Brickyard Healthcare - Golden Rule Care Center

Based on interview and record review, the facility failed to treat a resident with respect and dignity when requesting pain medications for 1 of 6 residents reviewed for dignity. (Resident E) Findings include:During an interview with Certified Nursing Assistant (CNA) 2 on 2/2/26 at 2:37 p.m., they indicated they witnessed Registered Nurse (RN) 5 not acknowledging Resident E when Resident E wanted to speak with them about their pain medication that was due. CNA 2 indicated Resident E came to the nurse's station to speak with RN 5 who was sitting at the desk. RN 5 would not look up or acknowledge that Resident E was standing in front of her. The CNA indicated Resident E then started pounding on the desk with her cane, kicking it, while holding her communication tablet in the other hand. Resident E used a tablet to communicate. The CNA told RN 5 that Resident E was trying to get her attention, and her reply was, I know, thanks captain obvious, I know how to do my job. CNA 2 indicated RN 5 continued not to acknowledge Resident E after that was said and continued to work. RN 5 did eventually respond back to Resident E, but did not look up at her. Resident E was very upset. The clinical record for Resident E was reviewed on 2/3/26 at 11:15 a.m. The resident's diagnoses included, but were not limited to, hemiplegia (paralysis affecting on side) and hemiparesis (weakness on one side) following cerebral infarction (blockage in a blood vessel causing brain death) to left side, and aphonia (total loss of voice). The Annual Minimum Data Set (MDS) assessment, dated 11/5/25, indicated Resident E was cognitively intact, had chronic pain syndrome, and used opioid pain medication. During an interview with CNA 3 on 2/3/26 at 10:02 a.m., they indicated they answered Resident E's call light around 6:00 a.m. Resident E wanted her prn (as needed) pain medication. CNA 3 indicated she told RN 5 that Resident E was requesting her prn pain medication, and RN 5 indicated she had it at 2:30 a.m. and was not due again until 8:30 a.m. The CNA went back to Resident E's room to inform her what RN 5 told her. The resident indicated that was incorrect because she had her last medication around midnight. CNA 3 indicated this had made Resident E very upset because Resident E knows when she needs her prn medications and when they are due. Resident E walked down to the nurse's station after that with her tablet and was standing in front of RN 5 who was sitting at the nurse's desk. CNA 3 indicated Resident E stood there for a few minutes, with RN 5 not acknowledging her, so Resident E began banging her cane on the desk and kicking the desk to get her attention. CNA 2 then alerted RN 5 that Resident E needed her attention and needed something. RN 5 indicated to CNA 2 that she could see that, captain obvious, rudely. RN 5 continued to not acknowledge the resident after that, then a few moments later, spoke to her without looking up from her computer. CNA 3 indicated Resident E was taken back to her room after that incident and was very upset. During an interview with Resident E on 2/3/26 at 10:15 a.m., the resident indicated a nurse gave her prn pain medication at 11 p.m. and refused to give her prn oxycodone (pain medication) at 5:00 a.m. The resident indicated she did not get her medications until 8:00 a.m. RN 5 withholds and prolongs giving her her pain medications frequently and not receiving her prn pain medications when she requests them, causes her to have increased pain. Resident E indicated she will wait up to two hours for her prn pain medications and by then her pain was completely out of control. No other nurses will do that except RN 5 who has done this to her ever since she began working there in Sept. During an interview with Licensed Practical Nurse (LPN) 8 on 2/4/26 at 3:41 p.m., the LPN indicated they did their training with RN 5 and she would specifically make Resident E wait hours to get her prn pain medication, and did not know why. A plan of care, dated 12/9/22, indicated Resident E had a communication problem due to not being able to speak and will be able to make basic needs known. The interventions included, but were not limited to, allow calm, unhurried environment to encourage communication, answer questions as needed and repeat as necessary, listen carefully, and validate verbal and non verbal expressions. A plan of care, dated 12/9/22, indicated Resident E needed pain management related to chronic pain syndrome. The interventions included, but were not limited to, distraction techniques, imagery, music, and relaxation techniques. A Resident Right policy was provided by the Executive Director (ED) on 2/4/26 at 9:35 a.m. It indicated .Resident Rights: 4. Respect and dignity. The resident has a right to be treated with respect and dignity. This citation relates to intakes 2728759 and 2728476.3.1-9(a)

Based on interview and record review, the facility failed to investigate and follow up with a resident related to a staff member not addressing needs and wants for 1 of 1 resident reviewed for grievances. (Resident E) Findings include:During an interview on 2/2/26 at 2:37 p.m., Certified Nursing Assistant (CNA) 2 indicated she filled out a grievance form for Resident E on 1/24/26 in relation to an incident that occurred that morning at the nurse's station between Resident E and Registered Nurse (RN) 5. The morning of 1/24/26, Resident E was at the nurse's station upset and wanting to speak with RN 5 regarding her pain medication and that she was due for them. RN 5 indicated it was not time for her prn (as needed) medicine. CNA 2 indicated RN 5 would not acknowledge Resident E when she was standing at the nurse's station, and Resident E, who communicated primarily by tablet use, was pounding her cane on the desk and kicking it attempting to get RN 5's attention. Resident E was completely aware of her medications, times they were given, and times they were due again. RN 5 would not acknowledge Resident E, and eventually responded to Resident E but did not look up at her while speaking. CNA 2 indicated Resident E was very upset and she assisted Resident E back to her room at that time. A grievance form was filled out that morning, which was a Saturday, and placed a copy under the Director of Nursing's (DON) and the Executive Director's (ED) doors. The clinical record for Resident E was reviewed on 2/3/26 at 11:15 a.m. The resident's diagnoses included, but were not limited to, chronic pain syndrome, cerebral infarction (blockage in a blood vessel, leading to brain tissue death from lack of oxygen), and anxiety. The Annual Minimum Data Set (MDS) assessment, dated 11/5/25, indicated Resident E was cognitively intact, had chronic pain syndrome, and frequently had pain. During an interview with CNA 2 on 2/3/26 at 9:45 a.m., they indicated no one followed up with her about the grievance. During an interview with Resident E on 2/3/26 at 10:15 a.m., Resident E indicated no one had come in to follow up with her about the grievance. A plan of care, dated 12/9/22, indicated Resident E had impaired neurological status related to cerebrovascular accident. The interventions included, but were not limited to, reassurance and patience when patient attempts to communicate. A plan of care, dated 12/9/22, indicated Resident E had communication problems due to not being able to speak (aphonia) and had a communication device. The interventions included, but were not limited to, answer questions as needed and repeat as necessary, communicate with resident using electronic communication device, listen carefully, validate verbal and non verbal expressions, and maintain eye contact. During an interview with the DON on 2/4/26 at 9:34 a.m., the DON indicated they had not followed up with Resident E about the grievance. After receiving a grievance from a staff member in regards to a resident, the facility should have investigated, talked to the resident and staff members involved. A Resident and Family Grievance policy was provided by the Administrator in Training (AIT) on 2/3/26 at 10:55 a.m. It indicated .8. Grievances may be voiced in the following forms: b. Written complaint to a staff member or Grievance Official.10. Procedure: e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards the resolution of the grievances.g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance. The written decision will include at a minimum: ii. The steps taken to investigate the grievance.iii. A summary of the pertinent findings or conclusions regarding the resident's concerns.12. The facility will make prompt efforts to resolve grievances. This citation relates to intake 2728759.3.1-7(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free from mental/verbal abuse and threats of seclusion resulting in fear, intimidation, and mental anguish for 2 of 6 residents reviewed for abuse (Resident B and Resident C). Using the reasonable person concept, it is likely this would lead to fear, confusion, anxiety, and intimidation for Resident B and Resident C.Findings include:1. Review of the clinical record of Resident B on 2/2/26 at 10:55 a.m., indicated the resident's diagnoses included, but were not limited to, bipolar disorder (a chronic mental health condition), anxiety, paranoid schizophrenia (a mental health condition characterized by intense, irrational delusions), dementia (a decline in mental abilities), and repeated falls.
The quarterly Minimum Data Set (MDS) assessment for Resident B, dated 12/5/25, indicated the resident was cognitively intact for daily decision making. The resident did not exhibit any behaviors during these assessment time frame. The resident utilized a wheelchair for mobility.
The change in condition progress note for Resident B, dated 1/6/26 at 4:32 a.m., indicated a new order was received to send the resident to hospital. The resident was paranoid, falsely accusatory toward staff, disoriented to situation, yelling and screaming in her room and in the hallway and was waking up other residents on the unit. The resident was threatening to beat up staff. The resident was rolling around in her wheelchair staring at staff and being intimidating. The resident cursed at staff. The resident believed staff knew her family and was conspiring against her to do evil things. Staff and other residents did not provoke resident in any way or respond to her behaviors except to reorient her to reality and ask her to lower her voice so other residents could sleep. Reoriented the resident to reality that it was the middle of the night and no one means her any harm, we just want her to quiet down to maintain a peaceful living environment for herself and other residents. The resident was transferred to the hospital via Emergency Medical Services (EMT). The progress note was electronically signed by RN 5.
The EMT run report for Resident B, dated 1/6/26 at 4:22 a.m., indicated the medics were dispatched to a mental and emotional patient at the nursing home. Once the medics were on scene the nurse said the patient was schizophrenic that was also bipolar. The nurse said the resident had been refusing her medications and not acting herself. The patient refused to come near the EMT and was in a wheelchair rolling around the day room. The patient was alert and oriented and cognitively intact. The patient was saying the head nurse was dangerous and was trying to hurt her. After the medics talked to the resident from a distance for some time, a medic was able to convince the resident to go with them. The patient reported to the medics she wanted to talk to the doctor at the hospital about the nursing home staff. The patient was assisted onto the stretcher and secured in the ambulance. The resident said the people that work at the nursing home need stopped and then the resident fell asleep during transport to the hospital.
The hospital note for Resident B, dated 1/6/26 at 4:54 a.m., indicated the resident was anxious and paranoid. The resident was sent from the Extended Care Facility (EFC) for reported agitation. The patient was calm and cooperative at this time. Discussed the case with psychiatry who was familiar with Resident B and felt that she was at her baseline. Psychiatry felt it was appropriate to discharge her back to the nursing facility as she did not meet criteria for acute hospitalization.
During an interview with Certified Nurse Assistant (CNA) 6 on 2/2/26 at 5:11 p.m., the CNA indicated in January 2026 (unsure of exact date) she witnessed RN 5 being abusive to Resident B. Resident B was having behaviors she was screaming and yelling. RN 5 requested CNA 5 to put the resident in the supply closet. CNA 5 refused to do it. The resident was sent to the hospital that night. Resident B tried to stand up from her wheelchair and RN 5 pushed her down and the resident fell to the floor. RN 5 told CNA 5 and CNA 6 not to say anything to anyone about what had happened. CNA 5 and CNA 6 stayed with Resident B until the EMT's came and got Resident B. CNA 6 indicated the Director of Nursing (DON) called her and the CNA reported to the DON about RN 5 trying to get the CNA's to put Resident B in the supply closet and about RN 5 causing the resident to fall. The DON indicated she would look into it and for the CNA to stay away from RN 5.
During an interview with CNA 5, on 2/2/26 at 5:46 p.m., the CNA indicated on 1/6/26, RN 5 was being emotionally abusive to Resident B. Resident B was having behaviors yelling and screaming and RN 5 was not used to dealing with behaviors. RN 5 would not leave the resident alone and was antagonizing her. RN 5 seemed to be spiteful to the resident. All the staff know to leave Resident B alone when she was having behaviors and she would calm down on her own. RN 5 attempted to get the CNA to push Resident B's wheelchair into the supply closet while she held the door open. CNA 5 refused to put the resident in the supply closet and RN 5 indicated for CNA 5 to hold the door open to the supply closet and she would push her in there, CNA 5 refused to do this also and told RN 5 that they could not put the resident in the supply closet. CNA 5 indicated RN 5 grabbed Resident B's wheelchair and the resident fell. RN 5 instructed CNA 5 and CNA 6 not to help the resident, but CNA 6 assisted the resident up into her wheelchair. CNA 5 and CNA 6 took Resident B away from the nurse. CNA 5 indicated all she could do was keep the resident away from the nurse. Resident B went with EMT's when they arrived because she did not want to be around RN 5. CNA 5 indicated she reported the incident to the Unit Manager and the Unit Manger indicated she would report it to the DON.
During an interview with RN 5, on 2/2/26 at 6:27 p.m., the RN indicated she was not aware of any resident abuse occurring in the facility. The RN was not aware of any resident's being physically restrained or attempted to be isolated. She just let the residents go and make sure they were safe when they were having behaviors. The RN was not sure of the exact date, but she had to send Resident B to the hospital for behaviors. RN 5 did not think the resident had a fall she was rolling up and down the hallway in her wheelchair. RN 5 did not know why Resident B was on a regular unit because she just blows up. She tried to stay out of view of the resident that night because for some reason the resident was irritated by the nurse. RN 5 indicated it was not a fun night; it was the worse [sic]. The staffing was low and it was horrible, Resident B was not redirectable and was waking up other residents. CNA 6 stayed with Resident B until EMT's came and got her on the stretcher to transport her to the hospital. The RN indicated she did not realize the facility had so my psychiatric residents with behaviors mixed in the with regular residents.
During an interview with Licensed Practical Nurse (LPN) 8, on 2/2/26 at 3:41 p.m., the LPN indicated CNA 5 reported to her on 1/20/26 that RN 5 attempted to get her to put Resident B in involuntarily seclusion in the supply closet about a week prior. Resident B had behaviors of yelling out and had outburst, the staff would leave her alone and eventually she would calm down. RN 5 wanted to put her in the supply closet because she was worried the resident was going to wake up other residents. LPN 8 indicated that CNA 5 also reported to her that Resident B had a fall that same night behind the nursing station. LPN 8 provided a text that she sent to the DON on 1/20/26 at 4:43 a.m. and reported that RN 5 tried to get CNA 5 to get to involuntarily seclude Resident B in a room behind the nursing station. LPN 8 texted the DON that she did not know all the details, so she had CNA 5 and CNA 6 write out a statement and put it under the DON's door. The DON indicated to the LPN 8, on 1/20/26 at 4:41 p.m., that she had not received any statements, but would talk to the staff.
During an observation with the Regional Director of Clinical Operations, on 2/4/26 at 10:20 a.m., the supply closet on the center unit where Resident B resided was located behind the nursing station and had two locked doors to the room, the key was kept at the nursing station. Located in the room was a crash cart with liquid oxygen, oxygen tubing, goggles, back board, and a suctioning machine. The room contained dressing supplies, nebulizers, gloves, call light system with wires, batteries for mechanical lifts, two sinks, a toilet, drug buster (a method of destroying medication utilizing charcoal to neutralize medications) and dishwasher cleaning pods.
2. During an interview with Resident C, on 2/2/26 at 11:28 a.m., she indicated RN 5 had been verbally abusive toward her. Resident C indicated she was in her room one night sitting in her chair and needed help repositioning, her medications, and assistance going back to bed. The resident indicated she could not find her call light, so she had to yell out for help. Resident C indicated RN 5 came into the room and said, I don't know what you're yelling about, but someone will be in to take care of it.it's late and now all of my residents are awake, then began yelling at her and telling her to be quiet. The RN 5 told her, if you can't be quiet, they need to find you a different floor. Resident C indicated RN 5 told her, .the next time I see you, it better not be on my floor, you need to grow up, you have all of these people who are sick and all you are worried about is yourself. Resident C indicated CNA 4 then came into the room and said to RN 5, excuse me, you are not going to talk to her that way, she needs help. Resident C indicated this interaction made her feel this big cinching fingers together. Resident C indicated she was crying and sobbing, her feelings were hurt, and this made her feel really low.
The clinical record for Resident C was reviewed on 2/2/26 at 11:55 a.m. The resident's diagnoses included, but were not limited to, idiopathic pulmonary fibrosis (a chronic progressive, and typically fatal lung disease), migraines, and cirrhosis of liver (long term liver disease).
The admission MDS assessment, dated 1/17/26, indicated Resident C was cognitively intact.
A written statement by CNA 4 was provided by the Executive Director (ED) on 2/4/26 at 9:44 a.m. It indicated Resident C was screaming for help at 10:50 p.m. Resident C stated she had been waiting for someone to take her blood pressure so she could be transferred back to bed. CNA 4 indicated he yelled for RN 5 to come help and she started to lecture the resident saying she was being loud and disrupting the other residents.
During an interview with LPN 8 on 2/4/26 at 3:41 p.m., she indicated CNA 4 reported to her on 1/25/26 at 11:20 p.m. that CNA 4 entered Resident C's room because she was yelling out and wanting her blood pressure taken so she could get her medications and go to bed. CNA 4 indicated RN 5 entered the room and was yelling at Resident C and telling her to be quiet because she was going to wake up the entire floor. CNA 4 asked RN 5 if they could get Resident C's blood pressure, so they could get her back to bed. RN 5 refused, then finally took the blood pressure when it was time to get Resident C back to bed. CNA 4 then asked RN 5 for assistance in getting Resident C back to bed. RN 5 refused, then finally assisted CNA 4. LPN 8 indicated she notified the ED immediately after CNA 4 reported this to her.
The Abuse, Neglect, and Exploitation policy was provided by the ED on 2/2/26 at 10:42 a.m. It indicated .Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse.Involuntary Seclusion refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will.Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation.Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents.
This citation relates to intakes 2728759 and 2728476.
3.1-27(a)(b)

Based on interview, and record review the facility failed to report an allegation of abuse to the Executive Director immediately for 1 of 6 residents reviewed for abuse (Resident B). Finding include: Review of the clinical record of Resident B on 2/2/26 at 10:55 a.m., indicated the resident's diagnoses included, but were not limited to, bipolar disorder (a chronic mental health condition), anxiety, paranoid schizophrenia (a mental health condition characterized by intense, irrational delusions), dementia (a decline in mental abilities), and repeated falls. The quarterly Minimum Data Set (MDS) assessment for Resident B, dated 12/5/25, indicated the resident cognitively intact for daily decision making. The resident did not exhibit any behaviors during these assessment time frame. The resident utilized a wheelchair for mobility. During an interview with CNA 6 on 2/2/26 at 5:11 p.m., the CNA indicated in January 2026 (unsure of exact date) she witnessed RN 5 being abusive to Resident B. Resident B was having behaviors she was screaming and yelling. RN 5 requested CNA 5 to put the resident in the supply closet. CNA 5 refused to do it. Resident B tried to stand up from her wheelchair and RN 5 pushed her down and the resident fell to the floor. CNA 6 indicated the Director Of Nursing (DON) called her and she did report to her about RN 5 trying to get the CNA's to put Resident B in the supply closet and she caused the resident to fall. CNA 6 indicated the Executive Director was not aware of this incident, she had reported it to the DON. During an interview with CNA 5 on 2/2/26 at 5:46 p.m., indicated on 1/6/26, RN 5 was being emotionally abusive to Resident B. Resident B was having behaviors yelling and screaming and RN 5 was not use to dealing with behaviors. RN 5 would not leave the resident alone and was antagonizing her. RN 5 seemed to be spiteful to the resident. All the staff know to leave Resident B alone when she was having behaviors and she would calm down on her own. RN 5 attempted to get the CNA to push Resident B's wheelchair into the supply closet while she held the door open. CNA 5 refused to put the resident in the supply closet and RN 5 indicated for CNA 5 to hold the door open to the supply closet and she would push her in there, CNA 5 refused to do this also and told RN 5 that they could not put the resident in the supply closet. RN 5 grabbed Resident B's wheelchair and the resident fell to the floor. CNA 5 indicated she reported the incident to the Unit Manager and the Unit manger indicated she would report it to the DON. CNA 5 was not aware if the Executive Director (ED)was aware of the incident with Resident B. During an interview with the ED on 2/3/26 at 10:22 a.m., the ED indicated no staff had reported to him that on 1/6/26 RN 5 requested staff to put Resident B in the supply closet or that RN 5 had caused Resident B to fall. The abuse policy provided by the Executive Director on 2/2/26 at 10:42 a.m., indicated allegations of abuse were to be reported to the Executive Director immediately but not later than 2 hours after the allegation was made. This citation relates to Intake 2728749.3.1-28(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an assessment after a fall for 2 of 3 residents reviewed for accidents (Resident B and Resident C). Findings include:1. Review of the clinical record of Resident B on 2/2/26 at 10:55 a.m., indicated the resident's diagnoses included, but were not limited to, dementia (a decline in mental abilities) and repeated falls.
The care plan for Resident B, dated 3/2/25, indicated the resident was at risk for falls related to: a history of falls, use of medication, wandering, vitamin D deficiency, Alzheimer's disease and dementia. The resident had also had disorders of bone density. There were no interventions implemented since 4/27/2023.
The quarterly Minimum Data Set (MDS) assessment for Resident B, dated 12/5/25, indicated the resident cognitively intact for daily decision making. The resident utilized a wheelchair for mobility.
The change in condition progress note for Resident B, dated 1/6/26 at 4:32 a.m., indicated a new order was received to send the resident to hospital. The resident was paranoid, falsely accusatory toward staff, disoriented to situation, yelling and screaming in her room and in the hallway and was waking up other residents on the unit. The resident was threatening to beat up staff. The resident was rolling around in her wheelchair staring at staff and being intimidating. The resident cursed at staff. The resident believed staff knew her family and was conspiring against her to do evil things. Staff and other residents did not provoke resident in any way or respond to her behaviors except to reorient her to reality and ask her to lower her voice so other residents could sleep. Reoriented resident to reality that it was the middle of the night and no one means her any harm, we just want her to quiet down to maintain a peaceful living environment for herself and other residents. The resident was transferred to the hospital via Emergency Medical Services (EMT). The progress note was electronically signed by RN 5. There was no documentation about Resident B having a fall or an assessment of the resident after the fall.
During an interview with Resident B on 2/2/26 at 11:25 a.m., the resident indicated she did have a fall at the nursing station about three weeks ago. The resident was unsure what caused the fall, she just lost her balance. There were 2 or 3 staff that seen her fall but she was unsure of their names.
During an interview with CNA 6 on 2/2/26 at 5:11 p.m., the CNA indicated in January 2026 (unsure of exact date) she witnessed Resident B trying to stand up from her wheelchair and RN 5 pushed her down and the resident fell to the floor. RN 5 told CNA 5 and CNA 6 not to say anything to anyone about what had happened. CNA 5 and CNA 6 stayed with Resident B until the EMT's came an got Resident B.
During an interview with CNA 5 on 2/2/26 at 5:46 p.m., the CNA indicated on 1/6/26, Resident B was having behaviors yelling and screaming and RN 5 was not use to dealing with behaviors. RN 5 grabbed Resident B's wheelchair and the resident fell. RN 5 instructed CNA 5 and CNA 6 not to help the resident, but CNA 6 assisted the resident up into her wheelchair. CNA 5 indicated she reported the incident to the Unit Manager and the Unit manger indicated she would report it to the DON. RN 5 had not assessed the resident.
During an interview RN 5 on 2/2/26 at 6:27 p.m., indicated she was not sure of the exact date but she had to send Resident B to the hospital for behaviors (1/6/26). RN 5 did not think the resident had a fall that night she was rolling up and down the hallway in her wheelchair.
During an interview with LPN 8 on 2/2/26 at 3:41 p.m., indicated CNA 5 reported to her on 1/20/26 that Resident B had fallen on 1/6/26 at the nursing station and RN 5 did not assess the resident and told staff to leave the resident on the floor. LPN 8 indicated there was nothing in report about Resident B falling and she would have never known the resident had a fall if CNA 5 had not reported it to her.
During an observation on 2/3/26 at 2:30 p.m., Resident B was wheeling herself in her wheelchair up and down the hallway independently.
2. The clinical record for Resident C was reviewed on 2/2/26 at 11:55 a.m. The resident's diagnosis included, but was not limited to, generalized anxiety disorder.
The admission Minimum Data Set (MDS) assessment, dated 1/17/26, indicated Resident C was cognitively intact, used a wheelchair for ambulation, was dependent with rolling side to side, sit to lying, lying to sitting, and partial/moderate assistance with chair/bed-chair transfers.
A Fall Risk Evaluation, dated 1/9/26, indicated Resident C was at risk for falls.
A progress note, dated 1/11/26 at 5:37 p.m., indicated Resident C was yelling out from her room, staff went to the room, and resident was lying on the floor against the wall. Resident C was crying out in pain with her left leg. Doctor notified and new order to send to the ER (Emergency Room). No post fall assessment was documented for Resident C.
A Facility Reported Incident, dated 1/11/26, indicated Resident C informed staff member that she fell while attempting to get out of bed. The resident was evaluated by the nurse and sent to the hospital for additional care and treatment.
A local hospital discharge summary note, dated 1/15/26, indicated Resident C had been admitted [DATE] following a mechanical fall resulting in a closed hip fracture and underwent surgery with nail and screw placement on 1/12/26.
A plan of care, dated 1/12/26, indicated Resident C was at risk for falls due to history of falls, poor balance, and unsteady gait.
During an interview with the Director of Nursing (DON) on 2/4/26 at 10:43 a.m., the DON indicated there was an IDT (Inter-Disciplinary Team) note about the fall in Resident C's Electronic Health Record (EHR), but there was no post fall assessment completed for Resident C after her fall on 1/11/26. The floor nurse was who was responsible to make sure that a post fall assessment was completed for every fall. The post fall evaluation/assessment included: fall details, contributing factors, medication changes, vitals, pain, skin, physical findings, and comments.
A Fall Prevention Program policy was provided by the DON on 2/2/26 at 10:42 a.m. It indicated .9. When any resident experiences a fall, the facility will: a. Assess the resident b. Complete a post-fall assessment.f. Document all assessments and actions.
This citation relates to intake 2728759
3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with a major mental illness was treated appropriately and failed to implement individualized interventions resulting in a physical/mental altercation between a staff member and the residents for 1 of 6 residents reviewed for mental/psychosocial services. (Resident B). Using the reasonable person concept, the resident would likely have psychological harm of chronic or recurrent fear and anxiety from how RN 5 handled the interactions with Resident B. Findings include:Review of the clinical record of Resident B on 2/2/26 at 10:55 a.m., indicated the resident's diagnoses included, but were not limited to, bipolar disorder a chronic mental health condition), anxiety, paranoid schizophrenia (a mental health condition characterized by intense, irrational delusions), dementia (a decline in mental abilities), insomnia (persistent difficulty falling asleep or staying asleep) and Alzheimer's disease (progressive irreversible neurodegenerative brain disorder).
The care plan for Resident B, dated 3/2/25, indicated the resident had depression and would become angry, make negative statements, tearful and withdrawn. The interventions included, but were not limited to, allow time to express her feelings and offer beverages/snacks.
The care plan for Resident B, dated 3/2/25, indicated the resident had a history of making comments about not wanting to live, but had not voiced a plan. The interventions included, but were not limited to, encourage the resident to speak about her thoughts and feelings when she was sad or upset.
The care plan for Resident B, dated 3/2/25, indicated the resident had behaviors which included, rejection of care, cursing at staff, wandering, verbalizing things that were not true, seeing things that were not there, physical aggression towards staff. The interventions included, but were not limited to, all me to have a specific staff member hold her hand, offer the resident a diversion, speak to the resident in a calm and unhurried voice.
The care plan for Resident B, dated 3/2/25, indicated the resident was at risk for sleep pattern disturbance related to the diagnosis of insomnia. The interventions included, but were not limited to, assess for pain, maintain a quiet, comfortable temperature, dimmed lights, offer a back rub, play soft relaxing music, offer warm milk and food.
The care plan for Resident B, dated 3/2/25, indicated the resident had social isolation due to her diagnosis of schizophrenia and bipolar. The resident forgot things, had altered sleep pattern, altered nutrition, falls, behaviors, depression and increased dependence on staff and social/activity isolation. The interventions included, but were not limited to, encourage the resident to express her feelings.
The care plan for Resident B, dated 3/2/25, indicated the resident had mood indicators of feeling bad about herself, failure to her family, depressed, little interest in pleasure, anxious, agitated, speaking slowly, poor appetite, thoughts of hurting herself, little energy, trouble concentrating, trouble sleeping, rapid movements, insomnia and often isolates herself. The interventions included, but were not limited to, take the time to discuss my feelings when she was sad and encourage activities related to her interest.
The care plan for Resident B, dated 6/10/25, indicated the resident was at risk for psychosocial well-being due to the diagnosis of bipolar disorder. The interventions included, but were not limited to, allow the resident time to answer questions and verbalize feelings and fears daily.
The care plan for Resident B, dated 9/14/25, indicated the resident wanted to maintain her personal preference of going to bed when she was tired.
The care plan for Resident B, dated 12/25/25, indicated the resident had a behavior problem of talking loudly to herself and yelling at others. The interventions included, but were not limited to, anticipate and meet the residents needs and if reasonable, discuss the resident's behavior of why the behavior was inappropriate or unacceptable to the resident.
The quarterly Minimum Data Set (MDS) assessment for Resident B, dated 12/5/25, indicated the resident cognitively intact for daily decision making. The resident did not exhibit any behaviors during these assessment time frame.
The change in condition progress note for Resident B, dated 1/6/26 at 4:32 a.m., indicated a new order was received to send the resident to hospital. The resident was paranoid, falsely accusatory toward staff, disoriented to situation, yelling and screaming in her room and in the hallway and was waking up other residents on the unit. The resident was threatening to beat up staff. The resident was rolling around in her wheelchair staring at staff and being intimidating. The resident cursed at staff. The resident believed staff knew her family and was conspiring against her to do evil things. Staff and other residents did not provoke resident in any way or respond to her behaviors except to reorient her to reality and ask her to lower her voice so other residents could sleep. Reoriented resident to reality that it was the middle of the night and no one means her any harm, we just want her to quiet down to maintain a peaceful living environment for herself and other residents. The resident was transferred to the hospital via Emergency Medical Services (EMT). The progress note was electronically signed by RN 5.
During an observation and interview with Resident B on 2/2/26 at 11:25 a.m., the resident was lying in her bed and thanked me for stopping in and checking on her.
During an interview with the Unit Manager, on 2/2/26 at 2:48 p.m., the Unit Manager indicated she was unsure if RN 5 knew how to deal with residents who had psychiatric issues. An example was RN 5 wanted to follow Resident B around, and the resident needed to be left alone. A couple weeks ago on third shift RN 5 reported to her that Resident B was acting out and the Unit Manager told RN 5 to leave her alone, but RN 5 continued to follow the resident around. The Unit Manager indicated she told RN 5 that the staff were not to do that with this resident.
During an interview with CNA 6, on 2/2/26 at 5:11 p.m., the CNA indicated in January 2026 (unsure of exact date) Resident B was having behaviors she was screaming and yelling. RN 5 kept trying to give the resident medication and telling her to and told her to stop yelling and be respectful to the other residents. CNA 6 indicated it was very chaotic on the unit. RN 5 did not attempt any interventions for Resident B. CNA 6 and CNA 5 took the resident took the resident away from RN 5.
During an interview with CNA 5, on 2/2/26 at 5:46 p.m., the CNA indicated on 1/6/26, Resident B was having behaviors yelling and screaming and RN 5 was not used to dealing with behaviors. RN 5 would not leave the resident alone and was antagonizing her. RN 5 seemed to be spiteful to the resident. All the staff know to leave Resident B alone when she was having behaviors and she would calm down on her own.
During an interview RN 5 on 2/2/26 at 6:27 p.m., the RN indicated she did not know why Resident B was on a regular unit because she just blows up. RN 5 indicated she did not realize the facility had so my psychiatric residents with behaviors mixed in the with regular residents.
During an interview with LPN 8, on 2/2/26 at 3:41 p.m., the LPN indicated CNA 5 reported to her on 1/20/26 that RN 5 attempted to get her to put Resident B in involuntarily seclusion in the supply closet about a week prior. Resident B had behaviors of yelling out and had outburst, the staff would leave her alone and eventually she would calm down. RN 5 wanted to put her in the supply closet because she was worried, she was going to wake up other residents. The LPN noticed there were a lot of residents on the center station agitated with RN 5 and seemed like RN 5 was trying to make the residents angry.
A Dementia policy was provided by the ED on 2/4/26 at 9:35 a.m. It indicated .It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental and psychosocial well-being.Definitions: Highest practicable physical, mental, and psychosocial well-being is defined as the highest possible level of functioning and well-being, limited to the individual's recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental, or psychosocial needs of the individual.
A Behavioral Health Services policy was provided by the ED on 2/4/26 at 9:35 a.m. It indicated .It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being.Definitions: Mental Disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.1. Behavioral health encompasses a resident's whole emotional and mental well-being.3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.5. Behavioral health care and services shall be provided in an environment that is conductive to mental and psychological well-being.6. Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports based upon residents' needs.c. Schizophrenia- Is a serious mental disorder that may interfere with a person's ability to think clearly, manage emotions, make decisions and relate to others.d. Bipolar Disorder- Is a mental disorder that causes dramatic shifts in a person's mood or energy, and may affect the ability to think clearly.11. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions to help meet behavioral health needs.
This citation relates to intake 2728759
3.1-43(a)(1)

