Every finding on record at Wheatland Nursing & Rehabilitation Center

The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 38 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: - During the initial tour of the kitchen on 06/24/25 at 07:45 AM, Dietary Staff (DS) BB stated she was not certified but started the course in February. On 06/26/25 at 10:50 AM, Administrative Staff A stated the dietary manager was not certified but was in classes for certification. The facility's Dietary Service-Staffing policy, dated 01/05/24, documented the facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. In states that have established standards of food service managers or dietary managers meet the State requirement for food service managers or dietary managers.

The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to employ a full time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the residents of the facility at risk for inadequate nutrition or food borne illness. Findings included: - On 10/24/23 at 08:10 AM, observation revealed Dietary Staff (DS) BB assisted with preparation and serving of the breakfast meal for the residents of the facility. She stated she did not have a dietary manager certification and was currently taking classes for it. On 10/30/23 at 09:16 AM, Administrative Staff A verified it was the facility's policy to employ a certified dietary manager. She stated the Registered Dietician came to the facility every other week. The facility's Food Services Manager policy, dated 12/2008, stated the daily functions of the Food Services Department were under the supervision of a qualified Food Services Manager licensed by this state. The facility failed to employ a full time CDM to supervise the preparation of meals and sanitation in the facility's kitchen, placing the residents of the facility at risk for inadequate nutrition or food borne illness.

The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner when dietary staff did not ensure complete hair coverage with the hairnet. This deficient practice placed the residents of the facility who received meals from the facility at risk for food borne illness. Findings included: - On 10/24/23 at 08:10 AM, observation revealed dietary staff in the facility kitchen preparing and serving breakfast to the residents. Dietary Staff (DS) CC wore a beard net but did not cover his mustache. On 10/25/23 at 11:20 AM, observation in the facility kitchen revealed DS CC prepared food without covering his mustache and his hairnet stopped at the middle of the back of his head. Approximately two inches of hair at the back of his head was uncovered. Further observation revealed DS DD had long, full sideburns in front of his ears to his jawline which were not covered with a beard net while he prepared drinks and desserts for the residents. On 10/26/23 at 11:33 AM, observation revealed DS CC did not wear a hair net over his beard and mustache. heads CC's hairnet he wore on his head did not contain the hair at the lower backside of his head. On 10/26/23 at 01:28 PM, DS BB stated staff were to wear hairnets to cover beards and have thorough hair coverage including mustaches and sideburns. The facility's Dietary Employee Personal Hygiene policy, date 2003, stated all dietary staff must wear hair restraints to prevent hair form contacting food. The facility failed to prepare and serve food in a sanitary manner when dietary staff did not implement thorough hairnet coverage, placing the residents of the facility who received meals from the facility at risk for food borne illness.

The facility had a census of 38 residents. The sample included 12 residents. Based on record review and interview, the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease or heavy tobacco use are most at risk of developing a pneumonia caused by legionella). This placed the residents in the facility at risk for infectious disease. Findings Included: - On 10/31/23 at 10:30 AM, Administrative Staff A stated the city conducted routine water testing for the whole city, however the facility did not have record of or knowledge of any of the results or if they included testing for Legionella. Administrative Staff A had the information for the facility's procedure for water management but was unable to provide evidence the facility implemented the procedure and actively monitored the water for Legionella disease. The facility's Legionella Surveillance policy dated March 2023, documented the Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system. The policy documented the purpose of the facility to establish primary and secondary strategies for the prevention and control of Legionella infections. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system. The policy further documented the facility should use the [NAME] criteria when diagnosing pneumonia. Residents with health care associated pneumonia or who have failed antibiotic therapy for community acquired pneumonia shall be tested for Legionella using both culture of lower respiratory secretions and Legionella urinary antigen test. Investigation for a facility source of Legionella, which may include culturing the facility water for Legionella. The Infection Preventionist will investigate all definite healthcare associated Legionnaires' disease for the source of the legionella. The Infection Preventionist will also investigate the source of Legionella when two or more possible health care associated Legionnaires' disease are identified. The policy further documented the requirements will be met by the following: cooling towers and potable water systems shall be routinely maintained. At -risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations. Non-potable water systems shall be routinely cleaned and disinfected. Nebulization devices shall be filled only with sterile fluid-water or aerosol medication. Cool water shall be stored below 68 degrees Fahrenheit, and hot water shall be stored above 140 degrees and circulated at a minimum return temperature of 124 degrees Fahrenheit. A full-scale environmental investigation to identify environmental sources may include perform environmental sampling, as indicated by the environmental assessment. Decontamination of identified environmental sources in accordance with current standards. Heightened surveillance and environmental sampling, including increased suspicion for legionella cases and increased frequency of testing above the facility's usual testing protocols. The facility failed to implement a water management program to test and manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia. This placed the residnets at risk for water borne illness.

The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to store medications in a safe manner consistent with the standards of practice when Certified Medication Aide (CMA) R dispensed medications into plastic pill cups, unlabeled without dosage and instructions or resident names, and left them, uncovered, in the medication cart to be administered at a later time. This placed the resident's at risk for medication errors and /or less than therapeutic medication regimens. Findings included: - On 10/24/23 at 08:30 AM, observation revealed five small plastic cups with various medications in the top drawer of the facility medication cart. The cups lacked a resident's name or initials on the cup and the pills were outside of the pharmacy provided packaging and had no label, expiration date,or administration instructions. On 10/24/23 at 8:30 AM, CMA R stated she dispensed five residents' morning medications into the medication cups and attempted to administer to the residents however the residents wanted her to administer them at a later time. CMA R stated she knew which residents the medications belonged to, and went through them and named the five residents names. On 10/30/23 at 10:30 AM, Administrative Staff A stated she was informed of the incident on 10/24/23 and verified that she spoke to CMA R. Administrative Staff A said she told CMA R to administer the residents medications and not store them in the plastic cups without appropriate names and labeling as that was not an acceptable nursing practice. The facility's Medication Administration policy undated, documented medications are to be administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy documented the nursing staff would identify the resident by photo on the medication administration record (MAR), review the MAR to identify medication to be administered, compare medication source such as bubble pack vial, with the MAR to verify the residents name, medication name, form, route, dose, and time. The policy documented the nursing staff would remove the medication from its source, taking care not to touch medication with bare hands, and administer the medication as ordered in accordance with manufactures specifications, and observe the resident for consumption, then sign the MAR after administration, Report and document any adverse side effects or refusals. The facility failed to store medications in a safe manner consistent with the standards of practice when CMA R dispensed the medications into plastic pill cups, unlabeled without dosage and instructions or resident names, and left them, uncovered, in the medication cart to be administered at a later time. This placed the resident's at risk for medication errors and /or less than therapeutic medication regimens.

The facility had a census of 36 residents. The sample included 13 residents with one reviewed for dignity. Based on observation, record review and interview the facility failed to treat Resident (R) 16 with respect and dignity during care of a gastrostomy tube (a tube inserted through the stomach that brings nutrition directly into the stomach). This placed the resident at risk for an undignified experience. Findings included: - R16's electronic medical record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, dated dated [DATE], documented R16 with severely impaired cognition, required extensive assistance with transfers, bed mobility and received all nutrition and medications by a gastrostomy tube. The Gastrostomy Care Plan, dated 01/15/22, directed the staff to administer all medications and nutrition for R16 by gastrostomy tube and the resident was NPO (nothing by mouth). On 03/31/22 at 10:45 AM, observation revealed Licensed Nurse (LN) G pushed R16 in his reclining wheelchair into his room. When entering the room observation revealed R16's roommate seated on his bed. LN G washed his hands and put on clean gloves, pulled up R16's shirt, opened the gastrostomy tube, and used a syringe and auscultated (listened with stethoscope) for placement. LN G then administered medications via the gastrostomy tube. When completed LN G closed the gastrostomy tube and pulled down the resident's shirt. The door to the room was left open during the procedure and the divider curtain was not pulled so the roommate could see the procedure. On 03/31/22 at 11:00 AM, LN G verified he did not provide privacy for R16 during the procedure and should have shut the room door and pulled the privacy curtain around the resident. On 03/31/22 at 02:00 PM, Administrative Nurse D verified privacy should have been provided for R16 during the gastrostomy procedure. The facility's Dignity policy, dated August 2009, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity and respect. Staff shall promote and maintain a resident's privacy including bodily privacy during procedures. The facility failed to provide privacy for R16 during gastrostomy use, placing the resident at risk for embarrassment and an undignified environment.

The facility had a census of 36 residents. The sample included 13 residents with one reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to provide reasonable accommodation of needs for Resident (R) 34, when staff placed him in a wheelchair where he was unable to reach the floor with his feet to allow him to self-propel around the facility. This placed the resident at risk for maintaining his independence. Findings included: - R34's electronic medical record (EMR) documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had a Brief Interview of Mental Status (BIMS) of 00, which indicated severely impaired cognition. The MDS documented the resident required extensive staff assistance with activities of daily living (ADLs) except limited staff assistance with locomotion off the unit, and supervision with eating. The MDS documented R34 had no upper or lower extremity impairment and used a wheelchair for mobility. R34's Self Care Deficit Care Plan, revised 03/24/22, documented R34 used a wheelchair for mobility and propelled himself at times, but staff needed to assist when needed. On 03/30/22 at 02:00 PM, observation revealed R34 sat in a wheelchair in the hallway with gripper socks on both feet and no foot pedals attached to the wheelchair. R34 leaned forward, placed the tips of his toes on the wood floor, and attempted to propel his wheelchair down the hall using his toes. R34 was unable to move his wheelchair forward. On 3/30/22 at 02:00 PM, observation revealed R34 sat in a wheelchair, without foot pedals on the wheelchair, and gripper socks on both feet. R34 leaned forward in the wheelchair, placed the tips of his toes on the wood floor, and attempted several times to self-propel the wheelchair down the hall. R34 was unable to move his wheelchair forward using the tips of his toes. On 03/31/22 at 08:56 AM, observation revealed R34 sat in a wheelchair, without foot pedals on the wheelchair, and gripper socks on both feet. R34 leaned forward and placed the tips of his toes on the wood floor, made several attempts to propel himself forward, but was unable to move his wheelchair any distance. On 03/31/22 at 09:17 AM, observation revealed R34 sat in a wheelchair in the hall, without foot pedals on the wheelchair, and gripper socks on both feet. R34 leaned forward, placed the tips of his toes on the wood floor, made several attempts to propel himself forward down the hall towards the nurses station, but was unable to move his wheelchair any distance. On 03/31/22 at 01:07 PM, observation revealed R34 sat in a wheelchair in the carpeted living room, leaned forward, and touched the tips of his toes on the carpet. R34 made several attempts to move his wheelchair forward, but was unable to move any distance. On 04/04/22 at 08:52 AM, observation revealed R34 sat in a wheelchair in the hallway with gripper socks on both feet, and placed the tips of his toes on the wood floor. R34 made several attempts to propel himself forward, but unable to move his wheelchair any distance. On 04/04/22 at 02:02 PM, Certified Nurse Aide (CNA) O stated R34 used to wear shoes when propelling his wheelchair, but staff had washed them and R34 would take them off. CNA O stated she had not noticed R34 was unable to place his feet flat on the floor to self-propel in his wheelchair. On 04/04/22 at 09:01 AM, Licensed Nurse (LN) G stated therapy made several adjustments to R34's wheelchair to allow him to propel around the facility and R34 would wear his shoes at times but a lot of time would take them off. On 04/04/22 at 09:36 AM, Physical Therapy Consultant (PTC) HH stated therapy staff last evaluated R34's wheelchair on 01/24/22 with his shoes on and she was unaware he was not wearing them. PTC HH stated she would have Occupational Therapy staff take a look at R34's wheelchair to see if it could be adjusted so he could place his feet on the floor. On 04/05/22 at 10:16 AM, Administrative Nurse D stated she expected staff to put foot pedals on the resident's wheelchair and propel him if he was having trouble self propelling his wheelchair. Since R34 liked to self propel in his wheelchair around the facility, staff should have reported his feet would not touch the floor to her and physical therapy staff so they could have reevaluated R34's wheelchair. The facility's Quality of Life-Accommodation of Needs policy, revised August 2009, documented the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, should be evaluated upon admission and reviewed on an ongoing basis. The facility failed to provide R34 accommodation of needs when staff placed him in a wheelchair where R34 could not reach the floor with his feet to self propel around the facility. This placed the resident at risk for maintaining his independence.

