Every finding on record at Signature Healthcare of Elizabethton Rehab & Welln

Based on facility policy review, medical record review, text message review, and interviews, the facility failed to report an allegation of abuse to the appropriate state agencies for 1 resident (Resident #32) of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 9/15/2023, revealed .It is the orgnaization's intention .to assure that alleged violations of federal or State laws which involve abuse .are .reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .The Facility Administrator is responsible for reporting all investigations' results to applicable State agencies .Mental abuse .Includes, but is not limited to humiliation .or any other statements or behavior that a reasonable person would consider to be humiliating, demeaning .Verbal abuse .Is use of any oral .language that includes .disparaging or derogatory language, to residents .Allegation of Abuse .This means a report .or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred, or plausibly might have occurred .Training .Stakeholders will be trained on reporting allegations of abuse .Reporting abuse .and to whom and when staff and others must report their knowledge related to any alleged violation .Reporting .Every Stakeholder shall immediately report any 'allegation of abuse,' .to the Facility Administrator or designee .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Heart Failure, Depression, and Morbid Obesity. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Resident #32 was dependent on staff for toileting and substantial/maximal assistance with personal hygiene. Review of a text message between Registered Nurse (RN) A and the Director of Nursing (DON) dated July 5, 2026 at 2:51 AM, revealed .Certified Nurse Assistant [CNA] C told me something that a resident told her .[Resident #32] had a bowel movement .[Resident #32] stated [CNA A] was questioning him why he doesn't use a bedpan and was making comments like you stink .this is disgusting . Further review revealed the DON responded to the message on 7/5/2026 at 12:34 PM and stated .we will address this . Review of the staffing assignment sheets from 7/3/2026 - 7/5/2026, revealed CNA A worked 6:00 PM to 6:00 AM on 7/3/2026, 7/4/2026, and 7/5/2026. CNA A was assigned to Resident #32 on 7/3/2026 from 6:00 PM to 6:00 AM. During an interview on 7/29/2026 at 8:29 AM, CNA C stated she worked nightshift on 7/4/2026 and Resident #32 reported to her that CNA A told Resident #32 he was nasty and disgusting for not wearing a brief and that he stunk. CNA C stated she reported this to RN A immediately. During an interview on 7/29/2026 at 10:28 AM, Resident #32 stated .about 3 weeks ago . CNA A was changing him after a bowel movement and was making comments that he was nasty and disgusting and that he stunk. Resident #32 reported it to either a CNA or a nurse on an unknown day and they were taking notes about what he had reported. During an interview on 7/29/2026 at 10:45 AM, the DON stated she had not been made aware of any allegations related to a staff member telling a resident that they stunk or were disgusting and nasty. During a telephone interview on 7/29/2026 at 12:25 PM, RN A stated she was working nightshift on 7/4/2026. CNA C came to her .around 2:00 AM . stating Resident #32 had just reported to her that CNA A had made statements to him while providing incontinence care after a bowel movement like he was nasty/disgusting and that he stunk. RN A immediately went to see Resident #32 and he reported the same thing. RN A was unaware exactly what day CNA A had made the comments to Resident #32. RN A sent a text message to the DON to notify her of the allegation on 7/5/2026 at 2:51 AM and received a text message response from the DON on 7/5/2026 at 12:34 PM saying .we will address this . RN A provided the text message to the survey for review. RN A further stated Resident #32 exhibited no behaviors or changes in mood. During an interview on 7/29/2026 at 1:57 PM, the Administrator stated she was the facility's abuse coordinator. The Administrator was unaware of any allegations of abuse regarding Resident #32. The Administrator confirmed if a staff member made statements to a resident that they stunk or were nasty and disgusting that would be considered an allegation of abuse and would need to be reported to the state agency, Adult Protective Services, local police department, and the Ombudsman within 2 hours of receiving the allegation. The Administrator further confirmed she had not been made aware of the allegations, so they had not been reported to the appropriate agencies. During an interview on 7/26/2026 at 2:00 PM, in the conference room, the Administrator, the DON, the Regional Nurse, the Regional [NAME] President, and the Senior Administrator, the DON denied she had received a text message from RN A on 7/5/2026 at 2:51 AM regarding Resident #32 and CNA A. Continued interviews revealed the Administrator stated staff were to report allegations of abuse to their charge nurse either by phone or text message immediately and if they didn't receive a response they needed to call to verify they were aware of the allegation.

