on the evening it happened. LN H stated she told Administrative Staff A it indeed needed to be reported and asked Administrative Staff A to go and look at the bruise herself. LN H stated she was unaware if Administrative Staff A had gone to look at R1's bruise. LN H stated she did what she was told and made the event and documentation to reflect what her superior told her to. LN H stated she asked Administrative Staff A what she wanted LN H to do about the bruise documentation, and Administrative Staff A told LN H to document R1's husband grabbed R1's arm while removing her sweater, but not to document what staff had reported regarding R1's husband losing his temper with R1. LN H was told the intervention would be for staff to assist R1 with her bedtime routine, as she allowed. LN H asked Administrative Staff A if she should add to the care plan that R1's bedroom door would remain open while R1's husband was visiting, and frequent visual checks while he was visiting R1, and was told not to. LN H stated due to being told to drop the incident and to leave it alone, she did what she was told. On 04/08/25 at 10:30 AM, observation revealed R1 sat in her recliner watching television. R1 had her sweatshirt sleeve pulled up on her left arm. R1's left forearm had a large purple bruise in various stages of healing. On 04/08/25 at 10:30 AM, R1 was very suspicious of this surveyor. R1 wanted to know why I wanted to know what happened to her arm. This surveyor pointed out a bruise on her upper shoulder and shared that her dog had caused the bruise when he jumped up on her. R1 appeared to relax and stated she got the bruise a couple of weeks ago and thought someone had grabbed her and pushed her, but she could not remember who. R1 stated that her left forearm hurt her. On 04/08/25 at 10:45 AM, CNA O stated she had not witnessed the event but had heard in report that R1's husband had grabbed her left forearm and bruised her when he was frustrated with her, and R1 had told the nurse what he had done. CNA O stated the reason R1 was admitted to the facility was because this kind of thing was happening to her in the couple's apartment at the facility. CNA O stated she could understand R1's husband getting frustrated with R1's dementia. CNA O stated she was not concerned about R1's husband hurting her, and the facility had done nothing to protect R1 from her husband. On 04/08/25 at 11:30 AM, LN H, the nurse manager of the unit R1 lived on, stated LN G, who was on duty that night, had called Administrative Staff A to let her know R1's husband had come out of R1's room and stated he and R1 had gotten into an argument. He had put his hands on R1 and caused a bruise on her left forearm. LN H stated that Administrative Staff A told LN G she did not believe her. Administrative Staff A told LN H to investigate the bruise on 04/03/25. R1 told LN H that her brother grabbed her arm and caused the bruise. R1's husband told LN H R1 had gotten her arm stuck in her sweater, and he had assisted her in getting her arm out of the sweater, which caused the bruise. LN H stated she was concerned for R1's safety with her husband visiting her and taking her out on excursions. LN H told Administrative Staff A that if this had happened outside the facility, it would have been domestic abuse, and the husband would have been arrested. LN H stated that Administrative Staff A told her to drop it and not report anything. LN H stated the facility had done nothing to protect R1 from her husband, and R1's husband visited two to three times a day. LN H stated she was scared of retribution from the facility and that she would lose her job. On 04/08/24 at 12:30 PM, CNA N stated she had heard about the incident in report the following morning, R1 had received a bruise on her forearm from her husband. CNA N stated she saw the bruise, and it was so black. CNA N stated CMA R from the evening shift was very upset about what had happened and was worried for R1's safety. On 04/08/25 at 01:30 PM, LN I stated she had been the nurse coming on the morning after the incident. LN I stated she went in to assess R1's bruise and asked R1 what had happened and R1 told LN I her brother had grabbed and twisted her arm. LN I stated R1 had dementia and it must have been traumatic to R1 for R1 to have the same story twelve hours later after the incident. On 04/08/25 at 02:00 PM, CMA R stated she had heard R1 and her husband arguing in the evening on 04/02/25, so she went into R1's room. R1 asked her to help her get changed for bed, but R1's husband told her no, he would do it and to just go. CMA R stated she went back to her medication cart to continue to pass medications and was standing at the cart when R1's husband left. CMA R stated that R1's husband stopped by her cart and asked her if R1's condition was getting worse, and CMA R stated no R1 was the same as she had been. CMA R stated that R1's husband then said, I lost my temper with her, and I shouldn't have lost my temper with her, and then left. CMA R stated CNA M had gone into R1's room, saw the bruise, and went and reported the bruise to her. CMA R said she and CNA M then called LN G and told LN G she needed to come up to assess R1's bruise. CMA R stated that LN G came out of R1's room and told CMA R and CNA M to fill out witness statements and that she was going to call Administrative Staff A to report the incident. CMA R stated LN G came back a short time later and told them she had been told by Administrative Staff A that she did not believe that happened, and to not report anything on the incident or have staff fill out any witness statements. CMA R stated she was fearful for R1's safety. CMA R stated she was scared she would lose her job at the facility for speaking out. On 04/08/25 at 02:15 PM, CNA M stated on 04/02/25 in the evening R1's husband had just left, and R1 put on her call light. CNA M went to R1's room and R1 pointed to her left forearm and said, Can you cover this up with something? I don't want to look at it. CNA M stated she asked R1 what had happened, and R1 stated her brother had gotten mad at her and grabbed her arm. CNA M stated she went right out to CMA R and told her about the bruise, and they then called LN G to come and assess R1. LN G assessed R1 and then told CNA M and CMA R to fill out witness statements. LN G then went to call Administrative Staff A and report the incident. LN G came back and told CNA M and CMA R she had been told not to document anything about the incident and not to have staff fill out witness statements. CNA M stated she was worried for R1's safety. CNA M asked if she was going to lose her job at the facility because she really liked it there. On 04/08/25 at 02:30 PM, when Administrative Staff A was asked about R1's bruise, Administrative Staff A signed into R1's chart on her computer and read the progress note about R1's bruise that occurred on 04/02/25. Administrative Staff A denied any reports of abuse related to R1's arm. Administrative Staff A reported that R1's husband reported it had occurred when he was helping R1 get her arm out of her sweater. When Administrative Staff A was asked if she had received any phone calls from staff with concerns regarding R1 on 04/02/25. Administrative Staff A stated she had received a phone call from LN G, who stated staff had concerns about abuse related to R1 and her husband. Administrative Staff A stated she stopped LN G and told her before she threw out the big A word, was there any reason to suspect abuse. Administrative Staff A told LN G she would have LN H assess R1 the next morning. Administrative Staff A confirmed she had not taken the allegation of abuse seriously and had not come to the facility to assess the situation, assess R1, or talk to staff. Administrative Staff A confirmed she had not reported the incident as an allegation of abuse, had not protected R1 from any further potential abuse and denied telling staff not to document the incident. On 04/08/25 at 06:00 PM, LN G stated she had been the nurse on duty the evening of the bruising incident. LN G stated she had been called to the unit by CMA R to assess R1's bruising to her left forearm. LN G stated that R1's arm was dark black and swollen, and R1 complained it was really painful. LN G stated that R1 asked her to please cover the bruise because she did not want to look at it. LN G stated that R1 stated her brother had gotten mad at her and grabbed her arm, causing a bruise. LN G stated she left R1's room, told CMA R and CNA N to fill out witness statements, and went to the office to call Administrative Staff A. LN G stated Administrative Staff A stated she did not believe what LN G was saying was true and LN G should not document the incident or the bruise and she would have LN H assess R1 and the situation in the morning. LN G stated she was agency staff and was worried that if she did not do what Administrative Staff A said, she would not be asked to come back to the facility. The facility's Resident Abuse, Neglect, and Exploitation Policy, revised October 2024, documented it was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation of residents by implementing specific procedures. It was the policy of this facility that each resident would be free from abuse, neglect, exploitation, and misappropriation of property. Abuse included verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents would be protected from abuse, neglect, and harm while residing in the facility. No abuse or harm of any type would be tolerated, and residents and staff would be monitored for protection. Any suspicion of abuse resulting in significant injury would be reported to the State Agency within two hours and local law enforcement per agreement with the agency. It was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation. It was the policy of this facility to prevent abuse by providing residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without fear of reprisal or retribution. The facility leadership would assess the needs of all residents residing in the facility to be able to identify concerns in order to prevent potential abuse. The facility failed to ensure staff responded appropriately with adequate supervision to prevent potential abuse and/or mistreatment of R1, a cognitively impaired resident. This placed R1 at risk for potential abuse and/or mistreatment. risk of abuse.

The facility identified a census of 79 residents with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to report an allegation of abuse for Resident (R) 1 immediately, but not more than two hours, to the required entities including Law Enforcement (LE) and the State Agency. This placed the resident at risk for unidentified and ongoing abuse or mistreatment. Findings included: - R1 ' s Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), weakness, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognitive function. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 required substantial staff assistance with bathing and donning footwear. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated [DATE], documented R1 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with toileting hygiene, bathing, and dressing. The MDS documented R1 required supervision or touching assistance with all of her other activities of daily living. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/19/24, documented R1 had orientation, memory, and recall deficits. The CAA documented R1 had dementia, change in mental status, and short and long-term memory loss. The Communication CAA, dated 06/19/24, documented R1 had difficulty understanding others and being understood by others. The CAA documented R1 suffered from cognitive loss and aphasia (a condition with disordered or absent language function). R1 ' s Care Plan documented R1 had the potential for side effects related to the use of aspirin (a non-steroidal anti-inflammatory drug used to treat fever, pain, inflammation, and as an antithrombotic {medications used to prevent or treat blood clots}) and may be prone to bruising of unknown origin and directed staff to observe R1 for bruising (03/11/25). The care plan documented R1 had a bruise to her chest (07/18/24), a bruise to right lateral forearm (07/11/24), a bruise to her forehead (09/13/24), a bruise to her right wrist (10/08/24), a bruise to her forearm (12/13/24), a bruise to her right upper arm (01/29/25), two bruises to her right outer lower extremity (02/25/25). The care plan documented R1 had experienced traumatic events. R1 reported her husband had twisted her arm which led to bruising and this event happened over a month ago. The care plan directed staff not to discuss traumatic events with R1 as R1 was concerned about others knowing of her traumatic events (03/11/25). The Progress Note, dated 01/09/25, documented R1 often called her husband her brother. The Progress Note, dated 01/28/25, documented R1 continued to have multiple bruises from a fall on 12/30/24. The Progress Note, dated 01/29/25, documented nursing staff was helping R1 get dressed for the day and noted a new bruise on her right upper arm. The bruise measured 6.0 centimeters (cm) by 4 cm with a small, reddened area in the middle. When nursing staff assessed the area, R1 reached over and scratched the area. The bruise and small reddened area were consistent with R1 scratching her arm. The Progress Note, dated 02/04/25, documented the weekly skin assessment had been completed. R1 had multiple areas of bruising in various stages of healing. The Progress Note, dated 02/25/25, documented R1 ' s skin assessment was completed that afternoon. Staff noted two small bruises next to one another on R1 ' s right outer extremity. Bruises were reddish/purple and measured 2.5 cm by 2.0 cm and 1.5 cm by 1.0 cm. R1 communicated to staff she did not want staff to fuss over it. The administrator, director of nursing, R1 ' s responsible party, and R1 ' s primary care physician were notified of the bruising. The location of the bruising was consistent with wheelchair foot pedals or a walker during ambulation. The Progress Note, dated 04/01/25, documented bruising was noted to R1 ' s right hand during her bath. The bruising measured 4.0 cm by 5.0 cm. R1 stated, Oh that has been there a long time. When R1 was asked what happened, R1 stated, I probably swung my hand too fast and bumped it on something. R1 ' s responsible party, administration, unit coordinator, and R1 ' s primary care physician were notified of bruising. The edited Progress Note, dated 04/02/25 at 08:45 PM was documented as being a late entry (04/03/25 at 11:19 AM), edited on 04/03/25 at 11:23 AM, documented R1 ' s husband visited R1 on 04/02/25 at approximately 08:45 PM. R1 ' s husband reported he assisted R1 with getting ready for bed and while helping R1 get undressed R1 ' s arm got stuck in her sweater so he grabbed R1 ' s arm to help pull her arm out of the sleeve. Evening staff reported a large bruise on R1 ' s left forearm after R1 ' s husband left her room. The bruising was dark blue/black in color with mild swelling noted in the area. R1 ' s husband in to visit R1 again on 04/03/25 and LN H educated R1 ' s husband to be cautious when assisting R1 as R1 bruised easily. LN H educated R1 ' s husband staff would assist R1 to get ready for bed as R1 allowed. R1 ' s primary care physician, administration, and R1 ' s responsible party were notified of the new bruise. The EMR lacked any further documentation regarding the large black/purple bruise on R1 ' s left forearm. LN G ' s Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at approximately 08:45 PM, CNA M called LN G up to R1 ' s living unit due to a bruise on R1 ' s left forearm. LN G stated she went into R1 ' s room and noted a bruise, dark in color, and edematous (swollen) to R1 ' s left forearm. LN G stated she asked R1 what happened and R1 replied, My brother got mad at me and twisted my arm! He gets mad a lot. CNA M told LN G R1 referred to her husband as her brother. LN G stated she reassured R1 she was okay. LN G stated she headed to the nurse ' s office to notify Administrative Staff A and told CNA M and CMA R to fill out witness statements when CMA R told LN G R1 ' s husband had stopped by her medication cart when he was leaving and told CMA R he had lost his temper. LN G stated she called Administrative Staff A and informed her of the bruise and what the staff had reported. Administrative Staff A said, I don ' t believe that. [NAME] ' t write up or chart anything and I will have LN H (unit manager) follow up in the morning. LN G stated she told CNA M and CMA R what Administrative Staff A had said and told them to write a report and keep it with them. R1 was safe at that time and her husband was gone. CMA R ' s Notified Witness Statement, dated 04/08/25, documented on 04/02/25 R1 ' s husband came to visit R1 in her room. CMA R stated she checked on R1 and her husband was attempting to dress R1. CMA R stated she went back to her medication cart and R1 ' s husband stopped at her cart and asked if R1 ' s condition was worsening. CMA R told R1 ' s husband no R1 was about the same. CMA R stated R1 ' s husband said he lost his temper and maybe he shouldn ' t have and then left. About five to ten minutes later, CNA M came and told CMA R she had found a bruise on R1 ' s left wrist and R1 stated it came from her husband. CMA R stated she and CNA M called LN G to the unit to do an assessment. LN G called Administrative Staff A and we were instructed to not report and not to do incident reports. CNA M ' s Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at around 08:30 PM, R1 called CNA M into her room and asked CNA M if she could cover her new bruise. CNA M asked R1 how it had happened and R1 said her husband had done it because he got mad. R1 stated her husband had grabbed her arm and applied pressure. CNA M stated she and CMA R reported the bruise to LN G and LN G measured the bruise and called Administrative Staff A. Administrative Staff A said not to report it or make witness statements and she would talk to LN H, the unit coordinator, and R1 ' s husband the next day. R1 ' s husband said it happened when he was taking R1 ' s sweater off for bed so they made that report of that statement because Administrative Staff A said she did not believe the first story and R1 ' s husband wouldn ' t do that. LN H ' s Notarized Witness Statement, dated 04/08/25, documented LN H had received a phone call on 04/02/25 in the evening from CMA R at approximately 08:52 PM. CMA R reported an incident regarding R1 and her husband. CMA R reported to LN H R1 ' s husband had come up to her before leaving and stated he shouldn ' t have lost his temper. Staff went in to assess R1 and located a large bruise developing on R1 ' s left forearm. CMA R reported R1 stated her husband had grabbed her arm. CMA R reported to LN H she had reported the incident to LN G. CMA R told LN H, LN G had reported the incident to Administrative Staff A and was told Administrative Staff A did not believe that is what happened, and to not make a report until Administrative Staff A and LN H were back in the office in the morning to investigate. CMA R reported to LN H Administrative Staff A told them not to document anything at that time including witness statements. On the morning of 04/03/25, Administrative Staff A told LN H to investigate the incident. LN H noticed a very large bruise to R1 ' s left arm. LN H asked R1 what had happened and R1 stated her brother was in her room and grabbed her arm. LN H questioned R1 further and R1 stated it was her husband who grabbed her arm. R1 ' s husband was visiting R1 later that morning and LN questioned R1 ' s husband on what had happened. R1 ' s husband reported he was getting R1 ready for bed and her arm got stuck in her sweater, so he grabbed R1 ' s arm to help remove her arm from the sweater. LN H told R1 ' s husband staff reported he had made a comment when he left the room, he shouldn ' t have lost his temper with R1. R1 ' s husband did not say anything to LN H ' s statement. LN H educated R1 ' s husband that staff would assist R1 get ready for bed and if he felt himself getting irritated or angry in R1 ' s presence he needed to leave immediately as this would not be tolerated. LN H informed R1 and her husband R1 ' s door would remain open while R1 ' s husband visited, and staff would peak in on them frequently. LN H called R1 ' s responsible party, her son, to discuss the incident. R1 ' s responsible party agreed staff should assist R1 with her bedtime routine and not her husband. Following the interviews, LN H reported her findings to Administrative Staff A. LN H told Administrative Staff A this incident should be reported, and Administrative Staff A told LN H it was outside of the reporting window and LN H needed to drop it. LN H stated she was concerned this was physical abuse due to the bruising that was left, and the statements made by R1 and her husband on the evening it happened. LN H stated she told Administrative Staff A it indeed needed to be reported and asked Administrative Staff A to go and look at the bruise herself. LN H stated she was unaware if Administrative Staff A had gone to look at R1 ' s bruise. LN H stated she did what she was told and made the event and documentation to reflect what her superior told her to. LN H stated she asked Administrative Staff A what she wanted LN H to do about the bruise documentation and Administrative Staff A told LN H to document R1 ' s husband grabbed R1 ' s arm while removing her sweater but to not document what staff had reported regarding R1 ' s husband losing his temper with R1. LN H was told the intervention would be for staff to assist R1 with her bedtime routine as she allowed. LN H asked Administrative Staff A if she should add to the care plan R1 ' s bedroom door would remain open while R1 ' s husband was visiting and frequent visual checks while he was visiting R1 and was told not to. LN H stated due to being told to drop the incident and to leave it alone, she did what she was told. On 04/08/25 at 10:30 AM, observation revealed R1 sat in her recliner watching television. R1 had her sweatshirt sleeve pulled up on her left arm. R1 ' s left forearm had a large purple bruise in various stages of healing. On 04/08/25 at 10:30 AM, R1 was very suspicious of this surveyor. R1 wanted to know why I wanted to know what happened to her arm. This surveyor pointed out a bruise on her upper shoulder and shared her dog had caused the bruise when he jumped up on her. R1 appeared to relax and stated she got the bruise a couple of weeks ago and thought someone had grabbed her and pushed her but she could not remember who. R1 stated her left forearm hurt her. On 04/08/25 at 10:45 AM, CNA O stated she had not witnessed the event but had heard in report that R1 ' s husband had grabbed her left forearm and bruised her when he was frustrated with her and R1 had told the nurse what he had done. CNA O stated the reason R1 was admitted to the facility was because this kind of thing was happening to her in the couple's apartment at the facility. CNA O stated she could understand R1 ' s husband getting frustrated with R1 ' s dementia. CNA O stated she was not concerned about R1 ' s husband hurting her and the facility had done nothing to protect R1 from her husband. On 04/08/25 at 11:30 AM, LN H the nurse manager of the unit R1 lived on stated LN G, who was on duty that night, had called Administrative Staff A to let her know R1 ' s husband had come out of R1 ' s room and stated he and R1 had gotten into an argument. He had put his hands on R1 and caused a bruise to her left forearm. LN H stated Administrative Staff A told LN G she did not believe her. Administrative Staff A told LN H to investigate the bruise on 04/03/25. R1 told LN H her brother grabbed her arm and caused the bruise. R1 ' s husband told LN H R1 had gotten her arm stuck in her sweater and he had assisted her in getting her arm out of the sweater which caused the bruise. LN H stated she was concerned for R1 ' s safety with her husband visiting her and taking her out on excursions and told Administrative Staff A that if this had happened out of the facility it would have been domestic abuse and the husband would have been arrested. LN H stated Administrative Staff A told her to drop it and not report anything. LN H stated the facility had done nothing to protect R1 from her husband and R1 ' s husband visited two to three times a day. LN H stated she was scared of retribution from the facility and that she would lose her job. On 04/08/24 at 12:30 PM, CNA N stated she had heard about the incident in report the following morning R1 had received a bruise on her forearm from her husband. CNA N stated she saw the bruise and it was so black. CNA N stated CMA R from the evening shift was very upset about what had happened and was worried for R1 ' s safety. On 04/08/25 at 01:30 PM, LN I stated she had been the nurse coming on the morning after the incident. LN I stated she went in to assess R1 ' s bruise and asked R1 what had happened and R1 told LN I her brother had grabbed and twisted her arm. LN I stated R1 had dementia and it must have been traumatic to R1 for R1 to have the same story twelve hours later after the incident. On 04/08/25 at 02:00 PM, CMA R stated she had heard R1 and her husband arguing in the evening on 04/02/25 so she went into R1 ' s room. R1 asked her to help her get changed for bed, but R1 ' s husband told her no he would do it and to just go. CMA R stated she went back to her medication cart to continue to pass medications and was standing at the cart when R1 ' s husband left. CMA R stated R1 ' s husband stopped by her cart and asked her if R1 ' s condition was getting worse, and CMA R stated no R1 was the same as she had been. CMA R stated R1 ' s husband then said, I lost my temper with her and I shouldn ' t have lost my temper with her, and then left. CMA R stated CNA M had gone into R1 ' s room, saw the bruise, and came and reported the bruise to her. CMA R said she and CNA M then called LN G and told LN G she needed to come up to assess R1 ' s bruise. CMA R stated LN G came out of R1 ' s room and told CMA R and CNA M to fill out witness statements and that she was going to call Administrative Staff A to report the incident. CMA R stated LN G came back a short time later and told them she had been told by Administrative Staff A she did not believe that happened and to not report anything on the incident or have staff fill out any witness statements. CMA R stated she was fearful for R1 ' s safety. CMA R stated she was scared she would lose her job at the facility for speaking out. On 04/08/25 at 02:15 PM, CNA M stated on 04/02/25 in the evening R1 ' s husband had just left and R1 put on her call light. CNA M went to R1 ' s room and R1 pointed to her left forearm and said, Can you cover this up with something? I don ' t want to look at it. CNA M stated she asked R1 what had happened and R1 stated her brother had gotten mad at her and grabbed her arm. CNA M stated she went right out to CMA R and told her about the bruise, and they then called LN G to come and assess R1. LN G assessed R1 and then told CNA M and CMA R to fill out witness statements. LN G then went to call Administrative Staff A and report the incident. LN G came back and told CNA M and CMA R she had been told not to document anything about the incident and not to have staff fill out witness statements. CNA M stated she was worried for R1 ' s safety. CNA M asked if she was going to lose her job at the facility because she really liked it there. On 04/08/25 at 02:30 PM, when Administrative Staff A when asked about R1 ' s bruise, Administrative Staff A signed into R1 ' s chart on her computer and read the progress note about R1 ' s bruise that occurred on 04/02/25. Administrative Staff A denied any reports of abuse related to R1 ' s arm. Administrative Staff A reported that R1 ' s husband reported it occurred when he was helping R1 get her arm out of her sweater. When Administrative Staff A was asked if she had received any phone calls from staff with concerns regarding R1 on 04/02/25. Administrative Staff A stated she had received a phone call from LN G, who stated staff had concerns about abuse related to R1 and her husband. Administrative Staff A stated she stopped LN G and told her before she threw out the big A word, was there any reason to suspect abuse. Administrative Staff A told LN G she would have LN H assess R1 the next morning. Administrative Staff A confirmed she did not take the allegation of abuse seriously, did not come to the facility to assess the situation, assess R1, or talk to staff. Administrative Staff A confirmed she did not report the incident as an allegation of abuse, had not protected R1 from any further potential abuse, and denied telling staff not to document the incident. On 04/08/25 at 06:00 PM, LN G stated she had been the nurse on duty the evening of the bruising incident. LN G stated she had been called to the unit by CMA R to assess R1 ' s bruise on her left forearm. LN G stated R1 ' s arm was dark black and swollen and R1 complained it was really painful. LN G stated R1 asked her to please cover the bruise because she did not want to look at it. LN G stated R1 stated her brother had gotten mad at her and grabbed her arm causing the bruise. LN G stated she left R1 ' s room, told CMA R and CNA N to fill out witness statements, and went to the office to call Administrative Staff A. LN G stated Administrative Staff A stated she did not believe what LN G was saying was true and LN G should not document the incident or the bruise and she would have LN H assess R1 and the situation in the morning. LN G stated she was agency staff and was worried if she did not do what Administrative Staff A said she would not be asked to come back to the facility. The facility ' s Resident Abuse, Neglect, and Exploitation Policy, revised October 2024, documented it is the policy of this facility to prohibit and prevent abuse, neglect, and exploitation of residents by implementing specific procedures. It was the policy of this facility that each resident would be free from abuse, neglect, and exploitation and misappropriation of property. Abuse included verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion and any physical or chemical restraint not required to treat the resident ' s medical symptoms. Additionally, residents would be protected from abuse, neglect, and harm while residing in the facility. No abuse or harm of any type would be tolerated, and residents and staff would be monitored for protection. Any suspicion of abuse resulting in significant injury would be reported to the State Agency within 2 hours and local law enforcement per agreement with the agency. It was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation. It was the policy of this facility to prevent abuse by providing residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without fear of reprisal or retribution. The facility leadership would assess the needs of all residents residing in the facility to be able to identify concerns in order to prevent potential abuse. The facility failed to report an allegation of abuse for R1 immediately, but not more than two hours, to the required entities including Law Enforcement (LE) and the State Agency. This placed the resident at risk for unidentified and ongoing abuse or mistreatment.

