Every finding on record at Taylor Healthcare Center

Based on observation, record review, and resident and staff interviews, the facility failed to provide necessary activities of daily living (ADL) assistance for two (2) of three (3) residents reviewed for ADL care. The facility failed to ensure that dependent residents received timely assistance with hygiene and positioning in accordance with their assessed needs. Resident identifiers: #42 and #3. Facility census: 60.Findings Include:a) Resident #42On 08/03/26 at 1:20 PM, Resident #42 requested assistance to be placed in bed. During the interview, the surveyor observed that the resident was not in proximity to her call light. The surveyor immediately notified Licensed Practical Nurse (LPN) #1 of the resident's request for assistance to be assisted to bed and the lack of access to the call light. At approximately 2:15 PM, Resident #1 was observed still seated in her wheelchair. During a follow-up interview the resident stated she was still waiting for staff to assist her to bed.b) Resident #3During an interview 08/03/26 at 1:25 PM, Resident #3 stated that she was soiled and needed assistance with getting cleaned up. Surveyor asked Resident #3 to put her call light on to get the assistance needed. During a second observation at 1:39 PM, Resident #3 reported that a Nurse Aide (NA) entered the room, deactivated the call light, and informed the resident she would return once she obtained assistance.A third observation revealed the call light was active again at 2:12 PM. Resident #3 remained in the same position, waiting for care.At approximately 2:20 PM, NA #2 entered the room and deactivated the call light. NA #2 then exited and informed two other NAs in the hallway that Resident #3 required assistance.Continued observation showed the two NAs exiting a different resident room and entering another room without checking on or providing care to Resident #3.The surveyor notified the Administrator of the lack of timely care. During an interview with the Administrator and Resident #3, it was confirmed that the resident waited over one hour for assistance. Furthermore, it was confirmed that staff deactivated the call light on two separate occasions without providing the required ADL assistance.

Based on observation and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect more than a limited number of residents. Resident identifiers:# 9, #31, #47, #48, #54, #58 and #66. Facility Census: 59 a) On 09/29/25 at 12:25 PM an observation revealed that when CNA # 65 and CNA #40 were assisting in passing lunch trays on A Hall they passed the noon meal trays to Resident #54, #48, and #58, and did not offer hand hygiene. The above finings were confirmed in an interview with the Administrator on 09/29/25 at 1:10 PM at which time she stated the residents were to be given wipes to clean their hands with each meal. Findings Include a) Resident #9, #31 and #47 On 09/29/25 at 12:10 PM it was observed when Unit Manager #23 was assisting in passing lunch trays on the A Hall. She pass the noon meal tray to Resident #9 and did not offer hand hygiene. When ask if they offer hand hygiene she commented, it is usually on the tray, I'm not sure why it isn't today. The Unit Manager #23 still did not offer the resident hand hygiene and continued to pass trays to Resident #47 and #31. The above finings were confirmed with the Administrator on 09/29/25 at 1:10 PM at which time she stated the resident are to be given wipes to clean their hands with each meal.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. issues with food storage were found in the facility kitchen walk in cooler, utensil drawer, and nourishment pantry. This had the potential to affect all residents in the facility. Facility census: 59Findings Included: a) On 9/29/25 11:35AM, during initial brief tour of Kitchen, with Corporate Dietary Manager (CDM) #82 CDM #82 who acknowledged the following:-Utensils found in drawer scattered in all different directions-The reach in cooler temperature per inner thermometer was at 41 degrees. On 9/30/25 at 9:30AM During the Nourishment Room visit with the facility Dietary Manager (DM) the DIM who acknowledged the following in the nourishment room cupboard, a jar of peanut butter, with no name or date label, The Corporate Dietary manager stated the peanut butter belonged to a staff member and that it should not have been there. 11/10/2025 11:14 AM kitchen re-visit with the corporate Dietary Manager, 82 who acknowledged the reach in cooler temperature per the inner thermometer was at 41 degrees. He stated he would get maintenance on it. Kitchen Policy Manual: -On 09/30/25 at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 revealed All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. -On 11/10/25 at 3:20PM, In an interview with the facility Dietary manager #82, She stated the reach in cooler temperature was probably higher due to the door being open for long periods of time as staff was cleaning out the cooler. It was reported to maintenance to be checked.

Facility failed to provide residents a dignified experience by pulling them down the hall backwards when the resident was unable to propel himself. Resident identifier: #43. Facility census: 59. a) Resident #43The facility failed to provide Resident #43 a dignified experience by pulling them down the hall backwards when resident was unable to propel himself. 11/11/25 1:15 PM observed Staff #77 puling Resident #43 down the hall backwards. When asked Staff #77 if that is how they normally transferred she stated, No he normally takes himself, but I needed to change his shirt. 11/11/2025 1:31 PM observed resident propelled himself up the hall towards the dining room. 11/11/2025 1:40 PM DON stated, We do not have a policy but that is not good practice. I will educate them no on not pulling them backwards.

Based on interview and record review, the facility failed to assist the resident in gaining access to hearing services by making appointments and arranging transportation. This failed practice was true for one (1) of three (3) residents reviewed for referral to specialized services during the Long Term Care Survey Process. Resident Identifier: #32. Facility Census: 59.Findings Include a) Resident #32During an interview with Resident #32 on 09/29/25 the resident stated that she had difficulty hearing what people were saying. Resident #32 stated I don't feel like I am a part of the world. I have to ask people to repeat themselves constantly. Resident further noted that her husband had Got us the railroad insurance. Everything is covered 100%. So, I should be able to get hearing aids.Record review on 09/29/25 at 10:05 AM revealed no documentation that the facility had set up any referrals or appointments for an evaluation with a hearing specialist. Record review further revealed that the resident has a Brief Interview for Mental Status (BIMS) of 15.A review of Resident #32's Care Plan on 09/29/25 at 10:55 AM revealed the following: During an interview on 09/29/25 at 2:25 PM with Registered Nurse (RN) #16, she confirmed that facility staff were aware that Resident #32 had difficulty hearing and spoke loudly to be heard. RN #16, accompanied by this surveyor, interviewed Resident #32 on 09/29/25 at approximately 11:57 AM. During the interview, RN #16 asked the resident whether she would like to have her hearing evaluated. Resident #32 stated that she would be willing to have her hearing evaluated. However, the resident questioned RN #16, asking her, Will they come here to do it?RN #16 stated, I guess they would, I will have to find out, but would you like to get yourself checked? Resident #32 then stated, I don't work with guesswork. Once you know if they will do it here, let me know. During an interview with Resident #32 on 11/10/25 at approximately 12:25 PM the resident stated that she had not had a hearing assessment at yet.Record review on 11/10/25 at 12:55 PM revealed no documentation of a scheduled hearing referral or assessment for Resident #32. Record review on 11/11/25 at 11:13 AM revealed a physician's assessment dated [DATE] for Resident #32. The evaluation noted the resident's hearing loss was not mentioned. This comprehensive assessment of the resident's problems failed to note the resident's hearing loss.On 11/11/25 at approximately 11:30, RN #16 provided the following documentation: A consent form for 360 Care, signed by Resident #32's Power of Attorney (POA) dated 12/18/24, which stated that residents with Medicaid would be provided Vision Services, Podiatry Services, Dental Services and Audiology services by 360 Care. A nursing note by RN #16 dated 11/10/25 at 4:00 PM which stated: [Typed as Written] Staff offered resident audiology appointment. Resident declines visit unless they come in house. Audiology 360 comes in-house yearly - is due at end of month - Resident is on list to be seen - scheduler in contact with audiology 360 for exact date of visit An email to 360 Care on 11/11/25 at 10:17 AM by RN #16 which stated: [Typed as Written] I am looking to schedule Audiology for our center. I have a Medicaid resident that is needing to be seen and will only see someone if they come to the facility. Can you pleasebassist?A nursing note by RN #56 on 11/11/25 at 10:27 which stated:[Typed as Written] Resident needing to be scheduled with audiology for an evaluation of hearing loss. Resident has previously declined going out of facility for appointments. Resident is willing to see a provider in-house for Audiology. 360 Cares facility provided emailed to request an evaluation of resident hearing loss. Currently awaiting a response from 360 Cares. Another nursing note dated 11/11/25 at 10:33 AM by RN #56 stated: [Typed as Written] Received an email back from 360 Care in regard to Audiology appointment. Per 360 Cares. There is not an audiologist available in areas for 360 cares. Spoke with the resident, ADON, and Administrator. Resident stated that she is willing to go to a provider out off acility. Appointment made with [Audiology] for November 18th at 2 PM. POA made awareof appointment. Resident aware of appointment at this time. During an interview on 11/11/25 at approximately 12:50 PM, DON confirmed that the facility had not made a referral or appointment for the resident until 11/11/25.