Based on facility policy review, medical record review, and interviews, the facility failed to develop a person-centered care plan related to specific Post Traumatic Stress Disorder (PTSD) triggers for 1 resident (Resident #51) of 1 resident reviewed for PTSD.The findings include: Review of the facility policy titled, Behavioral Health, last revised 9/15/2023, revealed .It is the organization's intent to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care .Post-traumatic stress disorder occurs in some individuals who have encountered a shocking, scary, or dangerous situation .GUIDELINES .Person-centered approaches will be implemented based on the comprehensive assessment in accordance with the resident's interests, preferences, and choices .Stakeholders will be alert to the effectiveness of interventions and the care plan will be reviewed and revised as necessary . Review of the medical record revealed Resident #51 was admitted to facility on 5/6/2026 and readmitted on [DATE] with diagnoses including Urinary Tract Infection, Hypertension, Restlessness and Agitation, Insomnia, Amnesia, Altered Mental Status, Dementia, Aphasia, and Anxiety. Review of the .Level I Form .Pre-admission Screening and Resident Review [PASRR] . dated 5/5/2026, revealed .DIAGNOSIS .No mental health diagnosis is known or suspected .Does the individual have .dementia/neurocognitive disorder .Yes . Review of the INITIAL HISTORY AND PHYSICAL dated 5/7/2026, revealed .Chief Complaint/Nature of Presenting Problem .Delirium, aggressive behavior, dementia .admitted for skilled services .History PTSD, early onset dementia, delirium and agitation with acute medical illnesses . Review of the Social Services/Initial/Annual History dated 5/8/2026, revealed .Trauma Screening .No traumatic history .Care plan implemented .include trauma identified, triggers that may re-traumatize resident cultural preferences .No trauma identified . Review of the PSYCHIATRIC PERIODIC EVALUATION dated 5/11/2026, revealed .Past Medical History .PTSD .Anxiety .Type of Visit: Follow-up Evaluation .Reason for Follow-up .Monitoring for benefit, effectiveness and assessment for potential adverse reactions to psychotropic medications .Chief Complaint/Nature of Presenting Problem .Aggressive behavior, dementia, agitation, hx of ptsd, anxiety .seen today for psych [psychiatric] consult per staff request due to hx of dementia with behaviors, ptsd, anxiety, agitation and combativeness .hx of significant ptsd, was prior marine combat veteran and documented agent orange exposure in hospital records .discussed the need to treat combative behaviors and severe anxiety for the safety of both the staff and resident and family is in agreement .DIAGNOSIS, ASSESSMENT AND PLAN .PTSD .GAD [Generalized Anxiety Disorder] .CARE PLAN .Recommendations .Long discussion with family regarding care and medication options, emotional support provided to family .Montior for changes in behaviors .Caregivers to provide nonpharmacological interventions .such as offering snack/fluids, toileting, offering comfort item, approach resident and introduce self and purpose of care, knock prior to entering room . Review of the comprehensive care plan dated 5/13/2026, revealed .PTSD due to military service .Encourage resident to voice feelings of nervousness, fears, and general uneasiness related to a trauma history and refer to the physician as needed .Give meds per orders .Observe and honor cultural preferences during care to support resident and help avoid trauma triggers .Observe resident for signs and symptoms of re-traumatization .Offer psych [psychiatric] and supportive services to resident .Offer resident choice in daily routine and involve resident in plan of care .Provide supportive contacts as needed . Continued review revealed no care plan for PTSD triggers for Resident #51. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 was unable to complete the Brief Interview for Mental Status (BIMS) assessment and had severely impaired cognitive skills for daily decision making. Resident #51 had unclear speech, was rarely able to make himself understood and was sometimes able to understand others. Resident #32's active diagnoses included PTSD. Review of the Notice of PASRR Level I Screen Outcome dated 6/1/2026, revealed .No Status Change .Anxiety Disorder .Trauma/Stress Related Disorder .Insomnia . Continued review revealed Resident #51 also had a history of .dementia/neurocognitive disorder . Review of the PSYCHIATRIC PERIODIC EVALUATION dated 7/13/2026, revealed .Follow-up Evaluation .Past Medical History .PTSD .Anxiety .Dementia .Chief Complaint/Nature of Presenting Problem .PTSD, dementia, anxiety, agitation, dementia .has had significant improvement in mood, anxiety, hypervigilance, and behaviors since starting Prazosin [a medication used primarily to treat high blood pressure and nightmares from PTSD] .has been on prazosin 3 weeks now and has been tolerating this well without obvious adverse effects .Staff reports .improvement in his behavior and they are able to give him a shower without him becoming agitated and combative, as water seemed to be a trigger for his ptsd . Review of the comprehensive care plan revised on 7/28/2026, revealed .PTSD due to military service .Assist the resident in identifying and avoid triggers from the traumatic experience which may include: bathing . During a telephone interview on 7/28/2026 at 1:12 PM, Resident #51's responsible party stated Resident #51 had a history of PTSD from .years ago . Resident #51's responsible party stated the facility had been in contact with her on multiple occasions to discuss the resident's PTSD history. Resident #51's responsible party denied any concerns related to care provided by the facility and stated the resident's behaviors had improved since being at the facility. During an interview on 7/29/2026 at 9:23 AM, the Social Service Director (SSD) stated she performed the Social Service Psychosocial Assessment on admission for Resident #51 with input from the resident's family because Resident #51 was unable to answer questions. The SSD stated Resident #51's family denied any history of trauma experiences during the assessment, so no triggers were identified. The SSD became aware of Resident #51's history of PTSD .probably the Tuesday after admission . when the psychiatric provider came to see him. The SSD stated she was unaware if any conversation had been conducted with Resident #51's family to identify PTSD triggers for the resident. During an interview on 7/29/2026 at 9:43 AM, the MDS Coordinator stated the SSD was responsible for completing the trauma assessment on admission to identify triggers for residents with PTSD. The MDS Coordinator was responsible for conducting the comprehensive assessment and formulating the care plan with person-centered interventions. The MDS Coordinator confirmed she identified Resident #51's history of PTSD from his military service while doing his admission comprehensive assessment from the medical record. The MDS Coordinator confirmed she had not discussed triggers with Resident #51's family. The MDS Coordinator stated the psychiatric provider documented that water seemed to be a trigger for Resident #51 during her visit on 7/13/2026. The MDS Coordinator confirmed specific person-centered PTSD triggers were to be care planned and confirmed the trigger of water identified by the psychiatric provider was not added until 7/28/2026, after the surveyors began asking about Resident #51's PTSD diagnosis. The MDS Coordinator confirmed Resident #51's PTSD trigger of water was not added to the care plan timely. During an interview on 7/29/2026 at 10:58 AM, the Director of Nursing (DON) stated residents were assessed by Social Services on admission for history of trauma to identify potential triggers. The DON confirmed PTSD triggers were to be care planned so the staff were aware of them.

