Schmitt Woodland Hills

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:15Number of residents cited: 2 OF 15 SAMPLED Based on observation, record review and staff interview, the facility did not ensure the resident's care plan was updated to reflect current care needs for 2 Resident (R33 and R41) of 15 sampled residents.
R33's care plan reflected R33 should always have bilateral hand splints on except for at mealtime. Surveyor made observations of R33 without hand splints on. Staff had discontinued hand splints and started using washcloths in place of hand splints and had not updated the care plan.
R41's care plan contained precautions from a Norovirus outbreak that occurred in the facility from December into January. The care plan was not discontinued once the outbreak was over. R41's care plan also contained a care plan for the use of an antidepressant which R41 is no longer taking.
Findings:
Facility policy titled Comprehensive Care Plan, last revised 1/2026 states in part.
Policy: 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 on the resident's comprehensive assessment and meet professional standards of quality.
5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (minimum data set) assessment.
Example 1
On 1/24/2022, the Surveyor reviewed R41's medical record. R41 was admitted to the facility 11/30/2023. R41's diagnoses included coronary artery disease, HTN (hypertension), BPH (benign prostatic hyperplasia), arthritis, non-Alzheimer's dementia, stroke, and hemiplegia.
R41's BIMS score on 2/27/2026 is documented as 04 indicating R41 has severe cognitive impairment.
R41's care plan states in part.
Focus: The resident is at risk for transmission of infection r/t (related to) vomiting/diarrhea. Date Initiated: 12/29/2025.
Goal: Initiate contact precautions per provider order and infection control policy. Monitor for signs and symptoms of infection. Coordinate enhanced environmental cleaning of high-touch surfaces. Disinfect shared equipment between uses per policy. Observe staff compliance with PPE (personal protective equipment) use. Perform hand hygiene before and after resident contact. Post contact-precautions signage outside resident room. Provide resident and visitor education regarding hand hygiene and limiting contact. Review lab results and cultures as ordered and report to physician. Staff to don gown and gloves upon room entry. Use dedicated or disposable resident-care equipment when possible. All goals initiated on 12/29/2026.
Note: The facility concluded its Norovirus outbreak on 1/29/2026.
Focus: The resident uses antidepressant fluoxetine r/t depression and poor prognosis. Date Initiated: 12/14/2023
Goal: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: Change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes. All goals initiated on 12/14/2023.
Note: R41's antidepressant medication was discontinued on 5/16/2025 and not removed from R41's plan of care.
On 3/4/2026 2:51 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator) regarding care plan revisions not done when R41 no longer taking antidepressant medication and the facility no longer in a Norovirus outbreak which since January. Surveyor asked DON B and NHA A who updated the plan of care. DON B states, all the nurses. If the nurse is not able or does not have time to update the care plan they fill out a form on changes that need to be made to the care plan and then the ADON or MDS nurse, make the change for them. Surveyor asked DON B and NHA A if changes in residents plan of care should the care plan be updated to reflect those changes. DON B and NHA A both indicate that is correct. Surveyor asked DON B when a medication is discontinued, or an outbreak is over should those care plans be resolved in the resident care plan. NHA A states, they should be resolved when discontinued or resolved.
On 3/5/2026 at 8:55 AM, Surveyor interviewed CNA C (Certified nursing assistant). Surveyor asked CNA C where she would look at to know how to care for a resident. CNA C states, I would look at the residents care plan and we also have walking care plans. Surveyor asked CNA C if changes need to be made to the care plan who makes those changes. CNA C states that if a change needs to be made to the care plan, I will tell the nurse, then she will update the care plan or the MDS Nurse, DON or ADON will. Surveyor asked CNA C how she knows if changes are made to a residents care plan. CNA C states, a lot is passed down in report, we do walk around report going room to room and then we also listen to nursing report at the beginning of our shift. If changes are made during the shift the nurses will let us know or we report changes to the nurse for changes on the care plan.
On 3/5/2026 at 9:03 AM, Surveyor interviewed CNA H. Surveyor asked CNA H where she would look to know how to care for a resident. CNA H states, we have walking care plans or look at the care plans on computer. Surveyor asked CNA H who would make the changes to care plan. CNA H states, changes to the care plan updated by the nurse or the nurse will give to MDS, ADON, or DON to make the changes for her. Surveyor asked CNA H how she is made aware of changes to a residents care plan. CNA H states, during report the nurse will tell us if there are any changes or when doing shift to shift report with off-going shift.
On 3/05/2026 at 9:10 AM, Surveyor interviewed RN I (Registered Nurse). Surveyor asked RN I where she would look to know how to care for a resident. RN I states, I would begin by reviewing care plan, doing assessments, asking other staff, and through report. Surveyor asked RN I who is responsible for making changes to the care plan. RN I states, any changes will be passed on through report. The nurses will remove items from the care plan when there are changes or at times if the nurse is not able to get to it the DON, ADON (Assistant Director of Nursing) or MDS Coordinator will make the changes. Surveyor RN I how is made aware of any changes to a residents plan of care. RN I states, I would get that through report and if you pull up the 24 hour report you can see when changes were made and update the care plan. Surveyor asked RN I about medication changes. RN I states that any medication changes would also be placed on the 24 hour board too so that changes can be made to the plan of care.
Example 2:
R33 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's Disease (a progressive, irreversible brain disorder that damages neurons, causing cognitive decline, memory loss, and behavior changes) and torticollis (a twisted, tilted neck caused by tightening of the sternocleidomastoid muscle).
R33's BIMS score on 11/16/26 is documented as 00 indicating R33 has severe cognitive impairment.
R33's Care Plan states, in part: .
Focus: The resident has limited physical mobility related to weakness. Date Initiated: 4/14/2022.
Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 8/01/2022.
Interventions: .
*The resident wears blue hand/digit splint to the right hand at all times except for mealtimes. Address hand hygiene with each removal of splint. No splints to the left hand at this time. Date Initiated: 8/04/2025.