Based on observation, record review, and staff interview, the facility failed to provide specialized drinking equipment ordered by the physician. This failed practice was found true for (1) one of (3) three residents reviewed for nutrition during the Long-Term care Survey Process. Resident identifier #56. Facility Census 59. Findings Include: a) Resident #56 A record review on 09/30/25 at 11:40 AM, revealed a physician's order for Resident #56 that read as follows: Dysphasia, advance texture, think liquids consistency, double portion entree with all meals, finger foods when available, food in bowls, Kennedy cup with all meals An observation on 09/30/25 at 12:25 PM revealed Resident #56 being served his lunch in the dining room. Registered nurse (RN) #13 served him his lunch tray and there was no [NAME] Cup. The RN opened his milk and put a straw in it. During an interview on 09/30/25 at 12:28 PM , RN # 13 stated, They send them out of the kitchen, He did not have one on his tray. The RN confirmed that Resident #56 was not provided with the Kennedy cup as ordered and written on his meal ticket.

Based on observation and staff interview the facility failed to ensure a walk-in cooler was cleaned to meet the professional standards for food service safety. During the kitchen tour it was discovered the floor of the walk-in cooler needed to be cleaned. This had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 59 Findings included: a) Kitchen tour During the kitchen tour on 12/18/23 at 11:39 AM, it was discovered the walk-in cooler along the front side wall had an accumulation of brown crusted debris on the floor. In an interview with the Nursing Home Administrator (NHA) on 12/18/23 at 1:10 PM, verified the crusted particles on the floor of the walk-in freezer needed cleaned.

Based on record review and staff interview, the facility failed to ensure that all alleged violations involving neglect and/or mistreatment were reported, no later than 24 hours of the alleged event brought to the facility's attention, to appropriate state agencies as required. Residents #40, #50, #46, and #55. Facility Census: 59 Findings included: During a review of the facility grievance log for the last six (6) months the following four (4) alleged concerns were noted and addressed at the grievance level but were not reported to the appropriate state agencies. a) Resident #40 On 07/04/23 Resident #40 reported that Resident was upset and reported that staff are not changing her clothes when putting her to bed. Stated she ask to have pajamas put on and was told no and put to bed in her clothes. Resident #40 has a Brief Intermediate Mental Status Score of 15 and according the the Physicians' Determination of Capacity form dated 03/28/23, she has capacity to make her own decisions. b) Resident #50 On 07/24/23 Resident #50 reported that she heard staff mocking residents and saying they were tired of having to take care of residents . Resident #50 has a Brief Intermediate Mental Status Score of 14 and according the the Physicians' Determination of Capacity form dated 09/08/23, she has capacity to make her own decisions. c) Resident #46 On 07/14/23 Physical Therapy staff (Doctor of Physical Therapy) #18 reported that Resident #46 was found saturated with urine and feces and bed was saturated. Resident #46 has a Brief Intermediate Mental Status Score of 3 and according to the Physicians' Determination of Capacity form dated 10/16/23, he did not have capacity to make his own decisions. Record review shows he is dependent on staff for all his activities of daily living (ADL) care. d) Resident #55 On 11/14/23 Resident #55 reported Staff is turning off his call light when he rings. Resident #55 had a Brief Intermediate Mental Status Score of 15 and according the Physicians' Determination of Capacity form dated 10/14/23, the resident had capacity to make his own decisions. On 12/20/23 at 2:45 PM Social Services Designee #6 confirmed the above information and agreed they could possibly be considered as neglect or mistreatment and should have been reported to the appropriate states agencies immediately upon being informed of the allegations and prior to the investigation of each allegation.

Based on record review and staff interview, the facility failed to ensure a resident had the right to be informed of, and participate in, her treatment. This was true for one (1) of 17 residents reviewed in the Long-Term Care Survey Process. Resident identifier# 34. Facility census: 59. Findings included: a) Resident #34 A record review, completed on 12/19/23 at 7:41 PM, revealed: -Resident #34 was admitted to the facility on [DATE]. At that time, Resident #34 lacked capacity to make her own medical decisions and a family member was appointed Health Care Surrogate (HCS) / decision-maker for resident. -A Physician Determination of Capacity, dated 09/08/23, indicated Resident #34 had regained CAPACITY to make her own medical decisions. -On 12/07/23, verbal consent was accepted from the HCS for Resident #34 to receive the Influenza Vaccine -On an unknown date [the date was left blank on the consent form], verbal consent was accepted from the HCS for Resident to receive the 2023-2024 COVID-19 Vaccine. Record review revealed the vaccine had been administered on 11/21/2023. During an interview on 12/20/23 at 11:43 AM, the Director of Nursing (DON) stated Resident #34 should have been approached, made aware of the risk/benefit of both vaccines, and been the one to provide consent for each vaccination.

Based on record review and staff interview, the facility failed to notify one (1) of three (3) resident's representative/family member in a timely fashion of a significant change and the need to alter treatment. The facility transferred Resident #28 to the hospital on 09/11/23. However, Resident #28's representative / family member was not notified of the transfer. Resident Identifier: #28. Facility Census: 59. Findings included: a) Resident #28 A medical record review, completed on 12/18/23 at 8:19 PM, revealed the following details: -A Nurses Note, dated 09/11/2023 at 6:00 PM, documented Resident #28 was going in and out of consciousness and 911 was called. -A second Nurses Note, dated 09/11/2023 at 6:01 PM, revealed resident's physician was contacted and updated on the resident's status. -A third Nurses Note, dated 09/11/2023 at 6:29 PM, documented the ambulance had arrived and report had been called to the hospital regarding resident's current status. -The eINTERACT Transfer form did not indicate the resident's representative had been notified of the transfer to the hospital and made aware of the clinical situation. During an interview, on 12/20/23 at 11:40 AM, the Director of Nursing stated the facility was unable to produce any evidence of Resident #28's representative/family member being notified of resident's change in condition and transfer to the hospital.

Based on recorded reviews and staff interviews, the facility failed to ensure the development of comprehensive person-centered care plans for three (3) of 17 residents. The care plans were not developed in the areas of schizophrenia for Resident #5, post-traumatic stress disorder (PTSD) for Resident #10, and hospice services for Resident #37. Resident identifiers: #5, #10, and #37. Facility census: 59. Findings included: a) Resident #5 Medical record review, on 12/20/23 for Resident #5, revealed the comprehensive care plan had not been developed for the medical diagnosis of schizophrenia. An interview with the Director of Nursing (DON) on 12/20/23 at 10:12 AM, verified the care plan had not been developed for Resident #5's diagnosis of schizophrenia. b) Resident #10 During a medical record review on 12/20/23 for Resident #10, revealed the comprehensive care plan had not been developed for the medical diagnosis of post-traumatic stress disorder (PTSD). An interview, with the DON on 12/20/23 at 10:30 AM, verified the care plan had not been developed for the diagnosis of PSTD for Resident #10. c) Resident #37 During a medical record review on 12/20/23 for Resident #37, it was discovered the care plan had not been developed to specify what days services would be provided by the hospice agency. An interview, with the DON on 12/20/23 at 3:10 PM, verified the care plan had not been developed to specify when hospice services would be provided.

Based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of 17 sampled residents reviewed during the Long-Term Care Survey process. Resident identifier: #34. Facility census: 59. Findings included: a) Resident #34 A record review, completed on 12/19/23 at 7:41 PM, revealed: -Resident #34 was admitted to the facility on [DATE]. At that time, Resident #34 lacked capacity to make her own medical decisions and a family member was appointed Health Care Surrogate (HCS)/decision-maker for resident. -A Physician Determination of Capacity, dated 09/08/23, indicated Resident #34 had regained capacity to make her own medical decisions. -A nurse practitioner encounter note, dated 10/23/23, documented, [Resident #34's First Name] [Resident 34's Last Name] is an [AGE] year-old female who resides at [NAME] Health Care Center. She is a DNR (Do Not Resuscitate) and lacks medical decision-making capacity. -A nurse practitioner encounter note, dated 11/01/23, documented, [Resident #34's First Name] [Resident 34's Last Name] is an [AGE] year-old female who resides at [NAME] Health Care Center. She is a DNR (Do Not Resuscitate) and lacks medical decision-making capacity. --A nurse practitioner encounter note, dated 12/12/23, documented, [Resident #34's First Name] [Resident 34's Last Name] is an [AGE] year-old female who resides at [NAME] Health Care Center. She is a DNR (Do Not Resuscitate) and lacks medical decision-making capacity. During an interview, on 12/20/23 at 11:47 AM, the Director of Nursing stated the Physician Determination of Capacity completed in September indicated Resident #34 did indeed have capacity to make her own medical decisions. The DON acknowledged the nurse practitioner encounter notes on 10/23/23, 11/01/23, and 12/12/23 incorrectly listed Resident #34 as lacking medical decision-making capacity.