Based on facility policy review, medical record review, text message review, staff assignment sheets, staff time sheets, and interviews, the facility failed to investigate an allegation of abuse for 1 resident (Resident #32) of 24 residents reviewed for abuse.The findings include: Review of the facility policy titled, Abuse, Neglect, and Misappropriation of Property, revised on 9/15/2023, revealed .It is the organization's intention to prevent .abuse .The organization will include .investigation .to provide protection for the health, welfare, and rights of each resident .the Facility Administrator, or he or her designee, will conduct a reasonable investigation of each such alleged violation .Mental abuse .Include, but is not limited to, humiliation .or any other statements or behavior that a reasonable person would consider to be humiliating, demeaning .to a resident .Verbal abuse .Is use of any oral .language that includes .disparaging or derogatory language, to residents .Allegation of Abuse .means a report .or other facts that a reasonable person would understand to mean that abuse .has occurred .Investigation .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse, .may delegate some or all of the investigation .Facility Administrator retains the ultimate responsibility to oversee and complete the investigation .investigation should include interviews of involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .investigation should be documented . Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Heart Failure, Depression, and Morbid Obesity. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment indicating the resident was cognitively intact Resident #32 was dependent on staff with toileting and required substantial/maximal assistance with personal hygiene. Review of a comprehensive care plan for Resident #32 dated 5/20/2026, revealed .ADLs [Activities of Daily Living] .1 assist with incontinence care/toileting .ADLs .selfcare deficit related to impaired physical functioning and medical conditions .provide the amount of assistance resident needs for completion of ADL cares . Review of a text message between Registered Nurse (RN) A and the Director of Nursing (DON) dated 7/5/2026 at 2:51 AM, revealed .[CNA C] told me something that a resident told her .[Resident #32] had a bowel movement .He [Resident #32] stated [CNA A] was questioning him why he doesn't use a bedpan and was making comments like you stink .you are disgusting . Further review revealed the DON responded to the message on 7/5/2026 at 12:34 PM and stated .we will address this . During a telephone interview on 7/29/2026 at 8:29 AM, CNA C stated she worked nightshift on 7/4/2026. Resident #32 reported to her that CNA A was providing incontinence care after a bowel movement and made comments to Resident #32 regarding being nasty or disgusting and that he stunk. CNA C notified RN A immediately. During an interview on 7/29/2026 at 10:28 AM, Resident #32 stated .about 3 weeks ago . CNA A was in his room providing incontinence care and made comments to him that he stunk and was nasty and disgusting. Resident #32 stated he reported the incident to either a CNA or nurse on an unknown day. During an interview on 7/29/2026 at 10:45 AM, the Director of Nursing (DON) stated she was unaware of any allegations related to a staff member making comments to a resident that they stunk or were nasty and/or disgusting. During a telephone interview on 7/29/2026 at 12:25 PM, RN A stated she was working nightshift on 7/4/2026. CNA C reported to her that Resident #32 had reported that CNA A had been providing him with incontinence care after a bowel movement and made statements like he stunk and was nasty or disgusting on 7/5/2026 at .around 2:00 AM . RN A immediately went to speak to Resident #32 and he verified what CNA C had reported. RN A stated she sent the DON a text message to notify her of the allegation on 7/5/2026 at 2:51 AM. The DON responded to the text message on 7/5/2026 at 12:34 PM. RN A provided the text message to this surveyor for review. RN A further stated Resident #32 exhibited no behaviors or changes in mood. During an interview on 7/29/2026 at 1:57 PM, the Administrator stated she was unaware of the allegations from Resident #32. The Administrator confirmed if she had been made aware that a staff member made comments to a resident about stinking or being nasty or disgusting that would be considered an allegation of abuse and would be investigated. During an interview on 7/29/2026 at 2:00 PM, in the conference room, with the Administrator, the DON, the Regional Nurse, the Regional [NAME] President of Operations, and the Senior Administrator, the DON continued to state she had not been made aware of any allegations related to a staff member making comments to a resident to the effect of he stunk or was nasty/disgusting. The DON was asked if she recalled receiving a text message from a staff member on 7/5/2026 at 2:51 AM and she stated she did not receive any message on 7/5/2026 at 2:51 AM. The DON stated if she had been made aware that a staff member had told a resident that they stunk or were nasty or disgusting it would depend on how the resident took it if it was investigated and reported.