The facility had a census of 36 residents. The sample included 13 residents of which five were reviewed for falls. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent a fall for one of the five reviewed for falls. Resident (R) 15, who had a history of falls, received a skin tear, and hematoma (bruise, pooling of blood under the skin) when she fell out of a shower chair. The facility further failed to ensure staff transferred R15 correctly from the wheelchair to the shower chair. Findings included: - The electronic medical record (EMR) documented R15's diagnoses of left femur fracture (broken left hip), Alzheimer's disease (progressive disease that destroys memory and mental functions), delusional disorder (altered reality), and anxiety (intense worry and fear). R15's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident severely cognitively impaired, required extensive assistance with transfers and bathing, and no falls. The Activities of Daily Living (ADLs) Care Plan, dated 10/16/21, directed the staff to provide extensive assistance with bathing with one to two staff. The Safety Care Plan, dated 10/16/21, informed the staff the resident had a history of falls and was at risk for falls. The Fall Risk Evaluation, dated 10/21/21, documented the resident a high risk for falls. The Nurses Note, dated 11/13/21 at 01:19 PM, documented an unidentified certified nurse aide called for help in the shower room. Upon entering the shower room Administrative Nurse D observed R15 lying on the floor in front of the shower chair. Certified Nurse Aide (CNA) O informed the nurse she was getting a towel for the resident and the resident fell out of the shower chair. (The towel rack/shelf approximately five feet from where the resident fell .) When R15 was assessed by Administrative Nurse D the resident had two skin tears to the left elbow which measured 0.1 centimeters (cm) and a lump on the top of her head. The resident was transferred by facility staff to the emergency room via the facility van. R15 had a computed tomography scan (CT scan) of the head while at the emergency room and the results were negative for a brain bleed. The resident then returned to the facility. The facility's Fall Investigation, dated 11/13/21, documented the resident was unable to answer questions regarding what had happened, and CNA O needed to get a towel for the resident before the fall occurred. CNA O turned away from the resident to grab a towel and during that time, R15 slid from the shower chair. The action documented by the facility was to gather supplies before providing a shower, and to use a reclining shower chair for the resident. Review of the written statement, dated 11/13/21, revealed CNA O documented she needed to get a towel for the resident after showering her, and when she got the towel the resident fell out of the shower chair onto the floor. Review of the written statement, dated 11/13/21, revealed Administrative Nurse D documented upon entering the shower room, R15 was lying on the floor in front of the shower chair, had a skin tear, and a bump to her head, and R15 was unable to verbalize what had happened. On 04/04/22 at 09:50 AM, observation revealed CNA M pushed R15 into the shower room. Further observation revealed CNA M placed a gait belt around R15's waist, CNA N stood on the opposite side, CNA M and CNA N lifted the resident under her arms not holding the gait belt, and transferred R15 to a shower chair. The resident was unable to bear weight with her legs bent and dangling. On 04/05/22 at 01:50 PM, observation of the shower room, revealed a metal three shelf towel rack approximately six feet from the shower stall, two feet from where CNA O stood during the occurrence, and three feet from where the resident sat in the shower chair at the time of the occurrence. On 04/05/22 at 01:55 PM, Administrative Nurse D verified the distance from the shower chair to the towel rack. Administrative Nurse D also verified CNA O would have had to walk over to the towel rack leaving R15 unsupervised. The facility's Falls policy, dated 11/20/20, documented the facility will assess each resident for fall risk, including ambulation, mobility, gait, balance, and excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. Will identify the risk factors to prevent falls or accidents for each resident. The facility failed to provide adequate supervision and safety for R15 during a shower and failed to properly transfer R15 from the wheelchair to the shower chair. This placed R15 at increased risk for major injury related to accidents and hazards.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to obtain Resident (R) 3's blood pressure prior to administrating her [MEDICATION(S)] (medication used to lower blood pressure) 100 milligram (mg). This placed the resident at risk for side effects from a low blood pressure. Findings included: - R3's electronic medical record (EMR) documented she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Medicare Five Day Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview of Mental Status (BIMS) score of two, which indicated severely impaired cognition. The MDS documented R3 required limited staff assistance with activities of daily living (ADLs) except supervision with eating. R3 received scheduled pain medications, antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication for four days, and antidepressant (class of medications used to treat mood disorders and relieve symptoms of abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and anticoagulant (medication used to prevent the formation of blood clots and to maintain open blood vessels) medications for five days during the lookback period. R3's Medication Care Plan, revised 01/11/22, instructed staff to report to the nurse immediately any sign or symptoms of allergic reactions, sudden change in mental status or sudden changes in vital signs(measurements of temperature, pulse (rhythmical throbbing of arteries produced by the regular contractions of the heart), respirations (rate of breathing) and blood pressure (pressure of blood pushing against the walls of your arteries). R3's Physician Order, dated 03/14/22, instructed staff to hold R3's [MEDICATION(S)] Tablet, 100 mg, if her systolic (the first number - indicates how much pressure your blood is exerting against your artery walls when the heart beats) blood pressure below 100 or diastolic (the second number - indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats) below 50. On 03/31/22 at 08:02 AM, observation revealed Certified Medication Aide (CMA) R administered [MEDICATION(S)], 100 mg, to R3 without checking her blood pressure prior to administration. On 03/31/22 at 08:02 AM, CMA R verified the finding above and stated the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/31/22 at 08:07 AM, Administrative Nurse D verified R3's EMAR lacked documentation to prompt staff to check the resident's blood pressure, stated staff should check R3's blood pressure prior to administering her [MEDICATION(S)], and follow physician ordered parameters (specific instructions) for the medication. The facility's Administration of Medication Policy, revised on 01/01/18, documented licensed nurses would make any new orders and/or changes to the resident's EMAR/Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The changes would be placed on the correct information record. The facility staff failed to check R3's blood pressure prior to administrating [MEDICATION(S)]. This placed the resident at risk for side effects from a low blood pressure.

The facility had a census of 36 residents. The sample included three residents reviewed for abuse. Based on record review and interview, the facility failed to protect the residents when Certified Nurse Aide (CNA) M allegedly verbally abused Resident (R) 1 and continued to work at the facility. Findings included: - R1's Quarterly Minimum Data Set, (MDS), dated [DATE], documented the resident had short and long-term memory problems, moderately impaired cognition, inattention, and disorganized thinking. The MDS documented the resident required extensive assistance of one staff for dressing, total assistance of one staff for bathing, limited assistance of one staff for toileting, and supervision of one staff for transfers and personal hygiene. The MDS documented the resident ate independently after staff set up, and independent with bed mobility, walking in room and corridor, and locomotion on and off the unit. The Activities of Daily Living Care Plan, dated 12/28/20, documented the resident ate her meals in the main dining room, fed herself after staff set-up, did not eat well, and staff needed to remind her to eat. The facility's CNA Work Schedule, dated January 2021, documented CNA M worked at the facility on 01/20, 01/21, 01/23, 01/24, 01/26, 01/27, 01/28, and 01/29. The facility's CNA Work Schedule, dated February 2021, documented CNA M worked at the facility on 02/01, 02/02, and 02/03. On 02/04/21 at 01:55 PM, CMA R stated on 01/20/21, she heard CNA M tell R1 you are a pain in the (expletive) and take a bite, eat it. I'm not playing games with you, while she assisted the resident with her meal in the dining room. CMA R stated she immediately reported the incident to LN G and LN G's response was okay, and he did not ask her any questions or to write a statement. CMA R stated she assumed LN G would take care of it. On 02/04/21 at 02:15 PM, Administrative Nurse D stated CNA M finished her shift on 01/20/21 after CMA R reported the incident to LN G on 01/20/21 and continued work several shifts in January and February 2021. The facility's Abuse, Neglect, Exploitation policy, dated December 2016, documented any staff member suspected of resident abuse would be removed from contact with that resident immediately and during the course of the investigation, or may be moved to another position, if deemed appropriate. The policy documented if the staff member is found responsible for resident abuse, appropriate counseling and/or discharge of the employee would occur. The facility failed to protect all residents in the facility when CNA M allegedly verbally abused R1 and continued to work at the facility.