Based on interview and record review, the facility failed to obtain a Hemoglobin A1C lab, as ordered, for 1 of 5 residents reviewed for unnecessary medications. (Resident 75)Findings include:The clinical record for Resident 75 was reviewed on 9/9/25 at 12:19 p.m. Her diagnoses included, but were not limited to, type 2 diabetes mellitus. The 8/17/25 diabetes mellitus care plan indicated an intervention was to administer diabetes medication as ordered by the doctor, and to monitor/document for side effects and effectiveness. The Medications section of Physician 13's, 7/30/25, progress note indicated to give one 750 mg tablet of Metformin Extended Release one time a day related to type 2 diabetes mellitus. The Assessments and Plans section of the note indicated, Type 2 diabetes mellitus with other specified complication: Recheck hemoglobin A1c and consider changing metforminto [sic] glargine insulin. The 7/30/25 physician order indicated to obtain a Hemoglobin A1c level. There were no Hemoglobin A1c level results in the clinical record after the above 7/30/25 order. An interview was conducted with the Director of Nursing on 9/9/25 at 1:00 p.m. She indicated she did not find the Hemoglobin A1c lab was completed. They needed to inform Physician 13 of this to see what he wanted to do now. An interview was conducted with Physician 13 on 9/9/25 at 1:12 p.m. He indicated he still wanted the lab to be completed. It was a missed order. The Laboratory Services and Reporting policy was provided by the Nurse Consultant on 9/9/25 at 1:32 p.m. It indicated, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. 3.1-49(a)

Based on observation, interview, and record review, the facility failed to treat a resident with respect and dignity by engaging in inappropriate conversation with 1 of 4 residents reviewed for dignity. (Resident 61)Findings include:The clinical record for Resident 61 was reviewed on 9/2/25 at 1:15 p.m. Her diagnoses included, but were not limited to, bipolar disorder, insomnia, and anxiety disorder. The bipolar disorder care plan, revised 6/24/25, indicated she had behavioral symptoms as exhibited by attempts at inappropriate conversations with staff. An interview was conducted with Resident 61 on 9/2/25 at 1:26 p.m. She indicated one day last week Housekeeper 11 informed her (Resident 61) that CNA (Certified Nurse Aide) 12 told Housekeeper 11 that CNA 12 did not like Resident 61. Resident 61 did not hear or see CNA 12 say this. An interview and observation was conducted with Housekeeper 11, on 9/8/25 at 12:01 p.m., in the presence of the Housekeeping Manager. Housekeeper 11 indicated other staff don't typically talk to her about residents. I heard a couple say they didn't like one person or another, but I don't feed into that. A couple of weeks ago, CNA 12 informed her she did not like Resident 61. This occurred in the hallway, outside of Resident 61's door to her room. The door was open at the time. Housekeeper 11 never told anyone about it, and she didn't think any other staff were around. CNA 12 said she couldn't stand her and raised her middle fingers on both hands, but it was where Resident 61 was unable to see her. Housekeeper 11 put both hands in the air and raised her middle finger on each hand at this time. When Housekeeper 11 went into Resident 61's room afterwards, Resident 61 asked Housekeeper 11 what CNA 12 said, but she didn't respond to her or tell her what CNA 12 said. Housekeeper 11 wasn't sure if Resident 61 heard CNA 12 say this. Housekeeper 11 was just trying to ignore it, but she probably should have told the ED (Executive Director) about it. An interview was conducted with the Housekeeping Manager on 9/8/25 at 12:01 p.m. She indicated this was her first time hearing about the incident. She tried to encourage her staff to not speak about residents or get involved in drama between them. She told her staff to stay out of stuff like that, but she knew Housekeeper 11 and Resident 61 were close. An interview was conducted with CNA 12 on 9/8/25 at 12:26 p.m. She indicated when she worked, on 9/4/25, she assisted Resident 61 with care. While providing care that day, Resident 61 questioned why CNA 12 didn't come into her room anymore. CNA 12 informed her she didn't work her hallway anymore. Resident 61 informed CNA 12 she thought CNA 12 [expletive] hated her guts, because that's what [name of Housekeeper 11] told me. CNA 12 informed Resident 61 she never said that and didn't talk to Housekeeper 11. Prior to 9/4/25, CNA 12 hadn't provided care for Resident 61 in approximately two months. An interview was conducted with the ED on 9/9/25 at 10:53 a.m. He indicated he spoke with Resident 61 about the conversation with Housekeeper 11. Resident 61 did not feel the situation was abusive, but she was put out by it. When he interviewed Housekeeper 11 about it, she would not maintain eye contact, and her story kept changing. He couldn't explain why Housekeeper 11 would involve a resident in something like this. He thought Housekeeper 11 was lying or embellishing about CNA 12. He did not know what Housekeeper 11's motivation was in all of this.The Promoting/Maintaining Resident Dignity policy was provided by the ED on 9/9/25 at 12:07 p.m. It indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights 5. When interacting with a resident, pay attention to the resident as an individual.3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure 1 of 7 residents were directly observed to receive and consume the medications which were administered to them during 1 of 4 medication pass observations with 7 residents and 5 staff members. (Resident 19, Registered Nurse 4) Findings include: During a medication pass observation on 9-3-25 at 12:06 p.m., with Registered Nurse (RN) 4, she was observed to prepare two tablets of buspirone hydrochloride 5 milligrams (mg) for a total of 10 mg to administer to Resident 19. She then crushed the medication and added it to a container of yogurt and placed it on her lunch tray. RN 4 indicated the resident does not like to have staff remain in her room while she eats lunch, including the yogurt which contained the medication. So we just leave the yogurt on her tray and check back. Normally, we leave the door cracked so we can check in on her to make sure she takes the med. At 12:12 p.m., RN 4 left Resident 19 unattended with the cup of yogurt with the medication in it. At that time, Resident 19 requested that her door be closed. RN 4 indicated this was Resident 19's normal routine and staff honored her preferences. RN 4 indicated the typical manner to administer medications was for the person giving the medication to remain with the resident while they take their medications to ensure medications were consumed. We just check on her throughout her meal and she normally eats all of her yogurt. At 12:18 p.m., RN 4 checked on Resident 19 again and indicated she was eating the yogurt. At 12:37 p.m., RN 4 had not been observed to return to check on resident's intake of yogurt w/medication in it. At 1:18 p.m., RN 4 indicated she did verify Resident 19 had eaten the yogurt with the crushed medication in it. RN 4 indicated she was unsure if Resident 19 was care planned to be able to receive her medications without staff direct observation.The clinical record for Resident 19 was reviewed on 9-3-25 at 1:35 p.m. It indicated her diagnoses included, but were not limited to, anxiety. Her physician orders indicated she was to receive buspirone 5 mg, two tablets for a total of 10 mg, three times daily for anxiety. A care plan, initiated on 2-7-20, and revised on 3-2-25, indicated she received some of her medications crushed and mixed in a drink or food. One of the listed approaches for this care plans included, but was not limited to, Nurse to observe and see that I take my medication in drink or food.On 9-4-25 at 8:47 a.m., the Executive Director provided a copy of a policy entitled, Medication Administration. It indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice.Observe resident consumption of medication.3.1-35(g)(1)3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to assist a resident to the restroom in a timely manner for 1 of 2 residents reviewed for activities of daily living (ADLs). (Resident 2)Findings include: The clinical record for Resident 2 was reviewed on 9/4/25 at 11:45 a.m. The diagnoses included, but were not limited to, retention of urine, hypertensive heart disease with heart failure, and emphysema. The Quarterly Minimum Data Set (MDS) assessment, dated 8/5/25, indicated Resident 2 was cognitively intact and utilized a manual wheelchair. Resident 2 indicated he had a Foley catheter (a thin tube inserted into the urethra to drain urine from the bladder) removed the day before, on 9/3/25. During an observation on 9/4/25 at 12:42 p.m., Resident 2 had his call light on. The Registered Dietician (RD) walked into Resident 2's room, and the resident indicated he needed help going to the restroom. The RD then went down the hallway to inform Certified Nurse Aide (CNA) 5 that Resident 2 needed assistance to the restroom. CNA 5 was passing meal trays with CNA 6. CNA 5 indicated to the RD that it was, going to be a little while. CNA 5 and CNA 6 continued to pass lunch trays down the main hallway and then proceeded to go down the opposite hallway from Resident 2's room and pass lunch trays. While passing lunch trays, Licensed Practical Nurse (LPN) 7 and LPN 8 were sitting at the nurses' station while the call light was going off. The RD turned Resident 2's call light off at that time. During an observation on 9/4/25 at 12:53 p.m., the RD went back into Resident 2's room and turned his call light back on. The RD informed the Unit Manager at that time that Resident 2 was waiting for assistance to go to the restroom, and she turned his call light back on so staff would be reminded that he still needed to go to the restroom. The UM did not get up at that time to assist the resident and replied ok to the RD. CNA 5 was observed on 9/4/25 at 12:55 p.m. answering Resident 2's call light and assisting him to the restroom. Resident 2 had a physician's order, dated 9/4/25 at 10:48 a.m., that indicated a urinalysis to be obtained due to difficulty urinating with burning upon urination. During an interview with CNA 5 on 9/4/25 at 1:09 p.m., they indicated if a resident needed assistance to the restroom while meal trays were being passed, residents were told they just have to wait. CNA 5 indicated they do not ask the nurse for help because they tell us (aides) to go do it. During an interview with the Director of Nursing (DON) on 9/4/25 at 3:25 p.m., she indicated it was expected of staff to provide the care when a resident asked to go to the restroom during meal pass times. The plan of care for Resident 2, dated 7/31/25, indicated the resident had an ADL performance deficit related to activity intolerance. The interventions included, but were not limited to, assisting with toileting as needed. A Call Lights: Accessibility and Timely Response Policy was provided by the Nurse Consultant on 9/9/25 at 10:26 a.m. It indicated, .10. All staff members who see or hear an activated call light are responsible for responding . The Activities of Daily Living (ADLs) Policy was provided by the Nurse Consultant on 9/9/25 at 10:26 a.m. It indicated, .Care and services will be provided for the following activities of daily living .3. Toileting .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good personal hygiene . 3.1-38(a)(2)(C)3.1-38(a)(3)(A)

Based on observation, interview and record review the facility failed to implement individualized pressure ulcer prevention and treatment of rotating the resident from the bed to the recliner every two hours as ordered by the physician for a stage 4 pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis or damage to muscle, bone, or supporting structure), failed to investigate the root cause of the stage 4 pressure ulcer and failed to date a pressure ulcer dressing for a stage 3 (full thickness tissue loss) pressure ulcer for 1 of 1 resident's reviewed for pressure ulcers (Resident 11). Finding include: During an observation on 9/5/25 at 11:39 a.m., Resident 11 was sitting in a wheelchair with a pressure reducing cushion. The resident had an air mattress on the bed. Resident 11 had a recliner with a pressure-relieving cushion in place in the room. During an observation on 9/5/25 at 1:25 p.m., Resident 11 was eating lunch independently and remained in the wheelchair with the cushion. The resident was in the same position. Resident 11 had a recliner with a pressure-relieving cushion in place in the room. During an observation on 9/5/25 1:43 p.m., Resident 11 was sitting in her wheelchair in the same position. During an observation on 9/8/25 at 11:05 a.m., Resident 11 was sitting in a wheelchair with a cushion. During an observation and interview on 9/8/25 at 11:54 a.m., Resident 11 remained in the wheelchair. Resident 11 indicated she only laid in bed when staff permitted her to, but they did not always let her. The resident indicated it was more comfortable laying in her bed. During an observation on 9/8/25 at 12:53 p.m., Resident 11 was sitting in the wheelchair in the same position. During an observation on 9/8/25 at 1:43 p.m., Resident 11 was in the same position in the wheelchair, the resident indicated she needed to go to the restroom. The call light was activated. Resident 11 had a recliner with a pressure relieving cushion in it. During an observation on 9/8/25 1:53 p.m., Certified Nurse Aide (CNA) 6 and CNA 10 were assisting Resident 11 to the bathroom utilizing a gait belt from the wheelchair to the toilet. There was no date on the pressure ulcer dressing on the left buttocks. Both CNAs indicated there was not a date on the dressing. Resident 11 requested to lay down in bed. CNA 6 and CNA 10 assisted the resident from the wheelchair to the bed. This indicated the resident had been sitting in the wheelchair for 2 hours and 48 minutes. During an interview with the Nurse Consultant on 9/8/25 at 10:09 a.m., they indicated Resident 11 acquired a stage 4 pressure ulcer on the left hip in the facility, on 3/19/25, that measured 2.5 centimeters (cm) by 3.0 cm by 0.1 cm and acquired a stage three pressure ulcer on the left buttock in the facility, on 8/20/25, that measured 2 cm by 2 cm by 0.1 cm. During an interview with the Director of Nursing (DON) on 9/8/25 at 10:35 a.m., they indicated the facility should have investigated the root cause of the stage 4 pressure ulcer on the left hip of Resident 11. During an interview with the DON on 9/8/25 at 12:02 p.m., they indicated there was no root cause analysis completed for Resident 11's stage 4 pressure ulcer on her hip. During an interview with the DON on 9/8/25 at 2:40 p.m., they indicated CNAs were responsible to ensure Resident 11 was repositioned and the CNAs were the first line of defense for residents with pressure ulcers. The DON indicated pressure ulcer dressings were supposed to be dated. The clinical record for Resident 11 was reviewed on 9/8/25 at 12:05 p.m. The diagnoses included, but were not limited to, osteoarthritis, congestive heart failure, chronic kidney disease, muscle weakness, hypertension, and stage 4 pressure ulcer of the left hip and stage 3 pressure ulcer to the left buttocks. The physician recapitulation for Resident 11, dated September 2025, indicated the resident was to alternate from the bed to the recliner every two hours (initiated on 4/3/25). The predicting pressure ulcer risk evaluation for Resident 11, dated 6/29/25, indicated the resident was at high risk of developing pressure ulcers. The Quarterly Minimum Data Set (MDS) assessment for Resident 11, dated 8/26/25, indicated the resident was severely impaired for daily decision making. The resident was dependent on staff to stand, roll left and right, transfer and did not ambulate. The resident was at risk of acquiring pressure ulcers and currently had a stage 3 and a stage 4 pressure ulcer. The resident had no behavior of refusal of care. The wound assessment for Resident 11, dated 9/3/25, indicated the resident had a stage 4 pressure ulcer on the left hip measuring 1.5 cm by 1.5 cm by 1.7 cm and acquired in the facility. There was a heavy amount of serosanguineous drainage. The wound status was stalled. The wound assessment for Resident 11, dated 9/3/25, indicated the resident had a stage 3 pressure ulcer on the right buttock measuring 1.5 cm by 1.6 cm by 0.1 cm that was not was acquired in the facility. The wound status was improving without complications. The wound assessment for Resident 11, dated 9/3/25, indicated the resident had a stage 3 pressure ulcer to left buttock measuring 1.6 cm by 1.4 cm by 0.1 cm acquired in the facility. The wound status was stable. The pressure injury prevention and management policy was provided by the Nurse Consultant on 9/9/25 at 10:25 a.m. The policy indicated the resident would commit to the prevention of avoidable pressure injuries and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers. The facility would establish and utilize a systematic approach for pressure ulcer prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying interventions as appropriate. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure ulcers with appropriate interventions. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to provide a nutritional supplement as ordered by the physician for a resident who had significant weight loss for 1 of 3 residents reviewed for weight loss (Resident 7). Findings include:The clinical record of Resident 7 was reviewed on 9/5/25 at 10:20 a.m. The diagnoses included, but were not limited to, hemiplegia, pain, hypertensive heart disease, and weakness. The care plan for Resident 7, dated 5/5/25, indicated the resident had a nutritional problem related to cerebral infarction with hemiplegia affecting resident's right dominant side requiring adaptive equipment with meals. The resident triggered for malnourishment related to history of significant weight changes. The interventions included, but were not limited to, provide nutrition interventions as ordered. A physician's order for Resident 7, dated 6/13/25, indicated the resident was ordered yogurt or equivalent with meals. Resident 7's weight, on 7/1/25, was 153.8 pounds and the resident's weight, on 8/31/25, was 134. This indicated the resident lost 12.87% of their body weight in two months. During an observation on 9/8/25 at 12:44 p.m., Resident 7 had tuna casserole, mashed potatoes, peas, and peach cobbler. The resident did not have yogurt. The resident's meal ticket indicated he was supposed to have yogurt. During an interview with the Unit Manager on 9/8/25 at 12:47 p.m., they indicated the dietary department was responsible to ensure Resident 7 received yogurt on his lunch tray. During an interview with Licensed Practical Nurse (LPN) 7 on 9/8/25 at 12:50 p.m., they indicated the dietary department was out of yogurt, but they should have sent something equivalent to the yogurt. LPN 7 indicated she would see if she had a mighty shake in her medication cart to give to the resident. During an interview with the Director of Nursing (DON) on 9/8/25 at 2:41 p.m., they indicated dietary was responsible to ensure Resident 7 had yogurt on the tray. The nutritional management policy was provided by the Nurse Consultant on 9/9/25 at 10:10 a.m. The policy indicated the facility would provide care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. The facility would evaluate the care plan to determine if the current interventions were being implemented and effective. 3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to ensure insulin pens were current and not outdated or expired, labelled for date when opened or put into use, with the directions for use and the prescribing physician's name during observations of 2 of 2 medication carts for medication storage. (Residents 23, 24 and 53). The facility failed to ensure the Change of Shift Control Substances Count Sheet, was routinely completed with signatures of the arriving nurse for duty and the departing nurse for duty present to signify that all controlled substances were accounted for during the time period of 8-15-25 at 6:00 p.m. through 9-4-25 at 6:30 a.m. for a total of 49 entries with concerns related to missing or illegible dates, times and/or missing signatures. This missing or incomplete information had the potential to adversely affect all 29 residents of the affected South Unit. Findings include:A. During an observation on 9/4/25 at 2:21 p.m., with Licensed Practical Nurse (LPN) 8, the Hall 5 medication cart contained an Ozempic medication pen for Resident 23 marked with an opened date of 6/24/25 and an expiration date of 8/20/25, and an undated albuterol 90 mcg inhaler for Resident 24. At the same time, LPN 8 indicated the nurses on the hall were supposed to remove expired medications from the medication carts. The nurses were supposed to put opened dates on the inhalers and insulin pens. She indicated the Ozempic had been discontinued within the past few days.
A review of Resident 23's physician orders, on 9/4/25 at 3:33 p.m., indicated the resident's order for Ozempic was discontinued on 8/29/25.
A review of Resident 24's physician orders, on 9/4/25 at 3:36 p.m., indicated the resident had an order for albuterol sulfate aerosol solution 108 (90) base – inhale two puffs orally one time a day for a diagnosis of allergic rhinitis.
During an interview on 9/4/25 at 3:50 p.m., LPN 7 indicated whatever nurse noticed a medication was expired or discarded should discard the medication. Opened dates were supposed to be marked on medications like inhalers, medication pens, and eye drops when they were opened.
During an interview on 9/4/25 at 3:53 p.m., the Director of Nursing (DON) indicated the floor nurses should remove medications that were expired or discontinued. The medications, such as medication pens, eye drops, and inhalers, should have opened dates once opened. The Ozempic should have been removed from the cart.
On 9/5/25 at 10:01 a.m., the Executive Director provided an undated facility policy, titled Insulin Pens. This policy indicated, .Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation.
On 9/5/25 at 10:01 a.m., the Executive Director provided an undated facility policy, titled Medication Storage. This policy indicated, .The pharmacy and all medications are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. These medications are destroyed.
B. During 1 of 2 observations of 1 of 5 medication carts on 9-5-25 at 11:25 a.m., with LPN 5, one insulin pen of Lantus/Basaglar KwikPen, Lot 0755924A, with an expiration date of 2-23-2026, was found without directions for use or the physician's name present. The insulin pen was labelled with Resident 53's handwritten name and an opened (or begin use) date of 9-5-25. LPN 5 indicated the KwikPen had been obtained from the facility's emergency supply this morning. She indicated when insulin pens were obtained from the emergency supply kit, they do not come with any labels for directions for use.
On 9-5-25 at 12:30 p.m., the Executive Director provided a copy of the emergency kit transaction record for Resident 53's insulin pen. It indicated, on 9-5-25 at 11:55:31 a.m., one Lantus/Basaglar KwikPen was dispensed to LPN 5. The transaction date and time were not explained regarding a clarification of the transaction date and time and the date and time of the observation.
A review of Resident 53's medication order summary, for 9-5-25, indicated he was to receive 34 units of Lantus (also known as insulin glargine or Basaglar KwikPen) subcutaneously (under the skin) daily at bedtime for a diagnosis of diabetes.
C. During 1 of 2 observations of 1 of 5 medication carts on 9-4-25 at 2:21 p.m., with LPN 8, on the South Unit, LPN 8 provided a copy of the Change of Shift Control Substances Count Sheet, for the time period of 8-15-25 at 6:00 p.m. through 9-4-25 at 6:30 a.m. for a total of 49 entries. This document indicated, Signature of the nurse arriving on duty and nurse departing from duty indicates that all items (including refrigerated items) are accounted for and that visual verification of placement of Fentanyl patches has been confirmed by both responsible parties. The document had columns to identify the date, time, nurse departing from duty and nurse arriving on duty to complete. Additional columns that were not being utilized included, Count (i.e., Number of Cards With Corresponding Blue Count Sheets), Additions (Medication Cards and/or Blue Sheets Added During Shift and Reason for Addition), and Subtractions (Medication Cards and/or Blue Sheets Removed During Shift and Reason for Removal).
Concerns for this document are listed below:
-An undated and untimed entry, listed between entries for 8-19-25 at 10:00 p.m., and 8-20-25 for 2:00 p.m. to 7:00 p.m., had the signature of the departing nurse and the initials of the arriving nurse.
-An entry for 8-22-25 at 6:00 a.m. to 2:30 p.m. did not have a signature or initials for the departing nurse.
-Three (3) sequential entries, dated 8-23-25 at 6:30 a.m. to 4:00 p.m., followed by an entry for 8-24-25 at 6:30 a.m. to 2:30 p.m. and the third for 8-25-25 at 6:30 a.m. to 6:30 p.m. These entries reflected a lack of reconciliation for the time periods of 8-23-25 at 4:00 p.m., until 8-24-25 at 6:30 a.m.; from 8-24-25 at 2:30 p.m., until 8-25-25 at 6:30 a.m. Additionally, the initials of the person for the entries on 8-23-25 at 6:30 a.m. to 4:00 p.m., and for 8-24-25 at 6:30 a.m. to 2:30 p.m., appeared to be the same initials of the departing and arriving nurse.
-Entries for 8-28-25 and 8-29-25, were present, but were not recorded in sequential order.
-Entry for 8-29-25, timed for 6:00 p.m. and until 8-30-25 at 7:00 a.m., did not have a signature for the arriving nurse, but did have Registered Nurse (RN) 14's signature as the departing nurse.
-Four (4) sequential entries, dated for 8-30-25 through 8-31-25, had an initial entry with the date only listed on that entry. The second entry, dated 8-30-25, entry had no time listed, but the arriving nurse was identified as RN 14, with no signature or initials listed for the departing nurse. The third entry, had the date of 8-30-25, listed with the time of 6p-7a, documented with only the departing nurse of RN 14 listed and no arriving nurse's signature present. The fourth entry, was undated and untimed, but assumed to be for 8-31-25 for the day shift, had only the arriving nurse's signature of RN 14 present.
-Entries dated for 9-1-25, reflected a lack of arriving nurse's signature for the time period of 6:30 a.m. through 2:30 p.m. There were no entries or signatures to indicate any nurses had reviewed or reconciled the controlled substances for the time period of 9-1-25 from 2:30 p.m. until 6:30 p.m. However, at 6:30 p.m., the document indicated 2 nurses had signed, one as the arriving nurse on duty and one as the departing nurse on duty.
-Entries dated for 9-2-25, reflected the presence of nurse signatures for arriving and departing duty for the time period of 6:30 a.m. through 2:30 p.m. There were no entries or signatures to indicate any nurses had reviewed or reconciled the controlled substances for the time period of 9-1-25 from 2:30 p.m. until 6:30 p.m. However, at 6:30 p.m., the document indicated 2 nurses had signed, one as the arriving nurse on duty and one as the departing nurse on duty.
-Entries dated for 9-3-25 at 6:00 p.m. through 9-4-25 at 7:00 a.m., reflected the nurse signatures for the departing and arriving nurse on duty. An entry dated 9-4-25 at 0630 – (blank) was present with the initials of the departing nurse present.
In an interview with LPN 8 on 9-4-25 at 2:21 p.m., she indicated she had already signed her departure signature for 9-4-25 at 6:30 p.m. She indicated she sometimes does this ahead of time, not necessarily at the time she was leaving.
On 9-5-25 at 11:16 a.m., the Executive Director provided a copy of policy entitled Controlled Substance Administration and Accountability. This policy indicated, It is the policy of this facility to promote safe, high-quality patient care compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent the loss, diversion or accidental exposure.Inventory Verification.For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.
On 9-5-25 at 12:30 p.m., the Executive Director provided a copy of a policy entitled, Labeling of Medications and Biologicals. This policy indicated, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration.All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices.Labels for individual drug containers must include the resident's name; the prescribing physician's name.The prescribed dose, strength, and quantity of the medication; the prescription date (if applicable); the date the drug was prescribed; appropriate instructions and precautions (such as shake well, take with meals, do not crush, special storage instructions).the route of administration.Only the issuing pharmacy may place a drug label on a medication container.
3.1-25(e)(2)
3.1-25(e)(3)
3.1-25(j)
3.1-25(k)(2)
3.1-25(k)(3)
3.1-25(k)(5)
3.1-25(k)(6)
3.1-25(k)(7)
3.1-25(o)
3.1-25(r)