Focus: The resident has an alteration in musculoskeletal status related to contractures of the neck, UES (upper extremities) and LES (lower extremities) .
Interventions: .
* At night, the resident is to wear bilateral elbow splints. During the day, the resident is to wear bilateral hand splints. Off at meals. Monitor for any redness.
On 3/03/26, at 9:29 AM, Surveyor observed R33 in Broda chair with bilateral hands curled closed with no hand splints or wash clothes and no cervical neck pillow or rolled blanket around neck.
On 3/04/2026 at 10:23 AM, Surveyor observed R33 lying in bed on back with rolled blanket around neck and no bilateral hand splints in hands.
On 3/04/2026 at 10:58 AM, Surveyor interviewed DON B (Director of Nursing) and ADON F (Assistant Director of Nursing). Surveyor asked ADON F and DON B, according to R33's Care Plan, is R33 to always have blue hand splints on to bilateral hands? ADON F indicated wash clothes were put into place this past fall. ADON F indicated she changed the blue hand splints to wash clothes after speaking with therapy due to the rough edges on the splints. The splints were leaving redness to R33's palms. Surveyor read R33's care plan to ADON F and DON B, The resident wears blue hand/digit splint to the right hand only, at all times except for mealtimes, and At night, the resident is to wear bilateral elbow splints. During the day, the resident is to wear bilateral hand splints. Off at meals . Surveyor pointed out the care plan shows two different interventions regarding hand splints. ADON F indicated she did not change it on the care plan to reflect to use wash clothes to bilateral hands and should have. Surveyor informed ADON F and DON B of observations of R33 without hand splints/wash clothes and the cervical neck pillow not placed on R33. Surveyor asked ADON F and DON B if they would expect care plans to be followed. ADON F indicated yes. DON B indicated his expectation is for care plans to be updated right away with any changes and followed. ADON F indicated she will update the care plan for R33 right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure residents with limited range of motion, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility for 1 of 2 residents (R33) reviewed for range of motion (ROM).R33 did not receive her bilateral hand splints/wash clothes, cervical pillow per comprehensive care plan and therapy recommendations.This is evidenced by:The facility policy entitled Prevention of Decline in Range of Motion, dated 1/10/26, states, in part: . Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable.Policy Explanation and Compliance Guidelines:1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care.3. Appropriate Care Planning a. Based on comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces, splints) . c. Care plan interventions will be developed and delivered through the facility's restorative program. d. Interventions will be documented on the resident's person-centered care plan. Documentation should include, but not limited to: i. Type of treatments; ii. Frequency and duration of treatments; . R33 admitted to the facility on [DATE] and has diagnoses that include Alzheimer's Disease (a progressive, irreversible brain disorder that damages neurons, causing cognitive decline, memory loss, and behavior changes) and torticollis (a twisted, tilted neck caused by tightening of the sternocleidomastoid muscle).R33's Brief Interview for Mental Status (BIMS) score on 11/16/26 is documented as 00 indicating R33 has severe cognitive impairment.R33's Care Plan states, in part: . Focus: The resident has limited physical mobility related to weakness. Date Initiated: 4/14/2022.Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 8/01/2022.Interventions: .*After each meal, lay the resident down in bed on her right side. Ensure appropriate support to head, neck, and back for positioning. Date Initiated: 5/30/2024.*Ensure hand stretches are being completed per the program listed on bathroom door twice daily, one time each AM and PM shift. Complete stretches with both hands. Date Initiated: 8/28/2025.*Ensure proper neck placement with cervical pillow or rolled blanket for proper neck alignment. Date Initiated: 9/19/2024.*The resident wears blue hand/digit splint to the right hand only at all times except for mealtimes. Address hand hygiene with each removal of splint. No splints to the left hand at this time. Date Initiated: 8/04/2025.Focus: The resident has an alteration in musculoskeletal status related to contractures of the neck, UES (upper extremities) and LES (lower extremities) .Interventions: .* At night, the resident is to wear bilateral elbow splints. During the day, the resident is to wear bilateral hand splints. Off at meals. Monitor for any redness. On 3/3/26 at 9:29 AM, Surveyor observed R33 in Broda chair with bilateral hands curled closed with no hand splints or wash clothes and no cervical neck pillow or rolled blanket around neck. On 3/4/26 at 10:23 AM, Surveyor observed R33 lying in bed on back with rolled blanket around neck and no bilateral hand splints in hands.On 3/4/26 at 10:26 AM, Surveyor interviewed CNA C (Certified Nursing Assistant) and asked if the CNAs do restorative cares such as passive and active range of motion exercises with residents. CNA C indicated yes with morning cares. CNA C indicated the active and passive range of motion exercises are documented in the computer system by the CNAs. Surveyor asked is R33 to have a cervical pillow around her neck at all times. CNA C indicated yes, the staff uses a rolled-up blanket for the cervical pillow per husband request. Surveyor asked if R33 is to have blue hand splints to bilateral hands. CNA C indicated the blue hand splints were discontinued, and they now use rolled wash clothes in place of the blue hand splints. Surveyor asked if R33 should have the wash clothes in place now, CNA C indicated the reason R33 did not have the washcloths in place at this time was because R33 had a shower this morning and staff are waiting for the areas to R33's hands to dry. CNA C indicated staff will place the wash clothes later when