Based on facility policy review, medical record review, text message review, and interviews, the facility failed to protect the resident's right to be free from abuse for 1 resident (Resident #32) of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, and Misappropriation of Property, revised on 9/15/2023, revealed .it is the organization's intention to prevent the occurrence of abuse .the organization will include prevention, identification, protection to provide protection for the health, welfare, and rights of each resident residing in the facility .Mental abuse .includes but not limited to humiliation, or any other statements or behaviors that a reasonable person would consider to be humiliating, demeaning .verbal abuse . any oral, written .that includes any .derogatory language, to residents .Allegation of abuse .this means a report .other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, had occurred, or plausibly might have occurred .Identification .identification includes having procedures to assist stakeholders in identifying abuse .this would include identifying the different types of abuse-mental . Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Heart Failure, Depression, and Morbid Obesity. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. MDS review revealed dependence on staff for toileting and required substantial/maximal assistance with personal hygiene. Review of a comprehensive care plan for Resident #32 dated 5/20/2026, revealed .ADLs [Activities of Daily Living] .1 assist with incontinence care/toileting .ADLs .selfcare deficit related to impaired physical functioning and medical conditions .provide the amount of assistance resident needs for completion of ADL cares . Review of the staffing assignment sheets from 7/3/2026 - 7/5/2026, revealed Certified Nursing Assistant (CNA) A worked 6:00 PM to 6:00 AM on 7/3/2026, 7/4/2026, and 7/5/2026. CNA A was assigned to Resident #32 on 7/3/2026 from 6:00 PM to 6:00 AM. Review of the time punches for CNA A revealed on 7/3/2926 In 5:47 PM and Out 6:08 AM, on 7/4/2026 In 6:01 PM and Out 6:00 AM, and on 7/5/2026 In 5:56 PM and Out 6:05 AM. Review of a text message from Registered Nurse (RN) A to Director of Nursing (DON) dated 7/5/2026 at 2:51 AM, revealed .[name of CNA C] told me something that a resident told her .[Resident #32] had a bowel movement .He [Resident #32] stated [CNA A] was questioning him why he doesn't use a bedpan and was making comments like you stink .this is disgusting . Further review revealed the DON responded to the message on 7/5/2026 at 12:34 PM and texted .we will address this . During a telephone interview on 7/29/2026 at 8:29 AM, CNA C stated she was working nightshift on 7/5/2026 when Resident #32 reported to her that CNA A told him that he was .nasty .disgusting for not wearing a brief and that he stunk. CNA C stated she reported this to RN A immediately. During an interview on 7/29/2026 at 10:28 AM, Resident #32 stated about 3 weeks ago CNA A was in his room changing him after having a BM (bowel movement) and CNA A asked why don't you use a bed pan and Resident #32 stated it's too hard to use. Resident #32 stated while CNA A was cleaning him up, she kept making comments like nasty and disgusting. Resident #32 stated he told her it's BM it's not supposed to smell good and if you can't handle it go get someone else. Resident #32 stated he told either another CNA or nurse and they took notes. Resident #32 stated he was initially mad but requested CNA A not to come back to his room. Resident #32 had no further concerns. During an interview on 7/29/2026 at 10:45 AM, the DON stated she had not been made aware of any allegation of abuse. At 10:51 AM, the DON was officially notified of Resident #3's statement of CNA A's comments reported to this surveyor on 7/29/2026. During an interview on 7/29/2026 at 12:25 PM, RN A confirmed on 7/5/2026 .around 2:00 AM . CNA C reported to her that while she was changing Resident #32, he reported that CNA A was cleaning him up after a bowel movement and was making comments like he was disgusting and said that he stunk. RN A went to talk to Resident #32 immediately after being made aware by CNA B and Resident #32 confirmed what CNA B had reported to RN A. RN A reported that when she spoke to Resident #32, he was upset but was calm while discussing the incident. RN A stated she was unaware of the exact day and time that the interaction occurred between Resident #32 and CNA A. RN A stated she sent the DON a text message on 7/5/2026 at 2:51 AM to notify her of the allegation. CNA A was working on the nightshift on 7/4/2026 but was not responsible for Resident #32. RN A stated she would send this surveyor a copy of the text message she sent to the DON on 7/5/2026 at 2:51 AM. During an interview on 7/29/2026 at 1:57 PM, the Administrator stated she had not been made aware of the abuse allegations. The Administrator stated that if a staff member told a resident they stunk or were nasty, disgusting that is an allegation of abuse and would need to be reported and investigated. During an interview on 7/26/2026 at 2:00 PM, in the conference room, with the Administrator, the DON, the Regional Nurse, the Regional [NAME] President of Operations, and Senior Administrator, the DON continued to state that she had not been made aware of any allegations related to a staff member making comments to a resident that he stunk or was disgusting, nasty. The DON was asked if she recalled receiving a text message from RN A on 7/5/2026 at 2:51 AM and she stated she did not receive any message. The DON stated if she had been made aware a staff member told a resident that they stunk, were nasty, or disgusting it would depend on how the resident took it if it was investigated.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices related to hand hygiene were followed by 1 staff member during meal service and failed to offer hand hygiene assistance to 1 resident (Resident #48) of 10 residents observed during meal tray distribution on 1 of 3 hallways. The findings include: Review of the facility's policy titled, Infection Control, revised 1/31/2025, revealed .facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, Muscle Weakness, and Need for Assistance with Personal Care. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was moderately cognitively impaired. Further review revealed the resident required setup or clean up assistance with eating and personal hygiene. Review of the comprehensive care plan for Resident #48 revised 4/24/2025, revealed .self care deficit .need for staff assistance for adequate completion of ADL [activities of daily living] care .care guide .assist resident with [meal] tray set up . During an observation on 5/5/2025 at 12:44 PM, Certified Nursing Assistant (CNA) C pushed the meal service cart down the 100 hallway, opened the plastic, clear covering to the meal cart, and removed Resident #48's tray. CNA C took the meal tray into Resident #48's room, opened the resident's silverware, picked up Resident #48's glass of tea to move closer to the resident, opened a straw to place inside the glass of tea, and opened the plate warming dome from the plate of food. Resident #48 picked up her fork and began eating her meal. Continued observation revealed CNA C failed to sanitize his hands before directly touching the resident's meal tray to include the eating and drinking utensils. CNA C failed to offer Resident #48 hand hygiene assistance prior to the resident eating the lunch meal. During an interview on 5/5/2025 at 12:46 PM, Resident #48 stated the staff did not offer hand hygiene assistance prior to the lunch service on 5/5/2025 and stated the staff had not offered her hand hygiene assistance .all day . During an interview on 5/5/2025 at 12:47 PM, CNA C confirmed he failed to complete hand hygiene prior to serving and touching Resident #48's meal tray and confirmed he had not offered hand hygiene assistance to Resident #48 prior to the lunch meal service. During an interview on 5/7/2025 at 9:32 AM, the Director of Nursing (DON) stated the staff were to complete hand hygiene before assisting a resident with the meal tray setup and to offer hand hygiene assistance to all residents before serving the meal. The DON confirmed infection prevention and control practices were not maintained during the lunch meal service on 5/5/2025 when CNA C failed to sanitize his hands prior to touching Resident #48's tray for the resident's consumption and failed to offer Resident #48 hand hygiene assistance prior to the lunch meal service.

