Every finding on record at Senator Ben Atchley State Veterans' Home

Based on medical record reviews, and interviews, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR's) were submitted to the state-designated authority for a Level II evaluation after diagnoses of serious mental illness were identified for 3 residents (Residents #1, #12, and #126) of 4 residents reviewed for PASARR's.The findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Insomnia, Post-Traumatic Stress Disorder (PTSD), and Recurrent Depression.Review of a PASARR for Resident #1 submitted on 1/25/2026 (prior to admission), revealed the resident had diagnoses of Anxiety Disorder and Mild or Situational Depression, but did not include the diagnoses of Insomnia, and PTSD. The PASARR outcome was .No Level II Required-Level I Negative .Review of the comprehensive care plan dated 1/29/2026, revealed Resident #1 .dx [diagnoses] of other recurrent depressive disorders, insomnia, generalized anxiety disorder and PTSD .Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #1 was marked as not having a Level II PASARR for a serious mental illness or related condition.Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Dementia without Behavioral Disturbance, Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Delirium, Anxiety Disorder, PTSD, and Nightmare Disorder.Review of a PASARR for Resident #12 submitted on 5/16/2024 (prior to admission), revealed the resident had diagnoses of Dementia/Neurocognitive Disorder and Anxiety Disorder, but did not include the diagnoses of Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Delirium, PTSD, and Nightmare Disorder. The PASARR outcome was .No Level II Required-Level I Negative .Review of an annual MDS assessment dated [DATE], revealed Resident #12 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #12 was marked as not having a Level II PASARR for a serious mental illness or related condition.Review of the comprehensive care plan dated 2/3/2026, revealed Resident #12 .dx of delirium . and .Mood/Behavior: I have dx of major depressive disorder, adjustment disorder with depressed mood and anxiety disorder .hx [history] nightmares .Review of the medical record revealed Resident #126 was admitted to the facility on [DATE] with diagnoses including Hallucinations, Major Depressive Disorder, and Other Specified Mental Disorders, Adjustment Disorder with Anxiety, and PTSD. Review of a PASARR for Resident #126 submitted on 11/14/2025, revealed the resident had a diagnosis of Major Depression but did not include diagnoses of Hallucinations, Other Specified Mental Disorders, Adjustment Disorder with Anxiety, and PTSD. The PASARR outcome did not indicate a Level II evaluation was required, with comments including .although this individual has a diagnosis of major depression, there are no indicators identified that would signify the need for further evaluation .Review of a significant change MDS assessment dated [DATE], revealed Resident #126 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident was marked as not having a Level II PASARR for a serious mental illness or related condition.Review of the comprehensive care plan dated 2/12/2026, revealed Resident #126 .Hallucinations and major depression noted .PTSD dx per psych [psychiatric services] . During an interview on 3/11/2026 at 4:00 PM, the Director of Nursing (DON) confirmed Resident #1's PASARR did not contain the diagnoses of PTSD, Recurrent Depressive Disorder, and Insomnia; Resident #12's PASARR did not contain the diagnoses of Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Delirium, PTSD, and Nightmare Disorder; Resident #126's PASARR did not contain the diagnoses of Hallucinations, Other Specified Mental Disorders, Adjustment Disorder with Anxiety, and PTSD.During an interview on 3/11/2026 at 4:30 PM, the Registered Nurse/Admissions/Case Manager (RN/ADM) stated, I [RN/ADM] do the PASARR's .the PASARR's for Residents #1, #12, and #126 must have been missed .

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store medication in 3 of 4 medication carts reviewed for medication storage.The findings include:Review of the facility policy titled, MEDICATION STORAGE IN THE FACILITY Storage of Medications, dated 1/2019, revealed .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .all medications dispensed from the pharmacy are stored in the container with the pharmacy label .Medication storage areas are kept clean .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated per facility policy .All expired medications will be removed from the active supply and destroyed .Review of the facility policy titled, MEDICATION ADMINISTRATION General Guidelines, dated 1/2019, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered at the time they are prepared .Medications are administered within 60 minutes of scheduled time .routine medications are administered according to the established medication administration schedule for the facility .During an observation and interview on 3/11/2026 at 1:05 PM, the C-Front medication cart was observed with dried debris in the bottom of the liquid medication storage drawer, and dried debris with a sticky substance on the outside of some liquid medication bottles. Licensed Practical Nurse (LPN) A stated the medication carts were cleaned weekly and as needed. LPN A confirmed the liquid storage drawer and some of the liquid medication bottles were not maintained in a clean condition.Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Dementia, Paraplegia, and Hypertension.During an observation and interview on 3/11/2026 at 1:07 PM, the C-Front medication cart revealed a 1-ounce clear medication cup in a drawer, a thick brownish colored substance filled 1/4 of the cup, and the cup was not labeled with a name, date, or time of preparation. LPN A stated the medication cup contained Resident #16's crushed medications mixed with applesauce, which the resident had refused to take on the morning medication pass, and had planned on attemptingg to administer the medication to Resident #16 later. LPN A confirmed the cup of prepared medications was in the medication cart's drawer and was not labeled with the resident's name, date, or time of preparation.Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Atrial Fibrillation, and Chronic Kidney Disease.Review of the Physician's Orders for Resident #24 dated 2/26/2026, revealed an order for Glargine insulin (also called Lantus - a long-acting injectable medication used to lower blood sugar levels) with directions to inject 30 units subcutaneously (injection into the fatty layer under the skin) two times daily.During an observation and interview on 3/11/2026 at 1:09 PM, the C-Front medication cart revealed a Lantus insulin pen for Resident #24 lying in the drawer, partially used, and was not labeled with an open date. LPN A confirmed the insulin pen was not dated when it was opened.Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including History of Sinusitis, Dementia, and Hypertension.Review of the Physician's Orders for Resident #87 dated 1/12/2026, revealed an order for Fluticasone Propionate 50 micrograms per actuate (mcg/act) (measured amount in each spray) with directions to give 1 spray into both nostrils in the morning.During an observation and interview on 3/11/2026 at 1:11 PM, the C-Front medication cart revealed a Fluticasone Propionate 50 mcg nasal spray for Resident #87 in a bag lying in the drawer and was not labeled with an open date. LPN A confirmed the nasal spray was not dated when it was opened.During an observation and interview on 3/11/2026 at 1:13 PM, the C-Front medication cart revealed a 100 milliliter (ml) container of Normal Saline 0.9% (percent), with a manufacturer's expiration date of 12/28/2025. LPN A confirmed the Normal Saline container had expired and was available for resident use.Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Congestive Heart Failure, and Hypertension.Review of the Physician's Orders for Resident #5 dated 3/2/2026, revealed an order for Lispro insulin (a short-acting injectable medication used to lower blood sugar levels quickly) with directions to inject 10 units subcutaneously before meals and at bedtime.During an observation and interview on 3/11/2026 at 1:30 PM, the C-Back medication cart revealed a Lispro insulin (Humalog) pen lying in the drawer with Resident #5's medications. The insulin pen was partially used, was not labeled with a resident's name or open date, and the pharmacy label was not on the pen. LPN B stated the Lispro insulin pen was Resident #5's and confirmed the insulin pen did not have the resident's name and was not dated when it was opened.Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease, and Chronic Respiratory Failure.Review of the Physician's Orders for Resident #11 dated 2/9/2026, revealed an order for Humalog insulin with directions to inject 10 units subcutaneously before meals and at bedtime.During an observation and interview on 3/11/2026 at 1:32 PM, the C-Back medication cart revealed a Lispro insulin pen lying in the drawer with Resident #11's medications. The insulin pen was partially used, was not labeled with a name or open date, and the pharmacy label was not on the pen. LPN B stated the insulin pen was Resident #11's and confirmed the insulin pen did not have the resident's name and was not dated when it was opened.Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis, Chronic Kidney Disease, and a current Urinary Tract Infection (UTI). During an observation and interview on 3/11/2026 at 1:33 PM, the C-Back medication cart revealed a vial of Ertapenem (injectable antibiotic - medication used to treat certain bacterial infections to include UTI) 1 gram per vial. The vial contained translucent yellow liquid, and was not labeled with a name, date, or time of preparation. LPN B stated the vial of medication had been reconstituted (mixed) earlier in the day. LPN B stated she had planned to administer the medication to Resident #3, but the powder (antibiotic medication) had not dissolved completely. LPN B confirmed the vial of prepared medication was in the medication cart's drawer, and was not labeled with the resident's name, date, or time of preparation.Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Dementia, and Heart Failure.Review of the Physician's Orders for Resident #61 dated 3/3/2026, revealed an order for Lispro insulin with directions to inject 14 units subcutaneously before meals and at bedtime.During an observation and interview on 3/11/2026 at 1:35 PM, the C-Middle medication cart revealed a Lispro insulin pen for Resident #61 lying in the drawer, partially used, and was not labeled with an open date. LPN C confirmed the insulin pen was not dated when it was opened.Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease, and Dementia.Review of the Physician's Orders for Resident #65 dated 2/3/2026, revealed an order for Lantus insulin with directions to inject 32 units subcutaneously twice daily.During an observation and interview on 3/11/2026 at 1:37 PM, the C-Middle medication cart revealed a Lantus insulin pen lying in the drawer with Resident #65's medications. The insulin pen was partially used and was not labeled with a name or open date. LPN C stated the insulin pen was Resident #65's and confirmed the insulin pen did not have the resident's name and was not dated when it was opened.During an interview on 3/11/2026 at 3:00 PM, the Director of Nursing (DON) confirmed the medication cart drawers and liquid medication bottles should be kept clean, and all resident's medications including nasal spray and insulin should be labeled with the resident's name and the date the medication was opened. The DON stated if resident medications were prepared, the medication should be administered promptly within the scheduled time frame, when a resident refuses to take medication, the medication should be discarded, and confirmed prepared medications should not be stored in the medication cart.

