Every finding on record at Sunset Home Inc

The facility had a census of 39 residents. Based on observation, record review, and interview, the facility failed to maintain an infection monitoring surveillance plan and Enhanced Barrier Protection (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) as staff wore gown and gloves (PPE - gowns, face shields and/or eyeglasses/goggles, and gloves) in the hallway. This deficient practice placed the residents at risk for exposure to infectious processes. Findings included: - On 03/25/25 at 08:25 AM, Certified Nurse Aide (CNA) M wore a yellow protective gown and gloves while pushing a resident in a wheelchair to the dining room. CNA M then went to a closet next to the dining room area and opened it with the PPE on. CNA M stated she wore the gown in the hallway so that the surveyor would know what she looked like in one. CNA M then proceeded to remove the gown and gloves in the service hall next to the dining room. On 03/26/25 at 11:30 AM, Administrative Nurse D verified the infection tracking system had not been correctly implemented before January 2025. The facility staff recognized that the infection tracking had not been correctly followed, and since January 2025, they had established an infection tracking system. Administrative Nurse D reported that the information gathered from the implemented system is reviewed at the monthly Quality Assurance meetings. Administrative Nurse D stated CNA M had been educated on the use of PPE outside of resident rooms and should not wear the PPE in the hallways. The facility's Enhanced Barrier Precautions (EBP) policy dated 12/31/24, documented that the facility follows recommended guidance from the Centers for Disease Control to keep all residents from Healthcare Acquired Infections (HAI). EBPs are implemented as one intervention that this facility uses to reduce transmission of resistant organisms, which employ targeted PPE use during high-contact resident care activities. Staff will not wear the same gown and gloves for the care of more than one resident or reuse the gown and gloves for the same resident. Position a trash can inside the resident's room and near the exit for discarding PPE after removing it before exiting the room, or before providing care for another resident in the same room. The facility's Infection Prevention and Control Program, dated 05/11/23, documented that the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. The facility failed to ensure the disposal of PPE before leaving residents' rooms and to maintain an infection monitoring surveillance plan. This deficient practice placed the residents at risk of infectious disease processes.

The facility had a census of 39 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for 39 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 03/24/25 at 09:00 AM, observation in the facility kitchen revealed three staff working, including Dietary Staff BB who stated she was the dietary manager. She stated she started about three months ago, and was not certified. Dietary Staff BB stated she had just started taking the classes for Certified Dietary Manager. On 03/26/25 at 02:32 PM, Administrative Staff A verified the facility's Dietary Manager was not certified. The facility Failed to provide a policy for Qualified Dietary Managers. The facility failed to provide the services of a full-time certified dietary manager for 39 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to remove expired medication from use and failed to date one insulin pen when opened. This deficient practice placed residents who may have received those medications at risk for ineffective medication. Findings included: - On 03/24/25 at 09:07 AM, observation of the one facility medication room revealed 14 bisacodyl (laxative) suppositories with an expiration date of November 2024 and a container of aspirin/diphenhydramine (pain relief/sleep aide) 500/25 milligrams (mg) tablets, expired December 2024. On 03/24/25 at 09:22 AM, the facility's nurse treatment cart contained an opened, undated glargine insulin pen. On 03/24/25 at 09:07 AM, Licensed Nurse (LN) G verified the medications in the medication room were expired and she disposed of them. On 03/24/25 at 09:22 AM, LN H verified staff should have dated the insulin pen when they opened it for use. On 03/26/25 at 07:50 AM, Administrative Staff D verified staff were to date insulin pens when opened. 03/26/25 at 08:22 AM, Administrative Staff D stated staff were to check for expiration dates when taking medications from the medication room to place on the cart for administration. The facility's undated Medication Expiration and Disposal policy stated the facility established a protocol for managing expired medications to prevent medication errors, ensure compliance with regulatory standards, and safeguard the health of residents. The facility would conduct a weekly audit of all medication inventories to identify that all medications have an expiration date, an opened-on date, and a use-by date based on manufacturer and pharmacy standards of practice. The policy stated nursing staff were responsible for checking expiration dates and use-by dates at the time of administration. The facility failed to remove expired medication from use and failed to date one insulin pen when opened. This deficient practice placed residents who may have received those medications at risk for ineffective medication.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 126 with an appropriate bed hold policy as required. This deficient practice placed the resident at risk of being unable to return to the facility in the same room or bed. Findings included: -R126's Electronic Medical Record (EMR) recorded diagnoses of dorsalgia (discomfort occurring anywhere on the spine or back, ranging from mild to disabling), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, chronic (persisting for a long period) kidney disease, diabetes mellites (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN - elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), multiple fractures (broken bone) of ribs, low back pain and history of disease of the blood-forming organs. The admission Minimum Data Set (MDS), dated [DATE], documented R126 had severe cognitive impairment, verbal behavioral symptoms directed toward others, and rejection of care that occurred one to three days of the look-back period. R126 required partial/moderate assistance with toileting and personal hygiene, upper body dressing, mobility, and transfers. R126 required substantial/maximal assistance with showering and lower body dressing. R126 had occasional incontinence of urine, and received as-needed pain medication for almost constant pain, which affected sleep, therapy participation, and day-to-day activities. The MDS further documented that R126 had an unhealed stage two (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) pressure ulcer on admission. R126's Care Plan dated 12/19/24 documented R126 required staff assistance with activities of daily living related to limited mobility and physical decline. The care plan documented R126 was alert with confusion, and required assistance of one staff member with bathing, bed mobility, dressing, personal and toileting hygiene, and toilet use. The care plan further documented R126 had a stage two pressure ulcer to the middle of the spine, had the potential to be verbally aggressive towards staff, and had weight loss. The Progress Note dated 12/05/24 at 04:51 PM documented that R126 had been admitted from a hospital with a self-care deficit. The progress note further documented R126 had a two centimeters (cm) in length by 1.5 cm in width red area to the middle spine with one cm length by one cm width open dried area. The Progress Note dated 12/25/24 at 02:45 PM documented R 126 found lying on the floor. The exam of R126's skin showed R126 had landed on his back, where he had an open wound. R126 was able to move all extremities without difficulty and complained of back pain. Vital signs obtained of temperature of 97.4 degrees Fahrenheit, blood pressure of 172/103, pulse 64, respirations 22, and oxygen saturation of 89 percent (%). The note further documented neurological checks initiated, the resident family member was notified, and the physician was notified by fax. The Progress Note dated 12/25/24 at 11:59 PM documented R126 rested in bed with eyes closed, no further injuries found, neurological check, and vital signs were within normal limits. The Progress Note dated 12/26/24 at 08:18 AM, documented R126 continued with fall follow-up assessment. R126 was sleepy but easily arousable. The progress note further documented no new areas of concern and moved extremities without difficulties. The Progress Note on 12/27/24 at 09:52 AM, documented that the facility received a call from the hospital that R126 was being transferred to them from the local hospital and requested information on the last given medications and treatments while R126 was at the facility. The note further documented that the facility nurse was to fax the medication and treatment administration records to the receiving hospital of R126. The medical record lacked nursing assessment and transfer documentation as to why or how R126 left the facility. On 03/26/25 at 02:30 PM, Administrative Nurse D verified the medical record lacked the assessment, reason, and to where R126 had been sent, and provided the bed hold form. Administrative Nurse D stated that the nurse who worked during that time no longer works at the facility and should have completed the transfer assessments and records. The facility's undated Bed Hold Policy documented before this facility transfers a resident to a hospital or the resident goes on therapeutic leave, the facility will provide information to the resident and/or resident representative that specifies: the duration of the state bed-hold policy during which the resident is permitted to return and resume residency in the facility: the reserve bed payment policy in the state plan; the facility's policies regarding bed-hold period, which are consistent with the law permitting the resident to return. The nurse responsible for the preparation of information that would accompany a resident when transferred to another healthcare facility would include the facility's policy for retaining the resident's current bedroom while absent from the facility. The facility failed to provide R126's representative with a bed-hold policy. This deficient practice placed R126 at risk of being uninformed of bed-hold requirements.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to monitor Resident (R)34's blood pressure as the physician ordered to monitor the effectiveness of her medication. This deficient practice placed R34 at risk of receiving unnecessary medication. Findings included: - R34's Electronic Medical Record documented diagnoses of hypertension (HTN - elevated blood pressure), transient cerebral ischemic attack (TIA - temporary episode of inadequate blood supply to the brain), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 received antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (narcotic) medications. The Care Plan, dated 02/17/25, directed staff to consult with a pharmacist as needed, monitor, and report adverse reactions to medication therapy. The Physician Order, dated 08/31/24, directed staff to administer losartan (blood pressure lowering drug) 100 milligrams (mg) daily. The order stated to hold the drug if R34's systolic blood pressure (SB/P) was less than 100 mmHg (millimeters of mercury) or the diastolic blood pressure (DB/P) was less than 60 mmHg. R34's blood pressure documentation revealed staff obtained her blood pressure weekly from 12/14/24 to 3/24/25, even though the 08/31/24 order was still active, and the resident still received the same medication. On 03/25/25 at 11:32 AM, Certified Medication Aide (CMA) S administered medications to R34 who took the pills whole without problems. On 03/25/25 at 02:10 PM, Administrative Nurse D stated R34 switched physicians and the order from the previous physician was still in the computer. They plan to contact the current physician to verify if he wants to set parameters. She verified staff should have obtained blood pressure with the administration of losartan. The facility's undated Medication Administration, policy stated all medications would be administered as ordered by a physician in a safe and sanitary manner. Each elder's drug regimen would be free of unnecessary drugs, defined as: without adequate, recommended monitoring. The nursing staff would monitor the elder's response to medications by relevant lab values and clinical response. The facility failed to monitor R34's blood pressure as the physician ordered to monitor the effectiveness of her medication. This deficient practice placed R34 at risk of receiving unnecessary medication.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, interview and record review, the facility failed to keep Resident (R) 35 free from verbal abuse during transport in the facility bus. This deficient practice placed R35 at risk for fear or mental anguish. Findings included: - R35's electronic medical record included diagnoses for cerebral infarction (stroke) causing hemiplegia (refers to complete paralysis on one side of the body) affecting the left side, cerebral edema (swelling of the brain tissue), and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R35 was dependent on staff for mobility, dressing, and hygiene. He used a manual wheelchair, had one non-injury fall, and a history of falls before admission. R35's Care Plan, dated 11/04/24, directed staff to transfer R35 with two staff and a total mechanical lift, initiated 11/04/24. Provide a Broda chair (specialized wheelchair) due to his inability to safely sit in a regular wheelchair, initiated: 11/06/2024 The Grievance Log complaint of 11/04/25 documented on 11/04/24 a new resident (R35) complained of being treated horribly by the transportation aide on his way to this facility. He reported he was yelled at, and cursed at several times because he kept sliding out of his wheelchair. He reported he was told, F***, I have stopped every five miles for you, and I am not going to keep stopping for this. R35 felt like he shouldn't be yelled at for something he could not help. He reported he slid completely out of his wheelchair and then she got really mad and started yelling. The resident also called his family and told them how he was treated. Resolution: The Transportation Aide was educated on Abuse/Neglect/Exploitation. The Witness statement from the transportation Aide, dated 11/01/24, stated she strapped the resident (R35) in the van securely, but she had to stop several times to pull him back up in his wheelchair. He told her he was sliding himself down. The transportation aide wrote she did show some frustration with him and told herself she needed to calm down. At one point his bottom was completely off the wheelchair and she could not pull him up, so she lowered him to the floor. She called the nursing home who sent out two aides to assist her. The Admission Note dated 11/04/24 at 05:21 PM documented a new male resident was transported via the facility van and wheelchair. R35 required a full lift. He leaned to his left and had no use of his left arm. R35 denied pain. The Social Services Note dated 11/04/24 at 02:15 PM documented the SSD introduced herself to R35 in his room. He was lying in bed and asked her to adjust his blankets and turn up the heater because he was cold. The SSD assisted R35 with putting away his personal items. The note lacked documentation of any complaint of abuse. The Progress Note dated 11/05/24 at 05:16 AM documented R35 did not sleep at all last night. Staff assisted him with repositioning about every 30 minutes during the night shift. R35 would throw the left side of his body out of bed. The nurse finally said to him You have to be pushing yourself this way in order for you to be off the bed like this. R35 responded, That's what they said in the hospital. The nurse educated him on ways to better keep himself from pushing himself out of bed and he did much better after the education. The Progress Note dated 11/6/24 at 04:47 AM documented R35 continued to adjust well to the facility. R35 slid out of his wheelchair at shift change around 06:00 PM. R35 stated he slid out of his chair onto the floor and then laid down. He denied hitting his head. A complete assessment was completed along with risk management. R35 slept well all night and only rang this morning for pain medication due to left hip pain. On 03/26/25 at 12:45 PM, R35 laid in bed, and a Broda chair with a three-inch pommel (raised area in the cushion to help prevent forward slipping) cushion was in his room. R35 was alert and oriented and reported he was verbally abused on the van ride to the facility when he was first admitted . R35 stated his wheelchair did not have the thing in the seat (pommel) that kept him from sliding. R35 reported the driver repeatedly got upset with him and cursed when he kept sliding forward during the ride. He reported no further problems when transported by the facility. On 03/26/25 at 02:18 PM, Certified Nurse Aide (CNA) and Transportation Aide O, stated she took a regular wheelchair to transport R35 from the previous facility, he did not come with his own wheelchair. CNA O stated the previous facility did not give our facility any information that the resident was at risk of sliding forward. CNA O verified she was angry but had not cursed while transporting R35 in November 2024. Training for transporting residents was a class every two years with a state agency. She stated they have to demonstrate securing a resident during the class. She stated after the incident the administration educated her for ANE. On 03/26/25 at 02:32 PM, Administrative Staff A verified the facility had not reported the allegation of verbal abuse to the state agency or investigated it that he knew of (he was not employed here in November). He stated the only documentation the facility could find was the grievance log and the transportation aide's note. The facility's undated Abuse, Neglect, and Exploitation policy stated all residents of the facility would be free of physical, emotional, and sexual abuse, neglectful treatment, and misappropriation of funds and resources. The policy stated verbal abuse included willfully disparaging and derogatory terms to residents or their families or within their hearing. Residents and their families could report a grievance orally or in writing and the Grievance Officer would immediately report the incident to the administrator of the facility. Any allegations of all types of staff-to-resident abuse would be reported to the facility administrator and to other official agencies including the State Agency. The policy stated witness statements would be obtained, an investigation performed, and a written report filed. The facility failed to keep R35 free from verbal abuse during transport in the facility bus. This deficient practice placed R35 at risk for fear or mental anguish.