The facility identified a census of 79 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to immediately investigate an allegation of abuse for Resident (R) 1 and initiate protective measures to prevent further potential abuse until an investigation was completed. This deficient practice placed R1 at risk for ongoing abuse and/or mistreatment. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), weakness, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognitive function. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 required substantial staff assistance with bathing and donning footwear. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated [DATE], documented R1 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R1 had no behaviors during the lookback period. The MDS documented R1 required moderate staff assistance with toileting hygiene, bathing, and dressing. The MDS documented R1 required supervision or touching assistance with all of her other activities of daily living. The MDS documented R1 had intact skin. The MDS documented R1 took antianxiety (class of medications that calm and relax people) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 6/19/24, documented R1 had orientation, memory, and recall deficits. The CAA documented R1 had dementia, a change in mental status, and short and long-term memory loss. The Communication CAA, dated 06/19/24, documented R1 had difficulty understanding others and being understood by others. The CAA documented R1 suffered from cognitive loss and aphasia (a condition with disordered or absent language function). R1's Care Plan documented R1 had the potential for side effects related to the use of aspirin (a non-steroidal anti-inflammatory drug used to treat fever, pain, inflammation, and as an antithrombotic {medications used to prevent or treat blood clots}) and may be prone to bruising of unknown origin and directed staff to observe R1 for bruising (03/11/25). The care plan documented R1 had a bruise to her chest (07/18/24), a bruise to right lateral forearm (07/11/24), a bruise to her forehead (09/13/24), a bruise to her right wrist (10/08/24), a bruise to her forearm (12/13/24), a bruise to her right upper arm (01/29/25), two bruises to her right outer lower extremity (02/25/25). The care plan documented R1 had experienced traumatic events. R1 reported her husband had twisted her arm, which led to bruising, and this event happened over a month ago. The care plan directed staff not to discuss traumatic events with R1, as R1 was concerned about others knowing of her traumatic events (03/11/25). The Progress Note, dated 01/09/25, documented R1 often called her husband her brother. The Progress Note, dated 01/28/25, documented R1 continued to have multiple bruises from a fall on 12/30/24. The Progress Note, dated 01/29/25, documented nursing staff was helping R1 get dressed for the day and noted a new bruise on her right upper arm. The bruise measured 6.0 centimeters (cm) by 4 cm with a small, reddened area in the middle. When the nursing staff assessed the area, R1 reached over and scratched the area. The bruise and small reddened area were consistent with R1 scratching her arm. The Progress Note, dated 02/04/25, documented the weekly skin assessment had been completed. R1 had multiple areas of bruising in various stages of healing. The Progress Note, dated 02/25/25, documented R1's skin assessment was completed that afternoon. Staff noted two small bruises next to one another on R1's right outer extremity. Bruises were reddish/purple and measured 2.5 cm by 2.0 cm and 1.5 cm by 1.0 cm. R1 communicated to staff that she did not want staff to fuss over it. The administrator, director of nursing, R1's responsible party, and R1's primary care physician were notified of the bruising. The location of the bruising was consistent with wheelchair foot pedals or a walker during ambulation. The Progress Note, dated 04/01/25, documented bruising was noted to R1's right hand during her bath. The bruising measured 4.0 cm by 5.0 cm. R1 stated, Oh, that has been there a long time. When R1 was asked what happened, R1 stated, I probably swung my hand too fast and bumped it on something. R1's responsible party, administration, unit coordinator, and R1's primary care physician were notified of bruising. The edited Progress Note dated 04/02/25 at 08:45 PM was documented as being a late entry (04/03/25 at 11:19 AM), edited on 04/03/25 at 11:23 AM, documented R1's husband visited R1 on 04/02/25 at approximately 08:45 PM. R1's husband reported he assisted R1 with getting ready for bed and while helping R1 get undressed R1's arm got stuck in her sweater so he grabbed R1's arm to help pull her arm out of the sleeve. Evening staff reported a large bruise on R1's left forearm after R1's husband left her room. The bruising was dark blue/black in color with mild swelling noted in the area. R1's husband in to visit R1 again on 04/03/25 and LN H educated R1's husband to be cautious when assisting R1 as R1 bruised easily. LN H educated R1's husband staff would assist R1 to get ready for bed as R1 allowed. R1's primary care physician, administration, and R1's responsible party were notified of the new bruise. The EMR lacked any further documentation regarding the large black/purple bruise on R1's left forearm. LN G's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at approximately 08:45 PM, CNA M called LN G up to R1's living unit due to a bruise on R1's left forearm. LN G stated she went into R1's room and noted a bruise, dark in color, and edematous (swollen) on R1's left forearm. LN G stated she asked R1 what happened, and R1 replied, My brother got mad at me and twisted my arm! He gets mad a lot. CNA M told LN G R1 referred to her husband as her brother. LN G stated she reassured R1 she was okay. LN G stated she headed to the nurse's office to notify Administrative Staff A and told CNA M and CMA R to fill out witness statements when CMA R told LN G R1's husband had stopped by her medication cart when he was leaving and told CMA R he had lost his temper. LN G stated she called Administrative Staff A and informed her of the bruise and what the staff had reported. Administrative Staff A said, I don't believe that. Don't write up or chart anything, and I will have LN H (unit manager) follow up in the morning. LN G stated she told CNA M and CMA R what Administrative Staff A had said and told them to write a report and keep it with them. R1 was safe at that time, and her husband was gone. CMA R's Notified Witness Statement, dated 04/08/25, documented on 04/02/25 R1's husband came to visit R1 in her room. CMA R stated she checked on R1, and her husband was attempting to dress R1. CMA R stated she went back to her medication cart, and R1's husband stopped at her cart and asked if R1's condition was worsening. CMA R told R1's husband no R1 was about the same. CMA R stated R1's husband said he lost his temper, and maybe he shouldn't have, and then left. About five to ten minutes later, CNA M came and told CMA R she had found a bruise on R1's left wrist, and R1 stated it came from her husband. CMA R stated that she and CNA M called LN G to the unit to do an assessment. LN G called Administrative Staff A, and we were instructed not to report and not to do incident reports. CNA M's Notarized Witness Statement, dated 04/08/25, documented on 04/02/25 at around 08:30 PM, R1 called CNA M into her room and asked CNA M if she could cover her new bruise. CNA M asked R1 how it had happened, and R1 said her husband had done it because he got mad. R1 stated her husband had grabbed her arm and applied pressure. CNA M stated she and CMA R reported the bruise to LN G, and LN G measured the bruise and called Administrative Staff A. Administrative Staff A said not to report it or make witness statements and that she would talk to LN H, the unit coordinator, and R1's husband the next day. R1's husband said it happened when he was taking R1's sweater off for bed, so they made that report of that statement because Administrative Staff A said she did not believe the first story, and R1's husband wouldn't do that. LN H's Notarized Witness Statement, dated 04/08/25, documented LN H had received a phone call on 04/02/25 in the evening from CMA R at approximately 08:52 PM. CMA R reported an incident regarding R1 and her husband. CMA R reported to LN H R1's husband had come up to her before leaving and stated he shouldn't have lost his temper. Staff went in to assess R1 and located a large bruise developing on R1's left forearm. CMA R reported R1 stated her husband had grabbed her arm. CMA R reported to LN H she had reported the incident to LN G. CMA R told LN H, LN G had reported the incident to Administrative Staff A and was told Administrative Staff A did not believe that is what happened, and to not make a report until Administrative Staff A and LN H were back in the office in the morning to investigate. CMA R reported to LN H Administrative Staff A told them not to document anything at that time, including witness statements. On the morning of 04/03/25, Administrative Staff A told LN H to investigate the incident. LN H noticed a very large bruise to R1's left arm. LN H asked R1 what had happened, and R1 stated her brother was in her room and grabbed her arm. LN H questioned R1 further, and R1 stated it was her husband who grabbed her arm. R1's husband was visiting R1 later that morning, and LN questioned R1's husband about what had happened. R1's husband reported he was getting R1 ready for bed, and her arm got stuck in her sweater, so he grabbed R1's arm to help remove her arm from the sweater. LN H told R1's husband that staff reported he had made a comment when he left the room, he shouldn't have lost his temper with R1. R1's husband did not say anything to LN H's statement. LN H educated R1's husband staff would assist R1 get ready for bed, and if he felt himself getting irritated or angry in R1's presence, he needed to leave immediately, as this would not be tolerated. LN H informed R1 and her husband that R1's door would remain open while R1's husband visited, and staff would peek in on them frequently. LN H called R1's responsible party, her son, to discuss the incident. R1's responsible party agreed that staff should assist R1 with her bedtime routine and not her husband. Following the interviews, LN H reported her findings to Administrative Staff A. LN H told Administrative Staff A this incident should be reported, and Administrative Staff A told LN H it was outside of the reporting window and LN H needed to drop it. LN H stated she was concerned this was physical abuse due to the bruising that was left, and the statements made by R1 and her husband on the evening it happened. LN H stated she told Administrative Staff A it indeed needed to be reported and asked Administrative Staff A to go and look at the bruise herself. LN H stated she was unaware if Administrative Staff A had gone to look at R1's bruise. LN H stated she did what she was told and made the event and documentation to reflect what her superior told her to. LN H stated she asked Administrative Staff A what she wanted LN H to do about the bruise documentation, and Administrative Staff A told LN H to document R1's husband grabbed R1's arm while removing her sweater, but to not document what staff had reported regarding R1's husband losing his temper with R1. LN H was told the intervention would be for staff to assist R1 with her bedtime routine, as she allowed. LN H asked Administrative Staff A if she should add to the care plan R1's bedroom door would remain open while R1's husband was visiting, and frequent visual checks while he was visiting R1, and was told not to. LN H stated due to being told to drop the incident and to leave it alone, she did what she was told. On 04/08/25 at 10:30 AM, observation revealed R1 sat in her recliner watching television. R1 had her sweatshirt sleeve pulled up on her left arm. R1's left forearm had a large purple bruise in various stages of healing. On 04/08/25 at 10:30 AM, R1 was very suspicious of this surveyor. R1 wanted to know why I wanted to know what happened to her arm. This surveyor pointed out a bruise on her upper shoulder and shared that her dog had caused the bruise when he jumped up on her. R1 appeared to relax and stated she got the bruise a couple of weeks ago and thought someone had grabbed her and pushed her, but she could not remember who. R1 stated that her left forearm hurt. On 04/08/25 at 10:45 AM, CNA O stated she had not witnessed the event but had heard in report that R1's husband had grabbed her left forearm and bruised her when he was frustrated with her, and R1 had told the nurse what he had done. CNA O stated the reason R1 was admitted to the facility was because this kind of thing was happening to her in the couple's apartment at the facility. CNA O stated she could understand R1's husband getting frustrated with R1's dementia. CNA O stated she was not concerned about R1's husband hurting her, and the facility had done nothing to protect R1 from her husband. On 04/08/25 at 11:30 AM, LN H, the nurse manager of the unit R1 lived on stated LN G, who was on duty that night, had called Administrative Staff A to let her know R1's husband had come out of R1's room and stated he and R1 had gotten into an argument. He had put his hands on R1 and caused a bruise on her left forearm. LN H stated Administrative Staff A told LN G she did not believe her. Administrative Staff A told LN H to investigate the bruise on 04/03/25. R1 told LN H her brother grabbed her arm and caused the bruise. R1's husband told LN H R1 had gotten her arm stuck in her sweater, and he had assisted her in getting her arm out of the sweater, which caused the bruise. LN H stated she was concerned for R1's safety with her husband visiting her and taking her out on excursions, and told Administrative Staff A that if this had happened out of the facility, it would have been domestic abuse, and the husband would have been arrested. LN H stated that Administrative Staff A told her to drop it and not report anything. LN H stated the facility had done nothing to protect R1 from her husband, and R1's husband visited two to three times a day. LN H stated she was scared of retribution from the facility and that she would lose her job. On 04/08/24 at 12:30 PM, CNA N stated she had heard about the incident in report the following morning R1 had received a bruise on her forearm from her husband. CNA N stated she saw the bruise, and it was so black. CNA N stated CMA R from the evening shift was very upset about what had happened and was worried for R1's safety. On 04/08/25 at 01:30 PM, LN I stated she had been the nurse coming on the morning after the incident. LN I stated she went in to assess R1's bruise and asked R1 what had happened, and R1 told LN I her brother had grabbed and twisted her arm. LN I stated R1 had dementia, and it must have been traumatic to R1 for R1 to have the same story twelve hours later, after the incident. On 04/08/25 at 02:00 PM, CMA R stated she had heard R1 and her husband arguing in the evening on 04/02/25, so she went into R1's room. R1 asked her to help her get changed for bed, but R1's husband told her no, he would do it, and to just go. CMA R stated she went back to her medication cart to continue to pass medications and was standing at the cart when R1's husband left. CMA R stated R1's husband stopped by her cart and asked her if R1's condition was getting worse, and CMA R stated no, R1 was the same as she had been. CMA R stated R1's husband then said, I lost my temper with her and I shouldn't have lost my temper with her, and then left. CMA R stated CNA M had gone into R1's room, saw the bruise, and came and reported the bruise to her. CMA R said she and CNA M then called LN G and told LN G she needed to come up to assess R1's bruise. CMA R stated LN G came out of R1's room and told CMA R and CNA M to fill out witness statements and that she was going to call Administrative Staff A to report the incident. CMA R stated LN G came back a short time later and told them she had been told by Administrative Staff A that she did not believe that happened and to not report anything on the incident or have staff fill out any witness statements. CMA R stated she was fearful for R1's safety. CMA R stated she was scared she would lose her job at the facility for speaking out. On 04/08/25 at 02:15 PM, CNA M stated on 04/02/25 in the evening, R1's husband had just left, and R1 put on her call light. CNA M went to R1's room and R1 pointed to her left forearm and said, Can you cover this up with something? I don't want to look at it. CNA M stated she asked R1 what had happened, and R1 stated her brother had gotten mad at her and grabbed her arm. CNA M stated she went right out to CMA R and told her about the bruise, and they then called LN G to come and assess R1. LN G assessed R1 and then told CNA M and CMA R to fill out witness statements. LN G then went to call Administrative Staff A and report the incident. LN G came back and told CNA M and CMA R she had been told not to document anything about the incident and not to have staff fill out witness statements. CNA M stated she was worried for R1's safety. CNA M asked if she was going to lose her job at the facility because she really liked it there. On 04/08/25 at 02:30 PM, when Administrative Staff A was asked about R1's bruise, Administrative Staff A signed into R1's chart on her computer and read the progress note about R1's bruise that occurred on 04/02/25. Administrative Staff A denied any reports of abuse related to R1's arm. Administrative Staff A reported R1's husband reported it occurred when he was helping R1 get her arm out of her sweater. When Administrative Staff A was asked if she had received any phone calls from staff with concerns regarding R1 on 04/02/25. Administrative Staff A stated she had received a phone call from LN G, who stated staff had concerns about abuse related to R1 and her husband. Administrative Staff A stated she stopped LN G and told her before she threw out the big A word, was there any reason to suspect abuse. Administrative Staff A told LN G she would have LN H assess R1 the next morning. Administrative Staff A confirmed she did not take the allegation of abuse seriously, did not come to the facility to assess the situation, assess R1, or talk to staff. Administrative Staff A confirmed she did not report the incident as an allegation of abuse, had not protected R1 from any further potential abuse, and denied telling staff not to document the incident. On 04/08/25 at 06:00 PM, LN G stated she had been the nurse on duty the evening of the bruising incident. LN G stated she had been called to the unit by CMA R to assess R1's bruising to her left forearm. LN G stated R1's arm was dark black and swollen, and R1 complained it was really painful. LN G stated R1 asked her to please cover the bruise because she did not want to look at it. LN G stated R1 stated her brother had gotten mad at her and grabbed her arm, causing the bruise. LN G stated she left R1's room, told CMA R and CNA N to fill out witness statements, and went to the office to call Administrative Staff A. LN G stated Administrative Staff A stated she did not believe what LN G was saying was true and LN G should not document the incident or the bruise and she would have LN H assess R1 and the situation in the morning. LN G stated she was agency staff and was worried that if she did not do what Administrative Staff A said, she would not be asked to come back to the facility. The facility's Resident Abuse, Neglect, and Exploitation Policy, revised October 2024, documented it was the policy of this facility to prohibit and prevent abuse, neglect, and exploitation of residents by implementing specific procedures. It was the policy of this facility that each resident would be free from abuse, neglect, exploitation, and misappropriation of property. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents would be protected from abuse, neglect, and harm while residing in the facility. No abuse or harm of any type would be tolerated, and residents and staff would be monitored for protection. Any suspicion of abuse resulting in significant injury would be reported to the State Agency within two hours and local law enforcement, per agreement with the agency. It is the policy of this facility to prohibit and prevent abuse, neglect, and exploitation. It was the policy of this facility to prevent abuse by providing residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without fear of reprisal or retribution. The facility leadership would assess the needs of all residents residing in the facility to be able to identify concerns in order to prevent potential abuse. The facility failed to immediately investigate an allegation of abuse for R1 and initiate protective measures to prevent further potential abuse until an investigation was completed. This deficient practice placed R1 at risk for ongoing abuse and/or mistreatment.