Based on facility policy review, medical record review, observations and interviews, the facility failed to prevent resident to resident sexual abuse for 2 residents (Residents #1 and #2) of five residents reviewed for abuse when Resident #1 was observed with a hand inside Resident #2's brief on [DATE]. The facility was cited at F-600 at a Scope and Severity of D and was cited as past non-compliance. Noncompliance began on [DATE], was corrected and ended on [DATE]. The facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Abuse and Neglect of Resident and Misappropriation of Resident's Property, dated [DATE], revealed .Sexual Abuse includes but is not limited to sexual harassment, sexual coercion or assault . Medical record review revealed Resident #1 was admitted to the facility [DATE] with diagnoses including Displaced Left Femur Fracture, Adjustment Disorder with Anxiety and Depressed Mood, Urinary Tract Infection, Unspecified Altered Mental Status, Insomnia, Chronic Kidney Disease, Multiple Rib Fractures, History of Falls, and Unspecified Dementia with Psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 10 on the Brief Interview of Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Continued review revealed Resident #1 had a history of wandering 1 to 3 days weekly which had improved since the last quarterly MDS assessment. Resident #1 utilized a wheelchair for ambulation and required assistance of 1 or 2 persons for activities of daily living (ADLs). Review of a repeat BIMS assessment dated [DATE], revealed Resident #1 scored an 8 on the assessment which indicated moderate cognitive impairment. Review of the care plan for Resident #1 revised [DATE], revealed the resident was considered at risk for bouts of confusion, wandering and anxiety with interventions in place on admission. Continued review revealed .touched female resident [Resident #2], 1:1 [one to one] observation, staff monitor proximity to others .BIMS ,d+[DATE] [8 out of 15 which indicated moderate cognitive impairment] . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anxiety Disorder, Dementia with Behaviors, and Hypertension. Review of the admission MDS assessment dated [DATE], revealed Resident #2 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Resident #2 had no history of behaviors, symptoms of depression, or signs of psychosis and required assistance of 1 or 2 persons for ADLs. Review of the care plan for Resident #2 dated [DATE], revealed the resident was considered at risk for wandering or bouts of confusion with interventions in place. The care plan was revised on [DATE] and revealed .residents [Resident #1 and Resident #2] had an intimate encounter .staff to provide supportive measures, staff to monitor resident's proximity to others .has code alert [a device to worn which uses radio frequency signals to lock doors in the event of attempted exit] .staff to orient to surroundings .NP [Nurse Practitioner] signed psych [psychiatric] rec [record] .no recommendations at this time . Review of the facility investigation dated [DATE], revealed at approximately 6:45 PM, Certified Nurse Aides (CNAs A and B) found Resident #1 in Resident #2's room. Resident #2 was in the bed in the supine position, with sheets pulled down, legs bent at the knee, her clothing pulled up, and her brief loosened on the right side. Resident #1 was observed seated beside the bed in a wheelchair with the right hand inside the front of Resident #2's loosened brief. As staff approached and entered the room, the female resident (Resident #2) stated . here they [staff] come . to the male resident (Resident #1) and Resident #1 withdrew his hand from Resident #2's brief. Resident #2 laughed and pulled the sheets back up covering herself. The residents were immediately separated without incident. CNA B asked Resident #2 if she was ok and Resident #2 responded, .we are fine . and laughed. Resident #1 and Resident #2 did not exhibit any mental or physical distress at the time. Review of a Psychiatric Evaluation for Resident #1 dated [DATE] revealed .Have been asked by facility staff to evaluation this patient for management of his psychiatric conditions .following an incident .wherein this resident was engaged in sexual behaviors with another resident .patient was found in female .room facility staff saw female resident laying supine on the bed with her legs spread, the covers pulled down and her pants partially removed. One side of her brief had been opened and [Resident #1] hand was noted to be inside the .brief .When staff entered the room [Resident #1] stated, ' .here they come .' At that time the female resident attempted to pull the sheets over herself .Facility staff state .both seemed to be enjoying themselves .No evidence of physical aggression, distress or nonconsensual activity was noted .[Resident #1] is alert makes good eye contact .affect is appropriate .patient is unable to recall/volunteer the events described above .when the scenario is described to him, patient states he ' .faintly .' recalls this situation .He does not remember which resident he was involved with in the above situation .Patient [Resident #1] was recently in romantic relationship with another resident who became his girlfriend. Unfortunately the girlfriend recently passed away .[Resident #2] .was residing in the room of his deceased girlfriend .Patient would frequently enter that room to visit his girlfriend to visit with her .Overall the patient has very poor recall and is unable to provide meaningful context or further details regarding the situation .it is felt possible that he was confused and thought he was with his previous girlfriend .Some of his responses to questions are inappropriate and disorganized .When asked if he would ever touch another person in a sexual manner without their consent he replies .I would never do that . While the patient has been involved in a romantic relationship previously, he had not exhibited sexually inappropriate behavior or any sexual disinhibition toward facility staff or other residents . There was no indication the situation above occurred in a non-consensual manner based on the disposition of each resident when they were found by staff and the lack of any behavior or expressions that would indicate any distress on behalf of either party . Review of a telemedicine Psychiatric Evaluation Note dated [DATE] for Resident #2 revealed, .I have been consulted to evaluate this patient for the management of her psychiatric conditions .following an incident where .this patient was involved in a sexual encounter with another resident .facility staff saw [Resident #2] laying supine on the bed with her legs spread, the covers pulled down, her pants partially removed .One side of her brief had been opened and the male resident's hand was inside the brief .The patient is alert, makes good eye contact, speaks clearly and discernably .She appears cheerful, jovial and makes small jokes throughout the interview .Affect is appropriate .She is an unreliable source of historical information .she denies any acute distress, anxiety, or other complaints .is unable to provide simple social information such as her age or whether she has been married in the past .She is oriented only to person .Currently tells me she is traveling with her father .She states ' .I did not even know I was at a nursing home .' .When questioned about the events above and whether or not she was recently involved in a sexual encounter, the patient states ' .no, I wish I had been though .' .Patient has a good laugh about this .Patient is unable to recall any of the events above .She is noted to have very poor recall .was asked how she would respond if ever someone attempted to touch her in a sexual manner without her consent .She replies ' . I would probably slap the shit out of them .' in report from family members .patient is described as a very social person who is flirtatious and enjoys male attention . During interview on [DATE] at 1:15 PM, Licensed Practical Nurse (LPN) A stated she was the nurse on duty at the time of the incident on [DATE] between Resident #1 and Resident #2. LPN A stated the incident occurred a few minutes prior to the evening shift change around 7:00 PM on [DATE]. LPN A stated CNAs B and C found the residents in Resident #2's room and Resident #1 had his hand in Resident #2's brief. LPN A stated the residents were separated without incident. LPN A stated when she interviewed the CNAs who found the residents, they reported Resident #2 was heard giggling as they approached the room and stated .here they come or they're coming . as staff entered the room and it appeared to them the residents were involved in a consensual act. LPN A stated Resident #2 was a new admission and was noted to be very sociable and at times flirtatious with males, but to that point had not exhibited any negative behaviors. LPN A stated Resident #2 occupied the bed previously occupied by a female resident who had passed away a few days prior, with whom Resident #1 had a consensual relationship for over 4 months with consent of both responsible parties. LPN A stated she believed Resident #1 in his confused state may have mistaken Resident #2 for the deceased resident. LPN A reported both residents had no recall of the incident a few hours afterwards and at that point still had no recall of it. During interview on [DATE] at 1:30 PM Resident #2 was pleasantly confused but cooperative. Resident #2 had a bright affect and was neatly groomed and showed no signs of neglect. Resident #2 had no recall of the incident. Resident #2 stated she felt safe in the facility. Resident #2 was asked if anyone touched her against her will in a private area and stated .if anybody did that and I didn't want it, I'd knock the shit right out of them . then began to laugh. Resident #2 stated she .liked it here [at the facility] . Resident #2 smiled throughout the interview and showed no signs of psychological distress. During interview with Resident #1 on [DATE] at 1:45 PM, Resident #1 reported he .was just passing