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility's consultant pharmacist failed to notify the director of nursing or R34's physician of the lack of monitoring R34's blood pressure as the physician ordered to monitor the effectiveness of her medication, placing R34 at risk of receiving unnecessary medication. Findings included: - R34's Electronic Medical Record documented diagnoses of hypertension (HTN - elevated blood pressure), transient cerebral ischemic attack (TIA - temporary episode of inadequate blood supply to the brain), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 received antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (narcotic) medications. R34's Care Plan, dated 02/17/25, directed staff to consult with a pharmacist as needed, monitor, and report adverse reactions to medication therapy. The Physician Order, dated 08/31/24, directed staff to administer losartan (blood pressure lowering drug) 100 milligrams (mg) daily. The order stated to hold the drug if R34's systolic blood pressure (SB/P) was less than 100 mmHg (millimeters of mercury) or the diastolic blood pressure (DB/P) was less than 60 mmHg. R34's blood pressure documentation revealed staff obtained her blood pressure weekly from 12/14/24 to 3/24/25, even though the 08/31/24 order was still active, and the resident still received the same medication. On 03/25/25 at 11:32 AM, Certified Medication Aide (CMA) S administered medications to R34 who took the pills whole without problems. On 03/25/25 at 02:10 PM, Administrative Nurse D verified the facility's consultant pharmacist had not notified her of the blood pressure not being monitored as ordered. The facility's undated Medication Administration, policy stated the contracted consultant pharmacist would review the elder's medication regimen monthly and document the findings and recommendations. The consultant pharmacist would communicate to the physician and those involved in the elder's care the findings, conclusions, and recommendations that result from monitoring the medication regimen. The facility's consultant pharmacist failed to notify the director of nursing or R34's physician of the lack of monitoring R34's blood pressure as the physician ordered to monitor the effectiveness of her medication, placing R34 at risk of receiving unnecessary medication.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 10 had physician-ordered fluid intake, which placed R10 at risk of ongoing dehydration and urinary tract infections. Findings included: - R10's Electronic Medical Record (EMR) included diagnoses of heart failure, weakness, intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and chronic (persisting for a long period) kidney disease. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R10 had intact cognition, no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. R10 required setup or clean-up assistance with eating and substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and was dependent with mobility and transfers. R10 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag), was incontinent of bowel, had renal (pertaining to kidneys) insufficiency, and neurogenic bladder. The MDS further documented that R10 had received oxygen, speech, occupational and physical therapy. R10's Care Plan, dated 02/13/25, documented R10 had a catheter in place due to a neurogenic bladder. The Care Plan directed staff to monitor and document intake and output and report to the Medical Doctor (MD) signs or symptoms of a urinary tract infection. The Physician Order dated 01/29/25 ordered R10 to drink two quarts (or eight cups) of water daily (1920 cubic centimeters - cc's) every 24 hours. The Progress Note dated 01/27/25 at 11:15 AM documented R10 had returned from the hospital with diagnoses of an acute urinary tract infection (UTI - an infection in any part of the urinary system), acute and chronic renal failure, and dehydration. The note further documented that R10 had an indwelling catheter due to retention. The Progress Note dated 02/11/25 at 11:54 PM documented that R10 had been sent to the emergency department and had started an antibiotic due to having a urinary tract infection. Upon review of the EMR fluid intake record from 02/24/25 to 03/12/25 (last recorded intake) revealed that R10 lacked the amount of physician-ordered intake of two quarts daily. On 03/26/25 at 07:54 AM, R10 sat in the dining room eating breakfast independently. R10 had two 240 cc cups with sipper lids and handles placed on the table with her meal. On 03/26/25 at 07:50 AM, Dietary Staff (DS) BB reported that the kitchen staff was not currently keeping track of anyone's fluid intake. DS BB reported that the dietary staff always placed a cup of water and a cup of juice at each meal. DS BB also stated that coffee, milk, and refills were also offered to the residents at mealtime. On 03/26/25 at 07:59 AM, Certified Medication Aide (CMA) R reported that the dietary staff kept track of fluid intake for residents who ate in the dining room, and the nursing staff kept track of the fluids for residents who chose to eat their meals in their rooms. On 03/26/25 at 09:01 AM, Licensed Nurse (LN) I stated she was not aware of the required fluid intake for R10. On 03/27/25 at 01:53 PM, Administrative Nurse D verified that R10 had a physician order of two quarts of water every 24 hours and should be included in the care plan. The facility failed to provide a urinary tract infection prevention policy. The facility's undated Hydration policy documented it is the policy of the facility to ensure that elders receive sufficient fluid to maintain proper hydration and health. When the elder developed a clinical condition that placed him/her at risk for dehydration, interventions acceptable and appropriate for the elder would be implemented. The facility failed to ensure R10 had a physician-ordered fluid intake, which placed R10 at risk of ongoing dehydration and urinary tract infections.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 10 had physician-ordered fluid intake, which placed R10 at risk of ongoing urinary tract infections. Findings included: - R10's Electronic Medical Record (EMR) included diagnoses of heart failure, weakness, intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and chronic (persisting for a long period) kidney disease. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R10 had intact cognition, no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. R10 required setup or clean-up assistance with eating and substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and was dependent on mobility and transfers. R10 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag), was incontinent of bowel, had renal (pertaining to kidneys) insufficiency, and neurogenic bladder. The MDS further documented that R10 had received oxygen, speech, occupational and physical therapy. R10's Care Plan, dated 02/13/25, documented R10 had a catheter in place due to a neurogenic bladder. The Care Plan directed staff to monitor and document intake and output and report to the Medical Doctor (MD) signs or symptoms of a urinary tract infection. The Physician Order, dated 01/29/25, ordered R10 to drink two quarts (or eight cups) of water daily (1920 cubic centimeters - cc's) every 24 hours. The Progress Note dated 01/27/25 at 11:15 AM documented R10 had returned from the hospital with diagnoses of an acute urinary tract infection (UTI - an infection in any part of the urinary system), acute and chronic renal failure, and dehydration. The note further documented that R10 had an indwelling catheter due to retention. The Progress Note dated 02/11/25 at 11:54 PM documented that R10 had been sent to the emergency department and had started an antibiotic due to having a urinary tract infection. Upon review of the EMR fluid intake record from 02/24/25 to 03/12/25 (last recorded intake) revealed that R10 lacked the amount of physician-ordered intake of two quarts daily. On 03/26/25 at 07:54 AM, R10 sat in the dining room eating breakfast independently. R10 had two 240 cc cups with sipper lids and handles placed on the table with her meal. On 03/26/25 at 07:50 AM, Dietary Staff (DS) BB reported that the kitchen staff was not currently keeping track of anyone's fluid intake. DS BB reported that the dietary staff always placed a cup of water and a cup of juice at each meal. DS BB also stated that coffee, milk, and refills are also offered to the residents at mealtime. On 03/26/25 at 07:59 AM, Certified Medication Aide (CMA) R reported that the dietary staff kept track of fluid intake for residents who ate in the dining room, and the nursing staff kept track of the fluids for residents who chose to eat their meals in their rooms. On 03/26/25 at 09:01 AM, Licensed Nurse (LN) I stated she was not aware of the required fluid intake for R10. On 03/27/25 at 01:53 PM, Administrative Nurse D verified that R10 had a physician order of two quarts of water every 24 hours and should be included in the care plan. The facility failed to provide a urinary tract infection prevention policy. The facility failed to ensure R10 had a physician-ordered fluid intake, which placed R10 at risk of ongoing urinary tract infections.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to provide an appropriate cover or dressing for Resident (R) 11's open pressure ulcer (PU) of her left heel. This deficient practice placed R11 at risk for pain or infection. Findings included: - R11's Electronic Medical Record documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) and left hip fracture (broken bone). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired decision-making. The MDS documented R11 required moderate staff assistance for bathing and maximum staff assistance for dressing her lower body and shoes. The MDS documented R11 had PU and PU care was provided. R11's Care Plan, dated 01/10/25, directed staff to monitor and document wound size, depth, granulation, and progress in healing. Notify the physician as indicated and report any signs of infection. The Physician Order, dated 03/25/25, directed staff to dress R11's left heel with saline-moistened promogram prisma (a wound dressing designed to maintain a moist environment and provide antimicrobial protection) to the wound bed followed by mepilex border (a self-adherent, five-layer foam dressing with a soft silicone border designed to maintain a moist wound environment, absorb drainage, and prevent pressure ulcers while minimizing pain and trauma). On 03/25/25 at 07:42 AM, R11 finished eating 100% of her breakfast. She wore house slippers with an open back and rubber soles. R11 carried one sock. Certified Medication Aide (CMA) S took R11 to her room, used a gait belt, and transferred her to the toilet. R11 had no dressing or covering on her left heel PU. CMA S requested a nurse to assess a skin tear. Administrative Staff D came to the room and left to call the wound clinic for directions on whether to apply a dressing to R11's PU. At 08:07 AM, Licensed Nurse (LN) I came in and treated the skin tear to R11's left inner calf, then assisted R11 to dress and transfer from the toilet to her wheelchair without a dressing or covering for the PU on her left heel. LN I took R11 to a recliner in the commons area and used a gait belt to transfer R11 into a recliner. LN I stated R11 had an appointment at the wound clinic at 09:00 AM and she had a shower at 06:00 AM. At 08:18 AM, LN I called the wound clinic and they directed her to cover the wound for now. LN I took R11 back to her room, cleansed the left heel wound, and applied a mepilex dressing to the wound. The PU was to the outside of the left heel, approximately two centimeters (cm) by two cm, with dry slough (dead tissue) visible. Staff were unable to determine if there had been drainage as the resident had worn fuzzy gray house slippers after her shower. On 03/25/25 at 08:33 AM, Certified Nurse Aide (CNA) N stated R11 liked to get up early and shower around 06:00 AM. CNA N stated on shower days when the resident was to go to wound care, she had been instructed to remove the old wound dressing and inform the nurse of that. On 03/25/25 at 10:17 AM, Administrative Nurse E verified an open wound should be covered at all times unless the physician ordered something different. The facility failed to provide a policy for treatment of pressure ulcers. The facility failed to provide an appropriate cover or dressing for R11's open PU on her left heel. This deficient practice placed R11 at risk for pain or infection.

The facility had a census of 39 residents. The sample included 13 residents. Based on the record review and interview, the facility failed to ensure that Resident (R) 126's transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving healthcare institution or provider. This placed R126 at risk for delayed treatment at the receiving institution. Findings included: - R126's Electronic Medical Record (EMR) recorded diagnoses of dorsalgia (discomfort occurring anywhere on the spine or back, ranging from mild to disabling), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, chronic (persisting for a long period) kidney disease, diabetes mellites (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN - elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), multiple fractures (broken bone) of ribs, low back pain and history of disease of the blood-forming organs. The admission Minimum Data Set (MDS), dated [DATE], documented R126 had severe cognitive impairment, verbal behavioral symptoms directed toward others, and rejection of care that occurred one to three days of the look-back period. R126 required partial/moderate assistance with toileting and personal hygiene, upper body dressing, mobility, and transfers. R126 required substantial/maximal assistance with showering and lower body dressing. R126 had occasional incontinence of urine and received as-needed pain medication for almost constant pain, which affected sleep, therapy participation, and day-to-day activities. The MDS further documented that R126 had an unhealed stage two (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) pressure ulcer on admission. R126's Care Plan dated 12/19/24 documented R126 required staff assistance with activities of daily living related to limited mobility and physical decline. The care plan documented R126 was alert with confusion, and required assistance of one staff member with bathing, bed mobility, dressing, personal and toileting hygiene, and toilet use. The care plan further documented R126 had a stage two pressure ulcer to the middle of the spine, had the potential to be verbally aggressive towards staff, and had weight loss. The Progress Note dated 12/05/24 at 04:51 PM documented that R126 had been admitted from a hospital with a self-care deficit. The progress note further documented R126 had a two cm in length by 1.5 cm width red area to the middle spine with one cm length by one cm width open dried area. The Progress Note dated 12/25/24 at 02:45 PM documented R 126 found lying on the floor. The exam of R126's skin showed R126 had landed on his back, where he had an open wound. R126 was able to move all extremities without difficulty and complained of back pain. Vital signs obtained of temperature of 97.4 degrees Fahrenheit, blood pressure of 172/103, pulse 64, respiration 22, and oxygen saturation of 89 percent (%). The note further documented neurological checks initiated, the resident family member was notified, and the physician was notified by fax. The Progress Note dated 12/25/24 at 11:59 PM documented R126 rested in bed with eyes closed, no further injuries found, neurological check, and vital signs were within normal limits. The Progress Note dated 12/26/24 at 08:18 AM documented R126 continued with fall follow-up assessment. R126 was sleepy but easily arousable. The progress note further documented no new areas of concern and moved extremities without difficulties. The Progress Note on 12/27/24 at 09:52 AM, documented that the facility received a call from the hospital that R126 was being transferred to them from the local hospital and requested information on the last given medications and treatments while R126 was at the facility. The note further documented that the facility nurse was to fax the medication and treatment administration records to the receiving hospital of R126. The medical record lacked nursing assessment and transfer documentation as to why or how R126 left the facility. On 03/26/25 at 02:30 PM, Administrative Nurse D verified the medical record lacked the assessment, reason, and to where R126 had been sent. Administrative Nurse D stated that the nurse who worked during that time no longer works at the facility and should have completed the transfer assessments and records. The facility's Transfers Between Facilities and Hospital policy, dated, stated that it was the policy of the facility to expedite communication between all units of the acute hospital and the facility for the best care of the elder. Transfers between the acute hospital and the facility would be carried out efficiently and effectively. When transferring elders, these records will be sent from the facility to an acute hospital, an elder transfer and referral record must be completed in full and sent with the elder including on this record the elder's normal level of Activities of Daily Living before the illness requiring transfer to the acute hospital, copies of the most current Interdisciplinary Notes and Medication Administration Records will be sent with the elder. If the elder is sent to the Emergency Department under emergency circumstances, copies of the clinical record are to accompany the elder: the transfer record should be completed as soon as possible, along with completed nurses' notes and medication record, and sent to the acute hospital. The facility failed to ensure that the transfer/discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider which placed R126 at risk for delayed treatment in the receiving facility.