The facility had a census of 78 residents. The sample included 18 residents, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to prevent a facility-acquired deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) for Resident (R) 15, who sustained a DTI to her left buttock (either of the two round fleshy parts that form the lower rear area of a human trunk) when staff placed a bed pan under R15 backward and left it under her for too long. The facility staff further failed to remove a mechanical lift sling (a material device used in conjunction with a hoist, to assist in safely transferring a person) from under R15 and she sustained a reddened area on her right buttocks. This placed the resident at risk for further skin injury and breakdown. Findings included: - The Electronic Medical Record (EMR) for R15 documented diagnoses of dementia with psychotic disorder (a progressive mental disorder characterized by failing memory and confusion), reduced mobility, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and cerebrovascular disease (conditions that affect blood flow to your brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R15 had moderately impaired cognition. R15 was dependent upon staff for toileting, transfers, and lower body dressing; she required partial assistance for mobility and did not ambulate. The assessment documented R15 was frequently incontinent of bowel, always continent of bladder, and did not have any skin issues. R15's Pressure Ulcer Care Area Assessment (CAA), dated 03/06/24 documented R15 had the potential for skin breakdown due to activities of daily living impairment and directed staff to assess her skin weekly, encourage her to change positions frequently and implement interventions as needed to prevent skin breakdown. The Braden Scale Assessment, (a formal assessment for predicting pressure ulcer risk) dated 08/24/24 documented R15 was at risk for skin breakdown. R15's Care Plan, initiated on 08/06/23, directed staff to encourage R15 not to scratch at areas and ask for lotion for dry areas. The update, dated 06/05/24, directed staff to use the call light to ask for assistance, keep skin clean and dry, report any changes in skin integrity, and reposition every two hours within 30 minutes of the two hours. The update, dated 10/04/24, directed staff to use a cushioned bed pan and to remove the old bed pan. The plan directed staff to turn R15 every two hours from the left to the right while in her bed. The plan directed staff to use the bedpan for 10 minutes at a time, then take it out. The update, dated 10/08/24, documented R15 had a raised, blanchable (skin that can be made to turn pale or white by applying pressure) area to her right buttock and directed therapy to do staff education on sling removal. The Nurse's Notes, dated 10/04/24 at 02:52 PM, documented R15 had an area to her left buttocks that measured 8.1 centimeters (cm) by 7.5 cm and had two purple discolorations that were slowly blanchable which measured 2.4 cm by 0.3 cm and measured 4 cm by 0.4 cm. The note further documented the area was consistent with a bedpan. The note documented that staff would remove the old bedpan, use a round bedpan, and ensure R15 was turned and repositioned from left to right every two hours while in bed until the area healed. The Physician Order, dated 10/04/24, directed staff to monitor the red, blanchable area to the left buttock every shift until healed. The Nurse's Note, dated 10/07/24, documented as a late entry on 10/08/24, included R15 had a red/purple area, that was unopened at that time. The area was blanchable, but the darker lines were slower to blanch, and staff repositioned R15 from left to right to ensure she stayed off that area as much as possible. The Nurse's Note, dated 10/08/24 at 12:45 PM documented Certified Nurse Aides (CNAs) assisted R15 back to bed after lunch and discovered a new area to R15's right buttock. The area measured 8.2 cm by 1.6 cm and 3.3 cm by 0.4 cm, The areas were red, blanchable, and tender to the touch. The areas were consistent with a full light sling that R15 sat on while in her wheelchair. The nursing staff requested therapy to perform staff education that week to assist with lift sling removal while in her wheelchair to help with skin integrity. The Physician Order, dated 10/08/24, directed staff to monitor the red, blanchable area to the right buttock for signs and symptoms of infection every shift until healed. The Nurse's Note, dated 10/09/24 at 07:36 AM, documented that the skin injury to the left buttock was improved and measured 6 cm by 6 cm, and was pink in color with light purple fading in the linear-shaped area. The area continued to be blanchable and more characteristic of normal tissue. The Wound Management Record, dated 10/09/24, documented R15 had an area on her left buttock that was identified on 10/04/24 and as of 10/09/24 the area measured 6 cm by 6 cm. The Physician Order, dated 10/09/24, directed staff to apply Skin-prep (liquid skin protectant) to R15's bottom as needed. On 10/08/24 at 10:54 AM, observation revealed CNA P applied barrier cream (a topical product designed to create a protective barrier on the skin's surface) to R15's left buttock which had a round, reddened area with a dark purple line through it. Further observation revealed after R15 was transferred to her wheelchair by the mechanical lift, she stated she did not feel right and was not comfortable. Staff attempted to reposition her by pulling on the sling that was left under her after she had been transferred. R15 continued to state she was not comfortable, and staff left the sling under her despite a question from the survey team about whether the sling might be bunched up under the resident. On 10/09/24 at 08:30 AM, observation revealed R15 sat at the dining table in her wheelchair with the mechanical lift sling still underneath her. Continued observation at 09:00 AM revealed CNA P and CNA N attached the sling to the mechanical lift and transferred R15 into bed. Observation revealed two reddened marks on R15's right buttock which were not opened. CNA N stated she was unaware she was supposed to remove the sling from under R15 after staff transferred R15 into her wheelchair. R15 stated she needed to use the bathroom and CNA N placed a large bedpan underneath the resident. R15 stated the area on her left buttock was sore. The bedpan was under R15 for less than 10 minutes and as CNA N removed the bedpan, there was an indention from the bedpan that ran directly in the center of the DTI on R15's left buttock. During an interview on 10/08/24 at 11:00 AM, CNA P stated R15 was left on the bedpan too long by agency staff so staff had replaced the old bedpan with one that fit her better. CNA P stated they could only leave the resident on the bedpan for 10 minutes. On 10/08/24 at 02:32 PM, Administrative Nurse D stated she was told that R15 was only on the bedpan for about 15 minutes. She considered the area a skin injury, but not a pressure injury from the plastic bedpan. Administrative Nurse D said she did not realize the area on R15's buttocks from the bedpan had not resolved. Administrative Nurse D stated she would assess the area and agreed, that since it was still reddened, it was most likely a DTI. Administrative Nurse D further stated the physician would be notified to see what treatment would be best for the area. On 10/09/24 at 09:20 AM, Licensed Nurse (LN) J stated she was notified of R15's DTI from the bedpan on Friday and said she felt that the agency staff had placed it under R15 backward and the reddened area was from the handle of the bedpan. LN J stated she did not know how long R15 was left on the bedpan and confirmed she had not contacted the agency staff to inform them that R15 had received a skin injury from the bedpan. LN J stated she arranged for staff to receive training regarding bedpan placement and how to remove the sling from under the resident on 10/24/24. LN J said she was waiting for an order for Skin-prep to be used on R15's bottom. On 10/09/24 at 11:57 AM, Administrative Nurse D stated she was notified that R15 had an area on her right buttock from the lift sling that was left under the resident and stated she directed LN J to request that the restorative nurse train her so that she could train the staff on sling removal and bedpan use. The facility's Pressure Ulcer Management policy, dated 03/24, documented all residents were considered to have some risk for the development of pressure ulcers. A licensed nurse would perform a full body skin assessment on the day of admission and after conducting an inspection of the resident's skin, the nurse would review the resident assessment protocol for pressure ulcers to identify risk factors for the development of pressure ulcers. An immediate plan to reduce a resident's risk of pressure ulcers or to treat an existing pressure ulcer would be developed and implemented. The facility's Bed Pan policy, undated, documented the facility ensured the dignity, safety, and comfort of residents who required the use of a bed pan while maintaining resident safety with high hygiene standards. The policy directed staff to stay with or near the resident if needed, ensure the resident call light was within reach for signaling when they were done, and no residents should remain on any bedpan for greater than 10 minutes to avoid skin impairment unless a tissue tolerance test indicated longer use was safe to avoid skin breakdown through pressure. The facility failed to prevent a facility-acquired pressure injury for R15, who obtained a DTI to her left buttock when staff placed an incorrectly sized bed pan backward under R15 and left it under her for too long. The facility staff further failed to remove the mechanical lift sling from under R15 resulting in a reddened area on her right buttocks. This also placed the resident at risk for further skin injury and breakdown.

The facility had a census of 78 residents and one kitchen. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 10/08/24 a 10:15 AM, observation in the kitchen revealed the following concerns: 1. Four upper and six lower wooden cupboards located by the three sinks had numerous different-sized scrapes on the outer surface. 2. Three wooden bottom cupboards and nine cupboard drawers located by the ice machine had numerous different-sized scrapes on the outer surface. 3. Two white fans on the wall had grayish debris on the blades. 4. The right door frame, located by the entrance to three sink areas, approximately four feet high, was missing a piece of trim. 5. A black trash can located to the left of the entrance door to the three sink areas had numerous different-sized streaks of brownish substance around the sides of it and on the lid. 6. Four bottom wooden and five upper cupboards located by the counter silver microwave, next to the bread rack, had numerous different size scrapes in the outer wood. 7. The mop board around the perimeter of the kitchen had numerous different-sized areas with a grayish-black substance on them. The facility's Kitchen Cleaning Sheet, had tasks listed for dietary staff to complete daily, weekly, and as used. On 10/08/24 at 12:30 PM, Certified Dietary Manager BB verified the above findings and stated the dietary aides had a cleaning schedule to follow. She said she was aware of the issues with the kitchen cupboards. The facility's Kitchen Cleaning and Sanitation of Dining and Food Service Areas Policy, revised 05/01/2013, documented that food service staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for the 78 residents who received their meals from the facility's kitchen. This placed the 78 residents at risk for foodborne illness.

The facility had a census of 78 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to identify and dispose of expired medications appropriately. This deficient practice placed residents at risk for ineffective medications. Findings included: - On 10/07/24 at 02:59 PM, observation revealed the Harvest Household medication cart contained the following expired medications: A bottle of calcium supplements with an expiration date of 11/2023. A bottle of senior multivitamins (MVI) with an expiration date of 10/2023. A bottle of MVI with an expiration date of 06/2024. A bottle of magnesium oxide (supplement) with an expiration date of 08/2024. A bottle of D3 (vitamin) with an expiration date of 08/2024. A Metamucil (fiber laxative) canister with an expiration date of 08/2024. A bottle of bisacodyl (laxative) pills with an expiration date of 09/2024. A bottle of Preservision (vision supplement) with an expiration date of 09/2024. On 10/07/24 at 02:59 PM, Certified Medication Aide (CMA) R verified the dates on the expired medications. On 10/08/24 at 03:10 PM, Administrative Nurse D stated staff periodically inspected the medication carts to check the expiration date for medications. Administrative Nurse D stated staff should have removed the expired medications. She stated the nurse coordinators were also responsible for checking for expired medications and the pharmacist consultant checked medication carts monthly. The facility's Disposition of Unusable and Outdated Drugs policy, dated 03/2024, stated all discontinued, outdated, contaminated drugs would be returned to the provider pharmacy for proper disposal or destroyed onsite. Those drugs would be stored in an isolated area designated for the storage of unusable drugs until the drugs could be destroyed or returned. All drug storage areas of the facility would be inspected, including the emergency kit, for outdated drugs on a weekly basis by facility nursing staff and on a monthly basis by the contracted consulting pharmacist. The responsible staff member conducting the inspection would remove all outdated drugs from the area and record the type and amount of drugs removed. The facility failed to identify and dispose of expired medications appropriately, placing residents at risk of receiving ineffective medication.

The facility had a census of 78 residents. The sample included 18 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide Resident (R) 25 and R277 complete information on the Notice of Medicare Non-Coverage (NOMNC) Form-10123 which informed the beneficiary of the right to an expedited review by a Quality Improvement Organization (QIO). This placed the residents at risk of uninformed decisions about their skilled services and the inability to appeal. Findings included: - A review of the CMS Form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included directions for the beneficiary (resident or resident representative) to contact the QIO for questions regarding appeals. R277's NOMNC revealed Medicare Part A skilled services ended on 05/23/24. The facility provided CMS Form-10123 lacked the QIO name and contact information for R277. R25's NOMNC revealed Medicare Part A skilled services ended on 05/09/24. The facility provided CMS Form-10123 lacked the QIO name and contact information for R25. During an interview on 10/08/24 at 11:45 AM, Administrative Staff A verified staff were to insert the QIO name and phone number on each CMS Form-10123 when the resident was discharged from Medicare Part A services. The facility's Medicare Denial Notices policy, dated 09/2022, stated the facility would provide each resident with written notification with the necessary information to decide whether or not to appeal a decision to terminate Medicare care and services at least three days prior to the planned change in payor status or discharge. The Notice of Medicare Non-Coverage (NOMNC-form 10123) would include the instructions for filing an appeal along with the address and phone number of the appointed QIO. The facility failed to provide complete information on the NOMNC which informed the beneficiary of the right to an expedited review by the QIO. This placed the residents at risk of uninformed decisions about their skilled services and the inability to appeal.

The facility had a census of 78 residents. The sample included 18 residents with seven reviewed for accidents. Based on observation, interview, and record review the facility failed to prevent accidents for Resident (R) 5 when staff transported her in a wheelchair without footrests and R5 fell forward onto the floor and hit her head. This placed R5 at risk for injuries and increased pain. The facility also failed to ensure an environment free from accident hazards when staff failed to secure hazardous chemicals placing all confused, independently mobile residents at risk for accidental ingestion. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), macular degeneration (progressive deterioration of the retina), and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. R5 was dependent on staff for toileting and required substantial assistance with dressing, personal hygiene, mobility, and transfers. R5 had no functional impairment, no falls, and was dependent on staff while in the wheelchair. The Annual MDS, dated [DATE], documented R5 had severely impaired decision-making skills and was dependent upon staff for toileting, dressing, personal hygiene, and required substantial assistance with mobility, and transfers. R5 had no functional impairment, had one fall with injury, and was dependent upon staff while in the wheelchair. The Fall Risk Assessment, dated 04/23/24, documented R5 was at risk for falls. R5's Care Plan, dated 08/20/24 and initiated on 11/16/23, directed staff to place a floor mat beside the resident's bed, rearrange the room so one side of the bed was against the wall, and use a winged mattress. An update, dated 08/11/24, directed staff to use wheelchair foot pedals on the resident's wheelchair for all mobility and to consider relocation of the scale to the unit. The Fall Investigation, dated 08/11/24 at 10:30 AM, documented that staff transported R5 in her wheelchair from her household to another household to obtain her weight without foot pedals. As staff started to push her up the incline, R5 planted her feet on the ground, fell forward out of the wheelchair, and hit her head on the floor. R5 sustained a large hematoma (collection of blood trapped in the tissues of the skin or an organ, resulting from trauma) to the left side of her forehead and was sent to the emergency room (ER) by ambulance. The Nurse's Notes, dated 08/11/24 at 04:23 PM, documented R5 returned to the facility and all scans were negative for any fractures. The staff was directed to initiate neurological checks (a physical examination to identify signs of disorders affecting the brain, spinal cord, and nerves) per facility protocol. R5 denied pain or discomfort. The Nurse's Note, dated 08/11/24 at 08:26 PM, documented that R5 had a hematoma to the left side of her forehead that measured six centimeters (cm) by 10 cm in size, red with a scant amount of serosanguineous (semi-thick blood-tinged drainage) drainage. R5's forehead also had a red abrasion which measured four cm by four cm in size and staff attempted to apply a cold pack which R5 did not tolerate. R5 did not complain of pain or discomfort. The Nurse's Note, dated 08/13/24 at 01:51 PM, documented R5 had new bruising to the right eye that measured 2.5 cm by 0.5 cm, bruising to the left hand which measured 1.5 cm by 1.5 cm, and bruising to her right knee which measured six cm by 4.5 cm. The note documented that R5 moaned when getting out of bed with transfers. On 10/08/24 at 12:45 PM, observation revealed R5 in her wheelchair with her feet on her wheelchair pedals as Certified Nurse Aide (CNA) Q pushed R5 to a recliner in the living room area. Further observation revealed CNA Q placed the sit-to-stand lift sling (a material device used in conjunction with a hoist, to assist in safely transferring a person) around R5's waist, cued her to hold onto the handles of the lift as CNA O used the lift controller to raise R5 to a standing position and then transferred her into a recliner. On 10/08/24 at 01:00 PM, CNA O stated she was not working at the time of R5's fall, but had since been instructed to make sure the wheelchair pedals were on when R5 was taken anywhere in her wheelchair. On 10/09/24 at 09:30 AM, Licensed Nurse (LN) I stated that staff assisted R5 to another area of the facility to get her weight and they did not put wheelchair pedals on R5's wheelchair. LN I explained that R5 put her feet down as staff were pushing the wheelchair and the resident fell from the chair. LN I said R5 did have a hematoma but did not have any broken bones. LN I stated that although it was not care planned, wheelchair pedals were to be used for every resident in a wheelchair when being transported anywhere. On 19/09/24 at 11:54 AM, Administrative Nurse D stated staff should have put the pedals on R5's wheelchair. Adminstrative Nurse D stated that after R5's fall, the nurse put black bags on the backs of all the wheelchairs in the facility to ensure the pedals stayed with the wheelchair and staff had them placed on the wheelchairs. The facility's Fall Prevention undated policy documented that each elder at the facility would be provided services and care that ensured the environment remained as free from accident hazards as possible and each elder received adequate supervision and assistive devices to prevent accidents. The policy documented every elder would be assessed for the causal risk factors for falls at the time of admission, upon return from a health care facility, and after every fall in the facility. The interdisciplinary team would develop a plan for services to improve or maintain the elders' standing and sitting balance and other interventions to reduce the elder's risk for falls. The facility failed to ensure R5's environment remained free from accident hazards when they failed to put wheelchair pedals on R5's wheelchair. This placed the resident at risk for increased pain and further falls with injury. 26768 - On 10/08/24 at 03:35 PM, observation revealed the elevator on the main floor had a green button to push that deactivated the door alarm. Two staircases on the main floor (one on the left side of the hall across from the medication cart, and one to the right of the elevator) also had a green button to deactivate the door alarms. The staircases and elevator led to the lower floor of the facility where a maintenance shop was accessible through an unlocked double door. Observation revealed four spray bottles and four one-gallon jugs of hazardous chemicals accessible in the maintenance room. The facility identified two residents who were cognitively impaired, independently mobile, and resided on the main floor of the facility. On 10/08/24 at 03:35 PM, Social Services X verified the maintenance door was unlocked with no staff in that area and hazardous chemicals were accessible in the room. On 10/08/24 at 03:40 PM, Administrative Nurse D agreed the elevator and the exits to the stairways being accessible was a potential accident hazard. She stated the facility did not have any residents attempting to use the elevator or stairs without staff. On 10/09/24 at 08:00 AM, Administrative Staff A stated the stairs were fire exits. The facility's Fall Prevention Protocol policy, undated, stated each elder residing at this facility would be provided services and care to ensure the elder's environment remained as free from accident hazards as possible. The facility failed to ensure hazardous chemicals were not accessible to confused, independently mobile residents.

The facility had a census of 78 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to ensure a communication process between the hospice provider and the facility for one of two residents reviewed for hospice services, Resident (R) 29. This placed the resident at risk of not receiving adequate end-of-life care. Findings included: - R29's Electronic Medical Record (EMR) documented the resident had diagnoses of chronic obstructive pulmonary disease (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure, and cerebrovascular disease (conditions that affect blood flow to your brain). R29's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment. The MDS documented R29 required partial to moderate staff assistance with toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, sitting to lying and lying to sit, sitting to stand and transfers, and supervision with ambulation and eating. The MDS noted that R29 received hospice services. R29's Care Plan, revised 09/04/24, documented the resident required supervision and limited staff assistance with activities of daily living (ADL). The care plan lacked mention of R29's hospice admission and guidance for staff regarding hospice services. The 07/02/23 Physician Order instructed staff to admit R29 to hospice service. On 10/08/24 at 08:15 AM, observation revealed R29 sat in a recliner in his room. He had his eyeglasses on, shoes on, and no signs or symptoms of pain. During an interview on 10/09/24 at 10:05 AM, Administrative Nurse D verified the facility care plan lacked a section regarding hospice services and stated it should have one. The Nursing Facility Hospice Services Agreement, dated October 2024, revealed hospice would provide a comprehensive set of services identified and coordinated by an interdisciplinary team to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and family members, as delineated in a specific plan of care in collaboration with the facility. The facility failed to ensure a communication process between the hospice provider and the facility for R29, to include a plan of care from the hospice and a description of the services provided, noting visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving adequate end-of-life care.

The facility had a census of 81 residents. Based on observation, record review and interview the facility failed to adhere to infection control for transmission based precautions (TBP-an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R)7, who had vancomycin resistant enterococci (antibiotic resistant bacterial infections), which placed the residents who received care from the exposed staff at risk for possible exposure of infection. Findings included: - On 04/24/24 at 04:00 PM observation revealed Certified Nurse Aide (CNA) O and CNA P entering the room of R7 who was on TBP. A sign was posted on the door giving instructions on personal protection equipment (PPE-gown and gloves). The room had a plastic tote with PPE supplies placed outside of the doorway. CNA O and CNA P entered the room wearing a surgical mask and transferred the resident from her wheelchair to the bed per sit to stand lift. The staff then assisted the resident with perineal cares and changed her brief. CNA O and CNA P verified they had not worn full PPE in the isolation room and were not aware they had to. On 04/24/23 at 4:20 PM observation revealed Licensed Nurse (LN) K donned (putting on) PPE gown, gloves and mask before entering R 7's room. CNA O and CNA P were also instructed by LN K they were to wear the PPE before caring for R7. LN K and CNA P entered R7's room and changed R7's left buttock wound dressing. The staff doffed (taking off) the PPE before exiting R7's room and placed in a plastic trash can inside of the resident's room. Staff cleansed their hands with antibacterial gel before exiting the resident's room. On 04/24/23 at 04:20 PM interview with LN K verified R 7's entrance door had a sign posted on the door with instructions for wearing appropriate PPE and a plastic tote with PPE outside the resident's door. LN K verified staff should wear appropriate PPE when providing cares for the resident. On 4/25/23 at 04:40 PM interview with Administrative Nurse D and Administrative Nurse E verified the staff should wear PPE when providing cares for R7 and verified they would immediately go and do some education with the staff in regard to the precautions and wearing PPE for the resident cares. Administrative Nurse E verified the aides would change their clothes before continuing to provide care for the residents for the rest of their shift. The facility's Vancomycin Resistant Enterococci (VRE) policy, undated, documented the facility would facilitate safe care of all residents and staff with unknown or suspected communicable disease. VRE can be transmitted by direct contact with a resident or by indirect contact with environmental surfaces or residents care items in the resident's environment. Resident with known or suspected communicable diseases would be placed in the appropriate type of isolation precautions consistent with Center for Disease Center recommendations and guidelines. Isolation equipment and supplies would be available at all times. All staff are responsible for complying with isolation precautions and for tactfully calling observed variances to policy to the attention of any person(s) not following the policy. VRE Contact Precautions require gloves with contact, gown when entering room, mask, discard soiled PPE in totally controlled and contained in plastic bags. Place instructional sign on the resident's door to direct inquires to nurse. Hands should be washed with antimicrobial soap after gloves removed. The facility failed to adhere to infection control standards and policies for R7 who required TBP for VRE, which placed placed the residents who received care from the exposed staff at risk for possible exposure of infection.