Based on interview and record review, the facility failed to administer insulin as ordered by the physician for Resident C and Resident V, failed to complete a weekly skin assessment timely for Resident C, and failed to complete neurological checks after a fall for 2 of 4 residents reviewed for falls and for 2 of 3 residents reviewed for quality of care (Resident C, Resident V, Resident T, and Resident O).Findings include:1. During an interview with Confidential Staff 5 on 7/15/25 at 12:23 p.m., they indicated the facility was not conducting weekly skin assessments for residents and was not administering insulin as ordered by the physician.
The clinical record for Resident C was reviewed on 7/15/25 at 11:00 a.m. The diagnoses included, but were not limited to, diabetes, Parkinson disease, chronic kidney disease, dementia, Alzheimer's disease, anxiety, muscle weakness, difficulty walking and morbid (severe) obesity.
A physician’s order, dated July 2025, indicated the resident was ordered insulin glargine (long-acting insulin) 24 units at bedtime for diabetes. The instructions were to hold the insulin if the blood sugar was below 120.
A physician’s order, dated July 2025, indicated the resident was ordered weekly skin assessments.
The pressure ulcer risk assessment for Resident C, dated 5/4/25, indicated the resident was at moderate risk for skin breakdown.
The clinical record for Resident C indicated the last skin assessment was completed on 7/3/25. The resident did not have a skin assessment completed for 13 days.
The July 2025 medication administration record (MAR) for Resident C indicated the resident did not receive her blood sugar check or insulin at bedtime, as ordered, on 7/12/25 and 7/13/25.
During an interview with the Director of Nursing (DON) on 7/16/25 at 2:50 p.m., she indicated the nurse was responsible to ensure Resident C's weekly skin assessments were completed and administer her insulin as ordered by the physician.
The skin assessment policy provided by the DON, on 7/17/25 at 2:10 p.m., indicated it was the policy to perform a full body skin assessment as a part of the facility’s systematic approach to pressure ulcer injury prevention and management.
2. The clinical record for Resident V was reviewed on 7/16/25 at 2:15 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, anxiety, and pain.
The Quarterly Minimum Data Set (MDS) assessment, dated 7/9/25, indicated Resident V was cognitively intact and received insulin.
A physician’s order, dated 3/25/25, indicated Resident V was to receive Lantus Subcutaneous (under the skin) Solution (insulin glargine): inject 18 units subcutaneously at bedtime.
The July 2025 MAR for Resident V indicated there were omissions of the medication on 7/12/25 and 7/13/25.
During an interview with Resident V on 7/16/25 at 2:25 p.m., he indicated he was not sure if he received insulin or not on those days.
During an interview with the DON on 7/16/25 at 2:40 p.m., she indicated she did not know why the bedtime dose of Lantus was not given on 7/12/25 or 7/13/25.
A “Timely Administration of Insulin” policy was provided by the Executive Director (ED) on 7/17/25 at 10:24 a.m. It indicated,”…1. All insulin will be administered in accordance with physician’s orders…”
3. The clinical record for Resident T was reviewed on 7/16/25 at 1:42 p.m. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, and weakness.
The Quarterly Minimum Data Set (MDS) assessment, dated 4/28/25, indicated Resident T was severely cognitively impaired, used a walker, and was dependent on staff for activities of daily living (ADLs).
A facility reported incident, dated 7/10/25, indicated Resident T had fallen on the floor beside her roommate’s bed. The resident was sent to the ER (Emergency Room) for evaluation and treatment. An investigation was initiated at that time.
A change in condition nursing note, dated 7/10/25 at 3:06 a.m., indicated the nurse was called to the unit because Resident T had fallen on the floor by her roommate’s bed. The note indicated Resident T had a small amount of blood on the floor by her head. The resident did not talk much and refused to open her eyes.
During a review of neurological checks on 7/16/25 at 1:45 p.m., the neurological checks were to be done every 15 minutes four times, every 30 minutes four times, every hour four times, every four hours four times, then every 12 hours four times. The neurological check sheet had omission times for neurological checks completed once resident returned to the facility from the hospital and for 19 hours post check, 23 hours post check, 48 hours post check, and 72 hours post check.
A fall risk evaluation, dated 7/10/25, indicated Resident T had balance problems with standing and walking, decreased muscular coordination, and had changes in gait pattern when walking through the doorway.
The plan of care for Resident T, dated 7/2/23, indicated the resident was at risk for falls related to poor safety awareness, dementia, and history of falls. Interventions included, but were not limited to, following facility fall protocol.
During an interview with Confidential Staff Member 4 on 7/15/25 at 12:23 p.m., they indicated residents were not getting neurological checks completed after falls.
4. The clinical record for Resident O was reviewed on 7/17/2025 at 2:05 p.m. The diagnoses included, but were not limited to, stroke and muscle weakness.
A Quarterly MDS assessment, dated 6/21/2025, indicated Resident O was cognitively intact, did not reject care, required substantial assistance with transferring, but did not have impairments to upper and/or lower extremities.
A fall care plan, initiated on 12/19/2024 and revised on 6/30/2025, indicated Resident O was at risk for falls related to balance problems and being unaware of safety needs. Interventions included, but were not limited to, follow facility fall protocol.
A nursing assessment, dated 5/19/2025, indicated Resident O was at risk for falls.
A post fall assessment, dated 5/29/2025, indicated Resident O had an unwitnessed fall.
Review of the clinical record did not disclose any neurological checks completed for Resident O after her fall on 5/29/2025.
During an interview on 7/17/2025 at 2:30 p.m., the DON indicated she could not find neurological checks for Resident O related to the fall on 5/29/2025. The facility’s expectation was that neurological checks were initiated and completed after an unwitnessed fall, and she was unsure why they were not completed.
This citation relates to Complaint IN00458299.
3.1-37(a)

A. Based on observation, interview, and record review, the facility failed to notify the physician of urinalysis results (Resident C), failed to implement contact isolation or enhanced barrier precautions (EBP) for a resident with multidrug-resistant organism (MDRO) (Resident C), failed to move a resident to a private room after a resident was revealed to have a MDRO (bacteria or other microorganisms that have become resistant to multiple antibiotics) (Resident C), and failed to implement EBP for Resident K for 2 of 3 residents reviewed for infection control (Resident C and Resident K).B. Based on observation and interview, the facility failed to properly store an ice scoop to ensure infection control measures for 1 of 1 random observation.Findings include: 1. During an interview with Confidential Staff 4 on 7/15/25 at 12:23 p.m., they indicated Resident C had a urinalysis completed, in December 2024, with the diagnoses of providencia stuartii (bacteria that was considered a MDRO). The facility did not implement any EBP or move the resident to a private room until April 2025.
The clinical record of Resident C was reviewed on 7/15/25 at 11:00 a.m. The diagnoses included, but were not limited to, cellulitis of left lower limb and diabetes.
The urinalysis for Resident C, dated 12/10/24, indicated the resident had a diagnosis of providencia stuartii. The lab was flagged by the laboratory as an organism known to possess inducible beta-lactamase. Suggest clinical observation for the development of resistance.
The physician recapitulation of orders for Resident C, dated July 2025, indicated the resident was ordered on 4/3/25, to be on enhanced barrier precautions. That included a sign outside the resident's room and utilization of gown and gloves for high contact resident care activities. This was used for residents with a known MDRO or have an increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). A face shield should be used for any task that has a high potential of splash or spray.
Resident C’s record indicated the resident was in a semi-private room with another resident, from 1/1/25 until 4/7/25, until she was moved to a private room.
The plan of care for Resident C, dated 4/3/25, indicated the resident required EBP related to a chronic wound to the left lower leg. The interventions included but were not limited to, following EBP precaution guidelines, inform my visitors of necessary precautions, and personal protective equipment (PPE) used for high contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing brief or assisting with toileting and wound care.
During an observation on 7/15/25 at 11:30 a.m., Resident C had a sign on the door for EBP. There was no observed PPE (gloves, gowns or face shields) observed in the hallway or in the resident’s room. There was no container observed for PPE disposal in the resident's room.
During an observation and interview with the Unit Manager on 7/15/25 at 11:43 a.m., they verified Resident C did not have PPE in the bedroom or outside the room available for staff to utilize. The Unit Manager also verified there was no container available for PPE disposal. The Unit Manager indicated she would find out why the appropriate PPE equipment was not available. The Unit Manager indicated it was the responsibility of the central supply staff person to ensure PPE was available for the care of residents on EBP. The reason Resident C was on EBP had something to do with a urine test, but she was unsure what the organism was. The Unit Manager indicated she would find out.
During an interview with the Unit Manager on 7/15/25 at 1:55 p.m., they indicated the organism was providencia stuartii in Resident C's urinalysis results dated 12/10/24.
2. During an observation on 7/15/25 at 11:51 a.m., Resident K had a sign on his door for EBP and there was no PPE outside the room or visible in the room. There was no container for PPE disposal observed.
The clinical record for Resident K was reviewed on 7/17/25 at 11:00 a.m. The diagnoses included, but were not limited to, cellulitis of the lower extremities.
The Quarterly Minimum Data Set (MDS) assessment for Resident K, dated 5/29/25, indicated the resident was cognitively intact for daily decision making. The resident was reasonable and consistent. The resident had no behaviors.
The physician recapitulation of orders for Resident K, dated July 2025, indicated the resident was ordered, on 6/16/25, to be on enhanced barrier precautions.
The plan of care for Resident K, dated 7/15/25, indicated the resident was on antibiotic therapy related to cellulitis. The interventions included, but were not limited to, EBP isolation.
During an observation and interview with Resident K on 7/16/25 at 11:30 a.m., there was no PPE or container inside or outside of the room. Resident K indicated the staff do not wear gloves, gowns or face shields when providing care. The resident's bilateral legs were red, swollen, and seeping clear fluid.
During an interview with Certified Nurse Aide (CNA) 1 on 7/16/25 at 11:40 a.m., she indicated she was Resident K's CNA and verified Resident K did not have PPE or a container for used PPE. CNA 1 indicated Resident K had never had PPE. CNA 1 did not know who was responsible for ensuring the PPE was in place for residents.
During an interview with Licensed Practical Nurse (LPN) 2 on 7/16/25 at 11:43 a.m., they indicated the medical supplies staff person was responsible for ensuring there was PPE available for Resident K.
During an interview with the Director of Nursing (DON) on 7/16/25 at 2:50 p.m., she indicated it was the responsibility of all nursing staff to ensure PPE was available for staff to utilize when caring for residents on EBP. The DON indicated she was not sure why Resident C was not moved to a private room until 4/7/25 or precautions were not implemented for Resident C after the urinalysis with providencia stuartii was received by the facility on 12/10/24. The DON indicated she was unable to find any documentation about the urinalysis/culture. The DON was unsure who the nurse was that received the lab for Resident C.
During an interview with the DON on 7/17/25 at 11:57 a.m., she indicated she was unable to find any documentation that the physician was notified of Resident C’s urinalysis, on 12/10/24, or that any physician’s orders were implemented for precautions for Resident C until 4/3/25. The infection control map captured the urinalysis, but it was not on the facilities infection control surveillance log.
The MDRO infection policy provided by the Executive Director (E.D.), on 7/14/25 at 1:00 p.m., indicated the facility would implement facility wide strategies for preventing the spread of infections with multidrug-resistant organisms. Infection, as opposed to colonization with MDRO would be determined by a physician in accordance with the Centers for Disease Control (CDC). The facility would report it to the Infection Preventionist for surveillance and other infection prevention and control program activities. Contact precautions would be initiated for a resident with MDRO, contact signage would be placed at the entry of the resident's room and the type of PPE that was required to enter the resident's room. When the physician and Infection Preventionist review the situation and determine the resident was no longer infectious and was colonized, contact precautions would be discontinued and the resident would be placed on EBP. When private rooms were available, assign the room to residents with known MDRO. When a private room was not available, cohort residents with the same MDRO in the same room.
The EBP policy provided by the E.D., on 7/17/25 at 10:25 a.m., indicated the facility would implement EBP precautions for the prevention of transmission of multidrug-resistant organisms. Implementation of EBP: make gowns and gloves available immediately near or outside of the resident's room. Note face protection may also be needed if performing activity with a risk of splash or spray. Position a trash can inside the resident room and near the exit for discarding the PPE after removal, prior to exit of the room or before providing care for another resident.
3. During an observation down the center hallway on 7/16/25 at 2:28 p.m., CNA 3 was observed passing ice water out of a portable cooler. CNA 3 opened the cooler, and the ice scoop was laying inside of the cooler. During an interview with CNA 3 at that time, when asked if the ice scoop should be inside of the cooler, CNA 3 indicated “I guess not”.
During an interview with the DON on 7/16/25 at 2:40 p.m., she indicated it was the facility’s expectations to put and store the ice scoop in the proper holder and not leave the scoop in the cooler for infection control practices.
This citation relates to Complaint IN00462315 and Complaint IN00458299.
3.1-18(b)(1)(A)
3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to promote residents' dignity by not answering call lights in a timely manner resulting in incontinence (Resident M, Resident Q, and Resident U), not assisting with activities of daily living (ADLs) as preferred with showers and after toileting care (Resident J), and refusing to assist Resident M to get into their recliner from the bed at night, and refusing to heat up a resident's food when the resident reported the food was cold (Resident M) for 4 of 4 residents reviewed for dignity.Findings include:
1. The clinical record for Resident J was reviewed on 7/14/25 at 1:45 p.m. The diagnoses included, but were not limited to, fracture of right lower leg and muscle weakness.
The Quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, indicated Resident J was cognitively intact, used a wheelchair for mobility, frequently incontinent of bladder and always incontinent of bowel, and required supervision or touching assistance with mobility.
During an interview with Resident J’s family member on 7/15/25 at 9:50 a.m., they indicated Resident J had been placed on a bedpan and put her call light on once she was done to let staff know she needed help. Resident J’s family member indicated she had waited thirty minutes with the call light on, and no staff ever came to take her off it. Resident J’s family member then walked to the nurses’ station herself to see if she could get help taking Resident J off of the bedpan. Resident J’s family indicated there was one nurse sitting at the nurses station and when she told her Resident J had her call light on and had been on the bedpan for over thirty minutes, and needed to be taken off, the nurse indicated, the aides were busy passing meal trays and someone would get to her once that was all done. Resident J’s family member indicated this type of incident happened several times. Resident J’s family member felt this behavior was very disrespectful to their family member and could have been detrimental by having the risk of skin breakdown.
The plan of care for Resident J, dated 2/13/25, indicated the resident required assistance with activities of daily living (ADLs) related to impaired balance and limited mobility. The interventions included, but were not limited to, the resident requires assistance of one to two staff to turn and reposition in bed.
The plan of care for Resident J, dated 2/14/25, indicated the resident was at risk for falls related to gait and balance problems. The interventions included, but were not limited to, the resident requiring prompt response to all requests for assistance.
During another interview with Resident J’s family member on 7/17/25 at 10:00 a.m., they indicated Resident J was in her room sitting in her wheelchair after receiving physical therapy that day. The family member indicated a certified nurse aide (CNA) had come into the room ready to assist Resident J with a bath. The family member indicated Resident J had reported being tired from just getting therapy and wanted to lay down for a little bit. The CNA then handed her a paper to sign. The family member asked what she was signing and the CNA indicated she needed to initial it; that she was refusing her bath and then she would help her back to bed. Resident J’s family member told the CNA, no she was not refusing, she just wanted to wait a little bit until she took one.
During an interview with the Director of Nursing (DON) on 7/17/25 at 11:57 a.m., she indicated if a resident was too tired at the time a bath was being offered, staff should offer to do it later or do a bed bath.
2. The clinical record for Resident Q was reviewed on 7/17/2025 at 11:20 a.m. The diagnoses included, but were not limited to, stroke and respiratory failure.
The last Quarterly Minimum Data Set Assessment indicated Resident Q was cognitively aware, did not reject care, and was always continent with bowel and bladder. The resident needed standby assistance for transferring and toileting needs.
A care plan, revised on 3/2/2025, indicated Resident Q was at risk for bowel and bladder incontinence related to the need for assistance with toileting, transfers, and stroke. Interventions included having a call bell within reach and providing one staff as needed for assistance with toileting.
During an interview on 7/15/2025 at 2:10 p.m., Resident Q indicated she needed assistance for transfers for safety. In the last month, there have been times she had to wait up to an hour to get assistance to the bathroom, resulting in her becoming incontinent of urine. She indicated she used the clock to tell time and was able to accurately discern the time displayed during the interview. Becoming incontinent of urine made Resident Q feel “humiliated”.
3. During an interview with Resident M on 7/15/25 at 11:57 a.m., they indicated they ate their meals in their room and the food was sometimes cold. The resident reported to the nursing staff that the food was cold, and they did not warm it up. It was not a certain meal; it happened with all three meals. The resident indicated their call light was not answered timely, and it mainly happened on third shift. The resident indicated they had to wait up to two and 1/2 hours for the call light to be answered. This caused the resident to become soiled with urine. The resident's pajamas, sheets and blankets would be soaked with urine. The resident indicated third shift refused to assist the resident to the recliner. Also, the resident had a bad back and could only lay for so long in the bed. The resident did not know the staffs’ names and had not reported it to anyone. The resident indicated they were afraid of retaliation and were dependent on staff for care. The resident had a cell phone and that was how they timed how long it was for the call light to be answered.
The clinical record for Resident M was reviewed on 7/15/25 at 2:20 p.m. The diagnoses included, but were limited to, weakness, age related physical debility and hypertensive heart disease.
The admission MDS assessment for Resident M, dated 6/10/25, indicated the resident was cognitively intact for daily decision making. The resident was reasonable and consistent. The resident had no behaviors, and the resident was dependent on staff for toileting needs.
4. During an interview and observation with Resident U on 7/16/25 at 2:08 p.m., she indicated sometimes she had to wait forever for the call light to be answered. Resident U indicated she messed my pants with bowel movement (BM) this morning. She had waited 45 minutes for the staff to come. The resident indicated this happened before where she had become incontinent with urine and BM because she had to wait so long for the call light to be answered. The resident had a clock in the room with the correct time and also had a cell phone to time how long it took for the call light to be answered. The resident indicated she had not reported it to anyone because she felt sorry for the staff because the facility did not have enough staff. The resident indicated she knew when she needed to use the restroom but was unable to hold her bowels and bladder for long periods of time.
The clinical record for Resident U was reviewed on 7/17/25 at 1:25 p.m. The diagnoses included, but were not limited to, spinal stenosis, hypertensive heart failure, syncope, repeated falls, muscle weakness, age related debility and chronic kidney disease.
The Quarterly MDS assessment, dated 6/24/25, indicated the resident was cognitively intact for daily decision making. The resident was reasonable and consistent. The resident required substantial to maximum assistance with toileting needs.
During an interview with the Director of Nursing (DON) on 7/16/25 at 2:50 p.m., she indicated the facility’s expectations were call lights to be answered within five minutes.
The resident rights policy provided by the Executive Director (E.D.), on 7/16/25 at 2:05 p.m., indicated the resident had the right to be treated with respect and dignity.
The call light policy provided by the E.D., on 7/17/25 at 10:25 a.m., indicated all staff members who see or hear an activated call light were responsible for responding.
This citation relates to Complaint IN00458694 and Complaint IN00462315.
3.1-3(t)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The clinical record for Resident D was reviewed on 3/27/2025 at 1:00 p.m. The medical diagnoses included emphysema and diabetes.
A Quarterly Minimum Data Set assessment, dated 2/4/2025, indicated Resident D was cognitively intact and received insulin.
A diabetes management care plan, revised 3/2/2025, indicated Resident D had diabetes mellitus. Interventions included to monitor Resident D's blood glucose as well as education about compliance and to document and report noncompliance.
A respiratory care plan, revised 3/2/2025, indicated Resident D had emphysema and was at risk for impaired gas exchange. Interventions included to administer medications as ordered.
A physician order, started on 7/5/2024 and discontinued on 3/25/2025, indicated Resident D received sliding scale insulin based upon the blood glucose reading. The order stated to inject as per sliding scale: if blood glucose was 150 - 200 to administer four units; if blood glucose was 201 - 250 to administer eight units; if blood glucose was 251 - 300 to administer 12 units; if blood glucose was 301 - 350 to administer 16 units; if blood glucose was 351 - 400 to administer 20 units; if blood glucose was above 400 to administer 25 units and recheck blood sugar in an hour, if blood glucose was still above 400 and then call the provider.
Review of the March 2025 MAR, completed on 3/27/2025 at 1:30 p.m., indicated Resident D's 3/12/2025 6:30 a.m. administration of sliding scale insulin was blank as well as the associated blood glucose for the 3/12/2025 6:30 a.m. administration.
During an interview on 3/27/2025 at 1:20 p.m., the Director of Nursing indicated if the administration was not documented on the MAR, she would expect that it was not completed. She was unsure why the 3/12/2025 administration of sliding scale insulin was not documented.
A policy entitled Medication Administration was provided by the Executive Director on 3/27/2025 at 2:13 p.m. The policy indicated staff were to, .Sign MAR after administration .
This citation is related to Complaint IN00456167.
3.1-50(a)(1)
3.1-50(a)(2)
Based on interview and record review, the facility failed to ensure complete and accurate documentation of residents' medication administration records (MARs) for 2 of 3 residents reviewed for medication administration. (Residents B and D)
Findings include:
1. The clinical record for Resident B was reviewed on 3/27/25 at 11:45 a.m. Her diagnoses included, but were not limited to, diabetes mellitus. She was admitted to the facility on [DATE] and discharged AMA (against medical advice) on 3/21/25.
The physician's orders indicated to administer ten units of Lantus (insulin glargine) subcutaneously at bedtime, effective 3/19/25.
The March 2025 MAR indicated the above medication was administered the evening of 3/19/25 but was blank for the 3/20/25 administration.
An interview was conducted with the Director of Nursing (DON) on 3/27/25 at 1:30 p.m. She indicated if a medication was not signed off, it either wasn't administered or wasn't documented that it was administered.
The nurse who worked the evening shift, of 3/19/25, and cared for Resident B was unavailable for interview.

