Every finding on record at St Mary's Alzheimer's Center

Based on observation, record review, interview, and facility policy review, the facility failed to ensure infection control practices were implemented correctly. This affected five Residents (#10, #12, #29, #56, and #82) of seven reviewed for infection control, and had the potential to affect 37 residents who resided on the south hall or who were observed for medication administration. The facility census was 75.Findings include:1.Review of the medical record for Resident #82 revealed an admission date of 03/20/26. Diagnoses included urinary tract infection (UTI), dementia, hypertension and heart failure. The comprehensive minimum data set (MDS) assessment was not yet completed at the time of the survey. Review of the physician's orders for March 2026 revealed an order for Levaquin (an antibiotic used to treat UTI's) 750 milligrams (mg) for five days. The order began on 03/21/26. There was also an order for contact isolation for a UTI which began on 03/20/26. Review of the baseline care plan dated 03/21/26 revealed Resident #82 was on contact isolation precautions for a UTI. Observation on 03/23/26 at 2:18 P.M. of Resident #82's room revealed no evidence contact precautions were identified. Interview at the time of the observation with the Director of Nursing (DON) confirmed Resident #82 was on contact precautions and should have a sign indicating such posted on his door. She confirmed there was no sign in place at the time of the observation. Review of the facility policy titled Procedure for Isolation: Initiation of Isolation dated February 2017 revealed contact precautions would be used for residents with a known infection which could be transmitted by direct or indirect contact and appropriate signage would be posted outside the door frame indicating the type of isolation or informing visitors to report to the nurses station before entering the room. 2. Observation on 03/25/26 from 8:22 A.M. to 9:05 A.M. of medication administration with Licensed Practical Nurse (LPN) #318 revealed the following: at 8:22 A.M., LPN #318 dispensed and administered oral medications for Resident #56. LPN #318 then put on gloves and administered the resident's eye drops. LPN #318 then removed his gloves and did not sanitize his hands afterwards. LPN #318 then immediately dispensed and administered medications to Resident #10 and did not sanitize his hands. LPN #318 then immediately put on a pair of gloves, administered different eyedrops to Resident #56, removed his gloves, and did not sanitize his hands. LPN #318 then proceeded to the medication room for breathing treatment supplies, prepared the breathing treatment for Resident #10, applied the nebulizer mask to Resident #10 for the breathing treatment, started the breathing treatment, exited the room and did not sanitize his hands afterwards. LPN #318 then immediately dispensed and administered the medications for Resident #12 and did not sanitize his hands afterwards. LPN #318 then immediately dispensed medications for Resident #29, applied gloves, picked up a capsule to empty its contents into a medication cup, removed his gloves and did not sanitize his hands afterwards, and then administered the medications to Resident #29. LPN #318 did not sanitize his hands afterwards. LPN #318 then immediately went into Resident #10's room to remove the nebulizer mask due to the breathing treatment being completed and did not sanitize his hands afterwards. LPN #318 exited Resident #10's room without sanitizing his hands and started to document on the medication cart computer. An interview on 03/25/26 at 9:07 A.M. with LPN #318 verified the above findings. Review of the facility policy titled Handwashing/Hand Hygiene Policy, dated 11/2024 revealed personnel would follow established procedures, the policy is based on Center for Disease Control and Prevention (CDC), and hand hygiene was used to prevent the spread of infections or disease. According to the same facility policy, hand hygiene was to be completed before contact with residents, before preparing or handling medication, after contact with intact resident skin, after touching contaminated surfaces, after touching objects immediately around the resident, and after glove removal. Review of the facility policy titled Medication Administration, dated 03/2026 revealed employees would follow infection control guidelines and would use a sanitizing solution between residents.

Based on record review, interview, and policy review the facility failed to ensure insulin administration was accurately documented and that skin checks were accurately documented. This affected three residents (#4, #5, and #27) out of 21 residents reviewed for resident records. The facility census was 75. Findings include:1.Review of the medical record for Resident #27 revealed an admission date of 04/06/23 with diagnoses including dementia, diabetes mellitus type two, noncompliance with medication regimen, high blood pressure, and need for assistance with personal care.Review of the physician orders revealed an order for Novolog (a fast-acting insulin) Injection Solution 100 units per milliliter (ml) inject four units subcutaneously (sq) in the morning, hold for blood sugar less than 80 milligrams (mg) per deciliter (dl).Review of the care plan revealed Resident #27 had diabetes mellitus dated 04/19/23 with a goal the resident would not have diabetic related complications. Interventions included to administer diabetic medications as ordered and to document effectiveness.Review of the medication administration record (MAR) from 02/01/26 to 02/28/26 revealed the absence of documentation for the administration Novolog Injection Solution 100 units/ml inject four units sq in the morning, hold for blood sugar less than 80 mg/dl on 02/25/26.Review of the MAR from 03/01/26 to 03/25/26 revealed the absence of documentation for the administration Novolog Injection Solution 100 units/ml inject four units sq in the morning, hold for blood sugar less than 80 mg/dl on 03/05/26, 03/15/26, 03/19/26, 03/20/26, 03/21/26, and 03/24/26.Review of the progress notes from 02/24/26 to 03/26/26 revealed the absence of documentation related to insulin administration on 02/25/26, 03/05/36, 03/15/26, 03/19/26, 03/20/26, 03/21/26, and 03/24/26.An interview on 03/26/26 at 12:09 P.M. with Licensed Practical Nurse (LPN) #314 revealed medication administration would be documented in the MAR, if the medication was not administered it would be documented as not administered on the MAR, and the medical team would be notified if a medication was not administered.An interview on 03/26/26 at 12:48 P.M. with the Director of Nursing (DON) verified the missing insulin documentation.Review of the facility policy titled Medication Administration, dated 03/2026 revealed all communication with the physician would be documented and medications would be charted on the MAR.2. Review of the medical record for Resident #5 revealed they were admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, colon cancer, anxiety, and high blood pressure.Review of the care plan revealed the resident would have a person-centered care plan dated 05/18/21 with interventions that included the resident would have skin checks every Friday and any abnormal findings would be documented.Review of the physician orders revealed an order dated 01/10/25 for a weekly skin check by a nurse every week.Review of the Evaluations screen in the electronic medical record (EMR) from 01/01/26 to 03/25/26 for weekly skin check documentation revealed skin evaluations were documented on 01/09/26, 01/16/26, 01/23/26, 02/13/26, 03/07/26, 03/13/26, and 03/20/26.Review of the treatment administration record (TAR) from 01/01/26 to 01/31/26 revealed the absence of documentation for a skin check on 01/02/26.Review of the TAR from 02/01/26 to 02/28/26 revealed the absence of documentation for a skin check on 02/06/26.Review of the progress notes 01/01/26 to 03/24/26 revealed the absence of documentation for the missing skin checks and skin evaluations.An interview on 03/26/26 at 11:47 A.M. with Registered Nurse (RN) #306 revealed skin checks were to be completed weekly, skin checks were to be documented in the TAR which is an attestation the skin check was completed. The actual condition of the resident's skin was to be documented as a skin evaluation in the EMR evaluation tab, and all skin documentation occurred in the EMR.An interview on 03/26/26 at 12:09 P.M. with Licensed Practical Nurse (LPN) #314 revealed skin checks were to be completed weekly, documented in the TAR, and the skin evaluation completed in the EMR evaluations tab.An interview on 03/26/26 at 12:48 P.M. with the DON verified the missing skin checks.3) Review of the medical record for Resident #4 revealed they were admitted to the facility on [DATE] with diagnoses that included dementia, schizoaffective disorder, depression, altered mental status, heart surgery, and disorientation.Review of the care plan revealed the resident was at risk for pressure ulcer development dated 08/30/23 with the goal to have intact skin. Interventions included follow facility policies for the prevention of skin breakdown.Review of the physician orders revealed an order dated 01/07/26 for a skin check to be completed by a nurse weekly.Review of the TAR from 02/01/26 to 02/28/26 revealed the absence of documentation for a skin check on 02/25/26.Review of the TAR from 03/01/26 to 03/25/26 revealed the absence of documentation for a skin check on 03/04/26 and 03/11/26.Review of progress notes from 02/01/26 to 03/25/26 revealed the absence of documentation for the missing skin checks.An interview on 03/26/26 at 11:47 A.M. with RN #306 revealed skin checks were to be completed weekly, skin checks were to be documented in the TAR which is an attestation the skin check was completed, the actual condition of the resident's skin was to be documented as a skin evaluation in the EMR evaluation tab, and all skin documentation occurred in the EMR.An interview on 03/26/26 at 12:09 P.M. with Licensed Practical Nurse (LPN) #314 revealed skin checks were to be completed weekly, documented in the TAR, and the skin evaluation completed in the EMR evaluations tab.An interview on 03/26/26 at 12:48 P.M. with the DON verified the missing skin checks.Review of the facility policy titled Skin Evaluations, Weekly, dated 09/2025 revealed weekly skin evaluations were to be completed by the nurse and documented in the EMR in the evaluation tab.