Based on review of facility policy, medical record review, and interview, the facility failed to follow their abuse policy for reporting allegations of abuse immediately and failed to report allegations of abuse to the State Survey Agency within the federally required time frame of 2 hours for 2 residents (Resident #2 and Resident #3) of 6 residents reviewed for abuse. The findings include: Review of the facility's abuse policy titled Abuse, Neglect and Misappropriation of Property, last reviewed 5/8/2019, showed .Abuse is the willful infliction of injury .Abuse includes physical abuse .verbal abuse .Allegation of Abuse Means a report, complaint, grievance, statement, incident .All alleged violations involving abuse .or mistreatment are reported immediately, but no later than 2 hours after the allegation is made .Every Stakeholder .immediately shall report any allegation of abuse, .to the charge nurse on duty .the Director of Nursing or Facility Administrator, or to another nurse manager or licensed nurse . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2's Brief Interview of Mental Status (BIMS) score was 99 indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADLs). During an interview on 9/7/2021 at 12:30 PM, the Director of Nursing (DON) stated .[CNA #1] called me at home .said she needed to report something to me .she said we [CNA #1 and CNA# 2] was in [Resident #2's] room .[Resident #2] was in the bed and was talking .[CNA #2] put her hand over the resident's mouth and said 'shut the F up' .she [CNA #1] said that it happened on Friday [7/30/2021] and this was 8/2 [8/2/2021] which was the following Monday .I reported it to the state that day [8/2/2021] . Review of the medical record showed Resident #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] showed Resident #3's BIMS score was 99 indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with ADL's. During an interview on 9/8/2021 at 11:50 AM, the DON stated .I was doing the abuse education on 8/3 [8/3/2021] .and [Licensed Practical Nurse (LPN) #1] come into my office and said she needed to tell me something .she said the other night [7/24/2021] I heard 3 slaps and heard [Resident #3] say 'why did you slap me' .[LPN #1] said [CNA #1] said 'I didn't slap you why are you lying' .[LPN #1] said she went home and she thought did that incident really happen .I said [LPN #1] you know to report that and she said she was trying to get everything together like labs, documenting, etc .she said I was just in a zone .I .contacted the state immediately that day [8/3/2021] . The DON confirmed the facility failed to follow their abuse policy and failed to report allegations of abuse to the state agency within 2 hours for Resident #2 and Resident #3.

Based on facility policy review, medical record review, observation and interview the facility failed to prevent abuse for 1 resident #22 of 8 residents reviewed for abuse of 29 sampled residents The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19 revealed It is the organization's intention to prevent the occurrence of abuse .Abuse .includes physical abuse .willful .means non-accidental .Willful as used in the definition of abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 5 indicated the resident had severe cognitive impairment and required extensive assistance for bed mobility, toileting, transfer, dressing and toileting. Medical record review revealed Resident #173 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #173's Significant Change MDS dated [DATE] revealed the resident had a BIMS score of 7, indicated the resident had severe cognitive impairment, coded with hallucinations and delusions, required extensive assistance for dressing, limited assistance for toileting and hygiene and supervision for locomotion, bed mobility, transfer and locomotion. Medical record review of Resident #173's care plan dated 2/12/19 revealed .Resident is a threat to self and/others .history of physical and verbal abuse . rejection of care, urinates in inappropriate places R/T (related to) Dementia, Depression, history of [MEDICAL CONDITION] .Goal .Resident will not harm self or others . Medical record review of Resident #173's nurse's note dated 7/4/19, revealed at 9:50 PM, Certified Nursing Assistant (CNA) was summoned to the room by resident (#173), who told him that he had beat up his roommate (#22). Roommate (Resident #22) said resident had hit him twice in the face and roommate's urinary catheter was pulled out. No injuries were noted to resident. Residents were separated and monitored. Contacted Director of Nursing (DON), MD (Medical Doctor), new orders to send out for behavioral modification and psych evaluation. Contacted both families. Resident had on roommates's shoes and refused to remove them, saying they were his. Resident left facility via EMS (Emergency Medical Services) at 11:18 PM. Medical record review of Resident #173's Psychiatric note dated 7/15/19, revealed the resident had continued inappropriate and bizarre behavior and had to move his roommate (Resident #22) out because of the resident's behavioral disturbances. Interview with CNA #1 on 10/1/19 at 2:20 PM, in the conference room, confirmed she was working as a CNA on the 200 hall on 7/3/19. Continued interview confirmed another CNA called for her and she went into the room while the other CNA separated Resident 173 and Resident #22. Further interview confirmed staff took Resident #173 out of the room and staff cleaned up Resident #22 because his catheter had been pulled out and and there was blood on Resident #22. Further interview confirmed Resident #22 told the CNA that Resident #173 had hit him in the face. Continued interview confirmed she was not aware of any other incidents of aggression. Further interview confirmed it was at the end of her shift and she left shortly after the incident. Interview with CNA #2 on 10/1/19 at 3:10 PM by phone, revealed he worked from 6 PM-10 PM on the day of the incident (7/3/19). Further interview confirmed he was passing ice and went in to resident's room and the lights were off, he turned the lights on and saw Resident #173 standing by Resident #22 in his bed. Further interview confirmed blood was on Resident #22's sheet and the urinary catheter had been removed from Resident #22. Continued interview confirmed Resident #173 stated that he had beat the hell out of him (resident #22). Further interview confirmed Resident #22 stated to the CNA that Resident #173 had hit him. Continued interview confirmed Resident #22 was checked for any injuries and no marks or injuries were found. Further interview confirmed the residents were separated he was unsure what room the residents were sent to. Further interview confirmed he was not aware of either residents having aggressive behavior prior to this event. Review of a statement by the DON dated 10/2/19 revealed .This nurse spoke with resident (#173) the next day on 7/4/19 about incident the night before. He had told me that his roommate left because he beat him up & there was blood all over the place but didn't remember much about the night except he went to jail & they released him . I had also spoke to the other resident (Resident #22)who stated to just forget it ever happened .I spoke with (Resident #173)'s daughter on 7/5/19 from home in regards to his behaviors & explained he may be more appropriate in a behavior unit if his behaviors continued with refusing care, etc .

Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to accommodate the request to transfer to bed timely for 1 resident (#49) of 3 residents reviewed for activities of daily living needs of 28 residents reviewed. The findings include: Review of the facility's policy Answering Call Light, undated, revealed .If you have promised the resident you will return with the item or information, do so promptly . Medical record review revealed Resident #49 was admitted to the facility on [DATE] and discharged home on[DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data set ((MDS) dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making, and required extensive assistance of 2 persons with transfers. Review of facility documentation revealed on 10/18/18 at approximately 6:15 PM the resident had requested Certified Nursing Assistant (CNA) #1's assistance to transfer to the bed. Continued review of facility documentation revealed CNA #1 told the resident she would return to assist the resident to transfer to bed after picking up dinner trays from the residents on the hall. Continued review of facility documentation revealed CNA #1 forgot to return to Resident #49's room to assist her to bed and when CNA #1 returned to the resident's room to put her to bed the resident was mad. Interview with the Director of Nursing on 11/5/18 at 1:45 PM, in the conference room, revealed it was approximately 45 minutes to an hour before the resident's request/need for transfer to the bed was completed. Further interview confirmed the resident's need was not met in a timely manner. Telephone interview with CNA #1 on 11/6/18 at 4:05 PM, revealed Resident #49 had requested assistance to transfer to bed on 10/18/18 at approximately 6:15 PM, and CNA #1 told the resident she would return after picking up dinner trays. Continued interview revealed CNA #1 had forgotten about the resident's request for assistance to bed and confirmed it was approximately an hour before CNA #1 returned to the resident's room to assist the resident to bed.

Based on medical record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) for 1 resident (#115) of 3 residents reviewed for hospice services of 28 residents reviewed. The findings include: Medical record review revealed Resident #115 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].>Medical record review of the Hospice Certification of Terminal Illness form revealed the start of care date for hospice services was 8/6/18. Medical record review of a significant change of status Minimum Data Set ((MDS) dated [DATE] did not reflect the resident was receiving hospice services. Interview with Licensed Practical Nurse (LPN) #1 on 11/7/18 at 11:00 AM, in the MDS office, confirmed the MDS dated [DATE] did not reflect the resident was receiving hospice services and was not accurate.

Based on facility policy review, observation, and interview, the facility failed to appropriately store medications and biologicals for 2 of 2 medication storage rooms. The findings included: Review of facility policy Storage of Medication Policy, dated ,[DATE] revealed .Medication and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .the provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices .medications are to remain in these containers .refrigerated medications should be kept in closed and labeled containers .the refrigerator should be kept clean and frost-free .outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . Observation with Licensed Practitioner Nurse #1 (LPN) on [DATE] at 10:50 AM, in the ,[DATE] Hall nursing station medication storage room revealed the following items available for resident use: 1). 1 Triple Antibiotic Ointment expired ,[DATE] 2). One 45% full clear spray bottle with gray and yellow gelatinous particles floating on top not labeled Observation with the Director of Nursing (DON) and LPN #1 on [DATE] at 11:27 AM, in the 300 Hall nursing station medication storage room revealed a heavy buildup of ice in the medication refrigerator and the following items available for resident use: 1). 2 opened and used Thera Honey Gel tubes (for wound care) in bin with new dressing packages 2). 1 opened Tega Derm 5x 9 (inch) Petroleum Dressing expired ,[DATE] 3). 2 opened silver antimicrobial wound dressings 4). 1 wound granufoam dressing marked sterile opened 5). one 22 fl oz (fluid ounces) bottle of alcohol not dated or labeled with 50% (percentage) used 6). one 16 fl oz Hydrogen Peroxide (wound cleaner) with 50% used with an open date of [DATE] 7). Four 300 ml (milliliters) canister with gel therapy system expired ,[DATE] 8). The following opened and used resident powder and creams stored in same bin with new and unused powder and creams: · 1 - antifungal powder · 2 - antifungal creams · 3 - diaper rash ointments · 1 - aloe protective open date [DATE] · 2 - protectant guard paste (skin protectant paste is meant to relieve discomfort associated with diaper rash caused by wetness, urine and/or stool) · 1 - zinc oxide based paste open date [DATE] · 2 - aspirin based cream (muscular pain relieving cream) · 6 - skin repair creams Interview with the DON and LPN #1 on [DATE] at 11:50 AM, in the 300 Hall nursing station medication storage room confirmed the facility failed to separate used and new stock, monitor expired stock, monitor opened medications and supplies, and monitor refrigerator ice buildup. Continued interview confirmed the facility failed to follow the facility policy to maintain a well-organized medication storage area.

