Every finding on record at Senior Care Center - Brunswick

Based on observations and staff interviews, the facility failed to ensure that the dumpster area was free of debris and maintained in sanitary conditions. In addition, the facility failed to ensure the dumpsters lids for three of the four dumpsters had a secure fit and closed properly. The deficient practice had the potential to promote the harboring of pests, insects, and other organisms and create the potential for disease transmission by pest and rodents. The census was 126 residents. Findings include:During the initial tour of the outside area on 7/21/2025 at 9:30 am revealed the dumpster area had garbage and litter on the ground. Further observation revealed that the dumpsters lids for three of the four dumpsters were not secured and opened. Observation and interview on 7/23/2025 at 3:25 pm of the facility's dumpster with Dietary Kitchen Manager (DKM) revealed the dumpsters lids for three of the four dumpsters were not secured and opened. One of the four dumpster's lid was damaged, allowing it not to close properly causing the lid to lift, not having a secure fit and preventing the trash from being securely contained. Debris and used nitrile exam gloves were thrown on the ground around the dumpsters; boxes and litter were thrown behind the dumpsters. The DKM confirmed the condition of the dumpsters lids, the debris, and litter on the ground. He reported that the lids should be always closed to contain the trash. He verified that the trash should not be on the ground, nor thrown behind the dumpsters. He stated that he did not know that it was the kitchen staff's responsibility to maintain the garbage and refuse; however, all staff should take responsibility. The DKM reported being unaware of the dumpster condition. The DKM stated that he would organize a cleanup day for them to clean the dumpster area. Observation on 7/24/2025 at 11:55 am of the facility dumpster area revealed no changes in the condition of the dumpster area from the previous day.

Based on observations, staff interviews, record reviews and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to follow professional standards of quality care for two of six residents (R) (R89 and R51). Specifically, the facility failed to ensure all medications ordered were administered and documented according to professional standards of clinical practice. Findings include: A review of the facility's policy titled, Medication Administration: General Guidelines, reviewed 7/22/2024 stated that, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. At the end of each medication pass, the person administering the medications reviews the paper Medication Administration Record (MAR) or the electronic version of e-MAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. patient/ resident not in healthcare center at scheduled dose time, initial dose of antibiotics), the space provided on the front of the paper MAR for that dosage administration is initialed and circled and for facilities utilizing the e-MAR system the NOT ADMINISTERED button will be utilized with the appropriate reason given for not administering medication at scheduled time. 1. A review of the facility's admission records for R89 revealed that the resident admitted with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD) with acute exacerbation, proximal atrial fibrillation (A-Fib), muscle weakness, pulmonary fibrosis, vascular dementia, rheumatoid arthritis without rheumatoid factor, depression, chronic kidney disease and moderate protein calorie malnutrition. A review of R89 admission Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) a Brief Interview of Mental Status (BIMS) score of 13 which indicated minimal cognitive impairment; Section N (Medications)indicated the use of antipsychotics, antianxiety, antidepressants, anticoagulant, diuretic, antiplatelet, and anticonvulsants.A review of R89's active physician's orders included acetaminophen tablet 325 milligrams (MG) two tablets (start date 7/1/2025), ascorbic acid tablet 500 MG two tablets (start date 7/2/2025) , azelastine hydrochlorothiazide 0.137 milligrams metered dose nasal spray, two sprays in each nostril (start date 7/8/2025), and cholecalciferol 1.25 MG one tablet (start date 7/1/2025). During a medication pass on 7/22/2025 at 8:35 am on Live Oak hall with Licensed Practical Nurse (LPN) CC revealed her administering medications to R89. Azelastine hydrochlorothiazide 0.137 milligrams metered dose nasal spray, one sprays in each nostril, ascorbic acid tablet 500 MG one tablet were all administered however, cholecalciferol 1.25 milligrams one tablet was not administered.Review of the MAR for R89 on 7/22/2025 at 8:45 am revealed LPN CC documented administration of all medications as administered without indicating any omissions or errors. During an interview on 7/22/2025 at 9:00 am with LPN CC, she admitted to not administering the correct dosage of azelastine hydrochlorothiazide nasal spray and ascorbic acid 500 milligrams. LPN CC admitted she only administered one spray of nasal spray in each nostril and only one ascorbic acid tablet. She also admitted to omitting one tablet of cholecalciferol 1.25 milligrams stating that she was nervous and it was an oversight. LPN CC stated that she will go back and administer the missed medications in the correct dosage of the medications given in error. 2. During a record review of R51 admission records revealed the resident was admitted to the facility with diagnosis that included but not limited to quadriplegia, peripheral vascular disease, incomplete lesion at unspecified level of cervical spinal cord, seizures, vitamin D deficiency, major depressive disorder, chronic idiopathic constipation and polyneuropathy. During a record review of R51's Quarterly MDS dated [DATE] revealed Section C (Cognitive Patterns) a BIMS score of 15 indicating no cognitive impairment and Section N (Medications) indicated the use of inside depressants, anticoagulants, opioids and anticonvulsants.A review of the active physicians orders for R51 revealed docusate sodium 100 mg oral capsule [Colace] two caps two times daily (start date 10/10/2024), vitamin b-12 1tablet daily (start date 10/10/2024), polyethylene glycol 3350 17000 mg powder for oral solution [MiraLax] 30 ml (milliliter) by mouth every three days (start date 10/10/2024), sertraline 50 mg oral tablet one tablet once a day (start date 12/20/2024), carbamazepine 200 mg extended-release oral tablet one tablet, (start date 10/10/2024) , famotidine tablet 20 mg one tablet (start date 10/10/2024) , phenytoin sodium extended capsule; 100 mg three capsules daily (start date 10/10/2024), tramadol tablet 50 mg one tab two times daily (start date 10/31/2024), apixaban five mg oral tablet; one tablet (start date 9/20/2024), baclofen 10mg oral tablet; one tablet (start date 10/10/2024) and Lactulose 10MG/15 milliliters (ML), amount 30ML(start date 10/10/2024). During a medication pass on 7/22/2025 at 9:30 am with LPN EE on Turtle Cove hall revealed her administering medications to R51. LPN EE was observed administering docusate sodium 100 mg oral capsule [Colace] one capsule, apixaban 5mg oral tablet one tablet, baclofen 10mg oral tablet one tablet, carbamazepine 200 mg extended-release oral tablet one tablet, famotidine 20 mg oral tablet one tablet, phenytoin 100 mg capsules three capsules and tramadol hydrochloride 50 mg extended-release oral tablet one tablet. A review of the MAR for R51 revealed LPN EE administered docusate sodium 100 MG capsule one capsule and did not administer vitamin B12 one tablet, Lactulose 10MG/15ML 30ML, polyethylene glycol 3350 17000 milligram powder 17grams nor sertraline 50MG one tablet. There was no documentation on the MAR indicating the administration of carbamazepine tablet; 200 mg one tablet two times daily, famotidine tablet 20 mg one tablet, phenytoin sodium extended capsule; 100 mg three capsules daily and tramadol - schedule IV tablet 50 mg one tab two times daily. During an interview on 7/22/2025 at 10:00 am with LPN EE revealed that not only was she new to the facility, but she was also new to using the current electronic medical records (EMR) system. She denied seeing the medications omitted on the MAR during her administration and acknowledged to not signing off the MAR after completing the medication administration. During an interview on 7/22/2025 at 2:00 pm with LPN DD, she confirmed the missing signatures on the EMR and stated that she could not explain why the medications omitted by LPN EE was not showing up on her EMR screen. She acknowledged the missing signatures on the EMR for the medications omitted by LPN EE stating she will look into it. During an interview on 7/29/2025 at 3:30 pm with the Director of Nursing (DON) she confirmed the missing signatures on the EMR reiterating that if it is not documented then it wasn't done. She also revealed that it is my expectation that the nurses are administering medications according to physician orders. If they are unsure about an order they are to contact the doctor or Nurse Practitioner (NP) for clarification and to document the reason for not giving the medication. She also stated that the nurses are to notify the doctor and document in the residence records according to the instructions given to them by the medical doctor (MD). The DON stated that if there was an omission or an error made during a medication pass that the nurse should document the error and/ or the omission. The resident should be notified as well as the responsible party (RP) and the resident should be monitored due to the omission and reported to the medical doctor (MD) of any findings.

Based on observations, residents and staff interviews, record review, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to ensure the medication error rate was less than five percent. There were nine errors with 56 opportunities for three of six residents (R) (R51, R89 and R92) observed for a medication administration with an error rate of 16.07 percent. This deficient practice had the potential to place all residents at risk of avoidable medical complications due to not receiving medications or receiving an incorrect dose of medication other than that prescribed by the physician. Findings include: During a review of the facility's policy titled, Medication Administration: General Guidelines, dated 7/22/2024, revealed under heading Procedure: Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the patient/ resident's age and condition, or a medication order seems to be related to the patient/ resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. This interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. patient/ resident not in healthcare center at scheduled dose time, initial dose of antibiotic), The space provided on the front of the paper Medication Administration Record (MAR) for that dose administration is initialed and circled and for facilities utilizing the e-MAR system the NOT ADMINISTERED button will be utilized with the appropriate reason given for not administering medication at scheduled time period an explanatory note is entered on the reverse side of the record provided for as needed (PRN) indication and general medication notes and for EMR the note can be typed in the appropriate space provided within the electronic system. If more than two consecutive doses of a vital medication or refuse, the physician is notified. 1. Review of R51 admission records revealed the resident was admitted to the facility with diagnosis that included but not limited to quadriplegia, peripheral vascular disease, incomplete lesion at unspecified level of cervical spinal cord, seizures, vitamin D deficiency, major depressive disorder, chronic idiopathic constipation and polyneuropathy.A review of the active physicians orders for R51 revealed docusate sodium 100 milligram (MG) oral capsule [Colace] two caps two times daily, vitamin b-12 1tablet daily, polyethylene glycol 3350 17000 mg powder for oral solution [MiraLax] 30 ml (milliliter) by mouth every three days, sertraline 50 mg oral tablet one tablet once a day, carbamazepine tablet; 200 mg one tablet two times daily, famotidine tablet 20 mg one tablet, phenytoin sodium extended capsule; 100 mg three capsules daily, tramadol tablet 50 mg one tab two times daily, apixaban 5 mg oral tablet; one tablet, baclofen 10mg oral tablet; one tablet, and 12 HR (hour) carbamazepine 200 mg extended-release oral tablet; one tablet. During a medication pass on 7/22/2025 at 9:30 am with LPN EE on Turtle Cove hall revealed her administering medications to R51. LPN EE was observed administering docusate sodium 100 mg oral capsule [Colace] one capsule (instead of two), apixaban 5 mg oral tablet one tablet, baclofen 10 mg oral tablet one tablet, 12 HR carbamazepine 200 mg extended-release oral tablet one tablet, famotidine 20 mg oral tablet one tablet, phenytoin 100 mg capsules three capsules and tramadol hydrochloride 50 mg extended-release oral tablet one tablet. Vitamin B12 one tablet, Lactulose 10mg/15ml-30ml, polyethylene glycol 3350 17000 milligram powder 17grams nor sertraline 50 mg one tablet was administered. A review of the MAR for R51 revealed LPN EE administered the docusate sodium 100 mg capsule one cap and did not administer vitamin B12 one tablet, Lactulose 10mg/15ml-30ml, polyethylene glycol 3350 17000 milligram powder 17grams nor sertraline 50 mg one tablet. During an interview on 7/22/2025 at 10:00 am with LPN EE revealed that not only was she new to the facility, but she was also new using the current electronic medical records (EMR) system. She denied seeing the medications omitted on the MAR during her administration and acknowledged to not signing off the MAR after completing the medication administration. 2. A review of the facility's admission records for R89 revealed that the resident admitted with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD) with acute exacerbation, proximal atrial fibrillation (A-Fib), muscle weakness, pulmonary fibrosis, vascular dementia, rheumatoid arthritis without rheumatoid factor, depression, chronic kidney disease and moderate protein calorie malnutrition.A review of R89's active physician's orders included acetaminophen tablet 325 milligrams (MG) two tablets, ascorbic acid tablet 500 MG two tablets, azelastine hydrochlorothiazide 0.137 milligrams metered dose nasal spray, two sprays in each nostril, and cholecalciferol 1.25 MG one tablet. During a medication pass on 7/22/2025 at 8:35 am on Live Oak hall with Licensed Practical Nurse (LPN) CC revealed her administering medications to R89. Azelastine hydrochlorothiazide 0.137 milligrams metered dose nasal spray, one sprays in each nostril, ascorbic acid tablet 500 MG one tablet were all administered however, cholecalciferol 1.25 milligrams one tablet was not administered. During an interview on 7/22/2025 at 9:00 am with LPN CC, she confirmed she did not administer the correct dosage of azelastine hydrochlorothiazide nasal spray and ascorbic acid 500 milligrams. LPN CC admitted she only administered one spray of nasal spray in each nostril and only one ascorbic acid tablet. She also admitted to omitting one tablet of cholecalciferol 1.25 milligrams stating that she was nervous and that it was an oversight. 3. Review of clinical records for R92 revealed that she was admitted to the facility with diagnoses that included but not limited to atherosclerotic heart disease of native coronary artery with unstable angina pectoris, vascular dementia, cerebrovascular disease, major depressive disorder, recurrent, here with psychotic symptoms, general anxiety disorder, seizures cognitive communication deficit and impacted cerumen. Review of the active physician's orders revealed folic acid 1 mg one tablet, isosorbide dinitrate 20 mg oral tablet one tablet, colchicine 0.6 mg oral capsule one capsule, Lacri- Lube opth application to both eyes, clopidogrel 75 mg oral tablet one tablet, nystatin 100000 unit/ml oral suspension 5 ml, lactulose 10 mg/15 ml oral solution 30 ml, aspirin 81 mg chewable tablet one tablet daily, amlodipine 2.5mg one tablet daily, acetaminophen 325 mg / oxycodone hydrochloride 5 mg oral tablet [Percocet], aripiprazole tablet 5 mg 0.5 tablet, Debrox (carbamide peroxide) drops 6.5 % 8 drops each ear; otic (ear) twice a day, divalproex capsule, delayed release sprinkle 125 mg three caps and escitalopram oxalate tablet 5 mg three tablets. During a medication pass on 7/23/2025 at 9:00 am with LPN AA revealed her administering medications to R92. LPN AA was observed administering Debrox (carbamide peroxide) drops 6.5 % into R92 ears. She administered two drops to each ear and inserted balls of cotton into both ears before leaving the room. During an interview on 7/23/2025 at 9:34 am with LPN AA, she confirmed she only administered two drops of Debrox to each ear before inserting the cotton ball. LPN AA then verified the medication order and stated, I forgot. She added that she was familiar with the residents but not with their medications. She stated that she checked the medication orders prior to getting ready for the administration but simply forgot the amount of drops to be given. During an interview on 7 29/2/25 at 3:30 pm with the Director of Nursing (DON) she confirmed the missing signatures on the EMR reiterating that if it was not documented then it wasn't done. She also revealed that it is my expectation that the nurses are administering medications according to physician orders. If they are unsure about an order they are to contact the doctor or Nurse Practitioner (NP) for clarification and to document the reason for not giving the medication. She also stated that the nurses are to notify the doctor and document in the residence records according to the instructions given to them by the medical doctor (MD). The DON stated that if there was an omission or an error made during a medication pass that the nurse should document the error and/ or the omission. The resident should be notified as well as the responsible party (RP) and the resident should be monitored due to the omission and report to MD any findings.