Based on record review, review of a facility self-reported incident (SRI), review of a social media post, review of the facility's policies on personal cell phone use and social media, and interviews the facility failed to protect the privacy of Resident #28 during personal care. This resulted in Immediate Jeopardy on 11/27/24 when Certified Nursing Assistant (CNA) #500 made a cell phone recording of Resident #28, who was observed in the video slouched in a shower chair with her pants around her ankles and her shirt pulled up above her breasts exposing her bare body from her breasts down to just above her ankles. There was a large amount of fecal matter on the floor under Resident #28 and the video panned around the shower room to show more fecal matter in another area of the room. CNA #500 posted the video to Snapchat (a social media website) and the text overlay on the video read bruh with a loudly crying face emoji. Resident #28 had a diagnosis of Alzheimer's disease and based on the reasonable person concept, a reasonable person would have suffered serious mental/emotional harm from a video of this nature being taken and then posted on social media for an undetermined number of people to access. Based on the reasonable person concept, Resident #28 suffered humiliation through the social media post. This affected one resident (#28) of four residents reviewed for privacy/confidentiality. The facility census was 83. On 12/09/24 at 10:45 A.M., the facility's Administrator, Director of Nursing (DON), and Regional Quality Assurance (QA) Nurse #503 were notified Immediate Jeopardy began on 11/27/24 when CNA #500 took a video of Resident #28, a violation of the resident's right and in a manner that would demean and humiliate the resident. After taking the video, CNA #500 posted the video to social media which had the potential to be viewed by an unlimited number of people via the social media platform and/or electronic communications without the resident's knowledge and/or consent. The Immediate Jeopardy was removed on 12/10/24 when the facility implemented the following corrective actions: On 11/27/24 at 6:50 P.M., Registered Nurse (RN) #502 and Licensed Practical Nurse (LPN) #506 spoke with Certified Nursing Assistant (CNA) #500 advising her of the allegation received that she posted a video on snapchat and that they needed to see her phone. RN #502 reviewed the contents of the phone and observed the video of Resident #28. The nurses required CNA #500 to delete the video from the camera roll and the recently deleted section of her phone. On 11/27/24 at 6:50 P.M., RN #502 informed CNA #500 that she was suspended, and CNA #500 was escorted from the building. On 11/27/24, RN #502 assessed Resident #28. Resident #28's physician was notified of increased lethargy and loose stools and new orders to hold medications and monitor vital signs was obtained and family was updated. Resident #28 family was notified. On 11/27/24 at 7:45 P.M., the Administrator began re-education of staff in the facility regarding the social media policy, which included protecting the privacy of others, and personal cell phone use. She also interviewed staff at this time to determine if they have witnessed or were aware of any staff taking pictures or videos of residents on their phones. As of 12/05/24, there were approximately 22 as needed (PRN) staff who had not received education with a plan for staff to continue as PRN staff arrive on-site for their scheduled shifts. On 11/27/24, the Administrator asked CNA #500 if she had taken pictures prior or posted any videos of residents in the past. The CNA denied taking any other photos or videos of residents and no other pictures or videos involving other residents were noted on the employee's phone. On 11/27/24 at 9:00 P.M., the Administrator sent text messages to approximately 77 employees (all staff members for which the Administrator had cell phone numbers, out of 118 staff) in regards to the facility social media policy, which included protecting the privacy of others, and then re-educated all employees again as they came into the facility per their schedule. Many employees worked PRN or worked one to two days a month and still required education. On 11/28/24, RN #511 provided re-education to 33 staff who arrived for their scheduled shift on this day on the facility social media policy, which included protecting the privacy of others, and personal cell phone. On 11/29/24, the Administrator began to complete audits during rounds for cell phone use. The Administrator made observations of staff on the units to ensure staff did not have cell phones out, were maintaining privacy and confidentiality during hands on care, and reviewed the cell phone audit sheets, which were completed by the floor nurses twice on each shift to monitor for staff cell phone use. The audit sheets included the date, time, unit location, whether cell phone use was observed, who was observed using their cell phone (if applicable), what corrective action was taken, and the initials of the nurse completing the form. On 11/29/24, Medical Director #512 was notified by Regional Quality Assurance (QA) Nurse #503 of the incident involving Resident #28. On 12/02/24 at 12:30 P.M., a meeting was held with Regional QA Nurse #503, Clinical Director #513 and Medical Director #512 to discuss the incident, actions being taken by the facility, and how continued re-education and auditing/monitoring of staff cell phone use while on duty and privacy/confidentiality during care would continue daily at this time. On 12/02/24, CNA #500's employment was terminated. On 12/09/24, an AD HOC meeting via telephone conference with Medical Director #512, Director of Nursing (DON), the Administrator, and Regional QA Nurse #503 to notify Medical Director #512 of the State agency survey and Immediate Jeopardy situation. A discussion occurred related to on-going education of all staff, and the continuation of monitoring staff cell phone use and resident privacy/confidentiality during care. On 12/09/24, signs were posted in resident care areas which included: no cell phone usage on the floor. On 12/10/24 all residents with a Brief Interview for Mental Status (BIMS) score of eight or higher (Residents #8, #24, #36, #43, #54, #67, #71, #72, and #73), were interviewed by Bookkeeper #515 revealed to Privacy/Confidentiality. The facility implemented a plan to continue to monitor/audit for cell phone use on the unit and ensure residents privacy was maintained during care. Audits/monitoring would be completed by the DON and/or designee by observation on the units for personal cell phone use and observation of privacy being maintained during resident care three times per day for five days a week on various shifts/times for three weeks and then three times per day on various shifts/times for three times a week for three weeks. All audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine the need for continuation of audits. In addition, the DON and/or designee would interview five staff members every week for eight weeks on various shifts and in various departments on abuse policies, definitions, reporting and understanding of the facility abuse policy and social media policy. Interviews would be reviewed by the QAPI committee to determine the need for continued education. Although the Immediate Jeopardy was removed on 12/10/24, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia, major depressive disorder, generalized anxiety disorder, disorientation, and altered mental status. The resident passed away at the facility on 12/06/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/24, revealed Resident #28 had severe cognitive impairment, was always incontinent of urine and bowel, and was dependent on staff for toilet transfers, toileting hygiene, shower transfers, and showering self. Review of the care plan, revised 11/13/24, revealed Resident #28 had an activities of daily living (ADL) self-care deficit requiring maximum to total assistance to complete tasks due to confusion, dementia, difficulty sequencing, incomplete performance, cognitive loss, and functional loss. Interventions included shower one to two times per week with total assistance by one staff for showering, total assistance by two staff for toilet use, dependent on two staff to transfer between surfaces, and encourage resident participation to the fullest extent possible with each interaction. Review of a progress note dated 11/27/24 at 11:28 A.M. revealed Resident #28 complained of lower abdominal discomfort, the resident's abdomen was soft when palpated and non-distended, bowel sounds were active, and a medium bowel movement was reported. Review of a progress note dated 11/27/24 at 5:15 P.M. revealed Resident #28 had a large loose bowel movement and was continuously moving bowels, vital signs were taken indicating an abnormal blood pressure of 80/68 (hypotensive) and blood oxygen saturation of 93%. The physician was notified and gave new orders to hold all oral medications and retake vital signs in one hour. A note dated 11/27/24 at 6:15 P.M. revealed Resident #28's vital signs were taken indicating an abnormal blood pressure of 82/52 (hypotensive). The physician was notified and gave new orders to discontinue medications and obtain a hospice consult due to end stage Alzheimer's disease. Review of an undated video with a time stamp in the corner of 6:40 (did not indicate whether it was A.M. or P.M.), shared to Snapchat (a social media website) by CNA #500, revealed Resident #28 was seen slouched in a shower chair with her pants around her ankles and her shirt pulled up above her breasts exposing her bare body from her breasts down to just above her ankles. There was a large amount of fecal matter on the floor under Resident #28 and the video panned around the shower room to show more fecal matter in another area of the room. The text overlay on the video reads bruh with the loudly crying face emoji. Review of a facility Self-Reported Incident (SRI), tracking number 254554, dated 11/27/24 and timed 7:21 P.M., revealed on 11/27/24 at 6:42 P.M. the Administrator was notified by Licensed Practical Nurse (LPN) #506 that the facility received an anonymous phone call reporting CNA #500 posted a video of a woman (identified to be Resident #28) after a shower to Snapchat (a social media platform). The Administrator instructed LPN #506 and Registered Nurse (RN) #502 to question CNA #500. Both LPN #506 and RN #502 saw the video of Resident #28 on CNA #500's phone, and CNA #500 was immediately suspended. As a result of an investigation, the facility unsubstantiated an allegation of abuse and included: The facility has determined that emotional abuse did not occur, Resident was unaware of the incident. The STNA was suspended pending outcome of investigation and terminated on 12/02/24 based on violation of facility social media policy. On 12/05/24 at 10:08 A.M., an observation of Resident #28 revealed the resident was laying in bed with her eyes closed, resting peacefully, and a blanket covered the resident's torso and legs. Resident #28 was not responsive at this time. On 12/05/24 at 10:14 A.M., an interview with Regional QA Nurse #503 confirmed a CNA (CNA #500) took a video of a resident (Resident #28) on her cell phone and then posted the video to Snapchat on the day before Thanksgiving (Wednesday, 11/27/24). Regional QA Nurse #503 said the CNA's cousin called the facility to report the video, the nurse on duty identified the video on the CNA's cell phone, the video was deleted from the CNA's cell phone, and the CNA was escorted out of the facility. On 12/05/24 at 11:10 A.M., an interview with Resident #28's representative revealed they received a call the evening before Thanksgiving to notify them that one of the (facility) aides took a video of Resident #28 and posted it to social media. Resident #28's representative stated they had not seen the video and they did not know whether the video was taken to make fun of someone who was dying or to be funny. Resident #28's representative said the situation was not funny and voiced they were absolutely livid about the incident. On 12/05/24 at 11:24 A.M., an interview with CNA #500 confirmed she took a video of Resident #28. The CNA claimed the video was taken out of concern to show the nurse the amount of feces the resident had. CNA #500 revealed she posted the video to a Snapchat story that was shared with four individuals. CNA #500 was unable to provide an explanation for posting the video on Snapchat and she stated the video was removed from Snapchat 15 to 20 minutes later when one of her friends told her it was inappropriate to post the video. CNA #500 confirmed she was escorted out of the facility and her employment was terminated (as a result of the incident). On 12/05/24 at 12:04 P.M., an interview with RN #502 revealed Resident #28 had a large loose stool that was not easy to clean, and Resident #28 was taken to the shower room to clean her up following bowel incontinence. Following the incident of the video post of Resident #28, RN #502 said she was instructed by the Administrator to talk to CNA #500 with LPN #506 to find out what happened. RN #502 said CNA #500 offered to show her phone to RN #502 and LPN #506. RN #502 said upon reviewing CNA #500's phone, there were two copies of a video of Resident #28 in CNA #500's saved Snapchat videos. RN #502 further stated Resident #28 was not wearing any pants in the video, her bottom half was completely exposed, and there was feces shown in the video. RN #502 said the videos were deleted from CNA #500's phone at that time and CNA #500 was escorted out of the facility. On 12/05/24 at 12:24 P.M., an interview with LPN #506 revealed Resident #28 had been ill around dinner time and RN #502 assisted with Resident #28 in the shower room. LPN #506 said she answered the facility's phone around 6:45 P.M. and was informed by an anonymous caller that CNA #500 added a post to Snapchat that showed a naked resident (identified to be Resident #28) in the facility. LPN #506 said she immediately notified the Administrator and after a few minutes, the Administrator instructed LPN #506 to question CNA #500 with RN #502. She stated at that time, a third nurse in the facility was on the phone with someone else who alleged the same incident as the first anonymous caller. LPN #506 said while she and RN #502 were questioning CNA #500 about the incident, they found the video of Resident #28 on CNA #500's phone in the album for saved Snapchat videos. LPN #506 said she watched as CNA #500 deleted the video from her cell phone. RN #502 educated CNA #500 on the Health Insurance Portability and Accountability Act (HIPAA) and explained that this incident was a HIPAA violation. LPN #506 said she escorted CNA #500 out of the building and watched until CNA #500 left the premises. On 12/05/24 at 12:37 P.M., an interview with LPN #505 revealed she was the third nurse who answered the phone when a second call was received. LPN #505 stated a lady called the facility to report an incident that she saw on social media (involving a resident at the facility). LPN #505 said while she was on the phone, LPN #506 approached from another hall and was already aware of the incident due to receiving the first phone call. LPN #505 said CNA #500 was the assigned shower aide for the day of the incident and she had given a lot of residents' showers. LPN #505 denied any additional involvement in the incident or the facility's internal investigation of the incident. On 12/05/24 at 12:55 P.M., an interview with CNA #507 revealed she was aware of a video taken of a resident who was naked, but she denied any involvement in the incident or the facility's internal investigation of the incident. On 12/05/24 at 1:42 P.M., an interview with CNA #508 revealed she was assigned to complete showers with CNA #500 on 11/27/24. CNA #508 said Resident #28 had multiple episodes of bowel incontinence and explosive diarrhea, which was cleaned up after each episode, and the resident was assessed by RN #502. While providing care, CNA #508 said Resident #28 was positioned over the toilet in the shower chair due to the frequency of her incontinence. CNA #508 said there was feces all over the floor and she began cleaning it up. CNA #508 stated while she was cleaning up the floor, she looked over at CNA #500 and noticed she was recording on her phone. CNA #508 said she asked CNA #500 why she was recording because that was a HIPAA violation and CNA #500 responded I know, but it's funny. CNA #508 said Resident #28 was cleaned up and taken back to her room, then a few minutes later the nurses came and got CNA #500 from the shower room. On 12/05/24 at 3:35 P.M., an interview with CNA #509 revealed on 11/27/24 she was working on Resident #28's unit with CNA #510. CNA #509 stated Resident #28 had multiple episodes of bowel incontinence after dinner that required multiple showers to clean the resident. CNA #509 stated CNA #500 was on her phone in the shower room and that was nothing new because CNA #500 was always on her phone texting people. CNA #509 said she tried to get Resident #28 dressed, but the resident was hard to position in the shower chair and she could not get Resident #28's clothes on all the way. CNA #509 stated Resident #28's shirt was not all the way down, leaving her breasts exposed, and she had no pants on. CNA #509 stated once Resident #28 was cleaned up and dressed, she was taken back to her room and put in bed by CNA #509 and CNA #510. CNA #509 said a few minutes after all that occurred, she heard RN #502 tell CNA #500 that she needed to speak with her and needed to see her cell phone. CNA #509 said she was unaware that a video was taken until RN #502 asked to see CNA #500's phone. CNA #509 further stated she did not see the video on Snapchat the day the video was taken, but stated she did see the video shared to a local Facebook page a few days after the incident occurred. CNA #509 reported the video shared to Facebook had since been removed. On 12/05/24 at 3:50 P.M., an interview with CNA #510 revealed on 11/27/24 Resident #28 was incontinent and had feces under her chair. CNA #510 said it was easier to clean Resident #28 up in the shower. CNA #510 said CNA #509 assisted with cleaning the floor in the hallway and CNA #508 assisted with showering Resident #28 after multiple episodes of incontinence in the shower room. CNA #510 stated CNA #500 was on her phone in the shower room but that was nothing new because CNA #500 was always on her phone texting while at work. Review of the facility's policy on personal telephone use, dated January 2009, indicated cell phones that were not provided by the company were not to be permitted to be ON in the building during working hours and they should not be on an employee's person. On 12/05/24 at 4:45 P.M., an interview with the Administrator, DON, and Regional QA Nurse #503 revealed facility staff were permitted to use their phones at the nurse's stations to contact medical practitioners and resident family members, but staff should not have their personal cell phones in resident care areas or while providing personal care. On 12/09/24 at 9:10 A.M., an interview with the Administrator confirmed the facility's personal phone policy indicated non-company cell phones were to be turned off during working hours and staff should not have their personal cell phones on them while at work. The Administrator further stated that was an outdated policy that needed revision because facility staff utilized their personal cell phones to communicate with practitioners and staffing agencies while working in the facility. Review of the facility's policy on social media use, dated January 2021, indicated staff members should exercise care when participating in social media, follow the same behavioral standards online that they would while engaging in personal and professional interactions, and staff members were accountable for anything they posted to social media about the facility and its staff or residents. The definition of social media, as defined in the facility's policy, included all forms of public, web-based communication, whether existing at the time of this policy's adoption or created at a future date, including but not limited to the following: social networking sites (e.g. Facebook, LinkedIn), video and photo-sharing websites (e.g. Instagram, YouTube), micro-blogging sites (e.g. Twitter, Snapchat, TikTok), blogs (e.g. corporate blogs, personal blogs, media-hosted blogs), forums and discussion boards (e.g. Yahoo! groups, Google groups), and collaborative publishing (e.g. Wikipedia). The policy indicated the privacy of others should be protected and staff members were not permitted to post any photographs or videos of facility residents without permission from those individuals and the Administrator. This deficiency represents non-compliance investigated under Complaint Number OH00160397 and Complaint Number OH00160368.