Based on interview and record review, the facility failed to notify a resident when they had outside physician appointments for 1 of 3 residents reviewed for notification of appointments (Resident E).
Findings include:
During an interview with Resident E on 3/17/25 at 1:40 p.m., they indicated they had several outside doctor appointments, and the resident was never notified about them. The resident indicated the man that drove the bus to appointments would show up at their door and say, let's go, you have an appointment. The resident indicated this happened at least four times and maybe even more than that. The resident indicated they were an early riser, so they were thankful they were always dressed and ready. The resident indicated they did not want to cause any trouble or get anyone in trouble, they just felt it was courteous to let them know they had an appointment.
During an interview with Licensed Practical Nurse (LPN) 1 on 3/17/25 at 1:45 p.m., they verified Resident E had five outside doctor appointments in January 2025, February 2025, and March 2025. There was no documentation in the resident's clinical record that the resident was notified about the appointments.
Review of the clinical record of Resident E, on 3/17/25 at 3:34 p.m., indicated the resident's diagnoses included, but were not limited to, chronic kidney disease, pleural plaque without asbestos, left ventricular failure, anemia, hypertensive heart disease, and respiratory failure with hypoxia.
The admission Minimum Data Set (MDS) assessment for Resident E, dated 1/11/25, indicated the resident was moderately impaired for daily decision making. The resident had the ability to make themselves understood and understood others.
The policy entitled resident self-determination and participation (schedules) was provided by the Director of Nursing (DON) on 3/18/25 at 9:18 a.m. The policy indicated the facility would promote and facilitate a resident's right to self-determination through support of the resident choice. The resident had the right to make choices about aspects of his or her life in the facility that are significant to the resident. The social service designee should assist the resident maintaining as normal a lifestyle as possible while in the facility.
This citation relates to Complaint IN00455179.
3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to provide residents with their preference to have the capability to open their bedroom window to get fresh air for 4 of 5 residents reviewed for accommodation of needs/preferences (Resident C, Resident E, Resident F, and Resident B).
Findings include:
1. Review of the clinical record of Resident C, on 3/17/25 at 12:25 p.m., indicated the resident's diagnoses included, but were not limited to, respiratory failure, chronic respiratory failure with hypoxia, morbid (severe) obesity, diabetes, age related debility.
The admission Minimum Data Set (MDS) assessment for Resident C, dated 1/15/25, indicated the resident was cognitively intact for daily decision making. The resident had no behavior consisting of wandering. It was important to the resident to get fresh air when the weather was good.
During an interview with Resident C's family member on 3/17/25 at 2:07 p.m., they indicated the resident was hot one day and requested for the family member to open their window to get some fresh air. Resident C's window was screwed shut and the family member was unable to open it.
2. During an observation and interview with Resident E on 3/17/25 at 10:55 a.m., the resident indicated they noticed they had screws in their window and was unable to open it. Observation the resident's window noted the window was screwed shut. The resident indicated they had always lived in the country and enjoyed a good breeze. The resident indicated they wanted to be able to open the window in their room.
Review of the clinical record of Resident E, on 3/17/25 at 3:34 p.m., indicated the resident's diagnoses included, but were not limited to, chronic kidney disease, pleural plaque without asbestos, left ventricular failure, anemia, hypertensive heart disease, and respiratory failure with hypoxia.
The admission Minimum Data Set (MDS) assessment for Resident E, dated 1/11/25, indicated the resident was moderately impaired for daily decision making. The resident had the ability to make themselves understood and understood others. It was important to the resident to get fresh air when the weather was good.
The elopement assessment for Resident E, dated 1/11/25, indicated the resident was not at risk of elopement.
3. During an observation and interview with Resident F on 3/17/25 at 11:05 a.m., the resident's window in their room would not open. Resident F indicated they would definitely like to have some fresh air when the weather was nice. The resident indicated they thought it was strange they could not open the window in their room.
Review of the clinical record of Resident F, on 3/18/25 at 12:11 p.m., indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease, diabetes, anxiety, muscle weakness, depression, and morbid (severe) obesity.
The elopement risk assessment for Resident F, dated 1/7/25, indicated the resident was not at risk for elopement.
The Quarterly Minimum Data Set (MDS) assessment for Resident F, dated 1/14/25, indicated the resident was cognitively intact for daily decision making.
4. The clinical record of Resident B was reviewed on 3-17-25 at 11:45 a.m. Her diagnoses included, but were not limited to, diabetes with neuropathy and abnormal gait and mobility. Her most recent Minimum Data Set assessment, dated 1-30-25, indicated she was cognitively intact. Her most recent elopement risk assessment, dated 8-14-24, indicated she was not at risk for elopement.
In an interview with Resident B on 3-17-25 at 2:02 p.m., she indicated she enjoyed having her room window open when the weather was nice, to allow fresh air in. Resident B indicated she was unable to open her room window as it was nailed or screwed closed.
In an observation of Resident B's room on 3-18-25 at 11:15 a.m., with Registered Nurse (RN) 3, she was observed to attempt to open the windows of Resident B's room several times without success. Several screws were observed located to the window frame, which prevented the windows from being opened. RN 3 indicated she was unaware the windows in Resident B's room were unable to open.
During an interview with the Maintenance Director on 3/17/25 at 11:36 a.m., he indicated there were screws in the windows in Resident B, Resident C, Resident E, and Resident F's hallway to prevent the windows from opening. The Maintenance Director indicated he had put the screws in the windows a long time ago and was instructed to do so by management to do it. The Maintenance Director indicated he was unsure why the windows were screwed shut.
On 3-18-25 at 9:18 a.m., the Director of Nursing provided a copy of a policy entitled, Resident Self Determination and Participation (Schedules), with a copyright date of 2025. This policy indicated, It is the policy of this facility to promote and facilitate a resident's right to self-determination through support of resident choice . According to federal regulations, the resident has a right to .Make choices about aspects of his or her life in the facility that are significant to the resident .The social service designee should assist the resident in maintaining as normal a lifestyle as possible while in the facility .
This citation relates to Complaint IN00452650.
3.1-3(u)(3)
3.1-3(v)(1)

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents reviewed for infections. (Resident B)
Findings include:
The clinical record of Resident B was reviewed on 3-17-25 at 11:45 a.m. Her diagnoses included, but were not limited to, diabetes with neuropathy and abnormal gait and mobility. Her most recent Minimum Data Set assessment, dated 1-30-25, indicated she was cognitively intact and required the use of a wheelchair for mobility. It indicated she had a foot infection, was receiving an antibiotic, and received dressing changes to her feet.
A review of a note from a podiatrist, dated 1-14-25, indicated she had started on an antibiotic for one week for cellulitis to the second toe of her left foot. A follow-up visit note, dated 1-28-25, indicated her affected toe still showed signs of cellulitis and a second round of antibiotics was ordered for another seven days.
A care plan was not located in Resident B's clinical record related to the cellulitis of the left second toe.
In an interview with the facility's Infection Preventionist on 3-17-25 at 2:35 p.m., she indicated I did not track her cellulitis and antibiotics and that was my responsibility. Part of my responsibility is if we get an order, I am to put it in the tracking system and make sure the order is in place, it is being given correctly and that a care plan is developed for the issue.
On 3-18-25 at 11:25 a.m., the Director of Nursing provided a copy of a policy entitled, Comprehensive Care Plans, with a copyright date of 2025. This policy indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psycho-social well-being .The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.
This citation relates to Complaint IN00455179.
3.1-35(a)
3.1-35(b)(1)

Based on interview and record review, the facility failed to follow and institute their antibiotic stewardship policies and protocols for 1 of 5 residents reviewed for infections, related to cellulitis. (Resident B)
Findings include:
The clinical record of Resident B was reviewed on 3-17-25 at 11:45 a.m. Her diagnoses included, but were not limited to, diabetes with neuropathy and abnormal gait and mobility. Her most recent Minimum Data Set assessment, dated 1-30-25, indicated she was cognitively intact and required the use of a wheelchair for mobility. It indicated she had a foot infection, was receiving an antibiotic, and received dressing changes to her feet.
A review of a note from a podiatrist, dated 1-14-25, indicated she had started on an antibiotic for one week for cellulitis to the second toe of her left foot. A follow-up visit note dated, 1-28-25, indicated her affected toe still showed signs of cellulitis and a second round of antibiotics was ordered for another seven days.
In an interview on 3-17-25 at 12:58 p.m., with the facility's Infection Preventionist, she indicated she began working in this capacity on/around 1-7-25, approximately one week prior to Resident B's cellulitis. She indicated she was unable to locate any information regarding the mapping (tracking) of Resident B's cellulitis in the infection control records for January, February or March of 2025. She indicated the facility typically follows McGeer's criteria related to tracking infection control issues (McGeer criteria are a set of guidelines utilized by long-term care facilities to identify and monitor infections).
An interview was conducted with the facility's Infection Preventionist on 3-17-25 at 2:35 p.m. She indicated, I did not track her cellulitis and antibiotics and that was my responsibility. Part of my responsibility is if we get an order, I am to put it in the tracking system and make sure the order is in place, it is being given correctly, and that a care plan is developed for the issue.
On 3-18-25 at 11:25 a.m., the Director of Nursing provided a copy of a policy entitled, Antibiotic Stewardship Program, with a copyright date of 2024. This policy indicated, It is the policy of this facility to implement an Antibiotic Stewardship Program as a part of the facility's overall infection prevention program. The purpose of the program is to optimize the treatment of infections while reducing the adverse effects associated with antibiotic use .The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the following partners: Infection Preventionist-utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms .
This citation relates to Complaint IN00455179.

Based on interview and record review, the facility failed to provide showers and/or baths to prevent body odor and failed to provide incontinent care timely to a resident to promote dignified care for 1 of 3 residents reviewed for activities of daily living (Resident C).
Findings include:
The clinical record for Resident C was reviewed on 3/17/25 at 12:25 p.m. The diagnoses included, but were not limited to, respiratory failure, chronic respiratory failure with hypoxia, morbid (severe) obesity, diabetes, age related debility.
The admission Minimum Data Set (MDS) assessment for Resident C, dated 1/15/25, indicated the resident was cognitively intact for daily decision making. The resident was dependent for showers/bathing, substantial/maximal assistance for upper dressing, and dependent for lower body dressing. The resident had no behavior consisting of rejection of care. The resident was frequently incontinent of their bowels and bladder.
During an interview with Resident C's family member on 3/17/25 at 2:07 p.m., they indicated the facility was not providing the resident with sufficient showers/bathing. The family member visited the resident 3-4 times a week. The resident always smelled of body odor and urine. The resident had two other family members that visited frequently, and they reported the same thing when they visited. The resident reported the staff were not providing showers/bathing or changing their incontinent brief. This was embarrassing for the resident. The facility was not treating Resident C with dignity, and this was disrespectful to the resident. Resident C did not have control of their bladder or bowels. The family member took a magic marker and marked the resident's incontinent brief. Two family members came back, on the third day, and Resident C still had the incontinent brief with the magic marker mark on it. The second family member reported this to the nursing staff, and they changed the resident.
The resident rights policy provided by the Director of Nursing (DON), on 3/18/25 at 9:18 a.m., indicated the resident had the right to respect and dignity.
This citation relates to Complaint IN00452650.
3.1-3(t)

Based on observation, interview and record review, the facility failed to initiate an investigation into an allegation of sexual abuse identified by a nurse and ensure adequate protection was provided to 3 of 18 residents on the unit. (Residents 49, 50, 56, and 74)
The immediate jeopardy began on 6/6/24, when 2 residents' clinical records indicated allegations of sexual abuse.
The Administrator, Director of Nursing, Area [NAME] President, [NAME] President of Risk and Regulatory Compliance, and Regional Director of Clinical Operations were notified of the immediate jeopardy on 6/18/24 at 3:23 p.m. The immediate jeopardy was removed on 6/14/24, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.
Findings include:
1. The clinical record for Resident 50 was reviewed on 6/17/24 at 1:10 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and insomnia.
The 5/15/24 Quarterly MDS (Minimum Data Set) assessment indicated the BIMS (brief interview for mental status) was not conducted, as she was rarely/never understood. The staff assessment for mental status indicated she had short and long-term memory problems. She did not know the current season or that she was in a nursing home. Her cognitive skills for daily decision making were severely impaired, in that she rarely/never made decisions. It indicated she had physical behavioral symptoms directed towards others, such as hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during one to three days of the past seven days. She had verbal behavioral symptoms directed towards others such as threatening, screaming at, and/or cursing at others during one to three days of the past seven days.
The 10/5/23 behavior care plan, last revised 12/19/23, indicated she demonstrated sexually inappropriate behaviors by entering male resident rooms, laying in male resident's bed, and making sex-related comments. The goal, with a target date of 8/13/24, was for her to interact with others appropriately during social and care situations. Interventions were to quietly attempt to redirect, reminding her that the behavior was not appropriate; to let her physician know if her behaviors were interfering with her daily care/living; and to please refer her to mental health services as needed.
There was no assessment/evaluation in the clinical record indicating Resident 50 had the capacity to consent to sexual activity in the facility.
2. The clinical record for Resident 74 was reviewed on 6/13/24 at 1:17 p.m. Her diagnoses included, but were not limited to: dementia, anxiety, and insomnia.
The 5/25/24 Significant Change MDS assessment indicated she was severely cognitively impaired. She had a behavior of wandering during one to three of the previous seven days. The wandering behavior significantly intruded on the privacy of activities of others.
The 4/8/24 behavior care plan indicated she demonstrated sexually inappropriate behaviors by entering a male resident's room, laying in male resident's bed, and inappropriate touching. The goal was for her behaviors to lessen. Interventions, effective 4/8/24, were to offer her something else she liked as a diversion; let her physician know if her behaviors were interfering with her daily are/living; and to refer her to mental health services as needed.
The 4/9/24 behavior care plan indicated she wandered in others' rooms; may crawl in bed with others; believed other male resident was her husband and became agitated and aggressive when attempting to redirect. The goal was for her to not harm herself or others due to her behaviors. Interventions, effective 4/9/24, were to attempt interventions before her behaviors began; make family aware of behaviors; let her physician know if her behaviors were interfering with her daily living, and offer here something she liked as a diversion.
There was no assessment/evaluation in the clinical record indicating Resident 74 had the capacity to consent to sexual activity in the facility.
The 6/6/24, 8:35 a.m. behavior note, written by LPN (Licensed Practical Nurse) 5, read, Resident was standing in the dining room next to a male resident allowing him to grope her butt in front of the other residents. Interventions attempted: Residents were separated and redirected. Effectiveness of the interventions: Somewhat effective, though resident is pacing the unit trying to figure out how to get back to this male resident. She is also becoming very irritated with anyone whom is standing in her way or attempting to keep them apart.
The 6/6/24, 9:35 a.m. behavior note, written by LPN 5 read, Resident was standing next to the couch in the dayroom while a male resident was sitting on the couch with his hand up her shirt and rubbing on her breast. Interventions attempted: Residents were separated and a CNA (Certified Nursing Assistant) was asked to monitor that they remain apart. Effectiveness of the interventions: Ineffective as the two residents continue to seek one another out.
The 6/6/24, 2:49 p.m. progress note, written by LPN 5, read, Resident has roamed the unit seeking out a certain male resident all shift. Whenever staff attempted to separate the two residents, both residents would become aggressive and begin to lash out at staff verbally and physically.
3. The clinical record for Resident 56 was reviewed on 6/14/24 at 11:37 a.m. The diagnoses included, but were not limited to: Alzheimer's disease, dementia, anxiety, and insomnia.
The 5/10/24 Quarterly MDS assessment indicated the BIMS was not conducted, as he was rarely/never understood. The staff assessment for mental status indicated he had short and long-term memory problems. He did not know the current season or that he was in a nursing home. His cognitive skills for daily decision making were moderately impaired, in that decisions were poor, requiring cues/supervision.
An observation of Resident 56 was made on 6/14/24 at 2:05 p.m. He was lying awake in bed. He began speaking but was unable to understand what he was attempting to say.
The 3/23/23 behavior care plan, last revised 4/16/24, indicated he demonstrated sexually inappropriate behaviors, believing others were his significant other. He would hug and sometimes attempt to kiss others. He displayed inappropriate touching and made sexually explicit comments to others. The goal was for him to interact with others appropriately during social and care situations. Interventions, effective 3/23/23, were to let his physician know if his behaviors were interfering with his daily care/living; quietly attempt to re-direct, reminding him that the behavior was not appropriate; let him know that his behavior was affecting others; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 10/5/23 behavior care plan, last revised 4/16/24, indicated he sometimes demonstrated sexually inappropriate behaviors by entering female residents' rooms, having female resident come into his room, and lay in bed with others. The goal was for him to interact with others appropriately during social and care situations. Interventions, initiated 10/5/23, were to let his physician know if his behaviors were interfering with his daily care/living; offer him something else he liked; quietly attempt to re-direct, reminding him that the behavior was not appropriate; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 8/31/23 behavior care plan, last revised 4/16/24, indicated he sometimes became frustrated or agitated, pushing, grabbing, being physically aggressive, and threatening when staff tried to redirect other residents from his room. He may resist care by hitting and kicking. The goal was for him to have fewer episodes of becoming frustrated and for his behavior to stop with staff intervention. Interventions were to attempt interventions before his behaviors began; give medications as doctor ordered; and to offer him something he liked as a diversion. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
There was no assessment/evaluation in the clinical record indicating Resident 56 had the capacity to consent to sexual activity in the facility.
The 6/5/24, 9:31 a.m. progress note for Resident 56, written by the DON (Director of Nursing) read, resident continues to have episodes of becoming agitated at staff when staff is attempting to assist female residents on the unit. resident believes that some of the female residents are his girls and becomes very protective. also continues to wonder [sic] about unit and at times will enter other resident's room uninvited, usually easily to redirect out of unwanted areas. word salad frequently present, however during periods of agitation speech becomes coherent and resident will begin cursing at staff. staff will continue to attempt to ensure safety, provide interventions and assistance as warranted. resident is followed by in-house mental health provider and is followed by in-house PCP [primary care physician] provider.
A behavior note, dated 6/6/24 at 9:01 a.m., for Resident 56, written by LPN (Licensed Practical Nurse) 5, indicated, Resident shoved this nurse out of the doorway as staff was attempting to keep he and a female resident separated due to sex behaviors. What was the resident doing prior to or at the time of behavior/mood: Resident was in the dining room and had been noticed rubbing a female resident's butt as she stood next to him. Interventions attempted: separation of resident's [sic.] Effectiveness of the interventions: Intervention was ineffective The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the behavior in the above progress note was the first behavior he witnessed on 6/6/24 between Resident 56 and Resident 74.
The next consecutive behavior note, dated 6/6/24 at 9:30 a.m., written by LPN 5 indicated, Resident was noted sitting in the sunroom with his hand up the shirt of the same female resident as earlier. Resident was rubbing the breast of this resident at this time. Interventions attempted: Both resident's [sic] were separated. Effectiveness of the interventions: Intervention was ineffective as these two resident's [sic] continue to seek one another out. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated he just happened to walk in the sunroom and see Resident 56 with his hand up Resident 74's shirt. There were quite a few other residents in the sunroom at the time, who were just sitting there, roughly six residents total including Resident 56 and Resident 74, and no staff.
The next consecutive behavior note, dated 6/6/24 at 9:40 a.m., for Resident 56, written by LPN 5 indicated, Resident walked up to the same female resident and grab [sic] her by the face them [sic] kissed her on the lips. Interventions attempted: Separated resident's [sic.] Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the kiss on the lips happened in the hallway and he just happened to see it. He was coming down hallway with the medication cart when Resident 74 walked past him, and Resident 56 came out of the dining room. Resident 56 grabbed Resident 74 on both sides of her face, leaned in, and kissed her. It happened quickly, more like a peck on the lips.
The next consecutive behavior note, dated 6/6/24 at 2:33 p.m., for Resident 56, written by LPN 5, read, Resident was noted sitting on the couch in the sunroom with a female resident on either side of him and the three of them were touching and rubbing on one another. Interventions attempted: Resident's [sic] were asked to stop and then separated. Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated there was another female resident, Resident 50, sitting on one side of Resident 56, and Resident 74 sitting on his other side in reference to the 6/6/24, 2:33 p.m. behavior note. The touching and rubbing he observed while the 3 of them were on the couch was outside of the clothing, rubbing legs, and holding hands. The two female residents weren't touching each other. Resident 56 was in the middle, touching both female residents, and both female residents were touching him. He stated, [Name of Resident 56] was a little too busy for me that day.
A progress note, dated 6/6/24 at 2:36 p.m., written by LPN 5, read, Resident has been aggressive with staff while they were attempting to redirect and separate him from the same female resident whom his [sic] is drawn to.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the 6/6/24, 2:36 p.m. progress note just referenced a continuation of separating Resident 56 and Resident 74 throughout the day. The 3 residents on the couch was the last occurrence he witnessed on 6/6/24. From the time he shoved me, it didn't get any better. He'd only worked at the facility for about 3 weeks through an agency but was off all last week. He normally worked other units and had only worked the memory care unit maybe twice. It was his understanding, from talking to other employees who'd worked on the unit for a while, that Resident 56 had been showing behaviors, and they were increasing and intensifying. When he spoke with someone about Resident 56's behaviors on 6/6/24, he made sure his behavior progress notes were documented to the best of my ability. Resident 56 was very sexual in nature, but also aggressive at times, with staff, including LPN 5. At one point, Resident 56 shoved him. He told full time staff management that day, because he noticed the issues, and he was trying to see how he was supposed to address them. I was told it was care planned. They could be together, just couldn't have sex, and the family was aware, so I just documented. He believed it was either the Unit Manager/Alzheimer's Care Director, the DON, or the Administrator who told him this, but he wasn't sure exactly who, because he was still trying to learn people. Resident 56's behaviors had been brought up on several occasions. He told quite a few people, including the CNAs (Certified Nursing Assistants) so they could keep an eye on them and keep them separated. He was just told to document everything he saw. He didn't think of it as sexual abuse, because both residents were seeking each other out, and it was clear they both became agitated due to staff trying to separate them, but with the residents being on the dementia unit and not having capacity to consent, he saw it as possible sexual abuse. His concern was that families would come in and be upset by it, because it was something that families should be aware of. That's why he went forward with making sure someone knew, and it didn't just stop with him. Prior to 6/6/24, he'd seen Resident 56 be flirtatious, but not touching, more like holding hands, helping and guiding them like they were lost, at least the way that he took it. On 6/6/24, there was no mistaking what was going on between Resident 56 and Resident 74. They were seeking each other out. He'd been trained on abuse multiple times. He worked full time for the PRN (as needed) Float Pool, and they trained him on abuse, but could not recall the last time. He thought it was less than a year ago. He had not received any abuse training in the facility itself.
An interview was conducted with the ACD (Alzheimer's Care Director) on 6/14/24 at 1:50 p.m. She indicated she'd been the ACD for about 2 years and was familiar with Resident 56. She did not consider his behaviors with other female residents as inappropriate. They will love on each other, kiss and cuddle. It was mostly with Resident 74, but Resident 50 gravitated toward Resident 56 as well, would sit and hold hands, nothing inappropriate. She'd spoken to both Resident 56's and Resident 74's families and made them aware. Resident 74's family was religious and understood, as long as nothing got out of hand. She knew others had seen Resident 56 with his hands up Resident 74's shirt, but she had not seen that. A male agency nurse told her Resident 56 put his hands up the back of Resident 74's shirt and he separated them. In the last month, Resident 56 had been generally harder to redirect. The IDT [Interdisciplinary Team] had talked about this; it was care planned; they talked to families and made a note about a month and a half ago.
An interview was conducted with CNA 8, on 6/14/24 at 2:00 p.m., who worked the day shift of 6/6/24. She indicated she normally worked the memory care unit of the facility and had witnessed Resident 56 wrap his arm around female residents and caught him attempting to kiss female residents. She was told by CNA 9 that Resident 56 groped women's breasts, but CNA 8 hadn't witnessed this. His behaviors had been going on at least a few months. Some days he was hard to redirect and would be loud and aggressive toward staff. Resident 56 pushed a male nurse on 6/6/24, who didn't normally work the unit. Resident 56 tended to try and kiss Resident 74, as she was the main female resident. They are like glue. CNA 8 was told their families were aware. Once in a while, Resident 56 would try to kiss Resident 50 and a few times tried to kiss Resident 49.
CNA 9 was unavailable for interview.
An interview was conducted with CNA 25 on 6/17/24 at 2:02 p.m. She indicated she worked on 6/6/24. The only thing she saw was Resident 56 kiss Resident 74 on the forehead in the sunroom, just a quick peck. She was coming out a resident's room when LPN 5 informed her in the hallway that Resident 56's hand was up Resident 74's shirt. She didn't report this to anyone, because LPN 5 informed her that he was going to take care of it. She thought LPN 5 had it handled, because he was the nurse in charge.
A progress note, dated 6/10/24 at 9:56 p.m., for Resident 56, written by the DON, read, Resident continues to have episodes of becoming easily irritated and upset with staff when staff provides interventions r/t [related to] behaviors displayed with female residents. Resident has been noted to be holding hands with female residents and occasionally kissing. Resident with severe impaired cognition status and unable to recall behavior as being inappropriate. resident with word salad and when staff intervenes, word salad becomes more severe, tone of voice becoming stern, with an occasional cursing noted. wanders about unit and at times will enter other resident's room without invitations. Resident frequently leaves unwanted areas without incident. family is aware of behaviors and understands [sic] that resident is not able to recognize inappropriateness of behaviors. Resident continues to be followed by in house PCP and in house psych provider. Staff will continue to attempt to ensure safety, offer interventions and assistance as warranted.
An interview was conducted with the Administrator, DON, [NAME] President of Risk and Regulatory Compliance, and Regional Director of Clinical Operations on 6/14/24 at 1:45 p.m. after they read Resident 56's 6/6/24 behavior notes from the electronic health record. The Administrator indicated she did not know about Resident 56's 6/6/24 behaviors. She knew Resident 56 was flirtatious, would hold hands, and thought Resident 74 was his wife. The ACD had spoken to both families in regard to these things. The Administrator did not report, investigate, or take action after the 6/6/24 occurrences, as she was unaware of them. The DON indicated she had never heard about Resident 56's 6/6/24 behaviors prior to just now reading the notes. She was not aware Resident 56 had his hand up Resident 74's shirt, nor was she aware of him rubbing on her buttocks in the dining room and touching on the couch. There was a male nurse on the unit on 6/6/24, so when he was trying to intervene, she thought Resident 56 may have had a problem with him being male and trying to intervene, as Resident 56 would say Those are my girls, and a protective mode would step in. They tried to intervene, distract, take him outside, and use various interventions to address his behaviors.
An interview was conducted with Family Member 6, Resident 74's daughter, on 6/18/24 at 10:33 a.m. She indicated the facility informed her, on 6/14/24, of the 6/6/24 sexual activity involving her mom. Resident 74 would have been very opposed to this behavior, as she was quite religious. If she didn't have dementia, she would be appalled. To her knowledge, nothing happened prior to 6/6/24. Resident 56 and Resident 74 had been kind of buddies for a while. They would sit together, but no hand holding or kissing that I know of, just sitting next to each other. One time she saw Resident 56 try to give Resident 74 a kiss on her forehead, which didn't bother Family Member 6. It was kind of sweet. Family Member 6 would have wanted to know about previous hand holding or kissing and didn't realize it had gotten into this.
An interview was conducted with Family Member 7, Resident 56's son, on 6/18/24 at 12:12 p.m. He indicated he wasn't notified about his father's 6/6/24 behaviors until 6/14/24. They called him a year ago and informed him Resident 74 was in bed with him, kinda messing around, not sure anything was done, kinda fooling around. The staff was responsible for his father and the other residents, so he questioned how this happened and thought the responsibility was on the facility.
An interview was conducted with the DON on 6/17/24 at 10:53 a.m. She indicated the home office was responsible for training PRN (as needed) Float Pool staff on abuse, identification, and reporting, as it was not provided to them in the facility. Her understanding was they were already trained when they came into the facility to work.
The Administrator provided a copy of the 6/12/24 Daily Census for the facility on 6/13/24 at 11:00 a.m. It indicated there were 18 residents on the Alzheimer's Care Unit of the facility including Residents 49, 50, 56, and 74.
The Abuse, Neglect, and Exploitation policy was provided by the DON on 6/17/24 at 11:08 a.m. It read, Sexual Abuse is non-consensual sexual contact of any type with a resident Prevention of Abuse, Neglect and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; .Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur Protection of Resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. responding immediately to protect he alleged victim and integrity of the investigation; .C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Reporting/Response A. The facility fill have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
3.1-28(d)