Based on observation, resident council meeting and staff interviews the facility failed to make accessible the ombudsman and the State Survey Agency contact information for Residents. This had the potential to affect an unlimited number of Residents. Resident Identifiers: #24, #38, #28, #16, #197, #198, #8, #97, #22, #17, #7, and #33. Facility Census: 51 Findings Included: a) Notifications Many observations made during the Long-Term Care Survey Process, the Resident Rights and contact information for the State Ombudsman and State Survey Agency contact information were not posted for the accessibility for the residents. During the Resident Council meeting held on 08/30/22 at 10:30 AM the Residents as a group were asked do you know where the ombudsman contact information is posted? The group stated, We do not how to contact ombudsman, we knew where it was posted in the old building, put not in this one. Another question asked during the Resident Council meeting have you been informed of your resident rights to formally complain to the State Agencies about the care you receive? The group stated, We know our rights as residents, but we don't know we the contact information is in this new building. On 8/30/22 at 10:58 AM, the Administrator acknowledged there was no contact information for the Ombudsman or the State Survey Agency posted in the facility and stated, we have only been here a month, I will try to find the board and put it up.

Based on observation, medical record review, and staff interview and the facility failed to implement a comprehensive person-centered care plan by not providing an in-room activity calendar. This is true for 4 of 16 resident review for the care area of care plan. Resident Identifiers: Resident #42, #22, #32, and #30. Facility Census: 51 Findings Included: a) Resident #42 During the initial tour of the facility on 08/29/22 observation found no monthly activity calendar posted in residents rooms. During a medical record review on 08/30/22 revealed Resident #42's care plan with a initiated date of 06/05/20 contained the following: Focus Statement: Resident #42's name will participate in most out of room activities. Goal Statement: Resident #42 name will remain active in out of room activities through next review date Interventions included: Provide calendar in room During an interview on 08/31/22 at 9:58 AM, the Activity Supervisor (AS), #32 stated calendars are to be in all the resident's rooms. When the care plan states provide calendar it means to provide a monthly activity calendar in the resident's room. b) Resident # 22 During the initial tour of the facility on 08/29/22 observation found no monthly activity calendar posted in residents rooms. During a medical record review on 08/30/22 revealed Resident #22's care plan with a initiated date of 12/16/17 and a revision date 09/07/21 contained the following: Focus Statement: Resident #22's name participates in most out of room activities. Goal Statement: Resident #22 name will remain active in out of room activities through next review date Interventions included: Provide calendar in room During an interview on 08/31/22 at 9:58 AM, the Activity Supervisor (AS) #32 stated calendars are to be in all the resident's rooms. When the care plan states provide calendar it means to provide a monthly activity calendar in the resident's room. c) Resident #32 During the initial tour of the facility on 08/29/22 observation found no monthly activity calendar posted in residents rooms. During a medical record review on 08/30/22 revealed Resident #32's care plan with a initiated date of 08/23/21 and revision date of 07/20/22 contained the following: Focus Statement: Resident #32's name is self-directed for activities in room daily per preference as she feels like it. Goal Statement: Resident #32 name will remain self-directed in room daily through next review date Interventions included: Provide calendar in room During an interview on 08/31/22 at 9:58 AM, the Activity Supervisor (AS) #32 stated calendars are to be in all the resident's rooms. When the care plan states provide calendar it means to provide a monthly activity calendar in the resident's room. d) Resident #30 During the initial tour of the facility on 08/29/22, observation found no monthly activity calendar posted in residents rooms. During a medical record review on 08/30/22 revealed Resident #30's care plan with a initiated date of 04/09/21 and revision date of 07/19/21 contained the following: Focus Statement: Resident #30's is at risk for social isolation. Goal Statement: Resident #30 name will actively participate in activities of interest of her choice in her room Interventions included: Provide activity calendar During an interview on 08/31/22 at 9:58 AM, the Activity Supervisor (AS) #32 stated calendars are to be in all the resident's rooms. When the care plan states provide calendar it means to provide a monthly activity calendar in the resident's room.

Based on observation, and staff interview, the facility failed to correctly document temperatures for the nourishment room refrigerator. This deficient practice has the potential to affect a limited number of residents that receive nutrients from the nourishment room. Facility Census: 51 Findings included: a) Nourishment Room An initial tour of the nourishment room with the Director of Nursing (DON) on 08/30/22 at 9:10 AM revealed the nourishment room refrigerator/freezer temperature log was void the temperatures for the following days: --08/29/22 AM Refrigerator temperature --08/29/22 AM Freezer temperature --08/30/22 AM Refrigerator temperature --08/30/22 AM Freezer temperature The DON stated the activity staff is to complete the temperature log for the refrigerator and freezer, and acknowledged the temperature log was not completed on 08/29/22 or 08/30/22.

Based on record review and staff interview, the facility failed to ensure timely notification was made to the physician after a change in condition was identified. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #8. Facility census: 51. Findings included: a) Resident #8 Review of Resident #8's medical records showed a nursing note written on 5/13/2022 at 5:53 AM that stated as follows: .CNA [certified nursing assistant] alerted UCN [unit charge nurse] while resident being showered that bruising and swelling noted to right foot. UCN assessed right foot. Purple/Green bruising noted to top of right foot. Purple bruising noted to 2nd and 3rd digits right foot and purple bruising noted to right ankle. Resident voices discomfort with ambulation. Interventions in Place to Prevent Reoccurrence: Monitored resident frequently. Encouraged to ask for assistance. Physician/NP [Nurse Practitioner] and Decision-Maker Communication: Will provide report to oncoming shift to on call. There was no documentation in the medical record the physician or NP were notified regarding the swelling, bruising, and discomfort in Resident #8's foot. Further review of Resident #8's medical records showed a nursing note written on 5/14/22 at 11:43 AM that stated as follows: Resident Concern/Evaluation: Resident's right ankle-edema noted around ankle and top of foot +2, discoloration noted to ankle and top of foot. Resident denies pain at rest and during ambulation. Medical Provider Response/Order(s): [Nurse Practitioner's name] notified and gave order to get x-ray of ankle. Resident/Decision Maker Notification: [Medical Power of Attorney' name] notified and verbalized understanding. The x-ray showed a non-emergent fracture to the ankle, and follow-up orthopedic care was obtained. During an interview on 08/30/22 at 1:40 PM, the Director of Nursing (DON) confirmed there was no documentation a medical provider was notified about the swelling and bruising to Resident #8's foot until the day after the symptoms had been identified. No further information was provided through the completion of the survey.

Based on medical record reviews and staff interview the facility failed to complete the Physician Orders for Scope of Treatment (POST) forms. This was discovered for two (2) of sixteen (16) residents reviewed for the area of Advance Directives. Residents #44 and #96 had incomplete POST forms. Resident identifiers: #44 and #96. Facility census: 51. Findings included: a) Resident #44 During a medical record review on 08/29/22, it was discovered the POST form was signed by Resident #44, but the signature was not dated. An interview with the Nursing Home Administrator (NHA) on 08/30/22 at 10:10 AM, verified Resident #44's signature was not dated. b) Resident #96 During a medical record review on 08/29/22, it was discovered the POST form for Resident #96 was not complete, there was no signature for the professional who assisted with completing the POST form. An interview with the NHA on 08/30/22 at 10:10 AM, verified the POST had no signature for the professional (Licensed Social Worker) who assisted with completing the POST form.

Based on observation, medical record review, and staff interview the facility failed to provide necessary respiratory care and services. This was true for one (1) of one (1) resident reviewed for respiratory services during the investigation phase of the survey process. It was observed Resident #32 was not receiving oxygen therapy at the prescribed rate. Resident identifier: #32 Facility census: 51. Findings Included: a) Resident #32 During an observation on 08/30/22 at 8:08 AM, Resident #32's oxygen flow rate was at three (3) liter/minute (l/m) via nasal cannula. On 08/30/22 at 8:10 AM Licensed Practical Nurse LPN #48 acknowledged Resident #32 was receiving her oxygen at three (3) l/m. A review of Resident #32's orders verified the physician orders for oxygen was two (2) m/l. A Physicians order dated on 08/02/22, typed as written: Oxygen at two (2) l/m via intermittent to maintain sats >90% as needed.

