Every finding on record at The Blossoms at West Dixon Rehab & Nursing Center

Based on record review and interview, it was determined that the facility failed to ensure pharmacist recommendations were addressed for two (Resident #4 and Resident #19) of five residents reviewed for unnecessary medications. Specifically, Resident #4 had pharmacist recommendations to decrease an antidepressant and change an insulin order that were not followed. Resident #19 had a pharmacist recommendation to have a laboratory blood draw for an anti-seizure medication that was not completed. The findings include: Resident #4 A review of the Resident #4's admission Record indicated the facility admitted the resident with diagnoses which included type two diabetes mellitus, major depressive disorder, and a long-term use of insulin. A review of Resident #4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/23/2025, revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment. A review of Resident #4's Care Plan Report, initiated on 04/07/2025, revealed the resident had diabetes with insulin therapy and was at risk for low and high blood sugars. Interventions included referring to the medication administration record in the electronic health record for insulin therapy and to have a fasting serum blood sugar, as ordered by the doctor. Resident #4's Care Plan also indicated the resident used antidepressant medication. A review of Resident #4's Order Summary Report revealed the resident had an order for a 30 milligram (mg) antidepressant, and to give two capsules to equal 60 mg daily. A review of a Pharmacy Review, with an effective date of 09/23/2025, revealed the pharmacist recommended to complete a gradual dose reduction of Resident #4's antidepressant from 60 mg to 30 mg daily. The physician reviewed the recommendation and indicated to decrease the medication to 30 mg, once the current supply was completed. A review of Resident #4's Order Summary Report, from 05/01/2025 through 01/31/2026, indicated there was no decrease to Resident #4's antidepressant. Resident #4's Order Summary Report also revealed an order for a short-acting insulin and to inject 11 units before meals and at bedtime. A review of a Pharmacy Review, with an effective date of 11/28/2025, revealed the pharmacist recommended to discontinue Resident #4's bedtime short-acting insulin and initiate five units of a long-acting insulin, due to the residents elevated blood sugar levels. The physician reviewed the recommendation and agreed with the pharmacist's recommendations. A review of Resident #4's Order Summary Report, from 05/01/2025 through 01/31/2026, indicated there was not an order to discontinue Resident #4's short-acting insulin and initiate five units of a long-acting insulin. A review of a Pharmacy Review from 07/2025 to 01/2026, indicated the pharmacist did not acknowledge that Resident #4 did not have a laboratory order for an A1C (a laboratory test to show an average blood sugar over the past two to three months). A review of a Diabetes Care article titled, Management of Diabetes in Long-Term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association, indicated, At the time of admission to a facility, transitional care documentation should include laboratory tests (including A1C, lipids, and renal function) . During an interview on 01/15/2026 at 10:45 AM, the Director of Nursing (DON) stated the process for a Pharmacy Review, included the pharmacist completing their review monthly. Once the pharmacist had completed their review, the pharmacist notified the unit manager, who then notified the resident's provider. If there were any new orders, the physician notified the unit manager, who in turn carried out any recommendations the physician may have had. The DON stated if a resident was taking insulin and there was not a physician's order for an A1C, staff were to contact the physician to get an order. The DON stated that Resident #4 did not have a physician's order for an A1C and after reviewing Resident #4's medical record, she indicated there was no order to discontinue the bedtime short-acting insulin or for the addition of five units of a long-acting insulin. Resident #19 A review of the Resident #19's admission Record, indicated the facility admitted the resident with diagnoses that included schizophrenia, epilepsy, major depressive disorder, mild intellectual disabilities, convulsions, and dissociative and conversion disorder. A review of Resident #19's quarterly MDS, with an ARD of 11/10/2025, revealed a BIMS score of 05, which indicated the resident had severe cognitive impairment. A review of Resident #19's Care Plan Report, initiated on 05/24/2024, revealed the resident had potential for complications associated with seizure disorder. One intervention included to obtain and monitor lab work as ordered and to report results to the physician and follow up as indicated. A review of Resident #19's Order Summary Report was completed from 05/01/2025 though -01/31/2026, which revealed Resident #19 had an order for 1500mg of anti-seizure medication to be administered two times a day. Further review indicated Resident #19 had a laboratory test for an anti-seizure medication on 05/29/2025, and on 07/31/2025. There were no other lab orders for the anti-seizure medication within the review period. A review of Resident #19's Lab Results Report indicated on 08/06/2025, Resident #19 had an anti-seizure lab result of 68.2 ug/mL (normal range was from 5.0 – 45.0 ug/mL). A review of Resident #19's Progress Notes indicated on 08/07/2025, Advanced Practice Registered Nurse #3 reviewed Resident #19's labs and indicated there were new orders to repeat the anti-seizure lab in one month. A review of Resident #19's Hospital Records indicated on 08/12/2025, Resident #19 was admitted to the emergency room due to possible seizures. Resident #19's Hospital Records also revealed that on 08/13/2025, the resident had an anti-seizure lab result of 166 ug/mL (normal range was from 10.0 – 40.0 ug/mL). A review of a Pharmacy Review, with an effective date of 08/29/2025, revealed the pharmacist indicated Resident #19 was taking 1500 mg of an anti-seizure medication and on 08/06/2025, the resident's level was high and consider follow-up levels, as levels were used more for toxicity than indicators of seizure control. There was no physician review completed, however the Assistant Director of Nursing indicated there were no changes made. During an interview on 01/15/2026 at 10:45 AM, the Director of Nursing (DON) reviewed Resident #19's electronic health record and acknowledged that on 08/29/2025, the pharmacist recommended the resident's seizure medication lab levels were to be checked in one month. The DON stated that the lab was not done and by not following the request to have a lab redrawn, the result could have led to seizures. The DON also stated that the physician did not review the pharmacist recommendations, and that the DON herself, along with the unit managers, were responsible for ensuring the pharmacist recommendations were being reviewed by the physician.

Based on observation, record review, and interview, the facility failed to ensure the water temperature in a resident's room was maintained in a comfortable temperature for use for one (Resident #78) of two resident's rooms located on the secured unit and failed to ensure three (100-Hall, 300-Hall, and 600-Hall, across the hall from room [ROOM NUMBER]) of six hall showers were maintained in a clean and sanitary condition. The findings include: Resident #78 During an observation on 01/12/2026 at 10:37 AM, this surveyor entered the bathroom in room [ROOM NUMBER] and turned on the hot water at the faucet and allowed the water to run. At 10:41 AM, this surveyor placed fingers from the right hand under the running water from the hot faucet and the water was cold to touch. At 10:43 AM, this surveyor again placed the fingers from the right hand under the water from the hot faucet and the water was still cold to touch. During an observation on 01/12/2026 at 3:39 PM, Resident #78 was sitting up in their chair, with their eyes closed. The hot water in the bathroom sink was tested using this surveyor's thermometer. The temperature on the thermal thermometer displayed 70.2 degrees Fahrenheit (F). During an observation on 01/14/2026 at 2:57 PM, Resident #78 was not in their room at this time. The hot water in the bathroom sink was tested using this surveyor's thermometer. After running the hot water for three minutes, the temperature on the thermal thermometer displayed 72.7 degrees F. During an observation on 01/14/2025 at 3:30 PM, this surveyor and the Maintenance Director entered Resident #78's bathroom. The Maintenance Director turned on the hot water at the sink in Resident #78's bathroom, and stated the water was cold and it may take a few minutes to warm up. At 3:35 PM, the water was still cold to touch, and the Maintenance Director stated he was leaving the room to turn on the hot water in another room on the odd side of the hall. He turned on the hot water in room [ROOM NUMBER]. At 3:37 PM, the hot water from the bathroom sink was still cold, and the Maintenance Director left the room again and turned on the hot water in a third room to see if that would help the water get warm in Resident #78's bathroom sink, because he stated the hot water in Resident #78's bathroom was only 60 degrees at that time. At 3:41 PM, after running for 11 minutes, the hot water from Resident #78's bathroom sink's temperature displayed 65.8 degrees F on the Maintenance Director's thermometer. A review of Resident #78's admission Record revealed the facility admitted the resident on 11/07/2025, with diagnoses which included Alzheimer's disease late onset, dementia, and full incontinence of feces. A review of Resident #78's admission Minimum Data Set (MDS) with an Assessment Reference Date of 11/09/2025, revealed a Brief Interview for Mental Status score of 00, which indicated the resident had severe cognitive impairment. Resident #78's MDS also indicated the resident did not use any mobility devices, required partial/moderate assistance with shower/bathing self, and was independent with transfers to the toilet and walking up to 150 feet. A review of Resident #78's Care Plan, dated 12/22/2025, revealed the resident required extensive assist of one staff with toileting, personal hygiene, and bathing. A review of the December 2025 Grievance Log revealed a grievance for Resident #78 on December 08, 2025, which indicated no working water. The grievance log indicated the department head responsible was Social/Maintenance. During a telephone interview on 01/12/2026 at 1:42 PM, Resident #78's family member stated there was no hot water in Resident #78's bathroom. The family member stated they allowed the hot water to run for five minutes one day, and the water never got hot. Resident #78's family member stated during some visits, the resident needed to be cleaned and the FM would clean Resident #78 up, if needed, using a towel and water [from the bathroom faucet]. The family member then stated they did inform the Director of Nurses (DON) of their concern about no hot water in Resident #78's room, after the resident returned from a recent hospital stay, but FM could not remember the exact date of this discussion. The family member stated they were told the facility was aware of the matter and was working on getting it fixed. During an interview on 01/14/2026 at 3:38 PM, the Maintenance Director stated the hot water temperature range for resident rooms should be 90-100 degrees Fahrenheit. He stated he did not know if 80 degrees [F] was a sufficient temperature for the hot water in the resident rooms because he didn't know what 80 degrees [F] would feel like. He then stated, 65.8 [F] was not a sufficient temperature for the hot water in a resident's room because it was too cool. The Maintenance Director indicated the holding tank should be set at 120 degrees [F], but he was not sure if the holding tank was where the water came from to the resident's rooms. He stated he had been at the facility over a year and was learning things. On 01/15/2026 as of 8:15 AM, the Nurse Consultant indicated the facility did not have a policy or guidance on water temperatures in resident room. During an observation on 01/12/2026 at 2:29 PM, this surveyor observed the 300-Hall shower and the grout on the floor. The walls and corners of the shower were black in color. During an observation on 01/13/2026 at 3:27 PM, this surveyor observed the 300-Hall shower and the grout on the floor. The walls and corners of the shower were black in color. During an observation on 01/15/2026 at 3:54 PM, this surveyor observed the 100-Hall shower and the grout on the floor. The walls and corners of the shower were black in color. During an observation on 01/15/2026 at 3:59 PM, this surveyor observed the 600-Hall shower, located across the hall from room [ROOM NUMBER]. The grout on the floor and the lower part of the wall of the shower was black in color. A review of a '73 Disinfecting Acid Bathroom Cleaner' sell sheet revealed this product was effective against soap scum and hard water build-up on hard, non-porous surfaces. The information sheet indicated this product could be used in bathrooms and showers. The dilution rate to disinfect was 8 ounces (oz) per gallon, with a dwell time of five minutes. A review of a 'Rapid Multi-Surface Disinfectant Cleaner' sell sheet revealed this product could be used in the following ways: for hospital disinfection, on different viruses, to sanitize non-food contact areas, for soft surface sanitization and soft surface disinfection. The information sheet revealed this product could be used areas such as public spaces and bathrooms. During an interview on 01/15/2026 at 3:30 PM, Certified Nursing Assistant (CNA) #1 stated housekeeping was responsible for cleaning the showers. CNA #1 went with this surveyor to the 300-Hall shower room and stated the grout in the shower appeared blackish in color and the discoloration had been there for a while, but she did not elaborate as to a definitive length of time. During an interview on 01/15/2026 at 4:06 PM, the Housekeeping Supervisor (HSK SPVR) stated housekeeping disinfected all showers (six total in the building), once in the morning and once before they left for the day, daily. She stated housekeeping used a disinfectant and an acid cleaner through [company name]. She stated the contact time for the acid cleaner was 15 seconds and then the acid cleaner was removed by pressure washing the area and wiping the area down. The HSK SPVR was asked to look at the grout in the 300-Hall shower, and she stated the grout needed to be regrouted. She described the color of the grout in the 300-Hall shower as dark gray and black looking. She stated all the showers needed to be regrouted. The HSK SPVR stated she was responsible for overseeing that the showers did not have any discoloration and were clean. As of 01/15/2026 at 5:03 PM, the Administrator did not provide a policy or guidance on Environmental Services. The Administrator and other facility staff stated they did not have any further documentation to provide to the survey team regarding the concern of water temperatures in the resident rooms or the hall showers in the facility.

Based on record review and interview, the facility failed to ensure the physician was promptly notified of a significant change in a resident's condition, for one (Resident #4) out of five residents reviewed for unnecessary medications. Specifically, Resident #4 was receiving insulin with physician orders for blood glucose monitoring, the facility failed to obtain physician orders identifying parameters for blood glucose values requiring notification. As a result, when the resident's blood glucose level exceeded 500 mg/dL, staff failed to notify the physician of this significant change in condition, placing the resident at risk for adverse outcomes related to uncontrolled hyperglycemia. The findings include: A review of Resident #4's admission Record indicated the facility admitted the resident with diagnoses that included type two diabetes mellitus, major depressive disorder, and a long-term use of insulin. A review of Resident #4's quarterly Minimum Data Set with an Assessment Reference Date of 10/23/2025, revealed a Brief Interview for Mental Status score of 09, which indicated the resident had moderate cognitive impairment. Further review indicated the resident was on insulin therapy and antidepressant therapy. A review of Resident #4's Care Plan Report initiated on 04/07/2025, revealed the resident had diabetes with insulin therapy and was at risk for low and high blood sugars. Interventions included referring to the medication administration record in the electronic health record for insulin therapy and to have fasting serum blood sugar as ordered by the doctor. Further review indicated the resident used antidepressant medication. A review of Resident #4's Order Summary Report, from 05/01/2025-01/31/2026, revealed Resident #4 had an order for 11 units of insulin to be given subcutaneously before meals and at bedtime. There were no parameters indicated when to notify the physician and no A1C labs ordered. A review of Resident #4's Medication Administration Record for January 2026 indicated Resident #4's blood sugar on 01/05/2026 at 4:00 PM, was 444 mg/dL and on 01/06/2026 at 4:00 PM, it was 400 mg/dL. A review of Resident #4 Medication Administration Record for December 2026, indicated the following elevated blood sugars for Resident #4: 12/16/2025 at 4:00 PM: 479 mg/dL 12/16/2025 at 9:00 PM: 479 mg/dL 12/18/2025 at 9:00 PM: 400 mg/dL 12/19/2025 at 4:00 PM: 427 mg/dL 12/22/2025 at 4:00 PM: 432 mg/dL 12/24/2025 at 4:00 PM: 400 mg/dL 12/25/2025 at 9:00 PM: 415 mg/dL 12/29/2025 at 4:00 PM: 557 mg/dL 12/31/2025 at 11:00 AM: 400 mg/dL A review of Pharmacy Review, with an effective date of 11/28/2025, revealed the pharmacist recommended to discontinue the bedtime administration of 11 units of insulin and initiate 5 units, due to the resident's blood sugars being elevated. There was no indication for notification of physician or recommendation for an A1C order. During an interview on 01/15/2026 at 9:38 AM, Licensed Practical Nurse (LPN) #4, who had documented on Resident #4's December MAR a blood sugar at and/or over 400, stated parameters were different for every resident and if there were not any parameters, and she would make a note in the resident's medical record and notify the physician. Regarding Resident #4, LPN #4 stated she should have notified the physician of the resident's blood sugar and lack of parameters. During an interview on 01/15/2026 at 9:54 AM, LPN #5, who had documented on Resident #4's December MAR a blood sugar at and/or over 400, stated parameters should be listed on the residents MAR but if the resident did not have any, the physician should be notified. LPN #5 stated the facility never told her about parameters or when to notify the physician, since she was contracted staff. During an interview on 01/15/2026 at 10:45 AM, the Director of Nursing (DON) stated that an A1C was drawn whenever the physician ordered one for that particular resident, and if the resident was taking insulin and there was no A1C order, then the nurse needed to notify the physician to see how often an A1C should be ordered. The DON stated the parameters for blood sugars may be different for each resident but typically, if they were below 60 or above 400, the nurse should notify the physician and if there were no parameters listed for that resident, the nurse needed to notify the physician to have an order for parameters. The DON stated for Resident #4, the nurse should have called the physician and received an order for parameters. On 01/15/2026 at 12:29 PM, Resident #4's physician was called and a voicemail was left with a callback number, however, the physician did not return the surveyors call during the survey.

Based on record review, interviews, and facility document review, it was determined that the facility failed to ensure unrestricted visitation for one (Resident #7) of three residents reviewed for visitation rights. Specifically, a health care liaison was interrupted by the Director of Nursing (DON) and not allowed to complete an assessment of Resident #7 following a received transfer referral to an outside facility.The findings include: A review of Resident #7’s admission Record revealed the facility admitted the resident on 09/27/2024, with diagnoses which included chronic kidney disease, type 2 diabetes, muscle weakness/paralysis of the left side, cognitive communication deficit, major depressive disorder, and a history of homelessness. A review of Resident #7’s quarterly Minimum Data Set, with an Assessment Reference Date of 01/01/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 08, which indicated the resident had moderate cognitive impairment. A review of a Progress Note, dated 02/18/2025, revealed Resident #7 had a BIMS of 15, completed by the Social Worker. A review of Resident #7’s Care Plan Report, initiated on 09/30/2024, revealed the resident had major depression with a goal to remain free of distress, anxiety, or sad mood. The Care Plan also included interventions of medication and pharmacy review only. During an interview on 07/14/2025 at 2:59 PM, Resident #7’s Military Benefits Advanced Practice Nurse case manager stated a health care liaison from another facility attempted to visit with the resident and complete a needed resident assessment after receiving a transfer referral but was kicked out by the facility. During an interview on 07/15/2025 at 1:28 PM, the Health Care Liaison for Resident #7 stated, “yes, I did visit with Resident #7 on February 20, 2025, I do not recall the time of day.” The Health Care Liaison stated when she entered the facility, there was no sign-in sheet and no one at the door, so she went to the nurse’s station and a nurse directed her to Resident #7’s room. While in the room with Resident #7, a nurse came to get the Health Care Liaison out of the room and said the Administrator wanted to speak with her. The Health Care Liaison stated when she got to the front, a gentleman came out of the office and asked, “are you her?” He said, “you can’t just come in here and talk to our residents, you need to call first.” The Health Care Liaison stated she had called and spoken with the Business Office Manager (BOM) and told her a transfer referral for Resident #7 was received from the Social Worker. The Health Care Liaison stated the gentleman walked off and the BOM escorted her out. During an interview on 07/17/2025 at 9:58 AM, the Director of Nursing (DON) stated an aide came to her and said there was a lady questioning Resident #7. The DON went and introduced herself asking, “Did you stop by and let the administration office know you were here?” The DON asked the Health Care Liaison, Would you mind coming with me to the administration office.” The DON stated “I stepped out of the office. I do remember him [the Administrator] saying, ‘Did you let someone know you were coming?’ The Health Care Liaison said the BOM knew I was coming.” The DON then stated, “I walked away and do not know if she left on her own or was asked to leave.” During an interview on 07/16/2025 at 9:13 AM, the Registered Nurse (RN) Unit Manager stated, “I do not know who interrupted the visit, I want to say that it was the DON. We did have a change in DONs around that time,” The circumstances as to why the visit was cut short were they did not introduce themselves, and it was like they were poaching. The RN Unit Manager stated residents were allowed visitors and denied visitors if there was a safety issue. There was no reason the Health Care Liaison would not have been allowed to visit Resident #7. During an interview on 07/16/2025 at 12:41 PM, the Social Worker stated under the Resident Rights-Visitation policy, residents were allowed visitors at any time and the facility had no set visiting hours. The only time a visitor would not be allowed was if the resident refused or did not want any visitors. This would then be documented in their medical record. During an interview on 07/16/2025 at 1:36 PM, the BOM stated Resident #7 told her about wanting to go to another facility. The BOM stated the Health Care Liaison called, and the BOM let the Health Care Liaison know Resident #7 had possibly changed their mind, and to wait on the Social Worker to call back. The BOM stated Resident #7 was back and forth about going or not going to another facility. During an interview on 07/16/2025 at 2:36 PM, the Administrator stated as far as visitation, the Health Care Liaison came in and was assisted by staff to Resident #7’s room. The Administrator stated that residents were allowed to have visitors per their rights, unless of course there was an issue of safety to the resident. The Administrator did not recall the Health Care Liaison being told to leave. During an interview on 07/17/2025 at 8:45 AM, the Social Worker stated he had not withdrawn Resident #7’s transfer referral and had not told the Health Care Liaison not to come visit the resident. A review of an undated document titled, “Resident Rights/Civil Rights, Ref: CMS.GOV,” which is provided to the residents at admission indicated, as a resident of a skilled nursing facility (SNF), you have certain rights and protections under federal and state law. These laws help ensure you get the care and services you need. Visitors: You have the right to spend private time with visitors at any reasonable hour. Any person who gives you help with your health or legal services may see you at any reasonable time. This includes doctor, representative from the health department, and your Long-Term Care Ombudsman, among others. A review of the facility policy titled, “Resident Rights-Visitation” reviewed January 2024, indicated, the facility will provide immediate access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to deny or withdraw consent at any time.

Based on record review, interviews, and facility document review, the facility failed to ensure resident rights were protected for one (Resident #7) of three residents reviewed. Specifically, the facility failed to ensure the resident's right of dignity and quality of life was maintained regarding activities of daily living care resulting in psychosocial distress; and failed to ensure Resident #7 was free from reprisal after the resident made a grievance. The findings include: A review of Resident #7’s admission Record revealed the facility admitted the resident on 09/27/2024, with diagnoses which included chronic kidney disease, type 2 diabetes, muscle weakness/paralysis of the left side, cognitive communication deficit, major depressive disorder, and history of homelessness. A review of Resident #7’s quarterly Minimum Data Set, with an Assessment Reference Date of 01/01/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. The MDS also indicated that Resident #7 had no behaviors, had an indwelling catheter, and was frequently incontinent of bowel. A review of a Progress Note for Resident #7 dated 02/18/2025, for BIMS completed by the Social Worker revealed a BIMS of 15. A review of Resident #7’s Care Plan Report, initiated 09/30/2024, revealed the resident had major depression with a goal to remain free from distress, anxiety, or sad mood. The Care Plan included interventions for medication and pharmacy review only. A review of a Grievance Form dated 02/18/2025, revealed it was assigned to the Registered Nurse (RN) Unit Manager to investigate. The resolved date of the grievance was 02/26/2025, with a summary statement of the resident’s grievance; Resident #7 put their call light on and informed Certified Nursing Assistant (CNA) #1 they needed to be changed. CNA #1 did not change the resident when Resident #7 wanted. The RN Unit Manager spoke with Resident #7 and CNA #1. Summary of conclusion: CNA #1 was making rounds and did not change Resident #7 as quickly as the resident would have liked. Action taken: CNA #1 was removed from the hall. Date resolved: 02/26/2025. A review of an updated Care Plan for Resident #7 initiated on the date the grievance was received, 02/25/2025 revealed that the facility amended Resident #7’s Care Plan to include, “expresses maladaptive behavioral symptoms related to calling, reporting false allegations to outside persons/entities stating [resident was] scared and fearful.” The goal was for Resident #7 to demonstrate an improvement or reduction in distressing behavioral symptoms in responding to behavior interventions. The Care Plan also included interventions to explain the desired behavior to Resident #7, that the resident was expected to behave respectfully and with maturity, review rules and expectations to improve judgement and self-control, utilize psychiatric management to psycho-active medications, provide support, and enhance “structure”, use behavior management techniques to promote and shape the desired behavior. Identify causal factors and work to reduce, minimize and/or treat the causal factors. Teach stress/anxiety, psychiatric symptom techniques to help resident cope with anger, poor ability to deal with frustration, impulsivity, hallucinations, and delusions. A review of Resident #7’s Progress Notes indicated no behaviors documented from date of admission [DATE] to discharge date on 03/18/2025. During an interview on 07/16/2025 at 12:27 PM, the Social Worker stated, the process for a grievance/complaint was that it was written on the Grievance/Complaint form when a resident was not getting something done, their needs met, or Activities of Daily Living (ADL) not met. The Social Worker stated he gave the grievance from Resident #7 to the RN Unit Manager the same day Resident #7 made the complaint on 02/18/2025, and then mentioned it again during the 02/19/2025, morning meeting. When it was completed, it got returned to him and stored in his book. Typically, the Social Worker liked the grievances returned within 24 hours. All completed complaints were brought to the Social Worker and reportables went to the Administrator. During an interview on 07/14/2025 at 2:00 PM, Resident #7’s Military Benefits Advanced Practice Nurse (MBAPN) stated, she came to visit the resident on 02/18/2025, and “found Resident #7 to be in dirty clothing, disheveled, and appearing to have lost weight.” Resident #7 reportedly had been asking to go outside and was not taken. The next week, Resident #7 was put on weekly visits, remained in poor condition, and missed appointments. As stated by the MBAPN, Resident #7 reported being fearful of leaving the facility. The resident stated they were not allowed to get out of bed, stayed in feces for hours as a punishment, and it was CNA #1 who was assigned to Resident #7. The MBAPN stated Resident #7 was cognitively intact and the Ombudsman had also been contacted. The MBAPN stated that on 02/25/2025, the Business Office Manager (BOM) stopped the MBAPN and the Military Benefits Therapist (MBT) and stated they were soliciting the resident. The MBAPN reported the incident to the Director of Nursing (DON). The MBAPN did locate another facility for Resident #7 to transfer to per Resident #7's request and confirmed the request by the resident. During an interview on 07/14/2025 at 4:01 PM, the MBT stated both herself and the MBAPN visited the facility on 02/25/2025. She stated, Resident #7 looked much thinner since her last visit made on 02/18/2025. The MBT stated, Resident #7 acted nervous, watched the door, looked uneasy, and guarded. Resident #7 looked emaciated and wanted to go outside and stated, “The facility won’t take me out; I just want some sunshine.” The MBT stated Resident #7 revealed CNA #1 had been rough with them, and the resident would get scolded when they attempted to get up to the bathroom unassisted. The MBT stated Resident #7 told her, “I get in trouble when I try to get up,” and that the resident was afraid of retaliation. During an interview on 07/15/2025 at 12:40 PM, Resident #7 stated, “The woman was very abusive and rude, her name was [CNA #1].” CNA #1 told the resident to wear a diaper and when CNA #1 provided perineal care, she was physically abusive. Resident #7 stated, “She [CNA #1] grabbed my sore hip and shook it. She let me know she was in charge, constantly yelling. Resident #7 continued, “I had to eat my meal with poop in my pants and wait all night to be changed.” Resident #7 stated they had trouble eating, but the meals did not appeal to them, and [the facility] never offered me anything different to eat. The resident continued, “Occasionally I got a [meal replacement shake] maybe once a week. Sometimes I got snacks if I asked for them; cookies or something like that.” During an interview on 07/16/2025 at 9:13 AM, the RN Unit Manager stated, “I believe it was a specific CNA who is not here anymore,” the RN unit manager identified the CNA as CNA #1. The RN Unit Manager recounted that Resident #7 stated CNA #1 did not change them, so Resident #7 did not want CNA #1’s care anymore. Resident #7 was assigned a different CNA from another hall. During a follow-up interview on 07/16/2025 at 10:57 AM, the RN Unit Manager stated Resident #7 did not get changed out of wet clothes in a timely manner. Resident #7 put their call light on, and CNA#1 told the resident they were going to have to wait. It was not as quick as Resident #7 wanted it to be or should have been, it was lunchtime. Resident #7 did not want the aide to care for them anymore. The RN Unit Manager stated, “We pulled another CNA from another hall to take care of Resident #7, I’m not sure if CNA #1 was suspended at that point.” The RN Unit Manager stated, “well if there’s meal trays out, that’s an infection control issue, but we have one aide out on the floor to assist with resident’s needs during meal pass. While a resident is eating, an aide cannot touch a meal tray and change a resident but the aide could have taken Resident #7 to the bathroom or shower room to change. The RN Unit Manager stated, “I wouldn’t expect Resident #7 to sit in wet clothes, [the resident] should have been changed.” The RN Unit Manager stated “If [the resident] told us they had to sit in in soiled clothes during lunch, that’s not acceptable. There are options to get residents changed.” The RN Unit Manager then stated, CNA#1 was no longer employed at the facility. During an interview on 07/16/2025 at 11:15 AM, the DON revealed that the Lead CNA told her Resident #7 did not want CNA #1 to be assigned to them anymore but would not say why. The DON stated “[Resident #7’s] original statement to me was they didn’t want CNA #1 to come back into their room; [Resident #7] denied it when we went back to talk.” The DON stated, “I wasn’t aware of this grievance from 02/18/2025, about the wet clothes.” Resident #7 did not like the way CNA #1 talked to them, and the Lead CNA was supposed to talk to CNA #1 about it. The DON stated Resident #7 made a lot of allegations, like even if something came up with door dash and due to Resident #7 changing their story when asked about the allegation of CNA#1 being verbally abusive and did not want her back in the room the resident’s care plan was updated to reflect Resident #7 made false allegations. A Review of a Care plan report dated 09/302024 to 03/31/2025 indicated the resident exhibited maladaptive behavioral symptoms related to calling and reporting false allegations to outside agencies stating the resident was scared and fearful and denied allegations to facility staff. Date initiated: 02/25/2025, same date as complaint received from the MBAPN to the facility. During a second interview on 07/16/2025 at 12:02 PM, the DON stated, “Yes, I was the one that updated the Care Plan for Resident #7 on 02/25/2025.” The update had nothing to do with the allegation; it was because of the back and forth with Resident #7 saying things. It was Resident #7’s roommate that stated, “they just do not like each other,” referring to Resident #7 and CNA #1. CNA #1 was moved off the hall. During an interview on 07/16/2025 at 1:20 PM, the Lead CNA stated all she could remember was the DON said CNA #1 had talked very rudely to Resident #7. The DON wanted the Lead CNA to send CNA #1 home, pending investigation. The Lead CNA did not recall any other complaints from Resident #7 and stated that Resident #7 was normally quiet. During an interview on 07/16/2025 at 2:11 PM, CNA #1 stated that the facility suspended them for nothing. CNA #1 said “One of the patients was afraid of me. I have never put my hands on a patient; I was dumbfounded.” CNA #1 was passing trays when Resident #7 called for CNA #1 to change them during mealtime. CNA #1 stated the facility was short-staffed and she was the only one around. CNA #1 stated, “The DON told [Lead CNA] to move me to another hall.” During an interview on 07/16/2025 at 2:36 PM, the Administrator stated that the Social Worker reported the next morning, in the morning meeting, any grievances from the day before. The grievance on 02/18/2025 regarding Resident #7 was that they had not been changed. The Administrator stated he was told Resident #7 had spilled something on his shirt, and that the resident told the lady passing out the trays [CNA #1]. The Administrator stated he did not recall if Resident #7 was changed at that time. He did not know if the resident had to eat while soiled and stated, “I can’t speak to that.” The Administrator confirmed Resident #7 no longer wanted CNA #1 to take care of them and was told it was a personality conflict. The facility started addressing it immediately. The Administrator stated, the resolution may be a few days down the road to make sure the solution worked. The Administrator stated the Military Benefit person called the facility and said Resident #7 was fearful and scared. An emotional assessment was performed for three days. The Administrator stated he was under the assumption another CNA was called to change [Resident #7] while CNA #1 continued to pass trays. The Administrator stated he did not know who put the revision into Resident #7’s Care Plan or why, regarding the false allegations. A review of an undated facility document, “Resident Rights/Civil Rights, Ref: CMS.GOV,” stated “You have the right to be treated with dignity and respect. You have the right to make a complaint to the staff of the SNF [Skilled Nursing Facility], or any other person, without fear of punishment. The SNF must resolve the dispute promptly By law, SNF’s must develop a plan of care (care plan) for each resident. You have the right to take part in the process.”