The facility had a census of 36 residents. The sample included three residents reviewed for abuse. Based on record review and interview, the facility failed to report an allegation of abuse, when Certified Nurse Aide (CNA) M allegedly verbally abused Resident (R) 1. Findings included: - R1's Quarterly Minimum Data Set, (MDS), dated [DATE], documented the resident had short and long-term memory problems, moderately impaired cognition, inattention, and disorganized thinking. The MDS documented the resident required extensive assistance of one staff for dressing, total assistance of one staff for bathing and toileting, and supervision of one staff for transfers and personal hygiene. The MDS documented the resident ate independently after staff set up, and independent with bed mobility, walking in room and corridor, and locomotion on and off the unit. The Activities of Daily Living Care Plan, dated 12/28/20, documented the resident ate her meals in the main dining room, fed herself after staff set-up, did not eat well, and staff needed to remind her to eat. The Nurse's Note, dated 12/18/20 at 11:32 AM, documented staff informed R1 of who to report abuse, neglect, or exploitation (ANE) to, who the Ombudsman (an official appointed to investigate individual's complaints against maladministration) was, and the location of the facility survey book. On 02/04/21 at 12:00 PM, observation revealed R1 seated at a table in the main dining room, eating independently after staff set up her meal. Further observation revealed staff was patient and spoke to the resident in a kind voice. On 02/04/21 at 11:00 AM, Licensed Nurse (LN) G, stated on 01/20/21 during the evening shift, Certified Medication Aide (CMA) R reported CNA M verbally abused R1. LN G stated he talked to CNA M, but did not consider the allegation to be abuse, and did not report the incident to anyone else. On 02/04/21 at 01:55 PM, CMA R stated on 01/20/21, she heard CNA M tell R1 you are a pain in the (expletive) and take a bite, eat it. I'm not playing games with you, while she assisted the resident with her meal in the dining room. CMA R stated she immediately reported the incident to LN G and LN G's response was okay, and he did not ask her any questions or to write a statement. CMA R stated she assumed LN G would take care of it. On 02/04/21 at 02:15 PM, Administrative Nurse D stated she was not aware of any abuse allegations, and LN G had not reported the allegation of abuse regarding CNA M toward R1. Administrative Nurse D stated the allegation should have been reported and investigated and staff had not followed the facility's ANE policy and procedure. The facility's Abuse, Neglect, Exploitation policy, dated December 2016, documented the facility staff would not use or allow others to use verbal, mental, sexual, or physical abuse, and would ensure all residents in the facility would be free of abuse. The policy documented all facility employees are educated that all alleged or suspected violations involving mistreatment, neglect, abuse, or exploitation would be reported immediately to the administrator, director of nursing, or their designee. The facility documented any report of neglect or abuse made by an employee would be investigated within 24 hours, and the administrator, director of nursing, or designee would be notified immediately. The facility failed to report an allegation of abuse when CNA M allegedly verbally abused R1.

The facility had a census of 37 residents. Based on observation, record review, and interview, the facility failed to prepare, store, and serve meals under sanitary conditions for the 35 residents who received meals from the facility kitchen. Findings included: - On 08/24/20 at 09:44 AM, observation during the initial tour of the kitchen revealed the following: One unlabeled (no resident names) box of Ensure (a nutritional supplement) with five individual containers with an expiration date of May 2020. Air intake registers dirty with a gray furry substance. Dead bugs dried to the wall in the south corner and a smooth gray substance on the corner of the south wall. A gray smooth substance on the wall above the freezers. On 08/25/20 at 12:07 PM, observation revealed Maintenance Staff (MS) U entered the kitchen without wearing a hairnet. On 08/26/20 at 01:17 PM, observation revealed Dietary Staff (DS) CC wore a hairnet with 2-3 inches(in) of multiple strands of hair along her neck line and approximately 3 in of pony tail hanging out of her hairnet. On 08/24/20 at 09:44 AM, DS BB stated the Ensure was brought in by family. On 08/25/20 at 12:07 PM, DS BB verified MS U should have worn a hairnet when he entered the kitchen. On 08/26/20 at 01:17 PM, DS BB verified DS CC should have all of her hair in the hairnet, there was dirt on two of the air returns in the kitchen, and stated maintenance cleaned the air returns. On 08/26/20 at 02:42 PM, DS BB verified the wall in the south corner was dirty and she was the one that cleaned the walls. On 08/27/20 at 09:45 AM, MS U verified he cleaned the air returns in the kitchen monthly. The facility's Foods Brought by Family/Visitors policy, dated July 2017, documented that food brought to the facility by visitors/family that is left for the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Containers will be labeled with the resident's name, the item, and the use by date. The facility's Food Preparation and Service policy, dated July 2014, documented that food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Dietary staff shall wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food. The facilities Sanitation policy, dated October 2008, documented that the food service area shall be maintained in a clean and sanitary manor. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently to prevent accumulation of grime. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 35 residents who received meals from the facility kitchen, placing the residents at risk for food borne illnesses.

The facility had a census of 37 residents. The sample included 12 residents with one reviewed for positioning. Based on observation, record review, and interview, the facility failed to ensure appropriate Broda chair (specialized wheelchair with the ability to tilt and recline) positioning in accordance with professional standards of practice for one sampled resident, Resident (R) 31. Findings include: - R31's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had moderately impaired cognition with memory problems, inattention, and verbal behaviors. The MDS recorded R31 required extensive staff assistance with transfers and positioning, impaired balance, unable to walk, and used a wheelchair for mobility. The Activities of Daily Living (ADLs) Care Plan, dated 07/24/20, recorded R31 had a history of [REDACTED]. The care plan directed staff to provide R31 extensive assistance to transfer and position. Review of R31's Electronic Medical Record (EMR) lacked documentation staff assessed the resident for positioning in her Broda chair. On 08/25/20 at 09:54 AM, observation revealed R31 rested quietly in her Broda chair with the chair tilted back and her feet dangled approximately a foot above the floor. On 08/26/20 at 11:47 AM, observation revealed staff propelled R31, seated in her Broda chair, to the dining room. Continued observation revealed R31's feet dangled approximately a foot above the floor. On 08/26/20 at 10:23 AM, Certified Nurse Aide (CNA) M stated staff provided R31 extensive assistance to transfer and position in her Broda chair. On 08/26/20 at 02:14 PM, Licensed Nurse (LN) G stated staff provided R31 extensive assistance to transfer and position in her Broda chair. LN G stated staff repositioned R31 in her Broda chair as needed, the resident's Broda chair had no lower extremity support device, and R31's lower extremities dangled without support. On 08/26/20 at 04:19 PM, Administrative Nurse D stated staff had not assessed R31 for positioning in her Broda chair, the resident's Broda chair had no lower extremity support device, and R31's lower extremities dangled without support. The facility's Repositioning policy, dated May 2013, directed staff to provide appropriate positioning for all chair bound residents to promote circulation, prevent pain and provide comfort. The policy directed staff to provide comfortable support for arms and legs with lack of strength and limited range of motion. The facility failed to ensure appropriate Broda chair positioning in accordance with professional standards of practice for R31, placing the resident at risk for increased pain and restlessness.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to follow up with the physician when Resident (R) 33 ran out of his [MEDICATION NAME] (a muscle relaxer) medication. Findings included: - On 08/26/20 at 07:42 AM, observation during medication administration revealed Certified Medication Aide (CMA) R went to administer R33's [MEDICATION NAME] medication but found the medication card empty. Observation revealed the medication card read ordered 08/22/20 and awaiting physician approval. The Physician Order, dated 03/03/20, instructed staff to administer [MEDICATION NAME], 10 milligrams (mg), one half tablet, three times a day. Review of the August 1-26, 2020 Medication Administration Record [REDACTED]. (11 missed doses) The Nurse's Note,' dated 08/23/20 at 12:25 PM, documented the resident remained out of [MEDICATION NAME] 10 mg tablets and awaited the refill approval. The Nurse's Note, dated 08/24/20 at 03:54 PM, documented the resident's [MEDICATION NAME] unavailable and the pharmacy awaited the physician's refill approval. The Nurse's Note, dated 08/25/20 at 05:34 PM, documented the resident's [MEDICATION NAME] unavailable and the pharmacy awaited the physician's refill approval. The Nurse's Note, dated 08/26/20 at 07:46 AM, documented the pharmacy had not delivered the resident's [MEDICATION NAME]. On 08/26/20 at 07:42 AM, CMA R verified the resident had been out of his [MEDICATION NAME] since 08/22/20 and the facility had none available to administer. On 08/27/20 at 09:13 AM, CMA S stated she called the pharmacy for a resident's refill on medication when the resident had seven-eight days of a medication left. On 08/26/20 at 08:27 AM, Administrative Nurse D verified the resident's [MEDICATION NAME] was unavailable, stated she called the pharmacy the previous day, and the pharmacy informed her they were waiting for the physician to approve the medication refill. Administrative Nurse D stated staff should call the pharmacy for medication refills when there was five days left in the medication card, it was not good that R33 was still out of his [MEDICATION NAME], the resident took it for muscle spasms in his back, and she would call the physician today. On 08/26/20 at 08:30 AM, Administrative Nurse D stated she called the physician and the physician's office nurse reported the approval for the resident's [MEDICATION NAME] had been sent to the wrong pharmacy. Administrative Nurse D stated the pharmacy delivered medications daily to the facility and they would bring it today. Upon request, the facility failed to provide a policy for pharmacy services. The facility failed to follow up with the physician, when R33 ran out of his [MEDICATION NAME], placing the resident at risk for developing back spasms and pain.

The facility had a census of 37 residents. The sampled included 12 residents. Based on observation, record review, and interview, the facility staff failed to properly administer [MEDICATION NAME] (a prefilled device with fast acting insulin) for Resident (R) 33 and Humalog Kwikpen (a disposable single patient prefilled pen containing a fast-acting insulin) for R3. Findings included: - On 08/24/20 at 11:32 AM, observation during medication administration revealed Licensed Nurse (LN) H informed R3 she was going to administer his [MEDICATION NAME] insulin. Observation revealed LN H turned the dose on the resident's [MEDICATION NAME] flex pen to 19 units and administered the medication to the resident without priming (removable of air) with two units prior to administration. On 08/27/20 at 03:00 PM, Administrative Nurse D stated the nurse should prime the resident's [MEDICATION NAME] with two units prior to administration. The undatedPatient Information [MEDICATION NAME] Injection Instructions for Use of [MEDICATION NAME] Instruction Sheet instructed staff to give the air shot before each injection, turn the dose selector to select two units, hold the [MEDICATION NAME] Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. The sheet instructed staff to keep the needle pointing upwards, press the push button all the way in until the dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. The facility staff failed to prime R3's [MEDICATION NAME] with two units prior to administration, placing the resident at risk for receiving an inadequate insulin dosage. - On 08/26/20 at 04:06 PM, observation during medication administration revealed Administrative Nurse G dialed 10 units of Humalog [MEDICATION NAME] (a prefilled device with fast acting insulin) and administered it to R33 without priming the Flex Pen with two units prior to administration. On 08/26/20 at 04:06 PM, Administrative Nurse G verified she had not primed the [MEDICATION NAME] with two units prior to administering the medication and stated she was unaware she was supposed to. The Humalog KwikPen Instruction sheet, dated April 2020, instructed staff to prime the resident's pen by turning the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the cop. Continue holding the pen with the needle pointing up. Push the dose knob in until it stops at 0. The facility staff failed to prime R33's Humalog [MEDICATION NAME] with two units prior to administration, placing the resident at risk for receiving an inadequate insulin dosage.

The facility had a census of 37 residents. Based on record review and interview, the facility failed to provide the resident (or their representative) the correct (SNFABN) Skilled Nursing Facility Advanced Beneficiary Notices (CMS) Centers for Medicare and Medicare Services form for 2 of the 3 residents reviewed. (#36, #27) Findings included: - The Medicare ABN form informs the beneficiary that Medicare may not pay for future skilled therapy services, and provides a cost estimate for continued services. The form includes an option for the beneficiary to (1) receive specific services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility lacked documentation staff provided Resident #36, or his/her representative, form with an estimated cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident/DPOA (durable power of attorney) was provided the notice on 7/25/2018, and recorded on 8/04/2018 the skilled nursing services ended. The facility lacked documentation staff provided Resident #27, or his/her representative, form with an estimated cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident/DPOA was provided the notice on 1/13/2019, and recorded on 1/27/2019 the skilled nursing services ended. On 2/06/2019 at 9:45 AM, Administrative Staff A verified the CMS form lacked documentation of the estimated cost to continue services and verified the facility had no designated staff who complete the forms. The facility's undated Advanced Beneficiary Notice of Non-Coverage/SNFABN Policy and procedure indicated the facility would ensure that Medicare residents are informed of their right to appeal and request demand billing of services when it is determined that a resident will no longer qualify for Medicare coverage services as evidenced by the policy. The provider will follow the regulations related to issuance of the non-coverage notice in order to appropriately inform beneficiaries ending Medicare coverage of appeal rights. The facility failed to provide Resident #36 and #27 or their representative the correct ABN form , when discharged from skilled care, which placed them at risk to make uninformed decisions about their skilled care.