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate the allegation of verbal abuse immediately. This placed Resident (R) 35 at risk for ongoing abuse and or mistreatment. Findings included: - R35's electronic medical record included diagnoses for cerebral infarction (stroke) causing hemiplegia (refers to complete paralysis on one side of the body) affecting the left side, cerebral edema (swelling of the brain tissue), and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R35 was dependent on staff for mobility, dressing, and hygiene. He used a manual wheelchair, had one non-injury fall, and had a history of falls before admission. R35's Care Plan, dated 11/04/24, directed staff to transfer R35 with two staff and a total mechanical lift, initiated 11/04/24. Provide a Broda chair (specialized wheelchair) due to his inability to safely sit in a regular wheelchair, initiated: 11/06/2024 The Grievance Log complaint of 11/04/25 documented on 11/04/24 a new resident (R35) complained of being treated horribly by a transportation aide on his way to this facility. He reported he was yelled at, and cursed at several times because he kept sliding out of his wheelchair. He reported he was told, F***, I have stopped every five miles for you, and I am not going to keep stopping for this. R35 felt like he shouldn't be yelled at for something he could not help. He reported he slid completely out of his wheelchair and then she got really mad and started yelling. The resident also called his family and told them how he was treated. Resolution: The Transportation Aide was educated on Abuse/Neglect/Exploitation. The Witness Statement from Transportation Aide O, dated 11/01/24, stated she strapped the resident (R35) in the van securely, but she had to stop several times to pull him back up in his wheelchair. He told her he was sliding himself down. The transportation aide wrote she did show some frustration with him and told herself she needed to calm down. At one point his bottom was completely off the wheelchair and she could not pull him up, so she lowered him to the floor. She called the nursing home who sent out two aides to assist her. The Admission Note dated 11/04/24 at 05:21 PM documented a new male resident was transported via the facility van and wheelchair. R35 required a full lift. He leaned to his left and had no use of his left arm. R35 denied pain. The Progress Note dated 11/05/24 at 05:16 AM documented R35 had not sleep at all last night. Staff assisted him with repositioning about every 30 minutes during the night shift. R35 would throw the left side of his body out of bed. The nurse finally said to him You have to be pushing yourself this way in order for you to be off the bed like this. R35 responded, That's what they said in the hospital. The nurse educated him on ways to better keep himself from pushing himself out of bed and he did much better after the education. The Progress Note, dated 11/6/24 at 04:47 AM, documented R35 continued to adjust well to the facility. R35 slid out of his wheelchair at shift change around 06:00 PM. R35 stated he slid out of his chair onto the floor and then laid down. He denied hitting his head. A complete assessment was completed along with risk management. R35 slept well all night and only rang this morning for pain medication due to left hip pain. On 03/26/25 at 12:45 PM, R35 was lying in bed and a Broda chair with a three-inch pommel (raised area in the cushion to help prevent forward slipping) cushion was in his room. R35 was alert and oriented and reported he was verbally abused on the van ride to the facility when he was first admitted . R35 stated his wheelchair did not have the thing in the seat (pommel) that kept him from sliding. R35 reported the driver repeatedly got upset with him and cursed when he kept sliding forward during the ride. He reported no further problems when transported by the facility. On 03/26/25 at 02:18 PM, Certified Nurse Aide (CNA)/Transportation Aide O, stated she took a regular wheelchair to transport the resident from the previous facility, he did not come with his own wheelchair. CNA O stated the previous facility did not give our facility any information that the resident was at risk of sliding forward. CNA O verified she was angry but had not cursed while transporting R35 in November 2024. Training for transporting residents was a class every two years with a state agency. She stated they have to demonstrate securing a resident during the class. She stated after the 11/04/24 incident the administration educated her for ANE. On 03/26/25 at 02:32 PM, Administrative Staff A verified the facility had not reported the allegation of verbal abuse to the state agency or investigated it that he knew of (he was not employed here in November). He stated the only documentation the facility could find was the Grievance Log and Transportation Aide O's note. The facility's undated Abuse, Neglect, and Exploitation policy stated all residents of the facility would be free of physical, emotional, and sexual abuse, neglectful treatment, and misappropriation of funds and resources. The policy stated verbal abuse included willfully disparaging and derogatory terms to residents or their families or within their hearing. Residents and their families could report a grievance orally or in writing and the Grievance Officer would immediately report the incident to the administrator of the facility. Any allegations of all types of staff-to-resident abuse would be reported to the facility administrator and to other official agencies including the State Agency. The policy stated witness statement would be obtained, an investigation performed, and a written report filed. The facility failed to thoroughly investigate the allegation of verbal abuse immediately. This placed R35 at risk for ongoing abuse and or mistreatment.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure staff reported an allegation of verbal abuse from Resident (R) 35 to the administrator immediately to investigate. This placed R35 at risk for ongoing abuse and or mistreatment. Findings included: - R35's electronic medical record included diagnoses for cerebral infarction (stroke) causing hemiplegia (refers to complete paralysis on one side of the body) affecting the left side, cerebral edema (swelling of the brain tissue), and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R35 was dependent on staff for mobility, dressing, and hygiene. He used a manual wheelchair, had one non-injury fall, and had a history of falls before admission. R35's Care Plan, dated 11/04/24, directed staff to transfer R35 with two staff and a total mechanical lift, initiated 11/04/24. Provide a Broda chair (specialized wheelchair) due to his inability to safely sit in a regular wheelchair, initiated: 11/06/2024 The Grievance Log complaint of 11/04/25 documented on 11/04/24 a new resident (R35) complained of being treated horribly by transportation aide on his way to this facility. He reported he was yelled at, and cursed at several times because he kept sliding out of his wheelchair. He reported he was told, F***, I have stopped every five miles for you, and I am not going to keep stopping for this. R35 felt like he shouldn't be yelled at for something he could not help. He reported he slid completely out of his wheelchair and then she got really mad and started yelling. The resident also called his family and told them how he was treated. Resolution: The Transportation Aide was educated on Abuse/Neglect/Exploitation. The Witness Statement from the transportation Aide, dated 11/01/24, stated she strapped the resident (R35) in the van securely, but she had to stop several times to pull him back up in his wheelchair. He told her he was sliding himself down. The transportation aide wrote she did show some frustration with him and told herself she needed to calm down. At one point his bottom was completely off the wheelchair and she could not pull him up, so she lowered him to the floor. She called the nursing home who sent out two aides to assist her. The Admission Note dated 11/04/24 at 05:21 PM documented a new male resident was transported via the facility van and wheelchair. R35 required a full lift. He leaned to his left and had no use of his left arm. R35 denied pain. The Social Services Note dated 11/04/24 at 02:15 PM documented the SSD introduced herself to R35 in his room. He was lying in bed and asked her to adjust his blankets and turn up the heater because he was cold. The SSD assisted R35 with putting away his personal items. The note lacked documentation of any complaint of abuse. The Progress Note dated 11/05/24 at 05:16 AM documented R35 did not sleep at all last night. Staff assisted him with repositioning about every 30 minutes during the night shift. R35 would throw the left side of his body out of bed. The nurse finally said to him You have to be pushing yourself this way in order for you to be off the bed like this. R35 responded, That's what they said in the hospital. The nurse educated him on ways to better keep himself from pushing himself out of bed and he did much better after the education. The Progress Note dated 11/6/24 at 04:47 AM documented R35 continued to adjust well to the facility. R35 slid out of his wheelchair at shift change around 06:00 PM. R35 stated he slid out of his chair onto the floor and then laid down. He denied hitting his head. A complete assessment was completed along with risk management. R35 slept well all night and only rang this morning for pain medication due to left hip pain. On 03/26/25 at 12:45 PM, R35 was lying in bed and a Broda chair with a three-inch pommel (raised area in the cushion to help prevent forward slipping) cushion was in his room. R35 was alert and oriented and reported he was verbally abused on the van ride to the facility when he was first admitted . R35 stated his wheelchair did not have the thing in the seat (pommel) that kept him from sliding. R35 reported the driver repeatedly got upset with him and cursed when he kept sliding forward during the ride. He reported no further problems when transported by the facility. On 03/26/25 at 02:18 PM, Certified Nurse Aide (CNA) and Transportation Aide O, stated she took a regular wheelchair to transport the resident from the previous facility, he did not come with his own wheelchair. CNA O stated the previous facility did not give our facility any information that the resident was at risk of sliding forward. CNA O verified she was angry but did not curse while transporting R35 in November 2024. Training for transporting residents was a class every two years with a state agency. She stated they have to demonstrate securing a resident during the class. She stated after the 11/04/24 incident the administration educated her for ANE. On 03/26/25 at 02:32 PM, Administrative Staff A verified the facility had not reported the allegation of verbal abuse to the state agency or investigated it that he knew of (he was not employed here in November). He stated the only documentation the facility could find was the Grievance Log and the transportation aide's note. The facility's undated Abuse, Neglect, and Exploitation policy stated all residents of the facility would be free of physical, emotional, and sexual abuse, neglectful treatment, and misappropriation of funds and resources. The policy stated verbal abuse included willfully disparaging and derogatory terms to residents or their families or within their hearing. Residents and their families could report a grievance orally or in writing and the Grievance Officer would immediately report the incident to the administrator of the facility. Any allegations of all types of staff-to-resident abuse would be reported to the facility administrator and other official agencies including the State Agency. The policy stated witness statements would be obtained, an investigation performed, and a written report filed. The facility failed to report an allegation of verbal abuse from Resident (R) 35 to the administrator and the state agency. This placed R35 at risk for ongoing abuse and or mistreatment.

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to maintain an environment that promoted the dignity of Resident (R) 34, who had blood sugar testing and insulin administration, and R9, who also had insulin administration in the facility's dining room with other residents, staff, and visitors.0 This deficient practice placed the residents at risk for an undignified experience and embarrassment. Findings included: - On 03/25/25 at 11:21 AM, Licensed Nurse (LN) I performed a finger stick to obtain a drop of blood for testing R4's blood sugar level. R34, seated across the same table, stated, I'm glad that's not me, I don't like needles. LN I then retrieved an insulin pen and injected insulin (a hormone that lowers the level of glucose in the blood) subcutaneously (beneath the skin) into R4's right arm at the dining room table. On 03/25/25 at 11:29 AM, LN I administered R9's insulin subcutaneously while seated in the dining room. The table R9 sat at had two other residents and a visitor also seated at the same table at the time of the administration of insulin. 03/26/25 at 09:25 AM, LN I reported giving insulin in the dining room if the resident wanted. LN I stated R34 had joked about needles, and the other residents and visitors did not mind if insulin was administered in the dining room, but could give the insulin and check blood sugars in the residents' rooms. On 03/26/25 at 01:50 PM, Administrative Nurse D verified that the residents could receive insulin privately if the resident chose to. The facility's undated Right to Dignity policy documented the facility would promote care for elders in a manner and an environment that maintained and enhanced each elder's dignity and respect in full recognition of the elder's individuality. The facility failed to maintain an environment that promoted the dignity of R34 and R9, who had insulin administered in the dining room with other residents, staff, and visitors present. The deficient practice placed the residents at risk for an undignified experience and embarrassment.

The facility identified a census of 38 residents with three residents reviewed for resident's rights. Based on record review, observation, and interview, the facility failed to promote Resident (R) 1's right to choose, failed to respect R1's wishes, and failed to treat R1 with dignity and respect. On 12/05/24 at approximately 09:30 PM, R1 sat in his room in his wheelchair. Certified Nurse Aide (CNA) O heard another CNA say R1 did not want to go to bed. CNA M and CNA N went into R1's room and made R1 go to bed despite his protest. R1 became resistant to the transfer from his wheelchair to the bed and started hitting and kicking out at CNA M and CNA N. R1 yelled, No, no, no, no, and Get out of here. CNA O entered R1's room and observed R1 lying on his bed with his arms and legs up in a defensive position. CNA O told CNA M and CNA N they could not force R1 to go to bed. This deficient practice created psychosocial impairment and placed him at risk for injury, impaired dignity, and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of age-related cognitive decline, anxiety, hypertension (high blood pressure), a need for assistance for personal care, and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R1 required partial to substantial assistance for all his activities of daily living (ADLs) except eating, which R1 only required set-up assistance. R1's MDS documented no behaviors or resistance to care occurred. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/17/24, documented R1 as alert and able to make his needs known. R1 had confusion and required cues for all cares. The Functional Abilities CAA, dated 05/17/24, documented R1 as toe-touch weight-bearing and required assistance from two staff for all ADLs. R1's Care Plan directed staff R1 required one to two staff assistance with ambulation for short distances and R1 required the assistance of one staff for bathing, bed mobility, dressing, toilet use, and transfers (08/15/24). The care plan documented R1 had impaired cognitive status and directed staff to cue, re-orient, and supervise R1 as needed (05/16/24). The care plan directed staff to know R1 required the use of oxygen at three liters (L) per nasal cannula to keep his oxygen saturation (percentage of oxygen in the blood) above 90%; R1 became short of air with exertion and when lying down (08/15/24). The Behavior Note, dated 12/05/24, documented Licensed Nurse (LN) G was notified by CNA M and CNA N that R1 had removed his nasal cannula. The CNAs reported during their time assisting R1 to bed, R1 experienced confusion and was combative grabbing at their arms. LN G entered R1's room and CNA O was consoling R1. R1's nasal cannula was intact. R1 sat at the edge of the bed with arms to each side grasping the edge of the bed. R1 was short of breath and his oxygen saturation was 90%. LN G checked the nebulizer treatment to see if all the medication had been used. While LN G placed the mask back to the nebulizer machine, R1 attempted to tell LN G how to put it; he became short of air and agitated but was quick to be redirected to focus on his breathing. LN G left CNA O to continue to console R1. CNA M's undated Witness Statement, documented CNA M was called into R1's room by CNA N around 09:00 PM to help ambulate R1 to bed. R1 had been in his wheelchair with no oxygen for an extended period of time. R1 stated he was ready to go to bed. CNA M and CNA N placed R1's walker in front of his wheelchair and told R1 he needed to stand up to go to bed. R1 responded, I know that. CNA M and CNA N then proceeded to assist R1 in standing and once R1 was up, he became increasingly agitated, screaming, pushing backward, flailing around, and stating he did not want to go to bed. CNA M recorded the staff's main concern was to stop R1 from falling. R1 had a gait belt on and started to flail and become unsafe and the wheelchair was already moved from R1 pushing backward, so CNA M and CNA N helped R1 to the side of the bed where R1 threw himself back and started kicking and punching. CNA M and CNA N tried to deflect R1's hands so they could get R1's oxygen tubing from around his and back into his nose and remove the gait belt. After that, the staff determined R1 was safe, so they did not do perineal care or finish the nightly routine due to severe agitation. CNA O entered R1's room and asked what was going on. R1 said, I want these broads to leave the room. CNA M and CNA N exited the room to notify LN G of the issue. CNA O stayed behind. LN G had CNA M check R1's oxygen saturation about 20 minutes later and it was back to 90%. At 09:45 PM CNA M took R1's foot pedals back to