The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to notify Resident, (R) 26's physician and the resident representative of a bruise of unknown origin on R26's inner thigh. This placed the resident at risk for emotional and physical decline. Findings included: - The Electronic Medical Record for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (a feeling of worry, nervousness or unease), and depression with psychotic features (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for toileting, dressing, and was independent with ambulation, transfers, and bed mobility. The MDS further documented R26 had physical behavior toward others four to six days, wandered one to three days, and had a wander guard (a security system to monitor residents who are at risk for elopement) bracelet. The Annual MDS, dated [DATE], documented R26 had severely impaired cognition and required supervision with ambulation, toileting, and independent with bed mobility and transfers. The MDS further documented R26 wandered one to three days, had no behaviors, and had a wander alarm daily. The Care Plan, dated 01/31/23, originated on 12/05/20, documented R26 may try to hit staff and others, may go into other resident rooms, and was not easily redirectable R26 may have altered level of consciousness, inattention, and disorganized thoughts. The care plan directed staff to document at the end of each shift how often and how the resident responded regarding her behaviors. The Nurse's Note, dated 01/16/23 at 08:52 PM, documented a Certified Nurse Aide (CNA) reported R26 had a bruise on her inner thigh but R26 was asleep when the nurse went to assess the resident. The note further documented the nurse was unable to assess the bruise and left a note for the dayshift to assess. The EMR lacked documentation an assessment was completed, or the physician and family were notified. On 04/24/23 at 03:09 PM, observation revealed R26 ambulated down the hall from her room, was pleasant and cooperated with staff. On 04/24/23 at 01:24 PM, Licensed Nurse (LN) G verified the physician and resident representative was not notified. On 04/25/23 at 09:45 AM, CNA M stated, R26 was often combative with staff but if you leave her alone for a while, then go back to assist her, she is more cooperative. CNA M further stated, you must report and bruise or skin tear to the nurse so she can fill out a report. CNA M stated she had never filled out any witness statement after she had reported a bruise. On 04/26/23 at 08:39 AM, Administrative Nurse D stated she expected staff to report the incidents to administration, physician, and family. The facility's Significant Changes in a Resident's Condition/Serious Medical Emergency policy, dated August 2007, documented the facility would notify a resident's attending physician of any significant change in a resident's condition or serous medical emergency that threatened the health, safety or welfare of a resident. If non-immediate change in a resident's condition, the resident's physician shall be notified of the non-immediate change immediately or as soon as practicable (but no later than 24 hours) after the physician shall be called. The facility shall notify the resident's family, legal guardian or responsible party whenever unusual circumstances such as accidents, sudden illness or disease arise. The facility failed to notify R26's physician and resident representative of a bruise of unknown origin, placing the resident at risk for emotional and physical decline.

The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to report to administration a bruise of unknown origin on an inner thigh and failed to report to the state agency bilateral bruising of unknown origin to wrists for one sampled resident, Resident (R) 26. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (a feeling of worry, nervousness or unease), and depression with psychotic features (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for toileting, dressing, and was independent with ambulation, transfers, and bed mobility. The MDS further documented R26 had physical behavior toward others four to six days, wandered one to three days, and had a wander guard (a security system to monitor residents who are at risk for elopement) bracelet. The Annual MDS, dated [DATE], documented R26 had severely impaired cognition and required supervision with ambulation, toileting, and independent with bed mobility and transfers. The MDS further documented R26 wandered one to three days, had no behaviors, and had a wander alarm daily. The Care Plan, dated 01/31/23, originated on 12/05/20, documented R26 may try to hit staff and others, may go into other resident rooms, and was not easily redirectable R26 may have altered level of consciousness, inattention, and disorganized thoughts. The care plan directed staff to document at the end of each shift how often and how the resident responded regarding her behaviors. The Nurse's Note, dated 01/16/23 at 08:52 PM, documented a Certified Nurse Aide (CNA) reported R26 had a bruise on her inner thigh but R26 was asleep when the nurse went to assess the resident. The note further documented the nurse was unable to assess the bruise and left a note for the dayshift to assess. The EMR lacked documentation an assessment was completed, or the physician and family were notified. The Event Report, dated 03/06/23, documented R26 had dark blue/purple bruises the size of a golf ball on the back of both of her wrists, had no swelling or pain, and R26 was regularly combative with staff. The report lacked documentation of how R26 obtained the bruises. The facility was unable to provide a completed investigation related to the bruises of unknown origin for either incident. On 04/24/23 at 03:09 PM, observation revealed R26 ambulated down the hall from her room, was pleasant and cooperated with staff. On 04/24/23 at 01:24 PM, Licensed Nurse (LN) G stated they had not completed any witness statements regarding the bruises on R26's wrists and could not say what exactly happened that caused the bruises. LN G verified there had not been an investigation and had not been reported for the bruise on the resident's inner thigh. On 04/25/23 at 09:36 AM, LN H stated if staff report a bruise or skin tear, a event report was completed and staff interviewed, witness statements, and documentation in the progress notes were also done. On 04/25/23 at 09:45 AM, CNA M stated, R26 was often combative with staff but if you leave her alone for a while, then go back to assist her, she is more cooperative. CNA M further stated, you must report and bruise or skin tear to the nurse so she can fill out a report. CNA M stated she had never filled out any witness statement after she had reported a bruise. On 04/26/23 at 08:39 AM, Administrative Nurse D stated she expected staff to do a thorough investigation for any bruises or injuries and reporting the incidents to administration, physician, and family. The facility ANE policy, dated October 2022, documented all allegations and reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown sours, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy further documented a report investigation and analysis would be completed, the information gathered and given to administration. Incidents in which a resident was injured or had the potential for injury and the cause of the incident was unknown will also be promptly investigated. Report all of the investigations to administration and/or his/her designated representative and to other officials in accordance with State law, including immediate or 24-hour reporting to the State Survey Agency, law enforcement and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report two separate incidents in which cognitively impaired R26 received bruises of unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate two separate areas of bruising for one sampled resident, Resident (R) 26, who had bilateral bruising of unknown origin to her wrists, and bruising of unknown origin to her inner thigh. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record for R26 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (a feeling of worry, nervousness or unease), and depression with psychotic features (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for toileting, dressing, and was independent with ambulation, transfers, and bed mobility. The MDS further documented R26 had physical behavior toward others four to six days, wandered one to three days, and had a wander guard (a security system to monitor residents who are at risk for elopement) bracelet. The Annual MDS, dated [DATE], documented R26 had severely impaired cognition and required supervision with ambulation, toileting, and independent with bed mobility and transfers. The MDS further documented R26 wandered one to three days, had no behaviors, and had a wander alarm daily. The Care Plan, dated 01/31/23, originated on 12/05/20, documented R26 may try to hit staff and others, may go into other resident rooms, and was not easily redirectable R26 may have altered level of consciousness, inattention, and disorganized thoughts. The care plan directed staff to document at the end of each shift how often and how the resident responded regarding her behaviors. The Nurse's Note, dated 01/16/23 at 08:52 PM, documented a Certified Nurse Aide (CNA) reported R26 had a bruise on her inner thigh but R26 was asleep when the nurse went to assess the resident. The note further documented the nurse was unable to assess the bruise and left a note for the dayshift to assess. The EMR lacked documentation an assessment was completed, or the physician and family were notified. The Event Report, dated 03/06/23, documented R26 had dark blue/purple bruises the size of a golf ball on the back of both of her wrists, had no swelling or pain, and R26 was regularly combative with staff. The report lacked documentation of how R26 obtained the bruises. The facility was unable to provide a completed investigation related to the bruises of unknow origin for either incident. On 04/24/23 at 03:09 PM, observation revealed R26 ambulated down the hall from her room, was pleasant and cooperated with staff. On 04/24/23 at 01:24 PM, Licensed Nurse (LN) G stated they had not completed any witness statements regarding the bruises on R26's wrists and could not say what exactly happened that caused the bruises. LN G verified there had not been an investigation for the bruise on the resident's inner thigh. On 04/25/23 at 09:36 AM, LN H stated if staff report a bruise or skin tear, a event report was completed and staff interviewed, witness statements, and documentation in the progress notes were also done. On 04/25/23 at 09:45 AM, CNA M stated, R26 was often combative with staff but if you leave her alone for a while, then go back to assist her, she is more cooperative. CNA M further stated, you must report and bruise or skin tear to the nurse so she can fill out a report. CNA M stated she had never filled out any witness statement after she had reported a bruise. On 04/26/23 at 08:39 AM, Administrative Nurse D stated she expected staff to do a thorough investigation for any bruises or injuries and reporting the incidents to administration, physician, and family. The facility ANE policy, dated October 2022, documented all allegations and reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown sours, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy further documented a report investigation and analysis would be completed, the information gathered and given to administration. Incidents in which a resident was injured or had the potential for injury and the cause of the incident was unknown will also be promptly investigated. The facility failed to investigate two separate incidents in which cognitively impaired R26 received bruises of unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to develop a baseline initial care plan (a care plan that includes the instructions needed to provided effective and person- centered care of the resident that meet professional standards of quality care) for Resident (R)185 who received dialysis services (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). This placed the resident at risk for complications related to uncommunicated care needs. Findings included: - R185's diagnoses included end stage renal disease (decline in kidney function) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R185's Admission Minimum Date Set (MDS), dated [DATE], recorded the resident had a Brief Interview Status (BIMS) score of eight, indicating moderately impaired cognition. The MDS recorded the resident required limited assistance of one staff for bed mobility, transfers, and was independent with dressing, toileting, and personal hygiene. The MDS recorded the resident received dialysis treatment. The Care Area Assessments (CAA) were not completed due to admission 04/20/23. R185's medical record lacked a baseline dialysis care plan. The Physician Order, dated 04/18/23, documented R185 had dialysis on Monday, Wednesday and Friday from 11:00 AM to 03:00 PM. It directed staff to monitor fistula for bruit (blowing or swishing sound heard which reflects the blood flow with a dialysis resident's shunt) and thrill (a fine vibration felt which reflects the blood flow by a dialysis resident's shunt) every shift. The facility lacked had a Dialysis Communication form the dialysis center on 04/19/23 and 04/24/23 and lacked a Dialysis Communication on 04/21/23. On 04/24/23 at 08:00 AM, observation revealed the resident dressed in street clothes and sat on the side of her bed eating breakfast. On 04/20/21 at 4:30 PM, Licensed Nurse (LN)G verified the facility lacked a care plan for dialysis. LN G verified the resident care plan lacked documentation the resident received dialysis services. On 04/24/23 at 02:30 PM, LN J verified the resident received dialysis three times a week and the facility did not send a communication sheet just a sheet for the dialysis facility to return a communication sheet when returned to the facility. The facility's Comprehensive Care Plan policy, dated June 2003, documented the facility would develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. A baseline care plan would be developed within 48 hours of admission, including initial goals, preference and services, as well as discharge goals of the resident. A copy of the care plan would be available upon request. The care plan would be prepared by the interdisciplinary team that includes a registered nurse, and other appropriate staff in disciplines as determined by the resident's needs, including a nurse aide, a representative of food and nutrition services and a Social Worker, and the resident, the resident's family or legal representative should participate in the care plan. Those in attendance are to sign the care plan review verification. The care plan would include any specialized services or specialized rehabilitation services. The facility failed to develop an initial care plan for R185 who received dialysis services, placing the resident at risk for inappropriate care and services.

The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically related social services to attain to maintain the highest practicable physical, mental, and psychosocial well-being of Resident (R) 56 who exhibited depression and had behaviors. This placed R56 at risk for further decline in depression. Findings included: - R56's Electronic Medical Record (EMR) recorded diagnoses of pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), repeated falls and hypertension (elevated blood pressure). The Quarterly Minimum Data Set, dated dated [DATE], documented R56 had intact cognition, exhibited no behaviors, was independent with most activities of daily living (ADL) with exception of bathing which required extensive assistance of one staff. R56 had diagnoses of depression, received scheduled pain medication, insulin (medication used to treat elevated blood sugars), antidepressant (medication to treat depressions), anticoagulant (medication used to prevent clotting of blood), diuretic (medication to promote the formation and excretion of urine), and an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing ] and other mental emotional conditions) on a routine basis. The Care Area Assessment (CAA), dated [DATE], documented R56 had depression and confusion with behaviors that usually occurred in the evenings and mostly having to do with bathing needs, had pain and received an antidepressant and an antipsychotic. The Care Plan dated [DATE], documented R56 may verbalized and/or demonstrate unresolved grief. The care plan directed staff to encourage R56 to verbalize feelings, offer emotional support as accepted/desired, provide one to one visits, assess for presence and source of grief, and establish a trusting relationship. It directed staff to encourage R56 to express grief in one to one visits, recognize and reinforce strengths. It further directed staff to discuss the impact of R56's loss and how it related to her function, observe her grief reaction and encourage identification of productive coping mechanisms. The Physician Order, dated [DATE], directed staff to administer Seroquel (antipsychotic) 25 milligrams (mg) at bedtime for depression. The Physician Order, dated [DATE], directed staff to administer sertraline (antidepressant) 200 mg daily for depression. The Resident Mood Interview (PHQ-9), dated [DATE], documented R56 felt down, depressed or hopeless, two to six days of a seven day look back and R56 was tired or had little energy nearly every day. The Progress Note, dated [DATE] at 12:49 PM, documented R56 complained of pain and feeling weaker. Staff explained importance of getting out of her room and socialize with others to build strength to walk again. R56 initially agreed with staff recommendations, then later stated the reason she had not came out of her room because the area was loud, everyone was sick, staff filled the chairs with people who slept so not one else could join in the area and stated it was rude. R56 became angry and stated she did not want to talk about it . On [DATE] at 08:05 AM, R56 reported she nearly died due to congested heart failure and the physician saved her by removing 50 pounds of fluid. She verified she took insulin, diuretic and an antidepressant. She was cognitively intact and pleasant during interview. R56 stated she liked the facility staff and had stated staff are too busy to listen. R56 discussed at length her life experiences, religious beliefs, losses, and connecting with friends and family. On [DATE] at 01:45 PM Certified Nurse Aide (CNA) N reported R56 once in a while had behaviors and R56 had yelled at her and when that happened CNA told the resident she would leave and come back at a later time when she wanted to talk about the concern. On [DATE] at 08:24 AM, Licensed Nurse (LN) J reported R56 moods fluctuated from day to day. LN J verified R56 had been offered counselling in [DATE], but the resident declined, reporting she had not been depressed. LN J verified counselling had not been offered since. LN J verified R56 had depression and was possibly trying to process grief and losses. On [DATE] at 08:55 AM, Social Service X stated she had visited with R56 recognized R56 had depression. Social Services X said she was assisting the resident as the care plan directed but had not documented the few visits that were made with R56. On [DATE] at 09:26 AM, Administrative Nurse D stated the care plan and interventions should be done to support the resident in behaviors, loss and grief. The undated Social Service policy, documented the facility will provide medically related social services to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Assisting residents in voicing and obtaining resolution to grievance about treatment, living conditions, visitation rights and accommodation of needs. Social service staff will identify and promoting individualized non-pharmacological approaches to care that meet the mental ad psychosocial needs of with each resident, meeting the needs of resident who are grieving losses and coping with stressful events. Social service staff will provide social service or obtain needed services from outside entities including but not limited to the following: difficulty coping change or loss and need for emotional support. The facility failed to identify and provide medically related social services to attain or maintain the highest practicable physical, mental ad psychosocial well-being for R56 who had depression and personal loss.

The facility had a census 81 resident. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a stop date for the use of an as needed antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) for Resident (R) 40 which placed R40 at risk for inappropriate use of antianxiety medication. Findings included: - R40'sElectronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) disorder, traumatic hemorrhage (loss of a large amount of blood in a short period of time) of left cerebrum (largest portion of the brain), and restlessness and agitation. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R40 had severe cognitive impairment, inattention and disorganized thinking continuously present, altered level of consciousness fluctuating behavior, required extensive to total assistance of one staff member with activities of daily living (ADL), and was incontinent or urine and bowel. The MDS further documented R40 received routine antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), hypnotic (sleep inducing), and opioid (used to treat pain) medications. The Care Plan, date 03/15/23, documented R40 had diagnoses which included dementia, depression and pain. R40 had confusion, memory problems, attention span which fluctuated, look for family in hallways, call out wanting to go home, tearful, irritated, agitated, and upset about being at the facility. R40 may make rude comments, be mean to staff and other residents, hallucinated, and had inattention and disorganized thoughts. The care plan directed staff to encourage R40 to share her personal stories and experiences, offer spiritual support, music as desired, offered group activities in the neighborhood. The Physician Order, dated 02/10/23, directed staff to administer lorazepam 0.5 milligram (mg) tablet one to two tablets by mouth ever four hours prn for restlessness and agitation. The order lacked a stop date. The CP monthly medication review for March 2023 lacked evidence the CP identified and reported the lack of a stop date for the as needed lorazepam The Electronic Medication Administration Record (EMAR) documented R40 received prn lorazepam on 02/06/23. The EMAR review revealed R40 lacked administration of prn lorazepam for 03/2023 and 04/2023. On 04/24/23 at 01:50 PM, observation revealed R40 seated in her recliner in her room. On 04/26/23 at 08:18 AM, Licensed Nurse (LN) J stated prn antianxiety medication should have a stop date of 14 days of date ordered. LN J stated R40's had the prn lorazepam reordered for six months and lacked a stop date and was left opened ended. On 04/26/23 at 09:33 AM Administrative Nurse D verified the prn lorazepam should have had a stop date. The facility's Drug Regimen Review, dated 01/2017, documented the consultant pharmacist will preform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when requested by team members of the facility but no longer of prn prescriptions of psychotropic drugs to include anti-psychotic drugs for longer than fourteen days and prn medication to be discontinued for non-use. The facility failed to ensure the CP identified and report to the Director of Nursing, medical director and physician the need for a stop date for lorazepam. This placed R40 at risk for inappropriate use of psychotropic medication.

The facility had a census of 81 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 40's as needed (prn) lorazepam (an antianxiety medication) had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic (altering mood or mind) medication use. Findings included: - R40'sElectronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) disorder, traumatic hemorrhage (loss of a large amount of blood in a short period of time) of left cerebrum (largest portion of the brain), and restlessness and agitation. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R40 had severe cognitive impairment, inattention and disorganized thinking continuously present, altered level of consciousness fluctuating behavior, required extensive to total assistance of one staff member with activities of daily living (ADL), and was incontinent or urine and bowel. The MDS further documented R40 received routine antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), hypnotic (sleep inducing), and opioid (used to treat pain) medications. The Care Plan, date 03/15/23, documented R40 had diagnoses which included dementia, depression and pain. R40 had confusion, memory problems, attention span which fluctuated, look for family in hallways, call out wanting to go home, tearful, irritated, agitated, and upset about being at the facility. R40 may make rude comments, be mean to staff and other residents, hallucinated, and had inattention and disorganized thoughts. The care plan directed staff to encourage R40 to share her personal stories and experiences, offer spiritual support, music as desired, offered group activities in the neighborhood. The Physician Order, dated 02/10/23, directed staff to administer lorazepam 0.5 milligram (mg) tablet one to two tablets by mouth ever four hours prn for restlessness and agitation. The order lacked a stop date. The Electronic Medication Administration Record (EMAR) documented R40 received prn lorazepam on 02/06/23. On 04/24/23 at 01:50 PM, observation revealed R40 seated in her recliner in her room. On 04/26/23 at 08:18 AM, Licensed Nurse (LN) J stated prn antianxiety medication should have a stop date of 14 days of date ordered. LN J stated R40's had the prn lorazepam reordered for six months and lacked a stop date and was left opened ended. On 04/26/23 at 09:33 AM Administrative Nurse D verified the prn lorazepam should have had a stop date. The facility's undated Psychotropic Medication Use policy, document Centers for Medicate and Medicaid Services (CMS) regulation state that each resident's drug regimen must ne free from unnecessary drugs and define what is considered an unnecessary drug. The resident's need for psychotropic medication will be monitored as well as when the resident received optional benefit from the medication and when medication dose can be lowered or discontinued. Both the physician and the nursing staff will evaluate the effectiveness of prn for psychotropic drug to manage behaviors. The facility failed to provide a stop date for the use of prn lorazepam for R40 placing the resident at risk for receiving unnecessary psychotropic medication.

The facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a medications error rate of less than five percent (%). The facility medications error rate was 8.33 % placing the residents at risk for complications related to medications errors. Findings included: - Resident (R) 68's Physician Order, dated 05/09/22, directed staff to administer levothyroxine (medication that treats a condition in which the thyroid gland doesn't produce enough thyroid hormone), 75 microgram (mcg), one tablet, by mouth daily and give on an empty stomach. R68's Physician Order, dated 10/22/22, directed staff to administer Novolog, (a rapid-acting insulin that helps lower mealtime blood sugar spikes) 10 units, subcutaneous, 30 minutes before meals. On 04/24/23 at 08:02 AM, observation revealed Licensed Nurse (LN) I administered levothyroxine 75 mcg and Novolog 10 U medication to R68 after she had already ate her breakfast. On 04/24/23 at 08:15 AM, LN I verified she had not followed the physician orders correctly when she administered R68 her medications. On 04/26/23 at 08:45 AM, Administrative Nurse D stated the nurse should follow physician orders when administering medications. The facility's Medication Administration policy, dated May 2006, documented the facility would provide pharmaceutical services to meet the needs of each resident and the medications would be administered at the right time. The policy further documented, medication errors and drug reactions should be reported to the physician and pharmacist. The facility failed to ensure a medication error rate of less than 5% when facility's error rate was 8.33%. This placed the residents at risk for complications related to medication errors.