R33 gets up for lunch. Surveyor asked CNA C if R33 is care planned to lay on right side. CNA C indicated she was not aware of that; the staff rotates positioning in bed from sides to back. CNA C indicated R33 cannot lay on her right side; staff places a pillow under her sides. Surveyor asked CNA C if R33 is lying flat on her back now and CNA C indicated yes.On 3/4/26 at 10:09 AM, Surveyor interviewed DR G (Director of Rehab). DR G indicated therapy had recommended R33 has bilateral resting hand splints to be placed during the day at all times except at meals to prevent further contracture and an elbow splint at night. DR G indicated R33 has a curvature of the neck which is more related to tightness and tone vs. contracture. Surveyor asked DR G if she would expect nursing staff to follow therapy recommendations and DR G indicated yes.On 3/4/26, at 10:58AM, Surveyor interviewed DON B (Director of Nursing) and ADON F (Assistant Director of Nursing). Surveyor asked if R33 is to be laid down after meals on her right side. DON B indicated R33 cannot lay on her right side. Surveyor read to DON B R33's care plan: After each meal, lay the resident down in bed on her right side. Ensure appropriate support to head, neck, and back for positioning. ADON F indicated yes, it is care planned to lay R33 on her right side. Surveyor asked DON B what his expectation is for R33 to be positioned in bed. DON B indicated staff are to prop a pillow under left side to bring tension off neck to help align R33's neck and back. Surveyor informed DON B and ADON F R33 is lying flat on her back now with no pillow and the CNAs are not aware of the care plan indicating R33 is to lay on her right side. Surveyor asked ADON F and DON B if R33 is to have blue hand splints placed at all times. ADON F indicated wash clothes were put into place this past fall. ADON F indicated she changed the blue hand splints to wash clothes after speaking with therapy due to the rough edges on the splints. The splints were leaving redness to R33's palms. Surveyor indicated to ADON F and DON B that Surveyor interviewed DR G and she informed Surveyor the recommendation in the computer was for bilateral hand splints. Surveyor read R33's care plan to ADON F and DON B, The resident wears blue hand/digit splint to the right hand only at all times except for mealtimes, and At night, the resident is to wear bilateral elbow splints. During the day, the resident is to wear bilateral hand splints. Off at meals . Surveyor pointed out the care plan shows two different interventions regarding hand splints. ADON F indicated she did not change it on the care plan to reflect to use wash clothes to bilateral hands and should have. Surveyor informed ADON F and DON B of observations of R33 without hand splints/wash clothes and the cervical neck pillow not placed on R33. Surveyor asked ADON F and DON B if they would expect care plans and therapy recommendations to be followed. ADON F indicated yes. DON B indicated his expectation is for care plans to be updated right away with any changes and followed. ADON F indicated she will update the care plan for R33 right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (R6) reviewed for catheter care.Staff failed to perform proper hand hygiene with R6's catheter care. Staff did not perform hand hygiene in between removing soiled dressing, cleansing catheter site, and applying new dressing. Evidenced by:The facility policy entitled Hand Hygiene, dated 2023, states, in part: . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.Policy Explanation and Compliance Guidelines:1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.-Before and after handling clean or soiled dressings, linens, etc.-After handling items potentially contaminated with blood, body fluids, secretions, or excretions-When, during resident care, moving from a contaminated body site to a clean body site. R6 admitted to the facility on [DATE] and has diagnoses that include neuromuscular dysfunction of the bladder (occurs when nerve damage from conditions like spinal cord injury, multiple sclerosis, or diabetes disrupts brain-bladder communication).R6's Minimum Data Set (MDS) assessment, dated 12/4/25, shows that R6 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R6 is cognitively intact.R6's Care Plan states, in part: . Focus: The resident has an altercation in elimination related to Neurogenic bladder with placement of supra pubic catheter and history of UTI (urinary tract infection). Date Initiated: 6/08/2016 Revision on 2/02/2022.Goal: .*The resident will be/remain free from catheter-related issues through review date. Date Initiated: 6/08/2016. Revision on: 9/26/2025. Target Date: 5/28/2026.Interventions: .*Resident has a 20 French catheter with a 5 cc (cubic centimeter) balloon. Date Initiated: 9/10/2025.*Resident has a suprapubic catheter dressing change to the catheter site daily and as needed, monitor for infection. Date Initiated: 8/17/2016. Revision on: 3/31/2025.On 3/4/26 at 9:09 AM, Surveyor observed CNA C (Certified Nursing Assistant) perform catheter care on R6. CNA C removed the soiled drain sponge dressing around the suprapubic catheter site, cleansed the suprapubic catheter site and the catheter. CNA C proceeded to place new drain sponge dressing around the catheter without performing hand hygiene.On 3/4/26 at 9:23 AM, Surveyor interviewed CNA C and asked when hand hygiene should be performed with catheter care. CNA C indicated before and after the procedure. Surveyor asked if hand hygiene should be performed from going from dirty to clean. CNA C indicated yes. Surveyor asked CNA C if hand hygiene should have been performed before a new dressing was applied. CNA C indicated hand hygiene should have been performed after removing soiled dressing and cleansing catheter site and before applying new dressing to site. On 3/4/26 at 10:20 AM, Surveyor interviewed DON B (Director of Nursing) and asked if he would expect hand hygiene to be performed with change of gloves. DON B indicated he would expect hand hygiene to be performed prior to starting a procedure, going from dirty to clean and with dressing changes.