his room and set the pedals in R1's doorway; R1 was calmed down and friendly and wanted his door cracked halfway open. R1 was back to his baseline and sat in his recliner. CNA N's undated Witness Statement, was identical to CNA M's Witness Statement. CNA O's Witness Statement, dated 12/06/24, documented another CNA told CNA O that R1 did not want to go to bed. CNA M and CNA N went into R1's room to put R1 to bed. CNA O stated she had gone into the bathroom when she heard R1 yell, No, no, no. CNA O also heard R1's chair alarm go off. CNA O went to R1's door and stood outside the door listening. CNA O heard CNA N say, You're going to die, you need to put your oxygen on. CNA O heard R1's chair alarm go off a second time and R1 yelled, Get out of here! CNA O then entered R1's room and told CNA M and CNA N they could not force R1 to go to bed if he refused. CNA M and CNA N stated they were just trying to put on R1's oxygen. CNA O stated she saw R1 on his bed with his arms and legs up in a defensive manner. CNA O told CNA M and CNA N to just go and that she would take care of R1. The Health Status Note, dated 12/06/24, documented LN H was in doing rounds at 06:30 AM and noticed R1's right hand was bruised from his knuckles up to his wrist, which measured 9 centimeters (cm) by 7 cm and two bruises on R1's left hand, which measured 5 cm by 4 cm and 3 cm by 4 cm. R1 was unsure how the bruises happened, but stated they did not hurt. R1 was on 325 milligrams (mg) of aspirin daily. The Health Status Note, dated 12/07/24 at 11:01 AM, documented a follow-up on R1's bruising. R1 continued to have bruising on his right hand and left arm and started to have bruising on his right and left upper arms and left chest. R1 stated he did not remember anything that happened, and he was not hurt. R1 was alert and oriented to person and place. R1's wife was present during the skin assessment. The Health Status Note, dated 12/07/24 at 11:13 PM, documented a follow-up on R1's bruising to the right hand, left arm, bilateral upper arms, and left chest. R1 did not remember how the bruising occurred. R1 was alert and oriented to person and place. The Health Status Note, dated 12/08/24, documented R1 continued to be monitored for bruising. No new bruising was noted, but R1 continued to have bruises on the right hand, left hand, lower forearm, upper arm, and a few little bruises on the left chest. R1 continued to deny pain. The Health Status Note, dated 12/09/24, documented the assessment showed no further bruising to R1's body. R1 denied pain at the time of assessment. The Facility Incident Report, dated 12/12/24, documented at approximately 04:23 PM on 12/06/24, Administrative Nurse D received a report from CNA O of a possible abuse, neglect, and exploitation (ANE) situation regarding R1. CNA O's allegation stated R1 may have been put to bed by CNA M and CNA N after R1 stated he did not want to go to bed. Staff noted bruising on R1's right wrist/hand on 12/06/24. CNA M and CNA N were suspended immediately and placed on the Do Not Return list to prevent them from picking up any further shifts during the investigation. CNA O was also immediately suspended. R1 was not able to verbalize if the allegation was true. R1 did not know what happened to cause the bruising and denied pain. The facility notified the police. The investigation included staff training on abuse and neglect on 12/06/24 but did not include education on residents' rights. On 12/16/24 at 09:30 AM, R1 sat in his recliner with his legs elevated. R1 visited with his wife. R1 had light pink to light red bruises that were fading on his right hand and left wrist. R1 stated he did not remember getting the bruises but thought he must have fallen. R1 stated he was not afraid to live in the facility and asked where that idea would come from. On 12/16/24 at 09:30 AM, R1's representative stated she came to visit R1 on 12/06/24 at 09:00 AM and saw all of the bruising and was very concerned about what had happened because she had been with R1 all day on 12/05/24 from 09:00 AM to 2:00 PM and he had no bruises. R1's representative stated she was told two CNAs had forced R1 to go to bed at around 09:30 PM and that was how the bruises happened. R1's representative stated R1 does not like to go to bed early and would not go to bed until after the news or sometimes not at all and would stay in his recliner. She stated R1 could not breathe well lying down. On 12/16/24 at 10:00 AM, CNA O stated she did not see anything that happened but heard R1 from the staff bathroom yelling, No, no, no, no. CNA O stated she was concerned and went to R1's door and then heard the chair alarm sound so she thought, Oh they are in there. CNA O stated the chair alarm was silent but then turned back on as if CNA M and CNA N had sat R1 down but then stood him right back up. CNA O stated she heard R1 yell, Get out of here! CNA O entered the room and saw R1 lying on the bed with his arms and legs up in a defensive position with CNA M and CNA N standing at the bedside. CNA O stated she told CNA M and CNA N they could not force R1 to go to bed if he did not want to. CNA O stated CNA M and CNA N left the room and CNA O stayed to console R1. R1 was breathing hard and was visibly upset. CNA O stated R1 had never been combative or resistant to care but would tell staff when he did not want to do something, and they would listen to him and let him be. CNA O stated she did not report the allegation until the next day when she came to work. On 12/16/24 at 10:30 AM, CNA P stated R1 had never been violent with care but would say he did not want to do something and sometimes was easily re-directable and other times was not. On 12/16/24 at 11:00 AM, LN I stated R1 could be resistant to care and stubborn, but she had never experienced him hitting, kicking, or pinching. LN H stated R1 had been taking aspirin 325 mg daily and bruised easily. LN I stated that R1's aspirin had been discontinued. On 12/16/24 at 11:30 AM, Administrative Nurse D stated she did not think CNA M and CNA N had forced R1 to go to bed. Administrative Nurse D stated she thought R1's oxygen was off and since no one knew how long it had been off R1 was confused. Administrative Nurse D stated all nursing staff were educated covering ANE on 12/06/24 and CNA M and CNA N refused to come in for the education because, in their words, Administrative Nurse D was taking the whole incident out of context. Administrative Nurse D stated the facility canceled all shifts with the CNAs' agency because they were so hard to deal with throughout the incident. The facility's undated Resident Rights Policy, documented that each resident in this facility has the right and will be afforded the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility without interference, coercion, discrimination, or reprisal. No staff member or contracted provider of care will hamper, compel, treat differently, or retaliate against a resident for exercising Resident Rights. It is the responsibility of all who work in this facility including employees of the facility and any others who provide services to the residents of the facility to advocate and protect the rights of each resident. All staff members are trained on the Resident Rights Policy at the time of employment, prior to providing care to residents, and at least annually to ensure understanding and competency related to ensuring each resident's Resident Rights. The facility failed to promote R1's right to choose, failed to respect R1's wishes, and failed to treat R1 with dignity and respect. This deficient practice created psychosocial impairment and placed him at risk for injury, impaired dignity, and decreased quality of life. The severity was determined to be actual harm based on the reasonable person concept due to the circumstances of R1's cognitive impairment and inability to self-identify and express his feelings.

The facility identified a census of 36 residents with three residents reviewed for pressure ulcers. Based on record review, observation, and interview, the facility failed to provide Resident (R) 1 with care consistent with professional standards of practice to prevent pressure ulcer development. R1 admitted to the facility on [DATE] without any skin issues to her buttock but had crevices to her bilateral heels from previous pressure ulcers. The facility failed to initiate a turning/repositioning program, cushion for wheelchair, or bilateral heel protectors/offloading to prevent R1 from developing pressure ulcers. On 03/27/23 R1 obtained suspected deep tissue injuries to her left sacrum and bilateral heels. R1's left sacrum wound later progressed into a Stage 4 pressure ulcer (a deep wound that reaches the muscles, ligaments, or even bone) and R1's right heel ulcers progressed to Stage 3 (full thickness pressure injury extending through the skin into the tissue below). This deficient practice also placed R1 at risk for further skin breakdown, delayed healing, and infection. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and hypertension (high blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living (ADLs) except eating. The MDS further documented R1 had intact skin with no pressure ulcers, was at risk for developing pressure ulcers, did not have a pressure reducing device for her chair or bed, and was not on a turning/repositioning program. The Significant Change MDS, dated [DATE], documented R1 had a BIMS score of 15, which indicated intact cognition. The MDS documented R1 required extensive assistance of one to two staff for all AMDS. The MDS further documented R1 had a Stage 4 (a deep wound that reaches the muscles, ligaments, or even bone) pressure ulcer (localized injury to the skin and/or underlying as a result of pressure, or pressure in combination with shear and/or friction). The MDS recorded R1 did not have a pressure relieving device for her chair or bed; R1 was not on a turning/repositioning program, was not receiving a nutrition or hydration interventions to manage skin problems and was not receiving pressure ulcer care. R1's Care Plan, initiated on 03/13/23, directed staff that R1 required assistance of one to two staff for turning/repositioning and required maximum assistance with transfer. The care plan directed staff R1 was incontinent of bowel and directed staff to provide peri care after each incontinent episode. The Care Plan dated 04/06/23 documented R1 had impairment to her skin as evidenced by wounds to her sacral area and bilateral heels. The care plan interventions dated 04/26/23 directed staff to reposition R1 every two hours from side to side while in bed and check R1 for incontinence at turn times, monitor/document location, size and treatment of skin injury and report any abnormalities or failure to heal to R1's primary care physician. The staff were to encourage good nutrition and hydration in order to promote healthier skin for R1 and change out her bed/mattress. The intervention dated 04/11/23 directed staff to refer R1 to a wound care clinic. The intervention dated 04/27/23 directed staff to change R1's foam cushion in her wheelchair to a ROHO cushion (pressure relief cushion that is made of soft, flexible air cells). The interventions dated 05/03/23 directed staff that R1 required an air mattress, as needed pain medication prior to wound treatments, and initiate a wound-vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal). The intervention dated 05/12/23 directed staff to provide R1 with 30 milliliters (ml) of liquid protein twice a day and a multivitamin with minerals to assist R1 with wound healing. The ADL/Rehabilitation Potential Care Area Assessment (CAA), dated 03/20/23, documented R1 required extensive assistance with bed mobility, transfer, locomotion on and off the unit, dressing, and toileting. Possible underlying problems that may have affected R1's functioning was changing cognitive status, communication problems, mood decline, and recent hospitalization . The Pressure Ulcer/Injury CAA, dated 03/20/23, documented R1 was at risk for pressure ulcer injury due to requiring extensive assistance for bed mobility, R1 was frequently incontinent of urine and always incontinent of bowel and had a recent hospitalization . The CAA documented pressure ulcer/injury would be addressed on R1's care plan. The facility failed to address pressure ulcer/injury on R1's care plan until after she had obtained pressure ulcers. The ADL/Functional Rehabilitation Potential CAA, dated 05/03/23, documented R1 required extensive assistance with bed mobility, transfer, locomotion on and off the unit, dressing, and toileting. Possible underlying problems that may have affected R1's functioning was changing cognitive status, communication problems, and mood decline. The Pressure Ulcer/Injury CAA, dated 05/03/23, documented R1 was at risk for pressure ulcer injury due to requiring extensive assistance for bed mobility, R1 was frequently incontinent of urine, always incontinent of bowel, and R1 had a one Stage 4 pressure ulcer. The Health Status Note, dated 03/13/23, documented R1 admitted to the facility at 12:15 PM. A skin assessment revealed R1's sacrum had no redness or open areas. The assessment noted right lateral heel indentions from previous pressure areas and left lateral heel indentions from previous pressure areas. The Braden Scale Assessment, dated 03/13/23, documented R1 had a score of sixteen which indicated R1 was at risk for developing pressure ulcers. The Skin/Wound Note dated 03/27/23, documented the Certified Medication Aide (CMA), reported to the charge nurse that R1 had blisters to her buttocks. An assessment revealed three open areas where blisters had opened. The area was firm and measured 5.6 centimeters (cm) by 6.2 cm with purple bruising to the peri wound (area around the wound). R1 complained of tenderness to the area when touched. R1 was alert but unable to notify staff in time when she needs to use the toilet. A bordered foam was applied to the area for protection and added the task to reposition every two hours and check for incontinence. The staff notified R1's primary care physician who told the facility wound nurse to let him know if wound care was needed. The Task History in R1's EMR documented a pressure relieving cushion in R1's wheelchair at all times was initiated on 03/27/23. The Task History also documented R1 required turning and repositioning and staff were to check for incontinence, initiated on 03/27/23. The Task History lacked a task for heel protectors to R1's bilateral heels. The Skin/Wound assessment dated [DATE], documented R1 had pressure injuries to her left buttock, right heel, and left heel that were all suspected deep tissue injuries. The assessment lacked any measurements and/or description. The Health Status Note, dated 03/31/23, documented R1's primary care physician ordered wound care to evaluate and treat the open sore to R1's buttock. The Plan of Care Note dated 04/03/23, documented staff placed shepherd's hooks (device to assist with turning and repositioning in bed) to R1's bed to increase bed mobility with turning/repositioning. The Skin/Wound Note dated 04/06/23, documented the open area to R1's sacrum measured 5.6 cm by 6.2 cm with a depth of 0.4 cm at the 5 to 6 o'clock area. The wound bed consisted of 75 percent (%) red granulation (new tissue formed during wound healing) and 25% of yellowish brown thick adherent slough (dead tissue, usually cream or yellow in color) with moderate amount of serosanguineous (semi-thick, blood-tinged drainage) to purulent (producing or containing pus) drainage, and slight odor. R1 complained of tenderness to the area when touched. Interventions noted: changed out bed/mattress, remind staff to report to charge nurse if dressing was soiled or off, so it could be replaced, continue to reposition every two hours from side to side when in bed and check for incontinence, and continue with cushion to her wheelchair. New concern to R1's right lateral heel noted, with red drainage noted on R1's sock and bed. R1 had a blood blister to the right lateral heel that was draining by a 0.3 cm slit and entire area measured 2.5 cm by 1.7 cm, dark red in color and tender to touch. The staff cleansed the area and applied skin prep (liquid skin protectant) and covered with a foam dressing. The Health Status Note dated 04/06/23, documented the wound nurse notified Administrative Nurse D and R1's responsible party of the new area to R1's right heel. The staff sent a request for a wound clinic referral to R1's primary care physician. The staff educated R1's responsible party on R1 no longer using Prevalon boots (special pressure reducing heel protectors) and would start using a foot cushion, and the facility changed out R1's mattress. R1's responsible party voiced understanding. The Skin/Wound Note dated 04/07/23, documented the facility received new orders from R1's primary care physician regarding R1's wound including to start Clindamycin (antibiotic) 300 milligrams (mg) by mouth, three times a day for seven days, and for the wound care clinic to evaluate and treat. R1's Electronic Medication Administration Record (EMAR) for April of 2023 documented the administration of Clindamycin 300 mg, three time a day for seven days for R1's wound infection. The Health Status Note dated 04/11/23, documented R1 returned from an appointment at the wound care clinic with orders to place Santyl (a prescription enzyme used to help break up and remove dead skin and tissue of a wound) to the wound beds of R1's right heel and left buttock, then cover with Mepilex (absorbent, bordered foam dressing) foam; apply Sorbact (a bacteria and fungi binding wound dressing) to the wound bed of the left heel, then cover with Mepilex foam, and change every twenty-four hours. The note documented R1 had a Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) to her left heel and Stage 3 pressure ulcers to her right heel and left buttock. R1 would have a return appointment in one week and noted wound cultures were obtained from all wounds. The Skin/Wound Note dated 04/13/23, documented the completion of R1's wound treatment that morning. R1's left sacral area was a Stage 3 pressure ulcer that measured 5.6 cm by 5.5 cm with an open area with eschar (dead tissue) at one o'clock with a depth of 0.7 cm. A large amount of red to purulent drainage expressed from the wound with foul odor. 75% of the wound consisted of dry eschar and the peri wound was reddened. R1 complained of discomfort with cleansing of the wound. R1's right lateral heel Stage 3 pressure ulcer, that started out as a blood blister, measured 3.5 cm by 3.3 cm with moderate amount of serosanguineous