Based on observation, staff interview, resident interview and medical record review, the facility failed to provide specialized eating utensils and specialized cup for residents at meal time. This was an random opportunity for discovery. Resident Identifiers: #30 and #31. Facility Census: 51 Findings Included: a) Resident #30 During an breakfast observation on 08/30/22 at 8:14 AM, Resident #30 had received her breakfast tray, the residents drinks were served in regular cups and the resident was not eating with weighted utensils. The diet order meal ticket on tray stated. Adaptive Equipment: Kennedy Cup and Weighted Utensils During an interview on 08/30/22 at 8:14 AM Nurses Aide (NA) #9 acknowledged there was no Kennedy cup or weighted utensils on breakfast tray. NA stated she rarely receives them on her tray. During an interview on 08/30/22 at 8:15 AM Resident #30 stated I might get the utensils and cup once and twice a month. A medical record review reveled a physician order dated 10/20/21, Consistent Carbohydrate diet, regular texture, regular consistency, Weighted utensils and Kennedy cup for meals. b) Resident #31 Review of Resident #31's physician's orders showed an order written on 08/10/22 for Kennedy cups (cup with handle and lid) for drinks. During breakfast observation on 08/31/22 at 8:12 AM, the resident's meal tray was observed as it was being delivered to the resident by Nursing Assistant (NA) #42. The drinks were not in Kennedy cups. The resident's milk was in a glass without a handle. The resident's coffee was in a cup with a handle but no lid. NA #42 confirmed the resident's meal tray ticket stated Resident #31 was to have Kennedy cups. NA #42 stated she would obtain the cups for the resident. No further information was provided through the completion of the survey.

Based on observation and staff interview the facility failed to maintain sanitary condition of the outside garbage receptacle to prevent the harborage and feeding of pests. This deficient practice has the potential to affect a limited number of residents that reside in the facility. Facility Census: 51 Findings Included: a) Outside garbage receptacle Observation made during the outside tour at 8:11 AM on 08/31/22, revealed a lid on the garbage receptacle was open, the area around the garbage receptacle had trash scattered about on the ground which included: used gloves, used masks, plastic silverware, toothbrushes, mouthwash bottles, full trash bags, undergarments, straws, straw papers, cereal bowls and empty orange juice containers. During an interview on 08/31/22 at 8:11 AM, the Administrator stated we will get it cleaned up right away.

Based on medical record review, incident/accident reports review, facility reportable allegation(s) of abuse review, policy and procedure review, and staff interviews, the facility failed to ensure residents were free from sexual abuse. This was true for seven (7) residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s), who received nonconsensual sexual contact by Residents #10, #11, and/or #62 which were reviewed during the Quality Indicator Survey (QIS) and complaint investigation. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (POC) was received at 6:16 p.m After verifying implementation of the POC, the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficient practice may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance.) A reasonable person, if touched inappropriately by another person putting hands his down ones pants, touching breasts, and/or rubbing genital area without consent in one's resident home, would feel fear, humiliation, anger, anxiety, and/or stress. These findings had the potential to affect more than a limited number of residents. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, and #20. Alleged perpetrators: #10, #11, and #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On August 16, 2016 (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from June 2016 through February 2017, there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from October 2016 through December 2016, there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from August 2016 through February 2017, there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. A. Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and hel(TRUNCATED)

Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (POC) was received at 6:16 p.m After verifying implementation of the POC, the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids, and provided no incontinence care. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, #20, and unidentified female residents. Alleged perpetrators: #10, #11, #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On August 16, 2016 (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from June 2016 through February 2017, there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from October 2016 through December 2016, there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from August 2016 through February 2017, there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. A. Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he Scared the crap out of her. She said she heard Resident #24 tel(TRUNCATED)

Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (POC) was received at 6:16 p.m After verifying implementation of the POC, the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids, and provided no incontinence care. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, #20, and unidentified female residents. Alleged perpetrators: #10, #11, #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On August 16, 2016 (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from June 2016 through February 2017, there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from October 2016 through December 2016, there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from August 2016 through February 2017, there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. A. Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he Scared the crap out of her. She said she heard Resident #24 tel(TRUNCATED)