through . Resident #1 had no recall of the incident, stated he was widower and did not recall his prior relationship with another resident, (the previous occupant of Resident #2's bed where she was located at the time of incident and with whom Resident #1 had intimate relations). Resident #1 stated he would never touch anyone without consent. Resident #1 denied any complaints or concerns, stated he felt safe in the facility, and hoped to go home in a few days. Resident #1 showed no signs of anxiety or other psychological distress and was clean, neatly groomed and appeared free of signs of neglect. During interview on [DATE] at 2:50 PM, CNA B stated she entered Resident #2's room with CNA C behind her on the evening of [DATE] and observed Resident #1 with his hand inside Resident #2's brief as reported in the facility investigation. CNA B stated both residents pulled the sheets up to cover Resident #2's groin as she entered the room and Resident #1 withdrew his hand from her brief. CNA B stated Resident #2 did not appear uncomfortable or in any distress and appeared to be engaged in a consensual act and was smiling and giggling as she pulled the bed sheet up to cover herself. CNA B reported the residents held hands briefly before she separated them while CNA C went to get LPN A. CNA B stated she remained in the room with the residents separated until evaluated by LPN A. CNA B stated she remained with Resident #1 and provided 1 to 1 supervision as directed by LPN A and noted Resident #1 did not exhibit any further behaviors. During interview on [DATE] at 3:05 PM, CNA C stated she entered the room behind CNA B and did not see Resident #1's hands clearly. CNA C confirmed she did see both residents as they pulled up the bed sheet and Resident #2 was laughing as she did so. CNA C stated she heard Resident #2 state .here they come . as the CNAs initially entered the room. CNA C stated it appeared Resident #2 had no distress during the occurrence. CNA C reported Resident #2 laughed at her when she asked Resident #2 if she was okay. CNA C reported Resident #2 stated .I am fine . as she laughed. CNA C reported Resident #1 was very confused at baseline and noted Resident #1's former paramour previously occupied the bed where Resident #2 was situated at the time of the incident. CNA C reported Resident #1's former paramour had died a few days earlier and she and Resident #2 looked very similar in terms of physical appearance and stated she thought it possible that Resident #1 may have mistaken Resident #2 for her. During interview on [DATE] at 3:15 PM, the Director of Nursing (DON) reported the facility investigation concluded the act between the residents was likely consensual. The DON acknowledged both residents involved in the incident were cognitively impaired and had no recall of the incident hours afterwards. The DON acknowledged the act was willful. The DON was unable to confirm or deny if the act was consensual based solely on the BIMS scores. The facility implemented multiple interventions in response to the incident which were validated onsite by the surveyor on [DATE] which are outlined as follows: On [DATE] at the time of the incident, Residents #1 and #2 were immediately separated. Resident #1 was placed on 1 to 1 supervision for monitoring as the incident was reported to Administration and an investigation was launched. Ad Hoc Quality Assurance (QA) of the incident by the DON and Administrator was performed as the investigation was initiated. On [DATE] the facility reported the incident to all authorities within 2 hours of occurrence as required by state and federal law. On [DATE] Care Plans for both residents were updated with orders to monitor proximity of both residents. On [DATE] the facility assessed all residents on the unit to ensure no impacts of the incident on others with no negative findings. No other residents were touched by Resident #1. On [DATE] Resident #2 was relocated to a different bed in a different room with family consent to move her from the bed previously occupied by Resident #1's paramour was recently deceased . On [DATE] the Psychiatric Provider performed an initial telehealth assessment of both residents with no new orders for Resident #2 and ordered Resident #1 maintained on 1 to 1 supervision until onsite evaluation could be performed the following day. On [DATE] the mental health provider and medical staff evaluated both residents in person. Neither resident recalled the incident. Neither resident exhibited negative impacts to physical or psychosocial health as a result of the incident. The mental health clinician determined there was no evidence of coercion or opposition to the acts reported as observed by staff by either resident and it was likely the acts were consensual. 1 to 1 supervision for Resident #1 was discontinued. Acute mental health referral for Resident #1 was ruled out by the mental health provider as medically unnecessary at that time as there was no evidence Resident #1 presented an imminent danger to self or others and was not in an acute psychiatric crisis. The mental health clinician recommended continued monitoring, redirection, and proximity management of both residents to prevent recurrences. The facility held additional QA of the incident with the Interdisciplinary team (IDT) and reviewed medication changes ordered for Resident #1 which included gradual dose reduction of antidepressant medications and increase in antipsychotic medication (Seroquel increased from 50mg once daily to 75mg administered in divided doses, 25mg in the morning and 50 mg at night). Staff education related to the facility abuse policy which had begun on the unit occupied by both residents, (D Wing) was expanded to include all facility staff. On [DATE] the mental health provider completed follow up assessments of both residents with no new negative findings. The mental health provider assessment was reviewed by administration and members of the IDT. Between [DATE] and [DATE] the facility performed re-education of all staff members on every unit to include non-clinical staff related to the facility abuse policies, definitions of abuse and abuse types and abuse reporting requirements. By [DATE] all staff currently scheduled or actively working were re-educated with 6 additional personnel to be educated identified. On [DATE] the mental health provider performed follow up visits with both residents which showed no evidence of changes in condition or needs for further interventions for either resident. The facility IDT team reviewed the findings during ongoing QA follow up of the incident. On [DATE] with consent of his family, the facility social worker documented that arrangements to transfer Resident #1 to a private room (401D) on the far end of the opposite wing from Resident #2 were arranged with the transfer date set for [DATE] when the room would become available. On [DATE] the facility completed education of all current active staff members and provided communications to 4 remaining employees scheduled to work that evening, education was required prior to taking assignments for their next scheduled shift. The surveyor validated facility interventions as follows: On [DATE] during the onsite investigation the surveyor conducted interviews with all personnel involved in the incident, the alleged victim and perpetrator and verified the incident occurred as reported to the SA. No evidence of psychosocial or physical harm to either resident was observed. Neither resident recalled the incident in interviews. On [DATE] the surveyor corroborated Resident #2's prior behavioral history with the responsible party and reported information contained in the FRI relevant to their feelings the act between their loved one and Resident #1 was likely due to confusion but was also likely consensual as reported. On [DATE] the surveyor reviewed care plans and observed both residents on the memory care wing. All interventions added to the care plan were in place and neither resident exhibited problematic behaviors. On [DATE] confirmed Resident #2 was relocated to a different bed on [DATE] as reported. On [DATE] the surveyor reviewed educational materials used to retrain staff, the facility abuse policy, and staff logs which documented staff member education was completed as reported. The surveyor interviewed 3 additional staff members in addition to those involved in the incident and verified all staff were knowledgeable of the facility abuse policy, definitions of abuse, reporting requirements, and the concept of capacity to consent with no negative findings. On [DATE] the surveyor interviewed 3 family representatives with attention to concerns for abuse or neglect, resident rights, resident protection, notification of changes in condition, administration, staffing, nursing services, access to clinical services, or unresolved grievances with no concerns identified. Resident interviews with 2 additional surveyed residents (Residents #4 and #5) showed no concerns. On [DATE] the surveyor reviewed updated staff re-education logs provided to the State Agency electronically, which showed all staff currently active at the facility had been re-educated as reported which included the remaining employees from the [DATE] employee education log. The facility also made communications to those who worked for contract agencies that were not scheduled, employed on an as needed (PRN) basis or were off work on vacation or on FMLA, which advised training would be necessary before resumption of duties had been sent per report of the facility leadership. The surveyor verified the incident had been forwarded to the facility Quality Assurance Committee for additional follow up review in February 2025 and the facility QA committee would make additional recommendations relevant to the incident if any were identified at that time. The facility was cited F-600 as past non-compliance and surveyor verified and validated the corrective actions on site on [DATE] and [DATE]. The facility is not required to submit a Plan of Correction.

Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record reviews, and interviews, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 3 residents (Resident #132, #32, and #73) of 27 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated 10/2023, showed .Review the medical record including the discharge plan and discharge orders for documentation of discharge location .The following is guidance .in which a resident receives tube feeding .If the resident does not eat or drink by mouth and relies solely on nutrition and liquids through tube feedings .code GG0130A as 88 .It is important to know what appliances [indwelling urinary catheter] are in use . Resident #132 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Prostate, Malignant Neoplasm of Bone, Type 2 Diabetes, Chronic Pain Syndrome, and Dementia. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE], showed Resident #132 had a planned discharge with a return not anticipated. Further review showed the resident was discharged on [DATE] to an acute care hospital. Review of a nursing progress note dated 12/12/2023, .Resident discharged .this morning to go home on hospice . During an interview on 2/14/2024 at 5:25 PM, the MDS Coordinator confirmed Resident #132's discharge MDS assessment dated [DATE], was inaccurate. 40606 Resident #32 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's Disease, Dementia, Type 2 Diabetes Mellitus, and Major Depressive Disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] showed .Section H .Urinary Catheter . Review of Resident #32's Comprehensive Care Plan showed Resident #32 was incontinent of bladder. No urinary catheter was documented. Review of the electronic Physician's Orders to include discontinued orders showed no order set for an indwelling catheter or order set for the care of an indwelling catheter had been documented. During an observation on 2/13/2024 at 11:55 AM, Resident #32 was sitting up in a wheelchair, in the dayroom with no indwelling urinary catheter in place. During an interview on 2/13/2024 at 8:05 AM, Licensed Practical Nurse (LPN) #1 stated Resident #32 has never had an indwelling urinary catheter to his knowledge. During an observation on 2/14/2024 at 1:25 PM, Resident #32 was sitting up in his wheelchair, in the dayroom with no indwelling urinary catheter in place. During an interview on 2/14/2024 at 2:35 PM, Certified Nursing Assistant (CNA) #1 stated Resident #32 has never had an indwelling urinary catheter to her knowledge. During an interview on 2/14/2024 at 3:26 PM, the Director of Nursing (DON) confirmed the MDS completed on 1/15/2024 which indicated Resident #32 had an indwelling urinary catheter was inaccurate. 49568 Resident #73 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Moderate Protein-Calorie Malnutrition, Vascular Dementia, Dysphagia (difficulty with swallowing), Hypertension, and Diabetes Mellitus. Review of a significant change MDS assessment dated [DATE], showed Resident #73 was dependent with eating and received tube feeding. Review of the comprehensive care plan dated 6/16/2023, showed Resident #73 .NPO [nothing by mouth] .Gtube [tube feeding] .for malnutrition .To maintain adequate nutrition and maintain stable wt [weight] .Tube feeding per order .NPO and dependent with tube feeding . Review of a physician's order dated 12/16/2023, showed .Enteral Feed [tube feeding] .NPO . During an observation on 2/12/2024 at 10:30 AM, showed Resident #73 lying in bed with tube feeding infusing. During an observation on 2/13/2024 at 9:30 AM, showed Resident #73 lying in bed with tube feeding infusing. During an observation on 2/14/2024 at 10:03 AM, showed Resident #73 lying in bed with tube feeding infusing. During an interview on 2/14/2024 at 10:25 AM, LPN #2 stated Resident #73 was NPO. During an interview on 2/14/2024 at 11:00 AM, CNA #2 stated Resident #73 was NPO. During an interview on 2/14/2024 at 5:30 PM, the MDS Coordinator confirmed Resident #73 was NPO, received tube feeding, and the significant change MDS assessment dated [DATE] was inaccurate.