The facility had a census of 37 residents. The sample included 14 residents of which 4 residents were reviewed for (ADLs) Activities of Daily Living. Based on observation, record review and interview the facility failed to provide the necessary services to supervise and monitor a dressing and grooming restorative program for 4 of 4 sampled residents. (#3, #4, #24, #34) Findings included: - Resident #24's quarterly (MDS) Minimum Data Set assessment, dated 01/02/19, recorded the resident had moderately impaired cognition, required extensive staff assistance with dressing, and received restorative services for dressing and grooming 7 days a week. The 01/09/19 care plan recorded the resident required extensive staff assistance with (ADLs) Activities of Daily Living, and received restorative services for dressing and grooming. The care plan directed staff to supervise and/or assist the resident as needed with oral care, combing hair, washing face/hands and dressing for the restorative program. The 30 day report for (CNA) Certified Nurse Aide Restorative Dressing and Grooming recorded staff provided the resident at least 15 minutes a day of training and skill practice for dressing and grooming. Review of the resident's medical record lacked documentation nursing staff supervised the resident's restorative program and/or completed a periodic evaluation of the resident's restorative program. On 02/04/19 at 1:45 PM, observation revealed the resident sat in a wheelchair in the common area near the nurse's station, well groomed and neatly dressed. On 02/06/19 at 8:42 AM, Administrative Nurse D stated nursing should supervise the resident's restorative program, complete a periodic evaluation of the resident's restorative program activities, and monitor the resident's functional status. The (RAI) Resident Assessment Instrument 3.0 Manual recorded a dressing and grooming restorative program should be individualized to maintain the resident's self-performance in dressing, bathing, washing and other personal hygiene. The RAI manual recorded a (RN) Registered Nurse or (LPN) Licensed Practical Nurse must supervise the resident's restorative nursing program, and complete a periodic evaluation of the restorative program in the resident's medical record. The facility's Restorative Nursing Services Policy, dated 07/2017, recorded restorative services should be individualized to maintain the resident's strength, safety and ADL function. The restorative policy directed nursing staff to supervise the restorative program and complete periodic evaluations to monitor restorative services and the resident's status. The facility failed to provide the necessary services to supervise and monitor a dressing and grooming restorative program for Resident #24, placing the resident at risk for decline in ADL function. - Resident #4's annual (MDS) Minimum Data Set assessment, dated 11/02/18, recorded the resident had a (BIMS) Brief Interview for Mental Score of 14 (cognitively intact) and no behaviors. The MDS recorded the resident required extensive staff assistance with dressing and personal hygiene, and received dressing and grooming restorative services 7 days a week. The 01/11/19 care plan recorded the resident required extensive staff assistance with (ADLs) Activities of Daily Living, and received restorative services for dressing and grooming. The care plan directed staff to supervise and/or assist the resident as needed with upper and lower extremity dressing and provide setup and verbal cues with other grooming tasks. The 30 day report for (CNA) Certified Nurse Aide Restorative Dressing and Grooming recorded staff provided the resident at least 15 minutes a day of training and skill practice for dressing and grooming. Review of the resident's medical record lacked documentation nursing staff supervised the resident's restorative program and/or completed a periodic evaluation of the resident's restorative program. On 02/04/19 at 9:47 AM, observation revealed the resident sat in a recliner in his/her room conversing with a visitor, the resident well groomed and neatly dressed. On 02/06/19 at 8:42 AM, Administrative Nurse D stated nursing should supervise the resident's restorative program, complete a periodic evaluation of the resident's restorative program activities, and monitor the resident's functional status. The (RAI) Resident Assessment Instrument 3.0 Manual recorded a dressing/grooming restorative program should be individualized to maintain the resident's self-performance in dressing, bathing, washing and other personal hygiene. The RAI manual recorded a (RN) Registered Nurse or (LPN) Licensed Practical Nurse must supervise the resident's restorative nursing program, and complete a periodic evaluation of the restorative program in the resident's medical record. The facility's Restorative Nursing Services Policy, dated 07/2017, recorded restorative services should be individualized to maintain the resident's strength, safety and ADL function. The restorative policy directed nursing staff to supervise the restorative program and complete periodic evaluations to monitor restorative services, and the resident's status. The facility failed to provide the necessary services to supervise and monitor a dressing and grooming restorative program for Resident #4, placing the resident at risk for decline in ADL function. - Resident #34's quarterly (MDS) Minimum Data Set assessment, dated 01/15/2019, recorded the resident had severely impaired cognition, required extensive staff assistance with dressing, and received restorative services for dressing and grooming 7 days a week. The 1/16/19 care plan recorded the resident required extensive staff assistance with (ADLs) Activities of Daily Living, and received restorative services for dressing and grooming. The care plan directed staff to supervise and/or assist the resident with dressing and grooming. The 30 day report for (CNA) Certified Nurse Aide Restorative Dressing and Grooming recorded staff provided the resident at least 15 minutes a day of training and skill practice for dressing and grooming. Review of the resident's medical record lacked documentation nursing staff supervised the resident's restorative program and/or completed a periodic evaluation of the resident's restorative program. On 2/0619 at 8:30 AM, observation revealed the resident sat in a wheelchair in his/her room, well groomed and neatly dressed. On 02/06/19 at 8:42 AM, Administrative Nurse D stated nursing should supervise the resident's restorative program, complete a periodic evaluation of the resident's restorative program activities, and monitor the resident's functional status. The (RAI) Resident Assessment Instrument 3.0 Manual recorded a dressing/grooming restorative program should be individualized to maintain the resident's self-performance in dressing, bathing, washing and other personal hygiene. The RAI manual recorded a (RN) Registered Nurse or (LPN) Licensed Practical Nurse must supervise the resident's restorative nursing program, and complete a periodic evaluation of the restorative program in the resident's medical record. The facility's Restorative Nursing Services Policy, dated 07/2017, recorded restorative services should be individualized to maintain the resident's strength, safety and ADL function. The restorative policy directed nursing staff to supervise the restorative program and complete periodic evaluations to monitor restorative services, and the resident's status. The facility failed to provide the necessary services to supervise and monitor a dressing and grooming restorative program for Resident #34, placing the resident at risk for a decline in ADL function. - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 1/07/2019, recorded the resident had severely impaired cognition, required extensive staff assistance with dressing, and received restorative services for dressing and grooming 7 days a week. The 1/21/2019 care plan recorded the resident required extensive staff assistance with (ADLs) Activities of Daily Living, and received restorative services for dressing and grooming. The care plan directed staff to supervise and/or assist the resident as needed with oral care, combing hair, shaving and dressing for the restorative program. The 30 day report for (CNA) Certified Nurse Aide Restorative Dressing/Grooming recorded staff provided the resident at least 15 minutes a day of training and skill practice for dressing and grooming. Review of the resident's medical record lacked documentation nursing staff supervised the resident's restorative program and/or completed a periodic evaluation of the resident's restorative program. On 2/05/2019 at 7:25 AM, observation revealed the resident sat reclined in a broda chair (a tilt-in-space reclining wheelchair) in the dining room, a blanket on his/her lap, well groomed, and neatly dressed. On 02/06/19 at 8:42 AM, Administrative Nurse D stated nursing should supervise the resident's restorative program, complete a periodic evaluation of the resident's restorative program activities, and monitor the resident's functional status. The (RAI) Resident Assessment Instrument 3.0 Manual recorded a dressing/grooming restorative program should be individualized to maintain the resident's self-performance in dressing, bathing, washing and other personal hygiene. The RAI manual recorded a (RN) Registered Nurse or (LPN) Licensed Practical Nurse must supervise the resident's restorative nursing program, and complete a periodic evaluation of the restorative program in the resident's medical record. The facility's Restorative Nursing Services Policy, dated 07/2017, recorded restorative services should be individualized to maintain the resident's strength, safety and ADL function. The restorative policy directed nursing staff to supervise the restorative program and complete periodic evaluations to monitor restorative services, and the resident's status. The facility failed to provide the necessary services to supervise and monitor a dressing and grooming restorative program for Resident #3, placing the resident at risk for a decline in ADL function.

The facility had a census of 37 residents. The sample included 14 residents, of which 5 residents were reviewed for unnecessary medications. Based on observation, record review and interview the facility failed to ensure an appropriate [DIAGNOSES REDACTED]. (#14) Findings included: - Resident #14's physician's orders [REDACTED]. The annual quarterly (MDS) Minimum Data Set assessment, dated 12/14/18, recorded the resident had moderately impaired cognition, inattention and disorganized thinking. The MDS recorded the resident required limited staff assistance with dressing, toileting, personal hygiene, and walked independently without an assistive mobility device. The MDS further recorded the resident received an antipsychotic medication 7 days a week. The annual (CAA) Care Area Assessment for [MEDICAL CONDITION] drug use, dated 12/14/18, recorded the resident received scheduled [MEDICATION NAME] (antipsychotic medication) for the targeted behaviors of agitation, [MEDICAL CONDITION] and wandering. The 01/18/19 care plan recorded the resident had anxiety and behaviors (wandering, [MEDICAL CONDITION], agitation) related to dementia. The care plan recorded the resident received scheduled [MEDICATION NAME] with the following (BBW) Black Box Warning (strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug): [MEDICATION NAME] is not approved for dementia-related [MEDICAL CONDITION] due to the medication is not effective for the treatment of [REDACTED]. The physician order, dated 01/22/18, directed staff to administer [MEDICATION NAME], 50 (mg) milligrams every morning and 100 mg every evening for dementia with behavioral disturbance. The Monthly Drug Regimen Review, dated 11/22/18, recorded the facility's Consultant Pharmacist identified and reported the inappropriate [DIAGNOSES REDACTED]. On 02/04/19 at 10:51 AM, observation revealed the resident walked independently with his/her spouse in the hall. Continued observation revealed the resident was well groomed, neatly dressed, and had no signs of anxiety or behaviors. On 02/05/19 at 08:50 AM, Nurse Aide M stated the resident was pleasantly confused, and had occasional behaviors of wandering, agitation or rejection of cares. Nurse Aide M stated staff easily redirected the resident's behaviors with conversation, activities, and/or snacks and drinks. On 02/05/19 at 1:48 PM, Nurse G stated the resident had impaired cognition, confusion, and occasional agitation and anxiety that staff easily redirected. Nurse G stated the resident received scheduled [MEDICATION NAME] medication for dementia with behaviors. On 11/14/18 at 9:30 AM, Administrative Nurse D stated the resident was pleasantly confused and staff easily redirected the resident's occasional behaviors of agitation, anxiety, or wandering. Administrative Nurse D stated the resident received scheduled [MEDICATION NAME] medication for dementia with behaviors, and this was not an appropriate [DIAGNOSES REDACTED]. The facility's Antipsychotic Medication Policy, dated 12/2016, directed staff to ensure the resident had an appropriate condition or [DIAGNOSES REDACTED]. The facility failed to ensure an appropriate [DIAGNOSES REDACTED].#14, placing the resident at risk for adverse side effects.