Based on observations, staff interviews and review of the facility's policy titled, Medication Storage in the Healthcare Center, the facility failed to ensure that all drugs and biologicals were discarded prior to the expiration date on one of nine medication carts (Harbor Side) and two of six medication rooms (Central Supply and Ocean Breeze). This deficient practice had the potential to place residents at risk for medical complications and delayed treatment. The facility census was 126 residents.Findings include: Review of the facility's policy titled, Medication Storage in the Healthcare Center, revised 6/20/2025, under the section titled, Procedure revealed, number three, Nurses and medication aides are required to check all medications for deterioration and expiration before administration. And medication aides are also required to inspect medication storage facilities, including medication cards, routinely. Medication storage areas are to be kept clean, well lit, and free of clutter. Nursing staff and medication aides who administer medications are responsible for the cleaning and organization of medication carts and storage areas.Number12 revealed, Outdated, or deteriorated medications and those in containers, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. During an observation on 7/22/2025 at 12:43 pm of the medication cart on Harbor Side, revealed a bottle of Allergy Relief with expiration date January 2025 in the medication cart. During an observation on 7/22/2025 at 1:04 pm of the central supplies medication storage area revealed two bottles of aspirin 325 milligrams (mg) with expiration date June 2025. During an observation on 7/22/2025 at 2:16 pm of the medication room on Ocean Breeze, revealed two boxes of COVID-19 antigen rapid tests with a used by date 4/30/2025.During an observation on 7/22/2025 at 12:45 pm with Licensed Practical Nurse (LPN) FF revealed that she did not normally work on Harbor Side Hall and that her regular hall was Live Oak. LPN FF also revealed that did not normally administer these medications and therefore did not check the expiration date. She confirmed that she knew to check the medication cart and to remove any expired medications but, she did not do so. During an interview on 7/23/2025 at 9:54 am with LPN GG revealed that when you can't tell the expiration date you're to discard the medication and replace it. She confirmed that she did not check the medication cart for expired medications when she returned to work after her scheduled days off. During an interview on 7/28/2025 12:05 pm with LPN AA revealed that the nurses on the cart were responsible for checking and removing expired medications from the cart. LPN AA stated that the cart should be checked weekly for expired medications. She also stated that I did an inventory about four weeks ago of both the medication cart and the medication storage room and removed all expired medications. LPN AA stated that all nurses were responsible for checking all medications for expiration date before administering the medication. She also stated that It was also an oversight on my part as well. LPN AA stated that the central supply person is generally responsible for the central supply medication closet. During an interview on 7/29/2025 at 10:04 am with the Central supply manager/ Transporter revealed she was responsible for stacking and auditing supplies in the nursing supply closet in the central supply room. She stated that I order as needed with a specific amount kept in the closet, I rotate the stuff according to what's going out first meaning what's expiring sooner gets pulled to the front. I check weekly for expired medications and if expired then I pull it and dispose of it. I'm not sure if the nurses placed extra stuff found in their carts back in my storage and that's why I had expired stuff in my closet. During an interview on 7/28/2025 at 3:38 pm with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that all nurses were responsible for disposing expired medications immediately if it was expired. The DON stated that if it is a continuous medication then the nurse should reorder it or replace it if it is an over-the-counter medication. She also stated that the pharmacy comes monthly and checks everything including expired medications. The DON revealed that nurses should be checking the expiration date before administering medications as well as the managers, just as an extra set of eyes. I think it's a team effort.

Based on staff and residents' representative interviews, record review, and review of the facility's policy titled, Resident Trust Funds, the facility failed to ensure two out of three residents (R) (R135 and R139) accounts reviewed, that the resident or residents' representative received a final refund within 30 days of expiration or discharge. Findings include:Review of the policy titled Resident Trust Fund revised date [DATE] revealed, when a patient whose funds are held and managed by the facility in the Patient Trust Fund expires or is permanently discharged , the Business Office will ensure that the balance of the account is refunded, and a full accounting is provided, within 30 days of expiration or discharge (or as required by state law) to the: patient or legal representative. 1. Review of the admission record revealed R135 admitted on [DATE] and expired on [DATE].Review of R135's resident statement landscape dated [DATE] revealed the resident had a credit balance of $25.01.Interview on [DATE] at 1:28 pm with the Administrator confirmed the facility owed R135's representative $25.01. The Administrator stated that the financial services person was terminated for not issuing money back to residents and or their representatives in a timely manner. The Administrator stated that the corporate office was going to issue $25.01 back to the resident's representative. 2. Review of the admission record revealed R139 was admitted on [DATE] and discharged on [DATE].An interview on [DATE] at 11:03 am with R139's representative revealed he had not received the balance of funds from R139's trust account. He revealed it was less than $100 but that the facility kept giving him the run around to get it. Review of R139's resident statement landscape dated [DATE] revealed the resident had a credit balance of $57.66.Interview on [DATE] at 10:30 am with the Administrator confirmed the facility owed R139's representative $57.66. The Administrator stated that her financial services person was terminated for not issuing money back to residents and or their representatives in a timely manner. The Administrator stated that the corporate office was going to issue $57.66 back to the resident's representative.

Based on observations, resident and staff interviews, the facility failed to ensure a safe, clean, comfortable, home-like environment for one out of 29 rooms (room [ROOM NUMBER] B) located on the 200 hall. Specifically, clean bed linens were not provided for the resident in room [ROOM NUMBER] B.Findings include:An interview on 7/21/2025 at 12:48 pm with the resident in room [ROOM NUMBER] B revealed that his sheets had not been changed in a month. He showed the surveyor where he placed his initials on the underside of the sheet to track if his sheets were being changed. Observation of room [ROOM NUMBER] B's bed linens on 7/21/2025 at 12:48 pm, 7/22/2025 at 12:55 pm, and 7/23/2025 at 1:00 pm revealed the resident's initials on the underside of his sheets indicating they had not been changed.Interview on 7/22/2025 at 12:15 pm with Certified Nurse Assistant (CNA) HH working on the 200 Hall, confirmed the sheets on resident's beds did not get changed as often as they should. She revealed the resident's sheets should be changed on bath days or as needed. She stated that CNAs were too busy doing other tasks and couldn't get to the resident's rooms to change bed linens. She revealed she did not change the resident's linens and did not know when the last time they were changed.Interview on 7/23/2025 at 12:50 pm with CNA KK working on the 200 Hall revealed bed linens should be changed on bath days or as needed. She stated CNA's were responsible for changing linens. She confirmed that the resident in room [ROOM NUMBER] B had a bath sometime that morning, but she did not change his sheets and had no idea when the last time his sheets were changed. An interview on 7/23/2025 at 1:40 pm with the Assistant Director of Nursing (ADON) revealed CNA's were to ensure bed linens were changed on shower days or as needed. Observation and interview on 7/23/2025 at 1:50 pm with the Director of Nursing (DON) confirmed that the bed sheets needed to be changed and saw the resident's initials. She said she would think best practice would be for linens to be changed daily but at least on bath days or as needed. She looked at the resident's initials and stated that his sheets not being changed for a month was unacceptable. She stated that she was going to get them changed.

Based on observations, staff interviews, record review and review of the facility's policies Care Plans and Smoke Free Policy, the facility failed to develop and implement care plan interventions for four out of 49 sampled residents (R) (R120, R10, R16, and R26). Specifically, care plans addressing the following were not developed and implemented for R10 and R120 related to elopement, R16 related to smoking, and R26 related to diet orders. This failure had the potential to cause the residents not to receive treatment and/or care according to their needs. Findings include: Review of the facility's policy titled, Care Plan, dated 7/27/2023 under the “Policy Statement” revealed, “It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice”. Under the section titled, “Procedure: New admission Baseline Plan of Care “revealed, “2. the baseline care plan will be updated to reflect changes to approaches, as necessary, that result from significant changes in condition or needs occurring prior to the development of a comprehensive care plan. Within the first few days of admission, a Post admission Care Conference (PACC) will be held for update and review of the baseline care plan.” Under the section titled admission Comprehensive Plan of Care revealed, 2. A comprehensive person-centered care plan will be developed by the interdisciplinary team for each patient /resident within seven days after the completion of the comprehensive assessments. The patient/resident and/or the patient/resident’s representative will participate to the extent practicable in the care planning process. An explanation must be included in a patient/resident's medical record if the participation of the patient/ resident and their patient/ resident’s representative is determined not practicable for the development of the patient/ resident’s care plan. 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychosocial needs. These services are to be furnished to attain or maintain the Resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment… 5. The comprehensive care plans will be developed electronically, printed and filed in the medical record for manual updates. For MatrixCare users, care plans are maintained and updated electronically. Review of the facility’s policy titled, “Smoke Free Policy” with a revised date 7/30/2024 under the section titled “Grandfathered in Patients/Residents: Assessment & Care Planning” revealed, (2). Grandfathered patients/resident(s) will be assessed, utilizing the Smoking Observation Form in the Electronic Health Record, by a Licensed Nurse upon admissions, re-admission, and/or with a significant change. A re-admission Smoking Care Plan shall be developed by the Licensed Nurse on the admission Interim Care Plan Form, or electronically. 1. Review of clinical records for R120 revealed diagnoses that included but not limited to dementia, with severity of other behavioral disturbances, type 2 diabetes, and major depressive disorder. Review of progress note dated 2/21/2025 for R120 revealed that R120 rolled out the front doors behind Emergency Medical Services (EMS); the resident was seen by housekeeping and was brought back inside but never left facility grounds. The resident was asked where she was going and stated she was going home. Review of progress note dated 4/24/2025 revealed that R120 was found sitting on the floor in her room beside a large black bag full of her belongings. The resident had packed all of her items and stated she was going home. Further review of the progress note documented that the resident did this from time to time and that this was not an abnormal occurrence for this resident. Review of R120’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate impairment. Section E (Behavior) revealed the presence of wandering behaviors one to three days during the assessment period. Section I (Active Diagnosis) revealed, diagnoses of Dementia, Cerebrovascular Accident, Depression, and Psychotic disorder. Review of the incident report for R120's elopement on 6/29/2025 revealed that R120 was observed outside the facility by Housekeeper TT who was dumping out water from her bucket. She looked up and saw R120 rolling down the alley road with her shower bag, headed towards [NAME] Avenue at 3:20 pm. The housekeeper alerted all the floors that R120 was getting away down the road. It was reported that staff observed R120 attempting to exit through the Turtle Cove unit's doors, but she was unable to do so because the doors were locked. Housekeeper TT was unsure how she had exited, but later discovered it was through the smoking door. After this incident, R120 was moved to the memory unit. Review of R120’s care plans revealed “ELOPEMENT: Requires admission to the specially designed secure unit R/T (related to) elopement, dementia, intermittent confusion, exit seek behavior.” with a problem start date of 7/2/2025. There was no evidence that an elopement risk care plan had been developed prior to 7/2/2025. 2. Review of clinical records for R10 revealed diagnoses that included but not limited to autistic disorder, bipolar disorder, current episode mixed, severe, with psychotic features, and depression. Review of R10’s admission MDS assessment dated [DATE] revealed Section C (Cognitive Patterns), a BIMS score of 3 which indicated severe cognitive impairment. Review of clinical records revealed, an “Elopement Risk Observation Form” was completed on 6/30/2025 which indicated R10 was a high risk for elopement, with a score of 12. Review of the Care Plan for R10 with last reviewed/revised date of 7/22/2025 revealed that an Elopement Risk care plan had not been developed for the resident. During an interview on 7/24/2025 at 1:02 pm, the Administrator revealed she was unsure about the care plan being updated after the assessment, and that she would have to look at the clinical records. During an interview on 7/24/2025 at 1:16 pm, the Nurse Consultant stated that there should be an assessment completed after each attempt, and a care plan should be in place for elopement risk. She further noted that their process involves assessing residents on admission, readmission, quarterly, and after a significant change of event. Interview on 7/24/2025 at 4:15 pm with the MDS Coordinator revealed that the Elopement Assessment was implemented for all staff once they answered the interview questions. Residents with high-risk scores are 11 and above, low-risk scores are 0-4, and moderate scores are 5-10. The MDS Coordinator revealed that CAA care assessments activate the care plan, that allows MDS to review progress notes, plan of care (POC), and the chart within a 7-day look back window. If it is missed within the seven days, she cannot code it in MDS, and it should be discussed in morning meetings. The care plan and interventions should be implemented for elopement. MDS confirmed that the Interdisciplinary team (IDT) reviews charts daily to gather reports on behaviors and that the nursing department should document information to ensure that elopement behaviors are appropriately recorded. Further interview revealed that once assessments are completed, a care plan should be updated/developed if the elopement scores are high risk or moderate. 3. Review of medical records for R16 revealed diagnoses that included but not limited to, other sequelae of other cerebrovascular disease, spastic hemiplegia affecting left nondominant side; type 2 diabetes mellitus with unspecified complications, borderline personality disorder, nicotine dependence, cigarettes, uncomplicated; and generalized anxiety disorder. Review of R16’s Annual MDS dated [DATE] for Section C (Cognitive Patterns) revealed, a BIMS of 15 which indicated the resident was cognitively intact. Review of the smoking list revealed R16 was identified as a tobacco user. Review of R16’s clinical record on 7/21/2025 revealed there was no “Smoking Observation Form “completed. Review of R16’s care plan on 7/21/2025 revealed she did not have a care plan related to smoking. Further review of clinical records revealed the care plan and the “Smoking Observation Form” was completed on 7/22/2025. Observation and interview on 7/21/2025 at 1:00 pm with Certified Nursing Assistant (CNA) LL entering R16’s room to find out if R16 to find out if she was ready to get dressed to go outside to smoke. She stated that R16’s smoke break was 2:00 pm when asked. Observation on 7/22/2025 at 2:10 pm of smoke break revealed R16 sitting outside in the designated smoke area smoking a cigarette with staff supervision. During an interview on 7/28/2025 at 3:20 pm with Unit Manager/LPN AA, revealed that the facility became a smoke-free facility after (Name of Facility) took over. She stated that R16 was smoking before she started working at the facility. She confirmed that R16 smoked and stating that R16 had been Grandfathered in. During an interview on 7/29/2025 at 1:05 pm with MDS coordinator revealed, there should have been a care plan and assessment completed for R16. She confirmed that there was not a care plan nor an assessment in the Electronic Health Record (EHR) before 7/22/2025. She stated that everything was electronic in February 2025 and that there should have been something in the EHR. She stated that she had been going through trying to update information on the care plan; however, she was the only MDS person and there was no one in the position for several months before she was hired. 4. Review of the medical records revealed R26 had diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, need for assistance with personal care, and dysphasia following cerebral infarction. Review of R26’s physician order dated 1/10/2025 listed a dietary order for no added salt, mechanical soft. Review of R26 's care plan with a start date of 9/30/2024 and last revised on 7/22/2025 revealed resident requires a mechanically altered and therapeutic diet related to dysphagia and hemiplegia. Interventions included Diet: mechanical soft diet. Record review revealed a progress note dated 5/21/2025 that revealed the resident had a choking incident. The note revealed the resident is on a mechanical soft diet that requires meat to be grounded and was mistakenly given a hamburger for lunch. Interview on 7/28/2025 at 2:06 pm with the Registered Dietician revealed mechanical soft meats are considered ground meats. A hamburger patty is not considered mechanical soft. Interview on 7/28/2025 with Licensed Practical Nurse (LPN) FF revealed she was the author of the progress note dated 5/21/2025. She confirmed R26 was given a meal tray that did not adhere to his prescribed diet. She revealed staff should know each residents diet because it is listed numerous places such as the resident's profile and the care plan. Interview on 7/29/2025 at 1:03 pm with the MDS Coordinator revealed the facility uses an IDT approach. Anybody can enter a care plan. They are done quarterly, annually, admission, and anytime there is a significant change. It is the supervisor’s responsibility to ensure their staff familiarize themselves with the care plan and interventions. All staff must follow the resident’s care plan. Interview on 7/29/2025 at 1:15 pm with the Director of Nursing (DON) and the Administrator revealed that care plans are implemented to provide the best care for each resident including providing and implementing interventions. The Administrator confirmed that the staff did not follow the resident’s care plan and provided a meal that was not mechanical soft.