Based on observation, record review, review of a facility self-reported incident (SRI), review of a social media post, review of the facility's policies on personal cell phone use, social media, and abuse, and interview, the facility failed to ensure Resident #28, who was assessed to be cognitively impaired, was free from staff to resident mental/emotional abuse when Certified Nursing Assistant (CNA) #500 took a video of Resident #28 during personal care on her personal cell phone and posted the video to the social media platform Snapchat. This resulted in Immediate Jeopardy on 11/27/24 when CNA #500 made a cell phone recording of Resident #28, who was seen slouched in a shower chair with her pants around her ankles and her shirt pulled up above her breasts exposing her bare body from her breasts down to just above her ankles. There was a large amount of fecal matter on the floor under Resident #28 and the video panned around the shower room to show more fecal matter in another area of the room. The text overlay on the video read bruh with a loudly crying face emoji. Resident #28 had a diagnosis of Alzheimer's disease and based on the reasonable person concept, any reasonable person would have suffered serious mental/emotional harm from a video of this nature being taken and then posted on social media for an undetermined number of people to access. Based on the reasonable person concept, Resident #28 suffered humiliation through the social media post. In addition, the content of the video and condition of the resident portrayed an incident of neglect (the lack of timely and necessary care and services by staff to meet the resident's total care needs resulting in mental anguish/emotional distress determined by the reasonable person concept) by the facility staff responsible for providing care to Resident #28. This affected one resident (#28) of four residents reviewed for abuse. The facility census was 83. On 12/09/24 at 10:45 A.M., the facility's Administrator, Director of Nursing (DON), and Regional Quality Assurance (QA) Nurse #503 were notified Immediate Jeopardy began on 11/27/24 when CNA #500 took a video of Resident #28 in a manner that would demean and humiliate the resident constituting a situation of abuse and then CNA #500 posted the video to social media which had the potential to be viewed by an unlimited number of people via the social media platform and/or electronic communications without the resident's knowledge and/or consent. The Immediate Jeopardy was removed on 12/10/24 when the facility implemented the following corrective actions: On 11/27/24 at 6:50 P.M., Registered Nurse (RN) #502 and Licensed Practical Nurse (LPN) #506 spoke with Certified Nursing Assistant (CNA) #500 advising her of the allegation received that she posted something on snapchat and that they need to see her phone. RN #502 reviewed the contents of the phone and observed the video of the resident. The nurses made CNA #500 delete the video from the camera roll and the recently deleted section of her phone. On 11/27/24 at 6:50 P.M., RN #502 informed CNA #500 that she was suspended, and CNA #500 was escorted from the building. On 11/27/24, RN #502 assessed Resident #28. Resident #28's physician was notified of increased lethargy and loose stools and new orders to hold medications and monitor vital signs was obtained and family was updated. Resident #28's family was notified. On 11/27/24 at 7:45 P.M., the Administrator began re-education of staff in the facility regarding the social media policy, which included protecting the privacy of others, and personal cell phone use. She also interviewed staff at this time to determine if they had witnessed or were aware of any staff taking pictures or videos of residents on their phones. As of 12/05/24, there were approximately 22 as needed (PRN) staff who had not received education. Education remained ongoing at this time for PRN staff as they arrive on-site for their scheduled shifts. On 11/27/24, the Administrator asked CNA #500 if she had taken pictures prior or posted any videos of residents in the past and she denied stating this was her first time. No other pictures or videos involving other residents were noted on the phone. On 11/27/24 at 9:00 P.M., the Administrator sent text messages to approximately 77 employees (all staff members for which the Administrator had cell phone numbers, out of 118 staff) in regards to social media policy, which included protecting the privacy of others, and then re-educated all employees again as they came into the facility per their schedule as many employees were PRN or work one to two days a month. On 11/28/24 RN #511 provided re-education to 33 staff who arrived for their scheduled shift on the social media policy, which included protecting the privacy of others, and personal cell phone use. On 11/29/24, the Administrator began to complete audits during rounds for cell phone use. The Administrator made observations of staff on the units to ensure staff did not have cell phones out, were maintaining privacy and confidentiality during hands on care, and reviewed the cell phone audit sheets, which were completed by the floor nurses twice on each shift to monitor for staff cell phone use. The audit sheets included the date, time, unit location, whether cell phone use was observed, who was observed using their cell phone (if applicable), what corrective action was taken, and the initials of the nurse completing the form. On 11/29/24, Medical Director #512 was notified by Regional QA Nurse #503 of the incident involving Resident #28. On 12/02/24 at 12:30 P.M. a meeting was held with Regional QA Nurse #503, Clinical Director #513 and Medical Director #512 to discuss the incident, actions being taken by the facility, and how continued re-education and auditing/monitoring of staff cell phone use while on duty and privacy/confidentiality during care would continue daily at this time. On 12/02/24, CNA #500's employment was terminated. On 12/09/24, an AD HOC meeting via telephone conference with Medical Director #512, Director of Nursing (DON), the Administrator, and Regional QA Nurse #503 to notify Medical Director #512 of the State agency Immediate Jeopardy. A discussion was held regarding education of all staff, and the continuation of monitoring staff cell phone use and resident privacy/confidentiality during care. On 12/09/24, signs were posted in resident care areas that stated: no cell phone usage on the floor. On 12/09/24 and 12/10/24 staff re-education was provided on the facility abuse policy and the relation to the social media policy in-person or via phone conversation by facility department heads. On 12/10/24 all residents with a Brief Interview for Mental Status (BIMS) score of eight or higher, (Residents #8, #24, #36, #43, #54, #67, #71, #72, and #73) were interviewed by Bookkeeper #515 related to Privacy/Confidentiality. On 12/10/24 Corporate QA Director #514 re-educated the Administrator on the facility abuse policy and the reasonable person concept. The reasonable person concept would be utilized for future investigations. At this time, the DON was also knowledgeable of the reasonable person concept and verbalized understanding of reporting requirements to the State agency. The facility implemented a plan for Corporate QA office staff to monitor abuse allegations on an on-going basis. On 12/10/24, Regional QA Nurse #503 added an addendum to the facility SRI to reflect the incident/allegation was substantiated. The facility implemented a plan to monitor/audit for cell phone use on the unit and ensure all residents privacy was maintained during care. Audits/monitoring would be completed by the DON and/or designee by observation on the units for personal cell phone use and observation of privacy being maintained during resident care three times per day for five days a week on various shifts/times for three weeks and then three times per day on various shifts/times for three times a week for three weeks. All audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine the need for continuation of audits. In addition, the DON and/or designee would interview five staff members every week for eight weeks on various shifts and in various departments on abuse policies, definitions, reporting and understanding of the facility abuse policy and social media policy. Interviews would be reviewed by the QAPI committee to determine the need for continued education. Although the Immediate Jeopardy was removed on 12/10/24, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia, major depressive disorder, generalized anxiety disorder, disorientation, and altered mental status. Resident #28 passed away at the facility on 12/06/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/24, revealed Resident #28 had severe cognitive impairment, was always incontinent of urine and bowel, and was dependent on staff for toilet transfers, toileting hygiene, shower transfers, and showering self. Review of the care plan, revised 11/13/24, revealed Resident #28 had an activities of daily living (ADL) self-care deficit requiring maximum to total assistance to complete tasks due to confusion, dementia, difficulty sequencing, incomplete performance, cognitive loss, and functional loss. Interventions included shower one to two times per week with total assistance by one staff for showering, total assistance by two staff for toilet use, dependent on two staff to transfer between surfaces, and encourage resident participation to the fullest extent possible with each interaction. Review of a progress note dated 11/27/24 at 11:28 A.M. revealed Resident #28 complained of lower abdominal discomfort, the resident's abdomen was soft when palpated and non-distended, bowel sounds were active, and a medium bowel movement was reported. Review of a progress note dated 11/27/24 at 5:15 P.M. revealed Resident #28 had a large loose bowel movement and was continuously moving bowels, vital signs were taken indicating an abnormal blood pressure of 80/68 (hypotensive) and blood oxygen saturation of 93%. The physician was notified and gave new orders to hold all oral medications and retake vital signs in one hour. A note dated 11/27/24 at 6:15 P.M. revealed Resident #28's vital signs were taken indicating an abnormal blood pressure of 82/52 (hypotensive). The physician was notified and gave new orders to discontinue medications and obtain a hospice consult due to end stage Alzheimer's disease. Review of an undated video with a time stamp in the corner of 6:40 (did not indicate whether it was A.M. or P.M.), shared to Snapchat (a social media website) by CNA #500, revealed Resident #28 was seen slouched in a shower chair with her pants around her ankles and her shirt pulled up above her breasts exposing her bare body from her breasts down to just above her ankles. There was a large amount of fecal matter on the floor under Resident #28 and the video panned around the shower room to show more fecal matter in another area of the room. The text overlay on the video reads bruh with the loudly crying face emoji. Review of a facility Self-Reported Incident (SRI), tracking number 254554, dated 11/27/24 and timed 7:21 P.M., revealed on 11/27/24 at 6:42 P.M. the Administrator was notified by Licensed Practical Nurse (LPN) #506 that the facility received an anonymous phone call reporting CNA #500 posted a video of a woman (identified to be Resident #28) after a shower to Snapchat (a social media platform). The Administrator instructed LPN #506 and Registered Nurse (RN) #502 to question CNA #500. Both LPN #506 and RN #502 saw the video of Resident #28 on CNA #500's phone, and CNA #500 was immediately suspended. As a result of an investigation, the facility unsubstantiated an allegation of abuse and included: The facility has determined that emotional abuse did not occur, Resident was unaware of the incident. The STNA was suspended pending outcome of investigation and terminated on 12/02/24 based on violation of facility social media policy. On 12/05/24 at 10:08 A.M., an observation of Resident #28 revealed the resident was laying in bed with her eyes closed, resting peacefully, and a blanket covered the resident's torso and legs. Resident #28 was not responsive at this time. On 12/05/24 at 10:14 A.M., an interview with Regional QA Nurse #503 confirmed a CNA (CNA #500) took a video of a resident (Resident #28) on their cell phone and then posted the video to Snapchat on the day before Thanksgiving (Wednesday, 11/27/24). Regional QA Nurse #503 said the CNA's cousin called the facility to report the video, the nurse on duty identified the video on the CNA's cell phone, the video was deleted from the CNA's cell phone, and the CNA was escorted out of the facility. On 12/05/24 at 11:10 A.M., an interview with Resident #28's representative revealed they received a call the evening before Thanksgiving to notify them that one of the (facility) aides took a video of Resident #28 and posted it to social media. Resident #28's representative stated they had not seen the video and they did not know whether the video was taken to make fun of someone who was dying or to be funny. Resident #28's representative said the situation was not funny and voiced they were absolutely livid about the incident. On 12/05/24 at 11:24 A.M., an interview with CNA #500 confirmed she took a video of Resident #28. The CNA claimed the video was taken out of concern to show the nurse the amount of feces the resident had. CNA #500 revealed she posted the video to a Snapchat story that was shared with four individuals. CNA #500 was unable to provide an explanation for posting the video on Snapchat and she stated the video was removed from Snapchat 15 to 20 minutes later when one of her friends told her it was inappropriate to post the video. CNA #500 confirmed she was escorted out of the facility and her employment was terminated (as a result of the incident). On 12/05/24 at 12:04 P.M., an interview with RN #502 revealed on 11/27/24 Resident #28 had a large loose stool that was not easy to clean, and Resident #28 was taken to the shower room to clean her up following bowel incontinence. RN #502 stated CNA #500 refused to shower Resident #28 because she stated she had given Resident #28 a shower the previous day. RN #502 said CNA #509 and CNA #510 agreed to shower Resident #28 and began preparing Resident #28 for a shower at that time. RN #502 stated Resident #28 had been assessed earlier in the day due to unresponsiveness and Resident #28's family was considering hospice at that time and did not want Resident #28 sent to the hospital. Following the incident of the video post of Resident #28, RN #502 said she was instructed by the Administrator to talk to CNA #500 with LPN #506 to find out what happened. RN #502 said CNA #500 offered to show her phone to RN #502 and LPN #506. RN #502 said upon reviewing CNA #500's phone, there were two copies of a video of Resident #28 in CNA #500's saved Snapchat videos. RN #502 further stated Resident #28 was not wearing any pants in the video, her bottom half was completely exposed, and there was feces shown in the video. RN #502 said the videos were deleted from CNA #500's phone at that time and CNA #500 was escorted out of the facility. On 12/05/24 at 12:24 P.M., an interview with LPN #506 revealed on 11/27/24 Resident #28 had been ill around dinner time and RN #502 assisted with Resident #28 in the shower room. LPN #506 said she answered the facility's phone around 6:45 P.M. and was informed by an anonymous caller that CNA #500 added a post to Snapchat that showed a naked resident (identified to be Resident #28) in the facility. LPN #506 said she immediately notified the Administrator and after a few minutes, the Administrator instructed LPN #506 to question CNA #500 with RN #502. She stated at that time, a third nurse in the facility was on the phone with someone else who alleged the same incident as the first anonymous caller. LPN #506 said while she and RN #502 were questioning CNA #500 about the incident, they found the video of Resident #28 on CNA #500's phone in the album for saved Snapchat videos. LPN #506 said she watched as CNA #500 deleted the video from her cell phone. RN #502 educated CNA #500 on the Health Insurance Portability and Accountability Act (HIPAA) and explained that this incident was a HIPAA violation. LPN #506 said she escorted CNA #500 out of the building and watched until CNA #500 left the premises. On 12/05/24 at 12:37 P.M., an interview with LPN #505 revealed she was the third nurse who answered the phone when a second call was received. LPN #505 stated a lady called the facility to report an incident that she saw on social media (involving a resident at the facility). LPN #505 said while she was on the phone, LPN #506 approached from another hall and was already aware of the incident due to receiving the first phone call. LPN #505 said CNA #500 was the assigned shower aide for the day of the incident and she had given a lot of resident's showers. LPN #505 denied any additional involvement in the incident or the facility's internal investigation of the incident. On 12/05/24 at 12:55 P.M., an interview with CNA #507 revealed she was aware of a video taken of a resident who was naked, but she denied any involvement in the incident or the facility's internal investigation of the incident. On 12/05/24 at 1:42 P.M., an interview with CNA #508 revealed on 11/27/24 she was assigned to complete showers with CNA #500 on 11/27/24. She said CNA #509 and CNA #510 brought Resident #28 to the shower room to clean her up after incontinence and CNA #500 refused the shower because Resident #28 was showered the prior day. CNA #508 said she offered to assist CNA #509 and CNA #510 with the shower as soon as she finished assisting another resident. CNA #508 stated there was a large amount of liquid feces when they removed Resident #28's clothing. CNA #508 stated that she, along with CNA #509 and CNA #510, assisted Resident #28 in getting cleaned up and then Resident #28 was incontinent again, which required her to be cleaned up again. CNA #508 said Resident #28 had explosive diarrhea, was cleaned up again, and was assessed by RN #502. CNA #508 said Resident #28 was positioned over the toilet in the shower chair due to the frequency of her incontinence. CNA #508 said there was feces all over the floor and she began cleaning it up. CNA #508 stated while she was cleaning up the floor, she looked over at CNA #500 and noticed she was recording on her phone. CNA #508 said she asked CNA #500 why she was recording because that was a HIPAA violation and CNA #500 responded I know, but it's funny. CNA #508 said Resident #28 was cleaned up and taken back to her room, then a few minutes later the nurses came and got CNA #500 from the shower room. On 12/05/24 at 3:35 P.M., an interview with CNA #509 revealed on 11/27/24 she was working on Resident #28's unit with CNA #510. CNA #509 stated Resident #28 had an episode of incontinence after dinner that required a shower to clean the resident. CNA #509 said Resident #28 was taken to the shower room, where CNA #500 refused to complete the shower because Resident #28 had been showered the day before. CNA #509 said she was in and out of the shower room cleaning up the hallway from where they transported Resident #28 to the shower room. CNA #509 said CNA #500, CNA #508, and CNA #510 were in the shower room with Resident #28. CNA #509 stated CNA #500 was on her phone in the shower room and that was nothing new because CNA #500 was always on her phone texting people. CNA #509 said Resident #28 kept having diarrhea and had to be showered again. CNA #509 said she tried to get Resident #28 dressed, but the resident was hard to position in the shower chair and she could not get Resident #28's clothes on all the way. CNA #509 stated Resident #28's shirt was not all the way down, leaving her breasts exposed, and she had no pants on. CNA #509 stated once Resident #28 was cleaned up and dressed, she was taken back to her room and put in bed by CNA #509 and CNA #510. CNA #509 said CNA #500 and CNA #508 continued giving showers. CNA #509 said a few minutes after all that occurred, she heard RN #502 tell CNA #500 that she needed to speak with her and needed to see her cell phone. CNA #509 said she was unaware that a video was taken until RN #502 asked to see CNA #500's phone. CNA #509 further stated she did not see the video on Snapchat the day the video was taken, but stated she did see the video shared to a local Facebook page a few days after the incident occurred. CNA #509 reported the video shared to Facebook had since been removed. On 12/05/24 at 3:50 P.M., an interview with CNA #510 revealed on 11/27/24 Resident #28 was incontinent and had feces under her chair. CNA #510 said it was easier to clean Resident #28 up in the shower. CNA #510 said CNA #509 assisted with cleaning the floor in the hallway and CNA #508 assisted with showering Resident #28 after multiple episodes of incontinence in the shower room. CNA #510 stated CNA #500 was on her phone in the shower room and that was nothing new because CNA #500 was always on her phone texting while at work. Review of the facility's policy on personal telephone use, dated January 2009, indicated cell phones that were not provided by the company were not to be permitted to be ON in the building during working hours and they should not be on an employee's person. On 12/05/24 at 4:45 P.M., an interview with the Administrator, DON, and Regional QA Nurse #503 revealed facility staff were permitted to use their phones at the nurse's stations to contact medical practitioners and resident family members, but staff should not have their personal cell phones in resident care areas or while providing personal care. On 12/09/24 at 9:10 A.M., an interview with the Administrator confirmed the facility's personal phone policy indicated non-company cell phones were to be turned off during working hours and staff should not have their personal cell phones on them while at work. The Administrator further stated that was an outdated policy that needed revision because facility staff utilized their personal cell phones to communicate with practitioners and staffing agencies while working in the facility. Review of the facility's policy on social media use, dated January 2021, indicated staff members should exercise care when participating in social media, follow the same behavioral standards online that they would while engaging in personal and professional interactions, and staff members were accountable for anything they posted to social media about the facility and its staff or residents. The definition of social media, as defined in the facility's policy, included all forms of public, web-based communication, whether existing at the time of this policy's adoption or created at a future date, including but not limited to the following: social networking sites (e.g. Facebook, LinkedIn), video and photo-sharing websites (e.g. Instagram, YouTube), micro-blogging sites (e.g. Twitter, Snapchat, TikTok), blogs (e.g. corporate blogs, personal blogs, media-hosted blogs), forums and discussion boards (e.g. Yahoo! groups, Google groups), and collaborative publishing (e.g. Wikipedia). The policy indicated staff members were responsible for anything they posted online, must be respectful to the facility and its staff and residents, ensure communications or postings do not violate any of the facility's policies including HIPAA, must not express pornographic or indecent content, never post anything to a social media site or on the internet that interferes with resident obligations, and remember everything written online can be traced back to its author. Violations of this policy would result in discipline up to and including discharge. Review of the facility's policy on abuse prevention, dated 03/2023, indicated the facility would protect all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, residents, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. The definition of mental abuse, as defined in the facility's policy, included nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. The definition of neglect, as defined in the facility's policy, included failures of the facility, its employees or service providers to provide a resident with goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. This deficiency represents non-compliance investigated under Complaint Number OH00160397 and Complaint Number OH00160368.