Based on record review, observations, review of incident reports, resident interview, and staff interview, the facility failed ensure female residents were provided care and services to enable them to physical and mental well-being. The facility failed to ensure it had an effective system to ensure incidents of nonconsensual sexual contact were identified and effectively managed to ensure dependent, cognitively impaired women did not experience loss of dignity, or become anxious or fear additional unwanted contacts. As a result of this systemic failure, Residents #26, #39, #51, #49, #24, #37, and #1 were determined to have experienced actual harm. The facility also failed to ensure a resident (#10) received his scheduled daily morning insulin as prescribed by the attending physician. Eight (8) of twenty-six (26) residents were affected. Resident identifiers: #10, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02), indicating severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. The MDS identified her as needing extensive assistance of two (2) persons for bed mobility and for transfer, total dependence for dressing, toilet use, personal hygiene, bathing, and limited assistance of one (1) person with eating. She sometimes understood others and could sometimes understand others. Confidential interviewees (CI) CI #3 and CI #4, in separate interviews, both said they had witnessed male Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. This resident lacked capacity and was not interviewable. A reasonable person would be distressed by this type of assault. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents, nor of notification of the resident's responsible party or physician. Review of the facility's [MEDICATION NAME] for 2016 and 2017 found no evidence this event was reported to state agencies During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said the incident on 12/08/16 was unwanted and should have been deemed sexual abuse. In an interview on 02/28/17 at 2:30 p.m., the licensed social worker (LSW) said anything that was deemed abuse, neglect, or misappropriation of property was sometimes reported to her. Sometimes she found it on her own. She said neglect also included not being taken care of by staff, and sexual things. She said she, the DON, the administrator, the nurse manager, and the secretary met daily Monday through Friday. At that meeting, they discussed incidents, but they did not always get the incidents the day they occurred for whatever reason. b) Resident #49 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. She presented with inattention and disorganized thinking that came and went, and changed in severity. Her speech was unclear. She sometimes understood others, and responded to simple direct communication only. Pertinent [DIAGNOSES REDACTED]. Confidential interviews with confidential interviewees (CI) #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews found all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses report inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents are known to touch female residents inappropriately over their clothing. She said the incidents of 02/20/17 are the first time she has ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occurred. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked the resident if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs and told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. This resident lacked capacity and was not interviewable. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. c) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/26/17, found her assesse to have a BIMS score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated the resident had severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission, which she estimated to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once over a month ago she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said Resident #24's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. This resident lacked capacity and was not a reliable interviewee for events. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. d) Resident #37 On 02/22/17, review of the annual minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident had a BIMS score of two (2), with inattention and disorganized thinking present that fluctuated over time. A BIMS score of two (2) indicated severely impaired cognitive functioning. The MDS assessment identified she sometimes understood others and was sometimes understood. Pertinent diagnosed included unspecified intellectual disabilities, and unspecified [MEDICAL CONDITION]. CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she told Resident #62 that he did not need to go into those ladies' rooms, to which he replied, She wanted it. CI #4 said she always reported the inappropriate behaviors to the nurse in charge. CI#5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said she told him no, and he jerked back his hard. This resident lacked capacity and was not interviewable for events. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. e) Resident #1 On 02/22/17, review of the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/01/16, found her assessed to have a BIMS score of twelve (12). The MDS with an ARD of 12/01/16 assessed her BIMS score of nine (9). Both scores indicated moderately impaired cognitive functioning. CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on her legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. He replied that he did not do anything. She said she reported this to the nurse in charge at the time. On 02/22/17 at 10:00 a.m., Resident #1 was playing bingo unassisted in activities, and was able to carry on conversation. When asked if any of the men at the facility had touched her inappropriately in private parts of her body, she replied in the negative. She said she would not put up with that. f) On 02/28/17 at 1:00 p.m., the information obtained during confidential interviews with numerous staff members was discussed with the director of nursing (DON). She was informed that one (1) or more of the interviewees said that they had witnessed inappropriate touching of female residents by male residents as follows: - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #51. - One of more staff members said they witnessed Resident #62 and Resident #11 inappropriately touched Resident #49. - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #24. - One or more staff members said they witnessed Resident #10 inappropriately touch Resident #37. - One or more staff members said they witnessed Resident #52 inappropriately touch Resident #1. The DON said she was not made aware by the staff that those female residents were inappropriately touched by those male residents, except for one day recently. She said that on 02/20/17 staff reported that Resident #49 was touched inappropriately by two (2) male residents the same morning. She said staff completed incident reports and reported to State agencies for those two (2) events. The DON said their facility policy explained that unwanted sexual touch was sexual abuse, and that should be reported to state agencies. She said the reporting to state agencies was not done because there was no incident report completed on inappropriate sexual touching. She said an investigation was not done because there was no incident report completed for those behaviors. She said the first step was getting the incident report completed, and any staff member could begin an incident report. She said she reviewed the incident reports daily. If there were any incident reports which require reporting to State agencies, then those incidents were assigned to the licensed social worker for follow-up. g) On 02/28/17 at 2:30 p.m., the licensed social worker was informed that one or more staff members in confidential interviews said they witnessed inappropriate touching of female residents by male residents. Those female residents inappropriately touched were Residents #51, #49, #24, #37, and #1. The LSW said she was aware Residents #62, #11, and #10 had sexual behaviors. She said staff should have completed incident reports each time not only for the male perpetrator, but also for the female victim. She said apparently nurses do not do so - that there were some things they need to work on and change to ensure the appropriate parties were notified, incident reports were completed, and the safety of female residents were ensured. The LSW said she had never heard of any inappropriate touching by Resident #52. She said Resident #52 and Resident #1 like each other, but they did not even hold hands and she had never seen any inappropriate behaviors between them. During an interview with the administrator on 02/28/17 at 4:38 p.m., she acknowledged that facility staff did not identify all issues of inappropriate touching and/or sexual abuse they were aware, or should have been aware of, as abuse situations. She said the lack of incident reports of abuse situations led to the absence of investigation into those issues, and failure to report all incidents of abuse to appropriate State agencies. She agreed that these practices led to the failure to protect some of its female residents from further abuse. h) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] had [DIAGNOSES REDACTED]. Resident #26 began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was not completed. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had the behaviors of inattention and disorganized thinking. In addition, the assessment identified the resident had no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. The Activities of Daily Living (ADL) assessment indicated she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfer, walking in room and had total dependence on staff for dressing, toilet use and personal hygiene. This resident is not interviewable. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated, Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. An approach for the goal, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11, and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occur. When asked how an incident of this type was reported, CI #1 stated they put it in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 was moved to Second Floor (12/02/16) to get her away from the men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On August 16, 2016 (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26's) pants. Resident #26 was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident-to-resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry noted Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 was again found reaching for the crotch of Resident #26 and the residents were separated. All of the incidents of sexual abuse toward Resident #26 would be upsetting by any reasonable person. The resident's inability to resist the repeated nonconsensual sexual contacts resulted in a determination of actual harm. Although this resident's feelings could not always be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. No evidence was found in the medical record to indicate Resident #26 was assessed after the incidents of sexual abuse. In an interview on 02/22/17 at 2:06 p.m., the Director of Nursing (DON) stated that staff did not complete incident reports regarding the sexual abuse of Resident #26 except for the incident on 08/16/16. In addition, she stated because no incident reports were completed, the sexual abuse was not investigated as stated in facility policy and procedure for abuse reporting. The DON was in agreement Resident #26 should have been assessed following these incidents and evidence recorded in the medical record. i) Resident #39 A review of the medical record from 02/13/17 through 03/01/17 revealed Resident #39 was originally admitted on [DATE], had [DIAGNOSES REDACTED]. Review of the resident's annual MDS with an ARD of 06/16/16 found she had no issues with hearing, speaking, and/or vision. The assessment identified she was usually understood and usually understood others. This resident had a court appointed conservator/guardian as she was not competent to act on her own behalf. The Brief Interview for Mental Status (BIMS) score on annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. The following incidents of sexual abuse by alleged perpetrator Resident #10 were noted in the medical record of Resident #10. No evidence was found of the incidents of sexual abuse and/or an assessment of the condition of Resident #26 in her medical record. - 09/28/16 at 14:06 (12:06 p.m.) - Behavior Monitoring nurse's note stated, Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. The MDS Coordinator stated on 02/03/17 at 9:06 a.m., in a behavior monitoring nurse's note for Resident #10 that the SW, DON, and NHA were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) - a CNA/Nurse's Note stated Resident (#10) in female resident room, she (Resident #39) was lying on her bed, male resident sitting on side of her bed, with her hand in his attempting to have her touch him, she attempting to pull her hand away when entering room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. All of the incidents of sexual abuse toward Resident #39 would be upsetting by any reasonable person. The resident's inability to resist the repeated nonconsensual sexual contacts resulted in a determination of actual harm. Although this resident's feelings could not always be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. No evidence was found in the medical record to indicate Resident #39 was assessed after the incidents of sexual abuse. In an interview with the Director of Nursing (DON) on 02/22/17 at 2:06 p.m., she stated that no incidents reports were completed regarding the sexual abuse of Resident #39. In addition, she stated because no incident reports were completed, the sexual abuse was not investigated as stated in facility policy and procedure for abuse reporting. The DON was in agreement Resident #39 should have been assessed following these incidents and evidence recorded in the medical record. j) Resident #10 Review of the medical record on 02/21/17 at 1:17 p.m. revealed Resident #10 was initially admitted on [DATE]. His [DIAGNOSES REDACTED]. He was prescribed accu-check (blood glucose monitoring) twice a day, with scheduled [MEDICATION NAME]90 units to be administered in the morning and scheduled [MEDICATION NAME]80 units to be administered in the evening at bedtime and [MEDICATION NAME]10 units scheduled to be administered in the morning before breakfast and [MEDICATION NAME]15 units scheduled to be administered in the afternoon before dinner. A Pharmacy consultation report with Comment issued on 12/07/16: Records show on 11/29/16, 12/03/16, 12/04/16 and 12/05/16 no morning [MEDICATION NAME] given. Recommendation: Please educate nursing on importance of proper dosing and [MEDICATION NAME] doses should not be held. Rationale for Recommendation: Basal insulins, such as [MEDICATION NAME] do not affect blood glucose concentrations immediately after administration. The Diabetic Flow Sheet revealed: ---on 11/29/16 at 0641 (6:41 a.m.) an accu-check was performed with a blood glucose result of 117, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 252. ---on 12/03/16 at 0600 (6:00 a.m.) an accu-check was performed with a blood glucose result of 259, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 245. ---on 12/04/16 at 0641 (6:41 a.m.) an accu-check was performed with a blood glucose result of 128, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 243. ---on 12/05/16 at 0600 (6:00 a.m.) an accu-check was performed with a blood glucose result of 69, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered or of blood glucose level being below 70 as ordered. At 2145 (9:45 p.m.) an accu-check was performed with a blood glucose result of 383. After reviewing the Pharmacy consultation report dated 12/07/16 and Diabetic Flow Sheet dated 11/28/16 to 12/07/16 on 02/27/17 at 2:10 p.m., the Director of Nursing (DON) agreed the scheduled morning insulin for Resident #10 was not administered as ordered by the physician. She also verified that no physician notification was conducted by the nurse on any of the days the morning insulin was not administered, because absolutely the physician should have been notified on each of those days. The DON stated, I don't know why the nurse held those doses and just glad that he (Resident #10) did not have any complications arising from the insulin being held. Resident #10 required multiple daily insulin doses and had blood glucose results from 11/29/16 to 12/05/16 ranging from 69 to 259 in the morning and blood glucose results in the evening ranging from 243 to 383 reveling he was considered to be an uncontrolled insulin dependent diabetic. Withholding his morning scheduled insulin doses put the resident at risk for potential complications related to his medical [DIAGNOSES REDACTED].