Based on medical record review and interview, the facility failed to refer 1 resident (Resident #94) after the resident was diagnosed with a serious mental disorder, to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASRR) evaluation and determination of 7 residents reviewed for PASRR. The findings include: Resident #94 was admitted to the facility on [DATE] with diagnoses including Depression, Altered Mental Status, and Diffuse Traumatic Brain Injury. Review of the medical record showed Resident #93 received a diagnosis of Post Traumatic Stress Disorder (PTSD) on 7/30/2021. Review of a Notice of PASRR Level I Screen Outcome dated 11/21/2022, showed .DIAGNOSIS Major Depression .Depression . Further review showed PTSD was not identified. During an interview on 2/14/2023 at 5:44 PM, The Director of Clinical Services confirmed Resident #94 was diagnosed with PTSD on 7/30/2021 and the facility failed to refer the resident for a level 2 PASRR evaluation.

Based on review of facility documentation, medical record review, observations, and interview the facility failed to complete an accurate falls risk assessment for 1 resident (#103) of 6 residents reviewed for accidents of 37 sampled residents. The findings include: Medical record review revealed Resident #103 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact, was continent of bowel and bladder, required limited assistance of 1 for mobility, tranfers, dressing and toileting and sustained a fall with injury. Medical record review of the falls risk assessments revealed the following: 4/18/18 - Falls risk score of 12 indicated the resident was a high risk for falls; 8/30/18 - Falls risk score of 18 indicated the resident was a high risk of falls; 12/7/18 - Falls risk score of 14 indicated the resident was a high risk for falls; 1/23/19 - Falls risk score of 6 indicated the resident was not at risk for falls; 3/18/19 - Falls risk score of 4 indicated the resident was not at risk for falls; Medical record review of facility documentation dated 1/23/19, revealed Resident #103 was observed on floor in shower in his bathroom with a laceration to the left side of his head. Continued review revealed the resident complained of left side rib pain, and the resident was sent to the hospital for evaluation. Interview with Licensed Practical Nurse (LPN) #2 on 4/24/19 at 4:34 PM, at the 200 nurse's station, revealed the nurse was responsible to complete a falls investigation and falls risk assessment after a fall. Continued interview confirmed LPN #2 had failed to include the fall on the 1/23/19 falls risk assessment. Interview with the Director of Nursing (DON) on 4/24/19 at 4:51 PM, in the DON's office confirmed the falls risk assessment dated [DATE] for Resident #103 was an inaccurate falls risk assessment.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide documentation of Certified Nurse Aide (CNA) participation in the Care Plan process for 20 residents (#7, #8, #18, #24, #31, #45, #48, #50, #55, #69, #83, #95, #104, #108, #110, #111, #112, #115, #118, and #121) of 37 residents reviewed. The findings include: Review of the facility policy Clinical Comprehensive Care Plans Policy, dated 3/1/16 revealed .utilize information gathered .to develop, review and revise the Resident's Comprehensive Plan of Care .the Care Planning/Interdisciplinary Team .develops and maintains a comprehensive plan of care .that identifies the Resident's unique problems/weaknesses, strengths, preferences, goals and interventions .include, but not limited to .Nursing Assistants . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 10/31/18 and 1/9/19 revealed no documentation of CNA participation for Resident #7. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #8. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/24/19 revealed no documentation of CNA participation for Resident #18. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 11/8/18 and 2/11/19 revealed no documentation of CNA participation for Resident #24. Medical record review revealed Resident #31 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting on 1/22/19 revealed no documentation of CNA participation for Resident #31. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 11/23/18 and 2/25/19 revealed no documentation of CNA participation for Resident #45. Medical record review revealed Resident #48 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting on 2/26/19 revealed no documentation of CNA participation for Resident #48. Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 2/24/19 revealed no documentation of CNA participation for Resident #50. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/17/19 revealed no documentation of CNA participation for Resident #55. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #69. Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 1/3/19 and 3/21/19 revealed no documentation of CNA participation for Resident #83. Medical record review revealed Resident #95 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting dated 4/2/19 revealed no documentation of CNA participation for Resident #95. Medical record review revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #104. Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/29/19 revealed no documentation of CNA participation for Resident #108. Medical record review revealed Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 10/3/18 and 12/10/18 revealed no documentation of CNA participation for Resident #110. Medical record review revealed Resident #111 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting dated 3/22/19 revealed no documentation of CNA participation for Resident #111. Medical record review revealed Resident #112 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/11/19 revealed no documentation of CNA participation for Resident #112. Medical record review revealed Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/22/19 revealed no documentation of CNA participation for Resident #115. Medical record review revealed Resident #118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 12/12/18 and 1/9/19 revealed no documentation of CNA participation for Resident #118. Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/3/19 revealed no documentation of CNA participation for Resident #121. Interview with the Director of Nursing, the Minimum Data Set (MDS) Coordinator, MDS Coordinator Registered Nurse #1 and MDS Licensed Practical Nurse #1 on 4/24/19 at 12:55 PM, in the D Wing MDS office, confirmed the facility failed to provide documentation of CNA participation in the Care Plan process for 20 residents (#7, #8, #18, #24, #31, #45, #48, #50, #55, #69, #83, #95, #104, #108, #110, #111, #112, #115, #118, and #121) residents.