The facility had a census of 80 residents. The sample included 19 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise care plans for five of eight sampled residents, Resident (R) 76, R15, R22, R48, and R23 who had several falls with no new interventions. Findings included: - R76's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set, (MDS) dated [DATE], documented the resident had short term memory impairment, wandered daily and was independent with transfers, ambulation, and bed mobility. R76 had steady balance except when turning, had no functional impairment, and had no falls. R76's Quarterly MDS, dated [DATE], documented the resident had moderately impaired decision-making skills and required extensive assistance of one staff for bed mobility, limited assistance of one staff for transfers, and extensive assistance of two staff for ambulation. The MDS further documented inattention, disorganized thinking, unsteady balance, and no upper or lower functional impairment. R76 had two or more non-injury falls since the prior assessment. The Fall Risk Assessments, dated 03/25/21, 04/21/21, and 06/18/21, documented the resident a high risk for falls. The revised Fall Care Plan, dated 09/21/21, originally dated 04/21/21, directed staff to maintain a clutter free pathway, encourage the resident to use the call light for assistance, and always keep all used items within reach. The update, dated 05/04/21, documented the resident may require 1:1 to reduce the risk for falls. The update, dated 06/12/21, directed staff to educate the resident's spouse to call for assistance. The update, dated 07/03/21, directed staff to place dycem (a non-slip mat) in the resident's wheelchair. The Fall Investigation, dated 04/23/21, documented at 01:47 PM the resident fell while walking in her room. The investigation documented staff witnessed the resident ambulating in her room, holding a photo album and falling onto her buttocks. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 04/27/21, documented at 03:15 AM, the resident fell after she stood up from her recliner and lost her balance. The investigation documented the fall was unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated on 05/17/21, documented at 08:15 PM, the staff found the resident on her bathroom floor. The resident's middle finger on her left hand had an open area on it, bruising on her left arm, two abrasions (scraping or rubbing away of a surface by friction) on the left side of her back. and her right eye was beginning to swell. The investigation documented the resident was taken by ambulance to the emergency room (ER). The investigation documented the resident was non compliant with asking for assistance due to her cognition. (The record lacked documentation of interventions to prevent further falls.) The Nurse's Note, dated 05/18/21 at 02:18 AM, documented the resident returned from the ER via facility transportation. The note documented the resident was alert, but drowsy, was noted to have a 2-centimeter (cm) x 1 cm and 2 cm x 2.5 cm abrasions to her upper left back, 0.2 cm scab to her left knee, and left finger wrapped in coban (a self adherent compression bandage). The Fall Investigation, dated 07/07/21, documented at 11:40 PM staff found the resident on the floor in her room. The investigation documented the resident had not been seated well in her recliner, slid out, and did not have any injuries. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 07/10/21, documented at 11:28 PM, the resident fell while ambulating to the bathroom. The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 08/14/21, documented at 10:26 PM, the resident fell after she stood up from her wheelchair and attempted to ambulate. The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/21/21, documented at 08:58 PM, the resident attempted to stand up by herself from the couch, lost her balance and fell . The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/23/21, documented at 12:35 AM, staff found the resident on her fall mat beside the bed after rolling out of bed. The resident was unable to state what happened and did not have any injuries. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/30/21, documented at 03:14 PM, the resident was in her wheelchair and started to lean forward, and fell out of her wheelchair. The investigation documented staff witnessed the resident lean over too far in her wheelchair fell and sustained no injuries. (The record lacked documentation of interventions to prevent further falls.) On 09/30/21 at 07:57 AM, observation revealed Certified Nurse Aide (CNA) D and Licensed Nurse (LN) H placed a gait belt around the resident's waist, stood the resident up from her wheelchair, pivot turned, and sat the resident down onto the bed. CNA D removed the gait belt and lifted the resident's legs on to the bed. The wheelchair had a roho cushion (pressure reducing cushion) and no dycem on the seat. On 09/30/21 at 07:57 AM, CNA D stated the resident was having a lot of falls and now the resident has a fall mat beside her bed. CNA D stated they try to get her up and dressed before her spouse tried to do it for her. On 10/04/21 at 02:11 PM, LN G stated staff try to distract the resident by reading to her or playing music to keep her from falling. LN G further stated the resident fell frequently and was hard to find other interventions to prevent falls. On 10/5/21 at 09:40 AM, Administrative Nurse D stated the unit coordinators developed the care plans and verified the care plan should have new interventions after falls. Administrative Nurse D stated she did not attend care plan meetings, but did attend the weekly risk meetings and the team go over resident falls. The team are expected to bring different interventions for fall prevention to the risk meetings. The facility's Comprehensive Care Plan policy, dated June 2019, documented the interdisciplinary team, resident or representatives would discuss approaches to be used by the various disciplines in dealing with each problem identified, and goals would be determined. The care plan would be reviewed at determined intervals and also be reviewed if the resident goes to the hospital or experiences significant changes in physical or mental conditions. The facility failed to update R76's care plan with interventions to prevent further falls, placing the resident at risk for further injury. - R15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required limited assistance of one staff for transfers, toileting and ambulation. R15 had hallucinations (sensing thing while awake that appear to be real, but the mind created), unsteady balance, no functional impairment, and had two non-injury falls since admission. The Fall Care Area Assessment (CAA), dated 11/05/20, documented the resident as a high risk for falls and had unsteady balance which increased her risk for falls. The CAA further documented the resident required total staff assistance with bed mobility, transfers, toileting, and grooming and fall interventions were placed. R15's Annual MDS, dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of two staff for toileting, dressing, and extensive assistance of one staff for transfers. The MDS documented R15 rejected care, had unsteady balance, no functional impairment, had two or more non-injury and two or more injury falls since the prior assessment. The Fall Risk Assessments, dated 09/25/20, 11/04/20, and 09/20/21, documented the resident a high risk for falls. The revised Fall Care Plan, dated 09/28/21, originally dated 10/08/20, directed staff to maintain a clutter free pathway, encourage the resident to use the call light for assistance, and always keep all used items within reach. The update, dated 05/19/21, documented back up locks added to her wheelchair. The update, dated 06/23/21, documented the resident may seat herself on the floor and staff assist her up before her husband does to prevent her from falling. The update, dated 07/11/21, directed staff to not leave the resident alone in her room. The update, dated 09/08/21, documented use call light as tolerated. The Fall Investigation, dated 12/12/20, documented at 02:45 AM, the staff found the resident at the foot of the recliner on the floor. The investigation documented the resident was in a tipped forward position which indicated the resident attempted to transfer out of the chair. The investigation documented the fall was unwitnessed and no injuries noted. (The record lacked documentation the care plan was updated with interventions to prevent further falls) The Fall Investigation, dated 01/04/21, documented at 03:20 PM, the staff found the resident on the floor seated in front of the manual recliner (uses a lever to move it into position) in the commons living room. The resident stood up from the recliner, fell and no injuries noted. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the recliner). The Fall Investigation, dated 01/27/21, documented at 04:10 AM, the resident was seated on the floor in front of the recliner. The investigation documented the fall as unwitnessed and no injuries noted. The resident stated she needed to go to the bathroom and staff reminded her to call for assistance. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the recliner) The Fall Investigation, dated 01/30/21, documented at 09:15 AM, the resident stood up from her wheelchair and fell . The investigation documented the resident had just finished breakfast and was by the nurse's office when she stood up without assistance and fell . The resident did not sustain any injuries. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the resident's wheelchair). The Fall Investigation, dated 02/10/21, documented at 09:25 AM, the staff found the resident seated on the floor next to her wheelchair. The investigation documented the resident did not lock her wheelchair when she stood up. The fall was unwitnessed, and no injuries noted. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the resident's wheelchair). The Fall Investigation, dated 03/01/21, documented at 08:40 AM, the dining room staff reported the resident lying on the floor in the dining room. The investigation documented the fall was witnessed and the resident's spouse stated she stood up and tripped over her own feet. The resident had a 0.75-centimeter (cm) x 1.25 cm abrasion to the side of her left eye. The investigation documented the resident was non-compliant with asking for assistance and neurological checks (assesses motor and sensory skills, hearing and speech, vision, coordination, and balance) initiated. (The record lacked documentation the care plan was updated with interventions to prevent further falls). The Fall Investigation, dated 03/17/21, documented at 06:45 PM, the resident fell in the hallway. The resident's spouse stated she stood up, turned around and fell backwards. The investigation stated she had a small abrasion to her mid spine. (The record lacked documentation the care plan was updated with interventions to prevent further falls). The Fall Investigation, dated 06/14/21, documented at 01:00 PM, the resident stated she fell while in her bathroom. The resident stated she felt like she had broken her jaw and teeth. The staff assessed the resident and noted the resident's right jawline, collarbone, and right knee were red and contacted the resident's physician to obtain an order to send the resident to the hospital. The investigation documented the hospital stated the resident did not have any broken bones or other injuries and sent the resident back to the facility. (The record lacked documentation the care plan was updated with interventions to prevent further falls). The Fall Investigation, dated 07/15/21, documented at 09:44 AM, the resident had a witnessed fall in the dining room. The resident's glasses were on the floor and her wheelchair was at a dining room table. The investigation documented the resident started to stumble and staff were unable to reach her before she fell . The resident did not sustain any injury. (The record lacked documentation the care plan was updated with interventions to prevent further falls). The Fall Investigation, dated 08/21/21, documented at 10:09 PM, the resident fell in the hallway by the dining room. The investigation documented the resident had an abrasion to her left cheek and family did not want her to go to the hospital. The investigation stated the resident stood up from her wheelchair, started walking on her own, fell and neurological checks initiated. (The record lacked documentation the care plan was updated with interventions to prevent further falls). The Fall Investigation, dated 09/08/21, documented at 09:20 PM, the resident's spouse reported the resident fell in their room. The investigation documented the resident did not sustain any injuries and had been in the resident room with her husband when she stood up and fell when attempting to ambulate. The investigation documented the resident did not sustain any injuries. (The record lacked documentation the care plan was updated with interventions to prevent further falls). The Fall Investigation, dated 09/10/21, documented at 12:35 PM, the staff heard a door slam and noted the resident's door to her room was shut. The staff tried to open the door and saw the resident on her hands and knees behind the door. The resident's spouse attempted to lift the resident off the floor as staff asked him to wait so the resident could be assessed, but he lifted her up and placed her into her wheelchair. The investigation stated the resident was changing her clothes by the closet and fell . (The record lacked documentation the care plan was updated with interventions to prevent further falls). The Fall Investigation, dated 09/20/21, documented at 03:35 PM, the resident fell while she ambulated behind her wheelchair. The investigation documented the fall was witnessed by staff and resident often tried to ambulate unassisted although staff remind her to wait for assistance. (The record lacked documentation the care plan was updated with interventions to prevent further falls). On 10/04/21 at 01:30 PM, observation revealed the resident sat in a recliner. She attempted to stand multiple times but would sit back down. Further observation revealed staff placed the resident's wheelchair beside the recliner. On 10/05/21 at 08:20 AM, observation revealed the resident standing up at a table by the nurse's charting room. At this time, this surveyor alerted Licensed Nurse (LN) H the resident was standing up and getting ready to ambulate unassisted. Further observation revealed LN H attempted to coax the resident to sit down in a chair, but the resident refused, and staff took her to her room to get her dressed for the day. On 10/04/21 at 01:53 PM, Certified Nurse Aide (CNA) N stated the resident did have a lot of falls and staff got the resident involved in activities, 1:1 visit, and family visit the resident. CNA N stated staff were able to offer interventions to prevent falls to the unit coordinator and to the Director of Nursing (DON) if they had ideas. On 10/04/21 at 02:11 PM, LN G stated the resident had numerous falls due to her dementia and they have been unable to come up with interventions to prevent her falls. The staff attempted activities with the resident but have been unsuccessful. LN G stated when the resident had a fall, and incident report, witness statements and root cause analysis was completed. On 10/5/21 at 09:40 AM, Administrative Nurse D stated the unit coordinators developed the care plans and verified the care plan should have new interventions after falls. Administrative Nurse D stated she did not attend care plan meetings but did attend the weekly risk meetings and the team go over resident falls. She expected the team to bring different interventions for fall prevention to the risk meetings. The facility's Comprehensive Care Plan policy, dated June 2019, documented the interdisciplinary team, resident or representatives would discuss approaches to be used by the various disciplines in dealing with each problem identified, and goals would be determined. The care plan would be reviewed at determined intervals and be reviewed if the resident goes to the hospital or experiences significant changes in physical or mental conditions. The facility failed to update R15's care plan with interventions to prevent further falls, placing the resident at risk for further injury. - R22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident was independent with all activities of daily living. The assessment further revealed the resident had two or more falls without injury during the lookback period. The Significant Change MDS, dated [DATE], documented the resident had a BIMS score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident required limited to extensive assistance of one to two staff for bed mobility, transfer, walking in corridor, dressing, toilet use, personal hygiene, and bathing. The assessment further revealed the resident was unsteady and had one fall without injury, one fall with minor injury, and one fall with major injury during the lookback period. The Fall Care Area Assessment (CAA), dated 07/18/21, documented the resident required limited to total assist with bed mobility, transfers, ambulation, locomotion, dressing, toileting, grooming, and bathing. The resident used a walker and assistance of one to two staff taking a few steps. The assessment further documented the resident did not use her call light in spite of having frequent educations by staff and took down cue posters in her room encouraging her to use her call light. The Fall/Injury Assessment, dated 07/15/21 documented the resident had poor safety awareness and was a high risk for falls. The Fall Care Plan, dated 07/27/21, directed staff to maintain a clutter free pathway and safe environment, encourage her to use the call light for assistance, always keep all frequently used items within reach, remind resident to reach back before sitting, and use a soft call light. The Nurse's Note, dated 12/06/20 at 01:50 PM, documented staff heard someone yelling help and went to the resident's room and found resident lying on floor next to walker. The resident stated she took her shoes off and then attempted to ambulate to the bathroom with a walker. The resident had compression socks on that caused her to slip. The resident stated she landed on her left hip and back and was in excruciating pain. She denied hitting her head. She was assisted off of the floor with the assistance of three staff members and gait belt, and then placed in bed. The care plan was not updated with any interventions after this fall The Nurse's Note, dated 12/24/20 at 06:40 PM, documented staff heard the resident knocking and went into her room and found the resident seated on the floor behind her bedroom door. The lights were found to be off in the room. Active range of motion checked, and the resident was without pain. Staff assisted the resident back to bed and gripper socks changed. The night light was left on in the room. The care plan was not updated with any interventions after this fall. The Nurse's Note, dated 03/12/21 at 10:46 AM, documented the resident was found on the floor in her room with non-skid socks on and walker nearby in the entry of the bathroom. The resident stated, I fall again and again. No broken bones. The resident stated she did not hit her head and neurological checks were intact, range of motion in all extremities, and no deformities noted. The fall investigation intervention: provide frequent visual checks as resident likes her door closed. This intervention was not noted on the resident's care plan. The Nurse's Note, dated 04/30/21 at 07:44 AM, documented staff heard a commotion, went to the resident's room, and found the resident on the floor. The resident stated she was going to the bathroom to brush her hair and when she pulled the bathroom door open she fell backwards. No visible injuries at the time of the fall. The resident was using her walker and fell out of her shoes. Vital signs were stable. Fall investigation intervention included: Possibly move closer to the nurses' station. The note indicated this was a non-injury fall . The Nurse's Note, dated 05/26/21 at 03:50 PM, documented the resident was found on the floor. The resident stated she fell over backwards coming out of the bathroom. The resident stated she didn't know if she had hit her head. No bruising noted, and the resident had range of motion in all extremities The Nurse's Note, dated 06/10/21 at 04:55 PM, documented staff heard yelling from the resident's room. Resident was found seated on the floor in front of her recliner. The resident stated she missed her chair. No red areas or bruises noted. Staff assisted the resident to the recliner with two staff assistance. Care plan interventions directed staff to remind her to reach for her chair. The note indicated this was a non-injury fall . The Nurse's Note, dated 06/28/21 at 05:10 PM, documented staff found the resident seated in the middle of the floor. The resident stated she thought there was a chair behind her and tried to sit down. The resident complained of pain in her lower back and bilateral knees. The resident was adamant to go to the emergency room to make sure nothing was broken. Staff transferred the resident to a local emergency room The resident did not have any broken bones, but was found to have a urinary tract infection ([CONDITION(S)]) and started an antibiotic. Fall investigation intervention included the resident had a [CONDITION(S)] and received antibiotic therapy . The Nurse's Note, dated 07/03/21 at 04:45 PM, documented staff witnessed the resident attempting to sit down in the lobby and when she went to sit down in chair, she did not turn all the way around, and missed the chair. The resident screamed, Oh I fell ! My hip! The resident was unable to straighten her leg. Staff transferred the resident to a local hospital. She had a left hip fracture and could not have surgery. Fall investigation intervention directed staff to intervene when the resident was up and moving for safety . The Nurse's Note, dated 09/06/21 at 08:15 PM, documented the resident was found on the floor seated on her buttocks with bare feet and her walker turned over near the door. The resident was bleeding from her left eyebrow. The resident stated she had tripped over the fall mat and fell on her face . The resident had a laceration that measured 1.2 centimeters (cm). Staff cleansed the laceration and applied closure strips. Left leg appeared to be shortened and rotated outwards and the thumb on the resident's right hand was swollen and bruised. Staff attempted range of motion to the lower extremities and the resident winced and appeared in pain, so staff stopped range of motion immediately. The resident transferred to the local emergency room . The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/30/21 at 12:35 PM, observation revealed R22 sat in her room, in her wheelchair and tried to remove her jacket. R22 asked for assistance. Licensed Nurse (LN) J assisted R22 in locking her wheelchair breaks and assisted her to a standing position without a gait belt. The resident stated, I'm afraid I'm going to fall. LN J reassured R22 that she would not let R22 fall . On 10/04/21 at 10:30 AM, observation revealed R22 sat in a recliner out in the living room area where she attempted to get out of the recliner. An unidentified staff member intervened and assisted the resident to her room. On 09/30/21 at 12:45 PM, LN J stated the resident had multiple falls. One of the falls she had a hip fracture that was not surgically repaired. She had a decline in her activities of daily living after that fall. Prior to that fall she was independent with all of her activities of daily living, but now she needed one to two staff assistance. She received therapies, but cognitively she was not able to participate very well and plateaued. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings, but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated. When they have the risk type meetings staff should come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents falls. The facility's Accident Prevention Program policy, revised July 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident was a high risk for potential falls by the fall risk assessment, it will be documented in the care plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility's Comprehensive Care Plan policy, dated June 2019, documented the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed at determined intervals. The care plan will also be reviewed if the resident is hospitalized or experiences a significant change in physical or mental condition. The facility failed to update R22's care plan with interventions to prevent further falls, placing the resident at risk for further injury. - R48's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and the resident required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had one non-injury fall and one minor injury fall during the lookback period. The Fall Care Area Assessment (CAA), dated 05/19/21, documented the resident had problems at times understanding, had disorganized thoughts, and hallucinations. Her cognition was noted as being intact but fluctuated often. The resident was documented as being independent to extensive assistance with activities of daily living and used a walker for her unsteady gait which at times she would forget to use but would use the furniture in the room to make it from place to place in her room. The resident was documented as being at risk for falls related to her unsteady gait and use of antidepressant medications. Interventions were in place with the residents' independence being her priority. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident hallucinated and required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had two or more non-injury falls and two or more minor injury falls during the lookback period. The Fall Care Plan, dated 08/20/21, directed staff to encourage resident to call for staff when she feels unsteady, encourage use of non-skid socks or shoes when up in room, have bed at height were she can reach the floor, place gripper strips to the floor in front of bed, motion sensor on the wall, and floor mat next to the bed while resident is in the bed. The Fall/Injury Assessment, dated 07/13/21 documented the resident had poor safety awareness and was a high risk for falls. The Nurse's Note, dated 01/07/21 at 08:50 PM, documented R48 was found lying on the floor between the bed and wheelchair. When asked what happened the resident stated she needed to use the bathroom. Noted abrasion to left knee and skin tear to left elbow and she complained of pain when abrasion was touched. The resident was assisted by two staff to sit up then stand and transferred to her wheelchair. The resident tolerated activity well with no increased pain. A dressing was applied to her left elbow. The new intervention for this fall was to review the care plan. The Nurse's Note dated 04/30/21 at 12:45 AM, documented the resident was found lying on the floor with her head close to the bathroom door, laying on her left side, facing the window. Blood was noted to the floor and to the back of the resident's head. R48 was able to respond to the staff and was able to answer questions appropriately. Resident was helped to sit down after assessing her safety. Bleeding was noted to the back of the resident's head and a hematoma but unable to tell the size of the open area due to very tangled hair. EMS was notified and came to transport the resident to the local area hospital. The new intervention for this fall was to revie [TRUNCATED]