Based on facility policy review, observation, and interview, the facility failed to ensure infection control precautions for 2 of 2 medication storage rooms. The findings included: Review of facility policy Administering Medications, revised ,[DATE] revealed .when opening a .container, the date opened shall be recorded on the container . Review of facility policy Personal Protective Equipment, revised ,[DATE] revealed .Employees required to perform tasks that may involve exposure to blood/body fluids will be provided appropriate protective clothing and equipment .Protective clothing provided .gowns .Personal protective equipment will be .replaced as needed to maintain its effectiveness . Review of facility policy Needle Handling and/or Disposal revised ,[DATE] revealed .to guide the safe handling and disposal of used needles .to prevent needlestick injuries and exposure .place .needles in the needle disposal box . Observation with the Licensed Practitioner Nurse #1 (LPN) on [DATE] at 10:50 AM, on the ,[DATE] Hall nursing station medication storage room revealed the following items available for resident use: a). One 45% full clear spray bottle with gray and yellow gelatinous particles floating on top not labeled b). 1 used resident razor stored by intravenous fluid bag c). 1 clear re-closable bag with used providene solution (wound cleaner) undated and used surgical instruments stored by 5 unopened boxes of wax paper d). 1 locked black box with approximately ¼ inch of dust on top Observation with the Director of Nursing (DON) and LPN #1 on [DATE] at 11:27 AM, on the 300 Hall nursing station medication storage room revealed the following items available for resident use: a). 2 opened and used Thera Honey Gel (for wound care) tubes in bin with new dressing packages b). 1 pair of used scissors with white and brown substance on blades and handle in bin with new dressing packages c). 1 soiled 2x 3 (inches) non-adherent pad with light brown colored substance on package d). 1 soiled 4x 4 adhesive Island dressing with light brown colored substance on package expired [DATE] e). 1 resident's opened paring-partner knife in the denture, tooth brushes, denture cups, and toothpaste bin f). 1 opened [MEDICATION NAME] lemon [MEDICATION NAME] 3 pack in the denture, tooth brushes, denture cups, and toothpaste bin g). 8 opened and exposed to air denture cleanser in the denture, tooth brushes, denture cups, and toothpaste bin h). 1 dirty and used applicator for vaginal or rectal crème in the denture, tooth brushes, denture cups, and toothpaste bin i). 1 oral pain relief medication opened in the denture, tooth brushes, denture cups, and toothpaste bin j). 2 used emery boards (nail file) in the denture, tooth brushes, denture cups, and toothpaste bin k). 1 wound [MEDICATION NAME] dressing marked sterile opened l). 4 Personal Protective Equipment gowns soiled with a dark brown colored substance m). 1 capped needle with syringe missing n). 6 opened venipuncture needles (to puncture the vein for surgical or therapeutic purposes) o). 1 opened influenza virus collection kit opened and expired ,[DATE] p). 1 opened lice treatment kit and used hair comb in re-sealable clear bag q). Two 22 g needles in drawer with resident razors Interview with the DON and LPN #1 on [DATE] at 11:50 AM, on the 300 Hall nursing station medication storage room confirmed the facility failed to ensure infection control standards were followed.

Based on medical record review and interview, the facility failed to ensure clinical justification for the use of an indwelling urinary catheter for one resident (#60) of three residents reviewed for the use of a urinary catheter of twenty-eight residents reviewed. The findings included: Resident #60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Interview with the Director of Nursing on September 25, 2014, at 8:45 a.m., in the conference room confirmed the facility had failed to ensure clinical justification prior to the use of an indwelling urinary catheter.

Based on medical record review and interview, the facility failed to ensure a safety alarm was functioning for one resident (#93), of three residents reviewed for falls of twenty-eight residents reviewed. The findings included: Resident #93 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment, required the assistance of two persons for transfers, and was wheelchair dependent for mobility. Review of the facility investigation dated September 11, 2014, at 4:30 a.m., revealed "...Detailed Description: CNA's (Certified Nurse's Aides) observed resident on floor and notified...(nurse). Resident was sitting up on floor...Were there any interventions in place at the time of the fall? Yes...Pressure alarm to bed..." Telephone interview with CNA #1 on September 23, 2014, at 7:10 p.m., confirmed no alarm was sounding at the time the resident was found on the floor. Continued interview confirmed the pressure pad bed alarm was on the bed but was unplugged when checked after the fall. Telephone interview with Licenced Practical Nurse (LPN) #1 on September 23, 2014, at 9:25 p.m., confirmed the CNA's were doing rounds when the resident was found on the floor and no alarm was sounding.

Based on medical record review and interview, the facility failed to obtain a laboratory test as ordered by the physician for one resident (#52) of thirty-two residents reviewed. The findings included: Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated August 1-31, 2013, revealed an order for [REDACTED]. Review of the laboratory reports revealed the last [MEDICATION NAME] level was completed on January 10, 2013. Interview with the Director of Nursing on August 14, 2013, at 8:30 a.m., at the nurses' station, confirmed the facility had failed to obtain the [MEDICATION NAME] level for May as ordered and confirmed the last [MEDICATION NAME] level obtained was on January 10, 2013.

Based on observation and interview, the facility failed to ensure the nutritive value was maintained for the mechanically altered diet for fourteen of fourteen residents on puree diet. The findings included: Observation in the dietary department on November 15, 2011, at 9:45 a.m., revealed cook #1 was preparing to mechanically alter the pork riblets into a puree. Continued observation revealed cook #1 opened the recipe book and referred to the recipe of breaded pork cutlet. Continued observation revealed cook #1 added 7 riblets (3 ounces) and 4 pieces of sliced white bread into a food processor. Continued observation revealed the cook then added tap water into a clear water pitcher. Observation revealed the cook then poured the unmeasured water into the processor and continued to process the meat and bread. After a few minutes the cook turned off the processor and with a spoon assessed the consistency of the processed meat and bread. When asked what the consistency is prescribed the cook responded "I dont know...I just go by how it looks..it cannot be runny." When asked if a recipe was followed the cook responded "No, that one was for breaded pork and what we have today is not breaded." Continued observation revealed the cook repeated the process with 7 riblets and 4 pieces of bread in the processor; and again added the unmeasured water. Continued observation revealed the cook repeated the process to puree a total of 17 riblets and 17 pieces of bread. Interview with the Dietary Manager in the dietary department on November 15, 2011, at 9:59 a.m., revealed the recipe to puree the riblet "Was not available because we just changed menus for the winter season." Continued interview revealed the facility failed to ensure the nutritive value was maintained for the mechanically altered diet.

Based on observation, review of facility policy, and interview, the facility failed to handle eating utensils used by all residents in a sanitary manner. The findings included: Observation on November 15, 2011, at 11:15 a.m., in the facility kitchen, revealed dietary staff with the bare hands picked up a fork, knife, and spoon, placed the utensils in a napkin and rolled it, repeating the task multiple times, and placed the utensils in a container ready to be placed on the resident trays for lunch. Review of facility policy, Handling of Eating Utensils, revealed "After the eating utensils and dishes have been sanitized, the fingers should not touch any surface that would come in contact with the food. This includes...forks, spoons, bowls, and knife blades..." Interview with the Dietary Manager on November 15, 2011, at 3:32 p.m., confirmed the facility failed to handle the utensils in a sanitary manner.