Based on record review and staff interview, the facility did not post the actual hours for licensed and unlicensed staff scheduled and did not update the postings in real time on the daily nurse staffing postings during the months of February and March 2026. This has the potential to affect all 40 residents in the facility.The facility's Nursing Staff postings were not updated and do not reflect actual hours worked and were not updated in real time to reflect any admission, discharges or staff call ins or additions.Evidenced by:Division of Quality Assurance (DQA) memo 12-020 titled Clarification Concerning Posting Requirements for Nurse Staffing documents: Required Staffing Information .Nursing homes must post information about the number of staff directly responsible for resident care on each shift. This information must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift .The information that is posted must include the following .1. Facility name.2. The current date.3. The total number of staff directly responsible for resident care per shift for each of the following categories: licensed (RNs (Registered Nurse), LPNs (Licensed Practical Nurse)), and unlicensed (CNAs (Certified Nursing Assistant)). (For example, 1 RN, 2 LPNs, and 4.5 CNAs.) The number of RNs must be separate from the number of LPNs. 4. The actual hours worked per shift for each of the following categories: licensed (RNs, LPNs), and unlicensed (CNAs).5. Resident census. Timing: Information is to be posted daily and must be present at the start of each shift. Nursing homes can choose to post staffing information for the entire day or for the current shift. Nursing homes are required to update the posted staffing if any changes arise, for example, if a nursing assistant calls in sick or goes home sick and is not replaced.The facility posts individual forms of the daily Nursing Staff sheet. Surveyor reviewed the facility's Nursing Staff and the facility's Staff Schedules for February 15th thru March 2nd, 2026, noting the following discrepancies: Staff posting do not include the actual hour staff worked and are not updated when staffing changes occur.On 3/5/26 at 9:19 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing). Surveyor asked NHA A and DON B to explain the process for completing the daily census postings for staff. DON B stated, The postings are completed on night shift. They night shift nurses look at the schedule and complete the census postings. Surveyor asked if the Nurse Staff postings should be updated to reflect any changes related to staff call-in's and total the actual hours worked as they occur, NHA A stated, I was aware it needed to include the hours worked but did not notice it was not there. DON B stated, I was not aware, no one has ever said anything. I have been completing them the same way for the last six years. I did not know that the posting needed to contain the total hours.The facility's Nursing Staff posting do not reflect actual staffing hours and are not updated with changes and should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:15Number of residents cited:1 o2 for hospiceBased on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 2 resident (R1) reviewed for hospice.R1's current hospice plan of care was not available to facility staff.This is evidenced by: The facility's Coordination of Hospice Services policy, reviewed/revised 1/2/26, states, in part: .3. The plan of care will identify the care and services that each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care. The hospice provider retains primary responsibility for the provision of hospice care and services that are necessary for the care of the resident's terminal illness and related conditions. The facility retains primary responsibility for implementing those aspects of care that are not related to the duties of hospice. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, acute monoblastic/monocytic leukemia not having achieved remission (cancer), anemia (low red blood cells), dysphagia (difficulty swallowing), facial weakness following cerebral infarction (stroke), hemiplegia (severe or total paralysis of one side of the body) and hemiparesis (weakness or partial paralysis of one side of the body).On 1/23/26 R1 was enrolled in hospice services.The facility did not have a record of R1's hospice plan of care. Upon Surveyor's request for the information, the facility contacted hospice to request this documentation.On 3/4/26 at 2:10 PM, Surveyor spoke with RN D (Registered Nurse). Surveyor asked RN D where the facility keeps R1's hospice plan of care. RN D stated it is in a hospice binder at the nurses' station. Surveyor and RN D observed the hospice binders at the nurses. Both Surveyor and RN D observed that neither binder contained R1's hospice plan of care. RN D notified Hospice RN E who was in the facility at the time.On 3/4/26 at 2:15 PM, Surveyor spoke with Hospice RN E (Registered Nurse). Surveyor asked Hospice RN E what the process is when a resident enrolls in hospice care. Hospice RN E stated that the hospice plan of care gets faxed to the facility. Surveyor asked RN E, should the facility have R1's hospice plan of care available for staff. RN E stated, yes. On 3/4/26 at 2:40 PM, Surveyor spoke with NHA A (Nursing Home Administrator) and DON B (Director of Nursing). Surveyor asked DON B if the facility should have R1's hospice plan of care in the facility and available to staff. DON B stated, yes. DON B stated the hospice plan of care is usually scanned under the miscellaneous tab in the electronic health record. Surveyor observed R1's hospice plan of care is not scanned under miscellaneous or elsewhere in R1's electronic health or hard chart. Surveyor asked DON B if there is a designated staff member to coordinate the plan of care with the hospice provider and ensure documentation is received and available to facility staff. DON B stated yes, ADON F (Assistant Director of Nursing) is responsible.On 3/5/26 at approximately 12:25 PM, Surveyor spoke with ADON F (Assistant Director of Nursing). Surveyor asked ADON F if she is the designated staff member to coordinate the plan of care with the hospice provider. ADON F stated, she tries to be the point person; if there are issues she emails Hospice RN E who gets back to her immediately if there's something the facility needs. ADON F stated, hospice will usually fax 10,000 sheets of paper and medical records will scan the documents into the electronic health record. ADON F stated, she works on the facility plan of care and assists the MDS (Minimum Data Set) Nurse. Surveyor asked ADON F if she follows up to ensure the hospice plan of care is received from hospice and made available to facility staff. ADON F stated, I don't have an answer, if it's an order it comes to me. ADON F stated, she does not confirm that the facility has received the hospice plan of care. ADON F stated, she reaches out to hospice for issues or supplies.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect the facility census of 35.
A kitchenette dishwasher was not registering the correct wash and rinse temperatures.
Facility staff were observed touching multiple items in the kitchenette while serving and handling food without performing proper hand hygiene.
Evidenced by:
The 2022 FDA (Food and Drug Administration) Food Code states under 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature and 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures state that wash temperatures of a high temperature sanitizing dishwasher must reach 160 degrees Fahrenheit, and the rinse temperature must reach 180 degrees Fahrenheit.
The facility's policy titled, High Temperature Dish Machine Temperature Testing states that dietary staff will test high temperature dish machines to ensure the thermostat/machine is reaching the correct temperature. The procedure for this is as follows:
1) Using proper dishwasher temperature test strips test the inside temperature of each unit once weekly.
2) Follow test strips printed instructions on how to properly test the cycles temperature.
3) Tape test strip to temp log to keep for documentation.
4) If the dishwasher is not getting to the proper temperature and fails testing, notify dietary manager and maintenance and write a work order
Facility policy, titled Hand Hygiene, dated 9/20/23 with revision date of 8/14/24, states in part: . Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
Example 1
The facility has a kitchenette on the first floor and second floor. Each kitchenette has its own high temperature dishwasher where temperatures are documented by dietary staff 3 times daily from the dishwasher's digital interface. The log for this documentation states that wash temperatures must reach 160 degrees Fahrenheit and rinse temperatures must reach 180 degrees Fahrenheit. Additionally, these dishwashers are tested weekly using a temperature test strip. This test strip has a visible black line on the strip, which is to turn orange when the test strip reaches the appropriate rinse temperature of 180 degrees Fahrenheit.