Based on observation, interview, and record review, the facility failed to assist a resident with eating (Resident 2) and a dependent resident with shaving to their preference (Resident 54) for 2 of 4 residents reviewed for activities of daily living.
Findings include:
1. The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure.
A baseline activities of daily living care plan, dated 5/28/2024, indicated to assist Resident 2 with eating as needed. This care plan did not indicate the amount of assistance, or the number of staff needed.
An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired, independent with eating, and needed substantial to maximum assistance with dressing.
An observation and interview, on 6/14/2024 at 11:30 a.m., with Family Member 12 indicated that Resident 2 had an overall decline in their condition since they were admitted to the facility at the end of May. Family Member 12 tried to come every day to spend time with her mother. She usually arrived between 11:00 and 11:30 a.m. Resident 2 needed assistance with eating and there had been multiple times that Resident 2 would be found covered in food on her clothing, have food spilled in her room on the floor, and still have her breakfast tray in her room when Family Member 12 came to visit around 11:00 a.m. to 11:30 a.m. Family Member 12 recalled an event that had happened less than a week ago, on what she believed was 6/9/2024, and during that time, staff came in to pass Resident 2's lunch tray. Family Member 12 indicated while she was visiting with her mother, Resident 2's lunch tray was passed, and no staff came back to assist Resident 2 with her meal. Resident 2 had not attempted to feed herself during this time. Family Member 12 began to assist her mother with eating about 45 minutes after the meal was passed because her food was getting cold, and her ice cream was melting. Family Member 12 indicated that staff had already picked up the rest of the trays on the unit when she started helping her mother eat, reiterating that no one ever came in to check on them or offer to assist her mother with eating.
A grievance form, dated 6/9/2024, indicated that staff believed that Family Member 12 was going to help Resident 2 with eating.
A confidential staff interview completed during the survey indicated that they assisted with Resident 2's care that day and it was a bad day. They did not offer to assist Resident 2 with eating because her daughter usually is here for lunch and so much was happening that day.
2. The clinical record of Resident 54 was reviewed on 6/18/24 at 11:30 a.m. The diagnoses included, but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other sequelae of cerebral infarction, and muscle weakness (generalized).
The Annual Minimum Data Set (MDS) assessment for Resident 54, dated 5/1/24, indicated the resident was cognitively intact for daily decision making.
A care plan, initiated on 7/19/22, indicated Resident 54 had a physical functioning deficit related to mobility and selfcare impairment.
An observation and interview of Resident 54, on 6/13/24 at 12:45 p.m., noted the resident was lying in bed with a moderate amount of facial hair. Resident 54 indicated he did not want a beard and preferred to be shaven. Resident 54 stated he was unable to shave his own face and he had a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the left hand.
An observation, on 6/14/24 at 11:25 a.m., noted Resident 54 in bed with a long beard.
An observation, on 6/17/24 at 12:04 p.m., noted Resident 54 sitting in a wheelchair with a shaved face. He indicated that he was shaved that morning.
An interview with the DNS (Director of Nursing Services), on 6/19/24 at 12:32 p.m., indicated that direct nursing staff were responsible for residents being shaved. DNS indicated that shaving should be offered with every shower and/or bath.
A policy entitled, Activities of Daily Living (ADLs), was provided by the Area [NAME] President, on 6/18/24 at 12:45 p.m. The policy indicated the following, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; 4. Eating to include meals and snacks. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene
3.1-38(a)(2)(D)
3.1-38(a)(3)(D)
3.1-38(b)(4)

Based on observation, interview, and record review, the facility failed to change the humidification for Resident 2's oxygen concentrator for 1 of 2 residents reviewed for respiratory care needs.
Findings include:
The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure.
An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired.
A physician order for Resident 2, dated 5/24/2024, indicated to change prefilled bottles on her oxygen concentrator and humifaction weekly and as needed.
An observation conducted, on 6/13/2024 at 11:45 a.m., noted Resident 2 sitting in her BRODA chair with her daughter sitting next to her. Resident 12 was utilizing oxygen via nasal cannula with the humidification bottle empty and labelled 6/6/2024.
An observation conducted, on 6/14/2024 at 11:30 a.m., noted Resident 2 sitting in her BRODA chair with her daughter sitting next to her. Resident 12 was utilizing oxygen via nasal cannula with the humidification bottle empty and labelled 6/6/2024.
An observation conducted, on 6/17/2024 at 12:50 p.m., noted Resident 2 lying in bed utilizing oxygen via nasal cannula with a humidification bottle empty and labelled 6/6/2024.
An observation and interview conducted, on 6/17/2024 at 12:55 p.m., with Licensed Practical Nurse (LPN) 11 indicated that the humidification bottle was empty, dated 6/6/2024, and that they should be changed weekly. LPN 11 indicated they would change the whole setup in regard to the nasal cannula and humidification.
A policy entitled, Oxygen Administration, was provided by the Area [NAME] President on 6/18/2024 at 12:45 p.m. The policy indicated the following, .Change humidified bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer .
3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to implement residents' behavior care plans and provide adequate monitoring and supervision to timely address residents' behaviors for 6 of 18 residents on the Alzheimer's Care Unit. (Residents 11, 14, 50, 51, 56, 57, 67, and 74)
Findings include:
1. The clinical record for Resident 50 was reviewed on 6/17/24 at 1:10 p.m. Her diagnoses included, but were not limited to: Alzheimer's disease, anxiety, and insomnia.
The 5/15/24 Quarterly MDS (Minimum Data Set) assessment indicated the BIMS (brief interview for mental status) was not conducted, as she was rarely/never understood. The staff assessment for mental status indicated she had short term and long-term memory problems. She did not know the current season or that she was in a nursing home. Her cognitive skills for daily decision making were severely impaired, in that she rarely/never made decisions. It indicated she had physical behavioral symptoms directed towards others, such as hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during one to three days of the past seven days. She had verbal behavioral symptoms directed towards others such as threatening, screaming at, and/or cursing at others during one to three days of the past seven days.
The 10/5/23 behavior care plan, last revised 12/19/23, indicated she demonstrated sexually inappropriate behaviors by entering male resident rooms, laying in male resident's bed, and making sex-related comments. The goal, with a target date of 8/13/24, was for her to interact with others appropriately during social and care situations. Interventions were to quietly attempt to redirect, reminding her that the behavior was not appropriate; to let her physician know if her behaviors were interfering with her daily care/living; and to please refer her to mental health services as needed.
There was no assessment/evaluation in the clinical record indicating Resident 50 had the capacity to consent to sexual activity in the facility.
The 6/6/24, 2:33 p.m. behavior note for Resident 56, written by LPN 5, indicated, Resident was noted sitting on the couch in the sunroom with a female resident on either side of him and the three of them were touching and rubbing on one another. Interventions attempted: Resident's [sic] were asked to stop and then separated. Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5 on 6/17/24 at 3:00 p.m., he indicated on 6/624 at 2:33 p.m., he observed Resident 50 sitting on a couch in between Resident 56 and Resident 74. LPN 5 indicated he observed Resident 56 touching and rubbing Resident 50 and Resident 74. The touching and rubbing he observed while the three of them were on the couch was outside of the clothing, rubbing legs, and holding hands. Resident 74 and Resident 50 weren't touching each other, but both Resident 74 and Resident 50 were touching Resident 56.
Resident 50's progress notes did not reference the behaviors indicated in Resident 56's 6/6/24, 2:33 p.m. behavior note.
There was no information in Resident 50's clinical record, including the progress notes, to indicate Resident 50's physician was informed of her behaviors referenced in Resident 56's above 6/6/24, 2:33 p.m. behavior note or that her mental health provider was made aware, as care planned.
An interview was conducted with LPN 5 on 6/17/24 at 3:00 p.m. He indicated he did not inform Resident 50's family or doctor or anything. He just documented the behaviors to the best of his ability.
2. The clinical record for Resident 74 was reviewed on 6/13/24 at 1:17 p.m. Her diagnoses included, but were not limited to: dementia, anxiety, and insomnia.
The 5/25/24 Significant Change MDS assessment indicated she was severely cognitively impaired. She had a behavior of wandering during one to three of the previous seven days. The wandering behavior significantly intruded on the privacy of activities of others.
An observation of Resident 74 was made on 6/13/24 at 1:17 p.m. She was continuously wandering about the unit from the dining room into the hallway and into the sunroom.
The 4/8/24 behavior care plan indicated she demonstrated sexually inappropriate behaviors by entering a male resident's room, laying in male resident's bed, and inappropriate touching. The goal was for her behaviors to lessen. Interventions, effective 4/8/24, were to offer her something else she liked as a diversion; let her physician know if her behaviors were interfering with her daily care/living; and to refer her to mental health services as needed.
The 4/9/24 behavior care plan indicated she wandered in others' rooms; may crawl in bed with others; believed other male resident was her husband and became agitated and aggressive when attempting to redirect. The goal was for her to not harm herself or others due to her behaviors. Interventions, effective 4/9/24, were to attempt interventions before her behaviors began; make family aware of behaviors; let her physician know if her behaviors were interfering with her daily living and offer here something she liked as a diversion.
There was no assessment/evaluation in the clinical record indicating Resident 74 had the capacity to consent to sexual activity in the facility.
A behavior note, dated 6/6/24 at 8:35 a.m., written by LPN (Licensed Practical Nurse) 5, read, Resident was standing in the dining room next to a male resident allowing him to grope her butt in front of the other residents. Interventions attempted: Residents were separated and redirected. Effectiveness of the interventions: Somewhat effective, though resident is pacing the unit trying to figure out how to get back to this male resident. She is also becoming very irritated with anyone whom [sic] is standing in her way or attempting to keep them apart. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
The next consecutive behavior progress note, dated 6/6/24 at 9:35 a.m., written by LPN 5 indicated, Resident was standing next to the couch in the dayroom while a male resident was sitting on the couch with his hand up her shirt and rubbing on her breast. Interventions attempted: Residents were separated and a CNA (Certified Nursing Assistant) was asked to monitor that they remain apart. Effectiveness of the interventions: Ineffective as the two residents continue to seek one another out.
The next subsequent progress note related to Resident 74's behaviors, dated 6/6/24 at 2:49 p.m., written by LPN 5, read, Resident has roamed the unit seeking out a certain male resident all shift. Whenever staff attempted to separate the two residents, both residents would become aggressive and begin to lash out at staff verbally and physically. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
There was no information in the clinical record, including the progress notes, to indicate Resident 74's physician was informed of her behaviors referenced in the above 6/6/24, 8:35 a.m. behavior note, 6/6/24, 9:35 a.m. behavior note, or 6/6/24, 2:49 p.m. progress note or that her mental health provider was made aware, as care planned.
An interview was conducted with LPN 5 on 6/17/24 at 3:00 p.m. He indicated he did not inform Resident 74's family or doctor or anything. He just documented the behaviors to the best of his ability.
An interview was conducted with Family Member 6 on 6/18/24 at 10:33 a.m. She indicated Resident 74, and Resident 56 had been kind of buddies for a while. They would sit together, but no hand holding or kissing that she knew of, just sitting next to each other. Family Member 6 would have wanted to know about prior kissing and hand holding. One time, she saw Resident 56 try to give Resident 74 a kiss on her forehead, which didn't bother her. There were a couple times Resident 74 was in Resident 56's bed, while he was in his recliner. The staff knew and kept having to move her. She'd walked into Resident 74's room before, and another resident was in her bed. No one informed her about Resident 56 rubbing Resident 74's buttocks in the dining room on 6/6/24. Resident 74 would have been very opposed to this behavior, as she was quite religious. If she didn't have dementia, she would be appalled.
3. The clinical record for Resident 56 was reviewed on 6/14/24 at 11:37 a.m. The diagnoses included, but were not limited to: Alzheimer's disease, dementia, anxiety, and insomnia.
The 5/10/24 Quarterly MDS assessment indicated the BIMS was not conducted, as he was rarely/never understood. The staff assessment for mental status indicated he had short and long-term memory problems. He did not know the current season or that he was in a nursing home. His cognitive skills for daily decision making were moderately impaired, in that decisions were poor, requiring cues/supervision.
An observation of Resident 56 was made on 6/14/24 at 2:05 p.m. He was lying awake in bed. He began speaking but was unable to understand what he was attempting to say.
The 3/23/23 behavior care plan, last revised 4/16/24, indicated he demonstrated sexually inappropriate behaviors, believing others were his significant other. He would hug and sometimes attempt to kiss others. He displayed inappropriate touching and made sexually explicit comments to others. The goal was for him to interact with others appropriately during social and care situations. Interventions, effective 3/23/23, were to let his physician know if his behaviors were interfering with his daily care/living; quietly attempt to re-direct, reminding him that the behavior was not appropriate; let him know that his behavior was affecting others; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 10/5/23 behavior care plan, last revised 4/16/24, indicated he sometimes demonstrated sexually inappropriate behaviors by entering female residents' rooms, having female resident come into his room, and lay in bed with others. The goal was for him to interact with others appropriately during social and care situations. Interventions, initiated 10/5/23, were to let his physician know if his behaviors were interfering with his daily care/living; offer him something else he liked; quietly attempt to re-direct, reminding him that the behavior was not appropriate; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 8/31/23 behavior care plan, last revised 4/16/24, indicated he sometimes became frustrated or agitated, pushing, grabbing, being physically aggressive, and threatening when staff tried to redirect other residents from his room. He may resist care by hitting and kicking. The goal was for him to have fewer episodes of becoming frustrated and for his behavior to stop with staff intervention. Interventions were to attempt interventions before his behaviors began; give medications as doctor ordered; and to offer him something he liked as a diversion. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
There was no assessment/evaluation in the clinical record indicating Resident 56 had the capacity to consent to sexual activity in the facility.
The 5/29/24 psychiatry progress note indicated, Patient was seen today per facility request for psychiatric evaluation, medication management, and GDR [gradual dose reduction] review. Patient was seen in the common area, pacing up and down the hallway. Patient presents anxious, restless and he continues to follow another female resident. Patient is confused at times during the interview. Staff reports that he has good appetite and sleeps well at night. Per facility, patient can get anxious, irritable, agitation, verbally and physically aggressive toward staff and some resident and hard to redirect at times. Starts Lorazepam 0.5mg po [by mouth] bid [twice daily .] Follow up in two weeks and as needed.
The 6/5/24, 9:31 a.m. progress note for Resident 56, written by the DON (Director of Nursing) indicated, resident continues to have episodes of becoming agitated at staff when staff is attempting to assist female residents on the unit. resident believes that some of the female residents are his girls and becomes very protective. also continues to wonder [sic] about unit and at times will enter other resident's room uninvited, usually easily to redirect out of unwanted areas. Word salad frequently present, however during periods of agitation speech becomes coherent and resident will begin cursing at staff. staff will continue to attempt to ensure safety, provide interventions and assistance as warranted. Resident is followed by in-house mental health provider and is followed by in-house PCP [primary care physician] provider.
A behavior note, dated 6/6/24 at 9:01 a.m., for Resident 56, written by LPN (Licensed Practical Nurse) 5, indicated, Resident shoved this nurse out of the doorway as staff was attempting to keep he and a female resident separated due to sex behaviors. What was the resident doing prior to or at the time of behavior/mood: Resident was in the dining room and had been noticed rubbing a female resident's butt as she stood next to him. Interventions attempted: separation of resident's [sic.] Effectiveness of the interventions: Intervention was ineffective The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the behavior in the above progress note was the first behavior he witnessed on 6/6/24 between Resident 56 and Resident 74.
The next consecutive behavior note, dated 6/6/24 at 9:30 a.m., written by LPN 5 indicated, Resident was noted sitting in the sunroom with his hand up the shirt of the same female resident as earlier. Resident was rubbing the breast of this resident at this time. Interventions attempted: Both resident's [sic] were separated. Effectiveness of the interventions: Intervention was ineffective as these two resident's [sic] continue to seek one another out. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated he just happened to walk in the sunroom and see Resident 56 with his hand up Resident 74's shirt. There were quite a few other residents in the sunroom at the time, who were just sitting there, roughly six residents total including Resident 56 and Resident 74, and no staff.
The next consecutive behavior note, dated 6/6/24 at 9:40 a.m., for Resident 56, written by LPN 5 indicated, Resident walked up to the same female resident and grab [sic] her by the face them [sic] kissed her on the lips. Interventions attempted: Separated resident's [sic.] Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the kiss on the lips happened in the hallway and he just happened to see it. He was coming down hallway with the medication cart when Resident 74 walked past him, and Resident 56 came out of the dining room. Resident 56 grabbed Resident 74 on both sides of her face, leaned in, and kissed her. It happened quickly, more like a peck on the lips.
The next consecutive behavior note, dated 6/6/24 at 2:33 p.m., for Resident 56, written by LPN 5, read, Resident was noted sitting on the couch in the sunroom with a female resident on either side of him and the three of them were touching and rubbing on one another. Interventions attempted: Resident's [sic] were asked to stop and then separated. Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated there was another female resident, Resident 50, sitting on one side of Resident 56, and Resident 74 sitting on his other side in reference to the 6/6/24, 2:33 p.m. behavior note. The touching and rubbing he observed while the 3 of them were on the couch was outside of the clothing, rubbing legs, and holding hands. The two female residents weren't touching each other. Resident 56 was in the middle, touching both female residents, and both female residents were touching him. He stated, [Name of Resident 56] was a little too busy for me that day.
The 6/6/24, 2:36 p.m. progress note, written by LPN 5, read, Resident has been aggressive with staff while they were attempting to redirect and separate him from the same female resident whom his [sic] is drawn to.
There was no information in Resident 56's clinical record, including the progress notes, to indicate Resident 56's physician was informed of his behaviors referenced in the above 6/6/24, 9:01 a.m. behavior note, 6/6/24, 9:40 a.m. behavior note, 6/6/24, 2:33 p.m. behavior note, or 6/6/24, 2:36 p.m. progress note or that his mental health provider was made aware, as care planned.
An interview was conducted with LPN 5 on 6/17/24 at 3:00 p.m. He indicated he did not inform Resident 56's family or doctor or anything. He just documented the behaviors to the best of his ability.
An interview was conducted with the Medical Director on 6/20/24 at 10:35 a.m. He indicated he did not really like the physical set up of the Alzheimer's Care Unit, as it was hard to have eyes on everyone, and there was not a lot of space for the residents to move about. A learning point for the facility was that when they see residents with certain types of behaviors, they needed to have a better plan to manage them. They needed to realize sooner that the relationship between Resident 56 and Resident 74 could be a track to a more intimate connection, so they needed to have more of a plan in place to address it, without adding medications. They needed to be able to identify Resident 56's issues earlier to get him the help he needed sooner. Their psychiatric provider used in the facility was good and could probably help them with this. He was not aware Resident 56 was having physical closeness with other residents, other than sitting next to each other. He was not made aware of Resident 56 and Resident 74 lying in bed together or him trying to be alone in the room together. The breakdown was the nursing staff not bringing these things forward to work on.
4. During an observation, on 6/17/24 at 1:51 p.m., Resident 11 was sitting on a couch in the sunroom. Resident 57 was observed to enter the sunroom with her walker and walk toward Resident 1. There were no other residents or staff in the sunroom at this time. Resident 11 was observed to loudly ask Resident 57 why Resident 57 was looking at Resident 11. Resident 57 stopped walking towards Resident 11 approximately 6 feet in front of her and swung her arm in the air. Resident 11 yelled at Resident 57 for doing so. Resident 57 then turned around and walked out of the sunroom. Resident 57 began saying how mean Resident 57 was and that Resident 11 didn't bother or talk to Resident 57. There were no staff present to address the interaction between these 2 residents.
On 6/17/24 at 1:57 p.m., CNA (Certified Nursing Assistant) 25 was observed in the dining room of the unit, across the hall from the sunroom. There were no staff present in the sunroom at this time. Commotion/yelling was heard coming from the sunroom, so CNA 25 went into the sunroom to address it.
An interview was conducted with CNA 25 on 6/17/24 at 1:59 p.m. She indicated when she went into the sunroom, Resident 11 informed her that Resident 57 was reaching for her walker. She stated, [Name of Resident 11] does yell at people a lot.
An observation and interview were conducted with CNA 25 on 6/17/24 at 2:00 p.m. in the hallway near the nurse's station. Resident 57 was standing in the hallway near Resident 51. CNA 25 indicated Resident 57 just smacked Resident 51 on the shoulder. Resident 57 was redirected down the hallway by staff.
An interview was conducted with CNA 25 on 6/17/24 at 2:02 p.m. She indicated she'd worked at the facility since March 2023. Resident 57's attitude and anger had increased lately, but never physically saw her hit anyone prior to her hitting Resident 51 in the hallway on 6/17/24 at 2:00 p.m. As far as the unit's physical set-up was concerned, she thought she was able to monitor the residents efficiently, as she was always on guard, and her head was going in a million directions. Usually, they tried to have three CNAs and one nurse working on the unit during the day. There were some days when they didn't run that way, due to staffing issues. There were only two CNAs working on 6/6/24. The nurses needed to do activities and stuff after they finished passing medications to assist with monitoring the residents. Two of the regular nurses would do that, but two of them wouldn't, so it just depended on who was working. Their ACD (Alzheimer's Care Director) was not normally on the floor and helping out. She was usually in her office, which was on another unit, or running around the facility.
On 6/17/24 at 2:21 p.m., a commotion was heard coming from the dining room. Upon entrance to the dining room, it was determined Resident 57 just hit Resident 14. CNA 27 was present in the dining room for a baking activity.
An interview was conducted with CNA 27 on 6/17/24 at 2:22 p.m. She indicated Resident 57 just punched Resident 14 in the shoulder. She heard Resident 14's wheelchair hit the wall first, and when she looked around the corner from the stove, she saw Resident 57 punch him. Resident 57 was getting ready to do it again, but she was able to intervene in time. She indicated she thought the unit needed to be more open back here, as I don't care to chase everyone around. When the residents are out and about the unit, the staff go back and forth between the sunroom, the dining room, the back dining room, and down the hallway. It was more difficult to monitor with the set up.
The clinical record for Resident 11 was reviewed on 6/18/24 at 11:00 a.m. The diagnoses included, but were not limited to, vascular dementia and anxiety.
The 5/18/24 Quarterly MDS assessment indicated she was severely cognitively impaired.
The 8/23/23 behavior care plan indicated she had a history of being confrontational and yelling at others. The goal was for her aggression to not cause harm to herself or others. Interventions were to not allow a lot of people to approach her at one time; during episodes of behaviors, to please redirect her by approaching slowly and speaking to her in a calm and steady voice, trying to redirect her to an alternative activity or topic of discussion; encourage activity and/or exercise that would allow her to release some energy; encourage her to get involved in activities related to her interests; remove any residents in the immediate area that may be in danger if she did become aggressive; if she and those around her were safe, to not bother her until she calmed down; medicate per physician orders and observe for possible side effects; refer her to mental health services as needed; provide a quiet, nonthreatening environment with decreased stimulation; slowly assess her needs such as toileting, hunger, thirst, and/or pain; and for staff to stay pleasant and in a non-defensive nature while being firm but not loud.
5. The clinical record for Resident 57 was reviewed on 6/13/24 at 1:35 p.m. Her diagnosis included, but were not limited to, Alzheimer's disease.
The 3/12/24 Quarterly MDS assessment indicated she was short tempered, easily annoyed for 12-14 days, nearly every day over the last 2 weeks.
6. The clinical record for Resident 67 was reviewed on 6/13/24 at 1:30 p.m. Her diagnosis included, but were not limited to, Alzheimer's disease.
The 10/28/22 behavior care plan, last revised 3/19/24, indicated she had little, or no awareness of safety or boundaries related to other's personal space, going into other resident's rooms, wandering about my living space. The goal was for her to continue to wander freely as she desired within the safety parameters of a secured, specialized unit. An intervention for when she wandered into other people's rooms was to gently redirect her with the suggestion of visiting at another time; offer her another place to visit.
During an observation, on 6/17/24 at 2:26 p.m., Resident 67 was observed wandering around in another resident's room, while the other resident was asleep in her recliner. There were no staff present to observe this, so CNA 25 was informed of Resident 67's presence in the room.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the layout of the unit was definitely a challenge for me, the way the nurse's desk was located and the layout of the unit. It was kind of hard to keep track of the residents and see everything that's going on.
The Behavioral Health Services policy was provided by the DON on 6/17/24 at 11:08 a.m. It indicated, The resident, and as appropriate the resident's family, are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall: .Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition.
The Dementia Care policy was provided by the DON on 6/19/24 at 3:00 p.m. It read, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being 1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible 6. If needed, the environment will be modified to accommodate individual resident care needs. 7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary. 8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker).
3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure services were provided to preserve the dignity of a dependent resident who required the assistance of staff for activities of eating and dressing by removing food debris from the resident's clothing after a meal and provide incontinent care in a timely manner for a resident dependent on staff assistance with toileting for 2 of 5 residents reviewed for dignity. (Resident 2 and confidential resident)
Findings include:
1. The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure.
A baseline activities of daily living care plan, dated 5/28/2024, indicated to assist Resident 2 with eating as needed. This care plan did not indicate the amount of assistance, or the number of staff needed.
An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired, independent with eating, and needed substantial to maximum assistance with dressing.
An observation and interview, on 6/14/2024 at 11:30 a.m., with Family Member 12 indicated that Resident 2 had an overall decline in their condition since they were admitted to the facility at the end of May. Family Member 12 tried to come every day to spend time with her mother. She usually arrived between 11:00 and 11:30 a.m. Resident 2 needed assistance with eating and there had been multiple times that Resident 2 would be found covered in food on her clothing, have food spilled in her room on the floor, and still have her breakfast tray in her room when Family Member 12 came to visit around 11:00 a.m. to 11:30 a.m. Family Member 12 recalled an event that had happened less than a week ago, on what she believed was 6/9/2024, resulted in Family Member 12 making a formal grievance that she had not received any follow through on. She stated she came in that morning of 6/9/2024, around 11:00 or 11:30 a.m., and her mother (Resident 2) was sitting in her chair. Family Member 12 recalled that when she pulled down Resident 2's blanket some, she found her mother with dried oatmeal all down the front of her clothing and had a gripper sock missing. Family Member 12 indicated that this was very upsetting to her, coupled with other events of 6/9/2024. So, Family Member 12 talked to the Director of Nursing about everything. Family Member 12 indicated that she had not heard anything about any of her concerns. She felt if her mother was more cognitively aware, she would have been embarrassed by the state she was found in. During this observation, it was noted there was tan debris built up on the brown recliner. Family Member 12 indicated it was oatmeal dried on the recliner and has been there since the aforementioned event.
An activities of daily living care plan, dated 5/28/2024, indicated to assist Resident 2 with eating as needed.
A grievance form, dated 6/9/2024, indicated that staff did not know/realize Resident 2 had oatmeal on her clothing that day.
A confidential staff interview completed during the survey indicated that they assisted with Resident 2's care, on 6/9/2024, and it was a bad day. They did not realize Resident 2 had oatmeal on her clothing, but so much was happening that day and they were unusually busy.
2. A confidential resident record was reviewed on 6/19/2024 at 2:25 p.m. The medical diagnosis for the resident indicated muscle wasting.
The most recent Minimum Data Set Assessment indicated the confidential resident was cognitively intact and dependent on staff for assistant with toileting.
The most recently revised care plans, last revised in April of 2024, indicated that the resident had incontinence of bladder and was at risk for skin break down related to incontinence. An intervention to provide the resident with incontinence care was listed
During a confidential resident interview conducted during the survey, the resident indicated that they were made to wait a long time for their call light to be answered. They indicated recently, over the weekend, they had to wait almost 45 minutes to have their call light answered. Due to the long wait time to receive assistance, they had lost their urine and soiled themselves with bowel movement. They indicated they had looked at their cellphone when they hit the call light, at 10:45 a.m., and the staff did not respond until 11:30 a.m. The resident stated they were sitting in their mess the majority of that time and it made them feel disgusted and humiliated.
An interview with the Director of Nursing, on 6/19/2024 at 2:00 p.m., indicated that residents should be treated with dignity and respect, that direct care staff should be assisting with cleaning of the resident and their clothing after meals if indicated, and all staff are responsible for answering call lights and delegating needs based on residents' need.
A copy of the resident rights was provided by the Area [NAME] President on 6/18/2024 at 12:45 p.m. The resident rights indicated that, The resident has the right to a dignified existence
3.1-3(t)