Based on medical record review, observation, and interview, the facility failed to implement the care plan for one (#31) resident of thirty-three resident's reviewed. The findings included: Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, was non-ambulatory, and required maximum assistance of two with transfers. Medical record review of the resident's current care plan dated September 19, 2011, and last revised on November 7, 2011, and the current CNA (Certified Nurse Assistant) ADL (Activities of Daily Living) sheets revealed the resident was transferred with assist of two persons and did not include the use of a mechanical lift. Observation on November 17, 2011, at 11:00 a.m., of CNA #4 and CNA #5 in the resident's room, revealed the CNA's used a sit to stand mechanical lift to assist the resident to stand for incontinence care. Observation revealed the CNA's placed the lift belt around the resident's chest just below the breasts. The belt was fastened by CNA #4 and was not snug. Continued observation revealed the CNA's placed the resident's hands on the lift bar, and initiated the lift, raising the resident to a semi-standing position. Continued observation revealed as the lift was rising the lift belt slid up to the resident's shoulders. Continued observation revealed the CNA's pulled the resident's pants down and removed the soiled brief. Continued observation revealed the resident slowly slid out of the lift belt, and fell approximately 12 inches onto the wheelchair seat below the resident. Continued observation revealed CNA #4 reapplied the lift belt below the breasts without ensuring a snug fit, and again placed the resident's hands on the lift bar. Continued observation revealed CNA #4 started lifting the resident to a semi-standing position and the lift belt again was sliding up to the resident's shoulders. The resident was yelling "...you're hurting my arms stop that..." The CNAs did not lower the resident, but continued to provide incontinence care. The CNAs applied the clean brief and pulled the resident's pants up. Continued observation revealed with the resident's arms/shoulders in the lift belt as the CNAs lowered the resident to the wheelchair. Interview with CNA #4 and CNA #5 at that time confirmed the resident had not been safely transferred. Interview with CNA #4 and CNA #5 on November 17, 2011, at 2:55 p.m., on the 200 hallway, revealed the appropriate way to transfer a resident is on the care plan. Continued interview revealed the resident "doesn't have an order for [REDACTED]." Continued interview also revealed the resident's ability to stand and transfer varies with how the resident feels and mood. Continued interview confirmed the resident's care plan was not implemented correctly.

Based on medical record review and interview, the facility failed to follow physician's orders for medication administration for one resident (#77) of thirty-three sampled residents. The findings included: Resident #77 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had a score of 13 (out of a possible total of 15), on the Brief Interview For Mental Status. Review of the November 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The dose was circled as not given. Continued review revealed documentation the dose was not available to be given. No documentation was found showing the pharmacy, physician, or any other staff was notified to obtain the dose. Interview with the Director of Nursing (DON) on November 17, 2011, at 9:30 a.m., at the 100/200 Hall nurse's station confirmed the physician order for [REDACTED].

Based on medical record review, observation, and interview the facility failed to evaluate the effectiveness of the care plan for one (#5) of thirty-three residents sampled. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan dated June 4, 2011, revealed an identified problem of "...difficulty chewing due to missing lower denture plate." Review of care plan interventions dated June 4, 2011, included a dental consult. Continued review revealed the care plan was revised in September 2011, with a projected goal date for the dental consult extended to December 2011. Observation and interview with the resident on November 14, 2011, in the resident's room, at 11:02 a.m., revealed the resident answered "yes" when asked about having any chewing or eating problems. Continued interview revealed "I don't know why it is taking so long (to replace the denture plate)." Observation on November 15, 2011, at 12:15 p.m., revealed the resident in the dining room eating independently. Observation revealed the meal was a mechanical soft diet. Observation revealed the resident had no lower teeth. Interview with the Minimum Data Set Nurse (MDS nurse #1) in the MDS office on November 17, 2011, at 9:41 a.m., revealed the care plan team discussed the missing denture plate and stated, "every body (the facility staff) knew dental had been consulted and was working on it." Continued interview revealed the care plan team did revise the care plan and extended the goal without developing new approaches or discuss the progress of the dental consultation. Continued interview revealed the care plan team failed to measure the effectiveness of the intervention of the dental consultation. Interview and medical record review with the Director of Social Services in the social services office on November 16, 2011, at 8:14 a.m., revealed the consultant dental company evaluated the resident in August 2011 and again in October when they made a impression of her lower gum. Interview with the Assistant Director of Nursing (ADON) in the conference room on November 17, 2011, at 9:53 a.m., confirmed the facility failed to re-evaluate the effectiveness of the dental consultation.

Based on medical record review, observation, review of facility policy, and interview the facility failed to ensure dignity was maintained for one resident (#87) of thirty-three sampled residents. The findings included: Resident #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan dated October 19, 2011 revealed the resident had impaired cognitive skills related to short term memory. Review of the listed approaches revealed, "Promote Dignity. Converse with resident and ensure privacy while providing care." Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was dependent on the staff for all activities of daily living. Review of the MDS revealed the resident was aphasic (unable to speak.) Observation on November 15, 2011, at 2:13 p.m., revealed three certified nursing assisants (CNA's #1, 2, 3) providing incontinence care to resident #87 in the resident's room. Observation revealed the resident was being supported to stand by a CNA on each side of the resident and one CNA provided incontinence care. Continued observation revealed the CNAs were providing care to the resident in the room between bed A and bed B. Continued observation revealed the alert roommate sitting in the chair watching the care being performed. Interview outside the resident room with CNA #1 on November 15, 2011, at 2:30 p.m., verified the curtain was not pulled, and the roommate did observe the personal care being performed. Review of the facility policy titled, Perineal Care dated 12-2010, revealed "...Provide privacy for the resident. Close the door, window blind and privacy curtain..." Interview at the 300 hall nurse's station with the Director of Nursing on November 16, 2011, at 9:22 a.m., confirmed the facility failed to ensure the dignity of resident #87 was maintained.