On 11/26/24 at 10:48 AM, Surveyor observed the facility's 1st floor dishwasher log with documented temperatures for the month of November 2024. The log indicated that on 13 occasions the dishwasher did not meet the necessary 160-degree wash temperature. Additionally, there was 3 temperature test strips affixed to the log, 2 of which still had visible black lines on them, indicating that on 11/6/24 and 11/12/24 the dishwasher did not reach the appropriate rinse temperature of 180 degrees.
On 11/27/24 at 10:45 AM, Surveyor interviewed DM J (Dietary Manager) who stated that if dietary staff had gathered temperatures either from the external digital readout or the internal temperature from the test strip and did not get the right temperature, she would expect them to contact her. DM J stated that she would then contact the technical representative for the dishwasher manufacturer as it is leased through them. DM J stated that she had not received any information, either from her dietary staff or from maintenance, that any issues had occurred with the temperature of the dishwasher on the first floor. DM J stated that she was told by technical representative that the wash temperature does not matter as the sanitizer (high temp) is what matters. When presented the test strips that were affixed to the November 2024 temperature log, DM J indicated that it did not look like the dishwasher was meeting the appropriate rinse temperature. DM J stated that she does follow the FDA (Food and Drug Administration) food code.
On 11/27/24 at 11:10 AM, Surveyor interviewed TR I (Technical Representative), who represents the manufacturer of the dishwasher on the first floor of the facility and coordinates with the facility to provide any technical service or maintenance to the machine. TR I stated that the dishwasher must always reach a temperature of 160 degrees Fahrenheit and if it does not, the machine must be serviced. Additionally, TR I stated that the facility was currently using the wrong test strips for the dishwasher, which is why they only sporadically turn the correct color (indicating the rinse temperature of 180 degrees Fahrenheit).
Example 2
On 11/25/24 at 12:13 PM, Surveyor observed dining room service on the 2nd floor of the facility. Surveyor observed [NAME] K serve food at the steam table, step away from the steam table and change gloves before touching ready to eat food, but without performing proper hand hygiene between glove changes. [NAME] K continued to serve food, stepped away from the steam table, removed gloves, and used the wall phone to call down to the kitchen for a hot dog for a resident. [NAME] K put on new gloves after touching the phone with bare hands and without performing proper hand hygiene and before putting on new gloves. Surveyor observed [NAME] K touch other surfaces in the kitchen, such as the cabinet door, refrigerator door, toaster lever, all with gloved hands then return to serving food and touching ready to eat items.
On 11/25/24 at 12:36 PM, Surveyor interviewed [NAME] K. Surveyor asked [NAME] K when it is necessary to change gloves and perform hand hygiene during meal service. [NAME] K replied hand hygiene should be performed before and after meal service and if necessary, such as something gets on the glove, or it breaks. Surveyor asked [NAME] K if hand hygiene should be performed after removing soiled gloves. [NAME] K replied yes but if she stays within her station in the kitchenette, she can change gloves without washing her hands. [NAME] K indicated that she only needs to wash her hands if she leaves the kitchenette or if she touchs uncooked food. Surveyor asked [NAME] K how often the surfaces in the kitchenette were sanitized. [NAME] K replied that the resident tables are wiped down after each meal but that the doors, cupboards, et cetera in the kitchenette were only cleaned once per week.
On 11/27/24 at 10:06 AM, Surveyor interviewed DM J (Dietary Manager). Surveyor asked DM J what her expectation was for hand hygiene in the dining room. DM J replied staff are to wash their hands before they start serving. Surveyor asked DM J what her expectation was for wearing gloves during meal service. DM J replied that she prefers that staff not wear gloves during meal service so that they don't get confused when touching everything. Surveyor asked DM J if it was appropriate for staff to remove gloves, make a telephone call, put on new gloves and resume meal service without performing hand hygiene. DM J replied no, staff should be washing their hands in between glove changes. Surveyor asked DM J if it was her expectation that staff change gloves and perform hand hygiene when changing tasks such as touching multiple services during meal service. DM J answered yes, that was her expectation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all alleged allegations of abuse were thoroughly investigated for 1 of 1 resident (R19) reviewed for abuse.
On 10/28/24, the facility became aware R19 reported an allegation of verbal/mental abuse by a Certified Nursing Assistant (CNA); the facility did not conduct a thorough investigation.
Evidenced by:
Facility policy titled Reporting Resident Abuse, Neglect, and Exploitation, dated 9/17/2007, with last revision date of 9/12/2024, states, in part: .All allegations of resident/client physical, mental or sexual abuse, neglect, mistreatment . are to be reported to one's supervisor immediately . Incidents will be reported to the Administrator and licensing agency as required. A full investigation will follow and be completed within 5 working days . Definitions: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Mental Abuse: Humiliation, harassment, threats . The Administrator or Director of Social Services or Director of Nursing or supervisor will immediately initiate a thorough investigation meeting with the Investigative Committee in whole or part. All allegations of mistreatment, misappropriation, neglect, or abuse . that involve a NH (Nursing Home) resident will be immediately reported to the Administrator and Bureau of Quality Assurance not to exceed 24 hours of the discovery of the incident . The Investigative Committee will determine the proper course of action to ensure residents/clients are protected. This may include the following . Determine all persons with knowledge of the allegation and complete interviews with such persons .
R19 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/7/24, indicates R19 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R19 is cognitively intact.