Based on observation, record review, review of a facility self-reported incident (SRI), review of a social media post, review of the facility's policies on personal cell phone use, social media, and abuse, and interview, the facility failed to effectively implement their abuse policy to prevent staff to resident abuse and to appropriately recognize the incident as abuse. This resulted in Immediate Jeopardy on 11/27/24 when Certified Nursing Assistant (CNA) #500 took a video of Resident #28 during personal care, in which the resident's bare body was from her breasts down to just above the ankles with a substantial amount of fecal matter on the floor around the resident, on her personal cell phone and posted the video to the social media platform Snapchat with a text overlay that read bruh with a loudly crying face emoji. While the facility did report the incident to the State agency, the facility concluded the incident of abuse was unsubstantiated based on the resident being unaware of the incident. Resident #28 had a diagnosis of Alzheimer's disease and based on the reasonable person concept, any reasonable person would have suffered serious mental/emotional harm from a video of this nature being taken and then posted on social media for an undetermined number of people to access. Based on the reasonable person concept, Resident #28 suffered humiliation through the social media post. This affected one resident (#28) of four residents reviewed for abuse. The facility census was 83. On 12/09/24 at 10:45 A.M., the facility's Administrator, Director of Nursing (DON), and Regional Quality Assurance (QA) Nurse #503 were notified Immediate Jeopardy began on 11/27/24 when CNA #500 took a video of Resident #28 in a manner that would demean and humiliate the resident constituting a situation of abuse, then CNA #500 posted the video to social media which had the potential to be viewed by an unlimited number of people via the social media platform and/or electronic communications without the resident's knowledge and/or consent. In addition, the facility failed to recognize this incident as a situation of abuse when their investigation concluded the allegation of abuse was unsubstantiated. The Immediate Jeopardy was removed on 12/10/24 when the facility implemented the following corrective actions: On 11/27 /24 at 6:50 P.M., Registered Nurse (RN) #502 and Licensed Practical Nurse (LPN) #506 spoke with Certified Nursing Assistant (CNA) #500 advising her of the allegation received that she posted something on snapchat and that they need to see her phone. RN #502 reviewed the contents of the phone and observed the video of Resident #28. The nurses made CNA #500 delete the video from the camera roll and the recently deleted section of her phone. On 11/27/24 at 6:50 P.M., RN #502 informed CNA #500 she was suspended, and CNA #500 was escorted from the building. On 11/27/24, RN #502 assessed Resident #28. Resident #28's physician was notified of increased lethargy and loose stools and new orders to hold medications and monitor vital signs was obtained and family was updated. Resident #28's family was notified. On 11/27/24 at 7:45 P.M., the Administrator began re-education of staff in the facility regarding the social media policy, which included protecting the privacy of others, and personal cell phone use. She also interviewed staff at this time to determine if they have witnessed or were aware of any staff taking pictures or videos of residents on their phones. As of 12/05/24, there were approximately 22 as needed (PRN) staff who had not received education with education on-going as PRN staff arrived on-site for their scheduled shifts. On 11/27/24, the Administrator asked CNA #500 if she had taken pictures prior or posted any videos of residents in the past. The CNA denied taking other pictures or posting videos of other residents. No other pictures or videos involving other residents were noted on the phone. On 11/27/24 at 9:00 P.M., the Administrator sent text messages to approximately 77 employees (all staff members for which the Administrator had cell phone numbers, out of 118 staff) in regards to social media policy, which included protecting the privacy of others, and then re-educated all employees again as they came into the facility per their schedule. PRN staff and staff who worked one to two days a month would be educated as they arrived to work. On 11/28/24 RN #511 provided re-education to 33 staff who arrived for their scheduled shift related to the facility social media policy, which included protecting the privacy of others, and personal cell phone use. On 11/29/24, the Administrator began to complete audits during rounds for cell phone use. The Administrator made observations of staff on the units to ensure staff did not have cell phones out, were maintaining privacy and confidentiality during hands on care, and reviewed the cell phone audit sheets, which were completed by the floor nurses twice on each shift to monitor for staff cell phone use. The audit sheets included the date, time, unit location, whether cell phone use was observed, who was observed using their cell phone (if applicable), what corrective action was taken, and the initials of the nurse completing the form. On 11/29/24, Medical Director #512 was notified by Regional QA Nurse #503 of the incident involving Resident #28. On 12/02/24 at 12:30 P.M. a meeting was held with Regional QA Nurse #503, Clinical Director #513 and Medical Director #512 to discuss the incident, actions being taken by the facility, and how continued re-education and auditing/monitoring of staff cell phone use while on duty and privacy/confidentiality during care would continue daily at this time. On 12/02/24, CNA #500's employment was terminated. On 12/09/24, an AD HOC meeting via telephone conference with Medical Director #512, Director of Nursing (DON), the Administrator, and Regional QA Nurse #503 was held to notify Medical Director #512 of the State agency Immediate Jeopardy. A discussion was held regarding on-going education of all staff, and the continuation of monitoring staff cell phone use and resident privacy/confidentiality during care. On 12/09/24, signs were posted in resident care areas which stated: no cell phone usage on the floor. On 12/09/24 and 12/10/24 re-education on the facility abuse policy and the relation to the social media policy was completed with all staff in-person or via phone conversation by facility department heads. On 12/10/24 all residents with a Brief Interview for Mental Status (BIMS) score of eight or higher, Residents #8, #24, #36, #43, #54, #67, #71, #72, and #73, were interviewed by Bookkeeper #515 related to Privacy/Confidentiality. On 12/10/24 Corporate QA #514 re-educated the Administrator on the facility abuse policy and reasonable person concept. The reasonable person concept would be utilized for future investigations. The DON was also knowledgeable of the reasonable person concept and verbalized understanding if she was required to report an SRI. The facility implemented a plan for Corporate QA office staff to monitor abuse allegations on an on-going basis. On 12/10/24 Regional QA Nurse #503 completed an addendum for the facility SRI involving the incident with Resident #28 on 11/27/24. The addendum noted the allegation of abuse was substantiated. The facility implemented a plan to monitor/audit for cell phone use on the unit and ensure residents privacy was maintained during care. Audits/monitoring would be completed by the DON and/or designee by observation on the units for personal cell phone use and observation of privacy being maintained during resident care three times per day for five days a week on various shifts/times for three weeks and then three times per day on various shifts/times for three times a week for three weeks. All audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine the need for continuation of audits. In addition, the DON and/or designee would interview five staff members every week for eight weeks on various shifts and in various departments on abuse policies, definitions, reporting and understanding of the facility abuse policy and social media policy. Interviews would be reviewed by the QAPI committee to determine the need for continued education. Although the Immediate Jeopardy was removed on 12/10/24, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia, major depressive disorder, generalized anxiety disorder, disorientation, and altered mental status. The resident passed away at the facility on 12/06/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/24, revealed Resident #28 had severe cognitive impairment, was always incontinent of urine and bowel, and was dependent on staff for toilet transfers, toileting hygiene, shower transfers, and showering self. Review of the care plan, revised 11/13/24, revealed Resident #28 had an activities of daily living (ADL) self-care deficit requiring maximum to total assistance to complete tasks due to confusion, dementia, difficulty sequencing, incomplete performance, cognitive loss, and functional loss. Interventions included shower one to two times per week with total assistance by one staff for showering, total assistance by two staff for toilet use, dependent on two staff to transfer between surfaces, and encourage resident participation to the fullest extent possible with each interaction. Review of a progress note dated 11/27/24 at 11:28 A.M. revealed Resident #28 complained of lower abdominal discomfort, the resident's abdomen was soft when palpated and non-distended, bowel sounds were active, and a medium bowel movement was reported. Review of a progress note dated 11/27/24 at 5:15 P.M. revealed Resident #28 had a large loose bowel movement and was continuously moving bowels, vital signs were taken indicating an abnormal blood pressure of 80/68 (hypotensive) and blood oxygen saturation of 93%. The physician was notified and gave new orders to hold all oral medications and retake vital signs in one hour. A note dated 11/27/24 at 6:15 P.M. revealed Resident #28's vital signs were taken indicating an abnormal blood pressure of 82/52 (hypotensive). The physician was notified and gave new orders to discontinue medications and obtain a hospice consult due to end stage Alzheimer's disease. Review of an undated video with a time stamp in the corner of 6:40 (did not indicate whether it was A.M. or P.M.), shared to Snapchat (a social media website) by CNA #500, revealed Resident #28 was seen slouched in a shower chair with her pants around her ankles and her shirt pulled up above her breasts exposing her bare body from her breasts down to just above her ankles. There was a large amount of fecal matter on the floor under Resident #28 and the video panned around the shower room to show more fecal matter in another area of the room. The text overlay on the video reads bruh with the loudly crying face emoji. Review of a facility Self-Reported Incident (SRI), tracking number 254554, dated 11/27/24 and timed 7:21 P.M., revealed on 11/27/24 at 6:42 P.M. the Administrator was notified by Licensed Practical Nurse (LPN) #506 that the facility received an anonymous phone call reporting CNA #500 posted a video of a woman (identified to be Resident #28) after a shower to Snapchat (a social media platform). The Administrator instructed LPN #506 and Registered Nurse (RN) #502 to question CNA #500. Both LPN #506 and RN #502 saw the video of Resident #28 on CNA #500's phone, and CNA #500 was immediately suspended. As a result of an investigation, the facility unsubstantiated an allegation of abuse and included: The facility has determined that emotional abuse did not occur, Resident was unaware of the incident. The STNA was suspended pending outcome of investigation and terminated on 12/02/24 based on violation of facility social media policy. On 12/05/24 at 10:08 A.M., an observation of Resident #28 revealed the resident was laying in bed with her eyes closed, resting peacefully, and a blanket covered the resident's torso and legs. Resident #28 was not responsive at this time. On 12/05/24 at 10:14 A.M., an interview with Regional QA Nurse #503 confirmed a CNA (CNA #500) took a video of a resident (Resident #28) on her cell phone and then posted the video to Snapchat on the day before Thanksgiving (Wednesday, 11/27/24). Regional QA Nurse #503 said the CNA's cousin called the facility to report the video, the nurse on duty identified the video on the CNA's cell phone, the video was deleted from the CNA's cell phone, and the CNA was escorted out of the facility. On 12/05/24 at 11:10 A.M., an interview with Resident #28's representative revealed they received a call the evening before Thanksgiving to notify them that one of the (facility) aides took a video of Resident #28 and posted it to social media. Resident #28's representative stated they had not seen the video and they did not know whether the video was taken to make fun of someone who was dying or to be funny. Resident #28's representative said the situation was not funny and voiced they were absolutely livid about the incident. On 12/05/24 at 11:24 A.M., an interview with CNA #500 confirmed she took a video of Resident #28. The CNA claimed the video was taken out of concern to show the nurse the amount of feces the resident had. CNA #500 revealed she posted the video to a Snapchat story that was shared with four individuals. CNA #500 was unable to provide an explanation for posting the video on Snapchat and she stated the video was removed from Snapchat 15 to 20 minutes later when one of her friends told her it was inappropriate to post the video. CNA #500 confirmed she was escorted out of the facility and her employment was terminated (as a result of the incident). On 12/05/24 at 12:04 P.M., an interview with RN #502 revealed on 11/27/24 Resident #28 had a large loose stool that was not easy to clean, and Resident #28 was taken to the shower room to clean her up following bowel incontinence. RN #502 stated CNA #500 refused to shower Resident #28 because she stated she had given Resident #28 a shower the previous day. RN #502 said CNA #509 and CNA #510 agreed to shower Resident #28 and began preparing Resident #28 for a shower at that time. RN #502 stated Resident #28 had been assessed earlier in the day due to unresponsiveness and Resident #28's family was considering hospice at that time and did not want Resident #28 sent to the hospital. Following the incident of the video post of Resident #28, RN #502 said she was instructed by the Administrator to talk to CNA #500 with LPN #506 to find out what happened. RN #502 said CNA #500 offered to show her phone to RN #502 and LPN #506. RN #502 said upon reviewing CNA #500's phone, there were two copies of a video of Resident #28 in CNA #500's saved Snapchat videos. RN #502 further stated Resident #28 was not wearing any pants in the video, her bottom half was completely exposed, and there was feces shown in the video. RN #502 said the videos were deleted from CNA #500's phone at that time and CNA #500 was escorted out of the facility. On 12/05/24 at 12:24 P.M., an interview with LPN #506 revealed on 11/27/24 Resident #28 had been ill around dinner time and RN #502 assisted with Resident #28 in the shower room. LPN #506 said she answered the facility's phone around 6:45 P.M. and was informed by an anonymous caller that CNA #500 added a post to Snapchat that showed a naked resident (identified to be Resident #28) in the facility. LPN #506 said she immediately notified the Administrator and after a few minutes, the Administrator instructed LPN #506 to question CNA #500 with RN #502. She stated at that time, a third nurse in the facility was on the phone with someone else who alleged the same incident as the first anonymous caller. LPN #506 said while she and RN #502 were questioning CNA #500 about the incident, they found the video of Resident #28 on CNA #500's phone in the album for saved Snapchat videos. LPN #506 said she watched as CNA #500 deleted the video from her cell phone. RN #502 educated CNA #500 on the Health Insurance Portability and Accountability Act (HIPAA) and explained that this incident was a HIPAA violation. LPN #506 said she escorted CNA #500 out of the building and watched until CNA #500 left the premises. On 12/05/24 at 12:37 P.M., an interview with LPN #505 revealed on 11/27/24 she was the third nurse who answered the phone when a second call was received. LPN #505 stated a lady called the facility to report an incident that she saw on social media (involving a resident at the facility). LPN #505 said while she was on the phone, LPN #506 approached from another hall and was already aware of the incident due to receiving the first phone call. LPN #505 said CNA #500 was the assigned shower aide for the day of the incident and she had given a lot of resident's showers. LPN #505 denied any additional involvement in the incident or the facility's internal investigation of the incident. On 12/05/24 at 12:55 P.M., an interview with CNA #507 revealed she was aware of a video taken of a resident who was naked, but she denied any involvement in the incident or the facility's internal investigation of the incident. On 12/05/24 at 1:42 P.M., an interview with CNA #508 revealed on 11/27/24 she was assigned to complete showers with CNA #500 on 11/27/24. She said CNA #509 and CNA #510 brought Resident #28 to the shower room to clean her up after incontinence and CNA #500 refused the shower because Resident #28 was showered the prior day. CNA #508 said she offered to assist CNA #509 and CNA #510 with the shower as soon as she finished assisting another resident. CNA #508 stated there was a large amount of liquid feces when they removed Resident #28's clothing. CNA #508 stated that she, along with CNA #509 and CNA #510, assisted Resident #28 in getting cleaned up and then Resident #28 was incontinent again, which required her to be cleaned up again. CNA #508 said Resident #28 had explosive diarrhea, was cleaned up again, and was assessed by RN #502. CNA #508 said Resident #28 was positioned over the toilet in the shower chair due to the frequency of her incontinence. CNA #508 said there was feces all over the floor and she began cleaning it up. CNA #508 stated while she was cleaning up the floor, she looked over at CNA #500 and noticed she was recording on her phone. CNA #508 said she asked CNA #500 why she was recording because that was a HIPAA violation and CNA #500 responded I know, but it's funny. CNA #508 said Resident #28 was cleaned up and taken back to her room, then a few minutes later the nurses came and got CNA #500 from the shower room. On 12/05/24 at 3:35 P.M., an interview with CNA #509 revealed on 11/27/24 she was working on Resident #28's unit with CNA #510. CNA #509 stated Resident #28 had an episode of incontinence after dinner that required a shower to clean the resident. CNA #509 said Resident #28 was taken to the shower room, where CNA #500 refused to complete the shower because Resident #28 had been showered the day before. CNA #509 said she was in and out of the shower room cleaning up the hallway from where they transported Resident #28 to the shower room. CNA #509 said CNA #500, CNA #508, and CNA #510 were in the shower room with Resident #28. CNA #509 stated CNA #500 was on her phone in the shower room and that was nothing new because CNA #500 was always on her phone texting people. CNA #509 said Resident #28 kept having diarrhea and had to be showered again. CNA #509 said she tried to get Resident #28 dressed, but the resident was hard to position in the shower chair and she could not get Resident #28's clothes on all the way. CNA #509 stated Resident #28's shirt was not all the way down, leaving her breasts exposed, and she had no pants on. CNA #509 stated once Resident #28 was cleaned up and dressed, she was taken back to her room and put in bed by CNA #509 and CNA #510. CNA #509 said CNA #500 and CNA #508 continued giving showers. CNA #509 said a few minutes after all that occurred, she heard RN #502 tell CNA #500 that she needed to speak with her and needed to see her cell phone. CNA #509 said she was unaware that a video was taken until RN #502 asked to see CNA #500's phone. CNA #509 further stated she did not see the video on Snapchat the day the video was taken, but stated she did see the video shared to a local Facebook page a few days after the incident occurred. CNA #509 reported the video shared to Facebook had since been removed. On 12/05/24 at 3:50 P.M., an interview with CNA #510 revealed on 11/27/24 Resident #28 was incontinent and had feces under her chair. CNA #510 said it was easier to clean Resident #28 up in the shower. CNA #510 said CNA #509 assisted with cleaning the floor in the hallway and CNA #508 assisted with showering Resident #28 after multiple episodes of incontinence in the shower room. CNA #510 stated CNA #500 was on her phone in the shower room but that was nothing new because CNA #500 was always on her phone texting while at work. Review of the facility's policy on personal telephone use, dated January 2009, indicated cell phones that were not provided by the company were not to be permitted to be ON in the building during working hours and they should not be on an employee's person. On 12/05/24 at 4:45 P.M., an interview with the Administrator, DON, and Regional QA Nurse #503 revealed facility staff were permitted to use their phones at the nurse's stations to contact medical practitioners and resident family members, but staff should not have their personal cell phones in resident care areas or while providing personal care. On 12/09/24 at 9:10 A.M., an interview with the Administrator confirmed the facility's personal phone policy indicated non-company cell phones were to be turned off during working hours and staff should not have their personal cell phones on them while at work. The Administrator further stated that was an outdated policy that needed revision because facility staff utilized their personal cell phones to communicate with practitioners and staffing agencies while working in the facility. On 12/09/24 at 10:50 A.M., an interview with Regional QA Nurse #503 verified the facility investigated the incident involving Resident #28 and initially determined the allegation of abuse was unsubstantiated. Regional QA Nurse #503 further stated she did not think there was any harm to Resident #28 because staff believed the resident was unaware of the incident. On 12/10/24 at 8:00 A.M., an interview with Regional QA Nurse #503 revealed the facility had abuse prevention policies in place and staff were educated on those policies. Regional QA Nurse #503 said it was not the facility's fault that CNA #500 chose not to follow the facility's abuse prevention policy. During a follow-up interview on 12/10/24 at 10:10 A.M., Regional QA Nurse #503 confirmed the incident involving Resident #28 could be considered abuse based on the reasonable person concept. Review of the facility's policy on social media use, dated January 2021, indicated staff members should exercise care when participating in social media, follow the same behavioral standards online that they would while engaging in personal and professional interactions, and staff members were accountable for anything they posted to social media about the facility and its staff or residents. The definition of social media, as defined in the facility's policy, included all forms of public, web-based communication, whether existing at the time of this policy's adoption or created at a future date, including but not limited to the following: social networking sites (e.g. Facebook, LinkedIn), video and photo-sharing websites (e.g. Instagram, YouTube), micro-blogging sites (e.g. Twitter, Snapchat, TikTok), blogs (e.g. corporate blogs, personal blogs, media-hosted blogs), forums and discussion boards (e.g. Yahoo! groups, Google groups), and collaborative publishing (e.g. Wikipedia). The policy indicated staff members were responsible for anything they posted online, must be respectful to the facility and its staff and residents, ensure communications or postings do not violate any of the facility's policies including HIPAA, must not express pornographic or indecent content, never post anything to a social media site or on the internet that interferes with resident obligations, and remember everything written online can be traced back to its author. Violations of this policy would result in discipline up to and including discharge. Review of the facility's policy on abuse prevention, dated 03/2023, indicated the facility would protect all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, residents, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. The definition of mental abuse, as defined in the facility's policy, included nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. The definition of neglect, as defined in the facility's policy, included failures of the facility, its employees or service providers to provide a resident with goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy also indicated all alleged, suspected, or observed abuse, neglect, and/or mistreatment of a resident would be thoroughly investigated by the Administrator and DON until a determination could be made as to whether abuse had occurred. If an employee was suspected of abuse, neglect, or mistreatment of a resident, they would be suspended of their duties until the investigation was complete. Review of the facility's policy on abuse allegation investigations, dated 05/2024, indicated the facility would immediately investigate and report any allegation of abuse. The facility Administrator and/or designee would ensure steps were taken to protect the resident from further abuse during the investigation, ensure a physical assessment of the resident was completed to determine if any injury or trauma occurred, ensure the alleged perpetrator was immediately suspended (facility staff) or requested to leave the building (visitor), ensure the allegation was reported to the State Agency, report the incident to local law enforcement if the allegation/incident was a suspected crime, interview the resident about the alleged incident as soon as possible, observe and assess if the resident had any changes as a result of the alleged incident, notify the resident's attending physician and the resident's legal representative of the alleged incident, document the date and time of the alleged incident as well as the location of the alleged incident, interview all staff and potential witnesses, secure staff witness statements, interview and assess (as applicable) other residents that may be at-risk, interview the alleged perpetrator and obtain a statement, ensure all interviews with staff and residents are witnessed and documented, review the employee file of the alleged perpetrator (if applicable), complete the investigation and document the determination if the alleged incident is verified/not verified or if the evidence was inconclusive. All allegations of abuse and investigations would be reviewed by the facility's quality assurance committee to determine if additional measures were necessary. This deficiency represents non-compliance investigated under Complaint Number OH00160397 and Complaint Number OH00160368.