Based on observation, interview, and record review, the facility failed to promote a clean environment for Resident 2 by having dried debris built up on her recliner, thick dust built up on a box fan utilized by Resident 17, and by having dust built up on an open ledge under the seat and food debris on the footboard of Resident 46's motorized scooter for 3 of 3 residents reviewed for a clean environment.
Findings include:
1. The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure.
An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired.
An observation and interview, on 6/14/2024 at 11:30 a.m., with Family Member 12 indicated that Resident 2 had declined since she was admitted to the facility at the end of May. Family Member 12 tried to come every day and spend time with her mother usually between 11:00 and 11:30 a.m. Resident 2 needed assistance with eating and there had been multiple times that Resident 2 would be found covered in food on her clothing, have food spilled in her room on the floor, and still have her breakfast tray in her room. An event that had happened less than a week ago resulted in Family Member 12 making a formal grievance that she did not receive any follow through on. During this observation, it was noted there was tan debris built up on the brown recliner that Family Member 12 indicated it was oatmeal and has been there since the event.
An observation conducted, on 6/17/2024 at 1:00 p.m., indicated that the tan debris build up on the brown recliner in Resident 2's room remained unchanged.
An observation conducted, on 6/18/2024 at 11:20 a.m., indicated that the tan debris built up on the brown recliner in Resident 2's room remained unchanged.
An interview and observation with Housekeeper 13, on 6/18/2024 at 11:25 a.m., indicated that the food built up on the brown recliner remained, he indicated he would clean it with a machine they have for upholstery, and that cleaning of the rooms should be done on their schedule and as needed.
2. The clinical record for Resident 17 was reviewed on 6/18/2024 at 1:22 p.m. The medical diagnosis included respiratory failure.
An Annual Minimum Data Set Assessment, dated 3/28/2024, indicated Resident 17 was cognitively impaired and needed assistance with activities of daily living.
An observation, on 6/13/2024 at 1:20 p.m., indicated that Resident 17 utilized a box fan on his bedside table. The front of the box fan had heavy dust build up and Resident 17 was utilizing oxygen at that time.
An observation, on 6/17/2024 at 1:07 p.m., indicated that the heavy dust built up remained to the box fan on the bedside table in Resident 17's room.
An interview and observation with Housekeeper 13, on 6/18/2024 at 11:20 a.m., indicated that the box fan had heavy dust built up on the front of the fan and that he could wipe it down with a rag.
3. The clinical record for Resident 54 was reviewed on 6/17/2024 at 11:05 a.m. The medical diagnosis included diabetes with neuropathy.
A Significant Change Minimum Data Set Assessment, dated 6/5/2024, indicated that Resident 54 was cognitively intact.
An interview and observation with Resident 54, on 6/13/2024 at 11:20 a.m., indicated he primarily utilized is motorized scooter to move about the facility. He indicated he drops food sometimes and it lands on the footboard. The footboard was noted to have a black grit non-skid top with tan and brown food debris. An open ledge under the seat of the motorized scooter was noted to have a light layer of dust build up with a handprint on the right front side in the dust. Resident 54 stated he needed to get it cleaned, but he was not able to do it himself.
An observation, on 6/17/2024 at 3:00 p.m., indicated that the footboard was noted to have a black grit non-skid top remaining with tan and brown food debris. The open ledge under the seat of the motorized scooter was noted to have a light layer of dust build up with a handprint on the right front side in the dust.
An interview with the Director of Nursing, on 6/18/2024 at 12:00 p.m., indicated that the staff should be cleaning Resident 54's wheelchair and scooter on his regular shower days and as needed.
A policy entitled, Safe and Homelike Environment, was provided by the Area [NAME] President on 6/18/2024 at 12:45 p.m. The policy indicated, .the facility will provide a safe, clean, comfortable, and homelike environment .
3.1-19(f)