The facility had a census of 38 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary and comfortable interior for incontinent, dependent Resident #32 and the residents, who reside on 3 of 4 halls in the facility, which had dead bugs in the light fixtures and discolored caulking around 2 toilets. Findings included: - Resident #32's significant change (MDS) Minimum Data Set assessment, dated 09/22/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 4 (severe cognitive impairment) with delusions (untrue persistent belief or perception held by a although evidence shows it was untrue) and hallucinations (sensing things while awake that appear to be real, but the mind created). The MDS also recorded the resident required extensive staff assistance with toileting and personal hygiene, and was frequently incontinent of urine. The 09/22/17 significant change (CAA) Care Area Assessment for urinary incontinence recorded the resident required extensive staff assistance with toileting and incontinent cares. The 10/01/17 care plan recorded the resident was incontinent of urine and wore incontinent pull-ups. The care plan directed 2 staff to assist the resident with toileting as scheduled, and provide appropriate incontinent cares. On 10/25/17 at 8:32 AM, observation revealed the resident resting in a low bed with his/her night clothes on and the resident's room had a strong urine odor permeating (affecting the whole space, throughout). Continued observation revealed Nurse K and Nurse Aide G provided incontinent cares for the resident, removed and bagged all of the resident's bedding, and sprayed a deodorizer on the resident's mattress. Continued observation revealed the strong urine odor remained in the resident's room and lingered into the hallway. On 10/25/17 at 9:48 AM, observation revealed housekeeping staff removed the mattress from the resident's room and placed a new mattress on the resident's bed. On 10/30/17 at 8:02 AM, observation revealed the resident's bed made and no urine odors in the room. On 10/25/17 at 9:02 AM, Nurse Aide G stated staff provide appropriate incontinent cares for the resident, changed the resident's bedding everyday and as needed, and sprayed a deodorizer on the resident's mattress frequently. Nurse Aide G stated the resident's room continued to have a strong urine odor that lingered in the hallway. On 10/25/17 at 10:45 AM, Housekeeping Staff L stated housekeeping staff were aware of the strong urine odors in the resident's room and cleaned the resident's mattress with a disinfectant every day. Housekeeping Staff L stated the resident's mattress was permeated with a urine odor that could not be cleaned and staff placed a new mattress in the resident's room. On 10/25/17 at 11:35 AM, Administrative Nurse F stated staff replaced the resident's mattress to eliminate the strong urine odor in the resident's room and hall. The facility's undated Room Cleaning Policy directed staff to ensure the resident's room and personal items were cleaned to prevent odors and infections. The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary and comfortable interior for Resident #32. - On 10/30/17 at 2:25 PM, observation during the environmental tour revealed the following: Residents #37's toilet had brownish colored grout around the base of the toilet. Resident #23's toilet had black/brown colored grout, which was pulling away from the base of the toilet. Resident #28's bathroom doorway had a rusty/black area, approximately 2 inches square, at the bottom of the door frame, with a small amount of rusty debris on the floor. The west hall had numerous (25-50) small, dead insects, and debris in 5 of 8 fluorescent ceiling fixtures. The center square of the facility had numerous (25-50) small, dead insects, and debris in 2 of 4 ceiling light fixtures. The north hall had numerous (25-50) small, dead insects, and debris in 4 of 9 ceiling light fixtures. The south hall had numerous (25-50) small, dead insects, and debris in 2 of 9 ceiling light fixtures. The above observations were confirmed by Maintenance Staff O on 10/30/17 during the environmental tour. Upon request, the facility did not provide a policy regarding housekeeping and general maintenance. The facility failed to ensure upkeep of toilets, a bathroom doorway, and cleaning of the overhead light fixtures in the facility, which placed the residents on 3 of 4 halls at risk to live in an unclean environment.

The facility had a census of 38 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to ensure stock medications had not expired in 1 of 1 medication room and 1 of 1 medication cart. Findings included: - On 10/23/17 at 3:30 PM, observation of the medication room revealed 4 unopened bottles of Vitamin B12 1000 (mcg) micrograms, with an expiration date of 10/2016. On 10/23/17 at 3:30 PM, observation of the medication cart revealed an open, partially used, 16 (oz.) ounce bottle of Milk of Magnesia (a laxative) with an expiration date of 7/2017. On 10/23/17 at 3:30 PM, Nurse C verified the Vitamin B12 in the medication room had expired. On 10/23/17 at 3:30 PM, Certified Medication Aide M verified the Milk of Magnesia in the medication cart had expired. On 10/30/17 at 1:43 PM, Administrative Nurse A stated the facility had no system in place to ensure medications in use, had not expired. On 10/30/17 at 2:00 PM, Administrative Staff F verified the facility had no current system in place to monitor for expired medications, and nursing staff were to ensure expired medications were removed from service, and disposed of properly. The facility's 12/2014 Medication Storage policy documented outdated medications are immediately removed from stock, and disposed of according to procedures for medication disposal. The facility failed to monitor and ensure stock medications in the medication room and the medication cart had not expired, placing the residents at risk to receive ineffective medications with a negative outcome.

The facility had a census of 37 residents. The sample included 4 residents reviewed for abuse. Based on observation, record review and interview the facility failed to protect the residents in the facility,when staff failed to immediately report an allegation of abuse to the charge nurse, director of nursing, or the administrator. Nurse Aide A stated to Nurse Aide B that he/she pushed Resident #1 into bed, and continued to work the rest of his/her shift (approximately 2 hours and 24 minutes) with access to all residents in the facility. This deficient practice placed all residents in immediate jeopardy. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 12/6/16, revealed the resident had a (BIMS) Brief Interview for Mental Status score of 12 (moderately impaired cognition) and had hallucinations (seeing things that aren't really there) and delusions (false beliefs that a person firmly holds to be true, despite what other people may think or say). The MDS revealed the resident required extensive staff assistance with bed mobility, locomotion on the unit and toilet use, and limited staff assistance with transfers, walking in room, toilet use, transferring, and personal hygiene. The 12/6/16 (ADL) Activities of Daily Living (CAA) Care Area Assessment revealed the resident required stand by to extensive assistance for ADL performance and instructed staff to offer the resident help as needed, allowing him/her to perform as much ADLs as possible, and assist him/her when no longer able to perform by himself/herself. The 12/8/16 care plan instructed staff to explain all cares to the resident prior to doing them, and ask his/her preferences with cares such as when he/she would like to go to bed. The care plan instructed staff to allow the resident time to do his/her ADLs, on his/her own, without rushing him/her, or doing it for the resident. The care plan revealed the resident received several medications around 7:30 PM that made him/her sleepy. The facility's 1/17/17 incident report revealed on 1/16/17 at approximately 8:00 PM, Nurse Aide A told Nurse Aide B he/she had pushed the resident into bed and Nurse Aide B did not report the alleged abuse to the charge nurse at that time. The report indicated the administrator and the director of nursing were notified of the incident on 1/17/17 at 8:30 AM, and staff suspended Nurse Aide A until the facility completed a full investigation. The report revealed Nurse Aide A admitted he/she did not follow the resident's care plan in regards to the resident had a history of [REDACTED]. The facility's witness statement from Nurse Aide A, dated 1/17/17, revealed Nurse Aide A answered the resident's call light about 7:30 PM or 8:00 PM on 1/16/17. The statement revealed Nurse Aide A asked the resident what he/she needed and the resident stated he/she was not ready to go to bed, but wanted to complete his/her nighttime cares and change clothes. The statement revealed Nurse Aide A assisted the resident in completing his/her nighttime cares and the resident was standing to the side of his/her bed with his/her hands on the chair in front of him/her. The statement revealed Nurse Aide A guided the resident's hand back to the bed and guided him/her to sit down on the bed and Nurse Aide A left the room. Nurse Aide A further stated he/she saw Nurse Aide B, and told him/her he/she had pushed the resident into bed. The statement revealed Nurse Aide A had been inserviced on the facility's abuse, neglect and exploitation policy. The statement lacked when Nurse Aide A had received the inservice. The facility's witness statement from Nurse Aide B dated 1/17/17, revealed on 1/16/17, Nurse Aide A had assisted the resident with going to bed and when he/she came out of the resident's room told Nurse Aide B the resident would not stand up, so Nurse Aide A pushed him/her backwards into the bed. The facility's 1/16/17 clock out record revealed Nurse Aide A (alleged perpetrator) clocked out to go home at 10:24 PM. (approximately 2 hours and 24 minutes after reporting the incident to Nurse Aide B) On 1/25/17 at 7:14 PM, observation revealed the resident seated on the floor in his/her room, Nurse Aide C entered the resident's room, turned on his/her call light, and Nurse D and Nurse Aide E responded to the resident's call light. Observation revealed Nurse D assessed the resident, then Nurse Aide E applied a gait belt to the resident's waist, and Nurse Aide C and Nurse D assisted Nurse Aide E with transferring the resident to his/her bed. On 1/25/17 at 1:45 PM, Nurse Aide B stated Nurse Aide A assisted the resident to bed on 1/16/17, and when he/she came out of the resident's room told Nurse Aide B that he/she had shoved the resident into bed. Nurse Aide B stated he/she did not report this incident to the charge nurse, but later on that night texted the resident's family member (who was also an employee of the facility) about the incident. On 1/25/17 at 2:08 PM Medication Aide F stated on the night of the allegation, he/she was in the resident's room, administered the resident's medications, and the resident requested to go to bed, so Medication Aide F activated his/her call light. Medication Aide F stated the resident required assistance of 2 staff at night, because once the resident received his/her medications he/she became groggy. Medication Aide F stated Nurse Aides A and B came to help the resident and he/she was unaware of anything occurring regarding the resident and Nurse Aide A. On 1/25/17 at 4:54 PM, Nurse H (a nurse employed at the facility) stated he/she was at home on 1/16/17 at approximately 9:00 PM when he/she received a text from Nurse Aide B, stating staff was rude to his/her family member, Resident #1. Nurse H indicated the text stated Nurse Aide A pushed the resident onto his/her bed. Nurse H stated he/she did not notify the director of nursing or administrator at that time, because he/she assumed the charge nurse notified them. On 1/25/17 at 5:12 PM, Nurse D stated he/she was working 1/16/17 at the time of the incident and was unaware it occurred until the next day, when he/she was called to come into the facility. On 1/26/17 at 9:59 AM, Administrative Staff G verified Nurse Aide B did not notify the facility of the allegation of abuse when it occurred on 1/16/17 at 8:00 PM. Administrative Staff G stated the resident's family member came to the facility and reported the allegation to the director of nursing, on the morning of 1/17/17. Administrative Staff G verified Nurse Aide A (alleged perpetrator) worked until 10:24 PM on 1/16/17. (approximately 2 hours and 24 minutes after the incident occurred) The facility's 12/2016 Abuse, Neglect and Exploitation Policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting physical harm or pain or mental anguish. Willful, as used in this definition of abuse, means that the individual must have acted deliberately. The policy defines physical abuse as hitting, slapping, cutting, shoving, pinching, kicking and handling a resident with any more force than is reasonable or apparently necessary of the resident's proper control, treatment or management. The policy stated staff are empowered with the responsibility and obligation to recognize, report and prevent abuse, to ensure the safety of all residents residing in the facility. The facility failed to immediately report to the charge nurse, director of nursing and administrator an allegation of abuse from staff to a resident, which placed 36 residents in immediate jeopardy, when the alleged perpetrator continued to work for approximately 2 hours and 24 minutes in the facility after the allegation of abuse. The facility abated the immediate jeopardy on 1/26/17 at 10:05 PM, after completion of all staff training regarding the facility's abuse, neglect and exploitation policy with emphasis on responsibility to immediately report any allegation or suspicion of abuse, neglect or exploitation to their immediate supervisor. The facility's administrator or director of nursing would have coaching sessions regarding staff's responsibility to report suspicion of abuse, neglect or exploitation with 3 staff per week over the next 90 days. The deficient practice remains at the scope and severity of an F.