Based on observation, staff interviews, review of safety data sheets, and review of the facility policy, the facility failed to ensure harmful cleaning chemicals were not accessible to severely cognitively impaired residents. This had the potential to affect 36 residents (#1, #7, #8,#11, #13, #12, #14, #19, #20, #21, #22, #25, #26, #34, #35, #39, #40, #41, #44, #45, #47, #49, #51, #52, #54, #58, #59, #60, #63, #64, #65, #67, #69, #74, #76, #180) identified by the facility as being both mobile and severely impaired cognitively. The facility census was 76. Findings include: Observation on 10/23/24 from 10:53 A.M. to 10:57 A.M. revealed there were four spray bottles of chemicals sitting in an open pocket of a floor technician's cart sitting unattended in the hallway as Floor Technician #431 was cleaning resident room [ROOM NUMBER]. Observation on 10/23/24 at 10:59 A.M of the floor technician's cart with Floor Technician #431 confirmed there was one spray bottle labeled Crew Restroom & Surface SC Non-Acid Disinfectant Cleaner, one spray bottle labeled Virex two 256 One-Step Disinfectant Cleaner, one spray bottle labeled Fantasik, and one spray labeled Clorox Germicidal Bleach in the open pocket of the floor technician cart he had been using. At the time of the observation, Housekeeper #431 confirmed he had just finished cleaning resident rooms numbered 11 and 14 and left his cart in the hallway as he cleaned the rooms. Interview on 10/23/24 at 11:29 A.M. with Housekeeping/Laundry Supervisor #429 revealed the floor technician's cart should not have had the chemical cleaners on it, and all chemicals should be locked. Review of the safety data sheet for Virex two 256 One-Step Disinfectant Cleaner and Deodorant; Quat Based Disinfectant, revised on 04/30/20, revealed the product caused severe skin burns and serious eye damage, was harmful if swallowed, and may cause damage to organs through prolong or repeated exposure. The product should be stored locked up. Review of the safety data sheet for Crew Restroom & Surface SC Non-Acid Disinfectant Cleaner, revised 07/31/24, revealed the product caused severe skin burns and serious eye damage, was harmful if swallowed, and may cause damage to organs through prolonged or repeated exposure. The product should be stored locked up. Review of the safety data sheet for Fantasik Multi-Surface Disinfectant Degreaser, revised 10/02/19, revealed the product should be stored out of reach of children and pets and contact with skin, eyes, and clothing should be avoided. Review of the safety data sheet for Clorox Healthcare Bleach Germicidal Cleaner, dated 01/05/15, revealed contact with eyes should be avoided since it may cause eye irritation. Review of the facility policy titled Housekeeping Services, revised January 2024, revealed all cleaning agents would be secured in a housekeeping cart when not in use.

Based on observation, record review and interview, the facility failed to ensure Resident #21 was provided timely incontinence care. This finding affected one (Resident #21) of three residents reviewed for incontinence care. Findings include: Review of Resident #21's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle weakness and need for assistance with personal care. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited severe cognitive impairment, required limited two person assist for toileting, was frequently incontinent of urine and always incontinent of bowel. Review of Resident #21's physician orders revealed an order dated 02/02/23 for incontinence checks every two hours and as needed. Observation on 03/21/23 from 7:47 A.M. through 11:40 A.M. revealed Resident #21 remained in common areas and the dining room, and was not offered incontinence care. Observation at 12:03 P.M. with Restorative Registered Nurse (RN) Supervisor #816, State tested Nursing Assistant (STNA) #849 and STNA #878 of Resident #21's incontinence care revealed the resident's pants were visibly wet on the posterior portion of the pants and when the pants were pulled down to change the resident, the adult incontinence brief was saturated with urine. The bottom portion of Resident #21's shirt also appeared to be wet. While the staff provided incontinence care to the resident's backside, he also had a small bowel movement. The pad in the resident's wheelchair appeared to be saturated with urine. Interview on 03/21/23 at 12:10 P.M. with STNA #878 indicated she had peeked at Resident #21's incontinence brief after breakfast and he appeared to be dry. When questioned, she indicated peeked meant she visually observed the resident and he was dry of urine. She stated the nightshift got the resident up for the day and put him in his wheelchair. When questioned, she stated she arrived in the facility for her shift at 7:00 A.M. and he was already up and placed in the wheelchair. She confirmed he was not provided incontinence care from 7:00 A.M. to 12:03 P.M. and at that time, his adult incontinence brief and clothing were saturated with urine. Review of the Incontinence Care policy revised 01/2017 indicated the purpose was to cleanse the perineum, prevent infection and maintain resident comfort. This deficiency represents non-compliance investigated under Complaint Number OH00140784.

Based on observation, record review, and interview the facility failed to ensure Resident #27's skin interventions for [CONDITION(S)] were completed as ordered. This finding affected one (Resident #27) of one resident reviewed for non-pressure skin conditions. The facility census was 74. Findings include: Review of Resident #27's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited severe cognitive impairment. Review of Resident #27's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's care plan dated 10/21/21 indicated the resident had impaired circulation related to dependent [CONDITION(S)] and an intervention was implemented dated 11/10/21 for bilateral knee hi TED hose on the morning and off at bedtime. Review of Resident #27's medication administration records (MAR) and treatment administration records (TAR) from 08/01/22 to 08/18/22 revealed the bilateral TED hose were implemented per the order. Observation on 08/18/22 at 9:05 A.M. with Licensed Practical Nurse (LPN) #801 revealed the left heel wound care treatment was completed and Resident #27 was sitting up in his room in a modified Broda (specialty chair) with a table across his lap. Resident #27 was in his room watching television at the time of the observation. The bilateral TED hose were not implemented at the time of the observation; however, the TED hose were signed off as completed on the MAR and TAR. Interview on 08/18/2 at 9:20 A.M. with Unit Manager Registered Nurse (RN) #802 confirmed Resident #27's bilateral TED hose were not implemented as ordered; however, the TED hose were signed off on the MAR and TAR on 08/18/22 as completed.

Based on observation, record review, interview, and Pressure Ulcer Prevention and Care Protocol review the facility failed to ensure Resident #27's pressure ulcer wound care interventions were implemented as ordered. This finding affected one (Resident #27) of two residents reviewed for pressure ulcer wounds. The facility census was 74. Findings include: Review of Resident #27's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited severe cognitive impairment. Review of Resident #27's Weekly Pressure Ulcer Tracking and Assessment Form dated 08/15/22 revealed he had a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) wound measuring three centimeters length, 4.5 cm (centimeters) width and less than 0.1 cm depth with a small amount of drainage and the pressure ulcer wound was acquired 07/07/22. Review of Resident #27's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Care Plan dated 07/08/22 revealed he had a stage 2 pressure ulcer to the left heel related to decreased mobility, confusion, and dementia with an intervention dated 07/08/22 for a HEELMEDIX boot to the left foot at all times. Review of Resident #27's medication administration records (MAR) and treatment administration records (TAR) from 08/01/22 to 08/18/22 revealed the left HEELMEDIX boot was signed off as administered on 08/18/22. Observation on 08/18/22 at 9:05 A.M. with Licensed Practical Nurse (LPN) #801 revealed the left heel wound care treatment was completed and Resident #27 was sitting up in his room in a modified Broda (specialty chair) with a flat table across his lap. Resident #27 was in his room watching television at the time of the observation. The HEELMEDIX left heel pressure boot was not implemented at the time of the observation; however, the boot was signed off as completed on the MAR and TAR. Interview on 08/18/2 at 9:20 A.M. with Unit Manager Registered Nurse (RN) #802 confirmed Resident #27's HEELMEDIX boot was not implemented to the left heel as ordered; however, the treatment was signed off on the MAR and TAR on 08/18/22 as completed. Review of the Pressure Ulcer Prevention and Care Protocol, revised 06/22, revealed the plan of care protocol for protection against pressure, friction, and shear included to manage tissue load through pressure reducing/redistribution devices.

Based on medical record review, staff interview and review of the facility's abuse policy and procedure the facility failed ensure residents were free from resident to resident abuse. This affected 11 of 99 facility residents, Residents #59, #84, #78, #89, #70, #38, #66, #62 and three unidentified residents. Findings include: 1. Review of the medial record revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and wandering behaviors. Review of discontinued orders revealed Resident #19 had a discontinued order dated 06/12/19 for 15 minutes checks for one week, an order dated 06/13/19 for a urinalysis and culture and sensitivity (C&S), and an order discontinued on 11/09/18 for [MEDICATION NAME] (antipsychotic) five milligram (mg) at 4:00 P.M. and start 2 mg daily. Review of a physician's telephone order dated 01/13/19 revealed to hold Resident #19's [MEDICATION NAME] (mood stabilizer) until available, an ordered dated 02/17/19 to hold the [MEDICATION NAME] until it was available from the pharmacy. The Neudexta was discontinued on 02/21/19. Review of progress notes dated 04/10/19 at 10:36 P.M. revealed Resident #19 and Resident #84 were seen in south hallway slapping each other with open hands in the arms and shoulders. The residents were separated, and their safety maintained. Resident #19 stated she was slapped on the right cheek. She had no apparent injuries and denied pain. The Power of Attorney (POA) was unable to be reached because he did not have an answering machine set up. A message was left at an alternate contact. Review of a progress note dated 04/26/19 at 11:30 [NAME]M. revealed Resident #19 was observed by a staff member pushing another unidentified resident in their wheelchair, when the other resident asked Resident #19 to stop pushing her Resident #19 slapped the other resident on the right side of the face. The residents were separated, and their safety was maintained. Resident #19 was brought to the south nurse's station. Review of the progress note dated 06/13/19 at 11:50 [NAME]M. revealed Resident #19 walked up to Resident #78, who was sitting in a wheelchair. Resident #78 screamed and Resident #19 struck the seated resident on the left cheek with open hand. The residents were immediately separated without difficulty. Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting Resident #89 in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review of a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another unidentified resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another unidentified resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. Review of a progress note dated 07/16/19 at 11:21 [NAME]M. revealed Resident #19 had a new order for [MEDICATION NAME] (mood stabilizer) 125 milligrams three times a day. Review of physician orders [REDACTED]. Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on [MEDICATION NAME] 125 mg and we will check her level soon. [MEDICATION NAME] was to be continued. Review of a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over Resident #70 in main dining room, who was in a wheelchair. Resident #19 was slapping Resident #70 repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders [REDACTED]. Review of a progress note dated 07/25/19 at 10:49 [NAME]M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her [MEDICATION NAME] dosage to twice daily. The son does not give consent for psychiatric services. A message was left for the son to update him on the new orders. Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another unidentified resident and there were no injuries to either resident. Review of physician orders [REDACTED].>Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of Resident #38 ' s room with Resident #38. Resident #19 was punching Resident #38 repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's PO[NAME] Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up Resident #66 who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped Resident #62 on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for [MEDICATION NAME] 20/10 mg every day. Review of physician orders [REDACTED]. Review of the progress note dated 08/08/19 at 11:15 [NAME]M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements of any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute checks. An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Review on the facility policy, Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of [REDACTED]. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation. 2. Record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #12 had severe cognitive impairment and physically aggressive behaviors towards others. He required limited assistance by staff for bed mobility, transfers and extensive assistance by staff for dressing, toileting and hygiene. Review of the Progress Notes from 01/05/19 to 07/13/19 revealed Resident #12 had acted out aggressively toward his room mate on 01/05/19 by putting a blanket over his head; on 02/24/19 he made statements he was going to kill someone; on 03/07/19 he was looking to fight someone; 03/21/19 showed aggression toward others; and on 06/27/19 he was sent to a psychiatric hospital for punching Resident #59 in the face with a closed fist ejecting her glasses from her face causing abrasions, discoloration and facial pain. Resident #12 returned to the facility on [DATE] with an order to be on every 15 minute checks. On 07/12/19 he made verbal threats to hit another resident and on 07/13/19 he made statements he was going to kill others. Record review was conducted for Resident #59 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #59 had severe cognitive impairment and needed extensive assistance by staff for bed mobility, transfers and toileting and total staff assistance for hygiene. An interview on 08/22/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) #965 verified Resident #12 was on every 15 minute checks due to known physical aggression towards staff and other residents. LPN #965 indicated Resident #12 had a history of [REDACTED]. Review of a Progress Note dated 06/25/19 authored by LPN #967 at 10:10 [NAME]M. revealed Resident #59 was punched in the face by a closed fist of Resident #12 resulting in swelling and dark discoloration area measuring four centimeters (cm) by two cm and a one cm by one cm abrasion to the bridge of her nose where glasses were ejected from her face. Review of a Progress Note dated 06/25/19 at 5:31 P.M. authored by LPN #967 revealed Resident #59 was experiencing pain during manipulation of her head for an x-ray and was medicated with Tylenol. Review of a Progress Noted dated 06/25/19 at 10:32 P.M. authored by LPN #967 revealed Resident #39's x-rays of nasal and facial bones were negative for fractures. Review of the facility document titled Summary Report, dated 06/26/19, authored by LPN #806 revealed at 10:10 [NAME]M. it was noted Resident #12 was involved in a resident to resident altercation with a female resident (Resident #59) where he drew his arm back and struck Resident #59 in the face with a closed fist. Review of the document titled Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property.