Based on facility policy review, medical record review, review of the facility's investigation, and interviews the facility failed to prevent misappropriation of property for 1 resident (#1) of 3 residents reviewed for misappropriation of property. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Review of the facility policy, Abuse and Neglect of Residents and Misappropriation of Residents' Property, undated, revealed .TSVH (Tennessee State Veterans Home) takes a firm stand on the issues of mistreatment, neglect, or abuse of residents and the misappropriation of resident's property .Residents must not be subjected to abuse by anyone including, but not limited to: facility staff . Review of the facility policy, Abuse, Neglect, and Misappropriation Prevention Policy, undated, revealed .Every precaution will be taken to prevent mistreatment, neglect, and /or abuse of a resident or misappropriation of their property. Residents must not be subjected to abuse, neglect, or misappropriation by anyone .Misappropriation of residents property means the deliberate misplacement, exploitation, or wrongful, temporarily or permanent use of a resident's belongs or money without the resident's consent . Review of the facility investigation revealed on 2/7/18 at approximately 3:00 PM, the Social Service Director (SSD) informed the Administrator that Resident #1 had reported his credit card missing. Further review revealed when the Administrator and SSD went to the resident's room, his wife was present and shared a copy of the Resident's December credit card statement. One traceable charge was a utility bill payment. Continue review revealed a report was filed with the (county) Sheriff's Department at 1:19 PM, on 2/8/18. On 2/9/18 at 2:50 PM, the Administrator was contacted by Human Resources and SSD who informed him a Detective had called asking if they knew .(alleged perpetrator's name). The officer was informed the individual was a previous employee of the facility. Interview with the Administrator on 2/26/18 at 8:42 AM, in the private dining room confirmed on 2/7/18, Resident #1 reported he had received his credit card statements which had charges on the card for November 30, 2017 through January 28, 2018, that neither he nor his wife had made. Further interview revealed the facility had been contacted on 2/9/18 by the detective investigating the incident inquiring about a previously employed individual who had been terminated on 1/25/18 for an unrelated incident prior to the discovery of the missing credit card. Observation and interview on 2/26/18 at 10:00 AM, with Resident #1 in his room revealed the resident seated in a wheelchair. Interview with Resident #1 confirmed the resident recalled the last time he used his credit card had been in August 2017. Continued interview revealed the resident and his wife had realized there were charges on the December statement that he hadn't made, and they thought the card had probably been lost. Interview with Resident #1's wife on 2/26/18 at 2:04 PM, revealed, the resident kept his wallet with credit cards in the drawer of his bedside table. Continued interview confirmed when she saw the December charges on the statement, she knew he had not made them. Someone started using it on November 30th (2017). Continued interview revealed on January 28, (2018), Resident #1's wife called the credit card company, and they (the credit card company) cancelled the card. Continued interview confirmed the residents' wife believed the card had been missing between 8/10/17 and 11/30/17. Interview on 2/27/18 at 12:10 PM, via telephone with the Detective investigating the incident confirmed the alleged perpetrator was a previous employee of the facility, and the incident timeline corresponded with the alleged perpetrators employment at the facility. Continued interview confirmed the Detective had viewed multiple video tapes of the alleged perpetrator making unauthorized purchases with Resident #1's credit card and charges were pending.

Based on observation and interview, the facility failed to dispose of garbage and refuse in a sanitary manner for 3 of 3 dumpsters observed. The findings included: Observation with the Assistant Dietary Manager on 3/5/17 at 9:30 AM, outside at the dumpster area, revealed: a). six blue disposable gloves. b). dried debris on the ground along the base of the middle dumpster c). multiple cigarette butts d). empty condiment packages, an empty potato chip bag, small pieces of paper, and a card board food package. All items were on the ground behind the dumpsters. Interview with the Assistant Dietary Manager on 3/5/17 at 9:35 AM, outside at the dumpster area confirmed the facility failed to dispose of garbage and refuse in a sanitary manner Interview with the Director of Clinical Services on 3/6/17 at 11:19 AM, in the conference room confirmed the dumpster area had not been maintained in a sanitary manner.

Based on review of facility policy, facility temperature logs, observation, and interview, the facility failed to maintain proper temperatures of refrigeration equipment in 1 of 3 refrigerated units, maintain regulatory temperatures for 26 thickened milks, to remove a scoop from a stored food container, and to date and label opened resident food for 1 of 2 nourishment room refrigerators and for 1 of 1 kitchen reviewed that could have affected 119 residents. The findings included: Review of the facility policy, Dietary Policies, dated 5/13/15 revealed .the refrigerator .must be 41 degrees or less .temperatures of refrigeration equipment shall be reviewed and recorded at least twice daily .keep scoops out of the stored food containers .cover, label and date container . Review of the Daily Refrigerator Temperature Log, for the milk box for March 2016, revealed .acceptable range: 32 degrees to 41 degrees . Further review revealed on 3/21/16 a recorded temperature of '42' for day shift and no recorded temperature for night shift. Continued review revealed the recorded temperature on 3/22/16 as '45' and not in use. Observation on 3/21/16 at 9:15 AM with Certified Dietary Manager (CDM) #1 at the milk box refrigerator in the kitchen revealed an internal temperature of 42 degrees Fahrenheit (F). Further review revealed the refrigerator contained thickened milks, house supplements, and juices. Observation with CDM #1 of the bottom shelf of the metal prep table on 3/21/16 at 9:40 AM, in the kitchen revealed a closed plastic container with 3 and ¾ quarts of powdered milk. Continued observation revealed a saucer in the powdered milk. Observation of the plating of the lunch service on 3/21/16 at 11:25 AM, with the CDM #1 during the plating of the lunch service revealed a large plastic bucket filled with 16 thickened 2% (percent) white milks and 10 thickened chocolate milks in covered cups and covered with ice. Further observation revealed the temperature of the thickened 2% white milk at 45.2 degrees F. Continued observation revealed the temperature of thickened chocolate milk at 47.0 degrees F. Observation with the CDM #1 on 3/21/16 at 12:05 PM, at the milk box refrigerator, revealed a temperature of 44 degrees F. Observation with the CDM #1 on 3/22/16 at 11:00 AM at the milk box refrigerator revealed a repairman working on the empty refrigerator. Observation with Registered Nurse/Unit Manager #1 on 3/22/16 at 12:30 PM, at the B wing Nourishment room at the resident refrigerator, revealed, in the freezer, 1 unlabeled 20 ounce (oz.) bottle of frozen citrus soda, and 1 opened, undated, unlabeled half gallon carton of chocolate ice cream. Further observation revealed in the refrigerator 1 opened, unlabeled, undated 64 oz. white cranberry juice and 1 opened, unlabeled, undated, 46 oz., white grape juice. Interview with the CDM #1 on 3/21/16 at 11:40 AM in the kitchen confirmed the facility failed to maintain proper temperatures of refrigerated units, to store thickened milks at the proper temperature, and to prevent scoops from remaining in stored food containers. Interview with the CDM #1 on 3/23/16 at 12:50 PM, at the C/D Nourishment Room, confirmed the facility failed to label and date opened foods in the nourishment rooms.