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to provide a call light for 1 of 2 residents in a shared room, and failed to ensure a call light was in reach of 2 (Residents #40 and #66); failed to ensure the call light was in safe working condition for 1 (Resident 76) to ensure residents could communicate with staff, and prevent accidents, or injury during 1 of 1 observation. Findings include: 1. A review of Medical Diagnosis revealed Resident #40 had diagnoses of Alzheimer ' s, left eye blindness, and failure to thrive. A review of the Medical Diagnosis revealed Resident #66 diagnoses of schizophrenia, dementia, and anxiety. a. A review of a policy titled, Answer the Call light, (Revised, 10/2010) revealed the call light should be within easy reach of the resident. b. Review of an in-service Answering Call lights, dated 08/21/23, indicated, call lights must be on residents when they are in their room or lying in bed, and to ensure call lights are answered in a timely manner. c. Review of an in-service titled Call Lights, dated, 06/17/2024, indicated all nursing staff should respond promptly to call lights because it could have a critical means for pain, discomfort or emergencies. d. On 08/19/24 at 08:06 AM, Resident #40 was observed standing in his/her room on a rollator (a walker with wheels on the front two legs) and stated he/she recently fell on the sidewalk. One call light was observed in Resident #40's shared room, resting on the direct floor behind a brown recliner. e. Resident #44 was observed standing near the bed on 08/19/24 at 11:52 AM, with the right hand wrapped in gauze. Resident #40 revealed being right-handed and cannot even get to the call light. f. On 08/20/24 at 03:08 PM, the Surveyor observed Resident #40's call light resting directly on the floor behind a brown recliner. g. During an interview with Certified Nursing Assistant (CNA) #6 on 08/20/24 at 03:16 PM, CNA #6 was asked how Resident #40, and Resident #66, could call for help if they needed assistance. She checked and located the call light behind a brown recliner and said it should have been in reach of Resident #40 and on closer inspection CNA #6 revealed that there is only one call light in the room to share between Resident #40, and Resident #66. CNA #6 confirmed that there should be two call lights so both residents could call if they needed assistance. 2. A review of Medical Diagnosis revealed Resident #76 with diagnoses of respiratory failure, schizoaffective disorder, and anxiety. a. On 08/21/24 at 09:10 AM, Resident #76 was heard from the doorway, I need help changing my brief. I need help. Resident #76 was asked several times if the call light button was pressed. The Surveyor observed that the call light alarmed but did not light up above the doorway. b. On 08/21/24 at 09:12 AM, Licensed Practical Nurse (LPN) #7 was asked if the call light above Resident #76's room should light up when the call light is pushed, and LPN #7 said Yes, it should, so that staff can see the light and know that she needs help. c. During an interview with the Director of Nursing (DON) on 08/21/24 at 11:00 AM, the DON stated that call lights should be available and in reach of residents and confirmed that if a call light is not working properly, it should be added to the maintenance log. The Surveyor asked if there is a procedure for checking call lights to make sure they are working. The [NAME] stated that maintenance goes through and periodically checks to make sure call lights are working, but she cannot remember how often at this time. The Surveyor asked who was responsible for making sure call lights are in reach, or working for residents The DON said nursing, CNAs, and really all staff members are responsible because residents may need their call light to call for help, and to prevent falls. d. On 08/21/24 at 01:35 PM, the Administrator provided the Maintenance Repair Log, showing a call light check was done at the facility on 07/12/2024, revealing Resident #40's room had no cord.

Based on observation, record review, and interview it was determined the facility failed to practice hand hygiene during meal service between 2 of 21 sampled residents. (Residents #76 and #83); failed to ensure proper hand hygiene during perineal care to prevent cross contamination for 1 (Resident #81) of 2 (Residents #34 and #81) sampled residents who were observed for bowel and bladder care during 1 of 1 observation; failed to ensure the tubing of an indwelling urinary catheter bag was not directly on the floor and the catheter bag drainage valve was in the protective plastic sleeve on the bag to decrease the potential for contamination for 1 (Resident #42) of 1 sampled residents who were reviewed for an indwelling catheter; and the facility failed to ensure the water management program was consistently implemented to monitor for legionella and other water-borne pathogens in 1 of 1 facility. The findings include: On 08/19/2024 at 09:35 AM, Certified Nursing Assistant (CNA) #3 was observed feeding Resident #76, and handling used napkins then walked over to Resident #83, picked up a napkin and assisted in removing eggs from Resident #83's face, and hands. CNA #3 then returned to Resident #76 and reached over Residents #76's left shoulder touched their left arm. On 08/16/2024 at 09:44 AM, CNA #3 confirmed that she did not perform hand hygiene between residents and there was a risk of cross contamination. The surveyor asked, what is the process staff follow when assisting between residents? CNA #3 replied their process was to sanitize hands between residents. On 08/21/24 at 12:11 PM, the Surveyor accompanied CNA #2 to Resident #81's room. The Surveyor observed CNA #2 using the right hand to pull out clean wipes, and wipe Resident #81's perineal area. The Surveyor asked CNA #2 if her right hand was the dirty hand and after confirming that it was CNA #2 was asked if she had any concerns using the right hand to pull out clean wipes and then wiping the perineal area with the right hand. CNA #2 replied that there is a concern for cross contamination and the right hand should not have been used to pull clean wipes from the package, and to clean the resident. During an interview with the Director of Nursing (DON) on 08/21/2024 at 11:05 AM, The DON confirmed that during perineal care, wipes should be used once going in one direction, and hand hygiene needs to be performed between clean and dirty tasks to prevent cross contamination. The DON stated that staff are expected to use alcohol gel or wash their hands between resident care. On 08/22/24 at 03:20 PM, the Administrator stated the facility did not have a policy for perineal care. Review of a provided Peri [Perineal] Care Audit, did not address cross contamination during peri care. 37925 3. Resident #42's Order Summary dated 08/19/2024 was reviewed and indicated the resident had diagnoses of Alzheimer's disease and an obstruction in urine flow. The Order Summary indicated an order dated 07/24/2024 to change the [brand name] catheter tubing and bag as needed. An admission Minimum Data Set with an Assessment Reference Date of 07/31/2024 was reviewed and indicated Resident #42 had a Brief Interview for Mental Status score of 10, which indicated moderate confusion, and for bladder and bowel appliances, an indwelling catheter. A Care Plan dated 08/01/2024 was reviewed and indicated Resident #42 required a [brand name] catheter and catheter care per protocol. On 08/19/2024 at 8:53 AM, Resident #42 was sitting in a chair in the hallway with a catheter bag hooked on the right side of the chair. The catheter tubing was lying directly on the floor and the drainage valve was not in the protective sleeve on the bag but positioned down towards the floor. On 08/22/2024 at 10:56 AM, Certified Nursing Assistant (CNA) #8 was interviewed and stated she knows how to care for residents by looking at their care plan. She confirmed the tubing should not be positioned on the floor. An Infection Control policy, with a reviewed date of 01/2024 and provided by the Administrator on 08/19/2024. This document was reviewed and indicated that for the prevention of infection, staff would be educated to ensure they adhered to proper techniques and procedures. A Urinary Catheter Care policy, with an effective date of 04/2021 and provided by the Director of Nursing on 08/22/2024, was reviewed and indicated a closed drainage system should be maintained. It did not address placement of the catheter tubing. 4. On 08/19/2024 at 8:56 AM, the Midnight Census Report, dated 08/19/2024 and provided by the Director of Nursing, was reviewed and indicated the following rooms were empty on the 300, 400 and 500 Halls: 300, 411, 412, 503, 506, 507, 511, 513, 515, 517 and 519. On 08/22/2024 at 10:40 AM, the Administrator provided a binder which included the water management program. The information in the binder was reviewed and on page 14, it indicated control measures and corrective actions were to be completed by maintenance, housekeeping, or designee. Section Number 1 indicated the facility would conduct weekly water flushing on all identified key locations where the building may be at risk for the growth and spread of Legionella. There was a monthly log titled Weekly Water Run Flushing Log with the dates from January 2024 to August 2024. Each log identified which hall was flushed, but did not indicate the type of water outlet, such as a toilet or faucet, no dates were present on the columns to indicate which day of the week the flushing was performed. There were no temperature logs included to indicate if the water temperatures were checked. On 08/22/2024 at 11:40 AM, the Administrator was interviewed and asked who was responsible for completing the water management program. He stated the main maintenance guy quit two weeks ago and the assistant maintenance guy had not been employed at the facility long. On 08/22/2024 at 11:43 AM, the Assistant Maintenance Director was interviewed and when asked if he was familiar with the water management program, he replied he was not and he started working at the facility about six months ago. He added in his statement, the other maintenance guy had quit about 2 months ago. He was asked if he was included in the water management program, and he stated he was not. On 08/22/2024 at 11:50 AM, the Administrator was interviewed regarding the water management program. The Administrator confirmed the Maintenance Director, Regional Maintenance Consultant (no name provided) and the Administrator were included in the program. He confirmed the Regional Maintenance Consultant had monitored and documented the facility's water management program since the Maintenance Director left. The Administrator was asked if water temperatures were checked in resident rooms, and he confirmed he saw the maintenance guy checking them but did not know if/where he was documenting the information. He confirmed the Assistant Maintenance Director was not included in the water management program because he was new and needed training. He was asked to review the documentation on the Weekly Water Run Flushing Log in the Legionella Testing binder. He confirmed he could not tell which rooms on the halls were checked because no room was indicated on the log, only a hall. He confirmed he could not describe the date the flushing was performed on, or if the toilet and the water was flushed in the residents' rooms by looking at the documentation on the log because that information was not included. On 08/22/2024 at 1:03 PM, the Administrator provided Weekly Water Temp Log forms. The forms were reviewed, and the last form included dates with a month and day for July and August, but not the year. For the month of July on this form, the kitchen, an Assisted Living Facility (ALF), and halls 200, 300 and 400 were listed with documented water temperatures. There were no water temperatures documented for halls 100, 500 or 600 on this form for July and August. The forms did not include any water temperatures for the month of February 2024 or June 2024. There were no weekly water temperatures documented for the following weeks: January 28, 2024, to February 3, 2024; March 3, 2024, to March 9, 2024; March 10, 2024, to March 16, 2024; May 19, 2024, to May 25, 2024; May 26, 2024, to June 1, 2024, and June 30, 2024, to July 6, 2024. A Water Management Program policy, not dated and included in the binder for the water management program provided by the Administrator on 08/22/2024, was reviewed and indicated on page five, key elements of the water management program which included making sure the program was running as designated and all activities were documented. The program review section indicated the facility water management program would be reviewed by the Safety committee annually or when certain events occurred. There was no review date documented on the water management program.

Based on observation and interview, and facility policy review, the facility failed to ensure the kitchen air vent was cleaned to provide a sanitary environment for food preparation; the dish washer, and kitchen walls, the door frames and baseboards were free of chipped, debris, dirt, rust, stains, and wall tiles were replaced; leftover food items were used in manner to maintain food quality; food items stored in the freezer were covered or sealed to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; the ice machine on the 300 Hall was maintained in clean and sanitary condition; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; and manufacturer's instructions were followed to prevent potential for food spoilage and or bacteria growth. The failed practices had the potential to affect residents who received meals from 1 of 1 kitchen (total census: 85), as indicated on a list provided by the Dietary Manager. The findings are: 1.On 8/19/24 at 7:44 AM, an opened box of salt was on a spice rack in the kitchen. The box was not covered. 2. On 8/19/2024 at 7:45 AM, zip top bags dated 8/18/2024 that contained leftover pureed sausage and leftover pureed eggs were on the counter to be reheated and served to the residents who required pureed diets. Dietary [NAME] (DC) #1 was asked what the leftover pureed sausage and pureed eggs were for. DC #1 stated, They were both for the pureed diets. On 8/21/24 at 9:19 AM, during an interview the Dietary Manager stated, We don't use left over food for anything. We make it fresh every day. 2. On 8/18/24 at 7:48 AM, the following observations were made in the kitchen area: a. At the entrance door to the kitchen, the wall was chipped, exposing the concrete and was covered with a brown residue. b. The door frames leading to the kitchen, dish washing machine, and storage room were chipped, the chipped areas were covered with rust. c. The wall in the dishwashing machine room had black and rusty stains. d. The floor around the door frames leading to the storage room were chipped, the area had an accumulation of dirt and debris. e. The wall below the hand washing sink was chipped. The chipped areas were covered with a yellow/black matter. f. The wall below the window by the spice rack in the kitchen was chipped, exposing the concrete. The area exposed was covered with brown dirt. g. The legs of the preparation counter between the 3-door refrigerator and the stove were chipped and had black stains on them. h. The wall below the window in the storage room was chipped and was covered with black stain. i. The wall by the door in the storage room leading to the outside was chipped, exposing the concrete. The area that was chipped had a rust stain on it. j. The door leading to the outside, between a metal rack where clean pans were stored, and the 3-door refrigerator was chipped, exposing the wood. 3. On 8/19/24 at 8:06 AM, there was an opened box of biscuits on a shelf in the freezer. The box was not covered or sealed. 4. On 8/19/24 at 8:17 AM, Dietary [NAME] (DC) #1 turned on the 3 compartment sink faucet and washed the blender bowl, blade and the lid. After washing the food processor equipment and sanitizing them, he turned off the faucet with his bare hands, contaminating his hands. He picked up a clean blade and attached it to the blender to be used in pureeing food items to be served to the residents on pureed diets. DC #1 was asked what he should have done after touching dirty objects and before handling clean equipment. He stated, I should have washed my hands. 5. On 8/19/24 at 8:32 AM, DC #1 was on the tray line serving the breakfast meal. DC #1 picked up tray cards and placed them on the trays. Without washing his hands, he picked up plates to be used in portioning foods to be served to the residents for breakfast with his fingers inside the plates. DC #1 was asked what he should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 6. On 8/19/24 at 8:34 AM, the following observations were made in the 3-door freezer in the storage room: a. An opened box of sausage patties. The box was not covered or sealed. b. An opened box of breaded cod fish. The box was not covered or sealed. c. An opened box of chicken nuggets. The box was not covered or sealed. 7. On 8/19/24 at 8:44 AM, an opened box of vegetable blend was on shelf in the freezer. The box was not covered or sealed. 8. On 8/19/24 at 8:53 AM, a bottle of lemon juice on a rack in the storage room was opened and partially used. The Dietary Manager was asked what they use the lemon juice for. The Dietary Manager stated, We use it when we bake lemon chicken. The manufacturer specification on the bottle indicated, Refrigerate after opening. 9. On 8/19/24 at 8:59 AM, the back of the oven had brown carbon build up on it. There were brown stripes of residue on it. The cart where clean plates were stored on the clean side of the dish machine was chipped exposing the metal. 10. On 8/18/24 at 9:23 AM, the ice machine on the 300 Hall had wet black residue on the panel and around the area where ice formed before dropping into the ice collector. The areas were pointed out to the Maintenance Man and he was asked if the residue build up could be wiped off. He used a rag and wiped it off. The wet black residue easily transferred to the rag. At 9:28 AM, the Maintenance Man was asked how often they cleaned it. He stated, I just cleaned it two weeks ago. At 9:31 AM, the Dietary Manger was asked who used the ice from the ice machine. He stated, CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. 11. On 8/19/24 at 11:20 AM, DC #1 wiped his face with tissue paper and threw them away, contaminating his hands. Without washing his hands, he picked up a pan and placed it on the counter with his fingers inside the pan. When DC #1 was ready to transfer the cooked pasta into the pan. DC #1 was asked what he should have done after touching dirty objects and before handling clean equipment. He stated, I should have rewashed my hand. 12. A facility policy titled, Hand Washing not dated, indicated, hand washing was to perform at the start of a shift and after engaging in other activities that contaminate the hands.

Based on observation, record review, and interview, the facility failed to ensure the meals were prepared in a method that maintained nutritive value and taste that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal preparation observed. The findings are: 1. A facility titled recipe for pureed sausage not dated and provided by the Dietary Manager on 8/19/2024 at 11:30 AM, indicated for 7 residents, place 7 portions of prepared sausage in food processor with hot broth and blend to a smooth consistency. On 8/19/24 at 8:12 AM, Dietary [NAME] (DC) #1 placed 12 servings of sausage into a blender, added 2 cups of hot water from the coffee maker, instead of hot broth, added 6 tablespoons of thickener and pureed. 2. A facility titled recipe for pureed scrambled eggs not dated and provided by the Dietary Manager on 8/19/2024 at 11:30 AM, indicated for 7 residents, place four #8 scoop (1/2 cup) prepared scrambled eggs in food processor with hot milk and blend to a smooth consistency, adding a small amount of hot milk as needed. On 8/19/24 at 8:20 AM, DC #1 used a #12 scoop (1/3 cup) to place 4 servings of scrambled eggs with no ham into a blender, added 2 cups of hot water from the coffee maker, instead of hot milk, added 5 tablespoons of thickener and pureed. 3. On 8/18/24 at 9:15 AM, DC #1 was asked how scrambled eggs and sausage pureed with water taste. DC #1 stated, They will taste like nothing.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu and the facility recipe to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. A facility recipe for the fortified oatmeal indicated, for 24 resident's use: 8 cups =2 quarts of water. Whole milk 6 ounces. Rolled oats 6-1/2 cup. Non-fat dry milk 2-1/4 cup. Margarine 3/4 cup. [NAME] sugar 1-1/4 cup. Granulated sugar 1-1/4 cup. Whole milk 6 ounces. 2. On 8/19/24 at 8:10 AM, during the breakfast meal service. Dietary [NAME] (DC) #1 was asked how he prepared oatmeal. DC #1 stated, I used a bag of brown sugar and 2 sticks of butter. 3. On 8/19/2024, a facility breakfast menu indicated residents on pureed diets were to receive 1/2 cup of pureed grits, and a #16 scoop (1/4) cup of pureed coffee cake. a. On 8/19/24 at 8:49 AM, DC #1 served regular grits to the residents on pureed diets, instead of pureed grits. b. There was no pureed coffee cake served to the residents on pureed diets. d. On 8/19/24 at 12:29 PM, DC #1 was asked if residents on pureed diets should receive pureed coffee cake. DC #1 stated, They did not get it. I was in a rush. DC #1 was asked if residents on pureed diets should receive regular grits. DC #1 stated, We have never served pureed grits. DC #1 was asked if he looked at the menu before preparing pureed food items. DC #1 stated, No ma'am.

Based on observation, record review, and interview, the facility failed to ensure a mechanical soft diet was provided during the lunch meal service for 1 (Resident #7) of 1 sampled resident reviewed for a therapeutic diet. The findings are: Resident #7's Order Summary dated 08/21/2024 was reviewed and indicated a diagnosis of type two diabetes and an order dated 05/21/2024 for a mechanical soft texture diet. A quarterly Minimum Data Set with an Assessment Reference Date of 06/14/2024 was reviewed and indicated Resident #3 had a Brief Interview for Mental Status score of 9, which indicated moderately confused. A Care Plan dated 06/27/2024 was reviewed and had no indication that Resident #7 required a mechanical soft texture diet, or the resident did not have upper teeth or dentures. A Dietary Progress Note dated 05/20/2024 was reviewed and indicated Resident #7 was recommended to be offered a mechanical soft diet related to difficulty chewing. On 08/19/2024 at 10:26 AM, Resident #7 was observed lying in bed awake and stated, I need my top teeth fixed. Resident #7 stated the breakfast meal could not be eaten due to no top teeth. On 08/21/2024 at 12:50 PM, Resident #7 was observed lying in bed and the lunch meal tray was on the over bed table. Resident #7 stated the resident did not have any top teeth in and began crying. The lunch meal tray had a slice of meat loaf, not ground, covered with a brown sauce, macaroni and cheese, green peas and a cookie. On 08/21/2024 at 1:26 PM, the Dietary Manager was interviewed and asked for a list of foods considered to be mechanical soft. He confirmed for a mechanical soft diet, foods were placed in the blender and ground. He was asked about the lunch meal today and if those foods were okay for a person on a mechanical soft diet to eat. He stated the spreadsheet indicates which foods should be ground and he needed to look at his spreadsheet to answer the question. He was asked to provide a copy of the spreadsheet for the lunch meal served today. The Daily Spreadsheet Week 3 Wednesday provided by the Dietary Manager on 08/21/2024, with no date, was reviewed and indicated the meatloaf should be ground for a mechanical soft diet with gravy on top. A Therapeutic and Modified Diets policy, dated 05/25/2012 and provided by the Administrator on 08/22/2024, was reviewed and indicated therapeutic diets would be prepared and served according to physician orders using standardized recipes.