Based on observation, record review, staff interview, and policy review, the facility failed to provide care and treatment to a resident to promote healing of existing pressure ulcers and to prevent new sores from developing. There was no system in place to ensure skin assessments were completed timely and accurately, that interventions were implemented, monitored, and revised as appropriate, and changes in condition were recognized, evaluated, and reported to the physician, and that staff were knowledgeable in identifying and caring for pressure ulcers. Resident #74 was admitted with pressure ulcers on both elbows and his history identified a recent pressure ulcer to his coccyx. Failure to provide preventative measures resulted in actual harm to the resident by the redevelopment of the sacral pressure ulcer, a deep tissue injury to the left heel, and multiple toe wounds. Additionally, during an observation of wound care for Resident #74's, the nurse did not employ appropriate infection control techniques to reduce the risk of infecting the wound. This affected one (1) of three (3) residents reviewed for pressure ulcers. Resident identifier: #74. Facility census: Findings include: a) Resident #74 1. Review of the resident's medical record at 8:12 a.m. on 02/16/17, revealed this eighty-two (82) year old resident was admitted to the facility on [DATE] from an acute care setting. The acute care discharge summary dated 12/18/16 stated the resident presented to the hospital with increased weakness, loss of appetite and weight loss, and the inability to perform his activities of daily living (ADLs). His discharge [DIAGNOSES REDACTED]. The plan of care included in the discharge summary include, Sacral decubitus ulcer, Protect skin from further breakdown and compromise, and Frequent repositioning, keep patient active, and enforce aggressive wound care. The nursing physical assessment admission note dated 12/19/16 stated Resident #74 was admitted from an acute care center with a history of increased weakness, frequent falls, loss of appetite, rhabdomyolysis (a condition in which damaged skeletal muscle tissue breaks down rapidly), failure to thrive, muscle weakness, incontinence, and a sacral pressure ulcer. The skin assessment described, Left elbow Stage II wound 3 centimeter (cm) circle with hole in middle open purple with serious serioussangus (sic) drainage noted. Right elbow 3 cm round hole 1.25 depth with brownish/tan drainage noted. Buttocks with old red scar right proximal. The resident care record assessment written at 9:57 p.m. on 12/19/16 by Nurse Aide #138 noted Resident #74 was incontinent of bowel and bladder, and required assistance with all ADLs. -- On 12/30/16 the Assistant Director of Nursing (ADON), who was also the wound care nurse, documented a wound assessment in the computerized progress notes that included, bilateral elbows were a stage 2 on admission - now are resolving and only has some redness around perimeter -- On 01/09/17 the ADON documented an assessment stating, Bilateral elbows were noted to have stage 2 pressure ulcers on admission - areas are now dry and slightly red area - continue to use skin prep bilaterally BID (twice a day) [MEDICATION NAME]. -- On 01/16/17 the ADON wrote, Right elbow - slightly pink - open area 0.50 cm round and 0.25 deep - using skin prep - added elbow protectors resident has tendency to lean to right and puts pressure on elbow - very bony all over -- The record was silent for any assessments related to the coccyx/sacral area since the resident's admission on 12/19/16, until 01/25/17. At 6:51 a.m., Nurse Aide (NA) #121 documented, When we turned resident we found he had two sores on his bottom. I reported it to the nurse -- On 01/25/17 at 2:02 p.m. the ADON wrote, A (left elbow per pressure ulcer/location unisex body form) - resolving stage 2 - 4 cm round dk (dark) purple - not open - skin prep and elbow protectors. b (right elbow per pressure ulcer/location unisex body form) resolving stage 2 - 4 cm round dk (dark) purple with open area - 0/10 deep - skin prep - elbow protectors. -- At 3:46 p.m., on 01/25/17 Registered Nurse (RN) #153 documented, Resident has 2 Stage III (3) open areas on buttocks Drsg (dressing) applied and turn resident every two hours to prevent further breakdown. -- On 01/26/17, the Director of Nursing (DON) documented the wound assessment in the section titled Pressure Ulcer Condition: Rt (right) buttocks with 2 open areas red periwound with yellow center. Lt (left) buttocks with 1 open area red periwound with pink center. Rt heel with DTI (deep tissue injury) skin intact. Rt great toe posterior (top) pinpoint open area. All areas no odor noted. Under the section titled Pressure Ulcer Stage, the DON documented: -- A - RT buttocks 0.5 x 0.25 cm Stage 2. -- B - RT buttocks 0.25 cm x <0.25 cm Stage 2. -- C - LT buttocks 0.25 cm x < 0.25 cm Stage 2. -- RT heel - DTI 1 cm x 1 cm unstagable. -- RT Great toe pinpoint area Stage 2. Interventions included heels elevated off of the bed with bilateral heel protectors, pillow for positioning and an air mattress for the bed. Turn every two hours and staff are to notify the physician. -- On 02/06/17, the DON documented a wound assessment evaluation in the computerized records: -- A - RT (right) buttock with open area pink center no drainage, 0.25 cm x 0.25 cm x 0,25 cm Stage 2 -- B - RT buttock no open area pink in color, 0.25 circular area superficial D/I (dry and intact) pink in color Stage 2 -- C - LT buttock no open area pink in color, superficial D/I (dry and intact) pink in color Stage 2 areas with healthy tissue -- D - RT heel DTI intact area drying 1 cm x 1 cm edges intact -- E - RT great toe pinpoint scabbed area posterior UTD (unable to determine) edges intact unable to determine -- F- RT elbow < (less than) 0.25 cm x < 0.25 cm x < 0.25 cm area no drainage, pink in color skin intact resolved Stage 2 -- G - LT elbow superficial area pink in color skin intact resolved Stage 2. After reviewing the resident's medical record with the ADON/wound nurse during an interview on 02/16/17 at 9:30 a.m., the ADON confirmed Resident #74 was admitted to the facility after a stay in an acute care center for treatment of [REDACTED]. She agreed the resident was at risk for skin breakdown because he was dependent on staff for all aspects of ADL care, he was incontinent of bowel and bladder, he was thin and bony, and at nutritional risk. The ADON reported he was admitted with pressure ulcers on both elbows, and his buttocks wounds were in-house acquired on 01/25/17. The ADON stated she had no education or training in wound care, nor did she have a mentor she could contact with questions. She reported the facility did not conduct any routine body audits on the residents and there are no wound rounds or scheduled rounds with the physician to evaluate the wounds and discuss treatment options. She selected wound care treatments based on past experiences at other facilities and then notified the physician. The Director of Nursing (DON) reviewed the medical record during an interview at 9:45 a.m. on 02/16/17. She acknowledged Resident #74's skin and wounds were initially assessed on admission on 12/19/16. Weekly skin assessments were not completed. No other wound assessments were documented until 01/26/17 when the wounds were discovered on his buttocks. Registered Nurse (RN) #126 was interviewed on 02/16/17 at 11:30 a.m. She reported Resident #74 was admitted on a regular mattress until he developed the pressure ulcers on his buttocks. The air mattress was started on 01/26/17. The Minimum Data Set (MDS) nurse, interviewed on 02/20/17 at 2:45 p.m., reported she completed Resident #74's Braden assessment on 12/28/16. His score was 13 indicating he was at moderate risk for developing pressure ulcers. At 9:15 a.m. on 02/21/17, the ADON was interviewed in Resident #74's room. Upon request, she pulled back the sheets and found the heel protectors were up on the resident's shins and not protecting his heels. She acknowledged there were new wounds on his toes, which were all related to the sheets on his bed. A follow up interview and observation of Resident #74's feet was conducted with the DON on 02/21/17 at 10:50 a.m. The DON confirmed the wound tracking records lacked complete and accurate documentation of the resident's wounds. Examination of his feet at that time revealed the following: -- left 2nd toe with lateral cut across the anterior aspect below the nail -- abrasion on the anterior of the left third toe -- Right great toe with large scab over bony prominence of the joint The DON reported they need to get a cradle or something to keep the sheets off of his feet. 2. The facility policy titled Preventing Pressure Ulcers included, Any resident with a Braden score of 18 or less will be considered to be at risk of developing pressure ulcers. All residents who are determined to be at risk of breakdown shall have a weekly skin assessment documented . 3. On 02/21/17 at 9:10 a.m., the Assistant Director of Nursing (ADON)/wound care nurse provided wound care to Resident #74's sacral pressure ulcers (3 small open areas). The ADON reported she had already removed the dressing and completed her wound measurements prior to this observation. The following breaches of infection control technique were observed: -- The wound was without protection and covered with a brief containing a small amount of stool near the wound's edge. This provided a potential for introduction of microorganisms into the wounds. -- The ADON placed 2 towels, 5 washcloths, a medicine cup with Dial soap, clean gloves, and a container of Oxivir TB (disinfectant) wipes on an uncovered geri-chair. The geri-chair was an unclean surface, thus contaminating the wound care supplies creating a potential for introducing microorganisms into the resident's wound. -- The ADON donned clean gloves, pulled the cubicle curtain and cleaned 3/4 of the bedside table with the Oxivir TB wipes. At this point, the nurse's gloves were considered contaminated, and to have residue from the disinfectant wipes. -- The ADON placed a bath-basin on the table, added the soap, and placed 3 washcloths on the table next to the basin. The cleanliness of the bath basin could not be assured, which again created an opportunity to introduce microorganisms into the resident's wounds. -- The nurse soaked the first washcloth and scrubbed the resident's bottom in a circular motion moving throughout the wound bed The nurse never addressed the feces other than folding the brief under when she started. This too had the potential to contaminate the wound bed. The ADON placed the first washcloth back in the water in the basin, retrieved a second cloth, and dipped it into the bath basin and padded the resident's bottom. The nurse used the third washcloth to pat the wound area. -- Skin prep was placed around the wound perimeter and a PolyMem dressing (wicks away exudate) applied. The ADON removed her gloves and exited the room to retrieve additional dressing material without washing and/or sanitizing her hands. After reviewing the wound care observations with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m., the DON stated the wound care nurse should have used 4 x 4 sponges with wound cleaner. The use of a bath basin and washcloths increased the risk for infection of the wound. The DON agreed, the ADON should have pulled the curtain before applying gloves, and should have washed her hands after removing the gloves and before exiting the room. When the wound care observations were reviewed with the ADON on 02/28/17, she stated the facility did not have wound cleaner and she did not think to use 4 x 4 sponges. She acknowledged she contaminated the water by placing the soiled washcloth back in the basin and agreed using a basin and washcloths may not be the best infection control practice when performing wound care. She was unaware she had not washed her hands after removing her gloves to retrieve an additional dressing. The ADON acknowledged she had not had any former training in wound care. 4. The facility failed to ensure staff assessing wounds and providing wound care were knowledgeable about pressure ulcers and wound care. Resident #74 was admitted to the facility following care and treatment at an acute care center for generalized weakness, frequent falls, weight loss and failure to thrive. His discharge [DIAGNOSES REDACTED]. All of these factors contributed to the resident's risk of developing pressure ulcers, but the facility failed to implement preventative measures resulting in actual harm to the resident when the sacral pressure ulcer recurred, Stage III pressure ulcers developed to the resident's buttocks, a deep tissue injury developed to the resident's left heel, and pressure areas developed on the resident's toes.