Based on facility policy review, medical record review and interview the facility failed to follow the care plan for 1 resident (#23) out of 4 residents reviewed for accidents of 32 sampled residents. The findings included: Review of the facility policy, Resident Lift Policy undated revealed .The Charge Nurse or Therapy staff representative will determine which lift is suitable for use. It is optimal for 2 staff members to be present during the use of resident lifts . Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE], revealed Resident #23 had a Brief Interview of Mental Status (BIMS) of 5 (indicating the resident was severely cognitively impaired). Continued review revealed the resident required extensive assistance of 2 persons for physical transfers. Medical record review of the Care Plan dated 1/27/14, revealed Resident #23 was care planned for being at risk for falls. Continued review revealed the resident required the assistance of 2 staff for Actvities of Daily Living (ADL's) and transfers. Review of the facility investigation dated 4/10/15 revealed a Certified Nurse Assistant used a sit to stand lift to transfer resident #23 into bed without assistance on 4/8/15. Interview with the Director of Nursing (DON) on 3/23/16 at 10:18 AM, in the DON Office, confirmed the resident was transferred on 4/8/15 by one person. Further interview confirmed Resident #23 required a 2 person assist with transfers and the facility failed to follow the care plan for Resident #23.

Based on facility policy review, medical record review, and interview the facility failed to ensure adequate supervision was provided during transfer for 1 resident (#23) of 4 residents reviewed for accidents of 32 sampled residents. The findings included: Review of the facility policy, Resident Lift Policy undated revealed .The Charge Nurse or Therapy staff representative will determine which lift is suitable for use. It is optimal for 2 staff members to be present during the use of resident lifts . Medical record review revealed resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE], revealed Resident #23 had a Brief Interview of Mental Status (BIMS) of 5 (indicating resident was severely cognitively impaired). Continued review revealed the resident was an extensive assist and required 2 person physical assistance with transfers. Medical record review of the Care Plan dated 1/27/14, revealed Resident #23 was care planned for being at risk for falls. Continued review revealed the resident required the assistance of 2 staff for Actvities of Daily Living (ADL's) and transfers. Review of the facility investigation dated 4/10/15 revealed a Certified Nurse Assistant used a sit to stand lift to transfer resident #23 into bed without assistance on 4/8/15. Interview with the Director of Nursing (DON) on 3/23/16 at 10:18 AM, in the DON Office, confirmed the resident was transferred on 4/8/15 by one person. Further interview confirmed resident #23 required a 2 person assist with transfers.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure proper hand hygiene during a dressing change for 1 resident (#108) of 1 resident observed for dressing changes. The findings included: Review of the facility's policy, Handwashing/Hand Hygiene, revealed If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations .3e. Before handling clean or soiled dressings, gauze pads, etc . Resident (#108) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED].cleanse . with Normal Saline, Pat Dry. Apply Ca (calcium) Alginate top with foam Dressing . Observation of Resident #108 in the resident's room on 3/23/16 at 9:09 AM, revealed the Treatment Nurse/Registered Nurse (RN) provided a dressing change to Resident #108's right ankle. Continued observation revealed the Treatment Nurse removed the soiled dressing from the wound, and placed the dressing into a red biohazard bag. Continued observation revealed the Treatment Nurse/RN removed her gloves, disinfected her hands, cleansed the open wound with a moistened gauze pad, discarded the moistened gauze pad in the red biohazard bag, and proceeded to prepare the clean treatment and dressing for the wound without removing the gloves and disinfecting the hands. Continued observation revealed the Treatment Nurse/RN trimmed the alginate dressing by holding it in the center and cutting around the edges to custom fit the wound site. Continued observation revealed the Treatment Nurse/RN placed the alginate dressing over the open wound, and covered it with a padded self-adhesive dressing. Interview with the Treatment Nurse/RN on 3/23/16 at 10:10 AM, in the treatment nurse's office confirmed the Treatment Nurse/RN had failed to follow infection control procedures by not disinfecting her hands after cleaning the open wound, and before preparing/applying the new dressing in accordance with the facility policy, Handwashing/Hand Hygiene.

Based on observation, review of facility policy, and interview, the facility failed to ensure expired food items were disposed of in the walk-in refrigerator and failed to ensure pans used for cooking were stored clean and dry in the dietary department. The findings included: Observation of the walk-in refrigerator in the kitchen with the Dietary Manager on January 21, 2014, at 9:12 a.m., revealed one plastic container of twelve purchased hard boiled eggs with an expiration date of January 16, 2014. Review of the facility's policy titled Food Storage Chart, updated August 2013, revealed, "...Commercially prepared food...recommended storage time when opened and stored in refrigeration...(is the) Manufacturers 'use by date'..." Interview with the Dietary Manager on January 21, 2014, at 9:12 a.m., in the walk-in refrigerator, confirmed the hard boiled eggs were expired and available for use. Observation in the kitchen, on January 21, 2014, at 3:40 p.m., revealed a white oily substance on the inside of three of eleven full size steam table pans, stored as clean. Further observation revealed three of six muffin pans, stored as clean, had dried tan debris and carbon build up. Interview during the observation with the Dietary Manager on January 21, 2014, at 3:41 p.m., confirmed the muffin pans and steam table pans were soiled.

Based on observation, interview, and review of facility policy, the facility failed to provide an environment that maintains or enhances each resident's dignity of thirty-two of seventy-five observed resident's during the dining observation. The findings included: Observation on November 13, 2012, at 11:15 a.m., in the Restorative Dining Room, revealed two Certified Nursing Assistants (CNAs) placing large cloth napkins on the resident's chest without asking the resident prior to placement. Further observation on November 13, 2012, at 12:10 p.m., in the Assisted Dining Room, revealed the Assistant Director of Nursing (ADON) and two CNAs placing large cloth napkins on the resident's chest without asking the resident prior to placement. Further observation on November 14, 2012, at 5:15 a.m., in the Restorative Dining Room, and 5:45 a.m., in the Assisted Dining Room, revealed CNAs placed large cloth napkins on the resident's chest without asking the resident prior to placement. Interview with the ADON on November 13, 2012, at 12:20 p.m., in the Assisted Dining Room, confirmed the staff placed large cloth napkins on each resident as a "clothing protector" without asking the residents if they wanted them. Interview with the Restorative Manager on November 14, 2012, at 6:00 a.m., in the Restorative Dining Room, confirmed the napkins were placed as "clothing protectors" without asking the residents if they wanted them. Review of facility policy, Dignity and Quality of Life Policy, revealed "...using bibs or other clothing protectors instead of napkins except by Resident's choice..." Observation on November 13, 2012, at 11:15 a.m., in the Restorative Dining Room, revealed the Speech Language Pathologist (SLP) was performing a swallowing study on one resident at a table of three. Prior to and during, observation the SLP failed to acknowledge the other residents at the table. Observation on November 13, 2012, at 12:25 p.m., in the Assisted Dining Room, revealed the Speech Language Pathologist (SLP) was performing a swallowing study on one resident at a table of four. Prior to and during, the observation the SLP failed to acknowledge the other residents at the table. Interview with the Restorative Manager, on November 13, 2012, at 12:45 p.m., in the Assisted Dining Room, confirmed the SLP did not interact with the other resident's while performing the swollowing assessment in the presence of other resident's.