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter bag was covered to promote dignity for 1 (Resident #42) of 1 sampled resident who was reviewed for an indwelling catheter. The findings are: Resident #42's Order Summary dated 08/19/2024 was reviewed and indicated the resident had diagnoses of Alzheimer's disease and an obstruction in urine flow. The Order Summary indicated an order dated 07/24/2024 to change the [brand name] catheter tubing and bag as needed. An admission Minimum Data Set with an Assessment Reference Date of 07/31/2024 was reviewed and indicated Resident #42 had a Brief Interview for Mental Status score of 10, which indicated moderate confusion and for bladder and bowel appliances an indwelling catheter. A Care Plan dated 08/01/2024 was reviewed and indicated Resident #42 required a [brand name] catheter and a privacy bag. On 08/19/2024 at 8:53 AM, Resident #42 was sitting in a chair in the hallway with a catheter bag hooked on the right side of the chair. The contents of the catheter bag were visible, and a yellow liquid was observed inside the bag. On 08/22/2024 at 10:56 AM, Certified Nursing Assistant (CNA) #8 was interviewed and confirmed she knows how to care for residents by looking at their care plan. She confirmed no one should be able to see inside of the bag. A Resident Dignity policy, with an effective date of 04/2021 and provided by the Director of Nursing on 8/22/2024, was reviewed and indicated staff shall promote dignity by helping the resident to keep urinary catheter bags covered.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure an uncapped razor was not left unattended in a resident's room to prevent accidents or injuries for 1 (Resident #44) of 1 sampled resident reviewed. to prevent accidents or injuries. The findings are: Review of the Medical Diagnoses revealed Resident #44 with diagnoses of schizoaffective disorder, dementia, and stroke. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 0f 02/28/2024 suggested a Brief Interview for Mental Status (BIMs) score of 4 (0-7 indicates severe cognitive impairment). Section GG 0130 indicated the resident was dependent for personal hygiene, and Section B1000 indicated the resident had impaired vision. a. Review of a facility policy titled, Shaving the Resident, (revised, October 2010) indicated after a resident is shaved the razor should be discarded in a designated sharps container labeled For Disposable Razors Only, located outside the resident rooms. b. Review of Resident 44's Care Plan, dated 03/28/2024, revealed the resident had complications related to impaired vision, with a change in the ability to perform activities of daily living. c. Review of Resident 44's Care Plan, dated 03/28/2024, revealed a self-care deficit related to weakness and cognitive deficit and Resident 44 was encouraged to use a call light for assistance, and staff to monitor for skin integrity and report cuts and scratches to the nurse. d. On 08/19/24 at 09:01 AM, the surveyor opened the door to Resident #44's room and observed an uncapped razor resting to the left of the in room sink on a brown napkin with a toothbrush and toothpaste. e. On 08/19/24 at 02:17 PM, an uncapped razor was observed resting to the left of the sink on a brown napkin with a toothbrush and toothpaste in Resident #44's room. f. On 08/20/24 at 08:52 AM, Resident #44 confirmed he had a razor in the room. g. During an interview with Licensed Practical Nurse (LPN) #4 on 08/21/24 at 10:30 AM, LPN #4 confirmed that residents should not have uncapped shaving razors in their room to prevent injuries. h. During an interview the Director of Nursing (DON) on 08/21/24 at 10:54 AM, the DON was asked the process for male residents to get shaven. The DON stated residents should be offered a shave on shower day. The DON was asked if a resident should have uncapped razors in their room. The DON replied, No, that residents could accidentally cut themselves with a razor, or another resident could take the razor and injure themselves.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure oxygen was set at the physician ordered rate for 1 (Resident #67) of 1 sampled resident with oxygen orders to prevent the potential for respiratory complications. Findings include: Review of Medical Diagnoses revealed Resident #67 had diagnoses of chronic obstructive pulmonary disease, acute respiratory failure, and pulmonary emphysema. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/2024 suggested a Brief Interview for Mental Status (BIMS) score of 12 (7-12 indicates moderately impaired). Section 0110 C1 indicates Resident #67 has been on oxygen while a resident. a. A review of Physician Order, dated, 07/03/2024, indicated Resident #67 receives oxygen at 2 liters as needed for shortness of breath. b. A review of the Care Plan, dated 06/08/2023, showed Resident #67 had chronic obstructive pulmonary disease and to give aerosol, bronchodilators, and oxygen 2 liters as needed per physician orders. c. On 08/19/24 at 07:43 AM, Resident #67 was observed resting in bed on 3 liters of oxygen by nasal cannula. Resident #67 said he/she is on 2 liters. d. On 08/19/24 at 01:25 PM, Resident #67 was observed wearing a nasal cannula with the concentrator set on 2.5 to 3 liters. A nebulizer with the mask stored was resting at Resident #67's feet. e. While checking Resident #67's oxygen on 08/20/24 at 09:00 AM, the concentrator was found to be on 2.5 to 3 liters. f. Licensed Practical Nurse (LPN) #4 accompanied Surveyor to Resident 67's room on 08/21/24 at 10:16 AM and confirmed the oxygen concentrator was set on 2.5-3 liters. LPN #4 pulled up the resident's orders and confirmed he was supposed to be on 2 liters as needed, and stated a concern for getting more oxygen than ordered is confusion, and a resident's body may not be capable of processing it, and it could make it harder to breath. g. During an interview on 08/21/24 at 10:50 AM, the Director of Nursing (DON) confirmed nursing should check each oxygen settings every shift while in a resident's room, because a few residents change their own oxygen and need checked behind, and not getting the ordered dose can affect their health including the heart rate. h. On 08/21/24 at 01:44 PM, the DON provided a policy titled, Oxygen Administration, the policy revealed unless otherwise ordered, oxygen flow should be started at the ordered rate.

Based on record review and interview, the facility failed to ensure a pneumococcal vaccine was provided for 1 (Resident #44) of 5 (Resident's #11, #44, #48, #80 and #81) sampled residents. reviewed for immunizations. The findings are: Resident #44's Order Summary dated 08/22/2024 was reviewed and indicated the resident had diagnoses of dementia and an irregular heartbeat. An order dated 02/23/2024 indicated Resident #44 could receive Pneumovax (a pneumonia vaccine) unless contraindicated. An order dated 08/20/2024 indicated, may give pneumococcal vaccine unless contraindicated or refused, and one dose of Prevnar 20 - 0.5 milliliters (ml) was ordered to be administered intramuscular (IM). On 08/22/2024, Resident #44's immunization screen was reviewed and Prevnar 20 was listed as an immunization required under consent status. On 08/22/24 at 1:21 PM, the Infection Preventionist was interviewed and provided a copy of an immunization record from a website. The document was reviewed and did not indicate if the pneumonia vaccine was administered to Resident #44. She was unable to explain why the pneumonia vaccine had not been administered once consent was given on 02/23/2024. A Pneumococcal Vaccine policy, with an effective date of 03/2020, provided by the Administrator on 08/19/2024, was reviewed and indicated all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.

Based on record review, and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) accurately reflected on section O0110, Special Treatment, Procedures, and Programs the resident received dialysis on admission or while a resident for 1 (Resident #31) of 1 sampled resident. This failed practice had the potential to inaccurately represent Resident #31's health status, impacting his care plan, reimbursement levels, and the ability to properly identify necessary interventions. Findings include: Review of the Medical Diagnoses revealed Resident #31 had diagnoses of end stage renal disease, right lower lobe cancer, and type II diabetes mellitus. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/2024 indicated a Brief Interview for Mental Status (BIMs) score of 06 (0-7 indicates severely cognitively impaired). Section I8000 revealed an active diagnosis of dependence on renal dialysis. a. A review of the Progress Notes, dated 07/08/2024 revealed Resident #31 had a port to the right chest, and received dialysis on Monday, Wednesday, and Friday. b. A review of Resident #31's Care Plan, dated 07/11/2024, revealed the resident was at risk for fluid volume excess related to fluid accumulation since last dialysis treatment, and was to be monitored for fluctuations in weight. c. A review of the Admission MDS, revealed under section O0110 J1, and J2 that Resident #31 was not on hemodialysis on admission, or while a resident. d. On 08/21/24 at 01:42 PM, the MDS Nurse was asked to check Resident #31's admission MDS dated [DATE], section O0110. The MDS Nurse confirmed that dialysis was forgotten on the MDS. The MDS Nurse was asked if she had a guide for coding to the MDS? The MDS Nurse revealed she uses the discharge summary from a resident's hospital stay, and the RAI (Resident Assessment Instrument) Manual. The Surveyor asked why is it important to code services like dialysis to the MDS? The MDS Nurse replied to ensure the residents were getting the proper plan of care it is important to code the MDS correctly. e. On 08/21/24 at 02:55 PM, the MDS Nurse provided O0110: Special Treatments, Procedures, and Programs, from the Resident Assessment Instrument (RAI) Manual, revealed documenting special treatments, procedures, and programs within a resident's 14 day look back period is important to ensure continuous appropriateness of procedures, treatments, or programs that residents receive. Staff should provide education and monitoring.

illness, failed to ensure 1 of 2 ice machines, 2 of 2 ice chests were maintained in clean and sanitary condition. These failed practices had the potential to affect 18 residents who received ice on 300 hall and 31 who received ice 600 hall and 84 residents who received meals from the kitchen, as documented on a list provided by the Assistant Dietary Supervisor on 08/29 /2023 at 12:43 p.m. The findings are: 1. On 08/28/23 at 09:09 AM, the following observations were made on the food preparation counter. a. A can opener attached at the end of the food preparation counter had dried black matter on the blade. b. An opened box of cream of wheat was on the counter. The box was not covered. 2. On 08/28/23 at 09:12 AM, the following observations were made on a shelf in the refrigerator: a. An opened box of sausage. The box was not covered or sealed. b. An opened bag of lunch meat. The bag was not sealed. c. An opened packet of cheese slices. it was not sealed. 3. On 08/28/23 at 09:16 AM. The following observations were made on a shelf in the freezer. a. An opened box of chicken breasts fillet. The box was not covered or sealed. b. An opened box of pork patties. The box was not covered or sealed. c. An opened box of sausage links. The box was not covered. 4. On 08/28/23 at 09:29 AM an open box of broccoli on a shelf in the second door refrigerator. The box was not covered or sealed. 5. On 08/28/23 at 09:39 AM the following observations were made in the kitchen area. The floor beside the deep fryer had a mixture of food crumbs and grease on it. There were debris hanging down from the edges of the deep fryer. b. Wall tile in the kitchen leading to the hall was missing, exposing the wood. One area of the wall was chipped exposing the concert. c. The wall by the door close to the kitchen entrance door was chipped, exposing the fiber. d. The floor in front of the dish washing machine and floor leading to the kitchen had gaps and chipped. The area had an accumulation of dirt and debris. e. The wall across the dish washing machine room had an accumulation of sage color substance on it. The air vent had dirt and lint particles stuck to the slats. f. The door frames leading to the dishwashing machine and the kitchen were chipped, exposing the metals. g. The shelf below the food preparation counter where loaves of bread were stored had loose food crumbs and grease on it. h. The air vent above the food preparation counter had dirt stuck to the slats. 5. On 08/28/23 at 09:49 AM Dietary Employee (DE) #1 picked up the water hose with his bare hand, used it to spray leftover food from inside of the dishes, contaminating his hands. He placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean rack to be used in serving the noon meal to the residents. The Surveyor asked him what should you have done after touching dirty objects or before handling clean equipment? He stated, I should have washed my hands. 6. On 08/28/23 at 10:28 AM DE #2 opened the refrigerator and removed a box of nectar milk and placed it on the counter. Without washing her hands, she picked up glasses by their rims and poured beverages to be served to the residents for lunch. 8. On 08/28/23 at 10:32 AM the back of the ice machine in an open room on 300 Hall had wet black residue. The panel of the ice machine had black/pink residue on it. The 6 sections attached to the panel had wet black residue on them. The surveyor asked the Dietary Supervisor to wipe the interior surfaces. He did so and stated, It was sticky. The sticky residue easily transferred to the tissue. He was asked to wipe the panel and the sections of it. He did so, the black/pink residues easily transferred to the tissue. 9. On 08/28/23 at 10:37 AM the ice scoop holder in a room on 300 Hall, had buildup of yellow slimy residue and a piece of brown paper at the bottom of it. The ice scoop was in direct contact with the buildup of yellow slimy residue. The surveyor asked the Dietary Supervisor to describe the appearance of what was observed in the scoop holder. He stated, It was slimy and nasty. The ice scoop was used to get ice from the ice chest for the resident rooms. 10. On 08/28/23 at 10:45 AM the surveyor asked Certified Nursing Assistant #1 if she passed ice to the residents' rooms on 300 Hall this morning and what time. She stated, Yes. I put ice in their water pitchers at 9:30 AM this morning. She was asked how the ice scoop holder looked like when she removed the ice scoop to obtain ice. She stated, I didn't see anything there. She was asked how often do you clean the ice scoop holder. She stated, I don't, and I don't know who cleans it. 11. On 08/28/23 at 10:50 AM The ice scoop holder at the nurse's station on 600 Hall, where the ice chest that contained fresh ice where CNAs obtained ice use for the water pitchers in the residents' rooms, had buildup of wet black residue at the bottom of it. The ice scoop was in direct contact with the buildup of wet black residue. The surveyor asked Certified Nursing Assistant #2 to describe the appearance of what was observed in the scoop holder and how often they clean the scoop holder. She stated, It was nasty. They are supposed to clean it after each shift. 12. On 08/28/23 at 10:55 AM DE #3 opened the refrigerator and removed fresh tomatoes from a box and placed it on the cutting board. Without rinsing the tomatoes, DE #3 sliced the tomatoes and placed them on a plate. DE #3 covered the plate with a piece of plastic wrap and placed it on a shelf in the refrigerator to be served to the residents their lunch meal. The surveyor asked him what you should have done before processing fresh tomatoes. He stated, I should have rinsed them. 13. On 08/28/23 at 12:45 PM DE #4 left the tray line, removed gloves from the glove box and placed them on her hands, without washing her hands. DE #4 then turned on the stove, the same gloved hands to pick up slices of bread with cheese to be used in preparing grilled cheese to be served to the residents. She was asked what should you have done after touching dirty objects and before handling food items? She stated, I should have washed my hands. 14. The facility policy on hand washing provided by the Dietary Supervisor on 08/28/2023 at 12:43 PM showed, When to wash hands. a. When entering the kitchen at the start of a shift. b. After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review the facility failed to ensure interventions were implemented for 1 (Resident #28) of 3 (Resident #68, #4, and #28) sampled residents who had an intervention for anti- rolled backs to wheelchair after a fall, and the facility failed to ensure a gait belt was used in a 2 person transfer for 1 (Resident #21) of 6 (Resident #11, #15, #20, #21, #49, and #76) sampled residents. The findings are: 1. Review of a care plan for Resident #28 for fall risk showed an intervention of anti-roll backs to the wheelchair initiated on 7/27/23. a. A review of an incident report dated 7/26/23 indicated that Resident #28 was found lying on the floor with feet under bed and head under wheelchair. Under the immediate action taken section the document showed, Antiroll back applied to wheelchair. b. On 8/30/23 at 11:59 AM there was no anti-roll back device observed on Resident #28 wheelchair. c. During an interview on 9/01/23 at 9:41 AM LPN (Licensed Practical Nurse) #3, stated, when a resident falls, interventions are put in place immediately and stated she was not aware Resident #28 had an order for an anti-roll back device. d. During an interview on 9/01/23 at 9:56 AM the DON (Director of Nurse), stated, when a resident falls the nurse on duty should put an immediate intervention in place, and another intervention should be added in a couple of days. She stated maintenance did not have any anti-roll backs to put on Resident #28 wheelchair. 2. On 8/29/23 at 8:30 AM observed Resident # 21 sitting up in wheelchair in doorway requesting to return to bed. CNA #3 and CNA #5 assisted Resident #21 to bed by pulling up on the resident's brief and sweatpants to stabilize and support the resident during the transfer. The surveyor asked CNA #5 if they used gait belts for transfers in the facility. CNA #5 said the gait belts are in restorative care and confirmed they are required for transfers. a. During an interview on 8/29/23 at 8:41 AM CNA #3 said some residents need gait belts when transferring residents. CNA #3 said she keeps her gait belt in her locker. b. On 8/31/23 at 9:30 AM LPN#2 confirmed the staff should use gait belts when transferring residents. Yes, to save the back and keep from injuring the patient. It's a safety option as well. c. On 08/31/23 at 09:45 AM the interim DON and Minimum Data Set (MDS) Coordinator #2 confirmed gait belts should be used for transfers.

47916 Based on observations, and interviews the facility failed to ensure the resident rooms, hallways, dining room, and bathrooms were maintained for 5 of 5 rooms observed (room [ROOM NUMBER], 109, 102, 300 and 302). The findings include: On 8/28/23 at 9:41 AM observed a ceiling tile in room [ROOM NUMBER] bathroom above the toilet that was bulging and had brown water spots extending one fourth of the length of the tile extending into corner of air vent. On 8/28/23 at 10:29 AM observed the door frame in the bathroom shared by room [ROOM NUMBER] and 109 was rusted with sharp jagged edges at the bottom where the frame meets the floor. There was paint peeling off the door frame at the bottom and the paint was bubbled about one fourth of the way up the door frame. On 8/28/23 at 12:34 PM observed the bathroom light switch was not working in room [ROOM NUMBER]. On 08/28/23 at 12:41 PM observed the dresser drawers in room [ROOM NUMBER] were crooked, and the top right drawer was missing. There were no personal items on the walls or in the room. The room lacks a homelike feeling. On 8/30/23 at 2:37 PM observed the handrails on hall 600 with broken plastic end pieces with sharp edges visible. The dining room on hall 500 had holes in the tile, paint peeling at the bottom of the doorframes, and the piano leg was broken and scratched. During an interview on 8/31/23 at 3:00 PM the Maintenance Director said, It's a lot for me to do by myself. The Maintenance Director said ceiling tiles and baseboards have been ordered. He noted there is a maintenance log in a book behind the nurse's desk where staff can write maintenance needs. He stated, I try to separate the major projects by hall starting with hall 600 because it needs so much done with the dining room and the smoking area. On 8/30/2023 at 8:07 AM the Director of Nurses (DON) confirmed the light switch in room [ROOM NUMBER] did not work and confirmed the dresser drawers were crooked, and one was missing. On 08/31/23 at 07:59 AM The Social Services Manager said, We have no policy on building maintenance.

Based on observation, record review and interview, the facility failed to ensure Activities of daily Living (ADL) care including was provided regularly for 5 (Resident #20, #28 #36, #65 & #72) of 17 (Residents #1,#2,#4,#8, #10, #13, #14 R#19, R#20, R#25, R#28, R#36, R#48, R#63, R#67, R#72, & R#74) sampled residents. The findings include: 1. Review of Resident #36 Quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 7/20/23 noted a Staff Assessment for Mental Status (SAMS) showed memory problems and severely impaired cognitive skills for daily decision making. The resident required extensive assistance for hygiene with 1-person physical assist. a. On 8/28/23 at 9:39 AM observed Resident #36 fingernails were uneven in length and jagged, with sharp edges on the corners of the nails on both hands. Nails varied in length from approximately 1/4 - 1/2 inches or more in length past the tips of fingers. b. On 8/29/23 at 2:38 PM observed Resident #36 fingernails remained long and uneven. The Surveyor asked Resident #36 if she would like to have the nails trimmed. Resident # 36 answered, Yes and nodded her head. Certified Nurse Assistant (CNA) #5 entered the room at 2:39 PM and confirmed the fingernails were long and said if the resident is diabetic, the nurse will need to trim the fingernails. CNA #5 said the family usually cuts Resident #36 nails. c. On 8/30/23 at 10:13 AM observed Resident # 36 fingernails remained the same and were approximately 1/4 - 1/2 inch in length or more from tips of fingers. The left thumbnail, index finger, and 5th fingernails were more than 1/2 inches long past fingertips. The right thumbnail, index and middle fingernails were more than 1/2-inch-long past fingertips. Nails were uneven lengths with jagged edges, and sharp corners. d. On 8/31/23 at 8:52 AM CNA #2 confirmed Resident #36 fingernails were long and needed to be clipped. CNA#2 said if a resident is diabetic, the treatment nurse trims the nails, but if they are not diabetic the CNA's trim them on shower days. CNA #2 confirmed the residents shower day was yesterday. e. On 8/31/23 at 9:30 AM the Surveyor asked Licensed Practical Nurse (LPN) #2 who was responsible for Resident # 36 nailcare. LPN#2 answered, Any staff, but nurses if they are diabetic. 2. Review of Resident #20 Quarterly Minimum Data Set [MDS] with an ARD of 7/7/23 noted the resident scored 8 on a Brief Interview for Mental Status, which indicates severely impaired cognitive status and required extensive, two-plus persons physical assist with personal hygiene. a. Review of a care plan for Resident #20 for type 2 diabetes without complications, initiated on 11/15/19 noted an intervention to refer to podiatrist/foot care nurse to monitor and document foot care needs and to cut long nails. Review of a care plan for potential impairment to skin integrity, initiated on 10/13/17 noted an intervention to keep fingernails short. b. On 8/28/23 at 1:54 PM Resident #20 nails were long with a black substance underneath. c. On 8/29/23 at 9:15 AM Resident #20 nails were long with a black substance underneath. d. During an interview on 9/01/23 at 9:30 AM CNA #6 said the nurse would trim Resident #20 nails because he is diabetic. e. During an interview on 9/01/23 at 9:41 AM LPN #3, said the CNA was responsible for providing nail care to Resident #20 because, he's not diabetic. f. During an interview on 9/01/23 at 9:56 AM the DON (Director of Nurses), stated the nurses provide nail care for diabetic residents and the CNA provides nail care to the non-diabetics, and stated she is not sure if Resident #20 is diabetic. 3. Review of Resident #28 care plan initiated 4/28/23 for physical mobility noted the resident requires assistance with activities of daily living (ADL) due to a stroke. a. On 8/28/23 at 2:31 PM, observed Resident #28 had facial hair approximately 1/2 inch long. b. During an interview on 9/01/23 at 9:30 AM CNA #6 said the CNA is responsible for shaving residents. During an interview on 9/01/23 at 9:41 AM LPN #3, stated, Resident #28 is diabetic, so the nurses are responsible for shaving. She confirmed she had not cleaned and trimmed the resident's nails and had not shaved him. LPN #3 stated, I'll have to get the CNAs to remind me. During an interview on 9/01/23 at 11:09 AM CNA #8, stated, he gave Resident #28 a shower yesterday. 4. Review of a care plan for Resident #65 for ADL care, initiated on 6/09/23 showed, check and trim fingernails and toenails as needed, unless diabetic, then notify the nurse. a. On 8/28/23 at 1:42 PM observed Resident #65 nails were long with a black substance underneath. The resident's facial hair was approximately 1/2 inch long. Resident #65 stated, It's been a while since they shaved me. They were doing it every week or so. The resident said he has been trying to get his nails cut for over a month. b. During an interview on 9/01/23 at 9:41 AM LPN #3, said the CNA usually provides nail care and shaves Resident #65 on the designated bath days. c. During an interview on 9/01/23 at 11:09 AM CNA #8, confirmed he was responsible for shaving and providing nail care to Resident #65, and stated he got him on Tuesday. 5. During an interview on 8/28/23 at 11:29 AM, Resident #72 said he wanted a shower and said his fingernails and toenails need to be cut. a. During an interview on 8/30/23 at 11:44 AM resident #72, said he asked the CNA two times yesterday to provide nail care and shave him and stated he does not normally have a beard. Observed fingernails measured 3/4-1 cm past the fingertips and facial hair was 1-2 cm long. b. On 8/31/23 at 9:55 AM Resident #72 observed sitting at the bedside, clean shaven, Resident #72 said, They gave me a shower and shave yesterday. My nails are digging into my toes, and it hurts. The surveyor asked why his fingernails and toenails were not trimmed during his shower and resident said, I do not know. c. During an interview on 8/31/23 at 3:30 PM CNA #4 said, if a resident has diabetes, it is the nurse's responsibility for trimming fingernails and toenails. If they are not diabetics, then the CNA's can cut a resident's nail. d. On 8/31/23 at 4:01 PM during an interview the DON, said, if a resident has diabetes or is on anticoagulants the nurse should cut their nails if they need them. Anyone else can have their nails trimmed by the CNA's. 47912 47916

Based on interview and record review the facility failed to ensure that 2 (Resident #1, #2) of 5 (Resident #1, #2, #3, #4 and #5) sampled residents were free from abuse. The Finding are: 1. Resident #1 was admitted to the facility with a diagnosis of dementia. The resident Minimum data Set (MDS) dated [DATE] documented the resident is rarely understood and severely impaired cognitively. The care plan dated 5/23/23 documented Resident #1 required extensive assistance of one staff with bed mobility, transfer, dressing, toileting, personal hygiene, bathing, eating and locomotion. A. Review of the Nursing Progress Note dated 6/03/23 at 7:54 PM, revealed the nurse noticed resident to have a yellow and red discoloration under and around right eye. Resident has no reported falls. B. Review of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities dated 06/05/23 revealed Resident #1 had discoloration to his right eye. Resident is unsure how it happened, but stated he got into a fight and lost. Resident is known to fall and hit objects. Resident was questioned who he got into a fight with, and he was unable to give any information related to discoloration of eye or who he had a fight with. The documentation noted the Administrator was notified on 6/5/23. C. On 6/27/23 at 9:55 AM an interview with the Social Services Director revealed he had heard a heavy-set black man with dreads hit Resident #1. The Social Services Director stated the Administrator was informed of this information. D. On 6/27/23 at 9:59 AM Certified Nursing Assistant (CNA) #2 stated that Resident #5 told her CNA #1 hit Resident #1 on 6/03/23. CNA #2 stated she reported it to the Assistant Director of Nursing (ADON). E. On 6/27/23 at 10:36 AM an interview with the ADON, with the administrator present, revealed the ADON interviewed Resident #5, who stated a large black man with long hair was hitting resident #1. He had Resident #1 in a head lock. The ADON said he filled out a witness statement and turned it in to the Administrator. F. On 6/27/23 at 10:11 AM the Surveyor asked the Administrator if she was aware of the allegation of CNA #1 hitting Resident #1 and she stated yes. The administrator stated she had interviewed CNA #1 about the incident, and he denied it happened. The administrator stated, I dropped the ball. I felt the resident had fallen and I did not investigate further. G. The Surveyor asked the administrator for the witness statement the ADON filled out on 6/5/23 after interviewing resident #5. She stated, I don't know what I did with it. H. On 6/27/23 at 11:05 AM the administrator stated she was reopening her investigation on the incident which occurred on 6/3/23 and she would be investigating the allegation of physical abuse. 2. Resident #2 was admitted to the facility with diagnoses of bipolar disorder and moderate intellectual disabilities. The resident MDS dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident has severely impaired Cognition. The care plan dated 3/10/20 documented Resident #2 required extensive assistance of one staff with bed mobility, transfer, dressing, toileting, personal hygiene and bathing. She prefers a woman caregiver. A. On 6/27/23 at 1:22 PM review of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities revealed an incident on 5/11/23 at 3:30 PM, and reported on 5/12/23, noting Resident #2 was agitated and hitting her face. One staff witness statement noted Resident #2 had a bruise on her lip the next day. A witness statement dated 5/22/23 noted the staff noticed a bruise to Resident #2 right eye. There was no conclusion documented in the investigation on how the resident received a black eye. C. On 6/27/23 at 1:14 PM in an interview with the Director of Nurses (DON) who stated the area on Resident #2 face was bruised where the bottom of her glasses sat on her face. D. On 6/27/23 at 1:18 PM the Administrator confirmed the incident was not reported; however, an internal investigation was done. 3. Review of policy, Abuse Prevention Program, last updated on 5/2/17 revealed, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator. The policy further stated, After notification of alleged abuse or neglect, the Administrator or person in charge of the facility shall immediately commence an investigation of the incident reported. The findings of such investigation will be provided to the Administrator within five working days of the occurrence of such incidents. The Administrator shall either rule-out or substantiate the allegation of abuse.