The facility identified a census of 41 residents. Based on observation, interview, and record review, the facility failed to protect (gender) residents from resident to resident sexual abuse regarding unwelcomed sexual advances. Resident #25 made inappropriate sexual advances toward four residents of the opposite gender, #13 (when he/she touched the resident's chest area), #33 (when he/she placed his/her hand under the resident's shirt), #36 (when he/she placed his/her hand on the resident's abdomen and did not stop when asked), and #43 (when he/she removed his/her clothing and sat down on the resident's bed). This deficient practice placed all 17 (gender) residents in immediate jeopardy. Findings included: - Resident #25's physician's orders [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 12/15/2015, indicated the resident had severe cognitive impairment with short and long term memory loss. The MDS indicated the resident required extensive assistance of two staff for bed mobility, transfers, toilet use, and personal hygiene. The 12/21/2015 care plan, directed staff to transfer the resident with extensive to total assistance of 2 with his/her walker, or with the sit to stand lift. The care plan stated the resident did not ambulate, and required extensive to total assistance of 2 to reposition. The care plan directed the staff to observe for any signs of depression, or anxiety which indicated the resident was more confused and may become agitated at times. The care plan directed the staff to provide physical assistance, reassurance, and if he/she refused cares then wait and offer a few minutes later. The 2/15/2016 updated care plan directed the staff to provide more assistance to transfer the resident in the morning and/or when tired. The care plan directed the staff to provide extensive assistance of two and ambulated with a front wheeled walker. The 3/01/2016 at 1:47 PM nurse's notes indicated the Nurse Practitioner H instructed staff to administer [MEDICATION NAME], (an antidepressant), 50 (mg) milligrams, every day, to the resident for anxiety and depression. The 3/03/2016 at 6:42 PM, nurse's notes indicated Resident #25 came up behind Resident #13, grabbed him/her inappropriately from behind, and touched his/her chest area. Staff notified Nurse Practitioner H regarding the resident's behaviors and he/she informed the staff to monitor the resident. Nurse Practitioner H reminded staff that he/she prescribed [MEDICATION NAME] the day before for anxiety and depression. The clinical record lacked evidence the facility developed or implemented any additional interventions to protect the (gender) residents in the facility. The 3/04/2016 at 7:12 AM, nurse's notes indicated the facility called the resident's family member to discuss finding temporary placement for the resident due to his/her behaviors. The family member was reluctant to transfer the resident. He/she visited with Administrator C and Social Service Staff J regarding the need for a special care unit. Continued contact with the special care unit indicated they would not be able to accept the resident to the special care unit because they were unable to meet his/her needs. The 3/04/2016 at 1:42 PM, nurse's notes indicated due to the resident's inappropriate behavior last evening, the primary care physician instructed staff to obtain lab and a urinalysis from the resident. The 3/04/2016 at 2:11 PM, nurse's notes indicated the facility called the physician regarding the resident's behaviors and he/she ordered [MEDICATION NAME] (an antipsychotic), 10 mg, twice a day, and the physician stated the medication would help with the resident's behaviors. This intervention was not added to the care plan. Review of the 30 minute check documentation revealed multiple entries at the same time and gaps in time from 1 minute to 7 hours and 54 minutes. The 3/07/2016 at 6:00 PM, nurse's notes revealed on 3/05/2016, in the evening, Resident #25 pulled himself/herself up on the back of Resident #33's wheelchair, to a standing position. The resident had one hand on the handle on the back of the wheelchair and the other hand over the shoulder and under Resident #33's shirt. Resident #25 was conversing with Resident #33 but staff was unable to hear what the resident was saying, and separated the residents. (The 30 minute visual documentation revealed no documentation from 1:30 PM to 9:24 PM - 7 hours and 54 minutes) The 30 minute visual checks was not added to the care plan. The 3/07/2016 at 6:52 PM, nurse's notes, documented as a late entry, indicated staff observed Resident #25 standing behind Resident #33 and the aide reported Resident #25 grabbed Resident #33's breast. Staff notified Administrative Staff C and Administrative Nurse D and received instruction to place the resident on 15 minute visual checks. Communication with Nurse Practitioner H verified it would take 3 days for the [MEDICATION NAME] to reach levels in the body to be able to observe desired results. Nurse Practitioner H instructed staff to redirect Resident #25 in the presence of (gender) residents to prevent any future incidents. The staff initiated 15 minute visual checks of the resident. Review of the 15 minute check documentation revealed multiple entries at the same time and gaps in the time from 2 hours to 10 hours and 12 minutes. The 3/09/2016 at 7:45 PM, nurse's notes indicated the resident sat in a wheelchair in front of the nurse's station with his/her right hand on the left side of Resident #36's abdomen. Resident #36 asked the resident to stop and when he/she did not Resident #36 slapped his/her right hand. Staff separated the residents. The clinical record lacked evidence the facility implemented any additional interventions to protect the (gender) residents in the facility. On 3/10/2016 at 11:30 AM, Medication Aide M stated, on 3/05/2016 at 6:45 PM, he/she witnessed Resident#25 reach over Resident #33's left shoulder and put his/her hands inside the front of his/her shirt and the aide placed his/her hand on the resident's forearm. The resident pulled his/her hand out as soon as the aide touched him/her. The resident stopped the physical contact but continued to hold onto the wheelchair handle. Nurse O spoke with the resident, and then Nurse Aide L removed Resident #25 from the situation. Medication Aide M stated when the facility admitted Resident #25 he/she was not medically stable, and had a personal care attendant. The resident continued to increase his/her ADL abilities, and the family decreased the time the personal care attendant stayed with the resident at the facility. That is when the aggressive and sexual behaviors increased. Medication Aide M stated the resident does have behaviors and he/she liked to strip naked, and the staff were to redirect the resident when he/she was aggressive and/or having behaviors. On 3/10/2016 at 2:09 PM, Nurse Aide L stated, on 3/05/2016, he/she witnessed Resident #25 right and left hand had a grip on the wheelchair. Staff removed Resident #25's hand from the other resident's shirt. Resident #33 does not talk, however a startled scared look was on his/her face. Nurse Aide L stated he/she observed Resident #25's behaviors increase when his/her personal attendant was no longer at the facility sitting with the resident, he/she is more mobile now. On 3/10/2016 at 1:28 PM, Resident #43 stated, on 3/03/2015 at 6:00 AM, Resident #25 walked into his/her room and lowered his/her pants and sat down on the side of his/her bed. The resident's roommate pushed the call light to get staff assistance. Nurse Aide B entered the room and escorted the resident to his/her room. Resident #43 stated Resident #25's confused, goes into other resident's room and has come in to his/her room [ROOM NUMBER] times. The 3/16/2016 at 11:10 AM, observation revealed the resident sat in his/her wheelchair, then stood up and took a few steps while holding on to a table across from the nurse's station on the South hall. Continued observation revealed Nurse A walked over to the resident and assisted him/her to sit back down in the wheelchair. Then the resident independently propelled him/herself down the hall to his/her room. On 3/14/2016 at 9:37 AM, Nurse Aide B indicated, on approximately 3/05/2016, observed Resident #25 sat on the foot of Resident #43's bed, after taking off his/her briefs, pants, and exposed his/her privates. Nurse Aide B redirected resident #25 out of Resident #43's room. On 3/10/2016 at 11:15 AM, Administrative Nurse D stated he/she had no idea why Resident #25's behaviors increased, and verified his/her mobility increased. Administrative Nurse D stated he/she contacted Nurse Practitioner H to consult for the increased behaviors. Nurse Practitioner H started Resident #25 on [MEDICATION NAME], 10 mg, twice a day, on 3/04/2016, for inappropriate touching. On 3/10/2016 at 1:45 PM, Administrative Staff C stated he/she had investigated the allegations that Nurse Aide L, Medication Aide M, Restorative Aide N, and Resident #43 had made regarding the inappropriate sexual advances Resident #25 made towards (gender) residents at the facility multiple times. He/she stated that it was a conspiracy and the incidents did not occur and the staff and residents are just making this up. Administrative Staff C stated all the incidents occurred on the shift the 3 staff who reported the allegations work, did not occur on any other shift and the 3 staff are the only ones who observed the incidents. Administrative Staff C stated if the incidents happen only on their shift then they apparently are not providing appropriate care and oversight for the resident. The facility's December 2014 Abuse, Neglect and Exploitation policy included that residents would be free from physical, emotional, and sexual abuse. The report of neglect or abuse made by a resident, family member, visitor or employee is investigated within 24 hours, Administrator, Director of Nursing or designee shall be notified immediately by report. Persons who might have knowledge of the incident are interviewed privately. A written record is made of the interviews and this written record becomes a part of the investigative file. In addition to interviews, the investigation may include analysis of the medical record, assessment of the resident and statements from various individuals, as well as resident. If you have reasonable suspicion that a crime has occurred against a resident or person receiving care at the facility, federal law requires that you report your suspicion directly to both law enforcement and the state survey agency, If the crime involves serious bodily injury including criminal sexual abuse to the resident, it must be reported immediately, but no later than 2 hours after forming the suspicion, or if the crime does not appear to cause serious bodily injury to the resident you must report it within 24 hours after forming the suspicion. The staff are responsible to protect residents from abusive staff members and from other residents who might be acting in an aggressive manner. The facility will take steps to prevent mistreatment while the investigation is underway, Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. All employees are educated concerning their responsibility to immediately report or cause a report to be made to the appropriate State agency, of any abuse or neglect they witness or are aware of. The facility failed to protect (gender) residents from resident to resident sexual abuse regarding unwanted sexual advances from Resident #25. This deficient practice placed the 17 (gender) residents in immediate jeopardy. The facility abated the immediate jeopardy, when they placed Resident #25 on 1 to 1 and after the completion of training all staff on 3/14/2016, regarding the protection of all residents during resident to resident behaviors and implementation of 1 of 1 as needed. The training also included the importance of following the abuse, neglect and exploitation policy and following up with the physician, and protection of all of the residents. The deficient practice remains scope and severity of an E.