On 10/28/24, the facility became aware of an allegation of abuse between a CNA E and R19 that happened on 10/26/24. The facility began an investigation on 10/28/24 and collected a statement from the charge nurse, but did not interview residents or other staff members, including CNA E, whom the allegation was against. The statement from the charge nurse, RN L (Registered Nurse), stated in part: .(R19) was visibly upset when I went to her room . She said she did not want 'that CNA' in her room ever again due to (CNA E) calling her 'bossy' and what sounded like a dismissive attitude towards her requests . A Grievance Form completed by LPN G (Licensed Practical Nurse) stated in part: Resident stated (CNA E) was rude and unfair to resident. CNA E stated I'm the caregiver and I will do things my way!
On 11/25/24 at 10:58 AM, during an interview, R19 indicated that on Saturday morning, 10/26/24, a staff member was rude and demeaning to her, yelled at her, and was rough with her during AM (morning cares). R19 stated CNA E told her she was too damned bossy and that she was the caretaker and would be doing things her way regardless of R19's preferences. R19 indicated she told CNA E that she needed to have lotion on her legs prior to donning compression stockings, however CNA E put R19's stockings on without lotion and was rough while putting them on. R19 stated she was treated like a dog, or worse than a dog, treated like dirt, because she wouldn't treat a dog that way.
On 11/27/24 at 8:23 AM, Surveyor interviewed CSW H (Certified Social Worker) about the incident between CNA E and R19. CSW H stated she was notified of the incident on 10/28/24. CSW H said it was her understanding that CNA E had been demanding, disrespectful, and unprofessional. CSW H indicated that normally she follows up with the residents on grievances, but because it involved a staff member, DON B (Director of Nursing) completed the follow up with R19. CSW H stated she did not consider the situation abuse, but rather treated it as a grievance.
On 11/27/24 at 10:40 AM, Surveyor interviewed DON B, who stated he was aware of the incident between CNA E and R19. DON B indicated that CNA E is not always professional with the residents, and that he has been coaching her on her approach. DON B stated that on 10/28/24 he had taken CNA E to R19's room, where CNA E apologized to and hugged R19. At that time, R19 stated she did not want any further help from CNA E. Surveyor asked DON B if he was aware that CNA E served R19 her dinner tray the previous evening. DON B replied that he had been aware of that, and he had CSW H follow up with R19. DON B stated he did not feel the incident rose to the level of abuse. Surveyor asked DON B if he had done a thorough investigation and collected other resident statements. DON B replied that he did not because he treated it as a grievance.
The facility did not follow their policy to complete a thorough investigation, as no other residents were interviewed to identify any further abuse by CNA E. The facility failed to protect the residents, as CNA E continued to work 9 of the 10 days following the incident. At no time was CNA E removed from caring for residents.
Cross Reference F600, F609.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature for 1 of 12 sampled residents (R19) and 2 supplemental residents (R34 and R29).
R19, R29, and R34 voiced concerns of food being dry and cold.
1 of 1 test trays were noted to have dry pork served.
Evidenced by:
The facility policy, titled Dining Room Service, dated 2019, states in part: . Meals will be served promptly to maintain adequate temperature and appearance .
Example 1
R19 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an ARD (Assessment Reference Date) of 11/7/24, indicates her cognition is intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15.
On 11/25/24 at 10:58 AM, Surveyor interviewed R19 who indicated the food is so dry, particularly the pork, that at times it is inedible.
Example 2
R29 admitted to the facility on [DATE]. Her most recent MDS with an ARD of 11/7/24 indicates her cognition is intact with a BIMS score of 15 out of 15.
On 11/25/24 at 11:30 AM, Surveyor interviewed R29 who indicated that the meat is always so dry that oftentimes her and the other residents just don't eat it. R29 stated she seldom eats any of the meat at the facility, and that she hasn't had a decent pork chop since admitting to the facility 2 years ago.
Example 3
R34 admitted to the facility on [DATE]. Her most recent MDS with an ARD date of 9/16/24 indicates her cognition is intact with a BIMS score of 15 out of 15.
On 11/25/24 at 2:01 PM, Surveyor interviewed R34 who indicated that the food served to her in her room is only lukewarm. R34 said she oftentimes will have to send the soup back for reheating because it is never hot.
Example 4
On 11/26/24 at 12:10 PM, Surveyor received a test tray and noted that the pork was hard and dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 6 residents (R4) observed during medication pass.
R4 was observed to have her medications left at bedside.
This is evidenced by:
The facility policy entitled Resident Self-Administration of Medication, with a date reviewed 11/26/24, states, in part: .
Policy: It is the policy of this facility to support each resident's right to self-administration medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.
Policy Explanation and Compliance Guidelines:
1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team.
2. Resident's preference will be documented on the appropriate form and placed in the medical record .
4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record .
14. The care plan must reflect resident self-administration and storage arrangements for such medications and CGM devices .
The facility policy entitled Medication Administration, dated 7/15/24, states, in part: .
Policy: Medications will be administered by RNs (registered nurses), LPNs (licensed practical nurse) .
Policy Explanation and Compliance Guidelines:
.15. Observe resident consumption of medication .
R4 was admitted to the facility on [DATE], and has diagnoses that include Hemiplegia (a condition that causes paralysis or weakness on one side of the body, usually due to a brain injury or other brain-related issue) and Hemiparesis (partial paralysis or weakness on one side of the body) following unspecified Cerebrovascular Disease (a term for a group of conditions that impact the brain's blood vessel and blood supply, including stroke, brain aneurysms, and transient ischemic attacks, or mini strokes) affecting right dominant side, and major depressive disorder.
R4's most recent Minimum Data Set (MDS) dated [DATE] states that R4 has a Brief Interview of Mental Status (BIMS) score of 15/15, indicating that R4 is cognitively intact.
R4's Medication Self-Administration Safety Screen, dated 9/18/24, states, in part:
. Approvals: IDTC (Interdisciplinary Team)
1a. IDTC Review Summary (safety concerns/recommendations, communication to physician): All medications are stored and administered by licensed nursing staff.
1b. IDTC feels resident is safe to self-administer listed medications? No .