Based on interview and record review the facility failed to complete a thorough investigation of an allegation of physical abuse for 2 (Resident #1, #2) of 5 (Resident #1, #2, #3, #4 and #5) sampled residents, which has the potential to affect all 87 residents currently residing in the facility. The findings are: 1. Review of the Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities noted on 06/05/23 the Administrator was notified of Resident #1 black eye which was found on 6/3/23. The summary of the incident noted, Resident is unsure how it happened, but states he got into a fight and lost. Resident is known to fall and hit objects. Resident was questioned who he got into a fight with, and he was unable to give any information related to discoloration of eye or who he had a fight with. The investigation conclusion documented, the resident is very unsteady and was noted to have a fall on 6/07/23 and 6/08/23. A. On 6/27/23 at 10:36 AM an interview with the Assistant Director of Nurses (ADON) with the administrator present, revealed, he interviewed resident #5, the resident stated a large black man with long hair was hitting resident #1. Resident #5 identified the man as Certified Nursing Assistant #1. Resident #5 stated the CNA had Resident #1 in a head lock. The ADON said he filled out a witness statement and gave it in to the Administrator. There is no documentation that the allegation was investigated. B. The facilities staffing schedule documented CNA #1 worked on 6/3/23, 6/4/23, 6/10/23, 6/11/23, 6/24/23 and 6/25/23. The staff member continued to work with Resident #1 five more 12-hour shifts after the incident was first identified on the Nursing Note dated 6/3/23 at 9:26 PM. C. The facility did not interview the staff who worked 6/3/23 when the incident occurred. 2. On 6/27/23 at 1:22 PM review of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities revealed an incident on 5/11/23 at 3:30 PM, and reported on 5/12/23, no time was listed, noting Resident #2 was agitated and hitting her face. One staff witness statement noted Resident #2 had a bruise on her lip the next day. A witness statement dated 5/22/23 noted the staff noticed a bruise to Resident #2 right eye. There was no conclusion documented in the investigation on how the resident received a black eye. A. On 6/27/23 at 1:14 PM an interview with the Director of Nurses (DON) who stated the area on Resident #2 face was bruised where the bottom of her glasses sat on her face. B. On 6/27/23 at 1:18 PM the Administrator confirmed the incident was not reported; however, stated an internal investigation was completed. C. Review of the investigation found there were four employee interviews on 5/22/23. All witness statements documented they did not know how resident #2 received her black eye. There were no other employee interviews documented. There was no conclusion in the partial investigation of what occurred to cause the black eye for resident #2. 3. Review of policy, Abuse Prevention Program, last updated on 5/2/17 revealed, Investigation: all incidents will be documented, whether abuse occurred, was alleged or suspected. The policy further states, Staff members who are suspected of abuse or misconduct shall immediately regardless of time left on shift be barred from any further contact with the residents of the facility and be suspended from duty pending the outcome of the investigation, prosecution or disciplinary actions against the employee.

Complaint # (AR 044) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure repeated episodes of sexual abuse were prevented for 4 of 4 (Residents #3, #4, #6 and #7) case mix residents who were sexually abused by Resident #2. This failed practice resulted in a past immediate jeopardy which caused or was likely to cause serious harm, injury or death to Residents #3, #4, #6 and #7, and had the potential to affect 33 female residents according to a list provided by the Administrator on 1/15/2021 at 11:29 a.m. The Administrator was informed of the past immediate jeopardy on 01/14/2021 at 3:40 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors and was independent with set up help only for locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem of being sexually inappropriate with staff and other residents, and when staff attempts to redirect me I state, I was married for a long time, so it's ok . Date initiated: 09/08/2020. 12/18/2020-Abuse allegation. b. A Physician order [REDACTED]. Give 1 tablet by mouth three times a day for sexually inappropriate behaviors. c. A Nurse's Note dated 12/15/2020 at 3:25 p.m. documented, Increased sexual inappropriate(ness). (Resident #2) is easily redirected. MD (Medical Doctor) aware. POA (Power of Attorney) made aware. No new orders noted at this time. d. The Point of Care documentation for December 2020 documented, Behavior symptoms . 10 = Sexually Inappropriate. The form documented the resident was sexually inappropriate on the 11 - 7 (11:00 p.m.-7:00 a.m.) shift on 12/07/2020, the 7-3 (7:00 a.m.-3:00 p.m.) shift on 12/08 and 12/09/2020, the 11-7 shift on 12/13/2020 and the 7-3 shift on 12/16/2020. e. A Physician order [REDACTED]. f. On 01/14/2021 at 8:30 a.m., Resident #2 was in a wheelchair in his room. A staff member was sitting in the room with him. Resident #2 was asked about the alleged incidents of sexual inappropriateness with female residents. The resident denied there being any sexual inappropriateness with any other resident. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/02/2020 documented the resident scored a 1 (0-7 indicates severely impaired) on the BIMS, had hallucinations, delusions, physical behaviors directed toward others, and was independent with locomotion on and off the unit. The Care Plan documented, I have impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's. I propel my broda chair around facility and enter other resident's rooms (men and women) and staff offices. Often times I seek out a certain male resident and go in his room despite redirection from staff. Date initiated: 1/21/2019. 3. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/18/2020 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS, had a behavior of wandering and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have impaired cognitive function or impaired thought processes r/t cognitive social/emotional deficit following nontraumatic [MEDICAL CONDITION]. I propel my w/c (wheelchair) around facility and will go in other resident's rooms, men and women . Date Initiated: 03/07/2017. b. On 01/14/2021 at 8:40 a.m., Resident #4 was lying in bed with her eyes open. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, I don't remember. 4. Resident #6 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/30/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem, I will make false accusations . make sexually inappropriate comments to staff and other residents. I can be hypersexual and make comments that in the past I was a prostitute and will solicit sex for money to men in the facility (staff and residents) r/t (related to) dx (diagnosis) of [MEDICAL CONDITIONS] disorder, depression. Date initiated: 11/05/2019. b. On 01/14/2021 at 8:45 a.m., Resident #6 was in a wheelchair in her room. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, That white man down there that goes to smoke with me. He won't let me pass unless I show him my titties. She was asked if the male resident had ever touched her and she stated, Yeah, he does this when I try to get by him (grabbed her own breasts). Resident #6 was asked if she was scare of the male resident. She stated, Yeah, but I think he's 1 on 1 now. I'm glad you're here. 5. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/21/2020 documented the resident scored 12 (8-12 indicates moderately impaired) per a BIMS, had verbal behaviors directed toward others and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I make unfounded accusations against staff members and people outside the facility of physical and sexual abuse . Date initiated: 03/02/2019. b. On 01/14/2021 at 8:55 a.m., Resident #7 was sitting in a wheelchair toward the end of 600 hall. She was asked if any male in the facility had made any sexual advances toward her or touched her in an inappropriate way. She stated, Yes. That man is always doing it down here at the end of the hall. 6. On 01/12/2021 at 11:48 a.m., Certified Nursing Assistant (CNA) #1 was asked about Resident #2's behaviors. She stated, He is very .you take him into the shower room, and he will say 'Ohhh, I want some of that black chocolate.' If you're not paying attention to him, he will try to touch your breast or bottom. Very perverted. He likes touching women. He has touched numerous women. Residents and employees. She was asked if he had always been that way. She stated, Yeah. When he first came it was with the workers. With the residents - I started seeing that a couple of months after he got here. The first time I saw it I told the nurse so she could document it. And I came and talked to social about it. That's all I could do. She was asked what happened after she reported it. She stated, I don't know. I did my part. I don't know. We asked at one point if he could be moved from back there because the lady was across from him. They moved him but the ombudsman said he had the right to stay in his room, so he was moved back. She was asked who was the first resident he touched. She stated, (Resident #6). She was asked where he touched her. She stated, Her breasts. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #3). He fondled her breasts. Another coworker was like . come here. She was coming out of the room and said (Resident #2) had his hands up under her shirt. When I got to the room his hand was between her legs. She was asked if his hand was on the inside of the resident's pants. She stated, On the outside of the pants. She was asked if she reported this to anyone. She stated, That was the incident I know for sure I came and talked to social about. She was asked if Resident #3 was alert and oriented. She stated, (Resident #3) is not in her right mind. She was asked where this took place. She stated, This took place in the hallway. We separated them of course. Later on that day we tried to get him moved. That's when the ombudsman said he had the right to stay in his room. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #4). He tried to go up under her shirt, but she kept moving his hand away and I stopped that. That was in the hallway. It's always when he goes to smoke. If there's a woman in the hallway he is going to try it. She was asked what the facility had done to prevent these sexually aggressive behaviors toward the female residents. She stated, I honestly don't know. I'm being honest. She was asked if the resident had been 1 on 1. She stated, No. She was asked if the facility had sent someone to stand with him in the hall when they go smoke since that's when he tries it. She stated, No. The only time I knew of them sending someone with him was when he was in isolation. She was asked if Resident #2 was 1 on 1 yesterday. She stated, He wasn't mine yesterday but there wasn't anybody with him. She was asked when was the most recent incident of sexually inappropriate behavior by Resident #2 and she stated, The most recent . I can recall it was (Resident #4). I don't remember exactly when that was. I haven't seen him do anything since her. She was asked how many times she had reported this. She stated, With (Resident #4) .I reported it to the nurse. She was asked who the nurse was and she stated, It could have been (Licensed Practical Nurse (LPN) #1). But I'm not sure. With (Resident #3), it made me so upset that they didn't do anything . 7. On 01/13/2021 at 12:25 p.m., CNA #2 was asked about Resident #2's behaviors. She stated, He can get sexually aggressive and feely. She was asked if he was that way with residents and she stated, With three that I know of. (Resident #4, Resident #3 and Resident #6). She was asked if she had actually observed him being sexually inappropriate. She stated, Yes. It was close to time for them to smoke and they were lined up in the hall and (Resident #2) loves to be the first one in line. (Resident #6) was in the hall and he was trying to get around her. She can be flirty and has been flirty with him more than once. She also has offered herself to him and other male residents. And this particular day he was trying to get past her, and she was rubbing on his arm. She wears a thin shirt and has offered to let him play with her breasts. I was going around the corner and I saw him put his hand under her shirt, but then she acted like she got upset about it. I think it was because she saw me come around the corner. She will also go into their rooms. Or be outside the door and make flirty comments. When I saw that I separated them. I went and told the nurse and the DON (Director of Nursing). She was asked when this happened. She stated, This was maybe 2 months ago. She was asked who the nurse was that she reported to and she stated, I don't remember. We have had so many. She was asked what was done to prevent it from happening again. She stated, They asked me to do witness statement, I think. That's the last I remember. She was asked if Resident #2 had been placed 1 on 1. She stated, No. She was asked if he had been moved to a different room. She stated, No. She was asked if the facility had sent someone to the hall at smoke time to monitor the activity there since that is when the residents are close together. She stated, No. She was asked if she had participated in any abuse in-services lately. She stated, We did have an in-service. She was asked if it was specific to Resident #2 and the behaviors. She stated, No. Just an overall in-service. She was asked about Resident #4. She stated, It was the same type of situation, but in the evening. He was in the hallway. (Resident #4) always rolls through the building and she loves to be by the smoke door. They were just sitting there talking. Me and a nurse was walking down the hall and we seen his hands under her shirt. She was asked what she did. She stated, We ran down, and I got him, and the nurse got her. I took him to his room. She was asked if this was reported to anyone and she stated, It was reported to the nurse . and it was reported to the DON. She was asked if the facility had done anything to prevent this from happening again. She stated, All I can recall is that they were separated. I do remember (Resident #2) was moved to 300 hall. They called his son I believe. But that same day something happened, and they said he had the right to stay in his same room, so he was moved back. She was asked if any extra monitoring was done to watch him more closely. She stated, Not that I know of. She was asked if she ever took the residents out to smoke. She stated, I'm on day shift. I take the residents out to smoke like at 9:30 a.m. and sometimes at 2. She was asked if the facility had asked her to increase the monitoring of him or to go to the smoke area hall a little early to monitor for any behaviors. She stated, No . She was asked if Resident #2 lined up in the hallway to go smoke yesterday. She stated, He did. She was asked if anyone was with him while in the hallway. She stated, No ma'am. 8. On 01/13/2021 at 1:04 p.m., CNA #3 was asked about Resident #2's behaviors. She stated, He has been very sexually inappropriate. I have had him ask me on several occasions do I love burger king because of them whoppers, because of how big my breasts are. His shower days are Monday, Wednesday, and Friday. I can be washing his private area and he does this moaning. He would try to look inside my shirt when I wore a V neck . I have witnessed on several occasions him touching female residents down by the smoke area. She was asked who he touched. She stated, (Resident #4, Resident #6 and Resident #3). Those are the only ones I can think of. She was asked if she personally had seen Resident #2 touch these female residents inappropriately. She stated, I have personally seen him touch them. I have seen him try to put his hands in their vagina area. (Resident #4) was asleep down at the end of the hall in her wheelchair and as I was coming down the hall, he had his hand in her private area. She was asked what she did when she saw that. She stated, I asked him to please move his hand away from her and removed (Resident #4) to her room, and I reported it to the charge nurse. And I documented in PCC (Point Click Care) that he was sexually inappropriate. She was asked who the charge nurse was that she reported to. She stated, I don't remember who the charge nurse was. She was asked when this happened and she stated, Maybe a month ago. She was asked what the charge nurse did about the allegation. She stated, She stated to me she was going to chart it. And I charted it . She was asked if she reported it to anyone else. She stated, No. The reason why I didn't is I have gone to administration and the DON plenty of times. We can go report it and they don't do nothing right then, so I report it to my charge nurse and let them take care of it. She was asked what happened with Resident #6. She stated, They were down at the smoke area lined up. I heard (Resident #6) say move away from me and I came out and asked her what was going on and she said he kept touching her. When they were coming back in, she was rolling down the hall. I witnessed him reaching over with his hand toward her private area. I stopped him and said what are you doing. He said nothing. She said he was trying to touch my pussy. I took her to her room and told the nurse. I also talked to one of my coworkers and she said well that's the second time today because she had already reported that he did it before the smoke break. She was asked about Resident #3. She stated, She wheels up and down the hall all day. Every time she passes by him in the hall she'll be really talking. He pulled her shirt up and had her breast out. I took her to her room and then came back and told him he couldn't be doing that and that I was going to have to report it. He said what did I do? He tried to act like he didn't know what he was doing to her. I'm pretty sure he is aware of what he is doing. But the DON (Director of Nursing) says it's his dementia and there's not much we can do. He was supposed to be 1 on 1 but wasn't put 1 on 1 until weeks later. They finally moved her to another hall . She was asked what the facility has done to protect the female residents from this happening again. She stated, Nothing. (Resident #3 and #6) are still back there. (Resident #3) roams the halls all day long. She was asked if the resident was 1 on 1 yesterday on day shift. She stated, I worked 7/3 the entire day and he was my resident. Nobody sat with him. I'm not sure why they had someone with him when ya'll got here. They called me Saturday and asked could I sit with him Saturday night and I couldn't. Saturday night someone did sit with him until the next morning. But Monday and Tuesday, nobody sat with him. I worked with him both days on day shift. After the incident happened with (Resident #3), no one sat with him. She was asked when the incident happened with Resident #3. She stated, About a month ago . 9. On 01/13/2021 at 1:46 p.m., CNA #4 was asked about Resident #2's behaviors. She stated, I witnessed him be inappropriate with (Resident #3). As I was coming up the hall he was rubbing in between her legs. She was just sitting there. She was just talking to him about something else because she isn't in her right mind. She was asked what she did when she observed this. She stated, I went down the hall to get her away from him. He got upset and started yelling at me. I moved her back up front to her room. I reported it to the nurse, and I think I charted it in my ADLs (Activities of Daily Living). She was asked how long ago this happened. She stated, Maybe 3 weeks ago, but I am not for sure. She was asked who she reported this to, and she stated, I think it was (LPN #1). She was asked what the nurse did, and she stated, She told the DON, I think. I think me and (CNA #1) came and told (Social Director) because he had been doing it to other women as well. She was asked what the facility did after this to prevent it from happening to anyone else. She stated, After we reported it, they asked us to move (Resident #1) and we moved him to another hall. And then (Social Director) talked to the Ombudsman and they told us we had to move him back because it was against his will. Other than that, nothing I know of. He was still doing it after this incident. She was asked about Resident #6. She stated, He told her every time she was in the way of him trying to get by, he was going to rub on her. She was asked what else the facility had done to prevent recurrences and she stated, After the incident with (Resident #3), a week later they moved her to another hall. Other than that, no. She was asked about Resident #4. She stated, A couple of other aides said they have witnessed him rubbing her breasts and between her legs. 10. On 01/13/2021 at 2:07 p.m., CNA #5 was asked if she had ever observed Resident #2 be sexually inappropriate with any female residents. She stated, Me personally, I have not seen it with my own eyes. She was asked if anyone had reported to her that they had observed it. She stated, Yes. I tell them to write a witness statement and tell the charge nurse and DON and administrator . First, I ask them if they have reported it to the charge nurse. If they tell me no, I tell them to do that also. She was asked if it had been reported to administration and she stated, I know for a fact the DON knew. But I don't know if the Administrator knew. She was asked how she knew the DON was aware and she stated, Because I have gone to her myself. I reported that the aides were telling me he was touching other residents inappropriately. And what do we need to do. We did move him, but he was moved back. She was asked if anything else was done after he was moved back to his room. She stated, (Resident #3) was moved to the front away from him. She was moved I think that same day. She was asked how long ago this was and she stated, Maybe 2 weeks ago. No one has reported to me that anything has happened with him since then. She was asked if anyone had reported anything to her about Resident #4. She stated, No not to me. She was asked if anything had been reported to her about Resident #6. She stated, Yes. An aide came to me and said he had been inappropriate with her. I told them to follow the same procedure - to write a witness statement and report it. She was asked if she reported it to anyone and she stated, I can't recall if I did. I think I just told the aide to tell the charge nurse and DON. 11. On 01/13/2021 at 2:21 p.m., CNA #6 was asked if she had ever seen Resident #2 be sexually inappropriate with female residents. She stated, Yes. I have witnessed him in the smoke hall with (Resident #6). I saw him stick his hand up under her gown (duster) in her private area. She was asked how long ago this happened and she stated, Maybe 3 months ago. She was asked what she did when she observed this. She stated, I told him we didn't need to be inappropriate. She was asked if she reported this to anyone and she stated, No. I said it around the nurse and CNAs at the nurse's station and everybody was like oh yeah we have already reported it. I just try not to go back there. She was asked if she had observed Resident #2 be inappropriate with anyone else and she stated, (Resident #7. He took his hand and put it under her butt in the back. She told him to stop. I told him to keep his hands to himself. She was asked if she had reported this to anyone and she stated, She did. Everybody was like what's going on and I said (Resident #2) touched her. I haven't seen him touch anyone else. She was asked what the facility had done to prevent this from happening to anyone else and she stated, We've been told to make sure 2 people go in to do care. But as far as I know, nothing has been done about him touching other residents. He is currently 1 on 1. 12. On 01/13/2021 at 2:56 p.m., LPN #1 was asked if she had ever observed Resident #2 be sexually inappropriate with any of the female residents. She stated, He is touchy feely. I have heard him talk inappropriate to staff and to residents. I have never seen it with my own eyes. She was asked if it had ever been reported to her that he was sexually inappropriate and she stated, Yes. Somebody has told me before they seen him touching a lady's breast or have her shirt raised up, and they told me they reported it to higher ups, too. She was asked when this happened and she stated, Before Christmas. She was asked which resident and she stated, (Resident #2). The CNA reported he had her shirt pulled up. Before they told me, they told me they had told the DON. Sometimes I am the last to know about my own residents. The CNAs like to pass me and go straight to the front. (Resident #3) daughter actually called checking on her after one incident. The incident was being taken care of by somebody other than myself. I was not asked to do a witness statement or I/A . She asked me what happened, and I told her the male does that when they get ready to go outside and smoke because he sits where no one can see him at the end of that hall. (Resident #3) gets stuck back there in that blind spot and I think he took advantage of that . I have overheard he touches women a lot but that incident with (Resident #3) was probably the first reported to me. I've only been on 600 hall for maybe 4-5 weeks. He was supposed to be moved but he was moved back. 13. On 01/13/2021 at 3:41 p.m., CNA #7 was asked if she had ever seen Resident #2 be sexually inappropriate with any female resident. She stated, I was coming back from smoke break on 600. He was in (Resident #3) room with his hand down in her pants. One of the aides was with me and we reported it to the nurse. She was asked if he had his hand inside or outside the pants and she stated, Not on the outside. Inside. She was asked which nurse this was reported to and she stated, I don't remember that. She was asked when this happened and she stated, Maybe 3 week ago. She was asked what happened after she reported it and she stated, I didn't hear no more about it until (CNA #1) reported it . I got so fed up because nothing was being done . The next I heard they caught him with his hand down (Resident #4) blouse . (Resident #3) was moved. (Resident #2) is 1 on 1 now. He wasn't on Monday. Monday night he was 1 on 1, but only like for 1 shift. I have reported his behavior. And I documented it in the kiosk. She was asked about Resident #6. She stated, They were outside smoking and him and (Resident #6) were over there to the side talking sexual to each other. I told them to stop it and I made (Resident #6) come over to me. He got mad, rolled to the door and went in. When I came back in that's when he called me a black [***] . I have never seen him touch her. She was asked about Resident #4 and she stated, I didn't see him touch her, but I heard (CNA #1) say she saw him touch her . 14. On 01/14/2021 at 9:30 a.m., Ombudsman #1 was asked if she had spoken with the facility concerning Resident #2 and moving him to a different room, but then moving him back to his original room. She stated, I don't remember anything about (Resident #2). I remember a call about a man that was doing some stuff. I don't remember them saying they were moving him to a different room. I thought I remembered they were asking about moving a resident out of the facility . I talked to them about (non-case mix resident), but I don't see any time I talked to them about anything other than that in December (2020) . 15. On 01/14/2021 at 10:03 a.m., the Social Director was asked how many times staff had reported to her about Resident #2's inappropriate behavior. She stated, I would probably say twice, but it was within the same day. More than one person came. She was asked how long ago this was and she stated, Probably a little over a month ago. They spoke with me and the DON. She was asked what was reported to her and she stated, They said he was caught with two female residents in his room. They said they were being sexual with each other. Different people came two different times to tell me about the same situation. She was asked what was done about it and she stated, They wanted to move his room but he . I told them they couldn't move him. He refused. So, we put him 1 on 1. I made sure that was the right thing to do. I told the DON we needed to investigate to find out more information. I believe they did 1 on 1 with him at that time. And then we spoke with his son. I think the DON spoke with the son. We talked to the resident about the situation. We spoke with both of the female residents. She was asked what she found out after speaking to the residents. She stated, (Resident #2) said it wasn't that type of situation. He said they came in there and it wasn't anything sexual. She was asked what the females said, and she stated, One of them has hallucinations and delusions and the other one acted like she didn't know what I was talking about. She was asked who the females were, and she stated, (Resident #3 and #4). At the time we couldn't move him because it was his word against theirs. From there I don't think .they never came back after that and said he was sexual. She was asked if increased monitoring was provided because of the allegations and she stated, I'm not sure after the 1 on 1 . 16. On 01/14/2021 at 12:56 p.m., the DON was asked when she first recalled hearing about Resident #2's behaviors. She stated, The very first time was with (Resident #3). That was December 18th. It was said that (Resident #3) was in his room and that he was touching her in an inappropriate way. She was asked who reported that and she stated, (CNA #1). She was asked what happened after it was reported. She stated, She was removed from his room. I called the daughter and told her. Got permission to move (Resident #3) to 100 hall. She was asked if a reportable incident was done and she stated, No ma'am. She was asked why, and she stated, I don't know. She was asked if anyone else had reported any inappropriate behaviors toward any other female resident to her and she stated, No. Not until someone called the hotline this past weekend. She was asked if any 1 on 1 was done with him prior to the hotline call on 01/09/2020. She stated, Not that I know of. We fail on documenting a lot of things we do. I have never been told anything about (Resident #4, #6 or #7.) 17. On 01/14/2021 at 2:30 p.m., the Administrator was asked when she first became aware of Resident #2's inappropriate behaviors. She stated, I can't recall a specific date and I don't know if it was told directly to me. I just remember that he was speaking inappropriate to staff. I don't remember anything about residents. The first time I remember hearing anything about him and residents is the hotline call. That was on Saturday (1/9/2021). She was asked what she did when she received information from that call. She stated, I got dressed and drove straight out here and immediately put him 1 on 1 and started an investigation. I started doing the 7734 (Incident and Accident Report). The RN supervisor - I had her start the body audits and obtain statements. I notified the DON. I got out here around 9:30 in the morning, I think. The hotline call mentioned (Resident #3 and #4). It didn't mention anyone else as far as the sexual stuff goes. Evidently the staff who called in couldn't remember when this happened. There was an incident in December that the DON and Social was aware of. I remember that somewhat. She was asked why no reportable was done on the December incident and she stated, If they both have a [DIAGNOSES REDACTED].? She was asked what interventions the facility had done since the hotline call. She stated, We reached out to Team Health for a psych eval. The physician was contacted about anymore medication adjustments. She was asked if an abuse in-service had been done since Saturday and she stated, We started one on one Saturday. Interviews were started with staff and residents. 18. The facility removed the immediate jeopardy situation when they placed the resident on continuous 1 on 1 supervision on 01/12/2021 prior to the survey entrance. On 1/9/2021, an investigation was started and inservices concerning implementation of abuse policy and procedures was initiated with staff. 19. The facility's Abuse Prevention Program documented, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property . The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party . Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator . Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potential mistreatment . All incidents will (TRUNCATED)