The facility identified a census of 41 residents. Based on observation, interview, and record review, the facility failed to protect (gender) residents from resident to resident sexual abuse regarding unwelcomed sexual advances and from physical aggression male to male physical abuse for 1 of 3 sampled residents reviewed for abuse. (#25) Findings included: - Resident #25's physician's orders [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 12/15/2015, indicated the resident had severe cognitive impairment with short and long term memory loss. The MDS indicated the resident required extensive assistance of two staff for bed mobility, transfers, toilet use, and personal hygiene. The 12/21/2015 care plan, directed staff to transfer the resident with extensive to total assistance of 2 with his/her walker, or with the sit to stand lift. The care plan stated the resident did not ambulate, and required extensive to total assistance of 2 to reposition. The care plan directed the staff to observe for any signs of depression, or anxiety which indicated the resident was more confused and may become agitated at times. The care plan directed the staff to provide physical assistance, reassurance, and if he/she refused cares then wait and offer a few minutes later. The 2/15/2016 updated care plan directed the staff to provide more assistance to transfer the resident in the morning and/or when tired. The care plan directed the staff to provide extensive assistance of two and ambulated with a front wheeled walker. The 3/01/2016 at 1:47 PM nurse's notes indicated the Nurse Practitioner H instructed staff to administer [MEDICATION NAME], (an antidepressant), 50 (mg) milligrams, every day, to the resident for anxiety and depression. The 3/03/2016 at 6:42 PM, nurse's notes indicated Resident #25 came up behind Resident #13 and grabbed him/her inappropriately from behind, and touched his/her chest area. Staff notified Nurse Practitioner H regarding the resident's behaviors and he/she informed the staff to monitor the resident and reminded staff that he/she prescribed [MEDICATION NAME] the day before for anxiety and depression. The clinical record lacked evidence the facility developed or implemented any additional interventions to protect the (gender) residents in the facility. The 3/04/2016 at 7:12 AM, nurse's notes indicated the facility called the resident's family member to discuss finding temporary placement for the resident due to his/her behaviors. The family member was reluctant to transfer the resident and he/she visited with Administrator C and Social Service Staff J regarding the need for a special care unit. Continued contact with the special care unit indicated they would not be able to accept the resident to the special care unit because they were unable to meet his/her needs. The 3/04/2016 at 1:42 PM, nurse's notes indicated due to the resident's inappropriate behavior last evening the primary care physician instructed staff to obtain lab and a urinalysis from the resident. The 3/04/2016 at 2:11 PM, nurse's notes indicated the facility called the physician regarding the resident's behaviors and he/she ordered [MEDICATION NAME] (an antipsychotic), 10 mg, twice a day, and the physician stated the medication would help with the resident's behaviors. Review of the 30 minute check documentation revealed multiple entries at the same time and gaps in time from 1 minute to 7 hours and 54 minutes. The 3/07/2016 at 6:00 PM, nurse's notes revealed on 3/05/2016, in the evening, Resident #25 pulled himself/herself up on the back of Resident #33's wheelchair, to a standing position. The resident had one hand on the handle on the back of the wheelchair and the other hand over the shoulder and under Resident #33's shirt. Resident #25 was conversing with Resident #33 but staff was unable to hear what the resident was saying, and separated the residents. (The 30 minute visual documentation revealed no documentation from 1:30 PM to 9:24 PM - 7 hours and 54 minutes) The 3/07/2016 at 6:52 PM, nurse's notes, documented as a late entry, indicated staff observed Resident #25 standing behind Resident #33 and the aide reported Resident #25 grabbed Resident #33's breast. Staff notified Administrative Staff C and Administrative Nurse D and received instruction to place the resident on 15 minute visual checks. Communication with Nurse Practitioner H verified it would take 3 days for the [MEDICATION NAME] to reach levels in the body to be able to observe desired results. Nurse Practitioner H instructed staff to redirect Resident #25 in the presence of (gender) residents to prevent any future incidents. The staff initiated 15 minute visual checks of the resident. Review of the 15 minute check documentation revealed multiple entries at the same time and gaps in the time from 2 hours to 10 hours and 12 minutes. The 3/09/2016 at 7:45 PM, nurse's notes indicated the resident sat in a wheelchair in front of the nurse's station with his/her right hand on the left side of Resident #36's abdomen. Resident #36 asked the resident to stop and when he/she did not Resident #36 slapped his/her right hand. Staff separated the residents. On 3/10/2016 at 11:30 AM, Medication Aide M stated, on 3/05/2016 at 6:45 PM, he/she witnessed Resident#25 reach over Resident #33's left shoulder and put his/her hands inside the front of his/her shirt and the aide placed his/her hand on the resident's forearm. The resident pulled his/her hand out as soon as the aide touched him/her. The resident stopped the physical contact but continued to hold onto the wheelchair handle. Nurse O spoke with the resident, and then Nurse Aide L removed Resident #25 from the situation. Medication Aide M stated when the facility admitted Resident #25 he/she was not medically stable, and had a personal care attendant. The resident continued to increase his/her ADL abilities, and the family decreased the time the personal care attendant stayed with the resident at the facility. That is when the aggressive and sexual behaviors increased. Medication Aide M stated the resident does have behaviors and he/she liked to strip naked,and the staff were to redirect the resident when he/she was aggressive and/or having behaviors. On 3/10/2016 at 2:09 PM, Nurse Aide L stated, on 3/05/2016, he/she witnessed Resident #25 right and left hand had a grip on the wheelchair. Staff removed Resident #25's hand from the other resident's shirt. Resident #33 does not talk, however a startled scared look was on his/her face. Nurse Aide L stated he/she also witnessed another incident (unsure of date) when Resident #25 punched Resident #31 in the jaw. Staff separated the two and Resident #25 continued to try to go back to Resident #31. Nurse Aide L stated he/she observed Resident #25's behaviors increase when his/her personal attendant was no longer at the facility sitting with the resident, and he/she is more mobile now. On 3/10/2016 at 1:28 PM, Resident #43 stated, on 3/03/2015 at 6:00 AM, Resident #25 walked into his/her room and lowered his/her pants and sat down on the side of his/her bed. The resident's roommate pushed the call light to get staff assistance. Nurse Aide B entered the room and escorted the resident to his/her room. Resident #43 stated Resident #25's confused, goes into other resident's room and has come in to his/her room [ROOM NUMBER] times. The 3/16/2016 at 11:10 AM, observation revealed the resident sat in his/her wheelchair, then stood up and took a few steps while holding on to a table across from the nurse's station on the South hall. Continued observation revealed Nurse A walked over to the resident and assisted him/her to sit back down in the wheelchair. Then the resident independently propelled him/herself down the hall to his/her room. On 3/10/2016 at 3:10 PM, Nurse O stated he/she had not witnessed any sexual behavior displayed by the resident during the time he/she worked at the facility. Nurse O stated he/she worked on an as needed basis at the facility. On 3/14/2016 at 9:37 AM, Nurse Aide B indicated, on approximately 3/05/2016, he/she observed Resident #25 sat on the foot of Resident #43's bed, after taking off his/her briefs, pants, and exposed his/her privates. Nurse Aide B redirected Resident #25 out of Resident #43's room. On 3/10/2016 at 11:15 AM, Administrative Nurse D stated he/she had no idea why Resident #25's behaviors increased, and verified his/her mobility increased. Administrative Nurse D stated he/she contacted Nurse Practitioner H to consult for the increased behaviors, and Nurse Practitioner H started Resident #25 on [MEDICATION NAME], 10 mg, twice a day, on 3/04/2016, for inappropriate touching. On 3/10/2016 at 1:45 PM, Administrative Staff C stated he/she had investigated the allegations that Nurse Aide L, Medication Aide M, Restorative Aide N, and Resident #43 had made regarding the inappropriate sexual advances Resident #25 made towards (gender) residents at the facility multiple times. He/she stated that it was a conspiracy and the incidents did not occur and the staff and residents are just making this up. Administrative Staff C stated all the incidents occurred on the shift the 3 staff who reported the allegations work, did not occur on any other shift and the 3 staff are the only ones who observed the incidents. Administrative Staff C stated if the incidents happen only on their shift then they apparently are not providing appropriate care and oversight for the resident. The facility's December 2014 Abuse, Neglect and Exploitation policy included that residents would be free from physical, emotional, and sexual abuse. The report of neglect or abuse made by a resident, family member, visitor or employee is investigated within 24 hours, Administrator, Director of Nursing or designee shall be notified immediately by report. Persons who might have knowledge of the incident are interviewed privately. A written record is made of the interviews and this written record becomes a part of the investigative file. In addition to interviews, the investigation may include analysis of the medical record, assessment of the resident and statements from various individuals, as well as resident. If you have reasonable suspicion that a crime has occurred against a resident or person receiving care at the facility, federal law requires that you report your suspicion directly to both law enforcement and the state survey agency, If the crime involves serious bodily injury including criminal sexual abuse to the resident, it must be reported immediately, but no later than 2 hours after forming the suspicion, or if the crime does not appear to cause serious bodily injury to the resident you must report it within 24 hours after forming the suspicion. The staff are responsible to protect residents from abusive staff members and from other residents who might be acting in an aggressive manner, The facility will take steps to prevent mistreatment while the investigation is underway, Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. All employees are educated concerning their responsibility to immediately report or cause a report to be made to the appropriate State agency, of any abuse or neglect they witness or are aware of. The facility failed to protect (gender) residents from resident to resident sexual abuse regarding unwanted sexual advances from Resident #25.