Number of residents sampled: Number of residents cited: Based on observation, resident and staff interviews, record reviews, and reviews of the facility's policy titled, Medication Administration: General Guidelines the facility failed to follow the physician's orders as recommended for one resident (R) (R94) of 49 sampled residents. Findings include: Review of the facility's policy titled, Medication Administration: General Guidelines with a revision date of 4/10/2019 documented in the section Policy Statement: Medications are administered as prescribed, in accordance with food nursing principles and practice an only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. In section Procedure: (2) Medication is administered in accordance with written orders of the attending physician. If a dose seems excessive considering the patient/resident's age and condition, or a medication order seems to be unrelated to the patient/resident's current diagnosis or condition, the physician is contact for clarification prior to the administration of the medication. This interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate. R94 was admitted to the facility on [DATE] with a diagnosis of but not limited to presence of coronary angioplasty implant and graft (main blood vessel supplying the heart). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R94 had a Brief Interview of Mental Status (BIMS) score of 7 indicating moderate cognitive impairment. Further review of the MDS in section (N) Medications documented he is on an antiplatelet (reducing the formation of blood clots) medication. Review of the care plan documented R94 is at risk for skin breakdown and pressure ulcers related to impaired bed mobility, fragile skin, and right-hand skin tears.Review of the Physician's order documented clean skin tear to the top of right hand with wound cleaner pat dry then apply calcium alginate (absorb wound fluid) cover with drying dressing once a day (QD). During an observation on 7/21/2025 at 12:48 pm and 7/22/2025 at 1:56 pm revealed R94 had a bandage on his right hand dated 7/18/2025.During an observation and interview on 7/23/2025 at 11:25 am with R94 stated the staff changed their bandage that morning and they change his dress every six days. During an interview on 7/23/2025 at 1:56 pm with Licensed Practical Nurse (LPN) PP confirmed she changed R94 bandage this morning because it was falling off of his hand. LPN PP continued to state the Wound Care Nurse (WCN) has been on vacation and she would be responsible for ensuring those dressings are changed based on the physician's order. She further revealed R94 dressing should be changed on Mondays, Wednesday, and Fridays or as needed. However, she was unaware R94 physicians' orders were to be cleaned and changed once a day. During an interview on 7/23/2025 at 2:04 pm with the Direct Health Service (DHS), stated the nurses on the unit are responsible for conducting treatments if the WCN is not in the facility, and they should be following the physicians' orders.

Based on observations, staff interviews, record review, and review of the facility's policies titled Occurrences and Smoke Free Policy, the facility failed to ensure the environment was free of accident hazards for one of 15 sampled residents (R) (120) reviewed for elopement and one of two residents (R16) reviewed for smoking. Specifically, the facility failed to complete an elopement assessment for R120 after an occurrence and failed to complete a smoking assessment for R16 with known tobacco use. The deficient practice created a potential risk to the safety and well-being of R120 and R16.Findings include: Review of the facility’s policy titled Occurrences revised date 1/11/2024 The health center recognizes that due to the frailty of the patients/ residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented by their plan of care. Occurrence hazards are physical features in the health care center environment which may pose a risk to a patient/resident's safety, including but not limited to: Elopement from healthcare center property, regardless of weather, there was an injury associated with elopement. Review of the facility’s policy titled, “Smoke Free Policy” with a revised date 7/30/2024 documented under the section Grandfathered in Patients/Residents: (1). Patients/residents who are grandfathered in will be assessed for risk/hazards prior to smoking in designated areas and shall be supervised as necessary based on the Smoking Observation Form located in the Electronic Health Record. Under the section “Assessment & Care Planning”: (3). An assessment utilizing The Smoking Observation Form in the Electronic Health Record is completed at lease quarterly thereafter only if the answer to either of the first (2) questions indicates the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident’s care plan. 1. Review of clinical records for R120 revealed diagnoses that included but not limited to dementia, with severity of other behavioral disturbances, type 2 diabetes, and major depressive disorder. Review of R120’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate impairment. Section E (Behavior) revealed the presence of wandering behaviors one to three days during the assessment period. Section I (Active Diagnosis) revealed, diagnoses of Dementia, Cerebrovascular Accident, Depression, and Psychotic disorder. Review of progress note dated 2/21/2025 for R120 revealed that R120 rolled out the front doors behind Emergency Medical Services (EMS); the resident was seen by housekeeping and was brought back inside but never left facility grounds. The resident was asked where she was going and stated she was going home. Review of R120 clinical records under “Observation History” revealed an elopement risk observation form was not completed after the occurrence on 2/21/2025. Review of progress note dated 4/24/2025 revealed that R120 was found sitting on the floor in her room beside a large black bag full of her belongings. The resident had packed all of her items and stated she was going home. Further review of the progress note documented that the resident did this from time to time and that this was not an abnormal occurrence for this resident. Review of the incident report for R120's elopement on 6/29/2025 revealed that R120 was observed outside the facility by Housekeeper TT who was dumping out water from her bucket. She looked up and saw R120 rolling down the alley road with her shower bag, headed towards [NAME] Avenue at 3:20 pm. The housekeeper alerted all the floors that R120 was getting away down the road. It was reported that staff observed R120 attempting to exit through the Turtle Cove unit's doors, but she was unable to do so because the doors were locked. Housekeeper TT was unsure how she had exited, but later discovered it was through the smoking door. After this incident, R120 was moved to the memory unit. Review of R120 clinical records under “Observation History” revealed an elopement risk observation form was completed until after the second occurrence on 6/29/2025. Interview on 7/23/2025 at 1:00 pm with Licensed Practical Nurse (LPN) CC revealed that R120 behaviors were not alarming to her because she packs her things every evening between the hours of 3:00 pm and 5:00 pm, and she attempts to exit the building; however, the doors are usually locked. She stated that she felt that resident R120 should have been on the memory lock unit, This is not the first elopement attempt. She revealed that R120 would have a bag with gowns, briefs, and other belongings and walked up and down the hall with her walker, checking exit doors, including the front exit door, attempting to elope. LPN stated that she heard a CNA on the other hall had propped the door open during a smoke break, which is how R120 exited. Interview on 7/23/2025 at 1:15 pm with Housekeeping TT revealed that she was the one who saw R120 off the facility property in the alley, by the doctor's office on 6/29/2025. She revealed she was not looking for the resident. She was outside dumping her mop bucket when she happened to see her with a bag of clothes in her hand. She explained that upon seeing her, she ran to her as quickly as possible and called for help. She stated that it was such a scary moment because she could have walked across the street, where traffic was hectic, due to the hospital directly across the facility on the opposite side of the road. During an interview on 7/24/2025 at 11:00 am, the Administrator revealed that elopement refers to a situation where a resident is in an unsafe and unsupervised area. She continued to state that when an elopement is identified, they call a code. The Administrator revealed, it is expected that the team members will respond, leave the floor safely, conduct a room and facility check, and then move to the outside of the facility with the radios and continue the search. Continued with the interview, the Administrator stated that if exit-seeking behaviors are present, such as physically going to the door wanting to open it or shaking and pushing at the door handle, the staff should intervene and get them back to the unit. She continued to state that when a resident elopes, and shows elopement behaviors, the clinical team should conduct an elopement assessment, create a care plan for them, and put interventions in place. The Administrator stated she is familiar with R120 and the elopement event on 2/21/2025. She noted that the February elopement is not her first attempt and has had historical behaviors of wandering and eloping for years. She stated that she is aware of the 6/29/2025 elopement event, and an elopement assessment, care plan, and interventions were implemented. However, regarding the attempt on 2/21/2025, they did not consider this to be an elopement risk. Therefore, no elopement assessment was implemented, nor was a care plan with interventions. Nevertheless, she believes interventions should have been implemented after the 2/21/2025 incident. During an interview on 7/24/2025 at 1:16 pm, the Nurse Consultant stated that there should be an assessment done after an attempt, and a care plan should be in place. She further stated that their process for when a resident should be assessed was on admission, readmission, quarterly, and a significant change of event. 2. Review of medical records for R16 revealed diagnoses that included but not limited to, other sequelae of other cerebrovascular disease, spastic hemiplegia affecting left nondominant side; type 2 diabetes mellitus with unspecified complications, borderline personality disorder, nicotine dependence, cigarettes, uncomplicated; and generalized anxiety disorder. Review of R16’s Annual MDS dated [DATE] for Section C (Cognitive Patterns) revealed, a BIMS of 15 which indicated the resident was cognitively intact. Review of the smoking list revealed R16 was identified as a tobacco user. Review of R16’s clinical record on 7/21/2025 revealed there was no “Smoking Observation Form “completed. Review of R16’s care plan on 7/21/2025 revealed she did not have a care plan related to smoking. Further review of clinical records revealed the care plan and the “Smoking Observation Form” was completed on 7/22/2025. Observation on 7/22/2025 at 2:10 pm of smoke break revealed R16 sitting outside in the designated smoke area smoking a cigarette with staff supervision. During an interview on 7/28/2025 at 3:20 pm with Unit Manager/LPN AA, revealed that the facility became a smoke-free facility after (Name of Facility) took over. She stated that R16 was smoking before she started working at the facility. She confirmed that R16 smoked and stating that R16 had been Grandfathered in. During an interview on 7/29/2025 at 1:05 pm with MDS coordinator revealed, there should have been a care plan and assessment completed for R16. She confirmed that there was not a care plan nor an assessment in the Electronic Health Record (EHR) before 7/22/2025. She stated that everything was electronic in February 2025 and that there should have been something in the EHR. She stated that she had been going through trying to update information on the care plan; however, she was the only MDS person and there was no one in the position for several months before she was hired.

Based on record review and staff interviews, the facility failed to ensure mechanical soft - chopped meats were prepared properly for one out of 36 residents resident (R) (R26) reviewed on a mechanical soft diet.Findings include:Review of the medical records revealed R26 had diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, need for assistance with personal care, dysphasia following cerebral infarction. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of nine, indicating moderate cognition impairment and Section K (Swallowing/Nutritional status) revealed, the holding of food in mouth/cheeks or residual food in mouth after meals, and received a mechanical altered diet/therapeutic dietReview of R26's physician order dated 1/10/2025 listed a dietary order for no added salt, mechanical soft.Review of R26 's care plan with a start date of 9/30/2024 and last revised on 7/22/2025 revealed resident required a mechanically altered and therapeutic diet related to dysphagia and hemiplegia. Interventions included Diet: mechanical soft diet.Record review revealed a progress note dated 5/21/2025 that revealed the resident had a choking incident. The note revealed the resident was on a mechanically soft diet that required meat to be grounded and was mistakenly given a hamburger for lunch.Interview on 7/28/2025 at 2:06 pm with the Registered Dietician (RD) revealed mechanical soft meats were considered ground meats and that a hamburger patty was not considered mechanical soft. The RD revealed that staff passing trays should be checking the resident's diet which was listed on the resident's profile, care plan, and meal ticket to the actual tray being served to the resident. Interview on 7/28/2025 at 2:44 pm with the Dietary Manager confirmed the R26 did receive a diet that was not mechanically soft. He revealed when the incident occurred, he went to the resident's room and saw that the resident had received his roommate's tray.

Based on observations, staff interviews, and review of the facility's policy titled, Standard Precautions, the facility failed to ensure resident personal care items were stored in a manner to prevent cross-contamination in three of 12 bathrooms shared between rooms (216 and 218, 215 and 217, 205 and 207) on the 200 Hall. The deficient practice had the potential to expose residents to infections due to cross-contamination. Findings include:A review of the policy titled Standard Precautions last reviewed on 12/4/2023, revealed 7. Patient Care Equipment and Instrument/Devices. Handle equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of pathogens to other patients or the environment.Observations on 7/21/2025 at 12:48 pm, 7/22/2025 at 1:01 pm, and 7/23/2025 at 12:38 pm of the bathroom shared between rooms [ROOM NUMBERS] revealed a bed pan and a bath basin not bagged or labeled. Observation on 7/21/2025 at 1:11 pm, 7/22/2025 at 1:00 pm, and 7/23/2025 at 12:59 pm of the bathroom shared between rooms [ROOM NUMBERS] revealed two urinals not bagged or labeled. Observation on 7/21/2025 at 1:14 pm, 7/22/2025 at 1:05 pm, and 7/23/2025 at 1:05 pm of the bathroom shared between rooms [ROOM NUMBERS] revealed five bath basins not bagged or labeled.Interview on 7/23/2025 at 2:50 pm with Certified Nurse Assistant (CNA) KK revealed bath basins and urinals should be cleaned, bagged, and labeled with resident's name and room number. An interview on 7/23/2025 at 1:40 pm with Assistant Director of Nursing (ADON) revealed that all urinals and bath basins should be bagged and labeled. Observation and interview on 7/23/2025 at 1:50 pm with the Director of Nursing (DON) confirmed that all urinals and bath basins should be labeled and bagged to ensure no spread of disease or contamination. She confirmed the bathroom shared between rooms [ROOM NUMBERS] contained a bed pan and a bath basin not bagged or labeled, the bathroom shared between rooms [ROOM NUMBERS] contained two urinals not bagged or labeled, and the bathroom shared between rooms [ROOM NUMBERS] contained five bath basins not bagged or labeled.

Based on observations, interviews, and review of the facility's policy titled Patient/Resident Rights, Accommodation of Needs, the facility failed to ensure privacy for two out of 29 resident rooms observed (room [ROOM NUMBER] A and 218 B) had privacy curtains. Findings include:Review of the facility's policy titled Patient/Resident Rights, Accommodation of Needs, revised 12/1/2023 revealed B. Privacy: 1. Patients/residents will be provided full visual privacy during routine care and treatments by means of privacy curtains and closed doors.Observation on 7/21/2025 at 1:11 pm during an initial tour shared rooms 217 A and 218 B revealed that the privacy curtains were missing. Further observations on 7/22/2025 at 11:55 am and 7/23/2025 at 12:39 pm revealed both 217 A and 218 B were still missing their privacy curtains.Interview on 7/23/2025 at 12:50 pm with Certified Nurse Assistant (CNA) KK revealed that all residents in a double room should have a privacy curtain. Interview and rounding on 7/23/2025 at 1:45 pm with the Director of Nursing (DON) revealed the facility prioritizes resident's privacy and dignity. The DON confirmed revealed that all shared rooms should have a privacy curtain for each bed. She confirmed that 217 A and 218 B did not have a privacy curtain. She stated she was going to get maintenance to hang both curtains.