On 11/25/24, at 4:12 PM, Surveyor observed RN C (Registered Nurse) leave R4's medications: Tylenol 325mg (milligrams) 2 tablets, atorvastatin 80 mg 1 caplet, baclofen 20 mg 1 tablet, carvedilol 3.125 mg 3 tablets, and mucus relief 400 mg 1 tablet on R4's bedside table.
On 11/26/24, at 8:26 AM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D what the process is for leaving a resident's medications at bedside. LPN D indicated the resident would have to have completed a medication self-administration evaluation and deemed safe. LPN D indicated the evaluation would be in the resident's chart. LPN D indicated there are no residents on this floor that can have medications left at bedside. LPN D indicated R4 always wants staff to dump medications on bedside table and leave them, but staff are not to leave them.
On 11/26/24, at 4:22PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked what the process is for a resident to have medications left at bedside. DON B indicated the resident should have a care plan for medication self-administration. DON B looked at R4's Care Plan and indicated R4 is not care planned for medication self-administration. DON B indicated if R4 was care planned for it we would have a medication self-administration evaluation assessment. Surveyor informed DON B of observation on 11/25/24 with R4's medications being left on bedside table and the nurse leaving R4's room without observing R4 take the medications. Surveyor informed DON B of R4's medication self-administration assessment dated [DATE] and results of R4 deemed unsafe to self-administrate medications. Surveyor asked DON B by looking at R4's assessment would you expect medications to be left at bedside, DON B indicated by looking at what is on the assessment, no but looking at R4 as we know her would be different.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect 1 of 35 residents (R19's) right to be free from verbal/mental/emotional abuse by a CNA (Certified Nursing Assistant).
R19 stated CNA E was rude and demeaning to her, yelled at her, and was rough with her during AM (morning cares). R19 stated she was treated like a dog, or worse than a dog, treated like dirt, because she wouldn't treat a dog that way.
Evidenced by:
Facility policy titled Reporting Resident Abuse, Neglect, and Exploitation, dated 9/17/2007, with last revision date of 9/12/2024, states in part: .All allegations of resident/client physical, mental or sexual abuse, neglect, mistreatment . are to be reported to one's supervisor immediately . Incidents will be reported to the Administrator and licensing agency as required . Definitions: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Mental Abuse: Humiliation, harassment, threats . If there is an allegation or belief that a resident/client has/or could be harmed, staff shall immediately take action to ensure the resident/clients are free from physical and emotional harm. Staff shall immediately notify their supervisor of the allegation when sure resident/client is safe. The Supervisor will take the following actions as appropriate to situation . Provide protection from the alleged abuser .
According to the State Operations Manual (SOM), abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.
Willful, as defined at §483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.
Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.
Examples of mental and verbal abuse include, but are not limited to:
o
Harassing a resident;
o
Mocking, insulting, ridiculing;
o
Yelling or hovering over a resident, with the intent to intimidate;
o
Threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends; and
o
Isolating a resident from social interaction or activities.
R19 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/7/24, indicates R19 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R19 is cognitively intact.
On 11/25/24 at 10:58 AM, during an interview, R19 indicated that on Saturday morning, 10/26/24, a staff member, CNA E, was rude and demeaning to her, yelled at her, and was rough with her during AM cares. R19 stated at about 20 minutes after 7:00 AM, CNA E came into her room and told her, I'm your caretaker and I do things my way! CNA E began to put R19's compression stockings on, and R19 asked CNA E to apply lotion first. CNA E told R19 she was too damned bossy and left the room. About 10 minutes later CNA E came back into R19's room and put R19's compression stockings on without lotion. R19 said that it was a good thing she had been sitting on the toilet at the time, because CNA E was so rough she would have fallen backwards. At that time, CNA E left R19's room. R19 stated she waited another 20 minutes for CNA E to come back and assist her, but she did not come back so R19 finished getting herself dressed. R19 stated she was treated like a dog, or worse than a dog, treated like dirt, because she wouldn't treat a dog that way.
Please note: CNA E left R19's room and came back into R19's room several times. At no time did CNA E change her tone or approach with R19; CNA E was rude and dismissive of R19 each time.
On 11/26/24 at 9:58 AM, Surveyor interviewed CNA F, who said she knew about the situation between CNA E and R19. CNA F indicated that she would consider the way CNA E treated R19 as abuse. CNA F stated that R19 was very hurt by the interaction and that if R19 sees CNA E working, she becomes really upset for the rest of the day. CNA F stated that CNA E is also not professional or appropriate in her interactions with other residents.
On 11/26/24 at 10:23 AM, Surveyor interviewed LPN G (Licensed Practical Nurse), who stated she was aware of the situation that occurred between CNA E and R19. LPN G indicated that CNA E is aware of her anger and that this was an isolated incident. LPN G stated that CNA E had tried to apologize to R19, but she didn't think R19 accepted her apology.
On 11/27/24 at 8:23 AM, Surveyor interviewed CSW H (Certified Social Worker) about the incident between CNA E and R19. CSW H stated she was notified of the incident on 10/28/24. CSW H said it was her understanding that CNA E had been demanding, disrespectful, and unprofessional. CSW H indicated that normally she follows up with the residents on grievances, but because it involved a staff member, DON B (Director of Nursing) completed the follow up with R19. CSW H stated she did not consider the situation abuse, but rather treated it as a grievance.
On 11/27/24 at 10:19 AM, Surveyor spoke with R19 who stated that the previous day (on 11/26/24), CNA E served her dinner tray to her, even though she has requested that CNA E not have any further interaction with her. R19 stated she was really upset by this, and that she doesn't feel safe when CNA E is working.
Please note: Despite over a month of time passing between the incident on 10/24/24 and Surveyor interviewing R19 on 11/27/24, R19 continued to be affected by the interaction between R19 and CNA E. R19 reported CNA E delivering her tray caused her to feel fearful and upset.