The facility had a census of 43 residents. The sample included 4 residents of which all were reviewed for nutrition. Based on record review and interview the facility failed to implement interventions to prevent significant weight loss for 1 sampled resident (#1). Findings included: - Resident #1's medical record revealed the facility admitted the resident on 10/31/2012 and discharged the resident on 2/15/2013. Review of Resident #1's admission (MDS) Minimum Data Set 3.0 assessment, dated 11/13/2012, indicated the resident scored 11 on the (BIMS) Brief Interview of Mental Status, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required extensive assistance of 1 staff for most (ADLs) Activities of Daily Living. The MDS indicated the resident needed supervision and set up help only for eating, was 54 inches tall and weighed 97 pounds. The assessment revealed the resident had a 5% significant weight loss in the last month, received a therapeutic diet and had abnormal mouth tissue (ulcers, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn). The resident's nutritional status (CAA) Care Area Assessment, dated 11/13/2012, indicated the resident received a soft, 2 gram sodium, low cholesterol diet and the resident weighed 98.9 pounds on admission. The CAAS indicated the resident had a significant weight loss and indicated the resident ate 62% of his/her meals. The assessment stated the resident had a [DIAGNOSES REDACTED].) As the name indicates (osteo meaning bone and necrosis meaning death), the bone begins to weaken and die. The CAA also indicated the resident had a tooth extracted by an oral surgeon on 11/8/2012 and received an antibiotic for 14 days. The CAA indicated the resident ate independently and required help with set up assistance and, on 11/12/2012, the registered dietician evaluated the resident and recommended to change the resident ' s diet to a regular diet with soft foods. The care plan, dated 11/29/2012, indicated the resident received a regular diet with soft food and preferred to eat in his/her room. The care plan indicated the resident ate independently and would ask for help if he/she needed. The updated 1/17/2013 care plan instructed the staff to encourage/offer high calorie foods at his/her meals such as pudding, ice cream and shakes. The updated 2/12/2013 care plan instructed the staff to continue to give the resident Two Cal, a nutritional supplement, 60 (cc) cubic centimeters, three times a day for weight loss. The updated care plan instructed the staff to provide the resident a high calorie protein snack three times a day to enhance the resident ' s nutrition. Review of the medical record revealed the resident had dental surgery on 11/8/2012 which required extraction of two teeth. The resident had required a narcotic pain medication and received an antibiotic for 14 days following surgery. The medical record indicated the physician had ordered the Two Cal nutritional supplement on 12/3/2012. Review of the resident 's medical record revealed the Two Cal (nutritional supplement) was not listed on the December 2012 or the January 2013 (MAR) Medication Administration Records after it was ordered by the physician on 12/3/2012. Review of the resident 's weight record after dental surgery revealed the following: 12/13/2012 -91 pounds (#) 12/20/2012-90.8 # 1/1/2013-84.6 # 1/7/2013-83.6 # 1/10/2013 81.6 # 1/16/2013-81.6 # 1/21/2013-81.6 # (9.4# or 10% weight loss in 39 days) The December 2012 Food Intake Record indicated the resident ate 10 to 90% and refused 2 of his/her breakfast meals, ate 5 to 80% of his/her lunch and refused 1 along with fluids and 2 lunch meals had no documentation of whether the resident refused or consumed the meal. For the evening meal the resident's intake averaged 40 to 100% with one refusal, fluids refused at 3 evening meals and 7 of the resident's evening meals had no documentation of refusal or consumption by the resident. The 1/14/2013 Nutrition risk evaluation record indicated the resident had a weight loss of 5% in the last 30 days. The resident ' s weight was 83.6 pounds. The record indicated the resident was not on a physician prescribed weight loss regimen. The nutrition risk evaluation record indicated the resident ' s intake appeared to be adequate and the resident had a greater than 10% weight loss since admission. The nutrition evaluation indicated the resident should continue to receive Two Cal nutritional supplement,60 cc, three times a day and high protein, high calorie snacks like Ensure or Boost, with milk and cookies although the MAR for December 2012 and January 2013 did not include the Two Cal. The January 2013 Food Intake Record indicated the resident ate 5 to100% with the resident refusing his/her breakfast meal 6 times and these 6 times the resident consumed no fluids. The resident ate 5 to100% of lunch meals with the resident refusing 6 of his/her lunch meals and his/her fluids, and the resident ate an 5 to100% of his/her supper meals with 8 of the residents supper meals had no documentation of the resident refusal or consumption of these 8 meals, and the resident refused 2 of his/her supper meals including fluids. The resident only received the Two Cal nutritional supplement, 60 cc dose, three times a day for a total of 9 doses from the original physician's orders [REDACTED]. Reivew of the residen'ts medical record lacked documentation the facility provided the high calorie snack as recommended and planned by the dietician. On 2/18/2013 at 3:35 PM, Nurse A verified the physician order [REDACTED]. The 2/12/2013 order was transcribed on the February MAR and the resident received 9 doses of the Two Cal nutritional supplement in February. Nurse A stated the nurse initials the MAR when a nutritional supplement is given and will circle it if the resident did not consume the entire amount. The nurse will write the reason why it was not consumed on the back of the MAR. Nurse A further stated the nurse who took the new physician order [REDACTED]. On 2/18/2013 at 4:12 PM, Nurse consultant B verified the physician's orders [REDACTED]. On 2/19/2013 at 9:25 AM, Dietary Staff C stated the nursing staff provided the Two Cal supplement. Dietary Staff C also stated any nutritional supplement the dietary department provided was given at snack time. Dietary Staff C further stated the dietary department does not give supplements at meal time. On 2/26/13 at 1:50 PM, Consultant Dietician Staff D stated when making a recommendation regarding a resident's weight loss and the physician ordered the recommended nutritional supplement the facility should follow through with the order and if the physician's orders [REDACTED]. The facility failed to transcribe and implement the physician ordered supplement following the Registered Dietician's recommendation for Resident #1's continued weight loss.

The facility had a census of 50 residents with 6 residents sampled for review. Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents sampled for hydration received sufficient fluid intake to maintain proper hydration which resulted in admission to the hospital with a medical [DIAGNOSES REDACTED]. Findings included: - Notes proved by administrative nurse B from a nurses' staff meeting for licensed staff in August of 2010 included the following: "It is your responsibility to monitor food and fluid intakes every meal for every resident and to act upon any problem as it occurs". Resident #2's 1/27/11 CAAs (Care Area Assessments) for ADLs (activities of daily living) stated the resident required extensive to total staff assistance with all ADLs. The assessment for dehydration stated the resident "does not remember to drink fluids unless drinks are offered. Will refuse some drinks. Loves pepsi". The resident's 1/27/11 nursing care plan for hydration included the following: "I usually drink fluids fairly well, so I am at lower risk for dehydration. I need your help to drink as I don't remember that I need to drink. I am able to drink by myself when you hand me a drink. Sometimes I will throw the drink if I don't like what you give me. Dehydration is when a person doesn't have enough fluids in (his/her) body. Dehydration can be caused from not drinking enough, diarrhea, excessive sweating or vomiting. Signs of dehydration include dry tongue, having small amounts of urine, dark urine, skin that tents when gently pinched, or low blood pressure. Let my doctor know if you see that I have any of these signs of dehydration" Resident #2's 3/23/11 Quarterly MDS (minimum data set) assessment revealed the resident rarely/never understood others or rarely/never had the ability to make oneself understood. The assessment also revealed the resident had moderately impaired cognition, totally dependent on 1 person for eating/drinking, and totally dependent on 2 persons for transfers and toilet use. Review of resident #2's fluid intake with meals revealed the following total intake for breakfast, lunch, and dinner ( 1318ml /24 hours recommended fluid intake by dietician): * 02/24/11 840ml (milliliters) * 02/25/11 960ml * 03/01/11 960ml * 03/02/11 360ml * 03/03/11 1300ml * 03/05/11 260ml * 03/06/11 480ml * 03/07/11 840ml Nurses notes dated 3/8/11 stated, made an appointment with doctor for increased weakness and appetite poor. Resident #2's 3/8/11 History and Physical stated the following: "Came to see me in the clinic in a wheelchair...chief complaint was decreased po (per os/ by mouth) intake and significant dementia...CBC (complete blood count), CMP (comprehensive metabolic panel) performed and the patient was sent back to Wheatland. When the lab results returned, I decided to direct admit (him/her) for [MEDICAL CONDITION] (elevated sodium in the blood) as it can cause [MEDICAL CONDITION] and other mental status complications. Review of systems: ....The patient's family provided a history of several years of severe dementia and personality changes...and significant decreased po intake recently to the point where the patient sometimes takes full meals but other times does not seem to eat anything. (He/she) does have Ensure ordered, the the patient family was unsure whether (he/she) was getting each of the three daily doses because of (his/her) mental status. Assessment and plan: ....Directly admitted to the hospital under observation for [MEDICAL CONDITION]. At this point my calculated free fluid deficit (formula physicians use to calculate the amount of fluids that should be replaced to correct the deficit) is approximately 4 L (liters) given (the) sodium and body weight. Would like to correct that over 48-72 hours and will start on D5W (5% [MEDICATION NAME] in water, a fluid used for intravenous infusion) at 90 ml/hour for 48 hours and re-assess at that time...At this point, the patient has no recently reported history of [MEDICAL CONDITION] and this is one of the reasons we are admitting (him/her) to prevent [MEDICAL CONDITION] and other complications from [MEDICAL CONDITION] etiology (cause) of the [MEDICAL CONDITION] most likely is not drinking and not eating; therefore, dehydration and free water deficit. If the sodium does not correct appropriately with D5W, will work (the patient) up for other causes. Would also expect creatinine to improve with hydration." Lab studies performed on 3/8/11 revealed the following: * Sodium 162 (normal 133-145) * BUN (blood urea nitrogen) 46 (normal 6-19) * Creatinine 1.3 (normal .4 - 1.1) Follow-up lab studies performed on 3/9/11 (after initiation of intravenous fluids): * Sodium 159 (normal 133-145) * BUN 33 (normal 6-19) Lab studies done on 3/11/11 revealed: * Sodium 142 (normal 133-145) Nurses notes dated 3/11/11 at 4:45pm revealed the resident returned to the facility with a [DIAGNOSES REDACTED]. During an observation on 4/5/11 at 5:50pm, resident #2 sat in a wheelchair at the dining room table. Dietary staff liquefied the resident's food and the resident held the glass and drank the meal and other fluids. During an observation on 4/6/11 at 9:18am, nursing staff C and D assisted resident #2 to the toilet, then to lay down in the bed to rest. A covered plastic cup with a straw contained 550ml of room temperature water sat by the sink. Staff failed to offer the resident any fluids while providing care. An interview on 4/6/11 at 3:51pm with licensed nursing staff E revealed the nurses aides usually assist the residents in the dining room, so they would know if a resident had poor intake. She added staff did not document fluid intakes from snacks, only document if taken or refused. Licensed staff E had no knowledge of resident #2's intake on the days prior to the resident's hospitalization . During an interview on 4/6/11 at 4:57, administrative nurse B stated an in-service for licensed staff had been held and the nurses should review each resident's intake daily and initiate I and O (intake and output) if they had poor intake. Administrative nurse B also confirmed that staff did not document in- room fluids and fluid intake with snacks. She added that resident #2's intake varied greatly due to the severe dementia and had no awareness of the resident's poor intake prior to hospitalization . On 4/6/11 at 5:37pm, administrative nurse B stated she had reviewed resident #2's intake record prior to the hospitalization and stated the nurses should have intervened. In summary, the facility failed to ensure resident #2 received sufficient fluid intake to maintain proper hydration which resulted in admission to the hospital with a medical [DIAGNOSES REDACTED]. .