Based on observation, interview and record review, the facility failed to ensure residents were free from sexual abuse on the Alzheimer's Care Unit of the facility for 3 of 5 residents reviewed for abuse. (Residents 50, 56, and 74)
Findings include:
1. The clinical record for Resident 50 was reviewed on 6/17/24 at 1:10 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and insomnia.
The 5/15/24 Quarterly MDS (Minimum Data Set) assessment indicated the BIMS (brief interview for mental status) was not conducted, as she was rarely/never understood. The staff assessment for mental status indicated she had short and long-term memory problems. She did not know the current season or that she was in a nursing home. Her cognitive skills for daily decision making were severely impaired, in that she rarely/never made decisions. It indicated she had physical behavioral symptoms directed towards others, such as hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during one to three days of the past seven days. She had verbal behavioral symptoms directed towards others such as threatening, screaming at, and/or cursing at others during one to three days of the past seven days.
The 10/5/23 behavior care plan, last revised 12/19/23, indicated she demonstrated sexually inappropriate behaviors by entering male resident rooms, laying in male resident's bed, and making sex-related comments. The goal, with a target date of 8/13/24, was for her to interact with others appropriately during social and care situations. Interventions were to quietly attempt to redirect, reminding her that the behavior was not appropriate; to let her physician know if her behaviors were interfering with her daily care/living; and to please refer her to mental health services as needed.
There was no assessment/evaluation in the clinical record indicating Resident 50 had the capacity to consent to sexual activity in the facility.
2. The clinical record for Resident 74 was reviewed on 6/13/24 at 1:17 p.m. Her diagnoses included, but were not limited to: dementia, anxiety, and insomnia.
The 5/25/24 Significant Change MDS assessment indicated she was severely cognitively impaired. She had a behavior of wandering during one to three of the previous seven days. The wandering behavior significantly intruded on the privacy of activities of others.
An observation of Resident 74 was made on 6/13/24 at 1:17 p.m. She was continuously wandering about the unit from the dining room into the hallway and into the sunroom.
The 4/8/24 behavior care plan indicated she demonstrated sexually inappropriate behaviors by entering a male resident's room, laying in male resident's bed, and inappropriate touching. The goal was for her behaviors to lessen. Interventions, effective 4/8/24, were to offer her something else she liked as a diversion; let her physician know if her behaviors were interfering with her daily care/living; and to refer her to mental health services as needed.
The 4/9/24 behavior care plan indicated she wandered in others' rooms; may crawl in bed with others; believed other male resident was her husband and became agitated and aggressive when attempting to redirect. The goal was for her to not harm herself or others due to her behaviors. Interventions, effective 4/9/24, were to attempt interventions before her behaviors began; make family aware of behaviors; let her physician know if her behaviors were interfering with her daily living and offer here something she liked as a diversion.
There was no assessment/evaluation in the clinical record indicating Resident 74 had the capacity to consent to sexual activity in the facility.
A behavior note, dated 6/6/24 at 8:35 a.m., written by LPN (Licensed Practical Nurse) 5, read, Resident was standing in the dining room next to a male resident allowing him to grope her butt in front of the other residents. Interventions attempted: Residents were separated and redirected. Effectiveness of the interventions: Somewhat effective, though resident is pacing the unit trying to figure out how to get back to this male resident. She is also becoming very irritated with anyone whom [sic] is standing in her way or attempting to keep them apart. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
The next consecutive behavior progress note, dated 6/6/24 at 9:35 a.m., written by LPN 5 indicated, Resident was standing next to the couch in the dayroom while a male resident was sitting on the couch with his hand up her shirt and rubbing on her breast. Interventions attempted: Residents were separated and a CNA (Certified Nursing Assistant) was asked to monitor that they remain apart. Effectiveness of the interventions: Ineffective as the two residents continue to seek one another out.
The next subsequent progress note related to Resident 74's behaviors, dated 6/6/24 at 2:49 p.m., written by LPN 5, read, Resident has roamed the unit seeking out a certain male resident all shift. Whenever staff attempted to separate the two residents, both residents would become aggressive and begin to lash out at staff verbally and physically. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
3. The clinical record for Resident 56 was reviewed on 6/14/24 at 11:37 a.m. The diagnoses included, but were not limited to: Alzheimer's disease, dementia, anxiety, and insomnia.
The 5/10/24 Quarterly MDS assessment indicated the BIMS was not conducted, as he was rarely/never understood. The staff assessment for mental status indicated he had short and long-term memory problems. He did not know the current season or that he was in a nursing home. His cognitive skills for daily decision making were moderately impaired, in that decisions were poor, requiring cues/supervision.
An observation of Resident 56 was made on 6/14/24 at 2:05 p.m. He was lying awake in bed. He began speaking but was unable to understand what he was attempting to say.
The 3/23/23 behavior care plan, last revised 4/16/24, indicated he demonstrated sexually inappropriate behaviors, believing others were his significant other. He would hug and sometimes attempt to kiss others. He displayed inappropriate touching and made sexually explicit comments to others. The goal was for him to interact with others appropriately during social and care situations. Interventions, effective 3/23/23, were to let his physician know if his behaviors were interfering with his daily care/living; quietly attempt to re-direct, reminding him that the behavior was not appropriate; let him know that his behavior was affecting others; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 10/5/23 behavior care plan, last revised 4/16/24, indicated he sometimes demonstrated sexually inappropriate behaviors by entering female residents' rooms, having female resident come into his room, and lay in bed with others. The goal was for him to interact with others appropriately during social and care situations. Interventions, initiated 10/5/23, were to let his physician know if his behaviors were interfering with his daily care/living; offer him something else he liked; quietly attempt to re-direct, reminding him that the behavior was not appropriate; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 8/31/23 behavior care plan, last revised 4/16/24, indicated he sometimes became frustrated or agitated, pushing, grabbing, being physically aggressive, and threatening when staff tried to redirect other residents from his room. He may resist care by hitting and kicking. The goal was for him to have fewer episodes of becoming frustrated and for his behavior to stop with staff intervention. Interventions were to attempt interventions before his behaviors began; give medications as doctor ordered; and to offer him something he liked as a diversion. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
There was no assessment/evaluation in the clinical record indicating Resident 56 had the capacity to consent to sexual activity in the facility.
The 5/29/24 psychiatry progress note indicated, Patient was seen today per facility request for psychiatric evaluation, medication management, and GDR [gradual dose reduction] review. Patient was seen in the common area, pacing up and down the hallway. Patient presents anxious, restless and he continues to follow another female resident. Patient is confused at times during the interview. Staff reports that he has good appetite and sleeps well at night. Per facility, patient can get anxious, irritable, agitation, verbally and physically aggressive toward staff and some resident and hard to redirect at times. Starts Lorazepam 0.5mg po [by mouth] bid [twice daily] . Follow up in two weeks and as needed.
A progress note, dated 6/5/24 at 9:31 a.m., for Resident 56, written by the DON (Director of Nursing) read, resident continues to have episodes of becoming agitated at staff when staff is attempting to assist female residents on the unit. resident believes that some of the female residents are his girls and becomes very protective. also continues to wonder [sic] about unit and at times will enter other resident's room uninvited, usually easily to redirect out of unwanted areas. Word salad frequently present, however during periods of agitation speech becomes coherent and resident will begin cursing at staff. staff will continue to attempt to ensure safety, provide interventions and assistance as warranted. Resident is followed by in-house mental health provider and is followed by in-house PCP [primary care physician] provider.
A behavior note, dated 6/6/24 at 9:01 a.m., for Resident 56, written by LPN (Licensed Practical Nurse) 5, indicated, Resident shoved this nurse out of the doorway as staff was attempting to keep he and a female resident separated due to sex behaviors. What was the resident doing prior to or at the time of behavior/mood: Resident was in the dining room and had been noticed rubbing a female resident's butt as she stood next to him. Interventions attempted: separation of resident's [sic.] Effectiveness of the interventions: Intervention was ineffective The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the behavior in the above progress note was the first behavior he witnessed on 6/6/24 between Resident 56 and Resident 74.
The next consecutive behavior note, dated 6/6/24 at 9:30 a.m., written by LPN 5 indicated, Resident was noted sitting in the sunroom with his hand up the shirt of the same female resident as earlier. Resident was rubbing the breast of this resident at this time. Interventions attempted: Both resident's [sic] were separated. Effectiveness of the interventions: Intervention was ineffective as these two resident's [sic] continue to seek one another out. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated he just happened to walk in the sunroom and see Resident 56 with his hand up Resident 74's shirt. There were quite a few other residents in the sunroom at the time, who were just sitting there, roughly six residents total including Resident 56 and Resident 74, and no staff.
The next consecutive behavior note, dated 6/6/24 at 9:40 a.m., for Resident 56, written by LPN 5 indicated, Resident walked up to the same female resident and grab [sic] her by the face them [sic] kissed her on the lips. Interventions attempted: Separated resident's [sic.] Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the kiss on the lips happened in the hallway and he just happened to see it. He was coming down hallway with the medication cart when Resident 74 walked past him, and Resident 56 came out of the dining room. Resident 56 grabbed Resident 74 on both sides of her face, leaned in, and kissed her. It happened quickly, more like a peck on the lips.
The next consecutive behavior note, dated 6/6/24 at 2:33 p.m., for Resident 56, written by LPN 5, read, Resident was noted sitting on the couch in the sunroom with a female resident on either side of him and the three of them were touching and rubbing on one another. Interventions attempted: Resident's [sic] were asked to stop and then separated. Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated there was another female resident, Resident 50, sitting on one side of Resident 56, and Resident 74 sitting on his other side in reference to the 6/6/24, 2:33 p.m. behavior note. The touching and rubbing he observed while the 3 of them were on the couch was outside of the clothing, rubbing legs, and holding hands. The two female residents weren't touching each other. Resident 56 was in the middle, touching both female residents, and both female residents were touching him. He stated, [Name of Resident 56] was a little too busy for me that day.
A progress note, dated 6/6/24 at 2:36 p.m., written by LPN 5, read, Resident has been aggressive with staff while they were attempting to redirect and separate him from the same female resident whom his [sic] is drawn to.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the 6/6/24, 2:36 p.m. progress note just referenced a continuation of separating Resident 56 and Resident 74 throughout the day. The 3 residents on the couch was the last occurrence he witnessed on 6/6/24. From the time he shoved me, it didn't get any better. He'd only worked at the facility for about 3 weeks through an agency but was off all last week. He normally worked other units and had only worked the Alzheimer's Care Unit maybe twice. It was his understanding, from talking to other employees who'd worked on the unit for a while, that Resident 56 had been showing behaviors, and they were increasing and intensifying. When he spoke with someone about Resident 56's behaviors on 6/6/24, he made sure his behavior progress notes were documented to the best of my ability. Resident 56 was very sexual in nature, but also aggressive at times, with staff, including LPN 5. At one point, Resident 56 shoved him. He told full time staff management that day, because he noticed the issues, and he was trying to see how he was supposed to address them. I was told it was care planned. They could be together, just couldn't have sex, and the family was aware, so I just documented. He believed it was either the Unit Manager/Alzheimer's Care Director, the DON, or the Administrator who told him this, but he wasn't sure exactly who, because he was still trying to learn people. Resident 56's behaviors had been brought up on several occasions. He told quite a few people, including the CNAs (Certified Nursing Assistants) so they could keep an eye on them and keep them separated. He was just told to document everything he saw. He didn't think of it as sexual abuse, because both residents were seeking each other out, and it was clear they both became agitated due to staff trying to separate them, but with the residents being on the dementia unit and not having capacity to consent, he saw it as possible sexual abuse. His concern was that families would come in and be upset by it, because it was something that families should be aware of. That's why he went forward with making sure someone knew, and it didn't just stop with him. Prior to 6/6/24, he'd seen Resident 56 be flirtatious, but not touching, more like holding hands, helping and guiding them like they were lost, at least the way that he took it. On 6/6/24, there was no mistaking what was going on between Resident 56 and Resident 74. They were seeking each other out. He'd been trained on abuse multiple times. He worked full time for the PRN (as needed) Float Pool, and they trained him on abuse, but could not recall the last time. He thought it was less than a year ago. He had not received any abuse training in the facility itself.
An interview was conducted with the ACD (Alzheimer's Care Director) on 6/14/24 at 1:50 p.m. She indicated she'd been the ACD for about 2 years and was familiar with Resident 56. She did not consider his behaviors with other female residents as inappropriate. They will love on each other, kiss and cuddle. It was mostly with Resident 74, but Resident 50 gravitated toward Resident 56 as well, would sit and hold hands, nothing inappropriate. She'd spoken to both Resident 56's and Resident 74's families and made them aware. Resident 74's family was religious and understood, as long as nothing got out of hand. She knew others had seen Resident 56 with his hands up Resident 74's shirt, but she had not seen that. A male agency nurse told her Resident 56 put his hands up the back of Resident 74's shirt and he separated them. In the last month, Resident 56 had been generally harder to redirect. The IDT [Interdisciplinary Team] had talked about this; it was care planned; they talked to families and made a note about a month and a half ago.
An interview was conducted with CNA 8, on 6/14/24 at 2:00 p.m., who worked the day shift of 6/6/24. She indicated she normally worked the Alzheimer's Care Unit of the facility and had witnessed Resident 56 wrap his arm around female residents and caught him attempting to kiss female residents. She was told by CNA 9 that Resident 56 groped women's breasts, but CNA 8 hadn't witnessed this. His behaviors had been going on at least a few months. Some days he was hard to redirect and would be loud and aggressive toward staff. Resident 56 pushed a male nurse on 6/6/24, who didn't normally work the unit. Resident 56 tended to try and kiss Resident 74, as she was the main female resident. They are like glue. CNA 8 was told their families were aware. Once in a while, Resident 56 would try to kiss Resident 50 and a few times tried to kiss Resident 49.
CNA 9 was unavailable for interview.
An interview was conducted with CNA 25 on 6/17/24 at 2:02 p.m. She indicated she worked on 6/6/24. The only thing she saw was Resident 56 kiss Resident 74 on the forehead in the sunroom, just a quick peck. She was coming out a resident's room when LPN 5 informed her in the hallway that Resident 56's hand was up Resident 74's shirt. She didn't report this to anyone, because LPN 5 informed her that he was going to take care of it. She thought LPN 5 had it handled, because he was the nurse in charge.
A progress note, dated 6/10/24 at 9:56 p.m., for Resident 56, written by the DON, read, Resident continues to have episodes of becoming easily irritated and upset with staff when staff provides interventions r/t [related to] behaviors displayed with female residents. Resident has been noted to be holding hands with female residents and occasionally kissing. Resident with severe impaired cognition status and unable to recall behavior as being inappropriate. resident with word salad and when staff intervenes, word salad becomes more severe, tone of voice becoming stern, with an occasional cursing noted. wanders about unit and at times will enter other resident's room without invitations. Resident frequently leaves unwanted areas without incident. family is aware of behaviors and understands [sic] that resident is not able to recognize inappropriateness of behaviors. Resident continues to be followed by in house PCP and in house psych provider. Staff will continue to attempt to ensure safety, offer interventions and assistance as warranted.
An interview was conducted with the Administrator, DON, [NAME] President of Risk and Regulatory Compliance, and Regional Director of Clinical Operations on 6/14/24 at 1:45 p.m. after they read Resident 56's 6/6/24 behavior notes from the electronic health record. The Administrator indicated she did not know about Resident 56's 6/6/24 behaviors. She knew Resident 56 was flirtatious, would hold hands, and thought Resident 74 was his wife. The ACD had spoken to both families in regard to these things. The Administrator did not report, investigate, or take action after the 6/6/24 occurrences, as she was unaware of them. The DON indicated she had never heard about Resident 56's 6/6/24 behaviors prior to just now reading the notes. She was not aware Resident 56 had his hand up Resident 74's shirt, nor was she aware of him rubbing on her buttocks in the dining room and touching on the couch. There was a male nurse on the unit on 6/6/24, so when he was trying to intervene, she thought Resident 56 may have had a problem with him being male and trying to intervene, as Resident 56 would say Those are my girls, and a protective mode would step in. They tried to intervene, distract, take him outside, and use various interventions to address his behaviors.
An interview was conducted with Family Member 6, Resident 74's daughter, on 6/18/24 at 10:33 a.m. She indicated the facility informed her, on 6/14/24, of the 6/6/24 sexual activity involving her mom. Resident 74 would have been very opposed to this behavior, as she was quite religious. If she didn't have dementia, she would be appalled. To her knowledge, nothing happened prior to 6/6/24. Resident 56 and Resident 74 had been kind of buddies for a while. They would sit together, but no hand holding or kissing that I know of, just sitting next to each other. One time she saw Resident 56 try to give Resident 74 a kiss on her forehead, which didn't bother Family Member 6. It was kind of sweet. Family Member 6 would have wanted to know about previous hand holding or kissing and didn't realize it had gotten into this.
An interview was conducted with Family Member 7, Resident 56's son, on 6/18/24 at 12:12 p.m. He indicated he wasn't notified about his father's 6/6/24 behaviors until 6/14/24. They called him a year ago and informed him Resident 74 was in bed with him, kinda messing around, not sure anything was done, kinda fooling around. The staff was responsible for his father and the other residents, so he questioned how this happened and thought the responsibility was on the facility.
An interview was conducted with the DON on 6/17/24 at 10:53 a.m. She indicated the home office was responsible for training PRN (as needed) Float Pool staff on abuse, identification, and reporting, as it was not provided to them in the facility. Her understanding was they were already trained when they came into the facility to work.
The Dementia Care policy was provided by the DON on 6/19/24 at 3:00 p.m. It read, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being 1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, the extent possible 6. If needed, the environment will be modified to accommodate individual resident care needs. 7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary. 8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker).
The Abuse, Neglect, and Exploitation policy was provided by the DON on 6/17/24 at 11:08 a.m. It read, Sexual Abuse is non-consensual sexual contact of any type with a resident Employee Training A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 2 Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators;4. Reporting process for abuse, neglect exploitation, and misappropriation of resident property, including injuries of unknown sources; 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as; a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. Prevention of Abuse, Neglect and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.
3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to notify the Administrator immediately of allegations of sexual abuse on the Alzheimer's Care Unit of the facility for 3 of 18 residents on the Alzheimer's Care Unit. (Residents 50, 56, and 74)
Findings include:
1. The clinical record for Resident 50 was reviewed on 6/17/24 at 1:10 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and insomnia.
The 5/15/24 Quarterly MDS (Minimum Data Set) assessment indicated the BIMS (brief interview for mental status) was not conducted, as she was rarely/never understood. The staff assessment for mental status indicated she had short and long-term memory problems. She did not know the current season or that she was in a nursing home. Her cognitive skills for daily decision making were severely impaired, in that she rarely/never made decisions. It indicated she had physical behavioral symptoms directed towards others, such as hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during one to three days of the past seven days. She had verbal behavioral symptoms directed towards others such as threatening, screaming at, and/or cursing at others during one to three days of the past seven days.
The 10/5/23 behavior care plan, last revised 12/19/23, indicated she demonstrated sexually inappropriate behaviors by entering male resident rooms, laying in male resident's bed, and making sex-related comments. The goal, with a target date of 8/13/24, was for her to interact with others appropriately during social and care situations. Interventions were to quietly attempt to redirect, reminding her that the behavior was not appropriate; to let her physician know if her behaviors were interfering with her daily care/living; and to please refer her to mental health services as needed.
There was no assessment/evaluation in the clinical record indicating Resident 50 had the capacity to consent to sexual activity in the facility.
2. The clinical record for Resident 74 was reviewed on 6/13/24 at 1:17 p.m. Her diagnoses included, but were not limited to: dementia, anxiety, and insomnia.
The 5/25/24 Significant Change MDS assessment indicated she was severely cognitively impaired. She had a behavior of wandering during one to three of the previous seven days. The wandering behavior significantly intruded on the privacy of activities of others.
An observation of Resident 74 was made on 6/13/24 at 1:17 p.m. She was continuously wandering about the unit from the dining room into the hallway and into the sunroom.
The 4/8/24 behavior care plan indicated she demonstrated sexually inappropriate behaviors by entering a male resident's room, laying in male resident's bed, and inappropriate touching. The goal was for her behaviors to lessen. Interventions, effective 4/8/24, were to offer her something else she liked as a diversion; let her physician know if her behaviors were interfering with her daily care/living; and to refer her to mental health services as needed.
The 4/9/24 behavior care plan indicated she wandered in others' rooms; may crawl in bed with others; believed other male resident was her husband and became agitated and aggressive when attempting to redirect. The goal was for her to not harm herself or others due to her behaviors. Interventions, effective 4/9/24, were to attempt interventions before her behaviors began; make family aware of behaviors; let her physician know if her behaviors were interfering with her daily living and offer here something she liked as a diversion.
There was no assessment/evaluation in the clinical record indicating Resident 74 had the capacity to consent to sexual activity in the facility.
The 6/6/24, 8:35 a.m. behavior note, written by LPN (Licensed Practical Nurse) 5, read, Resident was standing in the dining room next to a male resident allowing him to grope her butt in front of the other residents. Interventions attempted: Residents were separated and redirected. Effectiveness of the interventions: Somewhat effective, though resident is pacing the unit trying to figure out how to get back to this male resident. She is also becoming very irritated with anyone whom is standing in her way or attempting to keep them apart.
The 6/6/24, 9:35 a.m. behavior note, written by LPN 5 read, Resident was standing next to the couch in the dayroom while a male resident was sitting on the couch with his hand up her shirt and rubbing on her breast. Interventions attempted: Residents were separated and a CNA (Certified Nursing Assistant) was asked to monitor that they remain apart. Effectiveness of the interventions: Ineffective as the two residents continue to seek one another out.
The 6/6/24, 2:49 p.m. progress note, written by LPN 5, read, Resident has roamed the unit seeking out a certain male resident all shift. Whenever staff attempted to separate the two residents, both residents would become aggressive and begin to lash out at staff verbally and physically.
3. The clinical record for Resident 56 was reviewed on 6/14/24 at 11:37 a.m. The diagnoses included, but were not limited to: Alzheimer's disease, dementia, anxiety, and insomnia.
The 5/10/24 Quarterly MDS assessment indicated the BIMS was not conducted, as he was rarely/never understood. The staff assessment for mental status indicated he had short and long-term memory problems. He did not know the current season or that he was in a nursing home. His cognitive skills for daily decision making were moderately impaired, in that decisions were poor, requiring cues/supervision.
The 3/23/23 behavior care plan, last revised 4/16/24, indicated he demonstrated sexually inappropriate behaviors, believing others were his significant other. He would hug and sometimes attempt to kiss others. He displayed inappropriate touching and made sexually explicit comments to others. The goal was for him to interact with others appropriately during social and care situations. Interventions, effective 3/23/23, were to let his physician know if his behaviors were interfering with his daily care/living; quietly attempt to re-direct, reminding him that the behavior was not appropriate; let him know that his behavior was affecting others; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 10/5/23 behavior care plan, last revised 4/16/24, indicated he sometimes demonstrated sexually inappropriate behaviors by entering female residents' rooms, having female resident come into his room, and lay in bed with others. The goal was for him to interact with others appropriately during social and care situations. Interventions, initiated 10/5/23, were to let his physician know if his behaviors were interfering with his daily care/living; offer him something else he liked; quietly attempt to re-direct, reminding him that the behavior was not appropriate; and to refer him to mental health services as needed. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
The 8/31/23 behavior care plan, last revised 4/16/24, indicated he sometimes became frustrated or agitated, pushing, grabbing, being physically aggressive, and threatening when staff tried to redirect other residents from his room. He may resist care by hitting and kicking. The goal was for him to have fewer episodes of becoming frustrated and for his behavior to stop with staff intervention. Interventions were to attempt interventions before his behaviors began; give medications as doctor ordered; and to offer him something he liked as a diversion. The care plan did not include an intervention to provide adequate supervision to prevent resident to resident abuse.
There was no assessment/evaluation in the clinical record indicating Resident 56 had the capacity to consent to sexual activity in the facility.
The 6/5/24, 9:31 a.m. progress note for Resident 56, written by the DON (Director of Nursing) read, resident continues to have episodes of becoming agitated at staff when staff is attempting to assist female residents on the unit. resident believes that some of the female residents are his girls and becomes very protective. also continues to wonder [sic] about unit and at times will enter other resident's room uninvited, usually easily to redirect out of unwanted areas. Word salad frequently present, however during periods of agitation speech becomes coherent and resident will begin cursing at staff. staff will continue to attempt to ensure safety, provide interventions and assistance as warranted. Resident is followed by in-house mental health provider and is followed by in-house PCP [primary care physician] provider.
A behavior note, dated 6/6/24 at 9:01 a.m., for Resident 56, written by LPN (Licensed Practical Nurse) 5, indicated, Resident shoved this nurse out of the doorway as staff was attempting to keep he and a female resident separated due to sex behaviors. What was the resident doing prior to or at the time of behavior/mood: Resident was in the dining room and had been noticed rubbing a female resident's butt as she stood next to him. Interventions attempted: separation of resident's [sic.] Effectiveness of the interventions: Intervention was ineffective The note did not include documentation to show all of the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the behavior in the above progress note was the first behavior he witnessed on 6/6/24 between Resident 56 and Resident 74.
The next consecutive behavior note, dated 6/6/24 at 9:30 a.m., written by LPN 5 indicated, Resident was noted sitting in the sunroom with his hand up the shirt of the same female resident as earlier. Resident was rubbing the breast of this resident at this time. Interventions attempted: Both resident's [sic] were separated. Effectiveness of the interventions: Intervention was ineffective as these two resident's [sic] continue to seek one another out. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated he just happened to walk in the sunroom and see Resident 56 with his hand up Resident 74's shirt. There were quite a few other residents in the sunroom at the time, who were just sitting there, roughly six residents total including Resident 56 and Resident 74, and no staff.
The next consecutive behavior note, dated 6/6/24 at 9:40 a.m., for Resident 56, written by LPN 5 indicated, Resident walked up to the same female resident and grab [sic] her by the face them [sic] kissed her on the lips. Interventions attempted: Separated resident's [sic.] Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the kiss on the lips happened in the hallway and he just happened to see it. He was coming down hallway with the medication cart when Resident 74 walked past him, and Resident 56 came out of the dining room. Resident 56 grabbed Resident 74 on both sides of her face, leaned in, and kissed her. It happened quickly, more like a peck on the lips.
The next consecutive behavior note, dated 6/6/24 at 2:33 p.m., for Resident 56, written by LPN 5, read, Resident was noted sitting on the couch in the sunroom with a female resident on either side of him and the three of them were touching and rubbing on one another. Interventions attempted: Resident's [sic] were asked to stop and then separated. Effectiveness of the interventions: Ineffective. The note did not include documentation to show all the identified interventions to address behaviors were implemented, the facility initiated new interventions to address behaviors when the identified interventions were ineffective, or adequate supervision was provided to prevent further resident-to-resident abuse.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated there was another female resident, Resident 50, sitting on one side of Resident 56, and Resident 74 sitting on his other side in reference to the 6/6/24, 2:33 p.m. behavior note. The touching and rubbing he observed while the 3 of them were on the couch was outside of the clothing, rubbing legs, and holding hands. The two female residents weren't touching each other. Resident 56 was in the middle, touching both female residents, and both female residents were touching him. He stated, [Name of Resident 56] was a little too busy for me that day.
A progress note, dated 6/6/24 at 2:36 p.m., written by LPN 5, read, Resident has been aggressive with staff while they were attempting to redirect and separate him from the same female resident whom his [sic] is drawn to.
During an interview with LPN 5, on 6/17/24 at 3:00 p.m., he indicated the 6/6/24, 2:36 p.m. progress note just referenced a continuation of separating Resident 56 and Resident 74 throughout the day. The 3 residents on the couch was the last occurrence he witnessed on 6/6/24. From the time he shoved me, it didn't get any better. He'd only worked at the facility for about 3 weeks through an agency but was off all last week. He normally worked other units and had only worked the Alzheimer's Care Unit maybe twice. It was his understanding, from talking to other employees who'd worked on the unit for a while, that Resident 56 had been showing behaviors, and they were increasing and intensifying. When he spoke with someone about Resident 56's behaviors on 6/6/24, he made sure his behavior progress notes were documented to the best of my ability. Resident 56 was very sexual in nature, but also aggressive at times, with staff, including LPN 5. At one point, Resident 56 shoved him. He told full time staff management that day, because he noticed the issues, and he was trying to see how he was supposed to address them. I was told it was care planned. They could be together, just couldn't have sex, and the family was aware, so I just documented. He believed it was either the Unit Manager/Alzheimer's Care Director, the DON, or the Administrator who told him this, but he wasn't sure exactly who, because he was still trying to learn people. Resident 56's behaviors had been brought up on several occasions. He told quite a few people, including the CNAs (Certified Nursing Assistants) so they could keep an eye on them and keep them separated. He was just told to document everything he saw. He didn't think of it as sexual abuse, because both residents were seeking each other out, and it was clear they both became agitated due to staff trying to separate them, but with the residents being on the dementia unit and not having capacity to consent, he saw it as possible sexual abuse. His concern was that families would come in and be upset by it, because it was something that families should be aware of. That's why he went forward with making sure someone knew, and it didn't just stop with him. Prior to 6/6/24, he'd seen Resident 56 be flirtatious, but not touching, more like holding hands, helping and guiding them like they were lost, at least the way that he took it. On 6/6/24, there was no mistaking what was going on between Resident 56 and Resident 74. They were seeking each other out. He'd been trained on abuse multiple times. He worked full time for the PRN (as needed) Float Pool, and they trained him on abuse, but could not recall the last time. He thought it was less than a year ago. He had not received any abuse training in the facility itself.
An interview was conducted with the ACD (Alzheimer's Care Director) on 6/14/24 at 1:50 p.m. She indicated she'd been the ACD for about 2 years and was familiar with Resident 56. She did not consider his behaviors with other female residents as inappropriate. They will love on each other, kiss and cuddle. It was mostly with Resident 74, but Resident 50 gravitated toward Resident 56 as well, would sit and hold hands, nothing inappropriate. She'd spoken to both Resident 56's and Resident 74's families and made them aware. Resident 74's family was religious and understood, as long as nothing got out of hand. She knew others had seen Resident 56 with his hands up Resident 74's shirt, but she had not seen that. A male agency nurse told her Resident 56 put his hands up the back of Resident 74's shirt and he separated them. In the last month, Resident 56 had been generally harder to redirect. The IDT [Interdisciplinary Team] had talked about this; it was care planned; they talked to families and made a note about a month and a half ago.
An interview was conducted with CNA 8, on 6/14/24 at 2:00 p.m., who worked the day shift of 6/6/24. She indicated she normally worked the Alzheimer's Care Unit of the facility and had witnessed Resident 56 wrap his arm around female residents and caught him attempting to kiss female residents. She was told by CNA 9 that Resident 56 groped women's breasts, but CNA 8 hadn't witnessed this. His behaviors had been going on at least a few months. Some days he was hard to redirect and would be loud and aggressive toward staff. Resident 56 pushed a male nurse on 6/6/24, who didn't normally work the unit. Resident 56 tended to try and kiss Resident 74, as she was the main female resident. They are like glue. CNA 8 was told their families were aware. Once in a while, Resident 56 would try to kiss Resident 50 and a few times tried to kiss Resident 49.
CNA 9 was unavailable for interview.
An interview was conducted with CNA 25 on 6/17/24 at 2:02 p.m. She indicated she worked on 6/6/24. The only thing she saw was Resident 56 kiss Resident 74 on the forehead in the sunroom, just a quick peck. She was coming out a resident's room when LPN 5 informed her in the hallway that Resident 56's hand was up Resident 74's shirt. She didn't report this to anyone, because LPN 5 informed her that he was going to take care of it. She thought LPN 5 had it handled, because he was the nurse in charge.
An interview was conducted with the Administrator, DON, [NAME] President of Risk and Regulatory Compliance, and Regional Director of Clinical Operations on 6/14/24 at 1:45 p.m. after they read Resident 56's 6/6/24 behavior notes from the electronic health record. The Administrator indicated she did not know about Resident 56's 6/6/24 behaviors. She knew Resident 56 was flirtatious, would hold hands, and thought Resident 74 was his wife. The ACD had spoken to both families in regard to these things. The Administrator did not report, investigate, or take action after the 6/6/24 occurrences, as she was unaware of them. The DON indicated she had never heard about Resident 56's 6/6/24 behaviors prior to just now reading the notes. She was not aware Resident 56 had his hand up Resident 74's shirt, nor was she aware of him rubbing on her buttocks in the dining room and touching on the couch. There was a male nurse on the unit on 6/6/24, so when he was trying to intervene, she thought Resident 56 may have had a problem with him being male and trying to intervene, as Resident 56 would say Those are my girls, and a protective mode would step in. They tried to intervene, distract, take him outside, and use various interventions to address his behaviors.
An interview was conducted with the DON on 6/17/24 at 10:53 a.m. She indicated home office was responsible for training PRN (as needed) Float Pool staff on abuse, identification, and reporting, as it was not provided to them in the facility. Her understanding was they were already trained when they came into the facility to work.
The Abuse, Neglect, and Exploitation policy was provided by the DON on 6/17/24 at 11:08 a.m. It read, Sexual Abuse is non-consensual sexual contact of any type with a resident Employee Training. A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: .2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; .4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources .Prevention of Abuse, Neglect and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms Reporting/Response A. The facility fill have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
3.1-28(c)

Based on interview and record review, the facility failed to accurately encode minimum data set assessments for Resident 17's prognosis of six months or less and for Resident 54's utilization of hospice services for 2 of 2 residents reviewed for minimum data set assessment hospice accuracy.
Findings include:
1. The clinical record for Resident 17 was reviewed on 6/18/2024 at 1:22 p.m. The medical diagnosis included respiratory failure.
An Annual Minimum Data Set Assessment, dated 3/28/2024, indicated Resident 17 was cognitively impaired, did not have a life expectancy of six months or less, but utilized hospice services.
A physician order, dated 3/21/2023, indicated for Resident 17 to receive hospice services.
A hospice standing order, dated 12/31/2023, located inside of Resident 17's hospice binder at the nurses' station. The order indicated that Resident 17 had a terminal illness with a life expectancy of six months or less.
2. The clinical record for Resident 54 was reviewed on 6/17/2024 at 11:05 a.m. The medical diagnosis included diabetes with neuropathy.
A Significant Change Minimum Data Set Assessment, dated 6/5/2024, indicated that Resident 54 was cognitively intact, had a life expectancy of six months or less, but did not receive hospice services.
A physician order, dated 6/3/2024, indicated for Resident 54 to receive hospice services.
A hospice standing order, dated 5/31/2024, located inside of Resident 54's hospice binder at the nurses' station. The order indicated that Resident 54 had a terminal illness with a life expectancy of six months or less.
An interview with the Registered Nurse Assessment Coordinator (RNAC), on 6/19/2024 at 11:40 a.m., indicated the aforementioned assessment were encoded in error and she would initiate modifications of their records.
A policy entitled, Conducting an Accurate Resident Assessment, was provided by the Area [NAME] President on 6/18/2024 at 12:45 p.m. The policy indicated the purpose of the policy was for all residents to receive an accurate assessment.