drainage, and no redness to the peri wound. R1 had no complaints of discomfort. R1's left medial heel Stage 2 pressure ulcer, that started out as a blood blister, measured 1.5 cm by 1.6 cm. The wound bed consisted of granulation tissue and the peri wound was without redness. R1 had no complaints of discomfort. Interventions: R1 to be repositioned every two hours, use foot/leg cushion to offload pressure to heels, cushion in wheelchair, and antibiotic therapy. Staff notified the wound care clinic was on R1's sacral wound drainage. The Health Status Note dated 04/14/23, documented R1's primary care physician ordered Augmentin (antibiotic) 875 mg by mouth twice a day for ten days for wound infection. The Infection Note dated 04/15/23, documented R1 received Augmentin for her left buttock wound infection and R1 complained about pain at the site. The Health Status Note dated 04/18/23, documented R1 returned from her wound care clinic appointment. The wound care clinic ordered the facility to continue with the same dressing to R1's bilateral heels but changed the dressing to R1's left buttock to Santyl in the wound bed followed by saline moistened gauze, followed by dry gauze, and then placed a sacral border dressing. The facility was ordered to change the dressings daily. The Infection Note dated 04/24/23, documented R1 received her last dose of Augmentin for her wound infection. The Health Status Note dated 04/27/23, documented R1 had returned from the wound care clinic appointments. The wound care clinic notes documented R1's coccyx (area at the base of the spine) wound extended to the fascia (a thin sheath of fibrous tissue enclosing a muscle or other organ). New orders included Santyl to coccyx wound covered with moist gauze and then covered with ABD (large pad to absorb drainage) and place barrier cream to peri wound and change dressing daily. The orders for R1's right heel wound included to apply Santyl to the wound bed then Adaptic (a non-adhering dressing that helps protect regenerating skin), ABD, and wrapped with roll gauze with daily dressing change. The order continued to direct the facility to ensure Prevalon boots were on to bilateral heels at all times unless transferring or weight bearing, position R1 off of her back in bed at all times, and limit R1's time up in her wheelchair for meals to no longer than forty-five minutes. The wound care clinic directed the facility to apply a wound vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) for R1's coccyx wound and bring to the next appointment. The wound care clinic directed the facility to place a foam dressing to R1's left heel and change Monday, Wednesday, and Friday. R1 would return the wound care clinic in one week. The Skin/Wound Note dated 04/28/23, documented the Stage 4 pressure ulcer to R1's left sacral area measured 4.9 cm by 6.5 cm with a depth of 2.5 cm and tunneling (an opening underneath the surface of the skin) of 1.7 cm at eight o'clock. The wound was noted to have 90% red granulation tissue with moderate serosanguineous drainage without odor and the peri wound was without redness. The Stage 3 pressure area to R1's right heel measured 1.1 cm by 0.9 cm by 0.1 cm with 90% slough, scant drainage, and peri wound without redness. The Stage 2 pressure ulcer to R1's left heel measured 0.6 cm by 0.2 cm. The area was dry without drainage or redness to the peri wound. R1 was limited at forty-five-minute intervals up in her wheelchair, repositioned side to side when in bed, and Prevalon boots on at all times. The Skin/Wound Note dated 05/01/23, documented staff notified R1's primary care physician regarding R1 having a second open area on her coccyx to the right of the larger wound, that measured 0.5 cm by 1 cm. The physician ordered to continue R1's dressing as ordered. The Communication with Family/NOK/POA Note dated 05/02/23 documented staff notified R1's responsible party the facility would place an air mattress to R1's bed that evening when R1 was up for supper. On 04/27/23 therapy changed out the foam cushion in R1's wheelchair to a Roho cushion. The facility nurse relayed to R1's responsible party staff were repositioning R1 every two hours while in bed, Prevalon boots to her heels at all times while in bed and would only up for forty-five minutes at a time to off load pressure to the coccyx area. As needed Tramadol (pain medication) was administered to R1 prior to dressing changes. R1's responsible party expressed concern that R1 would need all forty-five minutes to eat as she was a slow eater. R1's responsible party voiced concern the Tramadol was not helping much with pain as R1 complained to her about pain. R1's responsible part stated he would be at R1's wound care clinic appointment the next day for the wound vac placement. The Communication Note dated 05/03/23, documented the facility requested orders for a protein supplement to promote wound healing process. The Nutrition/Dietary Note dated 05/03/23, documented due to R1 having pressure areas on her coccyx and heels, the dietitian suggested a multi-vitamin with minerals daily and one ounce of Prostat (protein supplement) twice a day to aid in wound healing. The Prostat will provide R1 an additional thirty grams of protein and two hundred calories daily. The Health Status Note dated 05/03/23, documented R1 had returned from the wound care clinic with wound vac in place to left sacrum, change Monday, Wednesday, and Friday. The wound care clinic ordered the facility not to change the dressing to R1's right heel and to continue a bordered foam dressing to R1's left heel and change weekly or as needed. The wound care clinic also ordered the facility to continue to have R1 only up thirty to forty-five minutes for meals and then back to bed side to side with heel protectors on. The Health Status Note dated 05/04/23, documented R1's wound vac was in place and working properly. Serosanguineous drainage was noted in the wound vac tubing and negative pressure was set at 120 millimeters of mercury (mm/Hg). R1 complained of pain and staff administered Tramadol. The Health Status Note dated 05/08/23, documented R1's wound vac dressing was changed and R1 received as needed Tramadol prior to the dressing change. During treatment R1 complained of pain when her wound was being cleansed. The treatment to her bilateral heels would be completed by the wound care clinic on 05/10/23. The Health Status Note dated 05/18/23, documented R1 returned from the wound care clinic. The wound care clinic noted R1's wound to her sacrum was improving. The wound care clinic directed the facility to place moist Prisma (wound dressing) over the fascia and cover with Adaptic spiral cut wound vacuum black foam to fill the depths and tunnels as well as the entire wound and increase the suction to 150 mm/Hg and change the wound vac dressing on Tuesday, Thursday, and Saturday. Place Prisma, foam and drape to the sacral satellite wound. R1's right heel wound was improving and new orders to place Sorbact to the wound bed and cover with foam, with a barrier cream to the peri wound, and dressing changes on Tuesday, Thursday, and Saturday. The Health Status Note dated 05/23/23, documented the completion of R1's wound vacuum dressing change. When removing the old dressing, the nurse noted the drape was not placed on the skin when channeling the tubing up R1's right hip. Skin irritation noted where the black foam was on R1's skin. R1's wound bed odorous after removing the old dressing but after cleansing the wound, noted no odor. R1's sacral wound bed was beefy red and moist, with a moderate amount of drainage in the cannister. R1 received Tramadol forty-five minutes prior to the dressing change. The Health Status Note dated 06/15/23, documented R1 had returned to the facility from the wound care clinic with new orders to place Duoderm (wafer type moisture-retentive wound dressing used for partial and full-thickness wounds leaking fluids) to the peri wound around the sacral wound, place moist Prisma to the undermining of the wound and over the bone with Adaptic spiral cut black foam to tuck into the tunnel undermining and then apply foam over the undermining area over draped skin and continue the wound vacuum at 150 mm/Hg and change Tuesday, Thursday, and Saturday. Upon dismissal from the nursing facility place saline moist gauze to wound and cover with ABD with barrier cream to peri wound. The Health Status Note dated 06/16/23, documented the healed Stage 3 pressure ulcer to R1's right heel. The Stage 4 pressure ulcer to R1's sacrum, measured 4.2 cm by 3.5 cm by 2.2 cm, had improvement, and a moderate amount of serosanguineous drainage noted with no odor, peri wound flesh toned, and the satellite wound continued to show signs of healing. R1 would be going home next week, and Home Health would perform wound care. The Discharge Not, dated 06/20/23, documented R1 discharged from the facility with her responsible party. On 10/19/23 at 10:00 AM, Licensed Nurse (LN) G verified R1 did not have a turning repositioning program, a pressure reducing mattress or wheelchair cushion until after she obtained wounds to her left sacrum and bilateral heels. On 10/19/23 at 10:45 AM, Certified Nurses Aide (CNA) M stated she R1 had not been on a turning/repositioning program prior to her acquired pressure ulcer. On 10/19/23 at 11:15 AM, Administrative Nurse D stated she did not feel the initial skin assessment was completed correctly, because the wounds just popped up out of nowhere and there had to be underlying skin issues on admission to the facility. The facility's undated Pressure Ulcer Management Policy documented it is the policy of the facility that all residents are considered to have some risk for the development of pressure ulcers. A licensed nurse will perform a full body assessment on the day of admission to the facility and then weekly thereafter. For the purpose of this policy, a skin assessment utilizes the Braden Scale. After conducting an inspection of the resident's skin, the nurse will review the resident assessment protocol for pressure ulcers to identify risk factors for the development of pressure ulcers. An immediate plan to reduce a residents' risk of pressure ulcers or to treat an existing pressure ulcer will be developed and implemented. The facility failed to initiate a turning/repositioning program, cushion for wheelchair, or bilateral heel protectors to prevent R1 from developing pressure ulcers which resulted in R1 developed pressure injuries which evolved into Stage 3 and 4 wounds. This deficient practice also placed R1 at risk for further skin breakdown, delayed healing, and infection.

The facility identified a census of 37 residents. Two residents were reviewed for roommate/room change notification. Based on observations, record review, and interviews, the facility failed to provide written notification, including the reason for the change, to Resident (R) 1 and/or her representative before R2 became her roommate. This deficient practice had the risk for miscommunication between R1/her representative and the facility and placed R1 at risk for decreased psychosocial well-being related to getting a new roommate. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance and repeated falls. The Annual Minimum Data Set (MDS)' dated 04/30/23, documented R1 had Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. R1 was independent with setup help for bed mobility and eating; required limited assistance with one staff for transfers, walking, locomotion, dressing, toileting, and personal hygiene. R1 had one non-injury fall since last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/05/23, lacked an analysis of findings. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 05/05/23, lacked an analysis of findings. The Care Plan, last revised 04/21/22, documented R1 had an ADL self-care performance deficit related to weakness and balance deficits and directed R1 chose to transfer independently at times but was encouraged to call for assistance. The Care Plan, last revised 04/21/22, documented R1 had impaired cognitive function/dementia or impaired thought processes. The Care Plan documented an intervention, last revised on 05/09/22, that directed staff used R1's preferred name, identified themselves at each interaction, faced R1 when speaking to her and made eye contact, reduced any distractions, and provided R1 with necessary cues and allowed her time to express her thoughts. R1's medical record lacked evidence that she and/or her representative were notified verbally or in written form that she was to receive a roommate. R2's EMR revealed a Communication with Family note on 07/19/23 at 02:42 PM that documented R2's representative gave permission to move to another room. The note recorded staff gave R2's representative the new room number, and that he was to be notified when R2 moved. R2's EMR revealed a Health Status Note on 07/20/23 at 01:35 PM that R2 and her belongings moved to R1's room and a message was left for her representative that she had been moved. On 07/31/23 at 02:00 PM, R1 laid in bed and asked the staff in the hallway where her husband was. She used the left bed rail with her left arm to move from a lying to a sitting position in bed. On 07/31/23 at 02:06 PM, Social Services X stated when a resident was to move rooms or to get a roommate, she contacted the family to let them know along with the resident. She stated the notification was documented in the progress notes. Social Services X stated R1and her family were not notified that she was to get a roommate. On 07/31/23 at 03:01 PM, Maintenance U stated the day R1 was to get a roommate, he moved a bed into the room and R1 asked if there were ants in the bed to run the roommate away. He stated R1 asked if there was anything she could throw at her and decided she would just sing to get the roommate out. Maintenance U stated R1 did not seem happy about getting a roommate and stated he reported her comments to a Certified Medication Aide (CMA). On 07/31/23 at 04:04 PM, Administrative Nurse D stated Social Services X did the family notifications to let them know about a new roommate and to see if it was okay. She stated it was reported to her from Maintenance U that R1 was plotting on how to get rid of R2. The facility's Transfers Within the Facility policy, not dated, directed transfers within the facility were made with the consultation of the resident and/or surrogate decision-maker. The resident and family were consulted and the reasons for the move were explained, and the resident or responsible party were notified prior to transfer. The policy directed if the resident was being transferred to a shared bedroom, any resident currently residing in that room was notified and the notification was documented in each resident's clinical record. The facility failed to provide written notification, including the reason for the change, to R1 and/or her representative before R2 became her roommate. This deficient practice had the risk for miscommunication between R1/her representative and the facility and placed R1 at risk for decreased psychosocial well-being related to getting a new roommate.

The facility identified a census of 37 residents. The sample included one resident reviewed for bed rail usage. Based on observation, record review, and interviews, the facility failed to assess Resident (R) 1 for safe usage of bed rails, failed to educate R1's Durable Power of Attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to)/representative on the risks versus benefits of using bed rails, and failed to obtain consent from the DPOA/representative to utilize bed rails on R1's bed. This deficient practice had the risk for accidents and/or hazards and miscommunication between the DPOA/representative and facility. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance and repeated falls. The Annual Minimum Data Set (MDS)' dated 04/30/23, documented R1 had Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. R1 was independent with setup help for bed mobility and eating; required limited assistance with one staff for transfers, walking, locomotion, dressing, toileting, and personal hygiene. R1 had one non-injury fall since last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/05/23, lacked an analysis of findings. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 05/05/23, lacked an analysis of findings. The Care Plan, last revised 04/21/22, documented R1 had an ADL self-care performance deficit related to weakness and balance deficits and directed R1 chose to transfer independently at times but was encouraged to call for assistance. The Care Plan, dated 07/25/23, documented R1 had a potential/actual impairment to skin integrity of the left upper arm and directed staff padded bed rails, wheelchair, or any other source of potential injury if possible. R1's medical record lacked evidence of a bed rail assessment, bed rail education, and/or bed rail consent. On 07/31/23 at 02:00 PM, R1 laid in bed and asked staff in the hallway where her husband was. She used the left bed rail with her left arm to move from a lying to sitting position in bed. On 07/31/23 at 03:48 PM, Licensed Nurse G stated if a resident requested to have bed rails put on, the facility put bed rails on, but she had not seen an assessment or consent form that was used before putting bed rails on the bed. On 07/31/23 at 04:04 PM, Administrative Nurse D stated the facility was not able to use full or half rails but quarter rails were used at nursing's discretion to her knowledge. She stated she found a bed rail policy with a consent form that was not being used but she would be implementing it from that point on. The facility's Bed Rails policy, not dated, directed the facility ensured correct installation, use and maintenance of bed rails including but not limited to: the facility assessed the resident for risk of entrapment from bed rails prior to installation; the facility reviewed the risks and benefits of bed rails with resident/representative and obtained informed consent prior to installation; the facility ensured the bed's dimensions were appropriate for the resident's size and weight; and the facility followed the manufacturer's recommendations and specifications for installing and maintaining bed rails. The facility failed to assess R1 for safe usage of bed rails, failed to educate R1's DPOA/representative on the risks versus benefits of using bed rails, and failed to obtain consent from the DPOA/representative to utilize bed rails on R1's bed. This deficient practice had the risk for accidents and/or hazards and miscommunication between the DPOA/representative and facility.