Based on medical record review, staff interviews and facility policy review the facility failed to follow their abuse policy and procedure in relation to reporting incidents of resident to resident abuse to the State agency. This affected four (Residents #3 #12, #19, and #80) of six residents reviewed for resident to resident abuse. Findings include: 1. Review of the medial record revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and wandering behaviors. Review of discontinued orders revealed Resident #19 had a discontinued order dated 06/12/19 for 15 minutes checks for one week, an order dated 06/13/19 for a urinalysis and culture and sensitivity (C&S), and an order discontinued on 11/09/18 for [MEDICATION NAME] (antipsychotic) five milligram (mg) at 4:00 P.M. and start 2 mg daily. Review of a physician's telephone order dated 01/13/19 revealed to hold Resident #19's [MEDICATION NAME] (mood stabilizer) until available, an ordered dated 02/17/19 to hold the [MEDICATION NAME] until it was available from the pharmacy. The Neudexta was discontinued on 02/21/19. Review of progress notes dated 04/10/19 at 10:36 P.M. revealed Resident #19 and another resident were seen in south hallway slapping each other with open hands in the arms and shoulders. The residents were separated, and their safety maintained. Resident #19 stated she was slapped on the right cheek. She had no apparent injuries and denied pain. The Power of Attorney (POA) was unable to be reached because he did not have an answering machine set up. A message was left at an alternate contact. Review of a progress note dated 04/26/19 at 11:30 [NAME]M. revealed Resident #19 was observed by a staff member pushing another resident in their wheelchair, when the other resident asked Resident #19 to stop pushing her Resident #19 slapped the other resident on the right side of the face. The residents were separated, and their safety was maintained. Resident #19 was brought to the south nurse's station. Review of a progress note dated 04/26/19 at 5:05 P.M. revealed Resident #19 and another resident grabbed onto each other's hands squeezing aggressively facing each other. The residents were separated to maintained safety. Review of the progress note dated 06/13/19 at 11:50 [NAME]M. revealed Resident #19 walked up to another female resident, who was sitting in a wheelchair. The resident screamed and Resident #19 struck the seated resident on the left cheek with open hand. The residents were immediately separated without difficulty. Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting another resident in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review on a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. Review of a progress note dated 07/16/19 at 11:21 [NAME]M. revealed Resident #19 had a new order for [MEDICATION NAME] (mood stabilizer) 125 milligrams three times a day. Review of physician orders [REDACTED]. Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on [MEDICATION NAME] 125 mg and we will check her level soon. [MEDICATION NAME] was to be continue. Review on a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over another female resident in main dining room, who was in a wheelchair. Resident #19 was slapping the other female resident repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders [REDACTED]. Review of a progress note dated 07/25/19 at 10:49 [NAME]M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her [MEDICATION NAME] dosage to twice daily. The son does not give consent for psychiatric services. A message was left for the son to update him on the new orders. Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another resident and there were no injuries to either resident. Review of physician orders [REDACTED].>Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of another resident's room with another resident. Resident #19 was punching the other resident repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's PO[NAME] Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up to another female resident who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped another resident on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for [MEDICATION NAME] 20/10 mg every day. Review of physician orders [REDACTED]. Review of the progress note dated 08/08/19 at 11:15 [NAME]M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. An interview on 08/20/19 at 1:23 P.M. with the Administrator indicated she did not file any Self-Reported (SRI) incidents related Resident #19's physical abuse of other residents. An interview on 08/20/19 at 2:06 P.M. with Registered Nurse #810 indicated there were not any SRIs completed because the residents all had dementia and there were no injuries. An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements of any of the incidents and she did not believe any SRIs were completed on any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute checks. An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review on the facility policy, Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of [REDACTED]. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation. 2. Record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #12 had severe cognitive impairment and physically aggressive behaviors towards others. He required limited assistance by staff for bed mobility, transfers and extensive assistance by staff for dressing, toileting and hygiene. Review of the Progress Notes from 01/05/19 to 07/13/19 revealed Resident #12 had acted out aggressively toward his room mate on 01/05/19 by putting a blanket over his head; on 02/24/19 he made statements he was going to kill someone; on 03/07/19 he was looking to fight someone; 03/21/19 showed aggression toward others; and on 06/27/19 he was sent to a psychiatric hospital for punching Resident #59 in the face with a closed fist ejecting her glasses from her face causing abrasions, discoloration and facial pain. Resident #12 returned to the facility on [DATE] with an order to be on every 15 minute checks. On 07/12/19 he made verbal threats to hit another resident and on 07/13/19 he made statements he was going to kill others. Record review was conducted for Resident #59 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #59 had severe cognitive impairment and needed extensive assistance by staff for bed mobility, transfers and toileting and total staff assistance for hygiene. An interview on 08/22/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) #965 verified Resident #12 was on every 15 minute checks due to known physical aggression towards staff and other residents. LPN #965 indicated Resident #12 had a history of [REDACTED]. Review of a Progress Note dated 06/25/19 authored by LPN #967 at 10:10 [NAME]M. revealed Resident #59 was punched in the face by a closed fist of Resident #12 resulting in swelling and dark discoloration area measuring four centimeters (cm) by two cm and a one cm by one cm abrasion to the bridge of her nose where glasses were ejected from her face. Review of a Progress Note dated 06/25/19 at 5:31 P.M. authored by LPN #967 revealed Resident #59 was experiencing pain during manipulation of her head for an x-ray and was medicated with Tylenol. Review of a Progress Noted dated 06/25/19 at 10:32 P.M. authored by LPN #967 revealed Resident #39's x-rays of nasal and facial bones were negative for fractures. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review of the facility document titled Summary Report, dated 06/26/19, authored by LPN #806 revealed at 10:10 [NAME]M. it was noted Resident #12 was involved in a resident to resident altercation with a female resident (Resident #59) where he drew his arm back and struck Resident #59 in the face with a closed fist. Review of the document titled Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. 3. Record review revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with no behaviors, required extensive assist of two for activities of daily living and supervision only for ambulation. Review of the progress note of 03/19/19 revealed Resident #3 was found by staff on the hallway by the south unit shower room hitting another female resident (Resident #54) repeatedly in the head. When staff tried to intervene, the other resident hit Resident #3 in the face. Staff separated the residents. Neither resident sustained [REDACTED]. Review of the progress note dated 04/26/19 revealed Resident #3 was in the south hallway with her arms around another resident squeezing the other resident's hand aggressively and yelling. There was no injury to the other resident. Review of the progress note dated 04/30/19 revealed Resident #3 was found yelling in the south hallway and being verbally and physically aggressive with staff and another resident (Resident #78). Resident #3 scratched the other resident. Review of the care plan dated 08/12/19 revealed care areas for behaviors, wandering, and communication problem due to cognitive loss. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review of the document titled Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of [REDACTED]. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission of a SRI was silent to any evidence of the alleged abuse related to Resident #3 and the three identified events of physical altercations and resident to resident abuse. 4. Record review revealed Resident #80 was admitted to the facility on ,[DATE]/. The primary [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] had a brief interview for mental status score of 02 of a possible 15 and indicating severe cognitive impairment. Review of the medical record for Resident #80 revealed a nursing note dated 06/25/19 stating Resident #80 had grabbed another resident by the back of the shirt and pulled the resident to the ground. The staff separated the residents for safety reasons. No injuries were sustained by either resident and psychology consults were placed with medication adjustments made and urine samples obtained to rule out a urinary tract infection. Review of a nursing note dated 07/26/19 revealed Resident #80 was involved in an altercation with another resident while seated at the dining room table, both residents were slapping at each other. No injuries were sustained by either resident and the physician was notified. Review of the document titled Resident Abuse Prevention Practices, last revised 10/2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of [REDACTED]. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission was silent to evidence the facility had completed the SRI on-line submission for the two identified incidents of physical altercations involving Resident #80 and evidenced non-compliance with the policy of reporting all allegations of alleged, suspected or observed mistreatment of [REDACTED]. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status.

Based on medical record review, staff interviews and review of the facility's abuse policy the facility failed to report incidents of resident to resident abuse to the State agency. This affected four (Residents #3, #12, #19, and #80) of six residents reviewed for resident to resident abuse. Findings include: 1. Review of the medial record revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and wandering behaviors. Review of discontinued orders revealed Resident #19 had a discontinued order dated 06/12/19 for 15 minutes checks for one week, an order dated 06/13/19 for a urinalysis and culture and sensitivity (C&S), and an order discontinued on 11/09/18 for [MEDICATION NAME] (antipsychotic) five milligram (mg) at 4:00 P.M. and start 2 mg daily. Review of a physician's telephone order dated 01/13/19 revealed to hold Resident #19's [MEDICATION NAME] (mood stabilizer) until available, an ordered dated 02/17/19 to hold the [MEDICATION NAME] until it was available from the pharmacy. The Neudexta was discontinued on 02/21/19. Review of progress notes dated 04/10/19 at 10:36 P.M. revealed Resident #19 and another resident were seen in south hallway slapping each other with open hands in the arms and shoulders. The residents were separated, and their safety maintained. Resident #19 stated she was slapped on the right cheek. She had no apparent injuries and denied pain. The Power of Attorney (POA) was unable to be reached because he did not have an answering machine set up. A message was left at an alternate contact. Review of a progress note dated 04/26/19 at 11:30 [NAME]M. revealed Resident #19 was observed by a staff member pushing another resident in their wheelchair, when the other resident asked Resident #19 to stop pushing her Resident #19 slapped the other resident on the right side of the face. The residents were separated, and their safety was maintained. Resident #19 was brought to the south nurse's station. Review of a progress note dated 04/26/19 at 5:05 P.M. revealed Resident #19 and another resident grabbed onto each other's hands squeezing aggressively facing each other. The residents were separated to maintained safety. Review of the progress note dated 06/13/19 at 11:50 [NAME]M. revealed Resident #19 walked up to another female resident, who was sitting in a wheelchair. The resident screamed and Resident #19 struck the seated resident on the left cheek with open hand. The residents were immediately separated without difficulty. Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting another resident in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review on a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. Review of a progress note dated 07/16/19 at 11:21 [NAME]M. revealed Resident #19 had a new order for [MEDICATION NAME] (mood stabilizer) 125 milligrams three times a day. Review of physician orders [REDACTED]. Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on [MEDICATION NAME] 125 mg and we will check her level soon. [MEDICATION NAME] was to be continue. Review on a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over another female resident in main dining room, who was in a wheelchair. Resident #19 was slapping the other female resident repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders [REDACTED]. Review of a progress note dated 07/25/19 at 10:49 [NAME]M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her [MEDICATION NAME] dosage to twice daily. The son does not give consent for psychiatric services. A message was left for the son to update him on the new orders. Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another resident and there were no injuries to either resident. Review of physician orders [REDACTED].>Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of another resident's room with another resident. Resident #19 was punching the other resident repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's PO[NAME] Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up to another female resident who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped another resident on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for [MEDICATION NAME] 20/10 mg every day. Review of physician orders [REDACTED]. Review of the progress note dated 08/08/19 at 11:15 [NAME]M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. An interview on 08/20/19 at 1:23 P.M. with the Administrator indicated she did not file any Self-Reported (SRI) incidents related Resident #19's physical abuse of other residents. An interview on 08/20/19 at 2:06 P.M. with Registered Nurse #810 indicated there were not any SRIs completed because the residents all had dementia and there were no injuries. An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements for any of the incidents and she did not believe any SRIs were completed on any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute checks. An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Review on the facility policy, Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of [REDACTED]. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation. 2. Record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #12 had severe cognitive impairment and physically aggressive behaviors towards others. He required limited assistance by staff for bed mobility, transfers and extensive assistance by staff for dressing, toileting and hygiene. Review of the Progress Notes from 01/05/19 to 07/13/19 revealed Resident #12 had acted out aggressively toward his room mate on 01/05/19 by putting a blanket over his head; on 02/24/19 he made statements he was going to kill someone; on 03/07/19 he was looking to fight someone; 03/21/19 showed aggression toward others; and on 06/27/19 he was sent to a psychiatric hospital for punching Resident #59 in the face with a closed fist ejecting her glasses from her face causing abrasions, discoloration and facial pain. Resident #12 returned to the facility on [DATE] with an order to be on every 15 minute checks. On 07/12/19 he made verbal threats to hit another resident and on 07/13/19 he made statements he was going to kill others. Record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #59 had severe cognitive impairment and needed extensive assistance by staff for bed mobility, transfers and toileting and total staff assistance for hygiene. An interview on 08/22/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) #965 verified Resident #12 was on every 15 minute checks due to known physical aggression towards staff and other residents. LPN #965 indicated Resident #12 had a history of [REDACTED]. Review of a Progress Note dated 06/25/19 authored by LPN #967 at 10:10 [NAME]M. revealed Resident #59 was punched in the face by a closed fist of Resident #12 resulting in swelling and dark discoloration area measuring four centimeters (cm) by two cm and a one cm by one cm abrasion to the bridge of her nose where glasses were ejected from her face. Review of a Progress Note dated 06/25/19 at 5:31 P.M. authored by LPN #967 revealed Resident #59 was experiencing pain during manipulation of her head for an x-ray and was medicated with Tylenol. Review of a Progress Noted dated 06/25/19 at 10:32 P.M. authored by LPN #967 revealed Resident #39's x-rays of nasal and facial bones were negative for fractures. An interview on 08/22/19 at 1:24 P.M. with Registered Nurse (RN) #810 revealed the facility had not considered physical attacks as reportable incidents due to the nature of dementia and the facility did not consider it willful physical aggression. RN #810 verified Resident #59 had been punched in the face by Resident #12 and did sustain injuries requiring head x-rays and pain medication. Review of the facility document titled Summary Report, dated 06/26/19, authored by LPN #806 revealed at 10:10 [NAME]M. it was noted Resident #12 was involved in a resident to resident altercation with a female resident (Resident #59) where he drew his arm back and struck Resident #59 in the face with a closed fist. Review of the document titled Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. 3. Record review revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with no behaviors, required extensive assist of two for activities of daily living and supervision only for ambulation. Review of the progress note of 03/19/19 revealed Resident #3 was found by staff on the hallway by the south unit shower room hitting another female resident (Resident #54) repeatedly in the head. When staff tried to intervene, the other resident hit Resident #3 in the face. Staff separated the residents. Neither resident sustained [REDACTED]. Review of the progress note dated 04/26/19 revealed Resident #3 was in the south hallway with her arms around another resident squeezing the other resident's hand aggressively and yelling. There was no injury to the other resident. Review of the progress note dated 04/30/19 revealed Resident #3 was found yelling in the south hallway and being verbally and physically aggressive with staff and another resident (Resident #78). Resident #3 scratched the other resident. Review of the care plan dated 08/12/19 revealed care areas for behaviors, wandering, and communication problem due to cognitive loss. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review of the document titled Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of [REDACTED]. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission of a SRI was silent to any evidence of the alleged abuse related to Resident #3 and the three identified events of physical altercations and resident to resident abuse. 4. Record review revealed Resident #80 was admitted to the facility on ,[DATE]/. The primary [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] had a brief interview for mental status score of 02 of a possible 15 and indicating severe cognitive impairment. Review of the medical record for Resident #80 revealed a nursing note dated 06/25/19 stating Resident #80 had grabbed another resident by the back of the shirt and pulled the resident to the ground. The staff separated the residents for safety reasons. No injuries were sustained by either resident and psychology consults were placed with medication adjustments made and urine samples obtained to rule out a urinary tract infection. Review of a nursing note dated 07/26/19 revealed Resident #80 was involved in an altercation with another resident while seated at the dining room table, both residents were slapping at each other. No injuries were sustained by either resident and the physician was notified. Review of the document titled Resident Abuse Prevention Practices, last revised 10/2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of [REDACTED]. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission was silent to evidence the facility had completed the SRI on-line submission for the two identified incidents of physical altercations involving Resident #80 and evidenced non-compliance with the policy of reporting all allegations of alleged, suspected or observed mistreatment of [REDACTED]. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status.