Based on record review and staff interviews, the facility failed to protect one of three residents (R) (R4) sampled for falls during transfer. Harm was identified to have occurred on 2/19/2025 when R4 fell while being transferred from a chair to the bed by staff, resulting in a mid-shaft radius fracture. Findings include: Review of the Electronic Medical Records (EMR) revealed an admission date of 2/26/2024 with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Muscle weakness (generalized), Atherosclerotic heart disease of native coronary artery without angina pectoris, Alzheimer's disease, unspecified. Record review of the most recent quarterly Minimum Data Set (MDS) for R4 dated 12/20/2024 revealed there was no Brief Interview for Mental Status (BIMS) score listed. Section GG (Functional Abilities and Goals) documented that R1 was dependent on staff for self-care and mobility requires two persons assistance for ADL care. The helper does all of the effort. The resident does none of the effort to complete the activity. A review of the progress notes for R4 dated 2/19/2025 at 6:02 pm revealed Resident was being transferred to bed by staff the Hoyer lift pad strap broke causing a fall. Resident have a small skin tear to left lower arm. cleansed with NSS, padded dry, applied Steri-strips, Allevyn dressing and secured with gauze. Notified Nurse Practitioner (NP) orders to send to E/R to be evaluated and treated. A review of the hospital Discharge Plan dated 2/20/2025 revealed an x-ray of right forearm revealed a nondisplaced transverse fracture of the mid-shaft of the right ulna. No radius fracture is identified. In the ED splint was placed on right arm, Ibuprofen ordered and referral to the orthopedic specialist. She returned to the facility in stable condition. A review of the facility's investigation documentation dated 6/1/23 revealed on 2/19/2025 the resident fell from a lift secondary to the strap breaking. Resident was transferred to the ER for evaluation. She returned to the facility the following morning with x-ray results showing a right radius break. Interview with the Administrator on 3/6/2025 at 11:48 am revealed she got a call from the Director of Health Services (DHS) nurse that R4 fell from the Hoyer lift as CNA FF was transferring her from the chair to the bed. The administrator stated that the CNA FF was using the wrong lift pad. She stated that the seams in the lift pad broke and R4 fell to the floor. The administrator stated that CNA GG was in the room but left the room and when he ame back into the room R4 was on the floor as CNA FF attempted to transfer her without assistance. CNA FF was not available by phone for interview. Review of CNA FF written statement dated 2/20/2025 revealed On 2/19/2025 as we were transferring resident to bed with the Hoyer lift the sling that was used to get the resident up that morning popped causing the resident to fall when the resident fell her left side fell on the legs of the Hoyer lift we then notified the nurse who came in and began her assessment, I collected her vitals the resident was transferred to bed as I was helping the nurse rotate the resident to look for any visible injuries the nurse came upon a skin tear on her left arm the nurse cleaned the wound and notified the nurse practitioner and called residents family and we prepared the resident to be sent out to the emergency room. CNA GG was not available by phone for interview. Review of CNA GG statement per text conversation with administrator from CNA GG dated 2/25/2025 revealed The other CNA asked me to help her secured the Hoyer pad to the Hoyer lift once attached to the Hoyer lift the resident was transported into the room the Hoyer pad somehow became unmatched, and the resident fell down. I just want it to be clear that I was not in the room at the time of the incident I just helped her attached the Hoyer pad to the lift I was in the middle of throwing away a solid brief when I was asked to help put the pad on the lift. Review of LPN HH written statement dated 2/25/2025 revealed On 2/19/2025 I was informed a resident had fell in room [ROOM NUMBER] at 6:00 pm. Resident had fell due to a sling strap had popped causing her to fall to the floor. Resident was assessed, received a skin tear to left lower arm. Resident was assessed and placed in bed. Left lower arm treated with Steri-strips, Allevyn pad, gauze, and secured with tape. Notified on call staff for doctor spoke to NP RN, orders to send to E/R to be evaluated and treated. Notified son via telephone. called EMS at 6:18 pm EMS arrived at 6:50 pm departed via stretcher at 7:05 pm. Resident was transferred to the emergency room for evaluation. On 2/20/2025 Maintenance inspected the lift and was satisfied the lift is in working order. The Annual PM on this lift is scheduled for 5/2025. On 2/20/2025 the Interim Director of Health Services (IDHS) instructed all lift pads resembling the one in question be collected from the units. The task was completed by supervisors. Both CNAs who were involved were suspended prior to their next shift. The Administrator, Director of Health Service (DHS), and the Clinical Competency Coordinator (CCC) provided a Hoyer Lift in-service to all nursing staff on 2/20/2025. (Reviewed) The Administrator, Director of Health Service (DHS), and the Clinical Competency Coordinator (CCC) provided abuse education to all staff 2/20/2025 through 2/27/2025. (Reviewed) The Social Service Director (SSD) completed an audit of residents who use lift and asked if they felt safe during lift transfer 2/24/2025. (Reviewed) The Administrator implemented the Lift Use Audits to include the proper number of staff, proper sling used, and sling used correctly 3/2/2025. Audits to be completed two times daily for three weeks, two times weekly for four weeks, four monthly for three months. Review of Separation Notice dated 2/27/2025 revealed CNA FF terminated 2/27/2025. Review of Separation Notice dated 3/3/2025 revealed CNA GG resigned without notice 3/3/2025.

Based on record review, resident, family, and staff interviews, and review of facility document titled, Facility Assessment , the facility failed to ensure there was sufficient staffing to provide the assistance residents needed with activities of daily living (ADLs). This deficient practice had the potential to affect the care provided to the 118 residents that resided in the facility. Findings include: Review of The Facility Assessment revealed: Staffing plan (c) Must provide a minimum of 3.48 hours per resident day (HPRD) of total nurse staffing care, which must include 0.55 HPRD or registered nurse (RN) care and 2.45 HPRD of nurse aide (NA) care. Must provide onsite RN coverage 24/7.Flexibility is allowed to choose nursing staff, including LPN/LVNs already on staff or newly hired to meet the remaining 0.48 HPRD. Review of R2's admission Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. During an interview with R2 on 3/31/2025 at 3:30 pm, R2 stated that she has been at the facility for 20 days. She stated that she only had three showers since her admission to the facility. She stated that it was because of lack of staff. Review of R3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognition. During an interview with the R3 on 3/26/2025 at 12:18 pm, he stated that he last shower was on 3/21/2025. He stated that there is not enough staff at the facility. He stated his was scheduled for showers on the 3-11 shift on Monday, Wednesday and Friday but he does not get them as scheduled due to no staff. Review of R6's Annual Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 14 out of 15, indicating intact cognition. During an interview with R6 on 3/26/2025 at 2:28 pm he stated that his last shower was 3/21/2025. He stated that he is supposed to get showers on Tuesdays, Thursdays, and Saturdays but that does not happen because there is no staff. Interview with Licensed Practical Nurse (LPN DD) on 3/26/2025 at 2:37 pm revealed there are two nurses today but normally there is only one nurse. She stated that it varies with the CNAs. LPN DD stated that there are residents that are listed on the Electronic Medication Record (EMAR) that should be up by 10:00 am for therapy or restorative but sometimes they are short staffed, and the residents are not up. She stated that sometimes therapy will help get them up. LPN DD stated that sometimes restorative CNAs are pulled to the floor. Interview with Certified Nursing Assistant (CNA BB) on 3/26/2025 at 3:00 pm revealed CNA BB stated that the facility is short staffed. She stated that sometimes she is working by herself after 3:00 pm. Interview with the Director of Health Services (DHS) on 3/26/2025 at 3:47 pm revealed she stated there needs to be more CNAs. The DHS stated that the residents are not getting showers. She stated that they had complaints from residents and families about not getting showers, and they provided education to the CNAs and Nurses telling them to make sure the residents get their showers. The DHS stated that she works the med cart as needed because of staffing. She stated that they hired some nurses and CNAs and thy are going to be in orientation this week. Interview with the Senior Nurse Consultant (RN EE) on 3/27/2025 at 1:33 pm revealed staffing is based on staff in the building and staff at facility. She stated it is based on how much staff you have and the acuity, caseload for therapy and type of residents. RN EE stated if there are 120 residents they have 6-8 staff. She stated that there is a plan in place reference to staffing. RN EE stated that they have quick hire interviews, sign on bonus for CNAs and nursing. She stated that they have seven CNAs starting in April, two nurses starting, five more CNAs hired and two LPNs with backgrounds pending. She stated they are working with CNAs and other staff to make sure showers are done, offered extra money to get staff in , and offered incentive of extra money. She stated that the DHS and therapy gave showers to help out. Interview with Certified Nursing Assistant (CNA AA) on 3/31/2025 at 1:03 pm revealed CNA AA stated that she give showers as much as she can. She stated that they are always short staffed, and she cannot give showers especially when she is the only CNA on the floor. She stated that she worked by herself one day and she had 38 residents. Interview with Certified Nursing Assistant (CNA CC) on 3/31/2025 at 1:55 pm revealed CNA CC stated that the facility is short staffed. She stated that sometimes she cannot give the residents a shower because there is not enough staff. She stated that residents are supposed to get showers three times a week but sometimes that is not possible. She stated that if she cannot give the residents a shower on their shower days, she will give them a shower on a Sunday and explain to them why she cannot give them a shower on their shower day. Interview with the Administrator on 3/31/2025 at 10:00 am revealed they are trying to get more staff in. She stated that they have walk in Wednesdays, sign on bonuses for nurses and CNAs, and they offer incentive bonuses. She stated that they make calls to try and get staff to come in earlier and sometimes some of the staff will stay over and help out. The Administrator stated that they had to close a wing down in December 2024 due to lack of staff. She stated that initially it was supposed to be for a couple of weeks. She stated that the wing remains closed due to lack of staff.

Based on observation, record review and staff and resident interviews, the facility failed to ensure three residents (R2, R3, and R 6) were given showers as scheduled from a sample of six residents. Findings include: 1. R2 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Paroxysmal atrial fibrillation, Chronic obstructive pulmonary disease with (acute) exacerbation, Unsteadiness on feet, Parkinsonism, unspecified, and Muscle weakness. The 3/17/2025 admission Minimum Data Set indicated the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident had intact cognition, Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. During an interview with R2 on 3/31/2025 at 3:30 pm, R2 stated that she has been at the facility for 20 days. She stated that she only had three showers since her admission to the facility. Review of Point of Care History Sheets revealed the R2 received four showers in 20 days. 2. R3 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Cerebral infarction, unspecified, History of falling, Muscle weakness (generalized, Other symptoms and signs involving the musculoskeletal system, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Localized swelling, mass and lump, unspecified, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, Pain in lower leg, vertigo, mild intermittent asthma, anxiety disorder, and osteoarthritis. The 12/25/2024 Quarterly Minimum Data Set indicated the resident had a Brief Interview for Mental Status (BIMS) of 13 indicating the resident had intact cognition, Shower/bathe self: Supervision or touching assistance. During an interview with the R3 on 3/26/2025 at 12:18 pm, he stated that he last showered on 3/21/2025. R3 stated his showers were scheduled on the 3-11 shift on Monday, Wednesday and Friday. 3. R6 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Chronic respiratory failure with hypercapnia, Chronic respiratory failure with hypoxia, Chronic obstructive pulmonary disease, unspecified, Chronic pulmonary edema, Complete traumatic amputation of two or more left lesser toes, subsequent encounter, other abnormalities of gait and mobility, Muscle weakness (generalized). The 1/30/2025 Annual Minimum Data Set indicated the resident had a Brief Interview for Mental Status (BIMS) of 14 indicating the resident had intact cognition, Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. During an interview with R6 on 3/26/2025 at 2:28 pm he stated that his last shower was 3/21/2025. He stated that he is supposed to get showers on Tuesdays, Thursdays, and Saturdays but that does not happen because there is no staff. Interview with the Director of Health Services (DHS) on 3/26/2025 at 3:47 pm revealed she stated there needs to be more CNAs. The DHS stated that the residents are not getting showers. She stated that they had complaints from residents and families about not getting showers, and they provided education to the CNAs and Nurses telling them to make sure the residents get their showers. Interview with Certified Nursing Assistant (CNA AA) on 3/31/2025 at 1:03 pm revealed CNA AA stated that she give showers as much as she can. She stated that they are always short staffed, and she cannot give showers especially when she is the only CNA on the floor. Interview with Certified Nursing Assistant (CNA CC) on 3/31/2025 at 1:55 pm revealed CNA CC stated that the facility is short staffed. She stated that sometimes she cannot give the residents a shower because there are not enough staff. She stated that residents are supposed to get showers three times a week but sometimes that is not possible. She stated that if she cannot give the residents a shower on their shower days, she will give them a shower on a Sunday and explain to them why she cannot give them a shower on their shower day.