The facility identified a census of 37 residents. The sample included four residents with two residents reviewed for abuse. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 received the necessary protective oversight to prevent potential abuse and/or neglect when the facility staff failed to report bruises of unknown origin as potential abuse or neglect to the State Agency (SA), within the mandated time frame. This deficient practice placed the resident at risk for unresolved and ongoing abuse, a decrease in psychosocial well-being, and further injuries. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance and repeated falls. The Annual Minimum Data Set (MDS)' dated 04/30/23, documented R1 had Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. R1 was independent with setup help for bed mobility and eating; required limited assistance with one staff for transfers, walking, locomotion, dressing, toileting, and personal hygiene. R1 had one non-injury fall since last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/05/23, lacked an analysis of findings. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 05/05/23, lacked an analysis of findings. The Care Plan, last revised 04/21/22, documented R1 had an ADL self-care performance deficit related to weakness and balance deficits and directed R1 chose to transfer independently at times but was encouraged to call for assistance. The facility's Investigation dated 07/26/23, documented on 07/22/23, R1 was found to have two small blue/yellow spots on her left upper extremity (LUE). R1 complained of increasing pain so the nurse had R1 transferred to the emergency room (ER) for further evaluation. The ER found no acute fracture with a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) noted in the ER report. Upon examination throughout the weekend, R1's LUE appeared to become increasingly swollen, red, tender, and warm to touch. She was sent to the walk-in clinic on 07/24/23 for further evaluation and was started on antibiotics. Licensed Nurse (LN) G interviewed R1 at the time of the noticed injury about abuse/neglect potential, R1 had memory/cognitive deficits but did not recall an injury or abuse. Administrative Nurse D interviewed evening staff from 07/21/23 to determine when the injury occurred and any evidence of abuse; there were no obvious signs of abuse, and no injury was noted by staff. The Notes tab of R1's EMR revealed the following: A Health Status Note on 07/22/23 at 08:15 AM documented at 06:00 AM, LN G observed R1 turning over on her left side in bed, adjusting the air conditioner in the room. At 07:30 AM, R1 complained about her left upper arm and showed LN G who noted on her upper left inner arm, a five centimeters (cm) by six cm light purple, yellow bruise and on her upper left lateral arm, a six cm by eight cm light purple bruise. R1 complained of not being able to lift arm and was asked not to move her left arm. The Note documented R1 denied falling and did not remember hurting her left arm. R1's family was notified and that she was to be transferred to the ER. Administrative Nurse D was notified. A Root Cause Analysis note on 07/24/23 at 09:00 AM documented R1 was evaluated for reported LUE pain/bruising. Nursing staff reported over the weekend [NAME] R1 had pain/bruising that started on 07/22/23 as a small yellowish area that progressively became larger in size and red. Staff reported R1 had no injuries, no falls, and no complaints on 07/21/23 evening when cares were provided. R1 got a new roommate on 07/20/23, however, the roommate was chair bound with severe cognitive deficit. There was no physical altercation noted or potentially possible given the roommate's level of function. Family and provider were informed of R1's condition and the incident report was called to the SA. On 07/31/23 at 02:00 PM, R1 laid in bed and asked staff in the hallway where her husband was. She used the left bed rail with her left arm to change from a lying to sitting position in bed. On 07/31/23 at 12:06 PM, Administrative Nurse D stated LN G called her on 07/22/23 that she planned to send R1 to the ER for lack of motion and two yellowish/blue spots on her left arm that might have been bruising. She stated the investigation process was started on 07/24/23 and she called the SA hotline to report the incident that day. On 07/31/23 at 03:33 PM, Certified Nurse Aide (CNA) M stated if there was an injury of unknown origin, he contacted the nurse so she could assess it then he filled out a witness statement. On 07/31/23 at 03:48 PM, LN G stated if there was an injury of unknown origin, the doctor, family, and Administrative Nurse D were notified. On 07/31/23 at 04:04 PM, Administrative Nurse D stated injuries of unknown origin were reported to the SA within two hours. Staff reported any injuries of unknown origin to the provider, family, and to her. She stated the nurse on duty did the initial investigation and she did the actual investigation for the SA when she came in. Administrative Nurse D was not sure who the abuse coordinator was for the facility but said it was probably Social Services X or herself. The facility's Abuse, Neglect, and Exploitation Policy, not dated, directed initial reporting of allegations were reported by the Administrator or designee within two hours or within 24 hours to the SA. The policy directed if events that caused suspicion did not result in serious bodily injury, the facility reported to the SA within 24 hours. The facility failed to ensure R1 received the necessary protective oversight to prevent potential abuse and/or neglect when the facility staff failed to report bruises of unknown origin as potential abuse or neglect to the SA, within the mandated time frame. This deficient practice placed the resident at risk for unresolved and ongoing abuse, a decrease in psychosocial well-being, and further injuries.

The facility had a census of 36 residents. The sample included 15 residents, with one closed record for death, reviewed. Based on record review and interview, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 41, who desired resuscitative measures indicated by his full code status (code status determination for residents who wish to receive CPR). On [DATE] at 05:00 PM, Licensed Nurse (LN) G observed R41 with irregular respirations. At 05:10 PM, LN G checked on R41 again and identified R41 had no pulse or respirations. Without considering R41's code status or initiating CPR, LN G placed a call to R41's representative, who did not answer. LN G then called Administrative Nurse E who informed LN G that R41 was a full code and directed LN G to start CPR. At 05:22 PM, LN G activated 911 and then initiated CPR. The facility failed to ensure staff immediately initiated CPR upon identification of R41's cardiac arrest when staff delayed 12 minutes to place calls to resources other than 911. The delay placed R41 and all residents with a full code status in immediate jeopardy. The facility further failed to have a system in place to identify and ensure CPR certified staff were always present in the facility. Findings included: - R41's Electronic Medical Record (EMR) documented R41 had diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), polyneuropathy (nerve disease, that affects many nerves), and dependence on wheelchair for mobility. R41's Quarterly Minimum Data Set (MDS), dated [DATE], documented R41 had a Brief Interview of Mental Status (BIMS) score 14, which indicated intact cognition. The MDS documented R41 required extensive staff assistance with activities of daily living (ADL) except eating. R41's Full Code Care Plan, revised [DATE], documented R41 desired to be a full code, and instructed staff to perform CPR in a code situation. The Physician Order, dated [DATE], instructed staff R41 was full code status. The [DATE] at 12:15 PM, Nurse's Note, documented R41 had an episode that morning where he had tremors (uncontrolled shaking) and was diaphoretic (sweaty). The note documented R41 had a blood pressure of ,d+[DATE] millimeters of Mercury (mmHg), pulse of 78 beats per minute, respirations of 20 per minute, and oxygen saturation of 90 percent (%) on room air. R41 ate a little breakfast then went back to bed. The note documented staff elevated the head of his bed. The [DATE] at 06:37 PM, Nurse's Note documented LN G entered R41's room at 05:00 PM and observed R41's respiration were rapid, then left the room. The note documented at 05:10 PM, LN G returned to R41's room and noticed R41 had oral secretions coming out of his mouth. LN G retrieved a cool cloth and washed around R41's mouth and realized R41 was not breathing. The note documented LN G checked R41's pulse and respiration at that time and noted both pulse and respirations were absent. LN G also noticed mottling (blotchy, red-purplish marbling of the skin, due to lack of blood flow) of R41's lower extremities. LN G then attempted to phone R41's representative who did not answer. LN G left a message for R41's representative then phoned Administrative Nurse E. Administrative Nurse E informed LN G that R41 was a full code and instructed LN G to call 911 and start chest compression. The note further documented LN G called 911 at 05:22 PM, then started CPR on R41. On [DATE] at 12:54 PM, LN H stated a stop sign sticker below the name plate outside the resident's doors, indicated the resident's code status; a red (sticker) indicated a do not resuscitate status (DNR) and green (sticker) indicated a full code status. LN H stated the residents' code status was also in the medical record. On [DATE] at 12:58 PM, LN G verified she had not checked R41's code status on the stop sign sticker by R41's name tag outside his door. LN G stated she just assumed R41 was a DNR because so many of the residents who resided in the facility were DNRs. She stated she did not even think about starting CPR. On [DATE] at 01:33 PM, Administrative Nurse D stated residents code status was indicated by a colored tags outside their room door by their name. Administrative Nurse D stated she expected staff to initiate CPR immediately if the resident was a full code. Administrative Nurse D said if staff did not know a resident's code status, staff should yell for help and immediately start CPR. On [DATE] at 01:49 PM, Administrative Nurse D stated the facility had no documentation regarding in-service training or re-education on CPR procedure and the facility did not provide CPR training for nurse aides or medication aides. Administrative Nurse D stated the facility did not have a list of staff certified in CPR. On [DATE] at 02:45 PM, LN G verified she had let her CPR certification lapse in [DATE]. On [DATE] at 04:00PM, Administrative Nurse D verified there were five residents currently in the facility with a full code status. The facility's CPR Policy, undated, documented any resident designating a desire for no resuscitation and is found to be without vital signs would have a small red stop sign sticker placed on the name tag of the door of the resident. The policy documented CPR would be initiated when cardiac arrest occurs for a resident who has requested CPR in the advance directive, when a resident has not formulated an advance directive, and when the resident does not have a valid DNR order from a licensed physician or professional practitioner. The facility failed to ensure staff immediately initiated CPR to R41, who desired resuscitative measures indicted by his full code status when staff delayed 12 minutes to place calls to resources other than 911. The delay placed R41 and five other residents with a full code status in immediate jeopardy. On [DATE] the facility implemented the following corrective actions to address the immediacy. Staff received education on signs/identification of cardiac arrest. Staff educated on when to start CPR procedure including location of equipment. Staff educated on CPR Policy. CPR certification status of all direct care staff was assessed to ensure currently certified CPR staff were on duty at all times. DNR/Full Code status of all residents reviewed. Door identifiers on resident's doors checked for accuracy. Removal of the immediacy was verified during the onsite survey on [DATE]. The scope and severity remained at the level of G to indicate the actual harm for R41.

The facility had a census of 25 residents. The sample included 14 residents with five reviewed for nutrition. Based on observation, record review, and interview, the facility failed to develop and implement effective nutritional interventions for one of five sampled residents, Resident (R) 17, who had a weight loss of 10.39% or 15.6 pounds (lbs) in six months. Findings included: - R17's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS recorded the resident required supervision with oversight, encouragement, or cueing, with eating. The Nutrition Care Area Assessment (CAA), dated 11/25/19, documented the resident fed himself, and ate a regular mechanical soft ground meat diet with thickened liquids. The CAA documented the resident weighed 152.4 lbs, 68 inches tall, and received [MEDICATION NAME] (a medication to treat depression and anxiety, and increased weight). The Nutrition Care Pan, dated 02/25/20, documented the resident had a potential nutritional problem due to the diet ordered. The care plan directed staff to serve the diet ordered, monitor intake and record every meal. Registered Dietician (RD) to evaluate and make diet change recommendations as needed. R17's Vital Signs- Weights documented the following weights: 12/17/19 - 150.2 lbs. 1/20 - no weight recorded 02/04/20 - 143.2 lbs. 03/12/20 - 140.4 lbs. 04/10/20 - 136.0 lbs. 05/18/20 - 138.2 lbs. 06/03/20 - 135.2 lbs. 07/09/20 - 134.4 lbs. 07/12/20 - 134.6 lbs. 08/20/20 - 132.6 lbs. (loss of 15.6 lbs. or 10.39 % in six months) 09/07/20 - 131.4 lbs. (loss of 18.8 lbs. or 12.52 % in seven months) The Meal Intake Log from 08/11/20 until 09/09/20 documented the resident had a total of 90 meals, with the following intakes: 22 meals at 0-25% 10 meals at 26-50% 26 meals at 51-75% 32 meals at 76-100% The Physician Order, dated 08/23/18, directed staff to administer a regular diet, mechanical soft texture, and nectar (liquids easily pourable consistency). The RD Assessment, dated 11/16/19, documented the resident's current weight was 152.0 lbs which was stable. The assessment documented the resident received [MEDICATION NAME], with a side effect of weight gain and [MEDICATION NAME] (fluid medication) 20 milligrams (mg) which could cause some weight fluctuations. The assessment documented the resident received a regular diet with mechanical soft texture and nectar thick liquids. The assessment directed staff to monitor the resident's weight trends with a goal for weight maintenance and no significant weight changes. The Physician Order, dated 02/19/20, directed staff to administer an in house supplement, twice daily for increased calorie and to prevent weight loss. The Physician Order, dated 08/20/20, directed staff to administer an in house supplement, three times a day for increased calories. The RD Assessment, dated 08/21/20, documented the resident's annual current weight was 132.0 lbs, down 2 lbs in one month, 4.3 lbs in three months, and 6 lbs in six months. The assessment documented the resident's weight had been trending down over the past six months, no significant weight changes, diet was regular with intakes averaging 50-75% of meals and increased the supplement from two to three times a day on 08/02/20. The assessment directed staff to monitor the resident's weight trends with a goal for gradual weight gain and no significant weight changes and refer to the RD as needed. On 09/03/20 at 07:55 AM, observation revealed the resident sat in his wheelchair in the living room dressed in street clothes and drank all of his vanilla nutritional supplement. On 09/03/20 at 11:35 AM, the resident sat in a wheelchair at the dining room table with mechanical soft chicken fried steak, mashed potatoes, gravy, and harvest beets. Continued observation revealed the resident independently ate approximately half of the meal. On 09/08/20 at 01:10 PM, Administrative Nurse B stated the resident had a weight loss of 15.6 lbs in six months, would review the RD's assessments, and reassess the resident's nutritional needs. On 09/09/20 at 03:30 PM, Certified Dietary Manager (CDM) BB verified the resident lost 18.8 lbs since 12/17/19. CDM BB stated she recommended a speech therapy assessment in August 2020. CDM BB stated the resident had recently been mixing his food and not eating it, and continued to lose weight. CDM BB stated she would recommend staff sit with the resident to cue and assist him to eat. On 09/09/20 at 04:10 PM, Consultant (C) GG verified the resident lost 18.8 lbs since 12/17/19. C GG recorded she evaluated the resident's weight loss, and on 02/16/20 recommended in house supplement twice daily. The 05/24/20 review recorded the resident's weight stable and made no recommendations. The 08/21/20 review recorded a weight loss and she recommended to increase the in house supplement to three times a day. C GG verified she would recommend staff provide the resident with a scoop of ice cream three times a day. C GG verified she would add new interventions for the resident to receive staff assistance with eating due to his forgetfulness. On 09/10/20 at 11:25 AM, Administrative Nurse D verified the facility identified weight loss and interventions at risk meetings, however they have not had any meetings since March 2020 due to personnel changes. Administrative Nurse D verified the present system to identify weight loss was C GG would review the resident's weight at least monthly and send an email to the facility with recommendations and interventions. Upon request the facility did not provide a policy for Weight Assessment, Interventions or Loss. The facility failed to implement timely and effective interventions to prevent weight loss for R17, who lost 15.6 pounds (10.39 % in six month), resulting in significant weight loss, placing the resident at risk for increased health concerns.