Based on medical record review, staff interview and review of the facility's abuse policy the facility failed to thoroughly investigate resident to resident abuse. This affected one (Resident #19) of six residents reviewed for resident to resident abuse. Findings included: 1. Review of the medial record revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and wandering behaviors. Review of discontinued orders revealed Resident #19 had a discontinued order dated 06/12/19 for 15 minutes checks for one week, an order dated 06/13/19 for a urinalysis and culture and sensitivity (C&S), and an order discontinued on 11/09/18 for [MEDICATION NAME] (antipsychotic) five milligram (mg) at 4:00 P.M. and start 2 mg daily. Review of a physician's telephone order dated 01/13/19 revealed to hold Resident #19's [MEDICATION NAME] (mood stabilizer) until available, an ordered dated 02/17/19 to hold the [MEDICATION NAME] until it was available from the pharmacy. The Neudexta was discontinued on 02/21/19. Review of progress notes dated 04/10/19 at 10:36 P.M. revealed Resident #19 and another resident were seen in south hallway slapping each other with open hands in the arms and shoulders. The residents were separated, and their safety maintained. Resident #19 stated she was slapped on the right cheek. She had no apparent injuries and denied pain. The Power of Attorney (POA) was unable to be reached because he did not have an answering machine set up. A message was left at an alternate contact. Review of a progress note dated 04/26/19 at 11:30 [NAME]M. revealed Resident #19 was observed by a staff member pushing another resident in their wheelchair, when the other resident asked Resident #19 to stop pushing her Resident #19 slapped the other resident on the right side of the face. The residents were separated, and their safety was maintained. Resident #19 was brought to the south nurse's station. Review of a progress note dated 04/26/19 at 5:05 P.M. revealed Resident #19 and another resident grabbed onto each other's hands squeezing aggressively facing each other. The residents were separated to maintained safety. Review of the progress note dated 06/13/19 at 11:50 [NAME]M. revealed Resident #19 walked up to another female resident, who was sitting in a wheelchair. The resident screamed and Resident #19 struck the seated resident on the left cheek with open hand. The residents were immediately separated without difficulty. Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting another resident in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review on a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. Review of a progress note dated 07/16/19 at 11:21 [NAME]M. revealed Resident #19 had a new order for [MEDICATION NAME] (mood stabilizer) 125 milligrams three times a day. Review of physician orders [REDACTED]. Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on [MEDICATION NAME] 125 mg and we will check her level soon. [MEDICATION NAME] was to be continue. Review on a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over another female resident in main dining room, who was in a wheelchair. Resident #19 was slapping the other female resident repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders [REDACTED]. Review of a progress note dated 07/25/19 at 10:49 [NAME]M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her [MEDICATION NAME] dosage to twice daily. The son does not give consent for psychiatric services. A message was left for the son to update him on the new orders. Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another resident and there were no injuries to either resident. Review of physician orders [REDACTED].>Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of another resident's room with another resident. Resident #19 was punching the other resident repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's PO[NAME] Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up to another female resident who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped another resident on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for [MEDICATION NAME] 20/10 mg every day. Review of physician orders [REDACTED]. Review of the progress note dated 08/08/19 at 11:15 [NAME]M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements of any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute checks. An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Review on the facility policy, Resident Abuse Prevention Practices, dated (MONTH) (YEAR) revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of [REDACTED]. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation.

Based on observation, interview and record review, the facility failed to ensure adequate infection control measures during catheter care for Resident #13. This affected one of nine residents observed for infection control. Findings include: An observation of catheter care was completed on 06/27/18 at 1:46 P.M. State tested Nurse Aide (STNA) #101 and Certified Nurse Aide (CNA) #102. STNA #101 and CNA #102 washed their hands and applied gloves. STNA #101 prepared a basin of water and gathered the bedside supplies for care. Resident #13 was sitting in a specialized wheelchair next to the bed. CNA #102 removed the residents shoe's, seatbelt and footrests. STNA #101 and CNA #102 assisted Resident #13 to stand and transferred her to her bed. Wearing the same gloves, STNA #101 placed a paper towel on the floor and placed a graduated container on the towel. STNA #101 unclamped the catheter tubing and drained the urine into the container. STNA #101 cleansed the catheter tip at the clamp area with an alcohol swab and and re-clamped the catheter. STNA #101 measured and discarded the urine into the toilet. STNA #101 rinsed the container. Wearing the same gloves, STNA #101 returned to the bedside. Simultaneously, CNA #102 elevated the bed. CNA #102 removed the catheter bag from the side of the bed and held the bag and tubing in order to provide slack on the tubing. STNA #101 positioned Resident #13 onto her left side. STNA #101 removed the resident's incontinence brief, cleansed the resident's perineal area, labia, groin and buttocks. STNA #101 used a separate wash cloth and towel for each area. However, STNA #101 initially discarded the wash cloths onto the residents bottom bed sheet. During the same process, STNA #101 moved the soiled wash cloths and towels to the unprotected surface of the resident's vinyl bedside chair. Wearing the same gloves, STNA #101 applied a clean incontinence brief. STNA #101 asked CNA #102 to get disposable bags. CNA #102 handed STNA #101 the catheter tubing and catheter bag. CNA #102 removed and discarded her gloves. CNA #102 exited the room. CNA #102 did not wash her hands after discarding the gloves or before exiting the room. CNA #102 returned to the room. Without washing her hands, CNA #102 applied clean gloves, placed the soiled linens in the disposable bag, removed the gloves and exited the room with the linens. Again CNA #102 did not wash her hands after removing her gloves or before exiting the room. STNA #101 remained in the room. STNA #101 continued to wear the gloves used during incontinence care. STNA #101 applied a wedge cushion to the resident's bed, adjusted the height of the bed and adjusted the resident's call light. Neither STNA #101 or CNA #102 cleaned the bedside vinyl chair after removing the soiled linens. STNA #101 and CNA #102 removed and discarded their gloves and washed their hands. An interview was completed with STNA #101 and CNA #102 immediately following the observation. STNA #101 and CNA #102 verified the observation. Review of the Handwashing/Hygiene Policy revised 06/2016 revealed: All personnel shall follow our established handwashing/hygiene procedures to prevent the spread of infection and disease to other residents, personnel and visitors. Review of the Catheter Care, Indwelling Urinary policy revised 06/2016 revealed: If resident's bed needs to be placed in the lowest position for safety, remove gloves and lower bed. Then wash hands before touching the resident or other objects in the room. Review of the Perineal Care policy and procedure revised 06/2016 revealed: If resident requires additional assistance or asks for an item during perineal care, remove gloves and wash hands before assisting the resident. Put on new gloves before returning to perineal care. If resident's bed needs to be placed in the lowest position for safety, remove gloves, lower the bed then wash hands before touching the resident or other objects in the room.

Based on observation, staff interview, review of infection tracking records, policy review and manufacturer labeling and product information, the facility failed to ensure the use of effective appropriate laundry chemicals and room cleaning products to prevent the spread of infectious diseases and failed to ensure comprehensive tracking and analysis of infections. This had the potential to affect all 94 resident's in the facility. Findings include: 1. Review of the Monthly Infection Control Report revealed infections were tracked by nosocomial or community acquired and broken down into four units. Symptomatic urinary tract infections, upper respiratory, lower respiratory, gastrointestinal tract infection, skin infection, eye infection, systemic infection and other were the tracking categories. The report was a tally of the infections. Review of the log revealed no community acquired infections recorded since the last annual survey November 2014. Review revealed no evidence the facility had any cases of isolation since the last annual completed in November of 2014. The infection control report revealed no evidence of the tracking of organisms, cultures, room numbers, treatment, onset date or if any of the infections required isolation. The January 2016 report indicated six urinary tract infections on West three and four, considered one unit. The trending did not indicate what the organism or rooms were to determine if there was a trend and if education was necessary. Review of the infection control log and process with Licensed Practical Nurse (LPN) #1 on 02/04/16 at 10:42 A.M. revealed she looks for telephone orders related to infections. LPN #1 indicated she continues to monitor and she makes a copy of the changes and compare it to what the lab and pharmacy sends her. For analysis LPN #1 indicated she does it in her head. On 02/04/16 at 10:54 A.M. LPN #1 revealed the log was inaccurate related to nosocomial or community acquired infections. LPN #1 indicated that they had a resident admitted with clostridium difficile in January that was not tracked under community acquired or tracked as an infectious organism requiring isolation. LPN #1 verified there was no evidence in the tracking of infections requiring the use of isolation and verified the facility currently had a resident in isolation with Methicillin Resistant Staph Aureus. The report also did not capture a resident who had staph aureus of a wound in [DATE]. 2. Observation of the laundry process took place at 2:36 P.M. on 02/04/16 with Laundry #2. Chemicals utilized for washing clothes using the isolation cycle revealed a detergent, sour and fabric softener were used for all isolation linen. Products utilized included Ecolab AdvaCare 120 sanitizer/sour 1.7 parts, Ecolab Tristar So Fresh softener 1.5 parts and Tri Star Solar Brite detergent 4.5 parts. There was no information on the labeling that the products were effective on clostridium difficile (c diff) spores and [MEDICATION NAME] Resistant [MEDICATION NAME]. Laundry #2 indicated bleach was not used in the laundry process for isolation. Laundry #2 revealed there facility did not have written policies related to doing the laundry. On 02/03/15 at 2:47 P.M. observation of the hot water tank for the laundry revealed a temperature reading of 150 degrees Fahrenheit. Interview of Maintenance #3 revealed that the hot water entering the laundry was not maintained at 165 degrees Fahrenheit as recommended by Center of Disease Control so they implemented adding more sour to the laundry to increase the sanitation level. On 02/03/2016 at 4:58 P.M. Corporate Director #4 indicated when they switched to the Ecolab they were told AdvaCare 120 Disinfect would kill organisms used for isolation. Corporate Director #4 provided a letter dated 04/05/11 indicating the product met Environmental Protection Agency requirements for laundry disinfection. The list of organisms provided to the facility did not include that AdvaCare 120 Disinfectant was effective against [MEDICATION NAME] Resistant [MEDICATION NAME] or clostridium difficile (c diff) spores. 3. On 02/03/2016 at 11:42 Laundry #2 indicated the isolation rooms are cleaned at the end of the day. Four people clean the room. One cleans, one gets the trash, one will mop and one picked up the laundry. On 02/04/16 at 1:28 P.M. observation of the cleaning of an isolation room housing a resident with MRSA of a wound took place with Housekeeping #5. Housekeeping #5 put on shoe covers, a gown, gloves and mask before entering the room. An isolation cart was outside of the room and there was a wood swinging gate attached to the door frame to push through to enter the room. Housekeeping #5 used a spray bottle of Clorox bleach spray germicidal to clean surfaces. Housekeeping #5 sprayed the surface of the counter and wiped it off, overbed table and wiped it off and bedside table and wiped it off before going to the bathroom. In the bathroom Housekeeping #5 refilled the glove box and changed the trash bag. Housekeeping #5 was asked what organism the resident was in isolation for and she did not know. Housekeeping #5 was asked if she was aware that there were minimum surface contact times for the [MEDICATION NAME] product to killed different organisms. Housekeeping #5 revealed she did not know there was a required contact time to kill bacteria or spores. Housekeeping #5 then sprayed the sink, mirror and toilet after she was made aware of the one minute contact time for MRSA. After waiting the minute she cleansed them along with wiping the glove holder and paper towel holder. Housekeeping #5 then went back into the room and sprayed the Clorox product on her rag and wiped the head and footboard of the bed and a mattress on the floor. There was no observed one minute contact time for the Clorox product on the bed and mattress. Housekeeping #5 then re-cleaned the counter, bedside table and night stand and cleaned her wheelchair using a contact time of one minute. Housekeeping #5 removed her personal protective equipment and touched the lid of the barrel trash can with her bare hand to open it and dispose of the trash. Housekeeping #5 then touched the swinging wooden gate with her right hand that she had used to open the lid of the trash isolation barrel. Laundry #2 indicated Housekeeping #5 was going to use the hand sanitizer in the top drawer of the isolation cart. The Surveyor informed Laundry #2 that Housekeeping #5 touched the wooden gate exiting the room with her right hand potentially contaminating the gate stretching across the with of the door entrance. Laundry #2 further identified that if she touched the handle of the isolation cart with that hand it would also contaminate the handle. Housekeeping #5 indicated she opens the drawer of the isolation cart to obtain the hand sanitizer when she leaves the room instead of hand washing. Verification was made at the time of the observation with Housekeeping #5 and Laundry #2 that Housekeeping #5 was unaware of the contact time needed to kill the bacteria MRSA that the resident was in isolation with. Further verification that the contact time was not achieved. Verification was made that Housekeeping #5 potentially contaminated her hand touching the trash lid with her bare hand and then potentially contaminated the wood swinging door and would have contaminated the drawer handle of the isolation cart to obtain the hand sanitizer if it was not brought to her attention by the surveyor. 4. Observation of Housekeeping #6 at 2:00 P.M. on 02/03/16 revealed he applied personal protective equipment except for a mask because he indicated the mask was personal discretion if the organism was not airborne. Housekeeping #6 revealed that he was the floorman. One person cleans the surfaces and another the floors. Housekeeping #6 indicated that the facility utilized a hand held wet dry pad device with the cleansing detergent loaded in the handle and squirt the floor by pushing the button on the handle. Housekeeping #6 placed a dry pad on the flat surface of the hand held device and dry dusted the floor surface. Housekeeping #6 then removed the pad and threw it in the trash with his right hand. Housekeeping #6 then reached across the wooden gate without changing his gloves and moved the handle of a supply bucket on the housekeeping cart with the same gloved right hand and placed his hand in a bag and pulled out a new dry pad. Housekeeping #6 attached the dry pad to the hand held device then sprayed the floor as he pushed the padded device across the floor. Laundry #2 was 02/04/16 at 2:07 P.M. was asked what cleaning product was being used on the floor. Laundry #2 indicated Stride Neutral Cleaner was used on the floor. Review of the Diversey Stride Citrus Neutral Cleaner manufacturer product information revealed it was a non alkaline formulation for daily use. The label and manufacturer instructions revealed no evidence the product was effective against infectious organisms including the MRSA in which the resident was in isolation. Laundry #2 verified the Stride product did not kill the MRSA that the resident isolated in the room was in isolation with. Laundry #2 then had Housekeeping #5 use Diversey Virex II 256 one step disinfectant cleaner and deodorizer on the floor which was labeled to be effective for MRSA. The label did not include that it was effective against[DIAGNOSES REDACTED]. Manufacturer instructions indicated the entire surface was to remain wet for 10 minutes for the product to be effective. Housekeeping #5 used the hand held spray device to spray and clean the floor with the hand held push pad. Observation revealed the floor dried within one minute and 22 seconds and did not remain wet for 10 minutes. Laundry #2 verified at the time of the observation that the product the facility used on the floors in isolation rooms did not kill MRSA,[DIAGNOSES REDACTED] or VRE. Review of the facility 03/11 facility policy Room Cleaning-Occupied Isolation revealed a double mopping outfit and wringer with one bucket germicidal detergent and one bucket germicidal rinse solution was to be utilized for room cleaning the floors. A small pail of germicidal solution was to be utilized for surface cleaning. On 02/03/16 at 3:29 P.M. Corporate Nurse #8 and at 4:58 P.M. Corporate Director #4 verified the 03/11 facility policy Room Cleaning-Occupied Isolation was not followed. 5. Observation of the process for removing the dirty linen from an isolation room took place with Laundry Employee #7 on 02/03/16 at 2:12 P.M. Laundry #7 applied gloves and a gown and entered the isolation room. After retrieving the dirty linen from the linen barrel she removed her protective equipment and touched the lid of the barrel trash can with her bare right hand to open it and dispose of the trash. Laundry #7 then touched the swinging wooden gate with her right hand that she had used to open the lid of the trash isolation barrel. Laundry #5 indicated she was going to use the hand sanitizer in the top drawer of the isolation cart. The Surveyor informed Laundry #7 she touched the wooden gate exiting the room with her right hand potentially contaminating the gate stretching across the with of the door entrance and if she touched the handle of the isolation cart that it also would be potentially contaminated. Verification occurred at the time of the observation with Laundry #7 that she touched the lid of the isolation trash barrel with her bare hand potentially contaminating it and then touched the wooden swing gate to the room and would have touched the drawer handle of the isolation cart with unwashed hands.