Based on observations, staff interviews, record review, and a review of the facility policy titled Abuse Prohibition, the facility failed to protect the resident's right to be free from sexual abuse by a resident and physical and verbal abuse by staff. Specifically, R84 was sexually abused by R41, and R14 was physically and verbally abused by a Certified Nursing Assistant (CNA) AA. There were five residents reviewed for abuse. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of facility policy titled Abuse Prohibition (last reviewed 6/16/2022) revealed It is the policy .the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. Allegations of abuse means a report complainant, grievance incident or other facts that reasonable person would understand mean that abuse (as defined in this policy is occurring, has occurred or might realistically have occurred. Immediately means as soon as possibility, but not later than 2 hours after the allegation is made, if the events that causes the allegation involve abuse or result in serious bodily injury, or not later 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury. Procedure Guidelines A. Upon identification of alleged abuse, the employee will take measures to ensure resident safety and then report the alleged incident to the Abuse Coordinator or designee immediately. Investigation A. 5. Observation of the physical environment pertinent to the allegation, and interaction between the resident and other residents and/or staff. 1.Record review of R84's Electronic Medical Record (EMR) record revealed the following diagnoses but not limited to unspecified dementia, unspecified severe, unspecified psychosis, hypertensive heart disease, and acute chronic-combined systolic. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed for Section C (Cognitive Pattern) a Brief Interview Score (BIMS) of 4, which indicated severe cognitive impairment, Section GG (Functional Abilities and Goals) required supervision and set up with most Activities of Daily Living (ADL) skills and was ambulatory with supervision/safety requirements. A record review of R84's nurse note dated 3/22/2023 at 1:16 am revealed that R84 was in bed while his roommate was rubbing his genitals, legs, and feet. The notes revealed staff intervened and the nursing supervisor was notified. R84 was moved to another room for safety. The incident was verified to have occurred on 3/21/2023 at 11:00 pm from the facility Investigation final report dated 3/24/2023. Record review of R84's Nurses Note dated 3/23/2023 at 5:27 am documented change in mental status, describing R84 as seeming more confused, depressed, and jumpy. Record review of nurses' note dated 3/24/2023 at 6:29 pm revealed that R84 was redirected several times during the day as to where his room is located. R84 talked about the situation concerning the incident that occurred on 3/21/2023. The resident stated that a man in his past attempted to do the same thing, Monkey Ball him, and he did have protection on him then. Staff reassured R84 that he was safe and okay. A record review of the census dated 3/22/2023 documented that R84 was moved to a different room away from R41's room. R84 's room is directly across from the nurse station. Review of R41's care plan initiated 3/16/2022 indicated a problem related to resident exhibiting inappropriate sexual behaviors and having a history of touching other residents in a sexual manner with/without consent. A review of the Nurses Progress Note dated 3/22/2023 at 1:10 am for R41 in the electronic medical record (EMR) revealed upon making rounds, R41 was observed sitting on the roommate's bed (R84) rubbing his genitals as well as his legs and feet. Staff heard R41 ask R84, Does that feel okay? Record review of R41's EMR record revealed the following diagnoses but not limited to Alzheimer's, dementia with severe behavioral disturbances, and anxiety disorders. The Annual MDS assessment dated [DATE] R41 revealed for Section C (Cognitive Pattern) a Brief Interview Score (BIMS) of 6, a score of 6 out of 15 indicated cognitive impairment. Section D (Mood) resident had no mood behavior, Section E (Behavior) resident had no behaviors, Sect GG (Functional Abilities and Goals) required set up and partial assistance with set up with most Activities of Daily Living (ADL) skills and was ambulatory with supervision/safety requirements. Interview on 5/23/2024 at 3:10 pm with Licensed Practical Nurse (LPN) DD reported that she was unable to recall the names of the Certified Nursing Assistant (CNA) that night and the actual time of the incident involving R84 and R41. She could not recall if she wrote a written statement. LPN DD stated that if she had written a statement, then she would have dated the form and signed her name. She recalled two incidents of sexually inappropriate behaviors of R41 with other residents prior to the incident with R84. She reported that she separated both residents. R84 was taken to another hall that night. (Record review revealed that R84 remained on the hall but in a different room). She noticed that R84 and R41 were on the bed. She did not document a skin check assessment on the sheet, but she did check the residents 's vitals. She doesn't recall seeing anything wrong with the resident or changes in condition with R84 before he left the hall. Both residents seem okay, just kind of caught off guard that they were caught. She recalls speaking only with the RN Supervisor that was on duty night but cannot remember the name. The Administrator and DON, at that time, did not ask her any questions that she recalled. She was not instructed to assess all the residents in the hall. R41 was seen by the Nurse Practitioner (NP) QQQ the next day. NP QQQ note dated 3/22/2023 revealed LTC male seen secondary to behavior rubbing roommate genitals, legs, feet, and making sexual statements x1 on 7 pm-7 am shift. Nursing staff redirected resident. Family decided to make room private. Today no reports of behaviors. The resident doesn't recall events of last night due to dementia. An interview on NP QQQ on 5/31/2024 at 2:20 pm confirmed that on 3/22/2023, according to her progress note, her recommendation was for the R41 to be placed in a private room and referred for psych services. Interview with Social Services (SS) WW on 5/23/2024 at 12:38 stated that she doesn't remember a lot about the incident between R84 and R41 and that both residents had advanced dementia. SS WW reported that she visits her memory care unit at least once a day. SS WW further revealed that if there are any behavior concerns or reports of sexual abuse in the unit, staff will address it with the nurse and then report it to Social Services. A report is filed for all abuse/ sexual abuse incidents. She reported that a floor monitor has been placed on the unit to ensure the safety of the residents. R41 and R84 have been assigned to private rooms. SS WW feels that the sexual abuse risk has been reduced by evidence of R84 and R41 having private rooms, and a monitor is now in the hall. It was further reported that their MD was aware of the incident. SS WW then reported that the residents were referred to receive psychiatric services, but she's not sure who made that referral. Interview on 5/23/2024 at 11:35 am with Psychiatric NP reported that he is the only Psychiatric NP on duty and that he does evaluations, medication adjustments, and assessments. He initially reported that R41 was not a patient; however, he recalled after reviewing his note and verifying that R41 was a patient of his a few years ago. R41 was last seen in 2022. The Psychiatric NP reported being unaware of R41's last incident of sexually aggressive behavior towards R84. Psychiatric NP reported that if he was called about residents with inappropriate sexual behaviors, he would have prescribed a medication to decrease the libido. He reported that R84 was not referred for services. He has seen other residents in the facility. He reported any resident who is admitted with psychotropic meds needs to be evaluated. The Psychiatric NP stated that he visits the facility once a month and, if needed, will do a virtual visit. Interview on 5/28/24 at 7:33 pm with CNA AAA, who reported that she has been employed at the MCU since August 2023. She was aware of incidents of abuse for residents R84 and R41. She reported that she was unaware of monitoring sexual abuse for any residents on the unit. She has received training on abuse and has not been assigned or given specific instructions to monitor R84 or R41. She has been working in the MCU with both residents and has not observed any behaviors of sexual abuse or any type of abuse. If she observed, then she will report to the supervisor. Interview on 5/28/24 at 7:45 pm with Patient Companion GGG, she reported that her job as a patient companion is to watch the residents in the MCU and give them snacks and water, and sit close to one particular resident who may fall. She stated that she is not a CNA and is not really required to go into the resident's room unless to give snacks. She stated that the nurse and CNA provide patient care. She was never told to watch out for sexual abuse from any residents. She was unaware of incidents of sexual abuse occurring between residents. She did receive training on abuse during her orientation. She has been working only for a month and a half. She works 12 hours shift. Interview on 5/31/2024 at 12:31 pm with Administrator DDD reported that once the incident had been discovered between R41 and R84, the physician and psychiatric services should have been contacted for an evaluation. She stated that education would be provided to teach the staff how to redirect and, if appropriate, allow him privacy to satisfy his sexual tendencies with himself (masturbating). Administrator DDD further revealed the family should have been notified, possibly medication adjustment, and witness/resident statements. She stated that law enforcement would also be notified. 49138 2. Record review revealed that R14 had a diagnosis that included but was not limited to dementia, alert with confusion. A review of the facility documents revealed the following: Incident: R14 was lying in a bed in the early morning hours of June 8, 2023. CNA AA walked into the room and attempted to get the resident out of a bed that was not his own bed. The resident was alone in bed. CNA AA hit the resident on the arm three times in an attempt to get his attention. It was witnessed by two staff. The staff in the room stated that CNA AA was rough when attempting to get R14 attention to get out of bed. After CNA, AA removed R14 from the bed and stated, Get your ass out of this room, while walking out of the room with the resident. R14 was unaware of the statement and did not respond to her/him. The investigation was unsubstantiated, and CNA AA was given a written reprimand and final warning. Documents revealed staff and residents have described CNA AA to be verbally abusive. Interview on 5/23/2024 at 11:51am with NP XX revealed that residents should have an evaluation even if non-verbal. NP XX reported that he was not informed of any abuse towards R14. During an interview on 5/23/2024 at 2:28 pm with the former DON BBB confirmed the alleged verbal and physical abuse from CNA AA to R14 occurred on 6/7/2023. DON BBB stated that the incident was reported to local law enforcement and to the State Agency (SA) on 6/8/2023. DON BBB stated that she made the report once she was notified of the incident. Interview on 5/29/2024 at 9:35 am with RN Supervisor LL confirmed that she had written a statement regarding the concerns of CNA AA snatching the covers off R14 and returning to assist the resident. The RN Supervisor LL stated that she tried to discuss the issue with CNA AA, but she was uncooperative. RN Supervisor LL revealed that this occurred on the night shift. RN Supervisor LL expressed that once abuse is found, it should be reported to the DON, called law enforcement, and then called the family. Telephone contact with CNA AA was attempted but unsuccessful due to the phone number being disconnected. Interview on 5/29/2024 at 12:02 pm with Social Services (SS) WW revealed R14 could ambulate and move around and was not considered a target for abuse. SS WW further reported that CNA AA is no longer employed at the facility.

Based on interviews, record review, and review of the facility's policy titled, Abuse Prohibition, the facility failed to complete a thorough investigation for two of five sampled Residents (R) (R84 and R41) reviewed for abuse. Specifically, there was no evidence the facility interviewed R84 the victim, other staff, or residents regarding the allegations of potential sexual abuse as a part of the facility's investigations. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of facility policy titled Abuse Prohibition (last reviewed 6/16/2022) revealed It is the policy .the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. Allegations of abuse means a report complainant, grievance incident or other facts that reasonable person would understand mean that abuse (as defined in this policy is occurring, has occurred or might realistically have occurred. Immediately means as soon as possibility, but not later than 2 hours after the allegation is made, if the events that causes the allegation involve abuse or result in serious bodily injury, or not later 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury. Procedure Guidelines A. Upon identification of alleged abuse, the employee will take measures to ensure resident safety and then report the alleged incident to the Abuse Coordinator or designee immediately. Investigation A. 5. Observation of the physical environment pertinent to the allegation, and interaction between the resident and other residents and/or staff. 1. A review of an undated document provided by the facility titled, Face Sheet indicated R84 was admitted with a diagnosis of dementia with behavior disturbances, psychosis not due to a substance or known physiological condition, and major depressive disorder Review of Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2024, indicated R84 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severely impaired cognition. The assessment indicated the resident transferred independently with use of a walker. Further review revealed R84 had no impairments of bilateral upper and lower extremities. 2. Review of an undated document provided by the facility titled, Face Sheet indicated R41 was admitted with a diagnosis of Alzheimer's disease with late onset, dementia with behavioral disturbances, altered mental status, major depressive disorder with severe psych symptom, mood disorder due to known physiological condition, other impulse disorders, restlessness and agitation onset, and anxiety disorder. Review of Annual MDS assessment with ARD of 2/16/2023, indicated R41 had a Brief Interview for Mental Status (BIMS) score of six of 15 indicating severe cognitive impairment. Section E indicated R41 did not display any behaviors. Resident required assistance from staff with Activities of Daily Living (ADLs). This assessment was completed prior to the incident which occurred 3/21/2023. Review of R41's care plan initiated 3/16/2022 indicated a problem related to resident exhibiting inappropriate sexual behaviors and having a history of touching other residents in a sexual manner with/without consent. Approaches: included: Set limits and discuss appropriate vs inappropriate behaviors, if resident tries to touch in appropriate, place your hands over his and gently but firmly push it away; intervene and redirect resident when any inappropriate behavior is observed, intervene while helping him maintain a sense of dignity, in a potentially embarrassing situation, and referral for Behavior Health as indicated. Review of R41's physician orders revealed an order to monitor for inappropriate sexual behavior. Review of Nurses Progress Note dated 3/22/2023 at 1:10 am in the electronic medical record (EMR) revealed upon making rounds, R41 was observed sitting on roommate's bed (R84) rubbing his genitals as well as his legs and feet. Staff heard R41 ask R84, does that feel okay? Nurse supervisor was called to the unit made aware and observed the situation. As staff began to intervene and ask R41 questions, he denied the actions and stated, I don't know. R41 was observed making his way over to his own bed to lie down. R84 was moved to another room for safety. R84 had no visible injuries or bruises noted. Protocol followed. Review of a file provided by the facility (referred to as the facility's investigation of a 3/21/2023 incident). There were only two sheets of paper in the file for the alleged abuse investigation. One of the papers was on facility letterhead, dated 3/24/2023, and addressed to the State Agency. The second paper was an undated, unsigned handwritten statement. There was no evidence the facility interviewed other staff regarding the incident of potential sexual abuse. In addition, there was no evidence R84 (the victim), or other residents residing on the unit were interviewed as part of the facility's investigation. There was no evidence a documented assessment was completed for R84 or R41 at the time of the incident, the physician and local police were notified at the time of the alleged incident, residents involved in incident were referred for psychiatric evaluation, the facility obtained written statements from witnesses pertaining to the incident, or other residents on the unit were interviewed to see if that had been affected by the same type of abuse. The record indicated R41 was moved to another room on the unit, even though R41 ambulated independently. There was no evidence the facility interviewed other staff regarding the allegations of potential sexual abuse. In addition, there was no evidence R84, the victim, or other residents residing on the unit were interviewed as part of the facility's investigation. Review of R84's and R41's electronic and paper clinical records revealed there were no staff witness statements documented for the incident dated 3/21/2023. Interview 5/21/2024 at 1:10 pm with Administrator DDD revealed she had only worked at the facility for 2 weeks. She further stated that she brought in all the Facility Reportable Incidents and investigations that she was able to locate in the office. She further stated she was learning that things were everywhere, and it was hard to locate any files from previous Administrator CCC. Adminstarator DDD looked at the red folder and verified there were only 2 sheets of paper in the folder pertaining to the allegation of sexual abuse. Administrator DDD responded That's what it is, that's all I got. Interview 5/23/2024 at 3:10 pm with Licensed Practical Nurse (LPN) DD revealed she was the nurse working when the incident occurred. She further stated she was not able to recall the names of the Certified Nursing Assistants (CNAs) working with her the night the incident occurred, the actual time of the incident, or if she wrote a statement detailing the incident. LPN DD stated that if she had written a statement, it would have been dated and signed. LPN DD further stated she recalled the incident with R41 and R84 and she separated the two residents. She further stated she did not document a skin assessment or any other type of assessment for the two residents. She also stated both residents seemed okay, just kind of caught off guard due to being caught in a sexual act. LPN DD stated she reported the incident to the Nurse Supervisor and DON EEE or Administrator CCC did not ask her any questions related to the incident. LPN DD further stated she was not asked to interview or assess any other residents on the unit. Interview on 5/24/2024 at1:38 pm with Social Services (SS) WW who reported she was never informed to monitor R41and R84 for any negative effects from abuse related to any mental status changes depression or behavior problems. She stated that her position was always limited when it came to investigating and following up on abuse allegations. SS WW further stated the former Administrator CCC never informed her to become involved in the abuse incident between the two residents. SSW WW stated she took directives from Administrator CCC. A follow-up interview on 5/28/2024 at 11:12 am with Administrator DDD revealed she was not able to locate any other documents pertaining to the resident-to-resident sexual incident between R41 and R84 which occurred 3/21/2023. Interview on 5/28/2024 at 2:41 pm with the Director of Nursing (DON) FFF reported that she started the position in April 2024 and prior to that she was a contract RN Supervisor at the facility. DON FFF further stated she was not made aware of the incident with R41 and R84 until it was brought to her attention during this survey. She confirmed that she had completed her search and there were no additional documents pertaining to the incident found in the facility. A follow-up interview on 5/28/2024 at 3:14 pm with DON FFF verified the one handwritten statement in the investigation file did not contain a date or signature of who provided the statement. Final interview on 5/31/2024 at 12:31 PM with Administrator DDD revealed she could not locate any evidence the previous Administrator completed a thorough investigation after receiving knowledge of the allegation of abuse with R41 and R84. She further states she could not speak on behalf of him, but the investigation should have consisted of the physician and psychiatric service provider being contacted to evaluate and possible adjust medications for the residents involved, police notified, written statements from all staff members who had knowledge of the incident, each residents care plans should have been updated and the staff should have received education related to the incident. Administrator DDD stated due to the lack of evidence, she believed proper channels of investigating the incident were not followed.

Based on staff interviews, record review, and the facility policy titled Nursing Care Plan, the facility failed to develop a care plan for two residents, R84 for sexual abuse from another resident and R14 for verbal and physical abuse by staff. In addition, the facility failed to ensure a care plan was created for elopement and safety concerns for R115. There were 52 residents sampled. This deficient practice had the potential to have an adverse effect for the residents. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of the facility policy titled Nursing Care Planning review dated 9/6/2023 stated It is the policy of facility that a framework for Nursing Care Plans for those patients in inpatient hospital settings in order to ensure the highest quality patient care, from admission to discharge. Nursing Care Plans are based on nursing diagnoses derived from detailed assessment findings and encompass the nursing process, including assessment, diagnosis, planning, implementation, and evaluation. Procedure: (1) Initiation (a). A Nursing Care Plan is to be started for each patient within 24 hours of admission and is initiated by a Register Nurse. (2). Components of Care Plans (a). The Nursing care Plan is comprised of three main components: i. Goals or Expected Outcomes: List the behaviors or results to be achieved within a specified timeframe. ii. Nursing Actions or Interventions: List appropriate actions necessary to meet the established goals. iii. Evaluations of Established Goals: Documentation of the progress made towards the set goals. (4). Updating and Revision. (a). The care plan is updated and revised throughout the patient's stay, based on their response to the nursing intervention. 1.Record review of R84's Electronic Medical Record (EMR) revealed that resident had the following diagnoses but not limited to unspecified dementia unspecified severe and unspecified psychosis. The Minimum Data Set (MDS) revealed that R84 had a Brief Mental Status Score (BIMS) of 3 (which indicated severe cognitive impairment). The Facility Self Reportable documented submitted to the State Agency (SA) documented that on 3/21/2023 at 11:00 pm, R84 was sexually abused by R41. Record review of R84's progress note dated 3/22/2023 provided detailed evidence of the abuse incidents describing inappropriate touching of the resident arms, legs, and genital areas. The nurse note dated described the traumatic experience that led to nurse describing the resident as becoming more confused, depressed, and reliving a past similar sexual life experience that he referred to as someone in the past monkey balling him. There was no care plan or interventions in place to address the abuse of R84 by R41. Interview with the Social Services (SS) WW on 5/24/2024 at 1:38 pm, who reported that she was never informed to develop a care plan for abuse. She was also never informed to follow up with the nursing staff and monitor residents for any negative effects from abuse relating to any mental status changes depression or behavior problems. 2. Record review revealed that R14 was admitted to the facility on [DATE]. R14 had diagnosis that included but was not limited to dementia, neoplasm, prostate, kidney failure. alert with confusion. Record review revealed alleged verbal and physical abuse towards R14 from Certified Nursing Assistant (CNA) AA on 6/7/2023 as evidenced by CNA AA using profanity and hitting R14 on the arm when trying to get him out of another resident's bed. There was no evidence that an abuse care plan had been created for R14. Interview on 5/29/2024 at 12:02 pm with SS WW who revealed R14 could ambulate and move around and was not considered a target for abuse. Therefore, abuse was not added to his care plan. 3. Record review of R115 's EMR revealed that resident has the following diagnoses but not limited to dementia severe and anxiety disorder. The Quarterly MDS assessment dated [DATE] (BIMS 10 and Quarterly MDS 4/19/2024 (BIMS score of 9) assessed both resident for moderate cognitive impairment and disorganized thinking. Both MDS assessment assessed resident for Section E (Behavior) for psychoses with delusion and wandering behaviors occurring at least 1 to 3 days. Record review revealed the resident was placed on Memory Care secure unit to prevent further elopement from the building. Record review of a Facility Self Reportable dated 2/3/2024 documented an elopement from the facility that occurred on 2/2/2024 at 6:16 pm. Record review of R115's Elopement Risk Assessment for dates of 12/4/2023, 1/10/2024, and 2/2/2024, and revealed that resident was assessed for Moderate Risk for wandering/elopement behavior. Record review of the resident care plan revealed no care plan for elopement to address safety precautions to prevent future elopement. Interview with Register Nurse (RN) Supervisor LL on 5/30/2024 at 2:10 pm, who reported that resident was found by her, outside the facility. The resident was observed standing outside the exit door. The physician had just left the resident's room, and the resident left the room. She reported that the resident did not leave the grounds of the facility. Interview with the Administrator DDD on 5/31/2024 at 1:55 pm, who reported being unaware that care plans were not created for R84 and R115. She reported that a care plan for a resident who was abused should have been created. The social worker or any nursing staff would have been the designated staff to put the abuse care plan into the system. She reported being unaware that the R115 's care plan was not created for elopement. She reported that her expectation that an elopement care plan should be done for residents who are at risk for elopement.