The facility had a census of 29 residents. The sample included 4 residents with 3 reviewed for abuse. Based on observation, record review and interview the facility failed to ensure all opposite gender residents, 14 in the Assisted Living, and 22 in the Nursing Center (who gather together in either the AL dining room or NC dining room for activities, which is connected by a hallway) were free from resident to resident sexual abuse, of inappropriate touching by resident #1 of resident #5 on two different incidents, which placed all opposite gender residents in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 12/29/16, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 8, which indicated moderately impaired cognition and physical behavior symptoms directed toward others 1 to 3 days. The MDS recorded the resident required extensive assistance of 2 staff for bed mobility, transfers, locomotion on unit, dressing, toilet use, personal hygiene, bathing, extensive assistance of 1 staff assistance for locomotion off unit, and limited assistance of 1 staff assistance for eating. The MDS recorded the resident had functional impairment in (ROM) Range of Motion on one side of upper and lower extremities, and used a wheelchair for mobility. The 10/6/16 Cognitive Loss/Dementia (CAA) Care Area Assessment recorded the resident had a [DIAGNOSES REDACTED]. the brain) and altered mental status. The CAA recorded the resident was able to answer yes/no questions best, had behaviors at times, and directed staff to ensure he/she understood what they were doing prior to completing the activity. The CAA recorded the resident's family member reported it was better if staff completed cares on resident's left side. The Alteration in Mood and Behaviors care plan, dated 7/18/16, recorded the resident had a history of [REDACTED]. The care plan instructed staff to monitor the resident's behaviors, increased agitation, depression, non-compliance, and other behavior changes, and document in the nurse's notes or behavioral sheets. When the resident was non-complaint or aggressive, the care plan directed staff to leave the area, try again later, and notify the charge nurse or another staff person to attempt. The care plan instructed staff to encourage the resident to verbalize frustrations, fears, reasons for non-compliance, administer medications as ordered, monitor for effectiveness, and/or notify the physician promptly as needed. The care plan instructed staff to monitor for signs and symptoms of depression, such as increased agitation, crying, loss of appetite, weight loss, and withdrawal. The care plan instructed staff to ensure other residents do not self-propel close to the resident's left side (incorrect documentation, resident's right side) to prevent resident to resident injury. The 2/16/17 care plan update instructed staff to provide close supervision when the resident was around others, and encourage others to approach resident on his/her left side, as resident had reaching out behaviors with his/her right upper extremity. The 2/23/17 care plan update instructed staff to keep others out of arms reach on the resident's right side related to grabbing outward tendencies. The 2/27/17 care plan update instructed staff to explain what they are doing prior to performing (ADLs) Activities of Daily Living and ensure the resident understood, as he/she displayed increased agitation with cares. Review of Resident #1's medical record lacked documentation of the incident that occurred on 2/16/17 between Resident #1 and an (AL) Assisted Living resident (Resident #5). The 2/16/17 at 6:50 PM, AL nurse's note recorded Resident #5 reported to the (CMA) Certified Medication Aide that another resident from the Nursing Center had inappropriately touched him/her while he/she was having people sign a birthday card. The note recorded Resident #5 was counseled that Resident #1 did have tendencies to do this, and Resident #5 should distance himself/herself from said resident. The 2/16/17 at 6:50 PM, AL nurse's note lacked documentation regarding how or where Resident #1 touched Resident #5. The 2/20/17 physician's visit notes recorded the resident had inappropriately grabbed another (opposite gender) resident standing close to him/her, between the legs. The 2/24/17 at 5:36 PM, nurse's notes recorded staff alerted the nurse at approximately 3:30 PM that Resident #1 had made contact with Resident #5's bottom with his/her right hand, and after that happened, the AL resident swatted him/her on the right shoulder. The note recorded staff moved resident #1 away from the AL resident and placed him/her at a different table, and staff examined the resident's shoulder with no areas of redness or impairment noted. The note recorded the nurse spoke with staff and instructed them to keep others out of close proximity of the resident's right hand to avoid contact. The note recorded the resident's physician would be faxed this nurse's note, and staff notified the resident's DPOA (Durable Power of Attorney). The 3/3/17 at 10:41 AM, nurse's notes recorded resident #1 continued on 1:1 cares today, the resident grabbed at staff in inappropriate ways during morning cares, staff redirected the resident several times during cares to hold on to the lift and not to grab staff. On 3/1/17 at 11:23 AM, observation revealed the resident seated in the (SDR) South Dining Room for lunch, at a table with 3 same gender residents. Observation revealed resident #1 used his/her right hand, visibly shaky, to eat independently without difficulty. Observation revealed during the meal, resident #1 grabbed the edge of the table with his/her right hand, toward the resident sitting to his/her right, several times. On 3/1/17 at 10:33 AM, Administrative Nurse A stated the resident exerts movements with his/her right hand, and had a history in other facilities of touching or hitting people in an inappropriate fashion. On 3/2/17 at 1:37 PM, Nurse Aide F stated the resident liked to grab at people, if people tell him/her no, he/she became angry and cussed at them. Nurse Aide F stated if you tell him/her that the behavior is not appropriate, he/she said yes it is, because women like that kind of thing. Nurse Aide F stated people never wanted to be on the resident's right side because the resident tried to grab people, it doesn't matter who, child or adult. On 3/2/17 at 4:17 PM, Nurse Aide E stated the resident was totally dependent, he/she could move a little but was not coordinated, and staff had to tell him/her what they were doing step by step, or the resident would become agitated. Nurse Aide E stated the resident was unable to move his/her left side, he/she had a lot of confusion, tried to hit people, grabbed private areas of people walking by, especially if they were on his/her right side. Nurse Aide E stated people needed to stay away from the resident's right side which he/she had control of and can pick up and reach for most anything he/she wanted. On 3/2/17 at 12:50 PM, Nurse C stated the resident had paralysis (the loss of muscle function, sensation, or both) on his/her left side, but was able to move his/her right hand. Nurse C stated the resident liked to touch inappropriately, he/she was aware of what he/she was doing, because he/she smiled and laughed when he/she did it. Nurse C stated the resident had a history of [REDACTED].#5 inappropriately in February. On 3/6/17 at 8:52 AM, Resident #5 stated on 2/16/17 he/she was standing between another (NC) Nursing Center resident and Resident #1. Resident #5 asked the NC resident if he/she wanted to sign the birthday card, and while waiting for the NC resident to sign the card, Resident #1 reached between Resident #5's legs near his/her crotch. Resident #5 asked Resident #1, what are you doing?, and Resident #1 just smiled. Resident #5 stated he/she was standing on Resident #1's right side and was shocked because he/she had no idea Resident #1 would ever do that. Resident #5 stated the following morning, Nurse D told Resident #5 the incident had to be reported to the State. Resident #5 stated the incident bothered him/her all day, he/she was unable to sleep. Resident #5 stated the second incident occurred on 2/24/17, when he/she went down to the dining room to help celebrate a resident's birthday. Resident #5 stated he/she sat down at a table with two other NC residents, then got up to wish a resident a happy birthday. Resident #5 stated while he/she was facing the birthday resident, Resident #5 felt someone pinch him/her on the buttock. Resident #5 stated he/she then turned around and saw that it was Resident #1, and hit Resident #1 on the shoulder with the back of his/her hand. Resident #5 stated staff tried to place Resident #1 at the table where Resident #5 was sitting, Resident #5 requested that Resident #1 not be seated there because he/she just assaulted him/her. Resident #5 stated the activity director pulled out another table and moved Resident #1 to the table by himself/herself. Resident #5 stated he/she sat down for a while and started feeling crappy so he/she went up to his/her room and started reading, then he/she started crying. Resident #5 stated that both times Resident #1 touched him/her, he/she just smiled like it was no big deal. Resident #5 stated the staff just told him/her to stay away from Resident #1. On 3/6/17 at 11:57 AM, Nurse D stated the first incident, between Resident #1 and Resident #5 occurred when Resident #5 was having another resident sign a birthday card, when Resident #1 slipped his/her hands between Resident #5's legs, which startled Resident #5. Nurse D stated the second incident occurred in the dining room when staff brought Resident #1 in and placed him/her beside Resident #5. When Resident #1 pinched Resident #5's buttock, Resident #5 was startled and swatted Resident #1's shoulder, causing no injury. Nurse D stated Resident #5 was shocked that this behavior happened to him/her again. The facility's February 2017 Abuse and Neglect Prevention Program policy, defined abuse as any act or failure to act performed intentionally or recklessly that causes harm to a resident including: any sexual act with a resident when the resident does not consent or when the other person knows or should know that the resident is incapable or resisting or declining consent to the sexual act due to mental difficulty, disease disorder, fear of retribution or hardship, or a threat or menacing conduct directed toward a resident that results or might be reasonable or expected to result in fear or emotional distress to a resident. The facility failed to protect opposite gender residents remained free sexual abuse, regarding inappropriate sexual touching and behavior from Resident #1 on two different incidents. This deficient practice placed the opposite gender residents in the facility, in immediate jeopardy. The facility abated the immediate jeopardy on 3/9/17 at 9:00 PM, when the facility placed Resident #1 on one on one supervision on 3/2 and 3/3 when the resident was out of his/her room until the resident was admitted to Geri-psychiatric unit on 3/7/17. Interventions also included: moved resident's place in the dining room where right arm is out of direct traffic of other residents, resident to be one of the last ones to activities with constant supervision by staff or volunteer and have others kept out of arms reach of right hand. The facility will hold a mandatory all staff meeting on 3/10/17 for training of all staff regarding the revised abuse, neglect, and exploitation policy. All staff will be retrained face to face on revised abuse and neglect prevention policy by 3/10/17 or will not be allowed to work until re-educated. Human resources will educate any new hires on abuse and neglect policy. Inter Disciplinary Team will ask on a quarterly basis, if resident's feel safe and if they know who to report concerns to. Social Services Director will review resident rights on freedom from Abuse, Neglect, Exploitation at least twice a year. This deficient practice remained at a scope and severity of an E.

The facility had a census of 29 residents. The sample included 4 residents with 3 reviewed for abuse. Based on observation, record review and interview the facility failed to ensure residents were free from resident to resident sexual abuse, of inappropriate touching by resident #1, which placed all opposite gender residents in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 12/29/16, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 8, which indicated moderately impaired cognition and physical behavior symptoms directed toward others 1 to 3 days. The MDS recorded the resident required extensive assistance of 2 staff for bed mobility, transfers, locomotion on unit, dressing, toilet use, personal hygiene, bathing, extensive assistance of 1 staff assistance for locomotion off unit, and limited assistance of 1 staff assistance for eating. The MDS recorded the resident had functional impairment in (ROM) Range of Motion on one side of upper and lower extremities, and used a wheelchair for mobility. The 10/6/16 Cognitive Loss/Dementia (CAA) Care Area Assessment recorded the resident had a [DIAGNOSES REDACTED]. the brain) and altered mental status. The CAA recorded the resident was able to answer yes/no questions best, had behaviors at times, and directed staff to ensure he/she understood what they were doing prior to completing the activity. The CAA recorded the resident's family member reported it was better if staff completed cares on resident's left side. The Alteration in Mood and Behaviors care plan, dated 7/18/16, recorded the resident had a history of [REDACTED]. The care plan instructed staff to monitor the resident's behaviors, increased agitation, depression, non-compliance, and other behavior changes, and document in the nurse's notes or behavioral sheets. When the resident was non-complaint or aggressive, the care plan directed staff to leave the area, try again later, and notify the charge nurse or another staff person to attempt. The care plan instructed staff to encourage the resident to verbalize frustrations, fears, reasons for non-compliance, administer medications as ordered, monitor for effectiveness, and/or notify the physician promptly as needed. The care plan instructed staff to monitor for signs and symptoms of depression, such as increased agitation, crying, loss of appetite, weight loss, and withdrawal. The care plan instructed staff to ensure other residents do not self-propel close to the resident's left side (incorrect documentation, resident's right side) to prevent resident to resident injury. The 2/16/17 care plan update instructed staff to provide close supervision when the resident was around others, and encourage others to approach resident on his/her left side, as resident had reaching out behaviors with his/her right upper extremity. The 2/23/17 care plan update instructed staff to keep others out of arms reach on the resident's right side related to grabbing outward tendencies. The 2/27/17 care plan update instructed staff to explain what they are doing prior to performing (ADLs) Activities of Daily Living and ensure the resident understood, as he/she displayed increased agitation with cares. Review of Resident #1's medical record lacked documentation of the incident that occurred on 2/16/17 between Resident #1 and an (AL) Assisted Living resident (Resident #5). The 2/16/17 at 6:50 PM, AL nurse's note recorded Resident #5 reported to the (CMA) Certified Medication Aide that another resident from the Nursing Center had inappropriately touched him/her while he/she was having people sign a birthday card. The note recorded Resident #5 was counseled that Resident #1 did have tendencies to do this, and Resident #5 should distance himself/herself from said resident. The 2/16/17 at 6:50 PM, AL nurse's note lacked documentation regarding how or where Resident #1 touched Resident #5. The 2/20/17 physician's visit notes recorded the resident had inappropriately grabbed another (opposite gender) resident standing close to him/her, between the legs. The 2/24/17 at 5:36 PM, nurse's notes recorded staff alerted the nurse at approximately 3:30 PM that Resident #1 had made contact with Resident #5's bottom with his/her right hand, and after that happened, the AL resident swatted him/her on the right shoulder. The note recorded staff moved resident #1 away from the AL resident and placed him/her at a different table, and staff examined the resident's shoulder with no areas of redness or impairment noted. The note recorded the nurse spoke with staff and instructed them to keep others out of close proximity of the resident's right hand to avoid contact. The note recorded the resident's physician would be faxed this nurse's note, and staff notified the resident's DPOA (Durable Power of Attorney). The 3/3/17 at 10:41 AM, nurse's notes recorded resident #1 continued on 1:1 cares today, the resident grabbed at staff in inappropriate ways during morning cares, staff redirected the resident several times during cares to hold on to the lift and not to grab staff. On 3/1/17 at 11:23 AM, observation revealed the resident seated in the (SDR) South Dining Room for lunch, at a table with 3 same gender residents. Observation revealed resident #1 used his/her right hand, visibly shaky, to eat independently without difficulty. Observation revealed during the meal, resident #1 grabbed the edge of the table with his/her right hand, toward the resident sitting to his/her right, several times. On 3/1/17 at 10:33 AM, Administrative Nurse A stated the resident exerts movements with his/her right hand, and had a history in other facilities of touching or hitting people in an inappropriate fashion. On 3/2/17 at 1:37 PM, Nurse Aide F stated the resident liked to grab at people, if people tell him/her no, he/she became angry and cussed at them. Nurse Aide F stated if you tell him/her that the behavior is not appropriate, he/she said yes it is, because women like that kind of thing. Nurse Aide F stated people never wanted to be on the resident's right side because the resident tried to grab people, it doesn't matter who, child or adult. On 3/2/17 at 4:17 PM, Nurse Aide E stated the resident was totally dependent, he/she could move a little but was not coordinated, and staff had to tell him/her what they were doing step by step, or the resident would become agitated. Nurse Aide E stated the resident was unable to move his/her left side, he/she had a lot of confusion, tried to hit people, grabbed private areas of people walking by, especially if they were on his/her right side. Nurse Aide E stated people needed to stay away from the resident's right side which he/she had control of and can pick up and reach for most anything he/she wanted. On 3/2/17 at 12:50 PM, Nurse C stated the resident had paralysis (the loss of muscle function, sensation, or both) on his/her left side, but was able to move his/her right hand. Nurse C stated the resident liked to touch inappropriately, he/she was aware of what he/she was doing, because he/she smiled and laughed when he/she did it. Nurse C stated the resident had a history of [REDACTED].#5 inappropriately in February. On 3/6/17 at 8:52 AM, Resident #5 stated on 2/16/17 he/she was standing between another (NC) Nursing Center resident and Resident #1. Resident #5 asked the NC resident if he/she wanted to sign the birthday card, and while waiting for the NC resident to sign the card, Resident #1 reached between Resident #5's legs near his/her crotch. Resident #5 asked Resident #1, what are you doing?, and Resident #1 just smiled. Resident #5 stated he/she was standing on Resident #1's right side and was shocked because he/she had no idea Resident #1 would ever do that. Resident #5 stated the following morning, Nurse D told Resident #5 the incident had to be reported to the State. Resident #5 stated the incident bothered him/her all day, he/she was unable to sleep. Resident #5 stated the second incident occurred on 2/24/17, when he/she went down to the dining room to help celebrate a resident's birthday. Resident #5 stated he/she sat down at a table with two other NC residents, then got up to wish a resident a happy birthday. Resident #5 stated while he/she was facing the birthday resident, Resident #5 felt someone pinch him/her on the buttock. Resident #5 stated he/she then turned around and saw that it was Resident #1, and hit Resident #1 on the shoulder with the back of his/her hand. Resident #5 stated staff tried to place Resident #1 at the table where Resident #5 was sitting, Resident #5 requested that Resident #1 not be seated there because he/she just assaulted him/her. Resident #5 stated the activity director pulled out another table and moved Resident #1 to the table by himself/herself. Resident #5 stated he/she sat down for a while and started feeling crappy so he/she went up to his/her room and started reading, then he/she started crying. Resident #5 stated that both times Resident #1 touched him/her, he/she just smiled like it was no big deal. Resident #5 stated the staff just told him/her to stay away from Resident #1. On 3/6/17 at 11:57 AM, Nurse D stated the first incident, between Resident #1 and Resident #5 occurred when Resident #5 was having another resident sign a birthday card, when Resident #1 slipped his/her hands between Resident #5's legs, which startled Resident #5. Nurse D stated the second incident occurred in the dining room when staff brought Resident #1 in and placed him/her beside Resident #5. When Resident #1 pinched Resident #5's buttock, Resident #5 was startled and swatted Resident #1's shoulder, causing no injury. Nurse D stated Resident #5 was shocked that this behavior happened to him/her again. The facility's February 2017 Abuse and Neglect Prevention Program policy, defined abuse as any act or failure to act performed intentionally or recklessly that causes harm to a resident including: any sexual act with a resident when the resident does not consent or when the other person knows or should know that the resident is incapable or resisting or declining consent to the sexual act due to mental difficulty, disease disorder, fear of retribution or hardship, or a threat or menacing conduct directed toward a resident that results or might be reasonable or expected to result in fear or emotional distress to a resident. The facility failed to ensure resident #5 remained free from sexual abuse, regarding inappropriate sexual touching and behavior from Resident #1 on two different incidents. This deficient practice placed the opposite gender residents in the facility, in immediate jeopardy. The facility abated the immediate jeopardy on 3/9/17 at 9:00 PM, when the facility placed Resident #1 on one on one supervision on 3/2 and 3/3 when the resident was out of his/her room until the resident was admitted to Geri-psychiatric unit on 3/7/17. Interventions also included: moved resident's place in the dining room where right arm is out of direct traffic of other residents, resident to be one of the last ones to activities with constant supervision by staff or volunteer and have others kept out of arms reach of right hand. The facility will hold a mandatory all staff meeting on 3/10/17 for training of all staff regarding the revised abuse, neglect, and exploitation policy. All staff will be retrained face to face on revised abuse and neglect prevention policy by 3/10/17 or will not be allowed to work until re-educated. Human resources will educate any new hires on abuse and neglect policy. Inter Disciplinary Team will ask on a quarterly basis, if resident's feel safe and if they know who to report concerns to. Social Services Director will review resident rights on freedom from Abuse, Neglect, Exploitation at least twice a year. This deficient practice remained at a scope and severity of an G.