Complaint # (AR 044) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure their abuse policy and procedure was implemented by not reporting and investigating allegations of sexual abuse for 4 of 4 (Residents #3, #4, #6 and #7) case mix residents who were sexually abused by Resident #2. This failed practice resulted in a past immediate jeopardy which caused or was likely to cause serious harm, injury or death to Residents #3, #4, #6 and #7, and had the potential to affect 33 female residents according to a list provided by the Administrator on 1/15/2021 at 11:29 a.m. The Administrator was informed of the past immediate jeopardy on 01/14/2021 at 3:40 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors and was independent with set up help only for locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem of being sexually inappropriate with staff and other residents, and when staff attempts to redirect me I state, I was married for a long time, so it's ok . Date initiated: 09/08/2020. 12/18/2020-Abuse allegation. b. A Physician order [REDACTED]. Give 1 tablet by mouth three times a day for sexually inappropriate behaviors. c. A Nurse's Note dated 12/15/2020 at 3:25 p.m. documented, Increased sexual inappropriate(ness). (Resident #2) is easily redirected. MD (Medical Doctor) aware. POA (Power of Attorney) made aware. No new orders noted at this time. d. The Point of Care documentation for December 2020 documented, Behavior symptoms . 10 = Sexually Inappropriate. The form documented the resident was sexually inappropriate on the 11 - 7 (11:00 p.m.-7:00 a.m.) shift on 12/07/2020, the 7-3 (7:00 a.m.-3:00 p.m.) shift on 12/08 and 12/09/2020, the 11-7 shift on 12/13/2020 and the 7-3 shift on 12/16/2020. e. A Physician order [REDACTED]. f. On 01/14/2021 at 8:30 a.m., Resident #2 was in a wheelchair in his room. A staff member was sitting in the room with him. Resident #2 was asked about the alleged incidents of sexual inappropriateness with female residents. The resident denied there being any sexual inappropriateness with any other resident. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/02/2020 documented the resident scored a 1 (0-7 indicates severely impaired) on the BIMS, had hallucinations, delusions, physical behaviors directed toward others, and was independent with locomotion on and off the unit. The Care Plan documented, I have impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's. I propel my broda chair around facility and enter other resident's rooms (men and women) and staff offices. Often times I seek out a certain male resident and go in his room despite redirection from staff. Date initiated: 1/21/2019. 3. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/18/2020 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS, had a behavior of wandering and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have impaired cognitive function or impaired thought processes r/t cognitive social/emotional deficit following nontraumatic [MEDICAL CONDITION]. I propel my w/c (wheelchair) around facility and will go in other resident's rooms, men and women . Date Initiated: 03/07/2017. b. On 01/14/2021 at 8:40 a.m., Resident #4 was lying in bed with her eyes open. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, I don't remember. 4. Resident #6 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/30/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem, I will make false accusations . make sexually inappropriate comments to staff and other residents. I can be hypersexual and make comments that in the past I was a prostitute and will solicit sex for money to men in the facility (staff and residents) r/t (related to) dx (diagnosis) of [MEDICAL CONDITIONS] disorder, depression. Date initiated: 11/05/2019. b. On 01/14/2021 at 8:45 a.m., Resident #6 was observed in a wheelchair in her room. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, That white man down there that goes to smoke with me. He won't let me pass unless I show him my titties. She was asked if the male resident had ever touched her and she stated, Yeah, he does this when I try to get by him (grabbed her own breasts). Resident #6 was asked if she was scare of the male resident. She stated, Yeah, but I think he's 1 on 1 now. I'm glad you're here. 5. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/21/2020 documented the resident scored 12 (8-12 indicates moderately impaired) per a BIMS, had verbal behaviors directed toward others and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I make unfounded accusations against staff members and people outside the facility of physical and sexual abuse . Date initiated: 03/02/2019. b. On 01/14/2021 at 8:55 a.m., Resident #7 was sitting in a wheelchair toward the end of 600 hall. She was asked if any male in the facility had made any sexual advances toward her or touched her in an inappropriate way. She stated, Yes. That man is always doing it down here at the end of the hall. 6. On 01/12/2021 at 11:48 a.m., Certified Nursing Assistant (CNA) #1 was asked about Resident #2's behaviors. She stated, He is very .you take him into the shower room, and he will say 'Ohhh, I want some of that black chocolate.' If you're not paying attention to him, he will try to touch your breast or bottom. Very perverted. He likes touching women. He has touched numerous women. Residents and employees. She was asked if he had always been that way. She stated, Yeah. When he first came it was with the workers. With the residents - I started seeing that a couple of months after he got here. The first time I saw it I told the nurse so she could document it. And I came and talked to social about it. That's all I could do. She was asked what happened after she reported it. She stated, I don't know. I did my part. I don't know. We asked at one point if he could be moved from back there because the lady was across from him. They moved him but the ombudsman said he had the right to stay in his room, so he was moved back. She was asked who was the first resident he touched. She stated, (Resident #6). She was asked where he touched her. She stated, Her breasts. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #3). He fondled her breasts. Another coworker was like . come here. She was coming out of the room and said (Resident #2) had his hands up under her shirt. When I got to the room his hand was between her legs. She was asked if his hand was on the inside of the resident's pants. She stated, On the outside of the pants. She was asked if she reported this to anyone. She stated, That was the incident I know for sure I came and talked to social about. She was asked if Resident #3 was alert and oriented. She stated, (Resident #3) is not in her right mind. She was asked where this took place. She stated, This took place in the hallway. We separated them of course. Later on that day we tried to get him moved. That's when the ombudsman said he had the right to stay in his room. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #4). He tried to go up under her shirt, but she kept moving his hand away and I stopped that. That was in the hallway. It's always when he goes to smoke. If there's a woman in the hallway he is going to try it. She was asked what the facility had done to prevent these sexually aggressive behaviors toward the female residents. She stated, I honestly don't know. I'm being honest. She was asked if the resident had been 1 on 1. She stated, No. She was asked if the facility had sent someone to stand with him in the hall when they go smoke since that's when he tries it. She stated, No. The only time I knew of them sending someone with him was when he was in isolation. She was asked if Resident #2 was 1 on 1 yesterday. She stated, He wasn't mine yesterday but there wasn't anybody with him. She was asked when was the most recent incident of sexually inappropriate behavior by Resident #2 and she stated, The most recent . I can recall it was (Resident #4). I don't remember exactly when that was. I haven't seen him do anything since her. She was asked how many times she had reported this. She stated, With (Resident #4) .I reported it to the nurse. She was asked who the nurse was and she stated, It could have been (Licensed Practical Nurse (LPN) #1). But I'm not sure. With (Resident #3), it made me so upset that they didn't do anything . 7. On 01/13/2021 at 12:25 p.m., CNA #2 was asked about Resident #2's behaviors. She stated, He can get sexually aggressive and feely. She was asked if he was that way with residents and she stated, With three that I know of. (Resident #4, Resident #3 and Resident #6). She was asked if she had actually observed him being sexually inappropriate. She stated, Yes. It was close to time for them to smoke and they were lined up in the hall and (Resident #2) loves to be the first one in line. (Resident #6) was in the hall and he was trying to get around her. She can be flirty and has been flirty with him more than once. She also has offered herself to him and other male residents. And this particular day he was trying to get past her, and she was rubbing on his arm. She wears a thin shirt and has offered to let him play with her breasts. I was going around the corner and I saw him put his hand under her shirt, but then she acted like she got upset about it. I think it was because she saw me come around the corner. She will also go into their rooms. Or be outside the door and make flirty comments. When I saw that I separated them. I went and told the nurse and the DON (Director of Nursing). She was asked when this happened. She stated, This was maybe 2 months ago. She was asked who the nurse was that she reported to and she stated, I don't remember. We have had so many. She was asked what was done to prevent it from happening again. She stated, They asked me to do witness statement, I think. That's the last I remember. She was asked if Resident #2 had been placed 1 on 1. She stated, No. She was asked if he had been moved to a different room. She stated, No. She was asked if the facility had sent someone to the hall at smoke time to monitor the activity there since that is when the residents are close together. She stated, No. She was asked if she had participated in any abuse in-services lately. She stated, We did have an in-service. She was asked if it was specific to Resident #2 and the behaviors. She stated, No. Just an overall in-service. She was asked about Resident #4. She stated, It was the same type of situation, but in the evening. He was in the hallway. (Resident #4) always rolls through the building and she loves to be by the smoke door. They were just sitting there talking. Me and a nurse was walking down the hall and we seen his hands under her shirt. She was asked what she did. She stated, We ran down, and I got him, and the nurse got her. I took him to his room. She was asked if this was reported to anyone and she stated, It was reported to the nurse . and it was reported to the DON. She was asked if the facility had done anything to prevent this from happening again. She stated, All I can recall is that they were separated. I do remember (Resident #2) was moved to 300 hall. They called his son I believe. But that same day something happened, and they said he had the right to stay in his same room, so he was moved back. She was asked if any extra monitoring was done to watch him more closely. She stated, Not that I know of. She was asked if she ever took the residents out to smoke. She stated, I'm on day shift. I take the residents out to smoke like at 9:30 a.m. and sometimes at 2. She was asked if the facility had asked her to increase the monitoring of him or to go to the smoke area hall a little early to monitor for any behaviors. She stated, No . She was asked if Resident #2 lined up in the hallway to go smoke yesterday. She stated, He did. She was asked if anyone was with him while in the hallway. She stated, No ma'am. 8. On 01/13/2021 at 1:04 p.m., CNA #3 was asked about Resident #2's behaviors. She stated, He has been very sexually inappropriate. I have had him ask me on several occasions do I love burger king because of them whoppers, because of how big my breasts are. His shower days are Monday, Wednesday, and Friday. I can be washing his private area and he does this moaning. He would try to look inside my shirt when I wore a V neck . I have witnessed on several occasions him touching female residents down by the smoke area. She was asked who he touched. She stated, (Resident #4, Resident #6 and Resident #3). Those are the only ones I can think of. She was asked if she personally had seen Resident #2 touch these female residents inappropriately. She stated, I have personally seen him touch them. I have seen him try to put his hands in their vagina area. (Resident #4) was asleep down at the end of the hall in her wheelchair and as I was coming down the hall, he had his hand in her private area. She was asked what she did when she saw that. She stated, I asked him to please move his hand away from her and removed (Resident #4) to her room, and I reported it to the charge nurse. And I documented in PCC (Point Click Care) that he was sexually inappropriate. She was asked who the charge nurse was that she reported to. She stated, I don't remember who the charge nurse was. She was asked when this happened and she stated, Maybe a month ago. She was asked what the charge nurse did about the allegation. She stated, She stated to me she was going to chart it. And I charted it . She was asked if she reported it to anyone else. She stated, No. The reason why I didn't is I have gone to administration and the DON plenty of times. We can go report it and they don't do nothing right then, so I report it to my charge nurse and let them take care of it. She was asked what happened with Resident #6. She stated, They were down at the smoke area lined up. I heard (Resident #6) say move away from me and I came out and asked her what was going on and she said he kept touching her. When they were coming back in, she was rolling down the hall. I witnessed him reaching over with his hand toward her private area. I stopped him and said what are you doing. He said nothing. She said he was trying to touch my pussy. I took her to her room and told the nurse. I also talked to one of my coworkers and she said well that's the second time today because she had already reported that he did it before the smoke break. She was asked about Resident #3. She stated, She wheels up and down the hall all day. Every time she passes by him in the hall she'll be really talking. He pulled her shirt up and had her breast out. I took her to her room and then came back and told him he couldn't be doing that and that I was going to have to report it. He said what did I do? He tried to act like he didn't know what he was doing to her. I'm pretty sure he is aware of what he is doing. But the DON (Director of Nursing) says it's his dementia and there's not much we can do. He was supposed to be 1 on 1 but wasn't put 1 on 1 until weeks later. They finally moved her to another hall . She was asked what the facility has done to protect the female residents from this happening again. She stated, Nothing. (Resident #3 and #6) are still back there. (Resident #3) roams the halls all day long. She was asked if the resident was 1 on 1 yesterday on day shift. She stated, I worked 7/3 the entire day and he was my resident. Nobody sat with him. I'm not sure why they had someone with him when ya'll got here. They called me Saturday and asked could I sit with him Saturday night and I couldn't. Saturday night someone did sit with him until the next morning. But Monday and Tuesday, nobody sat with him. I worked with him both days on day shift. After the incident happened with (Resident #3), no one sat with him. She was asked when the incident happened with Resident #3. She stated, About a month ago . 9. On 01/13/2021 at 1:46 p.m., CNA #4 was asked about Resident #2's behaviors. She stated, I witnessed him be inappropriate with (Resident #3). As I was coming up the hall he was rubbing in between her legs. She was just sitting there. She was just talking to him about something else because she isn't in her right mind. She was asked what she did when she observed this. She stated, I went down the hall to get her away from him. He got upset and started yelling at me. I moved her back up front to her room. I reported it to the nurse, and I think I charted it in my ADLs (Activities of Daily Living). She was asked how long ago this happened. She stated, Maybe 3 weeks ago, but I am not for sure. She was asked who she reported this to, and she stated, I think it was (LPN #1). She was asked what the nurse did, and she stated, She told the DON, I think. I think me and (CNA #1) came and told (Social Director) because he had been doing it to other women as well. She was asked what the facility did after this to prevent it from happening to anyone else. She stated, After we reported it, they asked us to move (Resident #1) and we moved him to another hall. And then (Social Director) talked to the Ombudsman and they told us we had to move him back because it was against his will. Other than that, nothing I know of. He was still doing it after this incident. She was asked about Resident #6. She stated, He told her every time she was in the way of him trying to get by, he was going to rub on her. She was asked what else the facility had done to prevent recurrences and she stated, After the incident with (Resident #3), a week later they moved her to another hall. Other than that, no. She was asked about Resident #4. She stated, A couple of other aides said they have witnessed him rubbing her breasts and between her legs. 10. On 01/13/2021 at 2:07 p.m., CNA #5 was asked if she had ever observed Resident #2 be sexually inappropriate with any female residents. She stated, Me personally, I have not seen it with my own eyes. She was asked if anyone had reported to her that they had observed it. She stated, Yes. I tell them to write a witness statement and tell the charge nurse and DON and administrator . First, I ask them if they have reported it to the charge nurse. If they tell me no, I tell them to do that also. She was asked if it had been reported to administration and she stated, I know for a fact the DON knew. But I don't know if the Administrator knew. She was asked how she knew the DON was aware and she stated, Because I have gone to her myself. I reported that the aides were telling me he was touching other residents inappropriately. And what do we need to do. We did move him, but he was moved back. She was asked if anything else was done after he was moved back to his room. She stated, (Resident #3) was moved to the front away from him. She was moved I think that same day. She was asked how long ago this was and she stated, Maybe 2 weeks ago. No one has reported to me that anything has happened with him since then. She was asked if anyone had reported anything to her about Resident #4. She stated, No not to me. She was asked if anything had been reported to her about Resident #6. She stated, Yes. An aide came to me and said he had been inappropriate with her. I told them to follow the same procedure - to write a witness statement and report it. She was asked if she reported it to anyone and she stated, I can't recall if I did. I think I just told the aide to tell the charge nurse and DON. 11. On 01/13/2021 at 2:21 p.m., CNA #6 was asked if she had ever seen Resident #2 be sexually inappropriate with female residents. She stated, Yes. I have witnessed him in the smoke hall with (Resident #6). I saw him stick his hand up under her gown (duster) in her private area. She was asked how long ago this happened and she stated, Maybe 3 months ago. She was asked what she did when she observed this. She stated, I told him we didn't need to be inappropriate. She was asked if she reported this to anyone and she stated, No. I said it around the nurse and CNAs at the nurse's station and everybody was like oh yeah we have already reported it. I just try not to go back there. She was asked if she had observed Resident #2 be inappropriate with anyone else and she stated, (Resident #7. He took his hand and put it under her butt in the back. She told him to stop. I told him to keep his hands to himself. She was asked if she had reported this to anyone and she stated, She did. Everybody was like what's going on and I said (Resident #2) touched her. I haven't seen him touch anyone else. She was asked what the facility had done to prevent this from happening to anyone else and she stated, We've been told to make sure 2 people go in to do care. But as far as I know, nothing has been done about him touching other residents. He is currently 1 on 1. 12. On 01/13/2021 at 2:56 p.m., LPN #1 was asked if she had ever observed Resident #2 be sexually inappropriate with any of the female residents. She stated, He is touchy feely. I have heard him talk inappropriate to staff and to residents. I have never seen it with my own eyes. She was asked if it had ever been reported to her that he was sexually inappropriate and she stated, Yes. Somebody has told me before they seen him touching a lady's breast or have her shirt raised up, and they told me they reported it to higher ups, too. She was asked when this happened and she stated, Before Christmas. She was asked which resident and she stated, (Resident #2). The CNA reported he had her shirt pulled up. Before they told me, they told me they had told the DON. Sometimes I am the last to know about my own residents. The CNAs like to pass me and go straight to the front. (Resident #3) daughter actually called checking on her after one incident. The incident was being taken care of by somebody other than myself. I was not asked to do a witness statement or I/A . She asked me what happened, and I told her the male does that when they get ready to go outside and smoke because he sits where no one can see him at the end of that hall. (Resident #3) gets stuck back there in that blind spot and I think he took advantage of that . I have overheard he touches women a lot but that incident with (Resident #3) was probably the first reported to me. I've only been on 600 hall for maybe 4-5 weeks. He was supposed to be moved but he was moved back. 13. On 01/13/2021 at 3:41 p.m., CNA #7 was asked if she had ever seen Resident #2 be sexually inappropriate with any female resident. She stated, I was coming back from smoke break on 600. He was in (Resident #3) room with his hand down in her pants. One of the aides was with me and we reported it to the nurse. She was asked if he had his hand inside or outside the pants and she stated, Not on the outside. Inside. She was asked which nurse this was reported to and she stated, I don't remember that. She was asked when this happened and she stated, Maybe 3 week ago. She was asked what happened after she reported it and she stated, I didn't hear no more about it until (CNA #1) reported it . I got so fed up because nothing was being done . The next I heard they caught him with his hand down (Resident #4) blouse . (Resident #3) was moved. (Resident #2) is 1 on 1 now. He wasn't on Monday. Monday night he was 1 on 1, but only like for 1 shift. I have reported his behavior. And I documented it in the kiosk. She was asked about Resident #6. She stated, They were outside smoking and him and (Resident #6) were over there to the side talking sexual to each other. I told them to stop it and I made (Resident #6) come over to me. He got mad, rolled to the door and went in. When I came back in that's when he called me a black [***] . I have never seen him touch her. She was asked about Resident #4 and she stated, I didn't see him touch her, but I heard (CNA #1) say she saw him touch her . 14. On 01/14/2021 at 9:30 a.m., Ombudsman #1 was asked if she had spoken with the facility concerning Resident #2 and moving him to a different room, but then moving him back to his original room. She stated, I don't remember anything about (Resident #2). I remember a call about a man that was doing some stuff. I don't remember them saying they were moving him to a different room. I thought I remembered they were asking about moving a resident out of the facility . I talked to them about (non-case mix resident), but I don't see any time I talked to them about anything other than that in December (2020) . 15. On 01/14/2021 at 10:03 a.m., the Social Director was asked how many times staff had reported to her about Resident #2's inappropriate behavior. She stated, I would probably say twice, but it was within the same day. More than one person came. She was asked how long ago this was and she stated, Probably a little over a month ago. They spoke with me and the DON. She was asked what was reported to her and she stated, They said he was caught with two female residents in his room. They said they were being sexual with each other. Different people came two different times to tell me about the same situation. She was asked what was done about it and she stated, They wanted to move his room but he . I told them they couldn't move him. He refused. So, we put him 1 on 1. I made sure that was the right thing to do. I told the DON we needed to investigate to find out more information. I believe they did 1 on 1 with him at that time. And then we spoke with his son. I think the DON spoke with the son. We talked to the resident about the situation. We spoke with both of the female residents. She was asked what she found out after speaking to the residents. She stated, (Resident #2) said it wasn't that type of situation. He said they came in there and it wasn't anything sexual. She was asked what the females said, and she stated, One of them has hallucinations and delusions and the other one acted like she didn't know what I was talking about. She was asked who the females were, and she stated, (Resident #3 and #4). At the time we couldn't move him because it was his word against theirs. From there I don't think .they never came back after that and said he was sexual. She was asked if increased monitoring was provided because of the allegations and she stated, I'm not sure after the 1 on 1 . 16. On 01/14/2021 at 12:56 p.m., the DON was asked when she first recalled hearing about Resident #2's behaviors. She stated, The very first time was with (Resident #3). That was December 18th. It was said that (Resident #3) was in his room and that he was touching her in an inappropriate way. She was asked who reported that and she stated, (CNA #1). She was asked what happened after it was reported. She stated, She was removed from his room. I called the daughter and told her. Got permission to move (Resident #3) to 100 hall. She was asked if a reportable incident was done and she stated, No ma'am. She was asked why, and she stated, I don't know. She was asked if anyone else had reported any inappropriate behaviors toward any other female resident to her and she stated, No. Not until someone called the hotline this past weekend. She was asked if any 1 on 1 was done with him prior to the hotline call on 01/09/2020. She stated, Not that I know of. We fail on documenting a lot of things we do. I have never been told anything about (Resident #4, #6 or #7.) 17. On 01/14/2021 at 2:30 p.m., the Administrator was asked when she first became aware of Resident #2's inappropriate behaviors. She stated, I can't recall a specific date and I don't know if it was told directly to me. I just remember that he was speaking inappropriate to staff. I don't remember anything about residents. The first time I remember hearing anything about him and residents is the hotline call. That was on Saturday. She was asked what she did when she received information from that call. She stated, I got dressed and drove straight out here and immediately put him 1 on 1 and started an investigation. I started doing the 7734. The RN supervisor - I had her start the body audits and obtain statements. I notified the DON. I got out here around 9:30 in the morning, I think. The hotline call mentioned (Resident #3 and #4). It didn't mention anyone else as far as the sexual stuff goes. Evidently the staff who called in couldn't remember when this happened. There was an incident in December that the DON and Social was aware of. I remember that somewhat. She was asked why no reportable was done on the December incident and she stated, If they both have a [DIAGNOSES REDACTED].? She was asked what interventions the facility had done since the hotline call. She stated, We reached out to Team Health for a psych eval. The physician was contacted about anymore medication adjustments. She was asked if an abuse in-service had been done since Saturday and she stated, We started one on one Saturday. Interviews were started with staff and residents. 18. The facility removed the immediate jeopardy situation when they placed the resident on continuous 1 on 1 supervision on 01/12/2021 prior to the survey entrance. On 1/9/2021, an investigation was started and inservices concerning implementation of abuse policy and procedures was initiated with staff. 19. The facility's Abuse Prevention Program documented, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property . The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party . Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator . Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potential mistreatment . Al (TRUNCATED)