Based on record review and staff interview the facility failed to hold quarterly quality assurance meetings. This had the potential to affect all 94 residents. Findings include: During the entrance conference held on 02/01/16, a request was made of the director of nursing (DON) for sign in sheets for any quality assurance (QA) meetings held over the previous year. One sign in sheet dated 11/04/15 was provided, indicating it was the QA meeting for information compiled from July, August, and September . Attendee signatures included the QA nurse, clinical coordinator, two lab representatives, a pharmacist, and a physician. On 02/04/16 at 1:40 P.M., licensed practical nurse (LPN) #1 (identified as the QA nurse) was interviewed and verified she could find no other sign in sheets for quarterly QA meetings. However, she had topic information for QA meetings held in January and July. LPN #1 verified she was unable to find any documentation regarding any additional quarterly QA meetings. LPN #1 stated the administrator, DON, herself, the clinical coordinator, laboratory and pharmacy representatives, and the medical director usually attended quarterly QA meetings. The meetings were scheduled at the convenience of the medical director. The DON, present during the above interview, stated she may have been on vacation during the QA meeting held in November but the clinical coordinator took her place when she was on vacation. The DON indicated although the November QA sign in sheet did not reflect three staff members attended, all department heads provided participation in QA activities by attending morning meetings on Mondays through Fridays, helping to identify concerns, giving input, and following up on concerns identified.

Based on record review and interview the facility failed to provide a forty-eight (48) hour notice prior to discontinuation of therapy services for Resident #76. This affected one resident (Resident #76) of three residents reviewed for liability notices. Findings include: Review of the Notice of Medicare Non-Coverage form completed for Resident #76 revealed the end effective date of the resident's current physical therapy (PT), occupational therapy (OT) and speech therapy (ST) was noted as 10/08/14. Registered nurse (RN) #4 documented the authorized representative was notified by telephone on 10/10/14. The form was signed by the resident's representative on 10/15/14. On 10/29/14 at 2:30 P.M., an interview with the business manager was conducted related to the process of issuance of the Medicare Non-Coverage letters/liability notices. She stated the therapist notifies her or the assessment nurse, RN #4 three to five days prior to the discontinuation of therapy services. She stated RN #4 processed the Notice of Medicare Non-Coverage letter for Resident #76. On 10/29/14 at 2:45 P.M. interview with RN #4 revealed she was not sure why she did not receive the information regarding Resident #76 until 10/10/14. The RN revealed the notice of non coverage was provided to the resident's representative on 10/10/14 and indicated she was aware the resident's family was not sure about Hospice services at that time. Record review of an interdisciplinary team note revealed the director of nursing (DON) noted on 10/03/14 that she had spoken to the resident's responsible party regarding Hospice. On 10/03/14 a physician's orders [REDACTED]. There was no further documentation related to Hospice services until 10/10/14. On 10/10/14 , licensed social worker (LSW) #102, noted she contacted the responsible party to ask if they wanted to continue with the Hospice consult and possible admission to Hospice. The LSW noted that all therapies were discontinued on 10/08/14. She also noted the responsible party did not want Hospice services at that time. RN #4 verified during the above interview the facility did not notify the responsible party forty-eight hours prior to the discontinuation of all therapies via a Non Coverage Notice. Review of the 12/2010, policy regarding issuance of the Notice of Medicare Non-Coverage noted the process to begin the notification process was three to five days prior to the termination of services. The time frame would give ample time to get the notice signed in person or reach the Beneficiary/Authorized Representative prior to the "2 days in the advance deadline".

Based on observation, record review and interview the facility failed to ensure a gradual dose reduction was attempted for an anti-psychotic medication for Resident #10. The medication was noted to be increased March 2014, however there was no documentation of continued behavioral issues from July 2014 through October 2014. This affected one resident (Resident #10) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #10 had [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed a care plan was initiated 05/04/12 that reflected the resident had [DIAGNOSES REDACTED]. Record review revealed the [MEDICATION NAME] was increased to 0.5 milligrams (mg) twice a day on 03/19/14. The care plan goals indicated a reduction trial would be done in six months or sooner to be free of side effects. The psychiatry progress notes dated 04/11/14 revealed the psychiatrist had a nice conversation with the resident. The resident was polite with poor memory. The resident was calm, polite and appropriate. There was no overt [MEDICAL CONDITION]. The psychiatrist indicated the resident would be followed by psychiatry and if there were any behavioral issues that came up, medications would be adjusted accordingly. There was no further documentation that indicated psychiatry monitored the resident. The social service progress notes dated 08/22/14 indicated the resident was taking [MEDICATION NAME] for behavior disturbances. The resident's family was noted to be supportive. The social service notes revealed social service was to monitor mood, behavior and psychosocial well being. The behavior grids for Resident #10 revealed the resident had a few behaviors from July 2014 through October 2014. The physician orders [REDACTED]. Record review revealed a physician's communication form, dated 10/02/14 that recommended an attempt to gradually reduce the dose of the [MEDICATION NAME]. The response by the nurse practitioner was "no" due to the increase behavior. Review of the social service notes, dated 10/28/14 revealed the resident had cognitive impairment and attended activities. The resident was observed throughout the survey at various time, including on 10/28/14 at 3:30 P.M. and 5:45 P.M., on 10/29/14 at 11:25 P.M. and 4:15 P.M. and on 10/30/14 at 8:45 A.M. with no observed behaviors. On 10/29/14 at 6:30 P.M. interview with the director of nursing (DON) and corporate registered nurse (RN) #138 revealed the increased [MEDICATION NAME] in March 2014 was effective in decreasing the resident's psychotic behaviors. They verified there was no gradual dose reduction attempted since the [MEDICATION NAME] was increased in March 2014. They verified the behavior grids for July 2014, August 2014, September 2014 and October 2014 had only a few behaviors documented each month. An interview with corporate RN #138 on 10/30/14 at 8:30 A.M. verified the goal on the care plan indicated a reduction trial would be done in six months or sooner to be free of side effects. She also verified there was no documentation that indicated the psychiatrist saw the resident after 04/11/14. An interview on 10/30/14 at 10:15 A.M. with licensed practical nurse (LPN) #32 revealed the resident's behaviors had improved. She stated the only behavioral issues the resident had were occasionally resisting care, but one to one conversation was usually effective. She stated the resident ambulated independently with the use of a walker.

Based on record review and interview the facility failed to ensure therapy services were provided to Resident #76 as per physician order [REDACTED]. This affected one resident (Resident #76) of four resident's reviewed for rehabilitation services. Findings include: Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hosptalized on [DATE] with pneumonia and re-admitted to the facility on [DATE]. On 09/21/14 the resident was hospitalized with recurrent right pleural effusion. The resident was re-admitted to the facility on [DATE]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive to total assistance from staff to complete all daily needs. Review of physician's orders [REDACTED]. On 10/06/14 speech therapy (ST) was ordered at five times per week for four weeks for dysphagia therapy. On 10/06/14 the ST noted the resident's diet was changed to pureed. On 10/08/14 a physician's orders [REDACTED]. On 10/10/14 physician's orders [REDACTED]. Record review of the physical therapy progress report revealed the resident was treated through 10/08/14. The final progress note revealed the plan was to discontinue the resident's therapy services due to Hospice. The PT notes revealed the resident had not reached the therapy goals due to progressive weakness. Record review of the occupational therapy progress report revealed the resident was treated through 10/08/14. The OT note revealed the resident was to be admitted to Hospice services and skilled OT was discontinued. On 10/29/14 at 2:45 P.M., review of the Notice of Medicare Non-Coverage letter for Resident #76 with registered nurse (RN) #4, who issued the letter revealed the notice stated the effective date to end the resident's current physical therapy (PT), occupational therapy (OT) and speech therapy (ST) was noted as 10/08/14. RN #4 documented the authorized representative was notified by telephone on 10/10/14. The form was signed by the representative on 10/15/14. RN #4 stated she was not sure why she did not receive the information until 10/10/14 to send the Non-Coverage notice. She stated she was aware the resident's family was not sure about Hospice services. Record review of an interdisciplinary team note revealed the director of nursing (DON) noted on 10/3/14 that she had spoken to the resident's responsible party regarding hospice. On 01/3/14 a physician's orders [REDACTED]. There was no further documentation related to Hospice services until 10/10/14. On 10/10/14, licensed social worker, (LSW) #102, noted she contacted the responsible party to ask if the responsible party wanted to continue with the Hospice consult and possible admission to Hospice. The LSW noted that all therapies were discontinued on 10/08/14. She also noted that the responsible party did not want Hospice services. On 10/29/14 at 5:36 P.M., interview with the unit manager, registered nurse (RN) #1 revealed there was no documentation between 10/03/14 and 10/10/14 regarding Hospice services for Resident #76. She stated the resident was not receiving Hospice services. She stated she would contact the Hospice and request additional information. On 10/30/14 at 10:05 A.M., interview with the director of nursing (DON) and review of the notes Hospice had provided regarding the resident's referral revealed Hospice noted they had received the referral on 10/03/14 and attempted to contact the responsible party on 10/04/14 without success. On 10/06/14 Hospice received a call from the responsible party and she agreed to meet on 10/07/14 with Hospice to discuss the program. On 10/07/14 the referral visit was made and on 10/08/14 the Hospice notes revealed the resident's terminal [DIAGNOSES REDACTED]. They noted they called the responsible party and she wanted to continue with the therapies. On 10/10/14, the Hospice noted they received a call from the responsible party who stated she wanted the resident to receive all the therapy she could before beginning Hospice care. The DON stated she was not sure why there was no documentation regarding what had occurred between 10/03/14 and 10/10/14 contained in the resident's medical record. On 10/30/14 at 10:42 A.M. interview with the therapy director, physical therapy assistant (PTA) #139 revealed the interdisciplinary team met as a team and usually within three to five days of discharge from therapy was planned to begin the notification process. She stated she would notify the business manager of an upcoming discharge from therapy and the business manager then would send out the letter to the resident and/or responsible party. She stated the medical condition of Resident #76 fluctuated and that continuing therapy would possibly interfere with her wound healing and weight loss. She stated the Hospice nurse had been in the facility, but was not sure when, and was not notified the resident had entered the Hospice program. She stated she thought it was on 10/08/14. She verified both the PT and OT discharge notes stated the therapy services were discontinued due to Hospice services, which did not occur. She was not aware the responsible party had indicated on 10/08/14 that she wanted the therapy to continue. She verified the resident had approval for therapy services through 10/24/14.

Based on observation, record review and interview the facility failed to ensure Resident #35 was involved in an ongoing program of activities designed to meet the resident's specific and individualized needs. This affected one resident (Resident #35) of three residents reviewed related to activities. The facility census was 97. Findings include: Resident #35 was admitted with [DIAGNOSES REDACTED]. The care plan dated 03/29/12 that addressed activities revealed the resident needed assistance to attend activities and keep his attention to task due to confusion and dementia. The goal was for the resident to attend and enjoy out of room activities two to three times a week with staff assistance. The interventions included that staff would try to determine the resident's activity preferences and provide those activities he liked, the resident liked and preferred to be a passive observer at music and kickball, the staff would invite him to small and large group activities and would provide him with a "busy pillow" to fiddle with instead of trying to put his hands in his pockets while sitting in the chair. The activity progress notes dated 04/20/13 revealed the resident was involved in music, television and exercise. The notes also indicated the resident showed an interest in and responded well to independent, large group, small group, parties, music and religious activities. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assistance to total dependence of one to two people with activities of daily living. The resident was observed on 07/27/13 at 11:00 A.M. in the Broda chair (a tilt back recliner) in the main dining room with his wife. The resident's eyes were closed with no verbal response. An interview at that time with the resident's wife revealed he no longer attended activities. The resident was observed on 07/26/13 at 2:50 P.M. in the low bed with a body pillow, the mat between the bed and the wall and eyes closed. The resident was observed on 07/27/13 at 9:20 A.M. in the Broda chair in his room with the television on and eyes closed. The resident was observed on 07/27/13 at 1:55 P.M. and 5:00 P.M. in bed with the body pillow, the mat between the bed and the wall and his eyes closed. The resident was observed at 5:30 P.M. being taken to the main dining room via the Broda chair and was returned to his room to await other residents' completion of their meals. The resident's eyes were closed. The resident was observed on 07/28/13 at 10:00 A.M. in the Broda chair in his room with his eyes closed, a stuffed animal on his lap and the television was on. The resident was never observed in an activity or with a busy pillow. The activity logs for May 2013 revealed the resident received 11 room visits and attended one group activity. The activities participation notes for May 2013 did not indicate the actual activity provided to the resident or that the resident was involved in during the room visits. The activity logs for June 2013 revealed the resident received 11 room visits and attended two group activities. The activities participation notes for June 2013 did not indicate the actual activity provided to the resident during the room visits. The activity logs revealed the resident only had ten room visits and one group activity for the month of July 2013. The activities participation notes for July 2013 did not indicate the actual activity provided to the resident during the room visits. Review of the resident's plan of care revealed room visits were not included as an intervention or an identified need for the resident. The care plan did not include activities that would be effective for a resident who required extensive to total assistance with minimal responses. An interview with the director of nursing and the corporate quality assurance registered nurse (RN) #2 on 07/28/13 at 10:30 A.M. verified the contents of the activity care plan, activity logs and the activities participation notes as noted above for Resident #35.