The facility had a census of 80 residents. The sample included 19 residents, with eight reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents, Resident (R) 76, R15, R22, R48, and R23. This placed the residents at increased risk for injuries related to accidents and/or hazards. Findings included: - R76's Physician Order Sheet (POS), dated 07/29/21, documented diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory, confusion), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Admission Minimum Data Set, (MDS) dated [DATE], documented the resident had short term memory impairment, wandered daily and was independent with transfers, ambulation, and bed mobility. R76 had steady balance except when turning, had no functional impairment, and had no falls. R76's Quarterly MDS, dated [DATE], documented the resident had moderately impaired decision-making skills and required extensive assistance of one staff for bed mobility, limited assistance of one staff for transfers, and extensive assistance of two staff for ambulation. The MDS further documented inattention, disorganized thinking, unsteady balance, and no upper or lower functional impairment. R76 had two or more non-injury falls since the prior assessment. The Fall Risk Assessments, dated 03/25/21, 04/21/21, and 06/18/21, documented the resident a high risk for falls. The revised Fall Care Plan, dated 09/21/21, originally dated 04/21/21, directed staff to maintain a clutter free pathway, encourage the resident to use the call light for assistance, and always keep all used items within reach. The update, dated 05/04/21, documented the resident may require 1:1 to reduce the risk for falls. The update, dated 06/12/21, directed staff to educate the resident's spouse to call for assistance. The update, dated 07/03/21, directed staff to place dycem (a non-slip mat) in the resident's wheelchair. The Fall Investigation, dated 04/23/21, documented at 01:47 PM the resident fell while walking in her room. The investigation documented staff witnessed the resident ambulating in her room, holding a photo album and falling onto her buttocks. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 04/27/21, documented at 03:15 AM, the resident fell after she stood up from her recliner and lost her balance. The investigation documented the fall was unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated on 05/17/21, documented at 08:15 PM, the staff found the resident on her bathroom floor. The resident's middle finger on her left hand had an open area on it, bruising on her left arm, two abrasions (scraping or rubbing away of a surface by friction) on the left side of her back. and her right eye was beginning to swell. The investigation documented the resident was taken by ambulance to the emergency room (ER). The investigation documented the resident was non compliant with asking for assistance due to her cognition. (The record lacked documentation of interventions to prevent further falls.) The Nurse's Note, dated 05/18/21 at 02:18 AM, documented the resident returned from the ER via facility transportation. The note documented the resident was alert, but drowsy, was noted to have a 2-centimeter (cm) x 1 cm and 2 cm x 2.5 cm abrasions to her upper left back, 0.2 cm scab to her left knee, and left finger wrapped in coban (a self adherent compression bandage). The Fall Investigation, dated 07/07/21, documented at 11:40 PM staff found the resident on the floor in her room. The investigation documented the resident had not been seated well in her recliner, slid out, and did not have any injuries. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 07/10/21, documented at 11:28 PM, the resident fell while ambulating to the bathroom. The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 08/14/21, documented at 10:26 PM, the resident fell after she stood up from her wheelchair and attempted to ambulate. The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/21/21, documented at 08:58 PM, the resident attempted to stand up by herself from the couch, lost her balance and fell . The investigation documented the fall unwitnessed and no injuries noted. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/23/21, documented at 12:35 AM, staff found the resident on her fall mat beside the bed after rolling out of bed. The resident was unable to state what happened and did not have any injuries. (The record lacked documentation of interventions to prevent further falls.) The Fall Investigation, dated 09/30/21, documented at 03:14 PM, the resident was in her wheelchair and started to lean forward, and fell out of her wheelchair. The investigation documented staff witnessed the resident lean over too far in her wheelchair fell and sustained no injuries. (The record lacked documentation of interventions to prevent further falls.) On 09/30/21 at 07:57 AM, observation revealed Certified Nurse Aide (CNA) D and Licensed Nurse (LN) H placed a gait belt around the resident's waist, stood the resident up from her wheelchair, pivot turned, and sat the resident down onto the bed. CNA D removed the gait belt and lifted the resident's legs on to the bed. The wheelchair had a roho cushion (pressure reducing cushion) and no dycem on the seat. On 09/30/21 at 07:57 AM, CNA D stated the resident was having a lot of falls and now the resident has a fall mat beside her bed. CNA D stated they try to get her up and dressed before her spouse tried to do it for her. On 10/04/21 at 02:11 PM, LN G stated staff try to distract the resident by reading to her or playing music to keep her from falling. LN G further stated the resident fell frequently and was hard to find other interventions to prevent falls. On 10/5/21 at 09:40 AM, Administrative Nurse D stated the unit coordinators developed the care plans and verified the care plan should have new interventions after falls. Administrative Nurse D stated she did not attend care plan meetings, but did attend the weekly risk meetings and the team go over resident falls. The team are expected to bring different interventions for fall prevention to the risk meetings. The Facility's Accident Prevention Program policy, dated July 2015, documented the facility would provide and maintain a safe, secure and protected environment for its residents and would prevent resident falls whenever possible. The policy further documented, each resident would receive adequate supervision and assistive devices to prevent accidents. The management would review all completed forms for causal factors and recommend appropriate action to be taken and falls would be reviewed weekly. The policy documented, if a resident was a high risk for falls by the fall assessment, it would be documented in the care plan and goals developed to reduce/prevent falls, these goals would be reviewed at least every 90 days and as necessary to determine progress. The facility failed to provide adequate supervision and develop and implement interventions to prevent or reduce falls for cognitively impaired R76, who had multiple falls. This deficient practice placed the resident at risk for further falls. - R15's Physician Order Sheet, dated 07/30/21, documented diagnoses of dementia with lewy bodies (progressive mental disorder characterized by failing memory, confusion), chronic pain (an unpleasant sense of discomfort), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and [CONDITION(S)] disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required limited assistance of one staff for transfers, toileting and ambulation. R15 had hallucinations (sensing thing while awake that appear to be real, but the mind created), unsteady balance, no functional impairment, and had two non-injury falls since admission. The Fall Care Area Assessment (CAA), dated 11/05/20, documented the resident as a high risk for falls and had unsteady balance which increased her risk for falls. The CAA further documented the resident required total staff assistance with bed mobility, transfers, toileting, and grooming and fall interventions were placed. R15's Annual MDS, dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of two staff for toileting, dressing, and extensive assistance of one staff for transfers. The MDS documented R15 rejected care, had unsteady balance, no functional impairment, had two or more non-injury and two or more injury falls since the prior assessment. The Fall Risk Assessments, dated 09/25/20, 11/04/20, and 09/20/21, documented the resident a high risk for falls. The revised Fall Care Plan, dated 09/28/21, originally dated 10/08/20, directed staff to maintain a clutter free pathway, encourage the resident to use the call light for assistance, and always keep all used items within reach. The update, dated 05/19/21, documented back up locks added to her wheelchair. The update, dated 06/23/21, documented the resident may seat herself on the floor and staff assist her up before her husband does to prevent her from falling. The update, dated 07/11/21, directed staff to not leave the resident alone in her room. The update, dated 09/08/21, documented use call light as tolerated. The Fall Investigation, dated 12/12/20, documented at 02:45 AM, the staff found the resident at the foot of the recliner on the floor. The investigation documented the resident was in a tipped forward position which indicated the resident attempted to transfer out of the chair. The investigation documented the fall was unwitnessed and no injuries noted. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 01/04/21, documented at 03:20 PM, the staff found the resident on the floor seated in front of the manual recliner (uses a lever to move it into position) in the commons living room. The resident stood up from the recliner, fell and no injuries noted. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the recliner.) The Fall Investigation, dated 01/27/21, documented at 04:10 AM, the resident was seated on the floor in front of the recliner. The investigation documented the fall as unwitnessed and no injuries noted. The resident stated she needed to go to the bathroom and staff reminded her to call for assistance. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the recliner.) The Fall Investigation, dated 01/30/21, documented at 09:15 AM, the resident stood up from her wheelchair and fell . The investigation documented the resident had just finished breakfast and was by the nurse's office when she stood up without assistance and fell . The resident did not sustain any injuries. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the resident's wheelchair.) The Fall Investigation, dated 02/10/21, documented at 09:25 AM, the staff found the resident seated on the floor next to her wheelchair. The investigation documented the resident did not lock her wheelchair when she stood up. The fall was unwitnessed, and no injuries noted. (The record lacked documentation the care plan was updated with interventions to prevent further falls from the resident's wheelchair.) The Fall Investigation, dated 03/01/21, documented at 08:40 AM, the dining room staff reported the resident lying on the floor in the dining room. The investigation documented the fall was witnessed and the resident's spouse stated she stood up and tripped over her own feet. The resident had a 0.75-centimeter (cm) x 1.25 cm abrasion to the side of her left eye. The investigation documented the resident was non-compliant with asking for assistance and neurological checks (assesses motor and sensory skills, hearing and speech, vision, coordination, and balance) initiated. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 03/17/21, documented at 06:45 PM, the resident fell in the hallway. The resident's spouse stated she stood up, turned around and fell backwards. The investigation stated she had a small abrasion to her mid spine. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 06/14/21, documented at 01:00 PM, the resident stated she fell while in her bathroom. The resident stated she felt like she had broken her jaw and teeth. The staff assessed the resident and noted the resident's right jawline, collarbone, and right knee were red and contacted the resident's physician to obtain an order to send the resident to the hospital. The investigation documented the hospital stated the resident did not have any broken bones or other injuries and sent the resident back to the facility. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 07/15/21, documented at 09:44 AM, the resident had a witnessed fall in the dining room. The resident's glasses were on the floor and her wheelchair was at a dining room table. The investigation documented the resident started to stumble and staff were unable to reach her before she fell . The resident did not sustain any injury. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 08/21/21, documented at 10:09 PM, the resident fell in the hallway by the dining room. The investigation documented the resident had an abrasion to her left cheek and family did not want her to go to the hospital. The investigation stated the resident stood up from her wheelchair, started walking on her own, fell and neurological checks initiated. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 09/08/21, documented at 09:20 PM, the resident's spouse reported the resident fell in their room. The investigation documented the resident did not sustain any injuries and had been in the resident room with her husband when she stood up and fell when attempting to ambulate. The investigation documented the resident did not sustain any injuries. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 09/10/21, documented at 12:35 PM, the staff heard a door slam and noted the resident's door to her room was shut. The staff tried to open the door and saw the resident on her hands and knees behind the door. The resident's spouse attempted to lift the resident off the floor as staff asked him to wait so the resident could be assessed, but he lifted her up and placed her into her wheelchair. The investigation stated the resident was changing her clothes by the closet and fell . (The record lacked documentation the care plan was updated with interventions to prevent further falls.) The Fall Investigation, dated 09/20/21, documented at 03:35 PM, the resident fell while she ambulated behind her wheelchair. The investigation documented the fall was witnessed by staff and resident often tried to ambulate unassisted although staff reminded her to wait for assistance. (The record lacked documentation the care plan was updated with interventions to prevent further falls.) On 10/04/21 at 01:30 PM, observation revealed the resident sat in a recliner. She attempted to stand multiple times but would sit back down. Further observation revealed staff placed the resident's wheelchair beside the recliner. On 10/05/21 at 08:20 AM, observation revealed the resident standing up at a table by the nurse's charting room. At this time, this surveyor alerted Licensed Nurse (LN) H the resident was standing up and getting ready to ambulate unassisted. Further observation revealed LN H attempted to coax the resident to sit down in a chair, but the resident refused, and staff took her to her room to get her dressed for the day. On 10/04/21 at 01:53 PM, Certified Nurse Aide (CNA) N stated the resident did have a lot of falls and staff got the resident involved in activities, 1:1 visit, and family visit the resident. CNA N stated staff were able to offer interventions to prevent falls to the unit coordinator and to the Director of Nursing (DON) if they had ideas. On 10/04/21 at 02:11 PM, LN G stated the resident had numerous falls due to her dementia and they have been unable to come up with interventions to prevent her falls. The staff attempted activities with the resident but have been unsuccessful. LN G stated when the resident had a fall, an incident report, witness statements and root cause analysis were completed. On 10/5/21 at 09:40 AM, Administrative Nurse D stated the unit coordinators developed the care plans and verified the care plan should have new interventions after falls. Administrative Nurse D stated she did not attend care plan meetings but did attend the weekly risk meetings and the team go over resident falls. She expected the team to bring different interventions for fall prevention to the risk meetings. The Facility's Accident Prevention Program policy, dated July 2015, documented the facility would provide and maintain a safe, secure and protected environment for its residents and would prevent resident falls whenever possible. The policy further documented, each resident would receive adequate supervision and assistive devices to prevent accidents. The management would review all completed forms for causal factors and recommend appropriate action to be taken and falls would be reviewed weekly. The policy documented, if a resident was a high risk for falls by the fall assessment, it would be documented in the care plan and goals developed to reduce/prevent falls, these goals would be reviewed at least every 90 days and as necessary to determine progress. The facility failed to provide adequate supervision and develop and implement interventions to prevent or reduce falls for cognitively impaired R15, who had multiple falls. This deficient practice placed the resident at risk for further falls. - R22's Physician Order Sheet (POS) dated 07/23/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), weakness, unsteadiness on feet, and repeated falls. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident was independent with all activities of daily living. The assessment further revealed the resident had two or more falls without injury during the lookback period. The Significant Change MDS, dated [DATE], documented the resident had a BIMS score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident required limited to extensive assistance of one to two staff for bed mobility, transfer, walking in corridor, dressing, toilet use, personal hygiene, and bathing. The assessment further revealed the resident was unsteady and had one fall without injury, one fall with minor injury, and one fall with major injury during the lookback period. The Fall Care Area Assessment (CAA), dated 07/18/21, documented the resident required limited to total assist with bed mobility, transfers, ambulation, locomotion, dressing, toileting, grooming, and bathing. The resident used a walker and assistance of one to two staff taking a few steps. The assessment further documented the resident did not use her call light in spite of having frequent educations by staff and took down cue posters in her room encouraging her to use her call light. The Fall/Injury Assessment, dated 07/15/21 documented the resident had poor safety awareness and was a high risk for falls. The Fall Care Plan, dated 07/27/21, directed staff to maintain a clutter free pathway and safe environment, encourage her to use the call light for assistance, always keep all frequently used items within reach, remind resident to reach back before sitting, and use a soft call light. The Nurse's Note, dated 12/06/20 at 01:50 PM, documented staff heard someone yelling help and went to the resident's room and found resident lying on floor next to walker. The resident stated she took her shoes off and then attempted to ambulate to the bathroom with a walker. The resident had compression socks on that caused her to slip. The resident stated she landed on her left hip and back and was in excruciating pain. She denied hitting her head. She was assisted off of the floor with the assistance of three staff members and gait belt, and then placed in bed. The care plan was not updated with any interventions after this fall The Nurse's Note, dated 12/24/20 at 06:40 PM, documented staff heard the resident knocking and went into her room and found the resident seated on the floor behind her bedroom door. The lights were found to be off in the room. Active range of motion checked, and the resident was without pain. Staff assisted the resident back to bed and gripper socks changed. The night light was left on in the room. The care plan was not updated with any interventions after this fall. The Nurse's Note, dated 03/12/21 at 10:46 AM, documented the resident was found on the floor in her room with non-skid socks on and walker nearby in the entry of the bathroom. The resident stated, I fall again and again. No broken bones. The resident stated she did not hit her head and neurological checks were intact, range of motion in all extremities, and no deformities noted. The fall investigation intervention: provide frequent visual checks as resident likes her door closed. This intervention was not noted on the resident's care plan. The Nurse's Note, dated 04/30/21 at 07:44 AM, documented staff heard a commotion, went to the resident's room, and found the resident on the floor. The resident stated she was going to the bathroom to brush her hair and when she pulled the bathroom door open she fell backwards. No visible injuries at the time of the fall. The resident was using her walker and fell out of her shoes. Vital signs were stable. The fall investigation intervention included: Possibly move closer to the nurses' station. The note indicated this was a non-injury fall. The Nurse's Note, dated 05/26/21 at 03:50 PM, documented the resident was found on the floor. The resident stated she fell over backwards coming out of the bathroom. The resident stated she didn't know if she had hit her head. No bruising noted, and the resident had range of motion in all extremities The Nurse's Note, dated 06/10/21 at 04:55 PM, documented staff heard yelling from the resident's room. Resident was found seated on the floor in front of her recliner. The resident stated she missed her chair. No red areas or bruises noted. Staff assisted the resident to the recliner with two staff assistance. Care plan interventions directed staff to remind her to reach for her chair. The note indicated this was a non-injury fall. The Nurse's Note, dated 06/28/21 at 05:10 PM, documented staff found the resident seated in the middle of the floor. The resident stated she thought there was a chair behind her and tried to sit down. The resident complained of pain in her lower back and bilateral knees. The resident was adamant to go to the emergency room to make sure nothing was broken. Staff transferred the resident to a local emergency room The resident did not have any broken bones, but was found to have a urinary tract infection ([CONDITION(S)]) and started an antibiotic. Fall investigation intervention included the resident had a [CONDITION(S)] and received antibiotic therapy. The Nurse's Note, dated 07/03/21 at 04:45 PM, documented staff witnessed the resident attempting to sit down in the lobby and when she went to sit down in chair, she did not turn all the way around, and missed the chair. The resident screamed, Oh I fell ! My hip! The resident was unable to straighten her leg. Staff transferred the resident to a local hospital. She had a left hip fracture and could not have surgery. Fall investigation intervention directed staff to intervene when the resident was up and moving for safety. The Nurse's Note, dated 09/06/21 at 08:15 PM, documented the resident was found on the floor seated on her buttocks with bare feet and her walker turned over near the door. The resident was bleeding from her left eyebrow. The resident stated she had tripped over the fall mat and fell on her face . The resident had a laceration that measured 1.2 centimeters (cm). Staff cleansed the laceration and applied closure strips. Left leg appeared to be shortened and rotated outwards and the thumb on the resident's right hand was swollen and bruised. Staff attempted range of motion to the lower extremities and the resident winced and appeared in pain, so staff stopped range of motion immediately. The resident transferred to the local emergency room . The resident sustained a broken right thumb. On 09/30/21 at 12:35 PM, observation revealed R22 sat in her room, in her wheelchair and tried to remove her jacket. R22 asked for assistance. Licensed Nurse (LN) J assisted R22 in locking her wheelchair breaks and assisted her to a standing position without a gait belt. The resident stated, I'm afraid I'm going to fall. LN J reassured R22 that she would not let R22 fall. On 10/04/21 at 10:30 AM, observation revealed R22 sat in a recliner out in the living room area where she attempted to get out of the recliner. An unidentified staff member intervened and assisted the resident to her room. On 09/30/21 at 12:45 PM, LN J stated the resident had multiple falls. One of the falls she had a hip fracture that was not surgically repaired. She had a decline in her activities of daily living after that fall. Prior to that fall she was independent with all of her activities of daily living, but now she needed one to two staff assistance. She received therapies, but cognitively she was not able to participate very well and plateaued. On 10/05/21 at 09:40 AM, Administrative Nurse D stated she does not attend the care plan meetings, but they have a weekly risk type meeting. The unit coordinators develop the care plans and Administrative Nurse D verified the care plan should be updated. When they have the risk type meetings staff should come with interventions and ideas for fall prevention. She verified there should be more interventions for the residents falls. The facility's Accident Prevention Program policy, revised July 2015, documented the facility will provide and maintain a safe, secure, and protected environment for its residents and prevent resident falls whenever possible. Each resident will receive adequate supervision and assistance devices to prevent accidents. If a resident was a high risk for potential falls by the fall risk assessment, it will be documented in the care plan and goals developed to reduce/prevent falls. These goals will be reviewed at least every 90 days and as necessary to determine progress. The facility failed to provide adequate supervision, staff assistance, and implement fall interventions to prevent falls for cognitively impaired R22, placing the resident at risk for further falls and injuries. - R48's Physician Order Sheet (POS), dated 08/03/21, documented diagnoses of hallucinations (sensing things while awake that appear to be real, but the mind created), unsteadiness on feet, and displaced fracture(broken bone) of head of left radius (left wrist). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and the resident required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had one non-injury fall and one minor injury fall during the lookback period. The Fall Care Area Assessment (CAA), dated 05/19/21, documented the resident had problems at times understanding, had disorganized thoughts, and hallucinations. Her cognition was noted as being intact but fluctuated often. The resident was documented as being independent to extensive assistance with activities of daily living and used a walker for her unsteady gait which at times she would forget to use but would use the furniture in the room to make it from place to place in her room. The resident was documented as being at risk for falls related to her unsteady gait and use of antidepressant medications. Interventions were in place with the residents' independence being her priority. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 14 which indicated the resident was cognitively intact. The assessment documented the resident had disorganized thinking that fluctuated (comes and goes and changes in intensity). The assessment further revealed the resident hallucinated and required limited assistance of one staff for bathing, toileting, transfers, walking in room, locomotion on the unit, and dressing. The assessment further revealed the resident had two or more non-injury falls and two or more minor injury falls during the lookback period. The Fall Care Plan, dated 08/20/21, directed staff to encourage resident to call for staff when she feels unsteady, encourage use of non-skid socks or shoes when up in room, have bed at height were she can reach the floor, place gripper strips to the floor in front of bed, motion sensor on the wall, and floor mat next to the bed while resident is in the bed. The Fall/Injury Assessment, dated 07/13/21 documented the resident had poor safety awareness and was a high risk for falls. The Nurse's Note, dated 01/07/21 at 08:50 PM, documented R48 was found lying on the floor between the bed and wheelchair. When asked what happened the resident stated she needed to use the bathroom. Noted abrasion to left knee and skin tear to left elbow and she complained of pain when abrasion was touched. The resident was assisted by two staff to sit up then stand and transferred to her wheelchair. The resident tolerated activity well with no increased pain. A dressing was applied to her left elbow. The new intervention for this fall was to review the care plan. The Nurse's Note dated 04/30/21 at 12:45 AM, documented the resident was found lying on the floor with her head close to the bathroom door, laying on her left side, facing the window. Blood w [TRUNCATED]