Based on minimum data set (MDS) review, medical record review, observation, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for pressure ulcers during Stage 2 of the survey did not develop an avoidable pressure ulcer. The facility failed to implement interventions in an effort to prevent the development of the pressure ulcer. An in-house acquired suspected deep tissue injury (DTI) was identified on the resident's heel seven (7) days after readmission to the facility. The facility was unable to provide evidence of the implementation of interventions to prevent the development of the pressure ulcer or to assist in the healing of the pressure ulcer once it was identified. Resident identifier: #65. Facility census: 59. Findings include: a) Resident #65 On 10/08/14 at 9:30 a.m., a review of the medical record revealed the resident was readmitted from a local acute care hospital on [DATE]. The medical [DIAGNOSES REDACTED]. At 11:04 a.m. on 10/09/14, a review of the resident's significant change MDS, with an assessment reference date (ARD) of 08/25/14, revealed Section M, G-2 was coded that a suspected DTI was present on readmission to the facility on [DATE]. Section M1200 B and C also noted a pressure reducing device and a turning/repositioning program was in place. This information was carried forward on the MDS's with ARD's of 09/23/14 and 10/01/14. Additional medical record review revealed Resident #65 was not readmitted with a suspected DTI. According to the medical record, on 08/07/14 an in-house acquired suspected DTI to the left heel was identified. Observation, on 10/14/14 at 8:15 a.m., revealed no pressure reducing device was on the bed of Resident #65. The care plan contained two (2) problem statements related to pressure ulcers: -- On 08/12/14, the care plan indicated the resident had a Stage II pressure ulcer on the coccyx related to decreased mobility, related to a fractured pelvis. The care plan did not contain any interventions relative to care of the resident while she was in bed to prevent further skin breakdown and/or to promote healing of the pressure ulcer. -- On 09/12/14, the care plan noted the resident had a suspected deep tissue injury (DTI) on the left heel related to the fractured pelvis. The care plan failed to have interventions related to care to prevent further skin breakdown, to promote healing of the area, or for the use of a pressure relieving boot device which was ordered by the physician. Neither care plan problem statements contained anything relative to a turning/repositioning program, as the MDS indicated was in place. An interview with the director of nursing (DON), on 10/14/14 at 10:34 a.m., confirmed the suspected DTI was not present on readmission and had developed in the facility. In addition, the DON confirmed no pressure relieving device had ever been used on Resident #65's bed. Upon inquiry, the DON was also unable to provide evidence the resident was on a turning/repositioning program. .

Based on observations, resident comment, and staff interview, the facility failed to provide an environment free from accident hazards. A resident (Resident #67) was observed to touch a metal heating unit in a room designated for dining on the second floor long term care unit and immediately withdraw his hand. When measured, the temperature on the top surface of this unit was 135 degrees Fahrenheit. The temperature in the area where heat was expelled was measured to be 200 degrees Fahrenheit. This area of the unit was also accessible to anyone who might decide to touch it. The unit was midway down the surface of the wall, immediately below the window, at the level accessible without requiring the resident to bend over. This practice had the potential to affect all residents residing on the 2nd floor long term care unit and rendered the mobile, self-ambulatory residents to be in immediate jeopardy of being burned on the unit. The administrator was advised of the immediate jeopardy at 11:18 a.m. on 06/18/2013. The administrator immediately turned the unit off and had the maintenance department disable the unit. The unit and other like units were subsequently removed from the walls. The immediate jeopardy was removed at 2:25 p.m. on 06/18/2013 and no deficient practice remained relative to the heating units. Census on this unit was 17. However, environmental safety issues were also identified that had a potential for more than minimal harm, but not actual harm or immediate jeopardy. A can of disinfectant deodorizer was left where it was accessible to residents, hand rails had areas that could cause injury to residents, and water temperatures were found to be in ranges above those safe for bathing and which could result in burns with exposure of three (3) to five (5) minutes. Facility census: 59. Findings include: a) While conducting a random tour of the 2nd floor long term care unit of the facility on 06/18/13 at 11:05 a.m., Resident #67 was wheeling about the unit and requested the surveyor look at the plants in the window in the room designated for dining. Upon approaching the window and plants, a heating unit was noted to be emitting heat directly under the window. The resident stated "that won't be on" , and touched the unit. The resident immediately withdrew his hand and said "hot". The resident was encouraged to leave the room to maintain his safety, with questioning him about other areas of the unit. The temperature on the upper surface of the metal unit was then measured and determined to be 135 degrees. The temperature of the area where the heating was actually exiting the unit, also accessible to residents, was measured to be 200 degrees. These observations were made by two (2) surveyors. The facility Administrator was asked to come to the dining room. Upon his arrival in the dining room, the temperatures were again measured by the surveyors while he observed. Temperature measurements at that time were noted to be 135 degrees on the top surface and 199 degrees in the area of heat expulsion. The facility administrator was advised the excessive surface temperatures of the heating unit constituted a risk of immediate jeopardy to facility residents at 11:18 a.m. on 06/18/2013. The Administrator immediately turned off the heating unit and called maintenance staff to disable the unit, temporarily removing the chance of harm to residents, until a plan for correction could be established and implemented. At 2:15 p.m. on 06/18/2013 the facility Administrator presented a plan of correction which included completely removing the wall heater units, repairing and fixing the walls. At 2:25 p.m. the heaters were determined to have been removed from the walls, walls had been repaired and were ready to be painted. The immediate jeopardy was removed at 2:25 p.m. on 06/18/2013 and no deficient practice remained. b) During a Stage 1 observation, on 06/18/13 at 8:49 a.m., an aerosol can was seen on the shelf above the sink, in room 039 on Unit 1. The sink was located to the left when entering the doorway. Employee #89, a nursing assistant (NA), said it was a disinfectant deodorizer. She said it belonged to the facility's housekeeping department, and acknowledged it was not supposed to be there. The director of nursing (DON) was interviewed on 06/18/13. She confirmed the deodorizer should not have been left in resident's room. c) A check of the water temperatures at hand sinks, on 06/20/13 at 10:50 a.m., located in the following resident rooms, found hot water temperatures as follows: Room 32 - 124.0 degrees F Room 33 - 123.0 degrees F Room 34 - 123.8 degrees F Room 31 - 123.9 degrees F Room 36 - 123.3 degrees F Room 27 - 122.4 degrees F Room 40 - 122.6 degrees F Room 41 - 122.0 degrees F Room 1 - 121.1 degrees F Room 3 - 121.1 degrees F Room 5 - 120.4 degrees F Room 8 - 120.5 degrees F Room 9 - 120.3 degrees F These temperatures were obtained by the maintenance supervisor, Employee #77, with a facility thermometer. While taking these temperatures, Employee #77 stated he was aware the temperatures should be 110 degrees. On 6/20/13 at 11:25 a.m., water temperatures at residents' sinks on nursing facility Unit 2 were obtained by Employee #77 using the facility's thermometer. The findings were as follows: Room 214 - 111.7 degrees F Room 215 - 119.0 degrees F Room 217 - 117.3 degrees F Information in the "Guidance to Surveyors" for this requirement, found in Appendix PP of the CMS State Operations Manual, revealed the following: "Water Temp - Time required for a 3rd Degree Burn to Occur 155 degrees F - 1 seconds 148 degrees F - 2 seconds 133 degrees F - 15 seconds 127 degrees F - 1 minute 124 degrees F - 3 minutes 120 degrees F - 5 minutes 110 degrees - Safe Temperature for Bathing (See Note) Note: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure." On 06/24/13 beginning at 10:45 a.m., water temperatures at residents' sinks were again obtained by Employee #77 with a facility thermometer. Water temperatures of the following rooms on nursing Unit 1 were obtained. Room 32 - 113.6 degrees F Room 33 - 113.6 degrees F Room 31 - 115.3 degrees F Room 34 - 113.2 degrees F Room 36 - 113.0 degrees F Room 27 - 112.2 degrees F Room 40 - 112.0 degrees F Room 41 - 111.5 degrees F Room 1 - 111.5 degrees F Room 3 - 111.3 degrees F Resident sink temperatures on nursing Unit 2 were all within required limits. Employee #77 stated he was working on adjusting the water temperatures. On 06/25/13 at 11:30 a.m., Employee #77 presented records of facility water temperatures. Employee #77 stated the facility did not record water temperatures in resident rooms. d) On 06/24/13 at 9:00 a.m., nursing Unit 2's handrails were observed with corner miter cuts that were no secured in place. Unsecured miter cuts were noted between resident room 214 and the elevator and between the nursing desk and staff restroom. Both of these areas were accessible to residents. Both of these unsecured miter cuts create a potential for a splinter, pinch, or skin tear. The condition of these hand rails had the potential to affect more than an isolated number of residents who used the handrails during ambulation. On 06/24/13 at 11:30 a.m., while touring nursing Unit 2, Employee #77 was shown the handrails of concern. The handrail between resident room 214 and the elevator had been repaired. The handrail between the nursing desk and staff restroom remained in disrepair. Employee #77 observed and acknowledged both mentioned areas of the handrails, but did not make a comment. .