Based on interviews, record reviews, and review of the job summaries for the Administrator and Director of Nursing (DON), the facility Administration failed to effectively oversee an abuse prevention program to promote, foster, and maintain an abuse-free environment. The facility census was 149. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Review of job summary for the Administrator revealed, plans, develops, organizes, implements, evaluates, and directs the programs and activities of the Long-Term Care Facility, ensuring the delivery of competent and age-appropriate care that encompasses the physiological and psychological needs of the resident. Promote a culture of safety, follow established policies, and adhere to all stated and federal regulatory requirements, Joint commission requirements, and national patient safety standards. The description included job duties and responsibilities: Ensuring that appropriate standards of resident care and practice are developed, consistent with current nursing and other research findings, as well as state and nationally recognized professional standards, develops and maintains written policies and procedures that govern the operations of the facility, assist department supervisors in the development and use of departmental policies and procedures, and reviews the policies and procedures annually to assure continues appropriateness and compliance with current regulations, interprets the facility's policies and procedures to team members, residents, families, visitors, and others as necessary. Acts as a liaison between the facility and the residents and families, maintains open communication with the medical director and other members of the medical staff, complies with all state and federal regulatory agencies and requirements, and consults with departmental supervisors to assist in correcting/elimination problem areas, or improving services. Review of job summary for Director of Nursing revealed, direct and supervises the work of nursing service team members on a designated patient/resident care unit. Is responsible for assignments, scheduling, orientation, supervision, guidance, and evaluation of nursing personnel on the unit so as to ensure and maintain a high quality of patient care. The description included job duties and responsibilities for: Accountable for the provisions of patient care on assigned unit 24 hours/day, 7 days/week, confers with supervisory personnel in other departments as the need arises, encouraging and maintaining good intra and inter departmental relationships and communication, initiates and maintains comprehensive and appropriate records and reports required for the effective functioning of the unit, maintains a high quality for patient care and patient teaching and assisting staff in ideas and implementation pf patient education and teaching, works and communicates with all individuals at the appropriate age, level of education, maturity, and understanding, works with physicians and physician extenders in a collegial manner for the resolution of patient/resident care problems, and contributes to team building by maintaining a positive, motivational attitude and a holistic approach toward nursing management 1.The Administration failed to protect resident (R) 84's right to be free from sexual abuse by not monitoring, supervising, and effectively addressing the sexual aggressive behavior of R41, (a resident with a known history of displaying sexually aggressive behaviors toward residents). This deficient practice resulted in R84 being sexually abused and experiencing psychosocial trauma. In addition, the facility failed to protect R14 from verbal abuse from staff. Cross-reference: F600 2. Administration failed to investigate, correct, and prevent allegations of abuse by resident to resident for one of seven residents (R) (R41) reviewed for sexual abuse. Specifically, the facility did not complete a thorough investigation of a facility reportable incident related to sexual abuse of a resident. Cross-reference: F610 3.Administration failed to develop and implement person-centered comprehensive care plans related to abuse for resident R84. In addition, the facility failed to implement a care plan for one resident R115 related to elopement risks and safety concerns. Cross-reference: F656 Interview on 5/24/2024 at 1:32 pm with Minimum Data Set (MDS) Coordinator VV revealed she was unaware that R84 as the victim of abuse needed to have a care plan, and this was an oversight on her part. She further stated the importance lie with monitoring residents for safety. MDS Coordinator further stated Social Services WW was responsible for ensuring that the care plan was implemented. Interview on 5/24/2024 at 1:38 pm with (Social Services) SS WW who revealed she was aware of the abuse incident with R84 but was not ever informed to develop an abuse care plan for R84. She further stated also was not informed to follow-up with nursing or to monitor R84 for any negative effects stemming from the sexual abuse incident. Interview on 5/31/2024 at 1:55 pm with Administrator DDD revealed she was unaware that R115's care plan was not developed for identified elopement risks or R84 had not been care planned for abuse. She stated the care plans should have been developed by social services or nursing staff. Interview on 5/31/2024 at 12:31 pm with Administrator DDD revealed she could not locate any evidence the previous Administrator CCC completed a thorough investigation after receiving knowledge of the allegation of abuse with R41 and R84. She further states she could not speak on behalf of him, but the investigation should have consisted of the physician and psych service provider being contacted to evaluate and possible adjust medications for the residents involved, police notified, written statements from all staff members who had knowledge of the incident, each residents care plans should have been updated and the staff should have received education related to the incident.

Based on staff interviews, record review, and review of the facility's policies titled Abuse Prohibition and General Medication Preparation and Administration, the facility failed to ensure that two residents (R) (R136 and R302) of 52 sampled residents were given medication without having a physician's order. Actual harm was identified on 1/23/2024 when LPN I2 administered her personal Melatonin to R136 and R302, which resulted in the residents becoming lethargic. Findings include: Review of the facility's policy titled Abuse Prohibition revised 3/1/2021 revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. This includes, but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical condition. Review of the facility's policy titled General Medication Preparation and Administration, review dated January 2021, it is the policy of the facility to assure medication preparation and administration is safe and cause no harm to residents. 3. Prior to administration of medication licensed staff should: a. Perform 5 rights - i. verify correct dose, ii. verify correct route, iii. verify correct medication, iv. verify correct time, v. and verify correct resident. Review of the facility's reportable incident file revealed the facility filed an initial Facility Incident Report Form (FRI) on 1/23/2024. This report indicated staff to resident abuse for R136 and R302 related to staff reported to Director of Nursing and Administrator a staff nurse was administering melatonin tablets and/or spray to residents on the Memory Care Unit without a physician's order. Review of the facility's 5 Day follow up report to the State Agency (SA) revealed the facility conducted a thorough investigation related to the incident that involved Licensed Practical Nurse (LPN) I2 administering Melatonin (pills and spray) to memory care residents without a physician order. The investigation concluded the allegation was substantiated. Further review of the file revealed staff witnessed a bottle of over-the-counter Melatonin pills and spray on the LPN I2 medication cart. Staff witnessed LPN I2 spraying melatonin spray around R302. Staff members in the memory care unit reported resident R136 had increased lethargy. Staff member witnessed Melatonin pills that were not on the facilities over the counter stock being poured into medication cups and taken into residents' rooms. LPN I2 admitted to having Melatonin pills on her medication cart and stated the medication was her personal melatonin, as she had difficulty sleeping. She denied having Melatonin spray. LPN I2 left her backpack in a resident's room after LPN I2 had clocked out. Upon searching for the backpack, the facility staff found an empty bottle of Melatonin. Based on investigations findings, the facility had strong reason to believe the LPN I2 was administering Melatonin to residents without a physician order. The facility's response upon knowledge of the alleged use of Melatonin by LPN I2 included: 1. Responsible parties for R136 and R302 were notified of the incident. 2. The physician was notified of the incident related to R136 and R302. 3. The Medical Director (MD) evaluated all residents of the Memory Care Unit (MCU) on 1/22/2024, with no negative outcomes or ongoing changes in resident conditions. 4. Staff questionnaires were completed to determine if they had worked on the MCU, identified anything unusual with staff, and who it was reported to. 5.Written statements by staff were also received. 6. On 1/21/2024, 1/23/2024, and 1/28/2024, licensed nurse staff were re-educated on the abuse policy, following MD orders, reporting chemical restraints, and having personal items stored at the facility. 7. The pharmacy was contacted, and it was determined that the Melatonin was not from the contracted pharmacy. No contraindication was identified. 8. LPN I2 was suspended and later terminated on 2/13/2024. 9. LPN I2 was reported to the nursing board. 1.Record review revealed R136 was admitted with diagnosis that included but not limited to dementia, major depressive disorder, delusional disorder, altered mental status, adult failure to thrive and metabolic encephalopathy. Record review of the most recent Quarterly Minimum Data Set (MDS) for R136, dated 2/20/2024, revealed a Brief Interview for Mental Status (BIMS) score of 4 (a BIMS score between 0 and 7 indicated severe cognitive impairment). Record review revealed R136 had a care plan initiated 11/20/2023 that indicated resident had the right to have personal preferences/choices for bathing, bedtime and awakening honored. Interventions included: resident will be assisted with bedtime routine as near to preferred time as possible, as resident will allow. Record review revealed R136's Physicians Orders for January 2024 did not have a physician order for melatonin tablets or spray. Record review of the January 2024 electronic Medication Administration Record (eMAR) for R136 revealed melatonin was not documented as administered. 2. Record review revealed R302 was admitted with diagnosis that included but not limited to dementia severe with agitation, weakness, other toxic encephalopathy, and altered mental status Record review of the most recent Admission Minimum Data Set (MDS) for R302, dated 12/03/2024, revealed a Brief Interview for Mental Status (BIMS) score of 8 (a BIMS score between 8 and 12 indicated moderate cognitive impairment). Record review revealed R302 had a care plan initiated 12/01/2023 that indicated resident exhibited changing awareness of environment related to medication interaction or toxicity. Record review revealed R302's Physicians Orders for January 2024 did not have a physician order for melatonin spray. Record review of the January 2024 electronic Medication Administration Record (eMAR) for R136 revealed melatonin was not documented as administered. Telephone interview on 5/23/2024 2:39 pm with former Director of Nursing (DON) BBB revealed a Certified Nursing Assistant (CNA) reported that LPN I2 was spraying Melatonin spray around residents and administering Melatonin tablets to residents on Memory Care Unit (MCU). She stated it was also reported that the nurse in questioned verbally told the other staff members she was medicating the residents. DON BBB revealed R136 was sleepy the next day after being medicated with melatonin. DON BBB stated she believed the LPN I2 was administering melatonin to all residents on MCU without a current physician's order. DON BBB further stated even though it was believed all residents on the MCU were dosed with melatonin, she was only able to prove 2 residents were dosed without an order. Interview on 5/29/2024 at 2:10 pm with DON FFF revealed she had worked at the facility for a short time and was not aware of the allegation/incident at this time. Interview on 5/29/2024 at 4:48 pm with Registered Nurse (RN) LL Nurse Supervisor revealed the nurse who witnessed LPN I2 with the melatonin, medicating residents on the MCU no longer worked at the facility. She further stated, the day nurse reported to her and RN MM that the nurse was medicating residents on the unit with Melatonin without a physician's order. RN LL stated she reported the allegation to DON BBB. A telephone interview on 5/30/2024 at 6:16 am with RN MM revealed the day nurse who reported the allegation of nurse having melatonin on the medication cart to administer to resident on the MCU no longer worked at the facility. RN MM stated after the allegation was reported to her, she went to the MCU and witnessed the bottle of Melatonin on the medication cart. She stated the LPN I2 stated the medication was hers and she brought the medication in to show her co-workers what she took to help her sleep. She stated another empty bottle of Melatonin was also discovered in the LPN's personal bag. Telephone Interview 5/30/2024 at 9:44 am with LPN KK revealed that LPN I2 relieved her from her duties on two separate occasions. LPN KK further stated she witnessed the nurse place a large container of Melatonin tablets and Melatonin spray on the medication cart after retrieving them from her personal belongings. LPN KK stated the nurse informed her that she was going to medicate the residents with melatonin to help them sleep better. LPN KK also stated she noticed residents on the unit were sedated and sleepy the next day but didn't think much of it because she did not routinely work the unit to know their normal behavior. Telephone interview 5/30/2024 at 9:54 am with former Administrator CCC revealed he was involved in the investigation related to the allegation. He further stated LPN I2 did not own up to the medications, but an empty Melatonin bottle was found in her personal bag which was left on the unit. He stated the nurse was seen on video surveillance spraying something around R302. Administrator CCC stated there was enough evidence through staff interviews to substantiate the allegation. Interview on 5/30/2024 at 11:46 am with Administrator DDD who revealed she was aware of the incident that occurred prior to her being employed at the facility. She stated that she expected that medications would not be administered to any resident in the facility unless a physician has ordered it. Interview 5/31/2024 at 10:47 am with CNA NN revealed in the evening the residents on the MCU started to sundown and have increased behaviors. She stated she observed LPN I2 pulled out a bottle of melatonin, began putting the melatonin into medication cups on the medication cart and stated, I am finna fix them up, I got something for them. CNA NN stated the nurse began to administer the melatonin to the resident and she reported this incident to the former DON BBB who was on the MCU at the time. CNA NN further stated on a different occasion she witnessed LPN I2 spray melatonin spray around R302. She stated she knew it was melatonin spray because she saw the label on the bottle.