The facility had a census of 113 residents, of which 19 resided in the special care unit. The sample included 5 residents. Based on observation, interview and record review the facility failed to protect the residents of the same gender from Resident #1, who inappropriately touched 4 residents of the same gender, in a sexual manner, on 2 occasions unwitnessed and on 2 occasions witnessed by staff. The facility failed to provide protection to residents of the same gender on the special care unit. On 8/9/15 Resident #5 reported Resident #1 had inappropriately touched him/her. On 11/6/15 Resident #3 wandered throughout the facility, and staff located him/her in Resident #1's bed, and Resident #1 was unclothed. On 3/2/16 Resident #4 complained of Resident #1 being in his/her room uninvited and had inappropriately touched him/her. The first witnessed incident occurred on 3/8/16, when Resident #1 inappropriately touched Resident #3, in the dining room of the special care unit. A second witnessed incident occurred on 4/4/16 when Resident #1 inappropriately touched Resident #2, while seated in the commons living room area of the special care unit while staff assisted another resident in the living room area. This failure placed the 8 residents of the same gender who resided in the special care unit in immediate jeopardy. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 8/6/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3, displayed disorganized thinking behavior, and was independent with (ADLs) Activities of Daily Living. The 1/27/16 significant change MDS indicated the same, except the only behaviors displayed were disorganized thinking and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and he/she required supervision with dressing. The MDS further indicated the resident received antipsychotic (medication used to treat [MEDICAL CONDITION]) medication. The 8/10/15 Cognitive Loss (CAA) Care Area Assessment indicated the resident was pleasant with disorganized thinking and word salad (confused or unintelligible mixture of seemingly random words and phrases), which fluctuated. The CAA further indicated the resident spent most of his/her days in his/her room or in the commons living room of the special care unit, with his/her neighbors. The 1/29/16 ADL CAA indicated the resident may come out to the commons living room area numerous times throughout night time hours. The 8/11/15 care plan informed staff the resident was independent with his/her ADLs, and to monitor for side effects of medications or changes in condition through observation and assessments. The 11/10/15 care plan update informed staff the resident may exhibit frustration with his/her inability to express understandable words, and may exhibit agitation with the behaviors of his/her neighbors at times. The 2/2/16 care plan instructed staff to redirect the resident and separate from a neighbor who may cause agitation, offer coffee, 1 to 1 staff visit, or the television. The care plan instructed staff to discuss delusions and to reassure the resident, and offer a snack to redirect. The 3/9/16 care plan update informed staff the resident may use unwelcome touch to his/her neighbors of the same gender, and instructed staff to provide 15 minute checks for 48 hours. The 4/5/16 care plan instructed staff to use a baby monitor to know when the resident leaves his/her room, and to avoid sitting next to his/her neighbors of the same gender. The 8/9/15 at 11:36 AM, nurse's note indicated Resident #5 shared a bathroom with Resident #1. The note further indicated cognitively impaired Resident #5 reported to staff Resident #1 came into the bathroom, exposed his/her external sex organs and touched Resident #5's external sex organs. The note further indicated Resident #5 stated it made him/her feel uncomfortable, he/she did not like it, and wanted to punch Resident #1. The note further indicated staff performed an assessment without signs of injury, but indicated the resident was visibly upset. The clinical record lacked evidence to support the facility developed and implemented interventions to protect the residents of the same gender from Resident #1. The facility's 8/9/15 informal investigation (quick investigation to detrmine if a formal investigation is necessary) indicated cognitively impaired Resident #5 denied Resident #1 touched him/her inappropriately, and due to his/her dementia the facility considered the incident a behavior, and staff would continue to monitor. Review of the informal investigation revealed the incident was not thoroughly investigated by the facility, or reported to the state. The 10/21/15 psychotherapy note indicated staff reported Resident #1 had increased agitation, and displayed unprovoked aggressive behavior toward various residents of the opposite gender. The note indicated he/she was attention seeking, and denied anxious episodes or incidents of aggressive behavior. The note stated the resident had difficulty with word finding and frequently lost his/her train of thought. The 10/28/15 at 7:30 AM, nurse's note indicated Resident #1 reported a person of the opposite gender came into his/her room this morning, wanting to take a bath. The note further indicated nobody entered the resident's room this AM and Resident #1 stated he/she was going to kill the person and chop him/her into little pieces. The 10/29/15 at 5:02 PM, nurse's note indicated the facility admitted Resident #1 into a geriatric psychiatric hospital. The 10/29/15 psychiatric admission progress note indicated Resident #1 had dementia with behavioral dyscontrol, confusion, short term memory impairment, and long term memory impairment. The note further indicated the physician started the resident on a low dose of [MEDICATION NAME] (an antipsychotic medication) that could be increased if needed, and increased his/her [MEDICATION NAME]. The 11/3/15 psychiatric progress note indicated the resident had no hallucinations, delusions, or behaviors to mention. The 11/6/15 at 9:13 PM, nurse's note indicated cognitively impaired Resident #3 wandered into Resident #1's room and laid in Resident #1's bed with him/her in it. The note indicated staff observed Resident #1 with his/her brief half way off and declined the need for staff assistance. The facility's 11/6/15 informal investigation indicated cognitively impaired Resident #3 wandered into Resident #1's room, which staff considered a behavior. Further review of the informal investigation revealed the incident was not thoroughly investigated (collecting witness statements, and reviewing documentation to provide a complete analysis of the incident) by the facility or reported to the state. The 11/7/15 at 5:44 PM, nurse's note indicated staff observed Resident #1 attempting to have Resident #3 stand up from a recliner in the commons living room area. The note further indicated staff intervened and asked Resident #1 what he/she was doing, and Resident #1 stated he/she was trying to get Resident #3 to come with him/her. The note indicated staff redirected Resident #1 from Resident #3, and Resident #1 went to watch TV in his/her room. The 11/10/15 at 3:57 PM, nurse's note indicated staff observed Resident #1 in an unsampled resident's room of the same gender, rubbing his/her back, and staff redirected Resident #1 out of the unsampled resident's room. The note further indicated staff later observed Resident #1 in the living room area holding the hand of Resident #3 attempting to get him/her to come with him/her. The note indicated staff redirected Resident #1. The 12/2/15 at 10:33 AM, nurse's note indicated staff contacted Resident #1's (DPOA) Durable Power of Attorney and he/she consented to move the resident to a private room. The 3/2/16 at 6:00 PM, nurse's note indicated staff observed Resident #1 open Resident #4's (same gender as Resident #1) room door, and Resident #1 stated Are you sleeping, I've come to see you. The note indicated staff heard Resident #4 tell Resident #1 to get out. The note indicated Resident #4 informed staff Resident #1 had done this before and it needed to stop, and threatened to beat up Resident #1. The note indicated staff informed Resident #4 it would not happen again, and staff in charge would handle the situation in the morning. The facility's 3/2/16 informal investigation indicated staff assured Resident #4 that Resident #1 would be kept out of his/her room, staff considered the incident a behavior, and staff would continue to monitor. Further review of the informal investigation revealed the incident was not thoroughly investigated by the facility or reported to the state. The 3/2/16 at 7:45 PM, nurse's note indicated staff observed Resident #1 in and out of his/her room multiple times to sit on the couch in the commons living room area in the special care unit. The note further indicated Resident #2 seated in a wheelchair in the living room, and Resident #1 stood up, walked behind Resident #2's wheelchair, and attempted to propel Resident #2 towards Resident #1's room. The note indicated staff intervened and informed Resident #1 he/she was not to take Resident #2 with him/her, he/she stated ok fine then, and sat back down on the couch. The 3/8/16 at 6:30 AM, nurse's note indicated Resident #1 had not slept and wandered in and out of his/her room throughout the night. The 3/8/16 at 8:30 PM, nurse's note indicated staff heard Resident #3 make a howling sound, while seated in a chair in the dining room. The note further indicated staff observed on the facility's surveillance camera which revealed Resident #1 moved his/her hand down the front of Resident #3's body in between his/her legs over Resident #3's clothing. The note further indicated staff intervened and told Resident #1 not to touch Resident #3 like that. The note indicated staff provided 15 minute checks for 48 hours, and Resident #1 was in and out of his/her room all evening. The 3/16/16 at 7:48 AM, nurse's note indicated staff reviewed the resident's care plan and updated to include the resident may use unwelcome touch for his/her neighbors of the same gender, and if it happened again staff were to redirect the resident and provide 15 minute checks for 48 hours. The note further indicated the psychiatric clinic was in the facility and would discuss the recent inappropriate behavior. The 3/17/16 at 12:15 PM, nurse's note indicated the resident had a new order by the psychiatric consultant to administer [MEDICATION NAME] (an antidepressant), 20 (mg) milligrams, daily, due to inappropriate behaviors towards residents of the same gender. The 3/21/16 psychotherapy note indicated staff reported an onset of sexually inappropriate behaviors, and making sexual advances to residents of the same gender on his/her unit. The note indicated residents complained to the facility about his/her unwelcome sexual intrusive gestures and invitations but because of the prevalence of cognitive deficits among the residents on the dementia unit the facility could not confirm the reports until staff personally witnessed the reported offensive behavior. The note further indicated the resident showed a considerable cognitive decline over the recent months, which was noted during the appointment. The note indicated the resident appeared confused by most questions, paused before answering questions, and answered with irrelevant answers. The 4/4/16 at 9:00 PM, nurse's note indicated staff observed the resident seated on the couch with Resident #2, and staff turned around to assist an agitated resident. The note indicated when staff turned back around, staff observed Resident #1 with his/her hand down the front of Resident #2's pants and brief, skin to skin. The note indicated staff told Resident #1 to go to his/her room, and staff provided 15 minute checks for 48 hours to ensure safety and privacy of all residents. The 4/5/16 at 12:10 PM, nurse's note indicated staff contacted the physician in regards to Resident #1's on-going sexually inappropriate behaviors towards residents of the same gender, and awaited a call back. The 4/5/16 at 5:00 PM, nurse's note indicated the physician returned staff's phone call and stated the incidents were out of his/her scope, and to continue to administer the [MEDICATION NAME] but administer in the evening instead of the morning. The clinical record lacked documentation that staff notified the psychiatric consultant. The 4/5/16 at 7:00 PM, nurse's note indicated the resident attempted to sit by another resident of the same gender in the living room, and staff redirected Resident #1 to another chair. The 4/5/16 at 7:14 PM, nurse's note indicated staff placed a baby monitor in the resident's room to use on the evening and night shift, since behaviors occurred on evening and night shift. The note indicated staff would be able to take the monitor with them when they provide care to other residents, and know when the resident leaves his/her room. On 4/19/16 at 8:27 AM, observation revealed the resident independently ambulated from the dining room to the living room in the commons area of the special care unit. Further observation revealed an Resident #7 (same gender as Resident #1) seated in a wheelchair directly in front of Resident #1. Continuous observation revealed no staff were in the commons living area of the facility, and at 8:33 AM, Nurse A walked through the living area, unlocked a door and went into an office with his/her back turned away from the living area. Observation revealed the resident remained unsupervised until 8:41 AM, when staff took Resident #1's hand and led him/her to his/her room to use the bathroom. On 4/19/16 at 9:52 AM, observation revealed the Resident #1 seated on the couch, in the commons living room area of the special care unit with no staff in the area. Further observation revealed Resident #3 seated in a recliner directly beside Resident #1. Continuous observation revealed at 9:53 AM, staff sat in between Resident #1 and Resident #3. Further observation revealed staff were in and out of the living area, and intermittently observed the resident between tasks. Observation revealed at 10:05 AM, 2 staff seated in the living room and providing supervision to the residents. On 4/18/16 at 12:21 PM, Nurse J verified all staff were aware of the on-going issue with Resident #1's inappropriate sexual behaviors directed toward other residents of the same gender. Nurse J stated the resident was not to sit next to other residents of the same gender, especially not one who can not speak to tell staff if something was wrong. Nurse J stated when Resident #5 stated he/she was touched inappropriately by Resident #1, staff were unable to determine if it was truthful because staff had not witnessed it happen. Nurse J stated when Resident #4 stated he/she was touched inappropriately by Resident #1 he/she felt there was more of an issue because Resident #4 was cognitive enough to tell, and he/she had seen Resident #1 go into Resident #4's room. Nurse J stated staff now monitor the resident's whereabouts, completed 15 minute checks for 48 hours after the incidents on 3/8/16 and 4/4/16, and night shift has a baby monitor to use to notify them when the resident leaves his/her room. Nurse J verified 90-95% of the time there is staff in the commons area of the special care unit, and now that staff observed Resident #1 inappropriately touching other residents staff are more aware of what he/she is doing. On 4/18/16 at 1:24 PM, Nurse A stated staff monitored Resident #1's whereabouts because he/she was in another resident's room of the same gender rubbing his/her back, and staff redirected him/her to a different room. Nurse A verified monitoring meant staff were expected to provide 15 minute checks of a resident's whereabouts. Nurse A verified this would provide staff knowledge to know his/her location and made it possible to monitor for any inappropriate behavior. Nurse A stated staff encourage Resident #1 to move when he/she sits next to residents of the same gender, and staff have a baby monitor for evening and night shift to monitor when he/she leaves his/her room. On 4/18/16 at 2:38 PM, Medication Aide E stated if given the opportunity the resident will sit next to Resident #2 or Resident #3. Staff redirect him/her by taking him/her to the bathroom, and then sat him/her in a different chair. Medication Aide E verified Resident #1's inappropriate behaviors have been going on for about 3 months. Medication Aide E stated the baby monitor will alert staff if he/she leaves his/her room. Medication Aide E stated that once Resident #1 realizes a resident is able to refuse his/her advances he/she will move on, and he/she goes for Resident #2 or Resident #3 who are more cognitively impaired and unable to consent. On 4/18/16 at 2:46 PM, Nurse Aide I stated on 3/8/16 staff were all in the living commons area of the special care unit, and all the residents had been put to bed (other than Resident #1 and Resident #3). Nurse Aide I stated Resident #3 was up wandering, and wandered into the dining room. Nurse Aide I stated staff heard someone yell, so staff turned on the surveillance camera, and staff observed Resident #1 reach in between Resident #3's legs. Nurse Aide I stated this was the first time staff realized this was a problem, although Resident #4 and Resident #5 complained in the past of being touched inappropriately in a sexual manner by Resident #1. On 4/18/16 at 3:06 PM, Medication Aide F verified Resident #5 complained to staff Resident #1 inappropriately touched him/her, and Resident #4 stated he/she would not sit next to Resident #1 because he/she had tried to touch him/her. Medication Aide F verified Resident #4 stated he/she would punch Resident #1 in the face if he/she tried to touch him/her again. Medication Aide F verified Resident #3 had wandered and staff looked for him/her, and Resident #3 was found in Resident #1's bed with Resident #1's brief partially off. Medication Aide F further verified staff was in the living room area and had the surveillance camera on, and staff noticed Resident #1 stood over Resident #3 with his/her hand down Resident #3's leg. Medication Aide F stated he/she told Resident #1 not to do that, and he/she slowly went to his/her room. Medication Aide F verified Resident #1 and Resident #2 sat on the couch in the living room commons area of the special care unit, holding hands, and 2 staff were monitoring the residents. Medication Aide F verified he/she provided care to a combative resident and looked away from Resident #1 and Resident #3. Medication Aide F verified when he/she turned back around Resident #1 had his/her hand down Resident #3's pants, and staff informed Resident #1 he/she cannot touch Resident #3 like that. Medication Aide F stated recently if Resident #1 sat by a resident of the same gender staff asked him/her to move if he/she was holding hands with another resident of the same gender, and staff do not let him/her get close to a resident of the same gender. Medication Aide F stated staff have a baby monitor in Resident #1's room, but he/she is unsure how it is suppose to help to keep Resident #1 away from the other residents and only works when he/she is in his/her room the staff can take it with them to listen if he/she leaves the room. On 4/18/16 at 3:40 PM, Medication Aide G verified on 4/4/16 he/she visualized Resident #1 and Resident #2 seated on the couch in the commons living room area of the special care unit, and shortly after that Resident #1 touched Resident #2 inappropriately. Medication Aide G stated he/she never thought that hand holding would be a problem and now staff discouraged that kind of behavior. On 4/18/16 at 3:56 PM, Nurse Aide H stated on 4/4/16 he/she observed Resident #1 seated with Resident #2 on the couch in the commons living area in the special care unit. Nurse Aide H verified he/she turned around with another staff member to assist a combative resident, and when they turned back around Resident #1 had his/her hand in between Resident #3's legs. Nurse Aide H stated staff noticed a strong decline in Resident #1's everyday behaviors, and he/she seemed to target residents of the same gender who can not talk, such as Resident #2 or Resident #3. Nurse Aide H stated that Resident #4 stated Resident #1 tried to touch him/her inappropriately, and Resident #4 threatened to hit Resident #1. Nurse Aide H stated Resident #2 and Resident #1 rooms are right beside one another and he/she worried about Resident #1 sneaking into Resident #2's room. Nurse Aide H stated staff had a baby monitor that will beep when there is movement in Resident #1's room, but he/she is unsure if it is still being used by staff. Nurse Aide H verified on 11/6/15 Resident #3 was found in Resident #1's bed, and Resident #1's external sex organs were visible with Resident #3's hand close by. On 4/19/16 at 9:09 AM, Nurse Aide B stated all staff are aware of the resident's inappropriate sexual behaviors, and try to stay vigilant to keep an eye out. Nurse Aide B verified there was not one staff specifically assigned to monitor the resident. On 4/19/16 at 9:10 AM, Resident #4 stated he/she had been touched inappropriately in between his/her legs by another resident of the same sex, in the special care unit about a month ago. Resident #4 stated he/she could not remember the resident's name, and told the resident to never do that again or Resident #4 would hit the resident. Resident #4 stated he/she notified staff about the incident, and had not seen the resident touch anyone else inappropriately in the special care unit. On 4/19/16 at 9:35 AM, Nurse Aide D verified there was not one staff specifically assigned to monitor Resident #1 and continued that staff perform 30 minute checks on all of the residents in the special care unit. On 4/19/16 at 9:38 AM, Nurse Aide C verified staff attempted to keep the resident separated from residents of the same gender, and staff do not use the baby monitor on the day shift. Nurse Aide C further verified staff monitor the resident as a team, and keep an eye out to monitor activity in the living room. Nurse Aide C stated the nurse will sit in the office to watch when staff are in resident rooms. On 4/19/16 at 11:45 AM, Administrative Nurse K verified the incident when Resident #5 accused Resident #1 of inappropriately touching him/her staff considered this a behavior of Resident #5's because he/she denied the incident the next day, after staff completed an informal investigation. The facility did not report the incident to the state. Administrative Nurse K further verified residents with dementia frequently wandered, and staff considered it a behavior. Staff also considered the incident when Resident #3 was found in Resident #1's bed a behavior after staff completed an informal investigation. The facility did not report the incident to the state. Administrative Nurse K further verified that staff considered the incident when Resident #4 reacted about Resident #1 being in his/her room a behavior because Resident #1 was up wandering. Staff did not make any changes to the care plan at that point. On 4/19/16 at 11:45 AM, Administrative Staff L verified Resident #1 was not 1 to 1 with staff at all times. On 4/19/16 at 12:05 PM, Nurse A stated after both witnessed incidents staff performed 15 minute checks on Resident #1 for 48 hours, and staff performed 30 minute checks on all residents in the special care unit. Nurse A verified there was not a specific member staff assigned to Resident #1, but all staff were aware of the concerns. Nurse A verified on 4/4/16 when Resident #1 and Resident #2 sat on the couch holding hands, staff should have intervened prior to the incident occurring. Nurse A verified Resident #1 was not specifically assigned to 1 to 1 with staff when out of his/her room, and he/she was not able to verify there was not times when staff do not have him/her in visual field because things happen that needs staff attention. On 4/19/16 at 3:15 AM, Psychiatric Consultant M verified the resident admitted into a geriatric psychiatric unit in late October early November for aggressive behaviors with residents of the opposite gender. Psychiatric Consultant M further verified on March 16th the resident was seen for inappropriate sexual behaviors and was prescribed [MEDICATION NAME] to decrease his/her sex drive, and staff noticed side effects. The [MEDICATION NAME] was held, the side effects diminished so he/she discontinued the [MEDICATION NAME], and started [MEDICATION NAME] (an antidepressant). Psychiatric Consultant M verified he/she was not notified of the incident which occurred on 4/4/16. He/She verified staff communicated with his/her office nurse but it was in reference to the medications. Psychiatric Consultant M verified he/she expected staff to provide safety of the other residents in the special care unit, and depending on the severity of the unwanted sexual touch would indicate if 1 to 1 supervision was required for the safety of all residents. Psychiatric Consultant M further verified he/she did not feel the facility had the staff to provide 1 to 1 supervision and the resident would probably need admitted into a behavioral unit. On 4/20/16 at 8:34 AM, Psychiatric Consultant M verified staff informed him/her of getting reports from other residents of the same gender they had been inappropriately touched by Resident #1. Psychiatric Consultant M stated the facility questioned the reports due to the credibility of the residents due to dementia, so they were not going to consider it until it was witnessed. Psychiatric Consultant M stated now that staff witnessed the incidents it now gives credibility to all the reports. Psychiatric Consultant M stated Resident #1 had a history of [REDACTED]. The facility's 1/2011 Resident Abuse policy defined sexual abuse as included but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy directed staff that any employee who had actual knowledge or suspect abuse or neglect of a resident shall report immediately to the administrator. The policy directed the administrator, who will be the investigating officer or designee, to immediately conduct a quick internal investigation of the incident, and based on the results of the internal investigation (credible evidence), appropriate action will be taken as follows: if the suspected perpetrator is another resident of the facility, that resident's condition will immediately be evaluated to determine the most suitable therapy and placement for the resident, considering the safety of the resident as well as the safety of other residents. The policy directed staff a resident abuse incident report would be compiled and completed immediately following a thorough investigation of the incident. The policy further instructed staff that a report must be made to the state and local law enforcement within the required department. The facility failed to protect the residents of the same gender as Resident #1, provide adequate supervision for Resident #1 who displayed behaviors of inappropriate touching in a sexual manner to Resident #2, Resident #3, Resident #4, and Resident #5, failed to protect the 8 residents of the same gender in the special care unit, and failed to thoroughly investigate and report to the state agency. The deficient practice placed the 8 residents in immediate jeopardy. The facility abated the immediate jeopardy on 4/22/16 after completion of training of all staff regarding the protection of residents after inappropriate touching in a sexual manner by a residents and implementation of 1 to 1 as needed. The training also included the importance of following the abuse, neglect and exploitation policy, reporting, and protection of residents. The facility also provided 1 to 1 supervision of Resident #1. The deficient practice remained at the scope and severity of an E.