Complaint # (AR 044) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure allegations of sexual abuse were reported to the Administrator/Designee, Office of Long Terms, local law enforcement and other officials in accordance with state law within 2 hours of the allegation for 4 of 4 (Residents #3, #4, #6 and #7) case mix residents who were sexually abused by Resident #2. This failed practice resulted in a past immediate jeopardy which caused or was likely to cause serious harm, injury or death to Residents #3, #4, #6 and #7, and had the potential to affect 33 female residents according to a list provided by the Administrator on 1/15/2021 at 11:29 a.m. The Administrator was informed of the past immediate jeopardy on 01/14/2021 at 3:40 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors and was independent with set up help only for locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem of being sexually inappropriate with staff and other residents, and when staff attempts to redirect me I state, I was married for a long time, so it's ok . Date initiated: 09/08/2020. 12/18/2020-Abuse allegation. b. A Physician order [REDACTED]. Give 1 tablet by mouth three times a day for sexually inappropriate behaviors. c. A Nurse's Note dated 12/15/2020 at 3:25 p.m. documented, Increased sexual inappropriate(ness). (Resident #2) is easily redirected. MD (Medical Doctor) aware. POA (Power of Attorney) made aware. No new orders noted at this time. d. The Point of Care documentation for December 2020 documented, Behavior symptoms . 10 = Sexually Inappropriate. The form documented the resident was sexually inappropriate on the 11 - 7 (11:00 p.m.-7:00 a.m.) shift on 12/07/2020, the 7-3 (7:00 a.m.-3:00 p.m.) shift on 12/08 and 12/09/2020, the 11-7 shift on 12/13/2020 and the 7-3 shift on 12/16/2020. e. A Physician order [REDACTED]. f. On 01/14/2021 at 8:30 a.m., Resident #2 was in a wheelchair in his room. A staff member was sitting in the room with him. Resident #2 was asked about the alleged incidents of sexual inappropriateness with female residents. The resident denied there being any sexual inappropriateness with any other resident. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/02/2020 documented the resident scored a 1 (0-7 indicates severely impaired) on the BIMS, had hallucinations, delusions, physical behaviors directed toward others, and was independent with locomotion on and off the unit. The Care Plan documented, I have impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's. I propel my broda chair around facility and enter other resident's rooms (men and women) and staff offices. Often times I seek out a certain male resident and go in his room despite redirection from staff. Date initiated: 1/21/2019. 3. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/18/2020 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS, had a behavior of wandering and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have impaired cognitive function or impaired thought processes r/t cognitive social/emotional deficit following nontraumatic [MEDICAL CONDITION]. I propel my w/c (wheelchair) around facility and will go in other resident's rooms, men and women . Date Initiated: 03/07/2017. b. On 01/14/2021 at 8:40 a.m., Resident #4 was lying in bed with her eyes open. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, I don't remember. 4. Resident #6 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/30/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem, I will make false accusations . make sexually inappropriate comments to staff and other residents. I can be hypersexual and make comments that in the past I was a prostitute and will solicit sex for money to men in the facility (staff and residents) r/t (related to) dx (diagnosis) of [MEDICAL CONDITIONS] disorder, depression. Date initiated: 11/05/2019. b. On 01/14/2021 at 8:45 a.m., Resident #6 was in a wheelchair in her room. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, That white man down there that goes to smoke with me. He won't let me pass unless I show him my titties. She was asked if the male resident had ever touched her and she stated, Yeah, he does this when I try to get by him (grabbed her own breasts). Resident #6 was asked if she was scare of the male resident. She stated, Yeah, but I think he's 1 on 1 now. I'm glad you're here. 5. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/21/2020 documented the resident scored 12 (8-12 indicates moderately impaired) per a BIMS, had verbal behaviors directed toward others and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I make unfounded accusations against staff members and people outside the facility of physical and sexual abuse . Date initiated: 03/02/2019. b. On 01/14/2021 at 8:55 a.m., Resident #7 was sitting in a wheelchair toward the end of 600 hall. She was asked if any male in the facility had made any sexual advances toward her or touched her in an inappropriate way. She stated, Yes. That man is always doing it down here at the end of the hall. 6. On 01/12/2021 at 11:48 a.m., Certified Nursing Assistant (CNA) #1 was asked about Resident #2's behaviors. She stated, He is very .you take him into the shower room, and he will say 'Ohhh, I want some of that black chocolate.' If you're not paying attention to him, he will try to touch your breast or bottom. Very perverted. He likes touching women. He has touched numerous women. Residents and employees. She was asked if he had always been that way. She stated, Yeah. When he first came it was with the workers. With the residents - I started seeing that a couple of months after he got here. The first time I saw it I told the nurse so she could document it. And I came and talked to social about it. That's all I could do. She was asked what happened after she reported it. She stated, I don't know. I did my part. I don't know. We asked at one point if he could be moved from back there because the lady was across from him. They moved him but the ombudsman said he had the right to stay in his room, so he was moved back. She was asked who was the first resident he touched. She stated, (Resident #6). She was asked where he touched her. She stated, Her breasts. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #3). He fondled her breasts. Another coworker was like . come here. She was coming out of the room and said (Resident #2) had his hands up under her shirt. When I got to the room his hand was between her legs. She was asked if his hand was on the inside of the resident's pants. She stated, On the outside of the pants. She was asked if she reported this to anyone. She stated, That was the incident I know for sure I came and talked to social about. She was asked if Resident #3 was alert and oriented. She stated, (Resident #3) is not in her right mind. She was asked where this took place. She stated, This took place in the hallway. We separated them of course. Later on that day we tried to get him moved. That's when the ombudsman said he had the right to stay in his room. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #4). He tried to go up under her shirt, but she kept moving his hand away and I stopped that. That was in the hallway. It's always when he goes to smoke. If there's a woman in the hallway he is going to try it. She was asked what the facility had done to prevent these sexually aggressive behaviors toward the female residents. She stated, I honestly don't know. I'm being honest. She was asked if the resident had been 1 on 1. She stated, No. She was asked if the facility had sent someone to stand with him in the hall when they go smoke since that's when he tries it. She stated, No. The only time I knew of them sending someone with him was when he was in isolation. She was asked if Resident #2 was 1 on 1 yesterday. She stated, He wasn't mine yesterday but there wasn't anybody with him. She was asked when was the most recent incident of sexually inappropriate behavior by Resident #2 and she stated, The most recent . I can recall it was (Resident #4). I don't remember exactly when that was. I haven't seen him do anything since her. She was asked how many times she had reported this. She stated, With (Resident #4) .I reported it to the nurse. She was asked who the nurse was and she stated, It could have been (Licensed Practical Nurse (LPN) #1). But I'm not sure. With (Resident #3), it made me so upset that they didn't do anything . 7. On 01/13/2021 at 12:25 p.m., CNA #2 was asked about Resident #2's behaviors. She stated, He can get sexually aggressive and feely. She was asked if he was that way with residents and she stated, With three that I know of. (Resident #4, Resident #3 and Resident #6). She was asked if she had actually observed him being sexually inappropriate. She stated, Yes. It was close to time for them to smoke and they were lined up in the hall and (Resident #2) loves to be the first one in line. (Resident #6) was in the hall and he was trying to get around her. She can be flirty and has been flirty with him more than once. She also has offered herself to him and other male residents. And this particular day he was trying to get past her, and she was rubbing on his arm. She wears a thin shirt and has offered to let him play with her breasts. I was going around the corner and I saw him put his hand under her shirt, but then she acted like she got upset about it. I think it was because she saw me come around the corner. She will also go into their rooms. Or be outside the door and make flirty comments. When I saw that I separated them. I went and told the nurse and the DON (Director of Nursing). She was asked when this happened. She stated, This was maybe 2 months ago. She was asked who the nurse was that she reported to and she stated, I don't remember. We have had so many. She was asked what was done to prevent it from happening again. She stated, They asked me to do witness statement, I think. That's the last I remember. She was asked if Resident #2 had been placed 1 on 1. She stated, No. She was asked if he had been moved to a different room. She stated, No. She was asked if the facility had sent someone to the hall at smoke time to monitor the activity there since that is when the residents are close together. She stated, No. She was asked if she had participated in any abuse in-services lately. She stated, We did have an in-service. She was asked if it was specific to Resident #2 and the behaviors. She stated, No. Just an overall in-service. She was asked about Resident #4. She stated, It was the same type of situation, but in the evening. He was in the hallway. (Resident #4) always rolls through the building and she loves to be by the smoke door. They were just sitting there talking. Me and a nurse was walking down the hall and we seen his hands under her shirt. She was asked what she did. She stated, We ran down, and I got him, and the nurse got her. I took him to his room. She was asked if this was reported to anyone and she stated, It was reported to the nurse . and it was reported to the DON. She was asked if the facility had done anything to prevent this from happening again. She stated, All I can recall is that they were separated. I do remember (Resident #2) was moved to 300 hall. They called his son I believe. But that same day something happened, and they said he had the right to stay in his same room, so he was moved back. She was asked if any extra monitoring was done to watch him more closely. She stated, Not that I know of. She was asked if she ever took the residents out to smoke. She stated, I'm on day shift. I take the residents out to smoke like at 9:30 a.m. and sometimes at 2. She was asked if the facility had asked her to increase the monitoring of him or to go to the smoke area hall a little early to monitor for any behaviors. She stated, No . She was asked if Resident #2 lined up in the hallway to go smoke yesterday. She stated, He did. She was asked if anyone was with him while in the hallway. She stated, No ma'am. 8. On 01/13/2021 at 1:04 p.m., CNA #3 was asked about Resident #2's behaviors. She stated, He has been very sexually inappropriate. I have had him ask me on several occasions do I love burger king because of them whoppers, because of how big my breasts are. His shower days are Monday, Wednesday, and Friday. I can be washing his private area and he does this moaning. He would try to look inside my shirt when I wore a V neck . I have witnessed on several occasions him touching female residents down by the smoke area. She was asked who he touched. She stated, (Resident #4, Resident #6 and Resident #3). Those are the only ones I can think of. She was asked if she personally had seen Resident #2 touch these female residents inappropriately. She stated, I have personally seen him touch them. I have seen him try to put his hands in their vagina area. (Resident #4) was asleep down at the end of the hall in her wheelchair and as I was coming down the hall, he had his hand in her private area. She was asked what she did when she saw that. She stated, I asked him to please move his hand away from her and removed (Resident #4) to her room, and I reported it to the charge nurse. And I documented in PCC (Point Click Care) that he was sexually inappropriate. She was asked who the charge nurse was that she reported to. She stated, I don't remember who the charge nurse was. She was asked when this happened and she stated, Maybe a month ago. She was asked what the charge nurse did about the allegation. She stated, She stated to me she was going to chart it. And I charted it . She was asked if she reported it to anyone else. She stated, No. The reason why I didn't is I have gone to administration and the DON plenty of times. We can go report it and they don't do nothing right then, so I report it to my charge nurse and let them take care of it. She was asked what happened with Resident #6. She stated, They were down at the smoke area lined up. I heard (Resident #6) say move away from me and I came out and asked her what was going on and she said he kept touching her. When they were coming back in, she was rolling down the hall. I witnessed him reaching over with his hand toward her private area. I stopped him and said what are you doing. He said nothing. She said he was trying to touch my pussy. I took her to her room and told the nurse. I also talked to one of my coworkers and she said well that's the second time today because she had already reported that he did it before the smoke break. She was asked about Resident #3. She stated, She wheels up and down the hall all day. Every time she passes by him in the hall she'll be really talking. He pulled her shirt up and had her breast out. I took her to her room and then came back and told him he couldn't be doing that and that I was going to have to report it. He said what did I do? He tried to act like he didn't know what he was doing to her. I'm pretty sure he is aware of what he is doing. But the DON (Director of Nursing) says it's his dementia and there's not much we can do. He was supposed to be 1 on 1 but wasn't put 1 on 1 until weeks later. They finally moved her to another hall . She was asked what the facility has done to protect the female residents from this happening again. She stated, Nothing. (Resident #3 and #6) are still back there. (Resident #3) roams the halls all day long. She was asked if the resident was 1 on 1 yesterday on day shift. She stated, I worked 7/3 the entire day and he was my resident. Nobody sat with him. I'm not sure why they had someone with him when ya'll got here. They called me Saturday and asked could I sit with him Saturday night and I couldn't. Saturday night someone did sit with him until the next morning. But Monday and Tuesday, nobody sat with him. I worked with him both days on day shift. After the incident happened with (Resident #3), no one sat with him. She was asked when the incident happened with Resident #3. She stated, About a month ago . 9. On 01/13/2021 at 1:46 p.m., CNA #4 was asked about Resident #2's behaviors. She stated, I witnessed him be inappropriate with (Resident #3). As I was coming up the hall he was rubbing in between her legs. She was just sitting there. She was just talking to him about something else because she isn't in her right mind. She was asked what she did when she observed this. She stated, I went down the hall to get her away from him. He got upset and started yelling at me. I moved her back up front to her room. I reported it to the nurse, and I think I charted it in my ADLs (Activities of Daily Living). She was asked how long ago this happened. She stated, Maybe 3 weeks ago, but I am not for sure. She was asked who she reported this to, and she stated, I think it was (LPN #1). She was asked what the nurse did, and she stated, She told the DON, I think. I think me and (CNA #1) came and told (Social Director) because he had been doing it to other women as well. She was asked what the facility did after this to prevent it from happening to anyone else. She stated, After we reported it, they asked us to move (Resident #1) and we moved him to another hall. And then (Social Director) talked to the Ombudsman and they told us we had to move him back because it was against his will. Other than that, nothing I know of. He was still doing it after this incident. She was asked about Resident #6. She stated, He told her every time she was in the way of him trying to get by, he was going to rub on her. She was asked what else the facility had done to prevent recurrences and she stated, After the incident with (Resident #3), a week later they moved her to another hall. Other than that, no. She was asked about Resident #4. She stated, A couple of other aides said they have witnessed him rubbing her breasts and between her legs. 10. On 01/13/2021 at 2:07 p.m., CNA #5 was asked if she had ever observed Resident #2 be sexually inappropriate with any female residents. She stated, Me personally, I have not seen it with my own eyes. She was asked if anyone had reported to her that they had observed it. She stated, Yes. I tell them to write a witness statement and tell the charge nurse and DON and administrator . First, I ask them if they have reported it to the charge nurse. If they tell me no, I tell them to do that also. She was asked if it had been reported to administration and she stated, I know for a fact the DON knew. But I don't know if the Administrator knew. She was asked how she knew the DON was aware and she stated, Because I have gone to her myself. I reported that the aides were telling me he was touching other residents inappropriately. And what do we need to do. We did move him, but he was moved back. She was asked if anything else was done after he was moved back to his room. She stated, (Resident #3) was moved to the front away from him. She was moved I think that same day. She was asked how long ago this was and she stated, Maybe 2 weeks ago. No one has reported to me that anything has happened with him since then. She was asked if anyone had reported anything to her about Resident #4. She stated, No not to me. She was asked if anything had been reported to her about Resident #6. She stated, Yes. An aide came to me and said he had been inappropriate with her. I told them to follow the same procedure - to write a witness statement and report it. She was asked if she reported it to anyone and she stated, I can't recall if I did. I think I just told the aide to tell the charge nurse and DON. 11. On 01/13/2021 at 2:21 p.m., CNA #6 was asked if she had ever seen Resident #2 be sexually inappropriate with female residents. She stated, Yes. I have witnessed him in the smoke hall with (Resident #6). I saw him stick his hand up under her gown (duster) in her private area. She was asked how long ago this happened and she stated, Maybe 3 months ago. She was asked what she did when she observed this. She stated, I told him we didn't need to be inappropriate. She was asked if she reported this to anyone and she stated, No. I said it around the nurse and CNAs at the nurse's station and everybody was like oh yeah we have already reported it. I just try not to go back there. She was asked if she had observed Resident #2 be inappropriate with anyone else and she stated, (Resident #7. He took his hand and put it under her butt in the back. She told him to stop. I told him to keep his hands to himself. She was asked if she had reported this to anyone and she stated, She did. Everybody was like what's going on and I said (Resident #2) touched her. I haven't seen him touch anyone else. She was asked what the facility had done to prevent this from happening to anyone else and she stated, We've been told to make sure 2 people go in to do care. But as far as I know, nothing has been done about him touching other residents. He is currently 1 on 1. 12. On 01/13/2021 at 2:56 p.m., LPN #1 was asked if she had ever observed Resident #2 be sexually inappropriate with any of the female residents. She stated, He is touchy feely. I have heard him talk inappropriate to staff and to residents. I have never seen it with my own eyes. She was asked if it had ever been reported to her that he was sexually inappropriate and she stated, Yes. Somebody has told me before they seen him touching a lady's breast or have her shirt raised up, and they told me they reported it to higher ups, too. She was asked when this happened and she stated, Before Christmas. She was asked which resident and she stated, (Resident #2). The CNA reported he had her shirt pulled up. Before they told me, they told me they had told the DON. Sometimes I am the last to know about my own residents. The CNAs like to pass me and go straight to the front. (Resident #3) daughter actually called checking on her after one incident. The incident was being taken care of by somebody other than myself. I was not asked to do a witness statement or I/A . She asked me what happened, and I told her the male does that when they get ready to go outside and smoke because he sits where no one can see him at the end of that hall. (Resident #3) gets stuck back there in that blind spot and I think he took advantage of that . I have overheard he touches women a lot but that incident with (Resident #3) was probably the first reported to me. I've only been on 600 hall for maybe 4-5 weeks. He was supposed to be moved but he was moved back. 13. On 01/13/2021 at 3:41 p.m., CNA #7 was asked if she had ever seen Resident #2 be sexually inappropriate with any female resident. She stated, I was coming back from smoke break on 600. He was in (Resident #3) room with his hand down in her pants. One of the aides was with me and we reported it to the nurse. She was asked if he had his hand inside or outside the pants and she stated, Not on the outside. Inside. She was asked which nurse this was reported to and she stated, I don't remember that. She was asked when this happened and she stated, Maybe 3 week ago. She was asked what happened after she reported it and she stated, I didn't hear no more about it until (CNA #1) reported it . I got so fed up because nothing was being done . The next I heard they caught him with his hand down (Resident #4) blouse . (Resident #3) was moved. (Resident #2) is 1 on 1 now. He wasn't on Monday. Monday night he was 1 on 1, but only like for 1 shift. I have reported his behavior. And I documented it in the kiosk. She was asked about Resident #6. She stated, They were outside smoking and him and (Resident #6) were over there to the side talking sexual to each other. I told them to stop it and I made (Resident #6) come over to me. He got mad, rolled to the door and went in. When I came back in that's when he called me a black [***] . I have never seen him touch her. She was asked about Resident #4 and she stated, I didn't see him touch her, but I heard (CNA #1) say she saw him touch her . 14. On 01/14/2021 at 9:30 a.m., Ombudsman #1 was asked if she had spoken with the facility concerning Resident #2 and moving him to a different room, but then moving him back to his original room. She stated, I don't remember anything about (Resident #2). I remember a call about a man that was doing some stuff. I don't remember them saying they were moving him to a different room. I thought I remembered they were asking about moving a resident out of the facility . I talked to them about (non-case mix resident), but I don't see any time I talked to them about anything other than that in December (2020) . 15. On 01/14/2021 at 10:03 a.m., the Social Director was asked how many times staff had reported to her about Resident #2's inappropriate behavior. She stated, I would probably say twice, but it was within the same day. More than one person came. She was asked how long ago this was and she stated, Probably a little over a month ago. They spoke with me and the DON. She was asked what was reported to her and she stated, They said he was caught with two female residents in his room. They said they were being sexual with each other. Different people came two different times to tell me about the same situation. She was asked what was done about it and she stated, They wanted to move his room but he . I told them they couldn't move him. He refused. So, we put him 1 on 1. I made sure that was the right thing to do. I told the DON we needed to investigate to find out more information. I believe they did 1 on 1 with him at that time. And then we spoke with his son. I think the DON spoke with the son. We talked to the resident about the situation. We spoke with both of the female residents. She was asked what she found out after speaking to the residents. She stated, (Resident #2) said it wasn't that type of situation. He said they came in there and it wasn't anything sexual. She was asked what the females said, and she stated, One of them has hallucinations and delusions and the other one acted like she didn't know what I was talking about. She was asked who the females were, and she stated, (Resident #3 and #4). At the time we couldn't move him because it was his word against theirs. From there I don't think .they never came back after that and said he was sexual. She was asked if increased monitoring was provided because of the allegations and she stated, I'm not sure after the 1 on 1 . 16. On 01/14/2021 at 12:56 p.m., the DON was asked when she first recalled hearing about Resident #2's behaviors. She stated, The very first time was with (Resident #3). That was December 18th. It was said that (Resident #3) was in his room and that he was touching her in an inappropriate way. She was asked who reported that and she stated, (CNA #1). She was asked what happened after it was reported. She stated, She was removed from his room. I called the daughter and told her. Got permission to move (Resident #3) to 100 hall. She was asked if a reportable incident was done and she stated, No ma'am. She was asked why, and she stated, I don't know. She was asked if anyone else had reported any inappropriate behaviors toward any other female resident to her and she stated, No. Not until someone called the hotline this past weekend. She was asked if any 1 on 1 was done with him prior to the hotline call on 01/09/2020. She stated, Not that I know of. We fail on documenting a lot of things we do. I have never been told anything about (Resident #4, #6 or #7.) 17. On 01/14/2021 at 2:30 p.m., the Administrator was asked when she first became aware of Resident #2's inappropriate behaviors. She stated, I can't recall a specific date and I don't know if it was told directly to me. I just remember that he was speaking inappropriate to staff. I don't remember anything about residents. The first time I remember hearing anything about him and residents is the hotline call. That was on Saturday. She was asked what she did when she received information from that call. She stated, I got dressed and drove straight out here and immediately put him 1 on 1 and started an investigation. I started doing the 7734. The RN supervisor - I had her start the body audits and obtain statements. I notified the DON. I got out here around 9:30 in the morning, I think. The hotline call mentioned (Resident #3 and #4). It didn't mention anyone else as far as the sexual stuff goes. Evidently the staff who called in couldn't remember when this happened. There was an incident in December that the DON and Social was aware of. I remember that somewhat. She was asked why no reportable was done on the December incident and she stated, If they both have a [DIAGNOSES REDACTED].? She was asked what interventions the facility had done since the hotline call. She stated, We reached out to Team Health for a psych eval. The physician was contacted about anymore medication adjustments. She was asked if an abuse in-service had been done since Saturday and she stated, We started one on one Saturday. Interviews were started with staff and residents. 18. The facility removed the immediate jeopardy situation when they placed the resident on continuous 1 on 1 supervision on 01/12/2021 prior to the survey entrance. On 1/9/2021, an investigation was started and inservices concerning implementation of abuse policy and procedures was initiated with staff. 19. The facility's Abuse Prevention Program documented, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property . The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party . Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator . Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the f (TRUNCATED)