Based on observation, record review and interview, the facility failed to ensure all beds, mattresses and bed frames fit together safely for two residents (R) (R#115 and R#234). Specifically, R#115 was found on 1/6/17, with her body partially on the floor with her neck and head caught between the upper assist rail and the bed mattress. R#115 had to be given oxygen to bring her oxygen level up from 92% to 97%. An ice pack was applied to her neck and skin tears on knee were treated. On 4/6/17 R#234 was found to have a bariatric bed with a regular mattress and ¼ bilateral upper side rails which left a 9 inch gap between the mattress, bed frame and side rails. The facility's failure to audit all beds in the facility, after the incident that occurred with R#115 on 1/6/17, put R#234, and all residents with siderails, at risk for serious physical harm and represented an immediate jeopardy situation to the health and safety of R#234 and all residents with side rails. There were 156 residents in the facility with siderails. On 4/7/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 4/7/17 at 11:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on 1/6/17. The Immediate jeopardy is ongoing. The immediate jeopardy is outlined as follows: On 1/6/17, resident (R#115) was found with her neck and her head stuck in between the side rails and the bed. At that time R#115 was assessed and found that her face was reddened, she was perspiring, her neck was swollen and slightly purpled with two small circular indentations under her chin from the hardware on the assist railing. The resident's oxygen saturation was assessed to be 92% and the resident required oxygen to bring her oxygen saturation level up to 97%. The resident also had skin tears to her knee. There was not any evidence of documentation that the resident, or the resident's representative, had given consent for the side rails to be used. Review of the residents Side rail Assessment Form dated 12/26/16 revealed that the resident did not express a desire for the side rails to be raised. After this incident occurred on 1/6/17, with R#115, the facility failed to audit the other beds in the facility to determine if there were any other residents at risk for being stuck between the side rails and the bed. During the survey, on 4/6/17 at 3:30 p.m., the bed for R#234 was observed to be a bariatric bed with a mattress that was not secured and could be easily moved from side to side creating a gap between the bilateral upper side rails and the mattress. This gap was measured and was found to be a 9 inch gap between the mattress and the side rails in which the resident could be entrapped. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R 483.25(d)(1)(2)(n)(1)-(3), Free From Accidents and Hazards (F323, Scope/Severity: J); 42 C.F.R.483.70, Effective Administration (F490, Scope/Severity: J; 42 C.F.R.483.75(g)(1)-(111)(2)(1)(2)(h)(1), Quality Assurance (F520, Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirement at 42 C.F.R 483.25(d)(1)(2)(n)(1)-(3), Free From Accidents and Hazards (F323, Scope/Severity: J. The Immediate Jeopardy is ongoing. Findings include: 1. A review of the clinical record face sheet, for R#115, revealed that she was admitted to the facility with [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. A review of the Significant Change Minimum Data Set (MDS) assessment for R#115, dated signed 12/21/16 indicated R#115 had a Brief Mental Status score of two indicating that she was severely cognitively impaired and also documented that the resident needed extensive assistance by one person for bed mobility and transfers. A review of the Care Plan, for R#115, initiated 12/21/16, indicated that the resident was care planned for unsafe behaviors noted of self-transferring. Further review of R#115's the clinical record, for R#115, revealed that she received a side rail assessment once a year. The assessment was entitled Side Rail Assessment. The Senior Care Center Brunswick (SCCB ) assessment dated [DATE] indicated that the resident did not express a desire to have side rails raised while in bed for her own safety or comfort and the Resident could use the side rails for positioning or support and to assist with the resident rising from a supine position to a sitting or standing position. The side rail assessment dated [DATE] documented that R#115 did not express a desire for the side rails to be raised. No evidence could be found that consent was given by R#115's family or representative to allow the facility to place the side rails. No evidence could be found that there was a physician's orders [REDACTED]. A review of the facility provided document entitled Safety Event Entry, for R#115, dated 1/6/17 at 6:30 a.m., revealed a Certified Nursing Assistant (CNA) in the secure Memory Unit, found R#115 sitting on the floor beside her bed, with her upper body partially on the bed. The bed was in lowest position. Resident's neck and head were caught in between the upper assist rail and the bed mattress. Assist rail was pressing into resident's neck. Residents face was reddened and she was perspiring .Residents neck was swollen and slightly purple with two small circular indentations under the chin from hardware on assist railing. R#115 was given oxygen to bring her oxygen level up from 92% to 97%. An ice pack was applied to her neck and skin tears on knee treated with Xeroform. Further review of the document revealed a section asking what contributed to the event occurring. The facility responded Resident with Alzheimer's Dementia with anxiety disorder. She (R#115) does not follow care directions easily. She has difficulty ambulating and will try to get up and walk without assistance. She had unsafe behaviors of self-transfer. During an observation in the Memory Care Unit on 4/4/17 at 12:15 p.m. the unit consisted of a large open common area used for dining and activities, surrounded by bedrooms on two sides with a Nurses station at one end and showers toilets on the other end. The unit was observed to have 29 Residents with 40 certified beds. Observations throughout the survey of 4/3/17 through 4/7/17 in the secure Memory Unit revealed multiple residents that were observed to not follow care directions, had difficulty ambulating and attempted to get up and walk without assistance. Interview with the Administrator on 4/6/17 at 5:03 p.m., revealed that the facility did not audit the other beds in the facility to ensure the safety of the other residents after the incident on 1/6/17. She stated that the facility thought it was an isolated incident and did not require auditing of other residents beds. She further stated that the facility did not seek consent for the use of any resident side rails. 2. Record review revealed that R#234 was admitted to the facility per to the resident's Face Sheet dated 4/7/17, with [DIAGNOSES REDACTED]. Further review revealed that the resident was admitted to the facility on [DATE]. The resident had a hospital stay from 9/15/16 and was readmitted to the facility on [DATE]. The Minimum Data Set (MDS), a quarterly assessment of overall health status dated 2/28/17, indicated that R#234 was severely cognitively impaired Brief Interview for Mental Status (BIMS 0/15), required limited assistance from one staff member for transfers and mobility within his room, and required supervision for ambulation due to unsteady gate while in the facility hallways. The assessment indicated no side rails were in use to restrain the resident. Physician Orders, signed by the physician and dated April 2017, were reviewed and no order for side rails could be found. The Care Plan most recently dated 3/24/17, did not address the use of bilateral side rails for R#234. The Care Plan indicated that the resident wandered and was exhibiting the Unsafe behavior of moving furniture. Staff was to redirect the resident from any unsafe behavior, monitor for safety, and notify the resident's physician and responsible party of behaviors. assessment dated [DATE], indicated R#234 was at high risk to experience falls (score of 10). The most recent Side Rail Assessment dated 12/26/16, indicated R#234 had not expressed a desire to have side rails, did have fluctuations in level of consciousness, had a history of [REDACTED]. The assessment indicated the resident could get out of bed safely and independently, did not have a problem with balance or trunk control, and would not climb over the rails. The assessment further indicated there was not a risk to the resident if side rails were used. There was no family consent signed for the side rails. Observation on 4/6/17 at approximately 3:30 p.m., revealed bilateral upper 1/4 side rails on R#234's bariatric bed for R#234. Further observation revealed that the mattress on the bed was not secured in any way to the bed's frame and could be moved easily from side to side, creating a gap between the side rail and the mattress. Observation on 4/6/17 at approximately 3:50 p.m., the gap between the side rail and the R#234's mattress was measured to be nine inches across by a member of the maintenance team with the surveyor present. On 4/7/17 the facility verified that 192 resident beds had side rails in place. The facility's failure to audit all beds in the facility put R#234, and all residents with siderails, at risk for serious physical harm. During an interview with the Maintenance man helper on 4/6/17 at 3:50 p.m., he stated that his job was primarily to paint in the building and that he did not know anything about beds, mattresses, or how large a gap between a mattress and a side rail was allowed to be. During an interview with RN AA, the RN Secured Unit Manager on 4/6/17 at 3:55 p.m., revealed, I don't know anything about gaps and whether there should be a gap (between a mattress and a bed rail) or not. During an interview with the Maintenance Team Leader on 4/7/17 at approximately 9:05 a.m., he indicated that a regular sized mattress had been placed on the resident's bariatric bed and that he was unaware that the resident had been placed on a bariatric bed with side rails, and he stated, I Took care of the bed in {R#234's room} last night. I found the right sized mattress and put it on the bed. I don't have a good answer about why the wrong size mattress was on the bed in the first place. The mattress on the bed now fits correctly. He indicated a checklist was completed on every single room at least quarterly and that all functions of each bed were checked when the quarterly checklist was done. When asked if he was aware of how large a gap between a mattress and a bedrail could be, he stated that the acceptable gap between a side rail and a mattress could not exceed between 4.5 to 4.75 inches. He stated, We don't actually put a tape measure on the mattresses because most of them fit pretty snug. It was the wrong mattress on that (R#234's) bed. I can look at the bed and tell if it is a bariatric bed or not .as far as anyone else .they might not know it's not the right mattress. The Maintenance Team Leader provided the survey team with the most recent quarterly checklist for 234's room, dated 1/14/17. The checklist included a General section, which listed Furniture and equipment in good working order as one of the inspection points. The form indicated no concerns with furniture. The Maintenance Team Leader stated, Equipment in good working order includes the bed being in working order and functioning properly, including making sure hand rails release and let down, and checking to see if the mattress fits snugly to the bed. The Maintenance Team Leader reconfirmed that he was unaware R#234 had a bariatric bed with a regular mattress creating a large gap between the mattress and the side rail until the facility was informed of the concerns by the survey team. He stated he did not know how long the bed had been in place.

Based on interview, record review, review of the facility document titled, Safety Event Entry the Administrator failed to have administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator failed to perform an audit of all of the facility beds to ensure resident safety after the incident occurred with R#115 on 1/6/17, when Resident (R) R#115 was found, sitting on the floor beside her bed, with upper body partially on the bed and the resident's neck and head were caught in between the upper assist rail and the bed mattress. The assist rail was pressing into the resident's neck. Observation on 4/6/17 at 3:30 p.m., revealed that R#234 was found to have a bariatric bed with a regular mattress and 1/4 bilateral side rails which left a 9-inch gap between the mattress and bed frame/side rails putting this resident at risk for entrapment between the mattress and side rails of the bed. The Administrator's failure to audit all beds in the facility after the incident of 1/6/17 put R#234, and all residents with side rails, at risk for serious physical harm and represented an immediate jeopardy situation to the health and safety of R#234. Additionally, the Administrator failed to be aware of, or act upon the problems the facility had with CNA behavior towards residents in the facility. (Cross reference F225 and F226 for documentation of 13 residents who reported allegations of neglect and mental abuse). On 4/7/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 4/7/17 at 11:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on 1/6/17. The Immediate jeopardy is ongoing. The immediate jeopardy is outlined as follows: On 1/6/17, resident (R#115) was found with her neck and her head stuck in between the side rails and the bed. At that time R#115 was assessed and found that her face was reddened, she was perspiring, and her neck was swollen and slightly purpled with two small circular indentations under her chin from the hardware on the assist railing. The resident's oxygen saturation was assessed to be 92% and the resident required oxygen to bring her oxygen saturation level up to 97%. The resident also had skin tears to her knee. There was not any evidence of any documentation that the resident, or the resident's representative, had given consent for the side rails to be used. Review of the residents Side rail assessment form dated 12/26/16 revealed that the resident did not express a desire for the side rails to be raised. After this incident occurred on 1/6/17, with R#115, the facility failed to audit the other beds in the facility to determine if there were any other residents at risk for being stuck between the side rails and the bed. During the survey, on 4/6/17 at 3:30 p.m., the bed for R#234 was observed to be a bariatric bed with a mattress that was not secured and could be easily moved from side to side creating a gap between the bilateral upper side rails and the mattress. This gap was measured and was found to be a 9 inch gap between the mattress and the side rails in which the resident could be entrapped. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R 483.25(d)(1)(2)(n)(1)-(3), Free From Accidents and Hazards (F323, Scope/Severity: J); 42 C.F.R.483.70, Effective Administration (F490, Scope/Severity: J; 42 C.F.R.483.75(g)(1)-(111)(2)(1)(2)(h)(1), Quality Assurance (F520, Scope/Severity: J). Additionally, Substandard Quality of Care was identified with the requirement at 42 C.F.R 483.25(d)(1)(2)(n)(1)-(3), Free From Accidents and Hazards (F323, Scope/Severity: J). The Immediate Jeopardy is ongoing. The findings include: 1. A review of the document provided by the facility titled Safety Event Entry dated 1/6/17 at 6:30 a.m., revealed a Certified Nursing Assistant (CNA) in the secure Memory Unit, found R#115 sitting on the floor beside her bed, with upper body partially on the bed. Bed was in lowest position. Resident's neck and head were caught in between the upper assist rail and the bed mattress. Assist rail was pressing into resident's neck. Residents face was reddened and she was perspiring .Residents neck was swollen and slightly purple with two small circular indentations under the chin from hardware on assist railing. R#115 was given oxygen to bring her oxygen level up from 92% to 97%. An ice pack was applied to her neck and skin tears on knee treated with Xeroform. Further review of the document revealed a section asking what contributed to the event occurring: The facility responded Resident with Alzheimer's Dementia with anxiety disorder. She does not follow care directions easily. She has difficulty ambulating and will try to get up and walk without assistance. She had unsafe behaviors of self-transfer. On 4/7/17 at 9:13 a.m., R#234, who resided in the secure Memory Care unit, was found to have a bariatric bed with a regular mattress and ¼ side rails which left a 9-inch gap between the mattress and bed frame and side rails. Record review revealed that the Physician's orders for R#234 for April 2017 documented [MEDICAL CONDITION] and frontal temporal dementia as diagnoses. A review of the care plan, for R#234 last revised 2/28/17 revealed that he was care planned for At risk for fall R/T (due to) [MEDICAL CONDITION], weakness, unsteady gait and poor balance and Requires assist with ADL's (activities of daily living) due to [MEDICAL CONDITION]. An interview with the Administrator on 4/6/17 at 5:03 p.m., revealed the facility did not audit the other beds in the facility to ensure the safety of beds with side rails after the incident on 1/6/17. She stated the facility thought it was an isolated incident and did not require auditing of other resident's beds. The Administrator's failure to audit all beds in the facility after the incident of 1/6/17 put R#234, and all residents with side rails, at risk for serious physical harm and represented an immediate jeopardy situation to the health and safety of R#234, and all residents with side rails. 2. A review of the facility policy titled Abuse dated May 2001, revealed that the facility was to investigate and report to appropriate agencies all allegations of abuse and neglect. (Cross reference F225 and F226) for documentation of 13 residents who reported allegations of neglect and mental abuse. R#74 alleged on 8/6/16 that she turned on her bathroom call light at 4:50 a.m., a CNA came in and stated she couldn't assist her as she was not her CNA. At 5:20 a.m., when no one came to assist I got up by myself. On 3/1/17 R#74 reported a second incident where a certain CNA had been ugly to her and she doesn't feel comfortable talking with the CNA or making requests of her. The allegation continued that the CNA will be worse in the treatment directed towards resident. It further stated the CNA purposely takes her to shower late so the CNA won't have to take her to Bingo. Interview with the administrator on 4/5/17 at 3:00 p.m., revealed she was aware of the complaints about staff behaviors, but had not identified the grievances as possible abuse or neglect, and the allegations had not been reported or investigated.