The facility had a census of 113 residents, of which 19 resided in the special care unit. The sample included 5 residents. Based on observation, interview and record review the facility failed to protect the residents of the same gender from Resident #1, who inappropriately touched 4 residents of the same gender, in a sexual manner, on 2 occasions unwitnessed and on 2 occasions witnessed by staff. The facility failed to provide protection to residents of the same gender on the special care unit. On 8/9/15 Resident #5 reported Resident #1 had inappropriately touched him/her. On 11/6/15 Resident #3 wandered throughout the facility, and staff located him/her in Resident #1's bed, and Resident #1 was unclothed. On 3/2/16 Resident #4 complained of Resident #1 being in his/her room uninvited and had inappropriately touched him/her. The first witnessed incident occurred on 3/8/16, when Resident #1 inappropriately touched Resident #3, in the dining room of the special care unit. A second witnessed incident occurred on 4/4/16 when Resident #1 inappropriately touched Resident #2, while seated in the commons living room area of the special care unit while staff assisted another resident in the living room area. This failure placed the 8 residents of the same gender who resided in the special care unit in immediate jeopardy. The facility also failed to thoroughly investigate the incidents and report the incidents to the state agency as required. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 8/6/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3, displayed disorganized thinking behavior, and was independent with (ADLs) Activities of Daily Living. The 1/27/16 significant change MDS indicated the same, except the only behaviors displayed were disorganized thinking and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and he/she required supervision with dressing. The MDS further indicated the resident received antipsychotic (medication used to treat [MEDICAL CONDITION]) medication. The 8/10/15 Cognitive Loss (CAA) Care Area Assessment indicated the resident was pleasant with disorganized thinking and word salad (confused or unintelligible mixture of seemingly random words and phrases), which fluctuated. The CAA further indicated the resident spent most of his/her days in his/her room or in the commons living room of the special care unit, with his/her neighbors. The 1/29/16 ADL CAA indicated the resident may come out to the commons living room area numerous times throughout night time hours. The 8/11/15 care plan informed staff the resident was independent with his/her ADLs, and to monitor for side effects of medications or changes in condition through observation and assessments. The 11/10/15 care plan update informed staff the resident may exhibit frustration with his/her inability to express understandable words, and may exhibit agitation with the behaviors of his/her neighbors at times. The 2/2/16 care plan instructed staff to redirect the resident and separate from a neighbor who may cause agitation, offer coffee, 1 to 1 staff visit, or the television. The care plan instructed staff to discuss delusions and to reassure the resident, and offer a snack to redirect. The 3/9/16 care plan update informed staff the resident may use unwelcome touch to his/her neighbors of the same gender, and instructed staff to provide 15 minute checks for 48 hours. The 4/5/16 care plan instructed staff to use a baby monitor to know when the resident leaves his/her room, and to avoid sitting next to his/her neighbors of the same gender. The 8/9/15 at 11:36 AM, nurse's note indicated Resident #5 shared a bathroom with Resident #1. The note further indicated cognitively impaired Resident #5 reported to staff Resident #1 came into the bathroom, exposed his/her external sex organs and touched Resident #5's external sex organs. The note further indicated Resident #5 stated it made him/her feel uncomfortable, he/she did not like it, and wanted to punch Resident #1. The note further indicated staff performed an assessment without signs of injury, but indicated the resident was visibly upset. The clinical record lacked evidence to support the facility developed and implemented interventions to protect the residents of the same gender from Resident #1. The facility's 8/9/15 informal investigation (quick investigation to detrmine if a formal investigation is necessary) indicated cognitively impaired Resident #5 denied Resident #1 touched him/her inappropriately, and due to his/her dementia the facility considered the incident a behavior, and staff would continue to monitor. Review of the informal investigation revealed the incident was not thoroughly investigated by the facility, or reported to the state. The 10/21/15 psychotherapy note indicated staff reported Resident #1 had increased agitation, and displayed unprovoked aggressive behavior toward various residents of the opposite gender. The note indicated he/she was attention seeking, and denied anxious episodes or incidents of aggressive behavior. The note stated the resident had difficulty with word finding and frequently lost his/her train of thought. The 10/28/15 at 7:30 AM, nurse's note indicated Resident #1 reported a person of the opposite gender came into his/her room this morning, wanting to take a bath. The note further indicated nobody entered the resident's room this AM and Resident #1 stated he/she was going to kill the person and chop him/her into little pieces. The 10/29/15 at 5:02 PM, nurse's note indicated the faclity admitted Resident #1 into a geriatric psychiatric hospital. The 10/29/15 psychiatric admission progress note indicated Resident #1 had dementia with behavioral dyscontrol, confusion, short term memory impairment, and long term memory impairment. The note further indicated the physician started the resident on a low dose of [MEDICATION NAME] (an antipsychotic medication) that could be increased if needed, and increased his/her [MEDICATION NAME]. The 11/3/15 psychiatric progress note indicated the resident had no hallucinations, delusions, or behaviors to mention. The 11/6/15 at 9:13 PM, nurse's note indicated cognitively impaired Resident #3 wandered into Resident #1's room and laid in Resident #1's bed with him/her in it. The note indicated staff observed Resident #1 with his/her brief half way off and declined the need for staff assistance. The facility's 11/6/15 informal investigation indicated cognitively impaired Resident #3 wandered into Resident #1's room, which staff considered a behavior. Further review of the informal investigation revealed the incident was not thoroughly investigated (collecting witness statements, and reviewing documentation to provide a complete analysis of the incident) by the facility or reported to the state. The 11/7/15 at 5:44 PM, nurse's note indicated staff observed Resident #1 attempting to have Resident #3 stand up from a recliner in the commons living room area. The note further indicated staff intervened and asked Resident #1 what he/she was doing, and Resident #1 stated he/she was trying to get Resident #3 to come with him/her. The note indicated staff redirected Resident #1 from Resident #3, and Resident #1 went to watch TV in his/her room. The 11/10/15 at 3:57 PM, nurse's note indicated staff observed Resident #1 in an unsampled resident's room of the same gender, rubbing his/her back, and staff redirected Resident #1 out of the unsampled resident's room. The note further indicated staff later observed Resident #1 in the living room area holding the hand of Resident #3 attempting to get him/her to come with him/her. The note indicated staff redirected Resident #1. The 12/2/15 at 10:33 AM, nurse's note indicated staff contacted Resident #1's (DPOA) Durable Power of Attorney and he/she consented to move the resident to a private room. The 3/2/16 at 6:00 PM, nurse's note indicated staff observed Resident #1 open Resident #4's (same gender as Resident #1) room door, and Resident #1 stated Are you sleeping, I've come to see you. The note indicated staff heard Resident #4 tell Resident #1 to get out. The note indicated Resident #4 informed staff Resident #1 had done this before and it needed to stop, and threatened to beat up Resident #1. The note indicated staff informed Resident #4 it would not happen again, and staff in charge would handle the situation in the morning. The facility's 3/2/16 informal investigation indicated staff assured Resident #4 that Resident #1 would be kept out of his/her room, staff considered the incident a behavior, and staff would continue to monitor. Further review of the informal investigation revealed the incident was not thoroughly investigated by the facility or reported to the state. The 3/2/16 at 7:45 PM, nurse's note indicated staff observed Resident #1 in and out of his/her room multiple times to sit on the couch in the commons living room area in the special care unit. The note further indicated Resident #2 seated in a wheelchair in the living room, and Resident #1 stood up, walked behind Resident #2's wheelchair, and attempted to propel Resident #2 towards Resident #1's room. The note indicated staff intervened and informed Resident #1 he/she was not to take Resident #2 with him/her, he/she stated ok fine then, and sat back down on the couch. The 3/8/16 at 6:30 AM, nurse's note indicated Resident #1 had not slept and wandered in and out of his/her room throughout the night. The 3/8/16 at 8:30 PM, nurse's note indicated staff heard Resident #3 make a howling sound, while seated in a chair in the dining room. The note further indicated staff observed on the facility's surveillance camera which revealed Resident #1 moved his/her hand down the front of Resident #3's body in between his/her legs over Resident #3's clothing. The note further indicated staff intervened and told Resident #1 not to touch Resident #3 like that. The note indicated staff provided 15 minute checks for 48 hours, and Resident #1 was in and out of his/her room all evening. The 3/16/16 at 7:48 AM, nurse's note indicated staff reviewed the resident's care plan and updated to include the resident may use unwelcome touch for his/her neighbors of the same gender, and if it happened again staff were to redirect the resident and provide 15 minute checks for 48 hours. The note further indicated the psychiatric clinic was in the facility and would discuss the recent inappropriate behavior. The 3/17/16 at 12:15 PM, nurse's note indicated the resident had a new order by the psychiatric consultant to administer [MEDICATION NAME] (an antidepressant), 20 (mg) milligrams, daily, due to inappropriate behaviors towards residents of the same gender. The 3/21/16 psychotherapy note indicated staff reported an onset of sexually inappropriate behaviors, and making sexual advances to residents of the same gender on his/her unit. The note indicated residents complained to the facility about his/her unwelcome sexual intrusive gestures and invitations but because of the prevalence of cognitive deficits among the residents on the dementia unit the facility could not confirm the reports until staff personally witnessed the reported offensive behavior. The note further indicated the resident showed a considerable cognitive decline over the recent months, which was noted during the appointment. The note indicated the resident appeared confused by most questions, paused before answering questions, and answered with irrelevant answers. The 4/4/16 at 9:00 PM, nurse's note indicated staff observed the resident seated on the couch with Resident #2, and staff turned around to assist an agitated resident. The note indicated when staff turned back around, staff observed Resident #1 with his/her hand down the front of Resident #2's pants and brief, skin to skin. The note indicated staff told Resident #1 to go to his/her room, and staff provided 15 minute checks for 48 hours to ensure safety and privacy of all residents. The 4/5/16 at 12:10 PM, nurse's note indicated staff contacted the physician in regards to Resident #1's on-going sexually inappropriate behaviors towards residents of the same gender, and awaited a call back. The 4/5/16 at 5:00 PM, nurse's note indicated the physician returned staff's phone call and stated the incidents were out of his/her scope, and to continue to administer the [MEDICATION NAME] but administer in the evening instead of the morning. The clinical record lacked documentation that staff notified the psychiatric consultant. The 4/5/16 at 7:00 PM, nurse's note indicated the resident attempted to sit by another resident of the same gender in the living room, and staff redirected Resident #1 to another chair. The 4/5/16 at 7:14 PM, nurse's note indicated staff placed a baby monitor in the resident's room to use on the evening and night shift, since behaviors occurred on evening and night shift. The note indicated staff would be able to take the monitor with them when they provide care to other residents, and know when the resident leaves his/her room. On 4/19/16 at 8:27 AM, observation revealed the resident independently ambulated from the dining room to the living room in the commons area of the special care unit. Further observation revealed an Resident #7 (same gender as Resident #1) seated in a wheelchair directly in front of Resident #1. Continuous observation revealed no staff were in the commons living area of the facility, and at 8:33 AM, Nurse A walked through the living area, unlocked a door and went into an office with his/her back turned away from the living area. Observation revealed the resident remained unsupervised until 8:41 AM, when staff took Resident #1's hand and led him/her to his/her room to use the bathroom. On 4/19/16 at 9:52 AM, observation revealed Resident #1 seated on the couch, in the commons living room area of the special care unit with no staff in the area. Further observation revealed Resident #3 seated in a recliner directly beside Resident #1. Continuous observation revealed at 9:53 AM, staff sat in between Resident #1 and Resident #3. Further observation revealed staff were in and out of the living area, and intermittently observed the resident between tasks. Observation revealed at 10:05 AM, 2 staff seated in the living room and providing supervision to the residents. On 4/18/16 at 12:21 PM, Nurse J verified all staff were aware of the on-going issue with Resident #1's inappropriate sexual behaviors directed toward other residents of the same gender. Nurse J stated the resident was not to sit next to other residents of the same gender, especially not one who can not speak to tell staff if something was wrong. Nurse J stated when Resident #5 stated he/she was touched inappropriately by Resident #1, staff were unable to determine if it was truthful because staff had not witnessed it happen. Nurse J stated when Resident #4 stated he/she was touched inappropriately by Resident #1 he/she felt there was more of an issue because Resident #4 was cognitive enough to tell, and he/she had seen Resident #1 go into Resident #4's room. Nurse J stated staff now monitor the resident's whereabouts, completed 15 minute checks for 48 hours after the incidents on 3/8/16 and 4/4/16, and night shift has a baby monitor to use to notify them when the resident leaves his/her room. Nurse J verified 90-95% of the time there is staff in the commons area of the special care unit, and now that staff observed Resident #1 inappropriately touching other residents staff are more aware of what he/she is doing. On 4/18/16 at 1:24 PM, Nurse A stated staff monitored Resident #1's whereabouts because he/she was in another resident's room of the same gender rubbing his/her back, and staff redirected him/her to a different room. Nurse A verified monitoring meant staff were expected to provide 15 minute checks of a resident's whereabouts. Nurse A verified this would provide staff knowledge to know his/her location and made it possible to monitor for any inappropriate behavior. Nurse A stated staff encourage Resident #1 to move when he/she sits next to residents of the same gender, and staff have a baby monitor for evening and night shift to monitor when he/she leaves his/her room. On 4/18/16 at 2:38 PM, Medication Aide E stated if given the opportunity the resident will sit next to Resident #2 or Resident #3. Staff redirect him/her by taking him/her to the bathroom, and then sat him/her in a different chair. Medication Aide E verified Resident #1's inappropriate behaviors have been going on for about 3 months. Medication Aide E stated the baby monitor will alert staff if he/she leaves his/her room. Medication Aide E stated that once Resident #1 realizes a resident is able to refuse his/her advances he/she will move on, and he/she goes for Resident #2 or Resident #3 who are more cognitively impaired and unable to consent. On 4/18/16 at 2:46 PM, Nurse Aide I stated on 3/8/16 staff were all in the living commons area of the special care unit, and all the residents had been put to bed (other than Resident #1 and Resident #3). Nurse Aide I stated Resident #3 was up wandering, and wandered into the dining room. Nurse Aide I stated staff heard someone yell, so staff turned on the surveillance camera, and staff observed Resident #1 reach in between Resident #3's legs. Nurse Aide I stated this was the first time staff realized this was a problem, although Resident #4 and Resident #5 complained in the past of being touched inappropriately in a sexual manner by Resident #1. On 4/18/16 at 3:06 PM, Medication Aide F verified Resident #5 complained to staff Resident #1 inappropriately touched him/her, and Resident #4 stated he/she would not sit next to Resident #1 because he/she had tried to touch him/her. Medication Aide F verified Resident #4 stated he/she would punch Resident #1 in the face if he/she tried to touch him/her again. Medication Aide F verified Resident #3 had wandered and staff looked for him/her, and Resident #3 was found in Resident #1's bed with Resident #1's brief partially off. Medication Aide F further verified staff was in the living room area and had the surveillance camera on, and staff noticed Resident #1 stood over Resident #3 with his/her hand down Resident #3's leg. Medication Aide F stated he/she told Resident #1 not to do that, and he/she slowly went to his/her room. Medication Aide F verified Resident #1 and Resident #2 sat on the couch in the living room commons area of the special care unit, holding hands, and 2 staff were monitoring the residents. Medication Aide F verified he/she provided care to a combative resident and looked away from Resident #1 and Resident #3. Medication Aide F verified when he/she turned back around Resident #1 had his/her hand down Resident #3's pants, and staff informed Resident #1 he/she cannot touch Resident #3 like that. Medication Aide F stated recently if Resident #1 sat by a resident of the same gender staff asked him/her to move if he/she was holding hands with another resident of the same gender, and staff do not let him/her get close to a resident of the same gender. Medication Aide F stated staff have a baby monitor in resident #1's room, but he/she is unsure how it is suppose to help to keep Resident #1 away from the other residents and only works when he/she is in his/her room the staff can take it with them to listen if he/she leaves the room. On 4/18/16 at 3:40 PM, Medication Aide G verified on 4/4/16 he/she visualized Resident #1 and Resident #2 seated on the couch in the commons living room area of the special care unit, and shortly after that Resident #1 touched Resident #2 inappropriately. Medication Aide G stated he/she never thought that hand holding would be a problem and now staff discouraged that kind of behavior. On 4/18/16 at 3:56 PM, Nurse Aide H stated on 4/4/16 he/she observed Resident #1 seated with Resident #2 on the couch in the commons living area in the special care unit. Nurse Aide H verified he/she turned around with another staff member to assist a combative resident, and when they turned back around Resident #1 had his/her hand in between Resident #3's legs. Nurse Aide H stated staff noticed a strong decline in Resident #1's everyday behaviors, and he/she seemed to target residents of the same gender who can not talk, such as Resident #2 or Resident #3. Nurse Aide H stated that Resident #4 stated Resident #1 tried to touch him/her inappropriately, and Resident #4 threatened to hit Resident #1. Nurse Aide H stated Resident #2 and Resident #1 rooms are right beside one another and he/she worried about Resident #1 sneaking into Resident #2's room. Nurse Aide H stated staff had a baby monitor that will beep when there is movement in Resident #1's room, but he/she is unsure if it is still being used by staff. Nurse Aide H verified on 11/6/15 Resident #3 was found in Resident #1's bed, and Resident #1's external sex organs were visible with Resident #3's hand close by. On 4/19/16 at 9:09 AM, Nurse Aide B stated all staff are aware of the resident's inappropriate sexual behaviors, and try to stay vigilant to keep an eye out. Nurse Aide B verified there was not one staff specifically assigned to monitor the resident. On 4/19/16 at 9:10 AM, Resident #4 stated he/she had been touched inappropriately in between his/her legs by another resident of the same sex, in the special care unit about a month ago. Resident #4 stated he/she could not remember the resident's name, and told the resident to never do that again or Resident #4 would hit the resident. Resident #4 stated he/she notified staff about the incident, and had not seen the resident touch anyone else inappropriately in the special care unit. On 4/19/16 at 9:35 AM, Nurse Aide D verified there was not one staff specifically assigned to monitor Resident #1 and continued that staff perform 30 minute checks on all of the residents in the special care unit. On 4/19/16 at 9:38 AM, Nurse Aide C verified staff attempted to keep the resident separated from residents of the same gender, and staff do not use the baby monitor on the day shift. Nurse Aide C further verified staff monitor the resident as a team, and keep an eye out to monitor activity in the living room. Nurse Aide C stated the nurse will sit in the office to watch when staff are in resident rooms. On 4/19/16 at 11:45 AM, Administrative Nurse K verified the incident when Resident #5 accused Resident #1 of inappropriately touching him/her staff considered this a behavior of Resident #5's because he/she denied the incident the next day, after staff completed an informal investigation. The facility did not report the incident to the state. Administrative Nurse K further verified residents with dementia frequently wandered, and staff considered it a behavior. Staff also considered the incident when Resident #3 was found in Resident #1's bed a behavior after staff completed an informal investigation. The facility did not report the incident to the state. Administrative Nurse K further verified that staff considered the incident when Resident #4 reacted about Resident #1 being in his/her room a behavior because Resident #1 was up wandering. Staff did not make any changes to the care plan at that point. On 4/19/16 at 11:45 AM, Administrative Staff L verified Resident #1 was not 1 to 1 with staff at all times. On 4/19/16 at 12:05 PM, Nurse A stated after both witnessed incidents staff performed 15 minute checks on Resident #1 for 48 hours, and staff performed 30 minute checks on all residents in the special care unit. Nurse A verified there was not a specific member staff assigned to Resident #1, but all staff were aware of the concerns. Nurse A verified on 4/4/16 when Resident #1 and Resident #2 sat on the couch holding hands, staff should have intervened prior to the incident occurring. Nurse A verified Resident #1 was not specifically assigned to 1 to 1 with staff when out of his/her room, and he/she was not able to verify there was not times when staff do not have him/her in visual field because things happen that needs staff attention. On 4/19/16 at 3:15 AM, Psychiatric Consultant M verified the resident admitted into a geriatric psychiatric unit in late October early November for aggressive behaviors with residents of the opposite gender. Psychiatric Consultant M further verified on March 16th the resident was seen for inappropriate sexual behaviors and was prescribed [MEDICATION NAME] to decrease his/her sex drive, and staff noticed side effects. The [MEDICATION NAME] was held, the side effects diminished so he/she discontinued the [MEDICATION NAME], and started [MEDICATION NAME] (an antidepressant). Psychiatric Consultant M verified he/she was not notified of the incident which occurred on 4/4/16. He/She verified staff communicated with his/her office nurse but it was in reference to the medications. Psychiatric Consultant M verified he/she expected staff to provide safety of the other residents in the special care unit, and depending on the severity of the unwanted sexual touch would indicate if 1 to 1 supervision was required for the safety of all residents. Psychiatric Consultant M further verified he/she did not feel the facility had the staff to provide 1 to 1 supervision and the resident would probably need admitted into a behavioral unit. On 4/20/16 at 8:34 AM, Psychiatric Consultant M verified staff informed him/her of getting reports from other residents of the same gender they had been inappropriately touched by Resident #1. Psychiatric Consultant M stated the facility questioned the reports due to the credibility of the residents due to dementia, so they were not going to consider it until it was witnessed. Psychiatric Consultant M stated now that staff witnessed the incidents it now gives credibility to all the reports. Psychiatric Consultant M stated Resident #1 had a history of [REDACTED]. The facility's 1/2011 Resident Abuse policy defined sexual abuse as included but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy directed staff that any employee who had actual knowledge or suspect abuse or neglect of a resident shall report immediately to the administrator. The policy directed the administrator, who will be the investigating officer or designee, to immediately conduct a quick internal investigation of the incident, and based on the results of the internal investigation (credible evidence), appropriate action will be taken as follows: if the suspected perpetrator is another resident of the facility, that resident's condition will immediately be evaluated to determine the most suitable therapy and placement for the resident, considering the safety of the resident as well as the safety of other residents. The policy directed staff a resident abuse incident report would be compiled and completed immediately following a thorough investigation of the incident. The policy further instructed staff that a report must be made to the state and local law enforcement within the required department. The facility failed to protect the residents of the same gender as Resident #1, provide adequate supervision for Resident #1 who displayed behaviors of inappropriate touching in a sexual manner to Resident #2, Resident #3, Resident #4, and Resident #5, failed to protect the 8 residents of the same gender in the special care unit, and failed to thoroughly investigate and report to the state agency. The deficient practice placed the 8 residents in immediate jeopardy. The facility abated the immediate jeopardy on 4/22/16 after completion of training of all staff regarding the protection of residents after inappropriate touching in a sexual manner by a residents and implementation of 1 to 1 as needed. The training also included the importance of following the abuse, neglect and exploitation policy, reporting, and protection of residents. The facility also provided 1 to 1 supervision of Resident #1. The deficient practice remained at the scope and severity of an E.