Complaint # (AR 044) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure allegations of sexual abuse were thoroughly investigated and failed to prevent further potential abuse after allegations were made for 4 of 4 (Residents #3, #4, #6 and #7) case mix residents who were sexually abused by Resident #2. This failed practice resulted in a past immediate jeopardy which caused or was likely to cause serious harm, injury or death to Residents #3, #4, #6 and #7, and had the potential to affect 33 female residents according to a list provided by the Administrator on 1/15/2021 at 11:29 a.m. The Administrator was informed of the past immediate jeopardy on 01/14/2021 at 3:40 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors and was independent with set up help only for locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem of being sexually inappropriate with staff and other residents, and when staff attempts to redirect me I state, I was married for a long time, so it's ok . Date initiated: 09/08/2020. 12/18/2020-Abuse allegation. b. A Physician order [REDACTED]. Give 1 tablet by mouth three times a day for sexually inappropriate behaviors. c. A Nurse's Note dated 12/15/2020 at 3:25 p.m. documented, Increased sexual inappropriate(ness). (Resident #2) is easily redirected. MD (Medical Doctor) aware. POA (Power of Attorney) made aware. No new orders noted at this time. d. The Point of Care documentation for December 2020 documented, Behavior symptoms . 10 = Sexually Inappropriate. The form documented the resident was sexually inappropriate on the 11 - 7 (11:00 p.m.-7:00 a.m.) shift on 12/07/2020, the 7-3 (7:00 a.m.-3:00 p.m.) shift on 12/08 and 12/09/2020, the 11-7 shift on 12/13/2020 and the 7-3 shift on 12/16/2020. e. A Physician order [REDACTED]. f. On 01/14/2021 at 8:30 a.m., Resident #2 was observed in a wheelchair in his room. A staff member was sitting in the room with him. Resident #2 was asked about the alleged incidents of sexual inappropriateness with female residents. The resident denied there being any sexual inappropriateness with any other resident. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/02/2020 documented the resident scored a 1 (0-7 indicates severely impaired) on the BIMS, had hallucinations, delusions, physical behaviors directed toward others, and was independent with locomotion on and off the unit. The Care Plan documented, I have impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's. I propel my broda chair around facility and enter other resident's rooms (men and women) and staff offices. Often times I seek out a certain male resident and go in his room despite redirection from staff. Date initiated: 1/21/2019. 3. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/18/2020 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS, had a behavior of wandering and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have impaired cognitive function or impaired thought processes r/t cognitive social/emotional deficit following nontraumatic [MEDICAL CONDITION]. I propel my w/c (wheelchair) around facility and will go in other resident's rooms, men and women . Date Initiated: 03/07/2017. b. On 01/14/2021 at 8:40 a.m., Resident #4 was lying in bed with her eyes open. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, I don't remember. 4. Resident #6 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/30/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I have a behavior problem, I will make false accusations . make sexually inappropriate comments to staff and other residents. I can be hypersexual and make comments that in the past I was a prostitute and will solicit sex for money to men in the facility (staff and residents) r/t (related to) dx (diagnosis) of [MEDICAL CONDITIONS] disorder, depression. Date initiated: 11/05/2019. b. On 01/14/2021 at 8:45 a.m., Resident #6 was in a wheelchair in her room. She was asked if any male in the facility had made sexual advances toward her or touched her in an inappropriate way. She stated, That white man down there that goes to smoke with me. He won't let me pass unless I show him my titties. She was asked if the male resident had ever touched her and she stated, Yeah, he does this when I try to get by him (grabbed her own breasts). Resident #6 was asked if she was scare of the male resident. She stated, Yeah, but I think he's 1 on 1 now. I'm glad you're here. 5. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/21/2020 documented the resident scored 12 (8-12 indicates moderately impaired) per a BIMS, had verbal behaviors directed toward others and was independent with locomotion on and off the unit. a. The Care Plan documented in the Focus section, I make unfounded accusations against staff members and people outside the facility of physical and sexual abuse . Date initiated: 03/02/2019. b. On 01/14/2021 at 8:55 a.m., Resident #7 was sitting in a wheelchair toward the end of 600 hall. She was asked if any male in the facility had made any sexual advances toward her or touched her in an inappropriate way. She stated, Yes. That man is always doing it down here at the end of the hall. 6. On 01/12/2021 at 11:48 a.m., Certified Nursing Assistant (CNA) #1 was asked about Resident #2's behaviors. She stated, He is very .you take him into the shower room, and he will say 'Ohhh, I want some of that black chocolate.' If you're not paying attention to him, he will try to touch your breast or bottom. Very perverted. He likes touching women. He has touched numerous women. Residents and employees. She was asked if he had always been that way. She stated, Yeah. When he first came it was with the workers. With the residents - I started seeing that a couple of months after he got here. The first time I saw it I told the nurse so she could document it. And I came and talked to social about it. That's all I could do. She was asked what happened after she reported it. She stated, I don't know. I did my part. I don't know. We asked at one point if he could be moved from back there because the lady was across from him. They moved him but the ombudsman said he had the right to stay in his room, so he was moved back. She was asked who was the first resident he touched. She stated, (Resident #6). She was asked where he touched her. She stated, Her breasts. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #3). He fondled her breasts. Another coworker was like . come here. She was coming out of the room and said (Resident #2) had his hands up under her shirt. When I got to the room his hand was between her legs. She was asked if his hand was on the inside of the resident's pants. She stated, On the outside of the pants. She was asked if she reported this to anyone. She stated, That was the incident I know for sure I came and talked to social about. She was asked if Resident #3 was alert and oriented. She stated, (Resident #3) is not in her right mind. She was asked where this took place. She stated, This took place in the hallway. We separated them of course. Later on that day we tried to get him moved. That's when the ombudsman said he had the right to stay in his room. She was asked if he had touched any other residents inappropriately and she stated, Yes. (Resident #4). He tried to go up under her shirt, but she kept moving his hand away and I stopped that. That was in the hallway. It's always when he goes to smoke. If there's a woman in the hallway he is going to try it. She was asked what the facility had done to prevent these sexually aggressive behaviors toward the female residents. She stated, I honestly don't know. I'm being honest. She was asked if the resident had been 1 on 1. She stated, No. She was asked if the facility had sent someone to stand with him in the hall when they go smoke since that's when he tries it. She stated, No. The only time I knew of them sending someone with him was when he was in isolation. She was asked if Resident #2 was 1 on 1 yesterday. She stated, He wasn't mine yesterday but there wasn't anybody with him. She was asked when was the most recent incident of sexually inappropriate behavior by Resident #2 and she stated, The most recent . I can recall it was (Resident #4). I don't remember exactly when that was. I haven't seen him do anything since her. She was asked how many times she had reported this. She stated, With (Resident #4) .I reported it to the nurse. She was asked who the nurse was and she stated, It could have been (Licensed Practical Nurse (LPN) #1). But I'm not sure. With (Resident #3), it made me so upset that they didn't do anything . 7. On 01/13/2021 at 12:25 p.m., CNA #2 was asked about Resident #2's behaviors. She stated, He can get sexually aggressive and feely. She was asked if he was that way with residents and she stated, With three that I know of. (Resident #4, Resident #3 and Resident #6). She was asked if she had actually observed him being sexually inappropriate. She stated, Yes. It was close to time for them to smoke and they were lined up in the hall and (Resident #2) loves to be the first one in line. (Resident #6) was in the hall and he was trying to get around her. She can be flirty and has been flirty with him more than once. She also has offered herself to him and other male residents. And this particular day he was trying to get past her, and she was rubbing on his arm. She wears a thin shirt and has offered to let him play with her breasts. I was going around the corner and I saw him put his hand under her shirt, but then she acted like she got upset about it. I think it was because she saw me come around the corner. She will also go into their rooms. Or be outside the door and make flirty comments. When I saw that I separated them. I went and told the nurse and the DON (Director of Nursing). She was asked when this happened. She stated, This was maybe 2 months ago. She was asked who the nurse was that she reported to and she stated, I don't remember. We have had so many. She was asked what was done to prevent it from happening again. She stated, They asked me to do witness statement, I think. That's the last I remember. She was asked if Resident #2 had been placed 1 on 1. She stated, No. She was asked if he had been moved to a different room. She stated, No. She was asked if the facility had sent someone to the hall at smoke time to monitor the activity there since that is when the residents are close together. She stated, No. She was asked if she had participated in any abuse in-services lately. She stated, We did have an in-service. She was asked if it was specific to Resident #2 and the behaviors. She stated, No. Just an overall in-service. She was asked about Resident #4. She stated, It was the same type of situation, but in the evening. He was in the hallway. (Resident #4) always rolls through the building and she loves to be by the smoke door. They were just sitting there talking. Me and a nurse was walking down the hall and we seen his hands under her shirt. She was asked what she did. She stated, We ran down, and I got him, and the nurse got her. I took him to his room. She was asked if this was reported to anyone and she stated, It was reported to the nurse . and it was reported to the DON. She was asked if the facility had done anything to prevent this from happening again. She stated, All I can recall is that they were separated. I do remember (Resident #2) was moved to 300 hall. They called his son I believe. But that same day something happened, and they said he had the right to stay in his same room, so he was moved back. She was asked if any extra monitoring was done to watch him more closely. She stated, Not that I know of. She was asked if she ever took the residents out to smoke. She stated, I'm on day shift. I take the residents out to smoke like at 9:30 a.m. and sometimes at 2. She was asked if the facility had asked her to increase the monitoring of him or to go to the smoke area hall a little early to monitor for any behaviors. She stated, No . She was asked if Resident #2 lined up in the hallway to go smoke yesterday. She stated, He did. She was asked if anyone was with him while in the hallway. She stated, No ma'am. 8. On 01/13/2021 at 1:04 p.m., CNA #3 was asked about Resident #2's behaviors. She stated, He has been very sexually inappropriate. I have had him ask me on several occasions do I love burger king because of them whoppers, because of how big my breasts are. His shower days are Monday, Wednesday, and Friday. I can be washing his private area and he does this moaning. He would try to look inside my shirt when I wore a V neck . I have witnessed on several occasions him touching female residents down by the smoke area. She was asked who he touched. She stated, (Resident #4, Resident #6 and Resident #3). Those are the only ones I can think of. She was asked if she personally had seen Resident #2 touch these female residents inappropriately. She stated, I have personally seen him touch them. I have seen him try to put his hands in their vagina area. (Resident #4) was asleep down at the end of the hall in her wheelchair and as I was coming down the hall, he had his hand in her private area. She was asked what she did when she saw that. She stated, I asked him to please move his hand away from her and removed (Resident #4) to her room, and I reported it to the charge nurse. And I documented in PCC (Point Click Care) that he was sexually inappropriate. She was asked who the charge nurse was that she reported to. She stated, I don't remember who the charge nurse was. She was asked when this happened and she stated, Maybe a month ago. She was asked what the charge nurse did about the allegation. She stated, She stated to me she was going to chart it. And I charted it . She was asked if she reported it to anyone else. She stated, No. The reason why I didn't is I have gone to administration and the DON plenty of times. We can go report it and they don't do nothing right then, so I report it to my charge nurse and let them take care of it. She was asked what happened with Resident #6. She stated, They were down at the smoke area lined up. I heard (Resident #6) say move away from me and I came out and asked her what was going on and she said he kept touching her. When they were coming back in, she was rolling down the hall. I witnessed him reaching over with his hand toward her private area. I stopped him and said what are you doing. He said nothing. She said he was trying to touch my pussy. I took her to her room and told the nurse. I also talked to one of my coworkers and she said well that's the second time today because she had already reported that he did it before the smoke break. She was asked about Resident #3. She stated, She wheels up and down the hall all day. Every time she passes by him in the hall she'll be really talking. He pulled her shirt up and had her breast out. I took her to her room and then came back and told him he couldn't be doing that and that I was going to have to report it. He said what did I do? He tried to act like he didn't know what he was doing to her. I'm pretty sure he is aware of what he is doing. But the DON (Director of Nursing) says it's his dementia and there's not much we can do. He was supposed to be 1 on 1 but wasn't put 1 on 1 until weeks later. They finally moved her to another hall . She was asked what the facility has done to protect the female residents from this happening again. She stated, Nothing. (Resident #3 and #6) are still back there. (Resident #3) roams the halls all day long. She was asked if the resident was 1 on 1 yesterday on day shift. She stated, I worked 7/3 the entire day and he was my resident. Nobody sat with him. I'm not sure why they had someone with him when ya'll got here. They called me Saturday and asked could I sit with him Saturday night and I couldn't. Saturday night someone did sit with him until the next morning. But Monday and Tuesday, nobody sat with him. I worked with him both days on day shift. After the incident happened with (Resident #3), no one sat with him. She was asked when the incident happened with Resident #3. She stated, About a month ago . 9. On 01/13/2021 at 1:46 p.m., CNA #4 was asked about Resident #2's behaviors. She stated, I witnessed him be inappropriate with (Resident #3). As I was coming up the hall he was rubbing in between her legs. She was just sitting there. She was just talking to him about something else because she isn't in her right mind. She was asked what she did when she observed this. She stated, I went down the hall to get her away from him. He got upset and started yelling at me. I moved her back up front to her room. I reported it to the nurse, and I think I charted it in my ADLs (Activities of Daily Living). She was asked how long ago this happened. She stated, Maybe 3 weeks ago, but I am not for sure. She was asked who she reported this to, and she stated, I think it was (LPN #1). She was asked what the nurse did, and she stated, She told the DON, I think. I think me and (CNA #1) came and told (Social Director) because he had been doing it to other women as well. She was asked what the facility did after this to prevent it from happening to anyone else. She stated, After we reported it, they asked us to move (Resident #1) and we moved him to another hall. And then (Social Director) talked to the Ombudsman and they told us we had to move him back because it was against his will. Other than that, nothing I know of. He was still doing it after this incident. She was asked about Resident #6. She stated, He told her every time she was in the way of him trying to get by, he was going to rub on her. She was asked what else the facility had done to prevent recurrences and she stated, After the incident with (Resident #3), a week later they moved her to another hall. Other than that, no. She was asked about Resident #4. She stated, A couple of other aides said they have witnessed him rubbing her breasts and between her legs. 10. On 01/13/2021 at 2:07 p.m., CNA #5 was asked if she had ever observed Resident #2 be sexually inappropriate with any female residents. She stated, Me personally, I have not seen it with my own eyes. She was asked if anyone had reported to her that they had observed it. She stated, Yes. I tell them to write a witness statement and tell the charge nurse and DON and administrator . First, I ask them if they have reported it to the charge nurse. If they tell me no, I tell them to do that also. She was asked if it had been reported to administration and she stated, I know for a fact the DON knew. But I don't know if the Administrator knew. She was asked how she knew the DON was aware and she stated, Because I have gone to her myself. I reported that the aides were telling me he was touching other residents inappropriately. And what do we need to do. We did move him, but he was moved back. She was asked if anything else was done after he was moved back to his room. She stated, (Resident #3) was moved to the front away from him. She was moved I think that same day. She was asked how long ago this was and she stated, Maybe 2 weeks ago. No one has reported to me that anything has happened with him since then. She was asked if anyone had reported anything to her about Resident #4. She stated, No not to me. She was asked if anything had been reported to her about Resident #6. She stated, Yes. An aide came to me and said he had been inappropriate with her. I told them to follow the same procedure - to write a witness statement and report it. She was asked if she reported it to anyone and she stated, I can't recall if I did. I think I just told the aide to tell the charge nurse and DON. 11. On 01/13/2021 at 2:21 p.m., CNA #6 was asked if she had ever seen Resident #2 be sexually inappropriate with female residents. She stated, Yes. I have witnessed him in the smoke hall with (Resident #6). I saw him stick his hand up under her gown (duster) in her private area. She was asked how long ago this happened and she stated, Maybe 3 months ago. She was asked what she did when she observed this. She stated, I told him we didn't need to be inappropriate. She was asked if she reported this to anyone and she stated, No. I said it around the nurse and CNAs at the nurse's station and everybody was like oh yeah we have already reported it. I just try not to go back there. She was asked if she had observed Resident #2 be inappropriate with anyone else and she stated, (Resident #7. He took his hand and put it under her butt in the back. She told him to stop. I told him to keep his hands to himself. She was asked if she had reported this to anyone and she stated, She did. Everybody was like what's going on and I said (Resident #2) touched her. I haven't seen him touch anyone else. She was asked what the facility had done to prevent this from happening to anyone else and she stated, We've been told to make sure 2 people go in to do care. But as far as I know, nothing has been done about him touching other residents. He is currently 1 on 1. 12. On 01/13/2021 at 2:56 p.m., LPN #1 was asked if she had ever observed Resident #2 be sexually inappropriate with any of the female residents. She stated, He is touchy feely. I have heard him talk inappropriate to staff and to residents. I have never seen it with my own eyes. She was asked if it had ever been reported to her that he was sexually inappropriate and she stated, Yes. Somebody has told me before they seen him touching a lady's breast or have her shirt raised up, and they told me they reported it to higher ups, too. She was asked when this happened and she stated, Before Christmas. She was asked which resident and she stated, (Resident #2). The CNA reported he had her shirt pulled up. Before they told me, they told me they had told the DON. Sometimes I am the last to know about my own residents. The CNAs like to pass me and go straight to the front. (Resident #3) daughter actually called checking on her after one incident. The incident was being taken care of by somebody other than myself. I was not asked to do a witness statement or I/A . She asked me what happened, and I told her the male does that when they get ready to go outside and smoke because he sits where no one can see him at the end of that hall. (Resident #3) gets stuck back there in that blind spot and I think he took advantage of that . I have overheard he touches women a lot but that incident with (Resident #3) was probably the first reported to me. I've only been on 600 hall for maybe 4-5 weeks. He was supposed to be moved but he was moved back. 13. On 01/13/2021 at 3:41 p.m., CNA #7 was asked if she had ever seen Resident #2 be sexually inappropriate with any female resident. She stated, I was coming back from smoke break on 600. He was in (Resident #3) room with his hand down in her pants. One of the aides was with me and we reported it to the nurse. She was asked if he had his hand inside or outside the pants and she stated, Not on the outside. Inside. She was asked which nurse this was reported to and she stated, I don't remember that. She was asked when this happened and she stated, Maybe 3 week ago. She was asked what happened after she reported it and she stated, I didn't hear no more about it until (CNA #1) reported it . I got so fed up because nothing was being done . The next I heard they caught him with his hand down (Resident #4) blouse . (Resident #3) was moved. (Resident #2) is 1 on 1 now. He wasn't on Monday. Monday night he was 1 on 1, but only like for 1 shift. I have reported his behavior. And I documented it in the kiosk. She was asked about Resident #6. She stated, They were outside smoking and him and (Resident #6) were over there to the side talking sexual to each other. I told them to stop it and I made (Resident #6) come over to me. He got mad, rolled to the door and went in. When I came back in that's when he called me a black [***] . I have never seen him touch her. She was asked about Resident #4 and she stated, I didn't see him touch her, but I heard (CNA #1) say she saw him touch her . 14. On 01/14/2021 at 9:30 a.m., Ombudsman #1 was asked if she had spoken with the facility concerning Resident #2 and moving him to a different room, but then moving him back to his original room. She stated, I don't remember anything about (Resident #2). I remember a call about a man that was doing some stuff. I don't remember them saying they were moving him to a different room. I thought I remembered they were asking about moving a resident out of the facility . I talked to them about (non-case mix resident), but I don't see any time I talked to them about anything other than that in December (2020) . 15. On 01/14/2021 at 10:03 a.m., the Social Director was asked how many times staff had reported to her about Resident #2's inappropriate behavior. She stated, I would probably say twice, but it was within the same day. More than one person came. She was asked how long ago this was and she stated, Probably a little over a month ago. They spoke with me and the DON. She was asked what was reported to her and she stated, They said he was caught with two female residents in his room. They said they were being sexual with each other. Different people came two different times to tell me about the same situation. She was asked what was done about it and she stated, They wanted to move his room but he . I told them they couldn't move him. He refused. So, we put him 1 on 1. I made sure that was the right thing to do. I told the DON we needed to investigate to find out more information. I believe they did 1 on 1 with him at that time. And then we spoke with his son. I think the DON spoke with the son. We talked to the resident about the situation. We spoke with both of the female residents. She was asked what she found out after speaking to the residents. She stated, (Resident #2) said it wasn't that type of situation. He said they came in there and it wasn't anything sexual. She was asked what the females said, and she stated, One of them has hallucinations and delusions and the other one acted like she didn't know what I was talking about. She was asked who the females were, and she stated, (Resident #3 and #4). At the time we couldn't move him because it was his word against theirs. From there I don't think .they never came back after that and said he was sexual. She was asked if increased monitoring was provided because of the allegations and she stated, I'm not sure after the 1 on 1 . 16. On 01/14/2021 at 12:56 p.m., the DON was asked when she first recalled hearing about Resident #2's behaviors. She stated, The very first time was with (Resident #3). That was December 18th. It was said that (Resident #3) was in his room and that he was touching her in an inappropriate way. She was asked who reported that and she stated, (CNA #1). She was asked what happened after it was reported. She stated, She was removed from his room. I called the daughter and told her. Got permission to move (Resident #3) to 100 hall. She was asked if a reportable incident was done and she stated, No ma'am. She was asked why, and she stated, I don't know. She was asked if anyone else had reported any inappropriate behaviors toward any other female resident to her and she stated, No. Not until someone called the hotline this past weekend. She was asked if any 1 on 1 was done with him prior to the hotline call on 01/09/2020. She stated, Not that I know of. We fail on documenting a lot of things we do. I have never been told anything about (Resident #4, #6 or #7.) 17. On 01/14/2021 at 2:30 p.m., the Administrator was asked when she first became aware of Resident #2's inappropriate behaviors. She stated, I can't recall a specific date and I don't know if it was told directly to me. I just remember that he was speaking inappropriate to staff. I don't remember anything about residents. The first time I remember hearing anything about him and residents is the hotline call. That was on Saturday. She was asked what she did when she received information from that call. She stated, I got dressed and drove straight out here and immediately put him 1 on 1 and started an investigation. I started doing the 7734. The RN supervisor - I had her start the body audits and obtain statements. I notified the DON. I got out here around 9:30 in the morning, I think. The hotline call mentioned (Resident #3 and #4). It didn't mention anyone else as far as the sexual stuff goes. Evidently the staff who called in couldn't remember when this happened. There was an incident in December that the DON and Social was aware of. I remember that somewhat. She was asked why no reportable was done on the December incident and she stated, If they both have a [DIAGNOSES REDACTED].? She was asked what interventions the facility had done since the hotline call. She stated, We reached out to Team Health for a psych eval. The physician was contacted about anymore medication adjustments. She was asked if an abuse in-service had been done since Saturday and she stated, We started one on one Saturday. Interviews were started with staff and residents. 18. The facility removed the immediate jeopardy situation when they placed the resident on continuous 1 on 1 supervision on 01/12/2021 prior to the survey entrance. On 1/9/2021, an investigation was started and inservices concerning implementation of abuse policy and procedures was initiated with staff. 19. The facility's Abuse Prevention Program documented, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property . The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party . Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator . Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potenti (TRUNCATED)

Complaint # (AR 032) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure a resident was free from staff neglect, as evidenced by failure of the facility van driver to apply a seat belt to secure a resident in a wheelchair during a van transport to prevent injury for 1 (Resident #1) of 1 case mix resident who was transported via the facility van. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who slid out of the wheelchair during transportation, resulting in a closed maxillary sinus fracture and [MEDICAL CONDITION] wall, and had the potential to cause more than minimal harm to 16 residents who were transported in a wheelchair via the facility van according to the provided by the Administrator on 2/16/18. The Administrator was informed of the past Immediate Jeopardy condition on 2/5/18 at 4:00 p.m. The findings are: 1. The Facility Policy and Procedure for Abuse Prohibition, provided by the Administrator on 2/6/18 at 11:00 a.m. documented, Neglect means failure to provide goods and services necessary to avoid physical, mental anguish or mental illness . Upon hire, each new employee shall be informed of the obligation to report alleged violations. Training shall include appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, definition of alleged violations and caregiver stress. Training shall also include examples of reportable incidents to assist staff in detection of such incidents. Each employee shall receive training no less frequently than annually on the requirements of the facility's policy and procedures regarding alleged violations and the requirements of state & federal law . 2. Resident #1 had a [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 1/22/18 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, required extensive assistance with transfers and locomotion on and off the unit, had functional limitation in range of motion in both lower extremities and one upper extremity, used a wheelchair for mobility, and received [MEDICAL TREATMENT]. a. An OLTC (Office of Long Term Care) Witness Statement dated 1/31/18 and completed by Van Driver #1 documented, I was driving when I looked in the rear view mirror and saw (Resident #1) leaning out of her chair. I asked her if she was okay as I was pulling over to get her situated in her chair. Before I could pull all the way over she had fell out of her chair. I went to the back of the van and started asking her questions and she insisted she was doing fine. The only problem is that her bottom is hurting. I sat with her until help arrived. Another OLTC Witness Statement dated 1/31/18, not timed, documented interview questions for the van driver that documented, .Did you use the seat belt? 'No but I did chain the w/c (wheelchair) to the van & (and) lock the wheels . b. An OLTC Witness Statement dated 1/31/18 at 7:10 p.m. and completed by the Maintenance Supervisor documented, On 1/31/18, I was called back to the facility to check the straps and locking devices on the van. I found no problems with the straps or the locking devices. I found no problems with the retractable devices. Also checked operation of lift, no problems. An OLTC Witness Statement dated 2/1/18 and completed by the Maintenance Supervisor documented, On or about 12/22/17, I in-serviced the van driver (Van Driver #1) on how to secure a wheelchair to the van. Show how to secure front and rear restraints. Explained how to use the Lap and Shoulder belt. Explained that there should not be any loose items unsecured in the van. I gave her a copy of Sure-Locks guide that I had. I didn't receive the check off sheet at the end of the pamphlet. c. An OLTC Witness Statement dated 1/31/18 at 6:45 p.m. and completed by the Director of Nursing (DON) documented, Received report that (Resident #1) had fallen out of w/c (wheelchair) in the van while driving back from [MEDICAL TREATMENT]. Immediately, this nurse, called the van driver to determine the location of van. I immediately left the facility . (at) 1717 (5:17 p.m.) told (van driver) to call 911 . Resident then transported to (hospital) ER (emergency room ) . d. The hospital emergency room Report dated 1/31/18 documented the [DIAGNOSES REDACTED]. Closed fracture of orbital wall . Facial pain . Fall from wheelchair . Closed head injury. Contusion lower back . The nursing home Progress Notes documented the resident returned to the facility on [DATE] at 8:30 p.m. e. On 2/5/18 at 3:15 p.m., the Administrator stated, When the CNA (van driver) stated that the seat belt would not work, I got the Maintenance Supervisor and the Physical Therapist, and we put someone larger in the wheelchair and the seat belt worked fine. 3. The facility removed the Immediate Jeopardy and corrected the failed practices on 2/1/18, prior to the survey, as evidenced by the following: a. On 2/5/18 at 3:15 p.m., the Administrator stated she stated that she terminated Van Driver #1 immediately after the incident and, I immediately in-serviced all potential van drivers. She was asked What have you done to prevent it from happening again? She stated We have a two-person check to ensure the resident is strapped in correctly . No one is to transport a resident without being checked off. b. An in-service sheet dated 1/31/18 documented, Always use the seat belt. This was signed by the two van drivers. c. An in-service sheet dated 2/1/18 documented transportation staff were trained on correct procedures for loading / unloading a resident on the lift and correctly securing a resident with proper tie down procedures. The 9 van drivers completed a return demonstration and were checked off by the instructor. d. The QAPI (Quality Assurance and Performance Improvement) meeting dated 2/1/18 documented the Medical Director was advised of the incident and what the facility was doing to prevent the reoccurrence and she stated, Nothing additional continue as placed below (in the corrective action plan). e. The corrective action plan 2/1/18 documented, Van drivers will complete safety training including securing residents prior to starting van. Van drivers will show competency by return demonstration. Maintenance Director will perform an audit 3 x (times a) week for 2 weeks then weekly for 4 weeks to assure compliance.

Complaint # (AR 032) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure a facility van driver applied the van safety restraints to secure a resident in a wheelchair during transport and prevent injury for 1 (Resident #1) of 1 case mix resident who was transported via the facility van. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who slid out of the wheelchair during transportation, resulting in a closed maxillary sinus fracture and [MEDICAL CONDITION] wall, and had the potential to cause more than minimal harm to 16 residents who were transported in a wheelchair via the facility van according to the provided by the Administrator on 2/16/18. The Administrator was informed of the past Immediate Jeopardy condition on 2/5/18 at 4:00 p.m. The findings are: 1. Resident #1 had a [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 1/22/18 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, required extensive assistance with transfers and locomotion on and off the unit, had functional limitation in range of motion in both lower extremities and one upper extremity, used a wheelchair for mobility, and received [MEDICAL TREATMENT]. a. An OLTC (Office of Long Term Care) Witness Statement dated 1/31/18 and completed by Van Driver #1 documented, I was driving when I looked in the rear view mirror and saw (Resident #1) leaning out of her chair. I asked her if she was okay as I was pulling over to get her situated in her chair. Before I could pull all the way over she had fell out of her chair. I went to the back of the van and started asking her questions and she insisted she was doing fine. The only problem is that her bottom is hurting. I sat with her until help arrived. Another OLTC Witness Statement dated 1/31/18, not timed, documented the van driver was asked, .Did you use the seat belt? 'No but I did chain the w/c (wheelchair) to the van & (and) lock the wheels . b. An OLTC Witness Statement dated 1/31/18 at 7:10 p.m. and completed by the Maintenance Supervisor documented, On 1/31/18, I was called back to the facility to check the straps and locking devices on the van. I found no problems with the straps or the locking devices. I found no problems with the retractable devices. Also checked operation of lift, no problems. An OLTC Witness Statement dated 2/1/18 and completed by the Maintenance Supervisor documented, On or about 12/22/17, I in-serviced the van driver (Van Driver #1) on how to secure a wheelchair to the van. Show how to secure front and rear restraints. Explained how to use the Lap and Shoulder belt. Explained that there should not be any loose items unsecured in the van. I gave her a copy of Sure-Locks guide that I had. I didn't receive the check off sheet at the end of the pamphlet. c. An OLTC Witness Statement dated 1/31/18 at 6:45 p.m. and completed by the Director of Nursing (DON) documented, Received report that (Resident #1) had fallen out of w/c (wheelchair) in the van while driving back from [MEDICAL TREATMENT]. Immediately, this nurse, called the van driver to determine the location of van. I immediately left the facility . (at) 1717 (5:17 p.m.) told (van driver) to call 911 . Resident then transported to (hospital) ER (emergency room ) . d. The hospital emergency room Report dated 1/31/18 documented the [DIAGNOSES REDACTED]. Closed fracture of orbital wall . Facial pain . Fall from wheelchair . Closed head injury. Contusion lower back . The nursing home Progress Notes documented the resident returned to the facility on [DATE] at 8:30 p.m. e. On 2/5/18 at 3:15 p.m., the Administrator stated, When the CNA (van driver) stated that the seat belt would not work, I got the Maintenance Supervisor and the Physical Therapist, and we put someone larger in the wheelchair and the seat belt worked fine. 2. The facility removed the Immediate Jeopardy and corrected the failed practices on 2/1/18, prior to the survey, as evidenced by the following: a. On 2/5/18 at 3:15 p.m., the Administrator stated she stated that she terminated Van Driver #1 immediately after the incident and, I immediately in-serviced all potential van drivers. She was asked What have you done to prevent it from happening again? She stated We have a two-person check to ensure the resident is strapped in correctly . No one is to transport a resident without being checked off. b. An in-service sheet dated 1/31/18 documented, Always use the seat belt. This was signed by the two van drivers. c. An in-service sheet dated 2/1/18 documented transportation staff were trained on correct procedures for loading / unloading a resident on the lift and correctly securing a resident with proper tie down procedures. The 9 van drivers completed a return demonstration and were checked off by the instructor. d. The QAPI (Quality Assurance and Performance Improvement) meeting dated 2/1/18 documented the Medical Director was advised of the incident and what the facility was doing to prevent the reoccurrence and she stated, Nothing additional continue as placed below (in the corrective action plan). e. The corrective action plan 2/1/18 documented, Van drivers will complete safety training including securing residents prior to starting van. Van drivers will show competency by return demonstration. Maintenance Director will perform an audit 3 x (times a) week for 2 weeks then weekly for 4 weeks to assure compliance.

Based on observation, record review and interview, the facility failed to ensure planned nutritional interventions were implemented in accordance with physician orders [REDACTED].#8) of 2 (Residents #5 and #8) case mix residents who had experienced significant weight loss in the last 30 days. This failed practice resulted in a pattern of actual harm to Resident #8, who experienced a severe weight loss, and had the potential to cause more than minimal harm to 4 residents who experienced significant weight losses in the last 30 days, as documented on a list provided by the Administrator on 11/17/16. The findings are: Resident #8 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 4/12/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, was independent in eating after set-up and independent with bed mobility, personal hygiene and dressing, weighed 216 pounds and had not experienced a weight gain or weight loss in the past 180 days (or that the weight loss / gain status was unknown) . a. The Resident Plan of Care dated as last revised on 4/20/16 did not address nutritional concerns or risk of weight loss. An undated Interdisciplinary Care Plan form provided by the Director of Nursing (DON) on 11/16/16 documented, .Approaches: Monitor weight . Regular diet, fortify and add extra item of protein to all meals. Resident request snack TID (three times a day). The Date, Problem and Goal columns of this form were left blank. b. The MDS with an assessment reference date of 5/31/16 documented the resident's weight was 210 pounds and that the resident had not experienced a weight loss or weight gain in the past 180 days (or that the weight loss / gain status was unknown). c. The facility's Monthly Weight Report, provided by the Administrator on 11/14/16, documented the following weights for this resident: April 2016: no weight documented (per MDS - 216 pounds). May 2016: no weight documented (per MDS - 210 pounds. June 2016: 209.5 pounds. July 2016: 213 pounds. August 2016: no weight documented (per MDS - 213 pounds). September 2016: 217 pounds (post-hospitalization ). October 2016: 225 pounds. November 2016: 202 pounds. d. The October 2016 Meal Consumption Record documented a total of 25 occasions when the resident consumed 25% or less of her meal. e. An Interdisciplinary Weight Variance form dated 11/11/16 documented, .Comments: (weight decreased) 10% in 30 days - Fortify all meals (and) extra protein to all trays . These recommendations were documented by the facility's Dietary Manager. There was no documentation of consultation with the Registered Dietician. The Registered Dietician (RD) Report dated 11/8/16 through 11/11/16 did not address this resident's 10% weight loss and there was no documentation in the clinical record to indicate the RD was notified of the weight loss. f. A physician's orders [REDACTED]. g. A Dietary Communication card dated 11/11/16 documented, Fortify all meals (and) add extra protein to all meals . h. The lunch menu for 11/15/16 documented the residents were to receive rotisserie style turkey, cornbread dressing, greens, wheat dinner roll or bread, margarine, ambrosia, milk and beverage of choice. On 11/15/16 at 12:20, during the lunch meal preparation, no butter or margarine was added to any resident's meal tray (including Resident #8's) and none was provided during table service to the residents. Resident #8's meal tray consisted of 1 slice of turkey (the same size portion served to all residents in the front dining room), cornbread dressing, greens, 1 dinner roll, ambrosia salad, milk, red punch, and 1 can of tomato juice. No fortified food or extra protein item was provided to the resident. The resident consumed approximately 25% of her meal. i. The dinner menu for 11/15/16 documented residents were to receive beef vegetable stew, tossed salad with dressing, wheat dinner roll or bread, margarine, chocolate éclair bar, milk and beverage of choice. On 11/15/16 at 5:40 p.m., during the dinner meal preparation, no butter or margarine was added to any resident's meal tray (including Resident #8's) and none was provided during table service to the residents. Resident #8's tray consisted of 1 small bowl of beef vegetable stew (the bowl was filled to approximately 1 inch from the top; this was the same sized bowl and portion size that was provided to all other residents in the front dining room), tossed salad with dressing, 1 corn bread muffin, 1 bowl of chocolate and vanilla pudding dessert, 1 carton of milk, 1 can tomato juice, one 8 ounce glass of red punch. No fortified food or extra protein item was provided to the resident. The resident consumed approximately 25% of her meal. j. On 11/15/16 at approximately 6:00 p.m., the Dietary Manager (DM) was asked what fortified foods and extra protein items were served to this resident for the lunch and dinner meals that day. The DM stated the fortified foods for lunch was a roll with butter and for dinner, cornbread with butter. At 6:46 p.m., the Administrator provided a list of foods, signed by the Dietary Manager, that were supposed to be served to residents with orders for fortified foods and / or extra protein for lunch and dinner on 11/15/16. For lunch, the list documented, Extra Protein: Lunch - 2 slices of Turkey . Dinner - 9 ounces of Beef Stew . Fortified: Lunch - Dinner roll with butter, Dinner - Cornbread, puree dinner - pudding. This list was signed by the Dietary Manager. k. The tray card for Resident #8, copied 11/16/16, documented, Diet: Regular (with) extra protein . The tray card did not document fortified foods were to be served to this resident. l. As of 11/16/16 at 12:40 p.m., the November 2016 Meal Consumption Record documented a total of 9 occasions when the resident consumed 25% or less of her meal, and there were multiple dates / meals when the consumption information was left blank. m. On 11/16/16 at 3:10 p.m., the Director of Nursing (DON) was asked, How do you determine what interventions are needed for weight loss? The DON stated, We have weekly meetings on Wednesdays or Thursdays to discuss residents with significant weight loss. The DON was asked, How do you communicate the new interventions to Dietary? The DON stated, The Dietary Manager attends the meeting. We fill out a Dietary Communication form with new interventions, and she takes them with her; if she is not there, we take the form to the kitchen and give it to the cook, or put it in her box on the door. The DON was asked, Who attends the weight loss meetings? The DON stated, The DON, Dietary Manager, Social Director, Quality Assurance Nurse, Administrator and the CNA (Certified Nurse Assistant) Coordinator. The DON was asked, What date was the resident weighed in November? The DON stated, It was either on the 4th or on the 7th. The DON was asked, What happens when there is a discrepancy in the weights from month to month? The DON stated, The CNA usually lets me know when she is turning in the weight list to look at any weight concerns she may have . n. On 11/16/16 at 4:30 p.m., the Dietary Manager (DM) was asked, Do you attend the weight meetings, and if so, what is discussed? The DM stated, Yes, we discuss previous interventions to see if they are working and to determine if new interventions need to be put in place. The DM was asked, What do you do with the Dietary Communication forms? The DM stated, I key them into the system. The DM was shown a copy of the Dietary Communication form that documented fortified foods and extra protein with all meals, then was asked, Is this your initial on the form? The DM stated, Yes. The DM was shown a copy of the resident's tray card copied on 11/16/16 at 12:30 p.m., and then was asked, How would the cook know to serve fortified foods? The DM stated. It's usually printed on the bottom of the tray card. The DM was asked, Does this card indicate fortified foods? The DM stated, No. The DM was asked why the tray card did not indicate fortified foods and stated, It was a keying error. The DM was asked if the facility had determined why the resident was losing weight and stated, No. The DM was asked if she had spoken with the resident to try to determine why she was not eating well and stated, No. The DM was asked, Have you reviewed the resident's meal consumption records? The DM stated, No, I haven't. The DM was asked, How do you communicate significant weight losses to the RD? The DM stated, She gets a copy of the facility's weight list. The DM did not state how often the weight list was provided to the RD. o. On 11/16/16 at 4:35 p.m., CNA #2 weighed the resident and obtained a reading of 197.7 pounds. Based on the DON's statement that the most recent weight of 202 pounds was obtained on 11/4/16 or 11/7/16, the resident had lost an additional 4.5 pounds in 9 to 12 days, for a total of 19.3 pounds (8.89%) lost in the 2-month period from September 2016 to November 2016.