Based on interview and record review, review of the facility's policy and procedure titled, Quality Assurance/Performance Improvement the facility failed to maintain an effective Quality Assurance (QA) program which systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies for the census of 171 residents. The QA failure to identify possible hazardous situations for residents and failure to audit all beds in the facility after an incident that occurred on 1/6/17 in which Resident (R)#115 was found with her neck and head caught in between the upper assist rail and the bed mattress put all residents with side rails at risk for potential harm. Additionally, the facility QA committee failed to address problems with CNA behavior towards residents in the facility. On 4/7/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 4/7/17 at 11:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on 1/6/17. The Immediate jeopardy is ongoing. The immediate jeopardy is outlined as follows: On 1/6/17, resident (R#115) was found with her neck and her head stuck in between the side rails and the bed. At that time R#115 was assessed and found that her face was reddened, she was perspiring, her neck was swollen and slightly purpled with two small circular indentations under her chin from the hardware on the assist railing. The resident's oxygen saturation was assessed to be 92% and the resident required oxygen to bring her oxygen saturation level up to 97%. The resident also had skin tears to her knee. There was not any evidence of any documentation that the resident, or the resident's representative, had given consent for the side rails to be used. Review of the residents Side rail assessment form dated 12/26/16 revealed that the resident did not express a desire for the side rails to be raised. After this incident occurred on 1/6/17, with R#115, the facility failed to audit the other beds in the facility to determine if there were any other residents at risk for being stuck between the side rails and the bed. During the survey, on 4/6/17 at 3:30 p.m., the bed for R#234 was observed to be a bariatric bed with a mattress that was not secured and could be easily moved from side to side creating a gap between the bilateral upper side rails and the mattress. This gap was measured and was found to be a 9 inch gap between the mattress and the side rails in which the resident could be entrapped. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R 483.25(d)(1)(2)(n)(1)(3), Free From Accidents and Hazards (F323, Scope/Severity: J); 42 C.F.R.483.70, Effective Administration (F490, Scope/Severity: J); 42 C.F.R.483.75(g)(1)-(111)(2)(1)(2)(h)(1), Quality Assurance (F520, Scope/Severity: J). Substandard Quality of Care was identified with the requirement at 42 C.F.R 483.25(d)(1)(2)(n)(1)-(3), Free From Accidents and Hazards (F323, Scope/Severity: J). The Immediate Jeopardy is ongoing. Findings include: A review of the facility's policy and procedure titled Quality Assurance/Performance Improvement indicated the Quality Assurance (QA) Committee had the following Program Objectives: 1. Focus primarily on opportunities to improve key activities, including direct care, management, and support services. 2. Understand and improve key functions in the delivery care. 3. Identify trends, potential problems, and actual problems in providing quality care in the Senior Care Center through data collection regarding indicators, performance measures, survey, reports, etc. 4. Address processes that have important direct or indirect effects on resident outcomes. 5. Monitor the appropriateness, timeliness, and effectiveness of process improvement or problem resolution. During an interview on 4/7/17 at 1:29 p.m. with the Administrator and Director of Nursing (DON) the Administrator said she was responsible for leading the QA committee. She said the committee met bi-monthly with the appropriate members. She said once an issue was identified by the staff a discussion took place about who the problem effects and who needed to be involved in solving it. Continued interview revealed that the Administrator said the QA committee discussed the incident of 1/6/17 with R#115 and the QA committee felt it was an isolated incident for that resident. Further interview with the Administrator revealed that no safety concerns with side rails were identified by the QA committee and the committee did not audit other beds in the facility. Observation on 4/6/17 at 3:30 p.m., revealed that R#234 was found to have a bariatric bed with a regular mattress and ¼ side rails which left a 9 inch gap between the mattress and bed frame and side rails. Putting this resident at risk for entrapment. The facility's failure to audit all beds in the facility after the incident of 1/6/17 put R#234, and all residents with side rails, at risk for serious physical harm and represented an immediate jeopardy situation to the health and safety of R#234. A review of the facility policy entitled Abuse dated May 2001, revealed that the facility was to investigate and report to appropriate agencies all allegations of abuse and neglect. (Cross reference F225) documentation of 13 resident grievances reporting allegations of mental abuse or neglect from 4/27/16 to current date that were not investigated. R#108 alleged a CNA was being mean rude and disrespectful on 3/1/17 and that the same CNA made her cry on more than one occasion. Interview with R#108 on 4/6/17 at 6:00 p.m., revealed it does no good to report staff behaviors. Interview with the administrator on 4/5/17 at 3:00 p.m., revealed the facility had not identified the grievances as abuse or neglect. Review of the personnel record for CNA FF with a hire date of 6/5/15, had a clear background screen. CNA FF was identified in the grievance reported by R#108 and continues to work with residents. A review of a facility provided document titled Abuse Surveillance (employee Section V: Resident Rights last revised May 2015, included the following procedures: any participants and/or observers who may have information concerning an allegation of abuse or neglect are interviewed. The policy also documented that the facility was to investigate all allegations of abuse and neglect. The policy also documented that The Administrator, Director of Nursing, or Designee are responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities as required by regulations and/or law. (Cross reference F226). Interview with the administrator on 4/5/17 at 3:00 p.m., the facility was aware of the staff behaviors, but had not identified the grievances as abuse or neglect. The grievances were not addressed by the QA committee. It was also confirmed by the administrator, that no action had been taken per facility policy with CNA FF who had been identified in a grievance reported by R#108.

Based on resident and staff interview, record review, review of the facility's policy titled, Abuse, review of the facility's Grievance / Complaint Report, and review of the facility provided Safety Event Entry forms the facility failed to investigate and report allegations of neglect and mental abuse alleged through Resident (R) grievances for 13 of 51 sampled residents (R#297, R#185, R#62, R#21, R#74, R#209, R#173, R#8, R#108, R#153, R#81, R#119, R#234). R#62, R#74 and R#108 sustained actual psychological harm. Three additional residents R#114, R#44 and R337 had complaints about staff behavior, but did not report the concerns. Sample size was 51 residents. The findings include: 1. A review of the facility policy entitled Abuse dated May 2001, revealed that the facility was to investigate and report to appropriate agencies all allegations of abuse and neglect. A review of facility Grievance /Complaint Report documents revealed the following: a. R#297 family made an allegation on 5/2/16 that over a time period of 4/27/16 through 5/2/16 no oral care was provided to the family member. They also alleged the Resident wore the same blood stained clothes for 2 of those days. b. R#185 alleged on 5/3/16, that CNAs belittled her for her lack of bladder control and a CNA left her in bathroom on the toilet for a very long time though I had pulled the cord for assistance and when she came back to her the CNA said she wasn't busy, she was sitting at the desk. c. R#62 alleged on 6/6/16, that the approach of the CNA scares her. She further alleged she pushed her call lights several times asking to be helped to the bathroom and {CNA} would come in, turn her light off, tell her to be patient, but never would return. She would then soil herself and have to stay in that condition until her day CNA came in to dress her for the day. d. R#21 alleged on 7/27/16 a CNA was often rude and on 7/26/16 the resident asked the CNA to help her transfer out of her recliner. Resident states {CNA} responded in a rude tone that I'm not going to hurt my back transferring you. e. R#74 alleged on 8/6/16 that she turned on her bathroom call light at 4:50 a.m., a CNA came in and stated she couldn't assist her as she was not her CNA. At 5:20 a.m., when no one came to assist I got up by myself. f. R#209 family alleged on 9/20/16 the lack of care given to the resident while they are visiting. They often visit for five plus hours a day. Concern has also been expressed about the tone and attitude of the staff toward the resident. A couple of Sundays ago they visited the resident from 12:30 p.m. until 5:30 p.m. and no one came to change the resident or check on him at all. The family alerted a new CNA at 3:30 p.m. that the resident was getting nasty and wanted to lay down for a nap. He needed assistance to be put back in the bed. The new CNA stated she didn't want to get him back up when it's time for a shower. The CNA told the family she had to tend to other residents and not to this resident. The family further noted they were afraid to speak up and say anything. g. R#173 family member alleged on 9/20/16 that when she came to visit her mother on 9/19/16 at 6:10 p.m. upon entering the room she could smell urine. She stated her mother's brief was saturated, her pants wet, as well as the cushion in her wheelchair. She stated that day she witnessed another resident request to go to the bathroom four times before she was taken around 8:00 p.m. h. R#8 alleged on 2/25/17 that the nurse was mean and when she requested cream for her neck to reduce pain the nurse told her to put it on yourself. i. R#74 alleged on 3/1/17 that a certain CNA has been ugly to her and she doesn't feel comfortable talking with the CNA or making requests of her. The allegation continued that the CNA will be worse in the treatment directed towards resident. It further stated the CNA purposely takes her to shower late so the CNA won't have to take her to Bingo. j. R#108 alleged on 3/1/17 that a CNA was being mean rude and disrespectful. R#108 further alleged that the same CNA had made her cry on more than one occasion. The resident further documented she was having problems sleeping due to mistreatment. The grievance further documented that the CNA slams her meal tray down and rushes her to eat. The grievance also stated the CNA's bully her and she can't take it anymore and losing sleep and she is also afraid of her. An interview on 4/6/17 at 6:00 p.m., with R#108, whose most recent BIMS score was 14, indicating the resident was cognitively intact, revealed a recent episode with the same CNA occurred two days ago when she was in her bed and the CNA entered her room. The Resident asked the CNA if she saw her TV remote control on the floor and would the CNA pick it up and give it to her. R#108 stated the CNA responded she did see the remote control on the floor but turned around and left the room without picking it up and giving it to the resident. The Resident further stated she did not report it as it does no good. R#153 and R#81 both alleged on 3/2/17 that staff wanted them out of bed to go to dinner and Bingo afterwards. Both complainants stated they had never had Bingo on a Sunday and were told by the CNA this was a Special Bingo and to get up. Both residents did get up and found that there was not any Bingo but that the CNAs had deceived them to get them out of bed. A review of the facility provided investigations revealed that there were not any investigations into the allegations listed above. An interview with R#114 on 4/4/17 at 9:17 a.m., when asked the question do staff treat you with respect and dignity? R#114 responded Not very much they talk back and tell you they are not gonna do whatever you need done. All depends on who it is. Sometimes it's noon before I can get any water. I'll call for water and they don't want to bother with it. Resident #44 on interview 4/3/17 at 2:54 p.m. when asked if treated with respect and dignity replied CNA's can be disrespectful but gave no specifics or names. Interview with R#37 on 4/3/17 at 2:29 p.m. complaint of the CNA's not giving her shower all week. they didn't come to get me last week. Further stated CNA's can be disrespectful. they drink my case of Dr. Pepper. They won't let me have but one pack of pull ups per week. I ran out and the Administrator told me I couldn't have but one pack. 2. A review of facility provided Safety Event Entry forms revealed the following: a. incident in the secure Memory Care Unit, dated 2/6/17, indicating R#119 became agitated and began yelling. Another resident sitting next to R#119 became agitated and grabbed R#119 and causing skin tears to the forearm of R#119. b. A review of facility provided Safety Event Entry forms revealed an incident in the secure Memory Care Unit dated 2/12/17, the form documented that R#234 was attempting to grab other resident's cake and staff intervened by requesting that he stop and take a seat. Resident then attacked another resident and was then separated and redirected again. Resident is very combative and residents afraid of him. Resident bullies other residents into giving him their snack or her takes it. There was not any evidence of documentation provided to indicate that the facility investigated the allegations of possible neglect, lack of supervision or possible emotional /mental abuse. c. A review of facility provided Safety Event Entry forms revealed an incident in the secure Memory Care Unit dated 2/23/17 revealed R#234 grabbed another resident causing a skin tear, to the other resident, when the other resident pulled Continued From page 20 away. There was not any evidence of documentation provided to indicate that the facility investigated the allegation of possible neglect or lack of supervision. d. A review of facility provided Safety Event Entry forms revealed an incident in the secure Memory Care Unit, dated 3/22/17, indicating R#119 became agitated and began yelling at another resident. The other Resident started waving her hand, and accidentally caused a small skin tear to R#119 chest. Family interview on 4/3/17 at 2:57 p.m. of Resident #119 repeated the issue of her mother being attacked and scratched by another resident and the facility did not do anything. A review of the facility provided investigations revealed that there were not any investigations into the allegations listed above or any investigation of the Resident to Resident altercations. An interview with the Administrator on 4/5/17 at 3:00 p.m., revealed that the facility had not identified the grievances as allegations of abuse or neglect and could not produce any evidence that the facility had reported the allegations and could not produce any evidence that the facility had investigated or reported the resident to resident altercations to the necessary agencies or thoroughly investigated the allegations or altercations.

Based on staff and resident interviews and record reviews, review of the facility provided document titled, Abuse Surveillance, and review of facility's Grievance /Complaint Report the facility failed to implement their policy for abuse and neglect. Specifically, the facility failed to identify, investigate, and report allegations of neglect and mental abuse alleged through Resident grievances for 13 of 51 sampled residents (R#297, R#185, R#62, R#21, R#74, R#209, R#173, R#8, R#108, R#153, R#81, R#119, R#234). R#62, R#74 and R#108 sustained actual psychological harm. Sample size was 51 residents. The findings include: A review of a facility provided document titled Abuse Surveillance (employee Section V: Resident Rights last revised May 2015, included the following procedures: any participants and/or observers who may have information concerning an allegation of abuse or neglect are interviewed. The policy also documented that the facility was to investigate all allegations of abuse and neglect. The policy also documented that The Administrator, Director of Nursing, or Designee are responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities as required by regulations and/or law. Review of the facility Grievance /Complaint Report documents revealed the following: (Cross Reference F225 for documentation of reported grievances for the 13 identified residents. R#74 had 2 reported grievances 8/6/16 and 3/1/17). Review of the personnel record for Certified Nursing Assistant (CNA) FF with a hire date of 6/8/15, had a clear background screen. CNA FF was identified in the grievance reported by R#108 and continues to work with residents. A request was made to review the facility provided investigations revealed no investigations into the allegations listed above or the Resident to Resident altercations. On 04/05/2017 at 12:26:35 p.m., the administrator confirmed nothing had been done at this point regarding the grievance where CNA FF was identified. Continued interview with the Administrator on 4/5/17 at 3:00 p.m. revealed the facility had not investigated or reported the resident to resident physical altercations for possible supervision or neglect issues.

Based on observations, resident and staff interviews and record reviews, it was determined that the facility failed to ensure that pain medication was adminstered prior to treatments for one resident ("A"), to promptly begin antibiotic treatment as ordered by the physician for one resident (#1), to identify a resident's allergy to a medication prior to administering the medication for one resident (#8), and to clarify physician's orders before holding a medication for two residents (#10 and #20 from a total sample of 24 residents. This failure resulted in actual harm for resident "A". Findings include: 1. Resident "A" had [DIAGNOSES REDACTED]. There was a 1/28/11 physician's order for 5/325 strength [MEDICATION NAME] every four hours as needed for pain. There was a 2/8/11 physician's order for nursing staff to provide wound care to the resident's sacral decubitus ulcer two times daily, and a 2/15/11 physician's order for licensed nursing staff to administer 5/325 strength [MEDICATION NAME] to him/her before each dressing change. During an interview on 2/23/11 at 11:45 a.m., resident "A" stated that he/she had pain daily because of his/her decubitus ulcer and arthritis. Resident "A" stated that, at times, the pain was excruciating. On 2/23/11 at 9:20 a.m., treatment nurse "KK" stated that resident "A" was given his/her pain medication in the morning before treatment because of his/her increased pain in the morning. However, a review of the February 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 2/23/11 at 5:00 p.m., resident "A" stated that licensed nursing staff did not always administer the pain medication prior to his/her wound care. Resident "A" stated that when he/she did not get pain medication before wound care, his/her pain increased to about a 9 to 10 on a pain scale of 0 to 10. 2. Resident #8 had a physician's visit on 8/27/10. The physician that visited the resident was filling in for his/her primary care physician. That physician documented that the resident had a cough and occasional ronchi and had recently been treated for [REDACTED]. However, a review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Licensed nursing staff documented on 8/29 and 8/30/10 that the medication was unavailable. However, there was no evidence that nursing staff informed a physician until 8/30/10 (three days later). The resident's primary care physician visited on 8/30/10 and documented that the resident had been prescribed [MEDICATION NAME] three days prior and had not received it. He diagnosed the resident with pneumonia and prescribed new medication. Resident #8 had a physician's order on 12/4/10 for licensed nursing staff to administer 875 milligrams (mg) of [MEDICATION NAME] twice daily for seven days. There was an order written [REDACTED]. A review of the December 2010 MAR indicated [REDACTED]. However, the resident was given the [MEDICATION NAME] by the nursing staff on 12/4/10 and 12/5/10 at 9 p.m., and on 12/5/10 at 9 a.m. before nursing staff identified the resident's allergy to it and notified the physician. 3. Resident #10 had a physician's order since at least 1/1/11 for licensed nursing staff to administer 12 units of [MEDICATION NAME]three times a day before meals. However, a review of the January 2011 MAR indicated [REDACTED]. There was not a physician's order to hold the insulin. 4. Resident #1 had a physician's order dated 11/19/2010 to be given 125 milligrams (mg) of [MEDICATION NAME] four times a day by gastrostomy tube for seven days. However, the November 2010 MAR indicated [REDACTED]. The licensed nurse documented in the resident's medical record on 11/22/10 that the facility had received [MEDICATION NAME] which could not be used for the resident because it was solidified and, the pharmacy had been contacted for a liquid solution. The nursing staff was informed that the medication would be in the facility on 11/23/10. 5. Resident # 20 had a physician's order since 1/29/10 to receive 5 mg of [MEDICATION NAME] twice a day. The order included that the licensed nurse check the resident's pulse and hold the medication if the resident's blood pressure (BP) was above 100/60. A review of the documentation on the resident's December MAR indicated [REDACTED]. The January 2011 MAR indicated [REDACTED]. The February 2011 MAR indicated [REDACTED]. However, the physician's orders did not include parameters for a low pulse or a low diastolic blood pressure. During an interview on 2/23/11 at 1:40 p.m., licensed nurse "EE" stated that there were no parameters for the medication to be held based on the resident's pulse or a low diastolic blood pressure. She stated that the physician needed to be contacted to clarify the order.