The facility had a census of 43 residents. The sample included 4 residents of which all were reviewed for abuse. Based on observation, record review and interview, the facility failed to investigate allegations of abuse for 2 of the 4 sampled residents, #1 and #3, by 3 staff members. The staff members continued to work throughout the facility, providing care to the residents, and remained on the facility's schedule until 7/22/15. This deficient practice placed all residents in immediate jeopardy. Findings included: - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 4/29/15, indicated the resident had short and long term memory problems, unclear speech, sometimes understood, and usually understands. The MDS indicated the resident had physical behaviors toward others, and required extensive staff assistance for bed mobility and transfers. The 4/29/15 care plan instructed the staff to provide assistance and encouragement to the resident, be gentle during care and transfers, and try to use a full palm of the hand when handling his/her extremities. The care plan directed the staff to leave and try again later, or ask another staff member to try, when the resident displays non-compliant behavior. In a signed and notarized statement, dated 6/11/15, Nurse Aide G stated on 6/11/15 at approximately 3:00-3:30 AM, he/she assisted Nurse Aide H with resident cares. Nurse Aide G stated the resident grabbed Nurse Aide H's arm, and Nurse Aide H used both of his/her hands, and bent the resident's arm back. Nurse Aide G stated he/she heard the resident's thumb pop when Nurse Aide H bent the resident's thumb back. In a signed and notarized statement, dated 6/11/15, Nurse Aide H stated on 6/11/15, during the last bed check at approximately 3:00-3:30 AM, he/she provided care for the resident and stated the resident grabbed his/her arm. Nurse Aide H stated he/she pinched the web of the resident's thumb to get the resident to release his/her arm. Nurse Aide H stated an emergency medical technician showed him/her that when you pinch the web of the thumb, the person had to release his/her grip. On 7/20/15 at 7:05 AM, observation revealed Nurse Aide C and Nurse Aide B provided cares for the resident. Further observation revealed the resident grabbed at Nurse Aide B's arm. Nurse Aide B took the resident's hand, and calmly asked him/her to be nice. Nurse Aide B continued to hold the resident's hand while Nurse Aide C provided the care. Observation revealed the resident was calm during the care and transfer into his/her wheelchair. On 7/16/15 at 3:40 PM, Nurse E stated he/she came on duty after the incident happened, and Nurse I reported what had happened. Nurse E stated Nurse Aide H had finished working his/her shift and had not been sent home. Nurse E stated Nurse Aide H's behavior was inappropriate, he/she considered this abuse, but Nurse Aide H was allowed to finish working his/her shift. On 7/20/15 at 4:45 AM, Nurse Aide G verified on 6/11/15 at approximately 3:00-3:30 AM, he/she and Nurse Aide H provided care for Resident #3. Nurse Aide G verified he/she witnessed Nurse Aide H use both his/her hands to hold the resident's arm down, and bend it back, then pinch the resident's thumb and bend it back, when the resident grabbed Nurse Aide H's arm. Nurse Aide G verified he/she heard the resident's thumb pop. Nurse Aide G verified he/she reported the incident to the charge nurse on duty and Nurse Aide H continued to work the rest of the shift. On 7/20/15 at 10:05 AM, Nurse I stated he/she was the charge nurse when Nurse Aide G reported to him/her that Nurse Aide H had been rough with the resident during cares, held the resident's arm down with both his/her hands, bent the resident's thumb back, and the aide reported he/she heard it pop. Nurse I stated he/she did not send Nurse Aide H home, and allowed Nurse Aide H to continue working the rest of the shift. On 7/20/15 at 1:05 PM, Administrative Nurse F stated he/she was aware of the allegation against Nurse Aide H, who had written a statement that he/she had pinched the resident's thumb. Administrative Nurse F stated Nurse Aide H had not been sent home after the incident, continued to finish working his/her shift, providing care to the residents in the facility, and continued to be employed by the facility. On 7/21/15 at 8:05 AM, in a telephone interview, Nurse Aide H verified on 6/11/15 at approximately 3:45 AM, he/she stated in his/her signed and notarized statement, that he/she had pinched the resident's thumb when the resident had grabbed his/her arm. Nurse Aide H stated he/she was not sent home after the incident and continued to work at the facility. Nurse Aide H stated he/she had been shown by emergency medical personnel to pinch the web part of the thumb when someone had a grip on them, and it would release the grip. On 7/22/15 at 8:45 AM, Administrative Nurse F stated the staff had not followed the facility's abuse policy when Nurse Aide H continued to work his/her shift, after alleged abuse to the resident, and continues to be employed by the facility. On 7/22/15 at 9:00 AM, Administrative Staff J stated the staff had not followed the facility's abuse policy when Nurse Aide H continued to work their shift, after alleged abuse to the resident, and continues to be employed by the facility. The facility's 11/9/09 abuse policy, stated the definition of abuse is any act or failure to act, performed or recklessly performed to a resident including a threat or menacing conduct, directed toward a resident that results in fear or emotional distress to a resident. The policy stated the aggressor will be removed from the situation immediately to a neutral location, usually their room if a resident, or sent home if staff, and further measures shall be taken as necessary, to protect the resident, including suspension of staff until the completion of the investigation outcome per policy. The facility allowed an alleged perpetrator to continue to work at the facility, and provide care to the residents, including Resident #3, who had unclear speech, and was unable to state what happened, placing residents in immediate jeopardy. In a signed and notarized statement, the alleged perpetrator verified he/she pinched Resident #3 when the resident grabbed his/her arm. The facility abated the immediate jeopardy on 7/24/15 at 4:00 PM, when the facility suspended Nurse Aide H until a thorough investigation was completed. The facility completed in-servicing to all staff on the updated abuse policy and guidelines, which included: a subsequent complaint investigation would be filed in 5 days (vs 7 days) of the complaint report date. The revision further included the staff would be sent home, immediately, and staff would be immedicately suspended. The deficient practice remains at a scope and severity of an F. - The 6/17/15 signed physician's note stated Resident #1 had a [DIAGNOSES REDACTED]. Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 6/17/15, indicated the resident had moderate cognitive impairment, with a (BIMS) Brief Interview for Mental Status score of 10. The MDS indicated the resident required total assistance for bed mobility, and extensive staff assistance for transfers. The 6/17/15 care plan instructed the staff to use gentle care with the resident during cares, transfers, and use the full palm of the hand when handling the resident's extremities. In a signed and notarized statement, dated 7/10/15, Nurse Aide A stated on 7/9/15, during the evening shift, he/she went into the resident's room with Nurse Aide B, to provide incontinent care for the resident. Nurse Aide A stated when they turned the resident, the resident started yelling and thought they were dropping him/her on the floor. Nurse Aide A stated he/she placed his/her hand on the resident's shoulder to offer reassurance they would not drop him/her, but the resident kept yelling. The resident yelled again when the staff lifted his/her arms to change clothes to prepare for bed. In a signed and notarized statement, dated 7/15/15, Nurse Aide B stated on 7/9/15, during the evening shift, he/she and Nurse Aide A provided care for the resident, and when they turned the resident, the resident yelled and said they were dropping him/her onto the floor. Nurse Aide B stated they told the resident they would not drop him/her, placed a pad under him/her, and rolled him/her back. Nurse Aide B stated when they got the resident ready for bed, he/she yelled when they raised his/her arms up to put a gown on. On 7/16/15 at 1:00 PM, observation revealed Nurse Aide A providing care for the residents in the facility. On 7/20/15 at 6:40 AM, observation revealed Nurse Aide C and Nurse Aide D, entered the resident's room to get him/her up for breakfast. Nurse Aide C and Nurse Aide D provided incontinent care for the resident. During the observation of the care, the resident's body was fully on the bed, and he/she did not yell at the staff that he/she was scared of falling out of bed. Nurse Aide C and Nurse Aide D, continued to provide care for the resident, then took him/her to the dining room in his/her wheelchair. On 7/20/15 at 10:15 AM, observation revealed Nurse Aide B providing care for the residents in the facility. On 7/16/15 at 1:05 PM, Nurse Aide A stated when providing incontinent care to the resident with Nurse Aide B, the resident started yelling that he/she thought they were dropping him/her. Nurse Aide A verified the resident's head was off the bed and he/she faced the floor when they turned him/her. Nurse Aide A verified the charge nurse on duty did not send him/her home after the incident. On 7/16/15 at 2:20 PM, Nurse Aide B stated when providing care with Nurse Aide A, they rolled him/her over, and the resident started yelling and stating they were dropping him/her, and he/she yelled when they got him/her dressed for bed. Nurse Aide B stated he/she was not sent home after the resident's family reported the incident to the charge nurse on duty. On 7/16/15 at 3:40 PM, Nurse E stated he/she was the charge nurse on duty when the resident's family reported to him/her that Nurse Aide A and Nurse Aide B had been mean to the resident. Nurse E stated he/she talked to Nurse Aide A and Nurse Aide B, but verified he/she did not send them home after learning about the incident. On 7/20/15 at 10:35 AM, Resident #1 stated he/she sometimes feels like the staff may drop him/her on the floor when they roll him/her over in bed. Resident #1 stated some of the staff are mean to him/her, but he/she could not remember the names of the staff. On 7/20/15 at 1:05 PM, Administrative Nurse F stated Nurse Aide A and Nurse Aide B were named as alleged abusers by the resident. Administrative Nurse F stated the charge nurse on duty at the time, did not send the staff members home, but allowed them to continue to work the rest of the shift, providing care to the residents in the facility, and are currently employed by the facility. On 7/22/15 at 8:45 AM, Administrative Nurse F stated the staff had not followed the facility's abuse policy when Nurse Aide A and Nurse Aide B continued to work the rest of the shift, providing care to the residents, after the alleged abuse to the resident occurred, and are currently employed by the facility. On 7/22/15 at 9:00 AM, Administrative Staff J stated the staff had not followed the facility's abuse policy when Nurse Aide A and Nurse Aide B continued to work shift their shift after alleged abuse to the resident, and are currently employed by the facility. The facility's abuse policy, dated 11/9/09, stated the definition of abuse is any act or failure to act, performed or recklessly performed to a resident including a threat or menacing conduct, directed toward a resident that results in fear or emotional distress to a resident. The policy stated the aggressor will be removed from the situation immediately to a neutral location, usually their room if a resident, or sent home if staff. Further measures shall be taken as necessary to protect the resident, including suspension of staff until the completion of the investigation. The facility failed allowed two alleged perpetrators to continue to work at the facility, and provide care to the residents, including Resident #1, placing all residents in immediate jeopardy. Resident #1 stated 2 staff members were mean to him/her, when they turned him/her in bed, and he/she felt like the staff may drop him/her on the floor. The facility abated the immediate jeopardy on 7/24/15 at 4:00 PM, when the facility suspended Nurse Aide A and Nurse Aide B until a thorough investigation was completed. The facility completed in-servicing to all staff on the updated abuse policy and guidelines, which included: a subsequent complaint investigation would be filed in 5 days (vs 7 days) of the complaint report date. The revision further included the staff would be sent home, immediately, and staff would be immediately suspended. The deficient practice remains at a scope and severity of an F.