Based on observation, record review, and interview, the facility failed to ensure the alarm sounded when an exit door was opened and there was a system in place to consistently check the door alarms sounding on 6 of 6 exit doors to prevent the potential for elopement for 1 of 1 (Resident #5) case mix resident who was at risk for elopement. This failed practice had the potential to affect 5 residents who were at risk for elopement, as documented on a list provided by the Director of Nursing (DON) on 6/16/16. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The 14 Day Medicare Minimum Data Set with an Assessment Reference Date of 5/6/16 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and had behaviors of wandering. a. As of 6/16/16 there was no documentation in the Resident Plan of Care that indicated the resident had been at risk for wandering or elopement. b. An Incident and Accident (I & A) Report dated 5/1/16 at 10:45 a.m., written by Licensed Practical Nurse (LPN) #4 documented, .Exact location of incident/accident . Other Specify Out of 100 Hall Exit door . Describe exactly what happened; why it happened; what the causes were . Pt. (patient) went out of 100 hall Fire exit door, fell on to ground into mud out of w/c (wheelchair). Pt outside approx 2 min (minutes) total. (no) apparent injury.Additional comments and/or steps taken to prevent recurrence: (no) apparent injury. Door alarm checked (and) in proper working order (at) present . The form was signed by Licensed Practical Nurse (LPN) #4 and there was no signature on the lines for the DON, Administrator, and Medical Director that indicated they had reviewed the incident report. c. An OLTC (Office of Long Term Care) witness statement form dated 5/1/16 at 10:45 a.m., written by LPN #4 documented, .Notified by RCF (Residential Care Facility) staff member that pt on ground (at) end of 100 hall door. Noted pt. on ground in mud outside facility. Exit door alarm was silent. Chair alarm was beeping. Pt (without) apparent injury. Pt assisted back to w/c (by) 4 staff members . 5/1/16 200 Hall Exit door alarm checked on 4/30/16 (and) working properly. Alarm reactivated per facility policy. d. A form titled Door Alarm Activation/De-activation February 25, 2016 received from the Assistant Director of Nursing (ADON) on 6/16/16 at 9:30 a.m. documented, The front entrance door operates with the wander bracelet system. East door on 300 Hall and 400 Hall have two types of door alarm systems. 300 and 400 east doors have the key pad system installed as well as the regular alarm system that is utilized on all additional exit doors throughout the facility . Nursing Documentation Each shift the unit nurse will check all exit doors within their unit and surrounding areas. If door alarms are operating properly that nurse will initial the respective form that is found on the front page of the nurses Medication Administration Record (MAR). If the alarm is not operational that nurse will notify the Administrator (and) Maintenance Supervisor of their findings. Until the defective system is repaired or replaced an employee will be stationed within eyesight of the door alarm in question. See attached form . An Inservice Attendance Record titled door alarms was attached that was dated 2/25/16, 3/2/16, and 3/15/16 with licensed nursing and direct care staff member signatures. The form attached documented each hall number, dining room, and dietary doors and listed each shift with 31 days for the months. e. The Door Alarm check in the MAR book, reviewed at 9:25 a.m. on 6/16/16, documented the door alarm was checked on the 100 Hall on the 1st shift on 6/4, 6/5, 6/11, 6/12, and 6/16/16, on the 2nd shift on 6/4, 6/5, 6/11, and 6/12/16, and on the 3rd shift on 6/3 and 6/10/16. The other dates up to 6/16/16 were blank. The other halls for 200 Hall, 300 Hall were marked as being done on 6/1, 6/3, and 6/10/16 and on the 400 Hall was marked as being done on 6/3, 6/4, 6/5, 6/10, 6/11, 6/12, and 6/16/16. f. On 6/16//16 at 9:15 a.m., the exit door at the end of the 100 Hall had a cloth stop banner that was draped across the doorway and attached to the door facing with Velcro tabs. When this Surveyor pushed on the door, the door easily opened and the alarm sounded. The door had not locked or engaged into the latch and when this Surveyor pushed on the door again, the door opened and there was no alarm that sounded. LPN #3 reset the alarm and when this Surveyor pushed on the door, the door was not engaged in the latch in the door facing, did not completely close, and the alarm did not sound when the door was opened. This Surveyor pushed on the door again and the door easily opened, the swung back toward the door facing but did not lock in the door latch and the alarm did not sound while the door was opened. The LPN reset the alarm. This Surveyor pushed on the door, and the alarm then sounded. The door was closed and this Surveyor tested the door again and the alarm did not sound and the door did not fully engage back into the door latch. LPN #3 was asked if the alarm sounded and the LPN stated, No. The LPN then continued to push the alarm buttons. The LPN was asked to summon the Administrator to the 100 Hall. The LPN left the area to get the Administrator. while this Surveyor remained at the door. The area outside of the 100 Hall exit door was an enclosed, fenced yard with a concrete sidewalk that led to another wing of the building. g. On 6/16/16 at 9:18 a.m., the Administrator arrived at the exit door on the 100 Hall. The Administrator was asked if there were any problems with the door alarm and door not locking or closing and stated, It has a Q (every) shift check on the MAR (Medication Administration Record) book. The Administrator was asked if there had been any residents who had eloped through the door and stated, We've had 1 resident go out. The Administrator was asked when this occurred and stated, Prior to the initiation of the check list, the corrective action taken. The Administrator was asked who the resident was and stated, (Resident #5). The Administrator was asked how it was discovered that the resident was out of the building and stated, Staff. Staff saw him go out. The alarm was reset by the Administrator at this time. The Administrator was asked if the wanderguard alarms worked on all exit doors and stated, No, (only) the front door. The Administrator was asked how the doors were monitored and stated, .staff watches and checks. They weren't being monitored at that time.added monitoring. The Administrator was asked how many residents were at risk for elopement and stated, 3 or 4. At 9:24 a.m., with the Administrator present, this Surveyor pushed on the door and the door opened easily then closed back, but did not lock in the latch and the alarm did not sound while the door was opened. The Administrator stated, Standing here till I can get someone. The Administrator was asked how they ensured that Resident #5 would not try to exit the door again and stated, Cause he was in the hospital recently with GI (gastrointestinal) bleed and he came back with contractures and he's in a geri-chair . not independent to propel . h. On 6/16/16 at 12:05 p.m., CNA #1 was asked what had occurred with Resident #5 on 5/1/16 and stated, When I went out to the back patio to take a break, I had sat down and looked, the door that came out of 100 (hall) and it's a little short part, he was kind of sitting in a wheelchair at the door. I opened the door and hollered at the nurse working, and by time I shut the door and turned back around, he was out when I'd seen him. He already had started rolling down and before I could get to him 2 wheels went off on left side and he just fell off into the mud . The CNA was asked if there were any alarms sounding and stated, No we can hear this close, and I reported it to Maintenance and I believe it was (LPN #5). At 12:15 p.m., the CNA accompanied this Surveyor outside onto the patio of the RCF unit to the chain link gate and viewed the property outside of the 100 Hall. There was a concrete sidewalk that led from the 100 Hall to the fenced in patio of the RCF unit. The sidewalk sloped downward toward the RCF unit and there was a chain link fence that surrounded and enclosed the facility property behind the 100 Hall. i. On 6/16/16 at 12:55 p.m., the Maintenance Supervisor was asked if there were any logs that documented the door alarms were checked and the Maintenance Supervisor stated, I don't have any logs on the door. The Maintenance Supervisor was asked, when the alarm did not work on the 100 Hall, was it replaced or repaired? The Maintenance Supervisor stated, No, the only thing I did was take the push bar off and oiled it. The Maintenance Supervisor was asked how often the door alarm was to be checked and stated, They are supposed to be checked daily by a nurse. The Maintenance Supervisor was asked how the facility ensured that the door alarms sounded and were in working order and stated, I check once weekly. Just making sure alarms go off and if they don't, I reset the alarm and change the batteries. The Maintenance Supervisor was asked if any of the door alarms had required work on them this year (2016) and stated, No.

Complaint # (AR 302) was substantiated, all or in part, in these findings. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided for management of [MEDICAL CONDITIONS], by failing to ensure the physician-ordered diuretic was available for administration to the resident and failure to consult the physician regarding missed doses of the medication for 1 of 1 (Resident #6) case mix resident who received a diuretic medication. This failed practice resulted in actual harm to Resident #6, who did not receive [MEDICATION NAME] as ordered by the physician, which likely contributed to a [MEDICAL CONDITION] exacerbation for which the resident was hospitalized for [REDACTED]. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date (ARD) of 5/3/16 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS) and required extensive assistance of 1 person for transfers and personal hygiene. a. The Resident Plan of Care dated 4/11/16 - 4/11/17 documented, [MEDICAL CONDITIONS] @ (at) risk for respiratory distress . with interventions of Administer medications as prescribed by the physician (See current MAR (Medication Administration Record) . Notify physician of changes in condition. Observe for [MEDICAL CONDITION], SOB (Shortness of Breath), distressed breathing, fever, cough & (and) congestion . The care plan also documented, Respiratory function @ risk for AEB (as evidenced by) = [MEDICAL CONDITION] [MEDICAL CONDITION], SOB, Sleep apnea . with interventions of .Administer medications as prescribed by the physician (See current MAR & physician order [REDACTED]. Monitor medication for effectiveness and side effects. Administer nebulizer tx's (treatments) & O2 (oxygen) as ordered . b. The Physician order [REDACTED].@ 0800 (8:00 a.m.) & 1400 (2:00 p.m.). c. A chest X-ray Report dated 5/28/16 documented, Reason: [MEDICAL CONDITION] / Respiratory . There is no focal lung opacity present. There are increased interstitial markings present throughout most likely chronic in etiology. The heart size it as the upper limits of normal. There is mild central [MEDICAL CONDITION] vascular congestion present . Impression: Cardiomegaly with central [MEDICAL CONDITION] vascular congestion . d. A Laboratory Report dated 6/3/16 documented, .BUN (blood urea nitrogen) 33 H (high) - Ref. (reference) range 7-18 . Creatinine 1.8 H - Ref. range 0.60-1.30 . e. The facility's Weekly Weight documentation for May 2016 documented the following weights for this resident: Week 1- 255.0 (pounds) Week 2-242.5 (pounds) Week 3- 244.0 (pounds) Week 4-245.0 (pounds) f. The June 2016 MAR (page 11) documented, 5/23/16 [MEDICATION NAME] 40 mg oral tablet (1) PO BID give @ 0800 &1400. Nurses' initials were documented to indicate the [MEDICATION NAME] was administered as ordered, at 8:00 a.m. and 2:00 p.m. on 6/1/16 through 6/8/16; however, the 8:00 a.m. and 2:00 p.m. slots on 6/9/16 and the 8:00 a.m. slot on 6/10/16 documented nurse's initials which were circled, indicating the [MEDICATION NAME] was not given. On 6/10/16 at 2:00 p.m., there were no nurse initials documented. There was nothing documented on the back of the Medication Administration Record to indicate why the medications were not given. Nurse's initials were documented on the morning of 6/11/16 to indicate the [MEDICATION NAME] 40 mg was administered as ordered at 8:00 a.m. On 6/17/16 at 2;45 p.m., Licensed Practical Nurse (LPN) #1 was asked if she passed medication on the 100 hall on 6/9/16 and 6/10/16 to Resident #6. The LPN stated, Yes. The LPN was shown the June 2016 MAR that documented the circled doses of [MEDICATION NAME] for 6/9/16 at 8:00 a.m. and 2:00 p.m. and 6/10/16 at 8:00 a.m., as well as the lack of a nurse's initials for the 2:00 p.m. slot on 6/10/16. The LPN stated, The [MEDICATION NAME] wasn't available that Thursday (6/9/16) morning. There were no cards in the 8:00 a.m. or the 2:00 p.m. slots. The [MEDICATION NAME] was not available on Friday 6/10/16; there still were no [MEDICATION NAME] cards in the 0800 or the 1400 slots. I made a second request for the medication to be ordered. The LPN was asked if she had called the Pharmacist. The LPN stated, No, I faxed in the request . (Resident #6) had [MEDICAL CONDITION], so I borrowed a [MEDICATION NAME] 40 mg from another resident on Friday 6/10/16, for the 2:00 p.m. dose, secondary to the [MEDICAL CONDITION]. The LPN was asked if she was supposed to borrow medication from another resident. The LPN stated, No, but the resident was in need of the medication. There were no cards ([MEDICATION NAME] 40 mg) for me to give at the 8:00 a.m. dose or the 2:00 p.m. dose the day before or the 8:00 a.m. dose for that morning. The LPN was asked why it was important to ensure the resident received his medication as prescribed by the physician. The LPN stated, It's very important due to the resident's [DIAGNOSES REDACTED]. The LPN stated, I explained to the oncoming Nurse and what was going on with the resident, the increase in [MEDICAL CONDITION]. The LPN was asked if she had called the physician regarding the [MEDICATION NAME] not being available, or the [MEDICAL CONDITION]. The LPN stated, No. The LPN was asked, Do you feel that you should have called the Physician? The LPN stated, I feel that the pharmacy should have had the medication here; we have 3 deliveries per day and they should have sent the medications. The LPN was asked, Do you feel that the physician should have been contacted? The LPN stated, I should have called the physician. I did speak with the family (daughter). I checked on him during the 3-11 (3:00 p.m. - 11:00 p.m.) shift even though I wasn't working that hall. The LPN was asked if she had spoken with the DON regarding the [MEDICATION NAME] 40 mg not being available. The LPN stated, No. g. The Skilled Daily Nurses Notes for 6/10/16 documented the following entries: 6/10/16 (day shift) R (Resident) (up) in w/c (wheelchair) remains on Skilled Nursing R/T (Related to) new Peg (percutaneous endoscopic gastrostomy) Tube & [MEDICAL CONDITION]. R [MEDICAL CONDITION] & leaning to left side. [MEDICATION NAME] ordered on [DATE]. [MEDICATION NAME] 40 mg given today (2:00 p.m.). R c/o not peeing much . 6/10/16 3-11, R remains on Skilled Care R/T new Peg Tube and [MEDICAL CONDITION].R has swelling to hands, has some SOB. Pulse Ox (oximetry) 93%. Updraft given. R had CXR (Chest X-ray) done. 6/10/16 at 1625 (4:25 p.m.) MD (Medical Doctor) notified of 16 lbs (pounds gained) in 1 week.Orders for BNP (B-type Natriuretic Peptide), CMP (complete metabolic panel), CBC (complete blood count) and Chest X-ray stat (immediately) and call MD (with) results when available. This note was signed by the Director Nursing (DON). 6/10/16 . N: (night shift) SaO2 (oxygen saturation) 96% . BP (blood pressure) 144/78, P (pulse) 80, R (respirations) 18 . h. The clinical record documented the following x-ray and lab reports for 6/10/16; 1) The X-ray Reports dated 6/10/16 at 6:03 p.m. documented, There are increased interstitial markings present throughout most likely chronic in etiology. The heart size is at the upper limits of normal. There is mild central [MEDICAL CONDITION] vascular congestion present . Impression: Stable appearing cardiomegaly with central [MEDICAL CONDITION] congestion. There was no significant change, as compared with the X-Ray Report dated 5/28/16. 2) CMP results 6/10/16: BUN (blood urea nitrogen) - 41- H (high) (Ref. (Reference) Range 7-18). Creatinine - 2.20 - H (Ref. Range 0.6-1.30) BNP - 7478 - H (Ref. Range 0.0-125.0) i. The facility's Weekly Weight documentation for June 2016 documented the following weights for this resident: Week 1 (5/29/16 through 6/4/16) - 247.5 (pounds) Week 2 (6/5/16 through 6/11/16) - 263.5 (pounds) It was not possible to determine the number of days between the 2 weights, due to no specific dates being documented. j. The Nurses Notes dated 6/11/16, no time noted, .c/o (complained of) inability to urinate this shift. Has [MEDICAL CONDITION] 3+ (plus) pitting to left upper and lower extremity and periorbital puffiness around the eyes. Called (Physician) on call for (Primary Care Physician). Received order to (increase) [MEDICATION NAME] from 40 mg to 60 mg BID. Repeat CMP on Tuesday 6/14/16 . (At) 1400 (2:00 p.m.) administered 60 mg including scored [MEDICATION NAME] tab (tablet). After lunch R (resident) c/o SOB (shortness of breath) . R verbalized he wanted to go to ER (emergency room ). Notified RN (Registered Nurse) Supervisor on Duty (at) 1600 (4:00 p.m.), Called (ambulance company) @ 1615 (4:15 p.m.), notified family at 1630 (4:30 p.m.). Based on information documented on the June 2016 MAR and these Nurses Notes, the resident received [MEDICATION NAME] 40 mg on 6/10/16 at 2:00 p.m. and 6/11/16 at 8:00 a.m.; and [MEDICATION NAME] 60 mg on 6/11/16 at 2:00 p.m., prior to being transferred to the hospital per his own request. k. The Hospital Records received from the facility on 6/17/16 documented, Admission 6/11/16 Time 6:55 p.m. Internal Medicine History and Physical HPI (history of present illness) Pt. (Patient) is a 77 yo (year old) male who by error was not receiving [MEDICATION NAME] as ordered and C/O SOB and 15# (pound) weight gain. Active Hospital Problems, [DIAGNOSES REDACTED]. l. On 6/17/15 at 3:33 p.m., LPN #2 was asked if she worked the 100 hall and passed medication to Resident #6. The LPN stated, Yes, I work 3 to 11 (3:00 p.m. to 11:00 p.m.) shift. The LPN was asked if she had any issues related to residents running out of medications. The LPN stated, I haven't had a resident run completely out of medications, but I would call or fax the pharmacy. The LPN was asked, On 6/10/16 on the 3 to 11 shift, were there any issues that were passed on to you in regarding (Resident #6)? The LPN stated, (Resident #6) was swollen, he already had stat lab ordered. He had retained fluid. He had gained weight. (Registered Nurse (RN) #1) had already had orders, and I took off the orders when I came in. I called for the chest x-ray and I had to call the lab for the second time . m. On 6/17/16 at 4:20 p.m., the DON was asked about Resident #6 running out of [MEDICATION NAME]. The DON stated, I found out about it after it had already happened, the following Monday (6/13/16). The DON was asked, When you found out that the resident had missed the medication, what did you do? The DON stated, I asked why the medications were circled. The LPN stated that the medication wasn't in the cart. The DON was asked, What does it mean when the medications are circled? The DON stated, The circle means that the medication was not given. The DON was asked if she was aware of how many doses of [MEDICATION NAME] Resident #6 had missed. The DON stated, I don't recall. I looked at it today. The DON was shown the Medication Administration Records that documented Resident #6 had missed 3 doses of [MEDICATION NAME]. The DON was asked if she felt this could have contributed to the resident being hospitalized . The DON stated, Yes. The DON was asked, Should the physician have been called when the resident had missed 3 doses of [MEDICATION NAME]? The DON stated, The physician should have been called when the first dose was missed. The DON was asked about the resident's weight gain. The DON stated that they had a weight meeting every Thursday and the weights were taken, .close to the day of the weight meeting. The DON also stated the weekly weights were not done on the same day of the week every week and that they did not write a specific date on the weight form. n. On 6/17/16 at 2:38 p.m., Physician #1 was asked if the 3 missed doses of [MEDICATION NAME] likely contributed to the resident's weight gain and subsequent hospitalization . The Physician stated, He missed 3 doses of [MEDICATION NAME]. Yes, I feel that this did contribute, due to the resident's history of Chronic [MEDICAL CONDITION].

Complaint # was substantiated, (all or in part) with these findings: Based on record review and interview, the facility failed to ensure a resident assessed to require gait belt transfers with 2-person assistance was not pulled up by the arms (chicken-winged) for 1 (Resident #4) of 2 (Residents #3 and #4) case mix residents who required the use of a gait belt for transfer assistance. This failed practice resulted in actual harm to Resident #4, who sustained a dislocated shoulder and humeral head fracture. The facility also failed to provide inservice training to the entire nursing staff and to monitor the use of gait belts and proper transfer techniques after the incident occurred to decrease the potential for further occurrences. The failed practice was likely to affect 18 residents who required the use of a gait belt for transfers, according to a list provided by the Administrator on 3/21/11 at 2:30 p.m. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 3/1/2012 documented the resident had short-term memory problems, was moderately impaired with cognitive skills for daily decision making per a staff assessment of mental status, and was totally dependent on one staff for transfers. a. A "Transfer Assistance Assessment" form dated 2/10/11 documented the resident required a Gait Belt/Stand-Up Lift with 2 person assist. b. The Plan of Care with a review date of 3/1/12 documented, "Physical Functioning- At risk for falls or injury...Approaches: ...Instruct staff on safety to ensure no resident injuries...Assist of 1-2 staff for all transfers..." c. The DMS (Division of Medical Services) form-762 dated 3/12/2012 at 11:00 a.m. documented, "Resident observed up to wheelchair by two nurses aids (Certified Nurse Aides). At this time resident was noted by aids to be sliding downward of wheelchair, actively falling to floor. According to witness statements, aids attempted to reposition resident by using pad in wheelchair, but the pad was noted to slide without resident. In an effort to prevent resident from falling to the floor, resident was repositioned by lifting resident from under her arms. At the time, resident did not complaint to aids of pain. Resident was placed near window per her request, and later complained to nurse of left shoulder pain, and requested to be put in bed at that time. PCP (Primary Care Physician's) nurse aware of situation, PCP notified and an x-ray was ordered. During assessment of resident, there was a bruise noted to resident's left side, and left axilla that were noted previously related to a separate incident documented the previous week. Once x-ray results available, they revealed that resident had a separated shoulder. Results were phoned to resident's PCP and an order to send resident to emergency room for evaluation and treatment of [REDACTED]." d. A x-ray report dated faxed to the facility on [DATE] at 5:40 p.m. documented, "...Impression: Complete left shoulder dislocation with mild superior lateral humeral head impaction fracture..." e. A Physician's Telephone Order dated 3/13/12 documented, "Send to (Hospital) r/t (related to) abnormal xray." f. A Radiology report dated 3/13/2012 at 6:32 p.m. documented, "...Impression: Anterior left shoulder dislocation..." g. The Hospital Discharge Summary dated 3/16/2012 documented, "...Details of Hospital Course: The patient was taken to surgery 03/15/2012 for left shoulder open reduction as it was irreducible under anesthesia closed..." h. On 3/21/12 at 9:50 a.m., Certified Nurse Aide (CNA) #1 stated, "She (Resident #4) was over by the dining room in her wheelchair. She was rocking on the outer edge of her wheelchair and was about to fall out. She had a cloth type pad under her. We (CNA #2 and I) grabbed the pad and the back of the wheelchair up under her arms to pull her back into the chair. She did not say 'Ouch' or anything - we did not know that she was hurt at that time. After she complained of hurting the Director of Nursing called me the next day to come fill out a witness statement. I received a written counseling. The Director of Nursing talked to me about the correct way to position the resident. I'm supposed to use my gait belt, do not chicken wing because that's what we really did, and do not go up under the arms even if they are about to fall. I learned to always take precautions and always use a gait belt even if they are about to fall. I had my gait belt on me when this happened and I had been taught to use a gait belt but she was so far forward on the chair that I thought she was going to fall." i. On 3/21/12 at 10:37 a.m., CNA #2 stated, "On 3/13/12 after breakfast I was getting ready to push (Resident #4) in her wheelchair back to her room. I stopped at the nursing station near the dining room on the 600 hall because someone called my name. I looked to see who it was. When I turned back around, (Resident #4) was on the front edge of her wheelchair rocking. I saw she was sitting on a cloth incontinent pad in her wheelchair. I tried to pull her back into the wheelchair with the incontinent pad. That didn't work - the pad was coming from under her but she wasn't moving backwards. Then I asked (CNA #1) to help me move her back in her chair before she hit the floor. I had taken my gait belt off in the (transport) van - so we under armed (chicken winged) her and used the pad also to pull her back. That didn't work. So we did it again the same way without using the pad and that worked. She (Resident #4) said, 'thank you - now take me to the windows.' She did not fuss or fight or complain of pain. Just thanked us and wanted to be at the windows... The Director of Nursing called me in to complete a report. He gave me an educational write up and told and showed me how to use a gait belt and transfer the right way again. It was a written counseling." j. On 3/21/12 at 10:42 a.m., the Certified Dietary Manager (CDM) stated, "On 3/13/12 after breakfast, I saw two of the CNA's slip their hands under each arm to keep (Resident #4) from falling. We've had a lot of inservices on that - that we're not supposed to lift the resident under their arms. I know that everyone is supposed to have their own gait belt, but this was so quick they were just trying to keep her from falling - they did it very gently." k. On 3/21/12 at 11:55 a.m., the Director of Nursing stated, "Not 100% of our nursing staff has been inserviced." The "Inservice Training Record" dated 3/14/12 at 14:00 (2:00 p.m.) documented an inservice relative to "Transfer and Positioning" had been presented. 36 staff signatures were affixed to the form. The signatures of the staff were compared to the payroll listing of the nursing department and there were 34 staff members that did not attend the inservice. l. On 3/21/12 at 1:55 p.m. a policy/procedure, "Gait Belts (For use in ambulation and transfer)" was received from the Director of Nursing. On 3/21/12 at 2:00 p.m., the Director of Nursing was asked if the content of the policy had been incorporated into the inservice presentation on 3/14/12. The DON stated, "This policy was not included in our last inservice on transfers on 3/14/12. This is what will be taught to our staff." m. On 3/21/12 at 2:05 p.m., the Director of Nursing was interviewed and asked if, since the inservice on 3/14/12 relative to "Transfer and Positioning", he had monitored his staff for the use of gait belts and transfers. The Director of Nursing stated, "I have watched them use gait belts on each shift and made sure they have gait belts available. I have not documented any monitoring since the incident and I have not done any skills check lists."