Based upon record review, staff interview, and observation, the facility failed to provide adequate supervision to prevent accidents and ensure the resident environment remained as free of accident hazards as possible. This resulted in falls and injury to one (1) resident. Two (2) of nine (9) residents on the sample were affected. Facility census: 65. (This was also cited during the annual survey of 01/31/12) Findings include: a) Resident #28 This [AGE] year old lady was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was found to have had a fall with a fracture on 03/23/12, a second fall on 06/08/12, and another fall with a fracture on 07/24/12. Her record was reviewed on 08/20/12 at 10:35 a.m. She had been assessed as being at risk for falls since her admission. Her comprehensive minimum data set (MDS) assessment, of 06/07/12, indicated she was not steady, only able to stabilize with staff assistance for moving from a seated to a standing position, walking, turning around, moving on and off of the toilet, and surface-to-surface transfers. She was assessed as being at risk for falls due to poor balance, psychotropic drug use, and poor safety awareness related to her dementia. She also had a built-up shoe for her right foot due to the right leg being shorter than her left. A review of her care plan found there was an intervention in place as early as 03/17/12 that stated "Do not leave alone in bathroom, activity, or hairdressing rooms." The KARDEX, or specific instructions for the nursing assistants concerning individualized care to be provided for Resident #28, contained the statement under the "comments" section: "Resident is not to be left alone in BR (bathroom)." The incident report of 03/23/12, for her fall with fracture, indicated she fell when left unattended by staff. Under the "Prevention" section was documented: "Two staff members should've remained with the resident until resident was seated in the wheelchair." The incident report for her fall with fracture of 07/24/12, indicated she fell again when left unattended by staff. Under the "Contributing Factors" section was documented "Alzheimer's - Resident in Bathroom - didn't ring when finished CNA (Certified Nursing Assistant) went to next room to get assist with transfer." An interview was conducted with Director of Nursing (DON), Employee #2, on 08/21/12 at 10:30 a.m. She acknowledged the intervention "do not leave alone in bathroom" was care planned as early as 03/17/12, due to the resident's poor balance, psychotropic drug use, and poor safety awareness related to dementia, all of which were continued concerns. She stated that although the intervention was developed for the interdisciplinary plan of care, it had never been added to the KARDEX care instructions until after the fall and fracture of 07/24/12. It was added so the nursing assistants would know not to leave her alone. She stated there was not sufficient staff on a consistent basis to permit someone to stay with every resident who might need such supervision for safety. b) Resident #48 This resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. His medical record was reviewed on 08/20/12 at 2:30 p.m. He experienced a fall on 04/07/12 and again on 08/15/12. He was assessed as being at high risk for falls upon his admission on 01/08/11 and on all subsequent assessments. He was determined to be at risk for falls due to his lack of balance, use of medications, and dementia. He had a care plan in place for risk for injury from falls. On 08/15/12, he fell while ambulating from his bed to the bedside commode. After the fall, recommendations were made by nursing and physical therapy to discontinue his scheduled toileting program and instead check, change, and toilet him as needed. There was also a recommendation to remove the bedside commode from the room for safety purposes and put a urinal at bedside. Observations throughout the survey found the bedside commode beside his bed all day on Monday, 08/20/12, Tuesday 08/21/12 and Wednesday 08/22/12. The intervention to remove the bedside commode from the room had not been added to the KARDEX, or specific instructions for the nursing assistants concerning individualized care to be provided for resident #48, which still contained a checkmark beside"Bedside Commode". Registered nurse (RN), Employee #58 was interviewed on 8/21/12 at 12:10 p.m. She acknowledged that the interdisciplinary decision to remove the bedside commode for safety reasons on 08/16/12 had not been implemented, nor had it been added to the KARDEX care instructions for the direct care staff. .

Based upon record review, resident interview, and staff interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident from a failure to correct deficient practices identified on the annual survey of 01/31/12. The facility had failed to complete all elements of the approved plan of correction, or implemented other corrective actions, in the areas of preventing injury from accidents, which was found for two (2) of nine (9) residents reviewed; responding and acting upon group grievances, which was found for one (1) complaint and had the potential to affect more than an isolated number of residents; and ensuring that physician's orders were signed in a timely manner, which was found for four (4) of six (6) records reviewed. All residents had the potential to be affected. Facility census: 65. Findings include: a) The facility was cited for failure to provide adequate supervision to prevent accidents for Resident #28. The resident was left alone while on the toilet which resulted in a fall with a fracture. Additionally, the facility had not ensured the resident environment remained as free of accident hazards as possible, which was found for Resident #48. A bedside commode that had been identified as an accident hazard was observed to remain in the resident's room throughout the survey. The facility was cited for the same deficient practices during the annual survey ending 01/31/12, and had submitted an approved plan of correction designed to address staff responsiveness to resident's needs and environmental hazards by 03/31/12. (See F323) b) The facility failed to respond to, and act upon, group grievances. Members of the resident council had expressed concern with call lights not being answered in a timely manner during their meeting of 06/28/12. The facility was to conduct an audit in an effort to investigate the concern, but this was never done. There was never any response given to the council regarding the issue. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted that was designed to address the issue by 03/08/12. The plan included tracking and monitoring of all grievances, revising the facility's policies and procedures, and implementing two (2) new forms. (See F244) c) The facility failed to ensure physician's orders were signed in a timely manner. One resident was found to have unsigned orders for March 2012. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted and approved that was designed to address the issue by 03/05/12. Interviews with the medical records coordinator, Employee #99 and administrator, Employee #64, found that many of the elements of the proposed corrective action had not been completed as pledged. (See F386) .

Based upon observation, record review, staff interview, and resident interview, the facility failed to maintain a quality assessment and assurance committee that developed and implemented appropriate plans of action to correct identified quality deficiencies in the areas of preventing injury from accidents, which was found for two (2) of nine (9) residents reviewed; responding and acting upon group grievances, which was found for one (1) complaint and had the potential to affect more than an isolated number of residents; and ensuring that physician's orders were signed in a timely manner, which was found for four (4) of six (6) records reviewed. These issues had the potential to affect all residents. Facility census: 65. Findings include: a) The facility was cited for failure to provide adequate supervision to prevent accidents for Resident #28. The resident was left alone while on the toilet which resulted in a fall with a fracture. Additionally, the facility had not ensured the resident environment remained as free of accident hazards as possible, which was found for Resident #48. A bedside commode that had been identified as an accident hazard was observed to remain in the resident's room throughout the survey. The facility was cited for the same deficient practices during the annual survey ending 01/31/12, and had submitted an approved plan of correction designed to address staff responsiveness to resident's needs and environmental hazards by 03/31/12. (See F323) b) The facility failed to respond to, and act upon, group grievances. Members of the resident council had expressed concern with call lights not being answered in a timely manner during their meeting of 06/28/12. The facility was to conduct an audit in an effort to investigate the concern, but this was never done. There was never any response given to the council regarding the issue. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted that was designed to address the issue by 03/08/12. The plan included tracking and monitoring of all grievances, revising the facility's policies and procedures, and implementing two (2) new forms. (See F244) c) The facility failed to ensure physician's orders were signed in a timely manner. One resident was found to have unsigned orders for March 2012. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted and approved that was designed to address the issue by 03/05/12. Interviews with the medical records coordinator, Employee #99 and administrator, Employee #64, found that many of the elements of the proposed corrective action had not been completed as pledged. (See F386) .