Based on medical record review, and interview, the facility failed to ensure a safety device was in place for one resident (#5) of twenty-six residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was "...total dependence..." and required "...two + (plus) persons physical assist..." for transfers. Medical record review of a Plan of Care, dated November 2, 2009, revealed the resident was at risk for falls and was to use a "...Sit to Stand (used for transfers) lift for all transfers..." Medical record review of facility documentation dated, December 26, 2009, revealed, " ...CNA (Certified Nursing Assistant) who was assisting res (resident) with transfer was loosing safe grip. Res was safely lowered to floor to prevent fall..." Continued review of facility documentation revealed, "...Comments/Conclusion: Use lift for transfers, Two person transfers..." Interview with CNA #1 (on duty at the time of the fall) and the Director of Nursing, on June 2, 2010, at 9:40 a.m., in the Director of Nursing's office, confirmed the Sit to Stand lift was not in use on December 26, 2009, when the resident sustained [REDACTED].

Based on medical record review and interview, the facility failed to update the care plan to include appropriate repositioning techniques to prevent pain and potential injury to the shoulder for one resident recovering from shoulder surgery (#5) of five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems, was independent with decision-making and required extensive assistance of two with bed mobility. Medical record review of the initial nursing assessment dated [DATE], revealed, " ... Incision line right shoulder has 23 staples, Incision (without) redness, a lot of bruising and [MEDICAL CONDITION] ..." Review of a Social Worker note dated November 2, 2008, revealed, " ... has use of both hands, although ... has to be careful due to ... recent right arm surgery / injury ..." Review of the care plan dated November 2, 2009, revealed the resident had discomfort related to the right shoulder surgery. Continued review of the care plan revealed, "... reposition frequently for comfort measures..." and revealed no interventions for safe and appropriate repositioning of the resident in bed. Review of documentation provided by the facility revealed on November 6, 2008, at 3:50 p.m., two Certified Nursing Assistants (CNAs) repositioned the resident in bed, with one CNA on the resident's left side and one on the right side, and the CNAs pulled the resident up in bed by the arms. The resident "cried out in pain." Continued review revealed the CNAs had no knowledge of the resident's recent surgery to the right shoulder prior to repositioning the resident in the bed and revealed the resident identified the pain level in the arm as '9' on a scale of 1 -10 (worst pain being 10) after being repositioned by the CNAs. Medical record review of a nurse's note dated November 7, 2008, at 7:15 p.m., revealed, "Received a call from (Physician Assistant) requesting this resident be sent to ... ER ... to have ... right shoulder evaluated for pain and possible trauma ..." Medical record review of a nurse's note dated November 7, 2008, at 8:45 a.m., revealed the resident was transported to the emergency room . Medical record review of an x-ray report dated November 7, 2008, revealed, " ...Surgical hardware associated with the right shoulder is unchanged in appearance compared to 10/16/08. There is no new fracture or dislocation ..." Interview on February 18, 2009, with the Registered Nurse (RN) supervisor on duty at the time of the incident confirmed two CNAs who had no knowledge of the resident's recent surgery to the right shoulder "pulled" the resident up in the bed, and the resident "yelled out in pain." Interview with CNA #1 revealed CNA answered the resident's call light at the nurse's station, and the resident's spouse requested the resident be pulled up in bed. Continued interview with CNA #1 confirmed CNA #1 and CNA #2 were not assigned to the resident; had no knowledge of the recent surgery to the resident's right shoulder; and the CNAs were not informed by the resident or the spouse of the recent surgery to the right shoulder. Continued interview with CNA #1 confirmed the CNAs "pulled on" both the resident's right and left arms to reposition the resident in the bed. Continued interview confirmed the resident immediately complained of pain in the right shoulder after being pulled up in the bed. Interview on November 19, 2009, at 1:00 p.m., with the facility's Quality Assurance nurse confirmed the care plan did not include interventions related to safe and appropriate repositioning of the resident. C/O #

Based on medical record review and interview, the facility failed to ensure staff appropriately repositioned to prevent pain and potential injury to the shoulder for one resident recovering from shoulder surgery (#5) of five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems, was independent with decision-making and required extensive assistance of two with bed mobility. Medical record review of the initial nursing assessment dated [DATE], revealed, " ... Incision line right shoulder has 23 staples, Incision (without) redness, a lot of bruising and [MEDICAL CONDITION] ..." Review of a Social Worker note dated November 2, 2008, revealed, " ... has use of both hands, although ... has to be careful due to ... recent right arm surgery / injury ..." Review of documentation provided by the facility revealed on November 6, 2008, at 3:50 p.m., two Certified Nursing Assistants (CNAs) repositioned the resident in bed, with one CNA on the resident's left side and one on the right side, and the CNAs pulled the resident up in bed by the arms. The resident "cried out in pain." Continued review revealed the CNAs had no knowledge of the resident's recent surgery to the right shoulder prior to repositioning the resident in the bed and revealed the resident identified the pain level in the arm as '9' on a scale of 1 -10 (worst pain being 10) after being repositioned by the CNAs. Medical record review of a nurse's note dated November 7, 2008, at 7:15 p.m., revealed, "Received a call from (Physician Assistant) requesting this resident be sent to ... ER ... to have ... right shoulder evaluated for pain and possible trauma ..." Medical record review of a nurse's note dated November 7, 2008, at 8:45 a.m., revealed the resident was transported to the emergency room . Medical record review of an x-ray report dated November 7, 2008, revealed, " ...Surgical hardware associated with the right shoulder is unchanged in appearance compared to 10/16/08. There is no new fracture or dislocation ..." Interview on February 18, 2009, with the Registered Nurse (RN) supervisor on duty at the time of the incident confirmed two CNAs who had no knowledge of the resident's recent surgery to the right shoulder "pulled" the resident up in the bed, and the resident "yelled out in pain." Interview with CNA #1 revealed CNA answered the resident's call light at the nurse's station, and the resident's spouse requested the resident be pulled up in bed. Continued interview with CNA #1 confirmed CNA #1 and CNA #2 were not assigned to the resident; had no knowledge of the recent surgery to the resident's right shoulder; and the CNAs were not informed by the resident or the spouse of the recent surgery to the right shoulder. Continued interview with CNA #1 confirmed the CNAs "pulled on" both the resident's right and left arms to reposition the resident in the bed. Continued interview confirmed the resident immediately complained of pain in the right shoulder after being pulled up in the bed. Interview on November 19, 2009, at 1:00 p.m., with the facility's Quality Assurance nurse confirmed the CNAs pulled on the resident's arms while repositioning the resident in the bed; the resident complained of pain in the right shoulder; and the resident was transferred to the emergency room for x-ray of the right shoulder which revealed no injury. C/O #