Based on interview and record review, the facility failed to ensure timely notification of the physician and/or resident representative for cognitively impaired residents of a skin-related issues of a pressure area, bruise and redness and of a significant weight loss for 2 of 3 residents reviewed for notification of a change in condition. (Residents B and N)
Findings include:
1. The clinical record for Resident N was reviewed on 4-4-23 at 10:45 a.m. His diagnoses included, but were not limited to, chronic ischemic heart disease, hypertension and occlusion, history of falls, epilepsy and stenosis of unspecified carotid artery. His most recent Minimum Data Set (MDS) assessment, dated 1-12-23, indicated he was moderately cognitively impaired, was at risk for skin pressure ulcers, but had no pressure ulcers or other skin issues.
A review of Resident N's progress notes, dated 4-2-23 at 10:29 a.m., an unidentified staff CNA had reported to the licensed nurse redness to resident sacral area, resident had several loose stools, barrier cream applied after incontinence care. Bruising to left arm was also reported, areas on left arm are old discolored areas.
In an interview with LPN 7 on 4-4-23 at 2:15 p.m., she indicated she was unable to locate any documentation of notification to the physician or responsible party for Resident N's bruising identified on 3-8-23 or the 4-2-23 identification of redness to Resident N's sacral area redness.2. The clinical record for Resident B was reviewed on 4/3/2023 at 10:10 a.m. The medical diagnoses included white matter disease and covid-19.
A Minimum Data Set Assessment, dated 7/25/2022, indicated that Resident B was severely cognitively impaired, needed assistance with eating, and did not have a weight change.
The faces sheet for Resident B indicated Family Member 8 as the emergency contact and power of attorney.
A nursing assessment, dated 7/24/2022, indicated that Resident B had a pressure area to his coccyx.
A physician order, dated 7/24/2023, indicated for Resident B to have a treatment completed to the coccyx.
An interview with Family Member 8 on 4/3/2023 at 2:15 p.m. indicated she was never notified about the wound to his bottom. She had only found out about the wound to his coccyx when she went to visit and observed Resident B receiving incontinence care.
Weights for Resident B were recorded as:
6/7/2022 - 258.8 lbs. (admission)
6/15/2022 - 306.6 lbs. (+18% from admission)
6/18/2022 - 307.0 lbs. (+19% from admission)
7/19/2022 - 223.4 lbs. (-13% from admission)
7/25/2022 - 230.6 lbs. (-11% from admission)
7/26/2022 - 230.5 lbs. (-11% from admission)
8/2/2022 - 230.0 lbs. (-11% from admission)
A weight progress note, dated 7/7/2022, indicated that Resident B had some weight change and there was a question about accuracy of the scale.
No weight notes for 7/14/2023.
A weight progress note, dated 7/21/2022, indicated some weight loss was desirable but amount of weight loss was not anticipated.
No physician notification was documented on the medical record regarding Resident B's weight changes.
An interview with DON on 4/4/2023 at 3:45 p.m. indicated she could not locate on the medical record where Resident B's family as notified of the coccyx wound prior to 7/27/2023 nor where Resident B's physician was notified of the weight variations.
A policy entitled, Notification of Changes, was provided by the DON on 4/4/2023 at 10:34 a.m. The policy indicated, .The facility must inform the resident, consult with the resident's physician and /or notice the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include .Circumstances that require a need to alter treatment .New Treatment .
This Federal tag relates to Complaint IN00405133.
3.1-5(a)(2)
3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure the appropriate transfer and discharge paperwork provided to a resident upon transfer to an area hospital was included in the resident's clinical record for 1 of 2 residents reviewed for hospitalization. (Resident 11)
Findings include:
The clinical record for Resident 11 was reviewed on 4-5-23 at 10:40 a.m. It indicated her diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetic polyneuropathy.
A progress note of a telehealth visit by a nurse practitioner (NP), dated 2-7-23, indicated Resident 11 had a cough and shortness of breath of one week duration. She ordered for the resident to have a chest xray and to start routine breathing treatments with plans to follow clinically. A progress note, change of condition notation, dated 1-7-23 at 9:59 p.m., indicated the chest xray results indicated a right basilar pneumonia and effusion and the results had been sent to the NP on call. The NP ordered for an oral antibiotic to be started. The resident requested to be sent to a local emergency room and the resident's request was honored. The record indicated the transfer/discharge record had been sent with emergency management staff and/or with Resident 11, including the facility's bed hold policy.
In an interview with the Medical Records staff on 4-5-23 at 12:10 p.m., she indicated she was unable to locate Resident 11's Transfer and Discharge paperwork. She indicated she does not recall scanning any transfer and discharge paperwork in the year she has been at the facility in this role.
In an interview on 4-5-23 at 12:34 p.m., with the Director of Nursing (DON), she indicated the paperwork for the transfer-discharge documents are kept at the nurse's station. Not sure if we keep a copy of the paperwork. In an interview with the DON on 4-5-23 at 1:55 p.m., she indicated after Resident 11 returned from hospital stay, her daughter spoke with one of the facility nurses and the daughter asked if the facility needed a copy of the paper work she found in her mother's purse and provided the nurse a copy of the transfer-discharge paperwork. The nurse told her it was for the resident and the family and did not make a copy of the paperwork. DON indicated at that time there was not a copy of the transfer-discharge paperwork in this resident's chart. On 4-5-23 at 2:45 p.m., the DON provided a copy of the transfer-discharge paperwork that she was able to access from Resident 11's family member.
On 4-5-23 at 2:28 p.m., the Administrator provided a copy of a policy entitled, Bed Hold Notice Upon Transfer, with a revision date of October, 2022. This policy indicated, At the time of transfer for hospitalization or therapeutic leave, the facility will provide the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed .The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file.
3.1-12(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code MDS (Minimum Data Set) assessments for Resident C and Resident F for 2 of 14 residents reviewed for MDS accuracy.
Findings include:
1. The clinical record for Resident C was reviewed on 4/3/2023 at 1:05 p.m. The medical diagnoses included chronic obstructive pulmonary disease and Alzheimer's disease.
A 5-day MDS Assessment, dated 3/15/2023, indicated that Resident C had an ostomy.
A Significant Change of Condition MDS Assessment, dated 3/29/2023, indicated that Resident C was receiving hospice care but did not have a life expectancy prognosis of 6 months or less.
An interview with MDS Nurse on 4/3/2023 at 2:40 p.m. indicated that Resident C did not have an ostomy for the 3/15/2023 assessment and should have been coded for 6 months or less prognosis for the 3/29/2023 assessment.
A physician statement, dated 3/25/2023, indicated that Resident C had a 6 months or less life expectancy if disease processes ran their normal courses.
2. The clinical record for Resident F was reviewed on 4/3/2023 at 10:55 a.m. The medical diagnoses included dementia and stroke.
A Significant Change of Condition Minimum Data Set, dated [DATE], indicated that Resident F was receiving hospice care but did not have a life expectancy prognosis of 6 months or less.
A physician statement, dated 1/20/2023, indicated that Resident F had a life expectancy of 6 moths or less if disease processes ran their normal courses.
An interview with MDS Nurse on 4/3/2023 at 2:40 p.m. indicated Resident F should have been coded for a 6 months of less life expectancy prognosis for the 1/25/2023 assessment.
A policy entitled, Conducting an Accurate Resident Assessment, was provided by the DON on 4/4/2023 at 10:34 a.m. The policy indicated the purpose of the policy was to receive an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plans were developed for the use of medications for hypothyroidism, hypertension and anti-platelets medications for 2 of 25 residents reviewed for care plans. (Residents F and N)
Findings include:
1. The clinical record for Resident N was reviewed on 4-4-23 at 10:45 a.m. His diagnoses included, but were not limited to, chronic ischemic heart disease, hypertension and occlusion and stenosis of unspecified carotid artery.
A review of his current medications indicated he was physician ordered for the use of Plavix Tablet, an anti-platelet medication, 75 milligrams (mg) once daily related to his diagnosis of chronic ischemic heart disease. This medication was last ordered on 12-14-22.
In an interview on 4-5-23 at 11:22 a.m., she indicated she was unable to locate a care plan for the use of Plavix. She indicated she ensured a care plan was developed today for its use. I don't know how we missed this because we had corporate do an audit on care plans not long ago.
2. The clinical record for Resident F was reviewed on 4/3/2023 at 10:55 a.m. The medical diagnoses included hypertension and hypothyroidism.
A Significant Change of Condition Minimum Data Set, dated [DATE], indicated that Resident F was cognitively impaired.
A physician order dated 1/25/2023 indicated for Resident F to receive medications for hypothyroidism.
A physician order dated 3/11/2023 indicated for Resident F to receive medication for hypertension.
An interview with RN on 4/3/2023 indicated that care plans were added for hypertension medications and hypothyroid medications on 3/31/2023.
A policy entitled, Comprehensive Care Plan, was provided by the DON on 4/4/2023 at 10:35 a.m. The policy indicated, .The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain to maintain the resident's highest practicable physical, mental, and psychosocial well-being . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .
3.1-35(b)(1)

Based on observation, interview and record review the facility failed to provide hair care and nail care for 2 of 3 residents reviewed for Activities Of Daily Living (ADL) (Resident J and Resident H).
Findings include:
1.) During an observation on 3/29/23 at 1:43 p.m., Resident H was sitting in a geriatric chair in the common area with greasy, dirty and uncombed hair.
Review of the record Resident H on 3/31/23 at 10:10 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson's disease, fracture of shaft of left femur, dehydration, rhabdomyolysis, anxiety, hypertension, dementia and history of falling.
The Quarterly Minimum Data Set (MDS) assessment for Resident 53, dated 3/13/23, indicated the resident was severely impaired for daily decision making. The resident was totally dependent of two people to transfer and did not ambulate. The resident required extensive assistance of two people for personal hygiene and totally dependent of two people for bathing.
The plan of care for Resident H, dated 3/15/23, indicated the resident had physical functioning related to mobility impairment, self care impairment secondary to need for assist related to Parkinson disease and encephalopathy.
During an observation on 3/31/23 at 11:45 a.m., Resident H was sitting in the common area in geriatric chair, her hair is uncombed, greasy and dirty.
During an observation on 3/31/23 at 1:25 p.m., Resident H was sitting in the common area in a geriatric chair, her hair was uncombed, greasy and dirty.
During an observation on 4/3/23 at 10:54 a.m. Resident H was sitting in the common area in a geriatric chair, her hair was uncombed, greasy and dirty.
During an interview the Director Of Nursing on 4/4/23 at 2:39 p.m., indicated the CNA's were responsible to ensure Resident H's hair was clean and combed.
2.) During an observation on 3/30/23 at 11:19 a.m., Resident J was laying in bed, the resident's fingernails were long with black substance underneath them, toenails are were long jagged and crooked.
During an observation on 3/31/23 at 11:50 a.m., Resident J was laying in bed his fingernails were long with black substance, his toenails were long on both feet.
During an observation on 3/31/23 at 1:25 p.m., Resident J was laying in bed, the resident's fingernails were long with black substance underneath them and the his toenails were long on both feet.
During an observation on 4/3/23 at 10:48 a.m., Resident J was sitting on the edge of his bed, his fingernails and toenails were long and dirty. The skin proximal to the toenails had a grayish tint.
Review of the record of Resident J on 3/31/23 at 12:00 p.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, depression, acute respiratory failure with hypoxia, prostate cancer and anxiety.
The Annual Minimum Data Set (MDS) assessment for Resident J, dated 3/28/23, indicated the resident was severely cognitively impaired for daily decision making. The resident required extensive assistance of two for personal hygiene and totally dependent of one person for bathing.
The of care for Resident J, dated 3/21/23, indicated the resident had physical functioning deficit and self care impairment. Then intervention included, but were not limited to nail care as needed.
During an interview with the Director Of Nursing (DON) on 4/4/23 at 2:41 p.m., indicated the nursing staff were responsible to ensure Resident J's fingernails and toenails were clean and trimmed. The resident had been refusing and the DON would look for documentation of the resident's refusal for nail care.
During an interview with the DON on 4/5/23 at 9:40 a.m., was unable to provide documentation of resident refusal of fingernail and toenail care.
The ADL policy provided by the Administrator on 4/5/23 at 9:00 a.m., indicated care and services would be provided for bathing and grooming.
The nail care policy provided by the Administrator on 4/5/23 at 9:00 a.m., indicated routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis.
This Federal tag relates to Complaint IN00405133.
3.1-38(a)(3)(B)
3.1-38(a)(3)(E)

Based on record review and interview, the facility failed to administer subcutaneous fluids as ordered by a provider for 1 of 4 residents reviewed for medication compliance. (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 4/3/2023 at 10:10 a.m. The medical diagnoses included white matter disease and covid-19.
A Minimum Data Set Assessment, dated 7/25/2022, indicated that Resident B was severely cognitively impaired and was not dehydrated.
A comprehensive metabolic panel, dated 7/28/2022, indicated that Resident B had an elevated blood urea nitrogen (BUN) of 71 mm/dl.
A normal range was listed as 7-25. An elevated BUN can indicate changes with the kidneys and hydration status.
A nurse practitioner's note for Resident B, dated 7/27/2022, contained an addendum on 8/2/2022 that stated .BUN 71, creatinine 1.0. Verbal order given to nurse for 500ml [milliliter] bolus of 0.9% NS SQ [normal saline subcutaneously] .
An interview with DON on 4/4/2022 at 2:45 p.m. indicated she could not find the order for fluids on Resident B's medical record nor where he had received fluids on the medication administration record.
A policy entitled, Provision of Physician Ordered Services, was provided by the Administrator on 4/5/2023 at 9:00 a.m. The policy indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services .:
This Federal tag relates to Complaint IN00405133.
3.1-37(a)

Based on record review and interview, the facility failed to timely initiate treatment as ordered to a pressure area to the right heel and failed to follow up on a pressure area to the left heel for 1 of 3 residents reviewed for pressure areas (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 4/3/2023 at 10:10 a.m. The medical diagnoses included white matter disease and covid-19.
A Minimum Data Set Assessment, dated 7/25/2022, indicated that Resident B was severely cognitively impaired, was at risk for developoing pressure areas, and had three stage two pressure areas.
A wound nurse note, dated 7/20/2023, indicated Resident B had a pressure area to the right lateral heel with a dressing of skin prep twice a day.
The medication administration record for Resident B indicated skin prep to the right lateral heel was not stated until 7/28/2023.
A nursing progress note, dated 7/21/2022, indicated Resident B had a pressure are of stage two to the left heel with measurements of 3.8 x 2.78 x 0 centimeters (cm).
A weekly skin assessment, dated 7/25/2022, indicated Resident B .Has black area on the left heel . No measurements for the left heel were included on the assessment.
A weekly skin assessment, dated 8/1/2023, indicated Resident B's .Left heel remains dark and purple . No measurements for the left heel were included on the assessment.
A policy entitled, Skin Assessment, was provided by the DON on 4/4/2023 at 10:34 a.m. The policy indicated that the documentation of skin assessment should include the date and time of the assessment, the staff's name and position title, observations of the skin conditions, type of wound, and description of the wound (measurements, color, type of tissue in the wound bed, drainage, odor and pain).
This Federal tag relates to Complaint IN00405133.
3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to maintain oxygen at the physician's ordered flow rate, and failed to date the oxygen tubing. This affected 1 of 1 resident reviewed for respiratory care. (Resident 34)
Findings include:
On 3/29/23 at 12:24 p.m., Resident 34 was seated in her recliner, her oxygen concentrator was set on 1 and 1/2 liters per minute and her oxygen tubing was not dated.
On 3/31/23 at 11:21 a.m., LPN 1 checked for a date on the oxygen tubing and said it was dated 3/20/23. She asked Resident 34 if they had changed the tubing when they changed the water bottle, and the resident said no. LPN 1 told the resident she would get get new tubing because it should have been changed a few days ago, and she got new tubing and replaced it.
Resident 34's record was reviewed on 3/31/23 at 11:35 a.m. and indicated diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, acute and chronic respiratory failure with low blood oxygen, atrial fibrillation, hypertensive heart disease with heart failure, congestive heart failure, anxiety and depression.
A quarterly Minimum Data Set assessment, dated 2/28/23, indicated Resident 34 was cognitively intact, and received oxygen therapy.
Physician's orders related to oxygen therapy included:
Change oxygen tubing and storage bag, date and initial both, on night shift every Saturday, dated 3/6/23
Oxygen at 3 liters via nasal cannula continuous. Dated 12/13/2022
A care plan for oxygen, dated 8/9/22, included, but was not limited to, a problem for alteration in respiratory status due to chronic obstructive pulmonary disease, congestive heart failure, respiratory failure with oxygen dependence, requires head of bed to be elevated when lying flat to prevent shortness of breath. Interventions: Administer oxygen as needed per physician's orders. Observe oxygen flow rate and response.
On 4/03/23 at 11:55 a.m., Resident 34 was observed sitting in her recliner watching TV. Her oxygen flow rate was set on 1 and 1/2 liters per minute.
On 4/03/23 at 03:25 p.m., LPN 2 said Resident 34's oxygen flow rate should be 3 liters per minute. LPN 2 checked the resident's flow meter and the flow rate was 1 and 1/2 lpm. LPN 2 said it was 3 lpm's this morning. LPN 2 tried to increase the flow rate to 3 liters per minute and the knob would not turn it up that high, it would go up to almost 3 liters and stopped. LPN 2 got another oxygen concentrator and replaced the one in Resident 34's room, then the flow rate was set on 3 liters per minute. Resident 34 indicated at that time that she hasn't had any shortness of breath but when she walks in her room she does and that is normal for her.
A policy for Oxygen Concentrator was provided by the Director of Nurses on 4/4/23 at 11:40 a.m. The policy included, but was not limited to: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators .2. Oxygen is administered under orders of the attending physician, except in the case of an emergency .The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.) .Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated
3.1-47(a)(6)

Based on interview and record review, the facility failed to have a CMS-approved (Centers for Medicare and Medicaid) indication for the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medication use. (Resident 55)
Findings include:
The clinical record of Resident 55 was reviewed on 3-31-23 at 10:50 a.m. His diagnoses included, but were not limited to, other specified depressive episodes, generalized anxiety, other Alzheimer's disease and dementia in other diseases classified elsewhere with behavioral disturbance. It indicated he was admitted to the facility less than 6 months ago and was admitted into the facility's secured memory care unit. His admission Minimum Data Set (MDS) assessment, dated 1-23-23, indicated he was severely cognitively impaired. It indicated he was admitted to the facility and received anti-psychotic medications 7 of 7 days each week. His admission medication orders indicated he was prescribed Zyprexa, an anti-psychotic medication, 7.5 milligrams (mg) twice daily for behavioral disturbance.
Behavioral documentation, dated 2-22-23 and 2-27-23, indicate Resident 55 had been observed by staff wandering into other resident's room. Upon attempting re-direction by staff, Resident 55 began hitting and kicking at staff. It indicated facility staff had notified the hospice nurse of the behaviors and obtained a physician's order to increase the Zyprexa to 10 mg twice daily and a one time stat (immediate) dose of Haldol 2 mg intramuscular (IM) injection. Progress notes reflected Resident 55 calmed down within 30 minutes.
A progress note, dated 3-2-23 at 3:00 p.m., indicated a pharmacy recommendation was requested on 2-18-23 to clarify diagnosis for Zyprexa and to consider GDR (gradual dose reduction) if no CMS approved diagnosis. [Name of physician] writes 'dementia with behavioral disturbances'.
The interpretive guidelines for this Federal tag indicates the following for the use of anti-psychotic medications for use in the elderly: Antipsychotic medications (both first and second generation) have serious side effects and can be especially dangerous for elderly residents. When antipsychotic medications are used without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there is little chance that they will be effective, and they commonly cause complications such as movement disorders, falls with injury, cerebrovascular adverse events (cerebrovascular accidents (CVA, commonly referred to as stroke), and transient ischemic events) and increased risk of death. The FDA Boxed Warning which accompanies second generation anti-psychotics states, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death, https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm053171.htm. The FDA issued a similar Boxed Warning for first generation antipsychotic drugs,https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm. Diagnoses alone do not necessarily warrant the use of an antipsychotic medication. Antipsychotic medications may be indicated if:
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behavioral symptoms present a danger to the resident or others;
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expressions or indications of distress that are significant distress to the resident;
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if not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptoms which are presenting a danger or significant distress; and/or
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GDR was attempted, but clinical symptoms returned.
If antipsychotic medications are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement care-planned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of these interventions .For any individual who is receiving a psychotropic medication to treat a disorder other than expressions or indications of distress related to dementia (for example, schizophrenia, bipolar mania, depression with psychotic features, or another medical condition, other than dementia, which may cause psychosis), the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to:
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The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder; or
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The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder.
On 4-5-23 at 2:05 p.m., the Administrator provided a copy of a policy entitled, Use of Psychotropic Medications, with a revision date of October, 2022. This policy indicates, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and and documented in the clinical record, and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication(s) .The indications for use of any psychotropic drug will be documented in the medical record .
3.1-48(b)(1)

Based on record review and interview, the facility failed to timely report out of range lab results to the medical provider for 1 of 3 residents reviewed for laboratory services. (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 4/3/2023 at 10:10 a.m. The medical diagnoses included white matter disease and covid-19.
A Minimum Data Set Assessment, dated 7/25/2022, indicated that Resident B was severely cognitively impaired.
A comprehensive metabolic panel, dated 7/28/2022, indicated that Resident B had an elevated blood urea nitrogen (BUN) of 71 mm/dl.
A normal range was listed as 7-25. An elevated BUN can indicate changes with the kidneys and hydration status. The laboratory report was indicated as reviewed on 8/1/2022.
A nurse practitioner's note for Resident B, dated 7/27/2022, contained an addendum on 8/2/2022 that stating intervention for elevated BUN.
An interview with the DON on 4/4/2023 at 2:45 p.m. indicated she could not find where the physician was notified of the laboratory results from 7/28/2022 prior to addendum dated for 8/2/2022.
A policy entitled, Diagnostic Testing Services, was provided by the DON on 4/4/2023 at 10:34 a.m. The policy indicated, .Qualified nursing personnel will receive and review the diagnostic test reporting and communicate the results to the ordering Physician within 24 hours of receipt unless the report results fall outside of clinical reference and require immediate attention as which time the Physician will be notified upon receipt .
This Federal tag relates to Complaint IN00405133.
3.1-49(f)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to follow up on a recommendation for a dental consultation for a Resident F for 1 of 4 residents reviewed for dental services.
Findings include:
The clinical record for Resident F was reviewed on 4/3/2023 at 10:55 a.m. The medical diagnoses included dementia and stroke.
A Significant Change of Condition Minimum Data Set, dated [DATE], indicated that Resident F was cognitively impaired.
A nutrition at risk progress note, dated 1/5/2023, indicated a recommendation for a dental consult.
An interview with the DON on 4/4/2023 at 2:15 p.m. indicated that the recommendation was never conveyed to the social service director or family in January, but Resident F's family declined dental services on 3/31/2023.
A policy entitled, Dental Services, was provided by the Administrator on 4/5/2023 at 2:05 p.m. The policy indicated, .It is the policy of the facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care .referrals to the dietician, speech therapist, physician, or dental provider shall be mad as appropriate .
3.1-24(a)(1)

Based on observation, interview and record review the facility failed to provide routine dental services for for 2 of 5 residents reviewed for dental services (Resident H and Resident 11).
Findings include:
1.) During an observation on 3/29/23 at 1:43 p.m., Resident H was sitting in the common area, the resident had visible teeth.
Review of the record Resident H on 3/31/23 at 10:10 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson's disease, fracture of shaft of left femur, dehydration, rhabdomyolysis, anxiety, hypertension, dementia and history of falling.
The plan of care for Resident H, dated 11/22/22, indicated the resident was at risk for dental problems related to some or all natural. The interventions included, but were not limited to, refer for dental services as needed.
The nutritional assessment for Resident H, dated 3/13/23, indicated the resident was at risk for malnutrition. The resident had dental problems and received a puree diet. Resident follows a Puree diet related to dentition & dysphagia diagnosis. The assessment was signed by Registered Dietician.
The physician recapitulation for Resident H, dated April 2023, indicated the resident had an order of may be seen by the dentist (original order date 12/13/22)
During an interview the Director Of Nursing on 4/4/23 at 2:39 p.m., indicated Resident H had not been seen by the dentist for routine care. The Social Service Director was responsible to ensure resident's received routine dental services.
2. The clinical record of Resident 11 was reviewed on 4-5-23 at 10:40 a.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetic polyneuropathy.
In an interview with Resident 11 on 3-29-23 at 2:19 p.m., she indicated she has dentures, but the dentures are now ill-fitting. She indicated she could not recall when she last saw a facility dentist.
Review of Resident 11's most recent visits with the facility-provided contracted dental service indicated those occurred on 3-13-19 and 3-3-20.
On 4-5-23 at 2:05 p.m., the Administrator provided a copy of a policy entitled, Dental Services, with a revision date of February, 2023. This policy indicated, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan and emergency dental care. Definitions: 'Routine dental services' means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full dental adjustments, smoothing of broken teeth, and limited orthodontic procedures, e.g., taking impressions for dentures and fitting dentures .Residents and/or resident representatives, during the admission process, are notified of dental services available under State plan (i.e., state-run programs), and of the potential charges that may apply in the case of routine or emergency dental care provided by outside sources. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan .
3.1-24(a)

Based on record review and interview, the facility failed to ensure a staff member working in the capacity of a licensed nurse had a current license to practice in Indiana who had the ability to care for 84 or 84 residents.
Findings include:
The employee records were reviewed on 4/4/2023 at 1:30 p.m. The nursing license for LPN 1 was indicated as Pending Application.
An interview Professional Licensing Agency Representative on 4/5/2023 at 11:21 a.m., indicated LPN 1 does not have a compact nursing license, but had an application for Indiana licensure based on endorsement (reciprocity) that was received in January 2023. As of 4/5/23, the application for Indiana licensure is still pending and LPN 1 is not able to work independently in Indiana at this time.
An interview with the Administrator on 4/5/2023 at 12:45 p.m., indicated that LPN 1 was pending license for reciprocity and the facility was under the impression she could work as a nurse while her application was pending. The facility does not have a policy for staff licensure, but they follow the State guidelines to employ staff with the appropriate licensure of each position.
5.1-4(h)(5)

Based on interview and record record review, the facility failed to complete an investigation and report an allegation of misappropriation of property for 1 of 5 residents reviewed for missing personal property. (Resident 78)
Findings include:
During an interview, on 3/29/23 at 1:50 p.m., Resident 78 indicated she had a cell phone stolen in December and the facility hasn't done anything to find it. She said she reported it to a nurse but couldn't remember her name. Resident 78 indicated she had left the cell phone in her room when she went to therapy, and it was gone when she returned. She talked to several people and was told RN 8 would investigate. RN 8 had asked her if she had a 'find my phone app' and she did not. Resident 78 told her she didn't have service on it that day. Resident 78 said she bought a new phone and nothing else was done. No one has ever gotten back with her or said they were looking for the phone. Resident 78 indicated she was still paying on the phone.
Resident 78's record was reviewed, on 3/31/23 at 1:33 p.m., and indicated diagnoses that included, but were not limited to, a nervous system disorder, depression, weakness, pain, and behavioral and emotional disorders.
A quarterly Minimum Data Set assessment, dated 3/6/23, indicated Resident 78 was cognitively intact.
A cell phone was listed on Resident 78's Inventory Sheet, dated 11/12/22.
On 4/03/23 at 3:16 p.m., Resident 78 indicated she didn't talk to the Administrator or the Social Service Director (SSD); she told her nurse.
On 4/04/23 at 10:39 a.m., the Administrator indicated she had not found any information about the cell phone yet and is still looking.
On 4/05/23 at 10:15 a.m., the SSD said when the phone went missing she wasn't informed right away, but she knew about it, and they don't know what happened to the phone.
On 4/05/23 at 12:40 p.m., the Administrator provided a copy of the Grievance Form related to the missing cell phone and indicated this was what they had. An attachment with the form indicated Resident [78] stated her phone came up missing on December 1st from her room. [Resident 78] stated she was sitting in her room, in her wheelchair, with the roller table in front of her with her phone and tablet both on the table. She said an Aide walked into her room and stated that the aide was taking [Resident 78] to therapy and pushed her in her wheelchair to the therapy area. [Resident 78] said when they got to the therapy room, [Name of Therapist] was standing at the door ad told aid and [Resident 78] it was almost lunchtime and to take [Resident 78] back to her room and then therapy would come back down after lunch and get her. [Resident 78] said this was around 12:00 noon when she and aide returned to her room. [Resident 78] said her tablet was still on the table, but her phone was not. When therapy came to the room [Resident 78] told [Name of speech therapist], the phone was missing. [Resident 78] said her understanding was that [Name of speech therapist] reported the missing phone to RN 8, the nurse and was told RN 8 would handle it. She said nothing was done because she gave RN 8 and the aides her stepmother's phone number three or more times to talk with her and her stepmother never heard from anyone. [Resident 78] said two weeks later the phone case and the stylist came up missing.
On 4/05/23 at 2:29 p.m., the Administrator indicated the information about the phone replacement was printed and given to the SSD yesterday (4/4/23) and they will run it through their corporate to be replaced and it was not reported to the State Department of Health.
A policy for Investigation and Reporting Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property was provided by the Administrator on 3/29/23 at 10:45 a.m. The policy included, but was not limited to: .The Company shall take the following steps to prevent, detect and report abuse, neglect, injuries of unknown origin and the misappropriation of resident property (alleged violations) .Misappropriation of Resident Property: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. This applies to spouses, family members, friends and staff
3.1-28(c)
3.1-28(d)
3.1-28(e)