On 11/27/24 at 10:40 AM, Surveyor interviewed DON B (Director of Nursing), who stated he was aware of the incident between CNA E and R19. DON B indicated that CNA E is not always professional with the residents, and that he has been coaching her on her approach. DON B stated that on 10/28/24, he had taken CNA E to R19's room, where CNA E apologized to and hugged R19. At that time, R19 stated she did not want any further help from CNA E. Surveyor asked DON B if he was aware that CNA E served R19 her dinner tray the previous evening. DON B replied that he had been aware of that, and he had CSW H follow up with R19. Surveyor asked DON B if this could be considered intimidation. DON B stated it was not willful, it was just a personality conflict between CNA E and R19. Surveyor asked DON B if he had followed up with R19 regarding her psychosocial well-being. DON B replied that after R19 accepted a hug and apology from CNA E, he thought the grievance was done and the solution was satisfactory. Surveyor asked DON B if he had protected the other residents from potential abuse. DON B stated it was not considered abuse, but a grievance.
The facility did not follow their policy to keep residents safe following an abuse allegation. The facility failed to protect R19 from ongoing mental anguish, as CNA E continued to work 9 of the 10 days following the incident and was continuing to interact with R19 at the time of the recertification survey.
Cross Reference F609, F610.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 1 abuse allegations of residents (R19).
R19 reported an abuse allegation involving CNA E (Certified Nursing Assistant) that occurred on 10/26/24. This incident was reported to NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CSW H (Certified Social Worker), but was not reported to the state agency.
Evidenced by:
Facility policy titled Reporting Resident Abuse, Neglect, and Exploitation, dated 9/17/2007, with last revision date of 9/12/2024, states, in part: .All allegations of resident/client physical, mental or sexual abuse, neglect, mistreatment . are to be reported to one's supervisor immediately . Incidents will be reported to the Administrator and licensing agency as required . Definitions: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Mental Abuse: Humiliation, harassment, threats .
R19 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/7/24, indicates R19 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R19 is cognitively intact.
On 11/25/24 at 10:58 AM, during an interview, R19 indicated that on Saturday morning, 10/26/24, a staff member was rude and demeaning to her, yelled at her, and was rough with her during AM (morning cares). R19 stated CNA E told her she was too damned bossy and that she was the caretaker and would be doing things her way regardless of R19's preferences. R19 indicated she told CNA E that she needed to have lotion on her legs prior to donning (putting on) compression stockings, however CNA E put R19's stockings on without lotion and was rough while putting them on. R19 stated she was treated like a dog, or worse than a dog, treated like dirt, because she wouldn't treat a dog that way.
Surveyor reviewed the Facility Grievance Log for October 2024 which indicated a grievance dated 10/28/24, Resident shared that CNA E that was providing care to R19 was disrespectful. Resident felt she was not heard by the CNA, and she was rude. Facility Grievance Log states this grievance was assigned to CSW H, and the resolution indicated in part: Spoke with resident, Administrator, and DON. CNA will not be providing care to resident. Education also provided to nursing staff regarding respect and approach.
Please note: The facility provided Surveyor with grievance forms, one completed by CSW H and another completed by LPN G (Licensed Practical Nurse), both indicate the date of the occurrence as 10/26/24, however nothing was addressed until 10/28/24.
On 11/27/24 at 8:23 AM, Surveyor interviewed CSW H about the incident between CNA E and R19. CSW H stated she was notified of the incident on 10/28/24. CSW H said it was her understanding that CNA E had been demanding, disrespectful, and unprofessional. CSW H indicated that normally she follows up with the residents on grievances, but because it involved a staff member, DON B (Director of Nursing) completed the follow up with R19. CSW H stated it was her opinion that the situation was not reportable because it was simply a personality conflict between CNA E and R19. CSW H stated she did not consider the situation abuse, but rather treated it as a grievance.
Please note: The Facility Grievance Officer (CSW H) did not follow up with R19 about the incident until 11/13/24 at a regularly scheduled Care Conference which was not attended by the DON B or NHA A. Facility Progress Notes indicate in attendance for the Care Conference with R19 was CSW H and the MDS Coordinator (Minimum Data Set). The Psychosocial Note entered by CSW H on 11/13/24 states in part: .Resident expressed concerns with a staff . writer along with MDS Coordinator let resident express her feelings .
On 11/27/24 at 10:40 AM, Surveyor interviewed DON B, who stated he was aware of the incident between CNA E and R19. DON B indicated that CNA E is not always professional with the residents, and that he has been coaching her on her approach. DON B stated that on 10/28/24 he had taken CNA E to R19's room, where CNA E apologized to and hugged R19. At that time, R19 stated she did not want any further help from CNA E. Surveyor asked DON B if he was aware that CNA E served R19 her dinner tray the previous evening. DON B replied that he had been aware of that, and he had CSW H follow up with R19. DON B stated he did not feel the incident rose to the level of abuse, as R19 simply didn't like CNA E's tone, and therefore it was handled as a grievance.
The facility considered this a grievance instead of an abuse allegation, therefore, they did not follow their policy and did not report this accusation of abuse to the state reporting agencies.
Cross Reference F600, F610.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that all alleged violations involving abuse are thoroughly investigated and that resident(s) are protected during the investigation in accordance with State law through established procedures in 1 of 1 alleged abuse investigations involving (R1 and R2) of a total sample of 3 residents reviewed.
R2 was observed by facility staff to be touching R1's left breast on 2 occasions and had his hand up R1's pant leg on another occasion. The facility failed to separate the residents, perform an assessment on R1, monitor both residents when they were together, ensure R1's safety, and complete a full investigation.
Evidenced by:
The facility's policy titled Investigation of resident abuse, neglect, exploitation, misappropriation, injuries of origin, and reasonable suspicion of a crime dated 1/18/18, states in part: .Procedure: 1. When an allegation of resident abuse, neglect, exploitation, misappropriation, injury of unknown source, or reasonable suspicion of a crime is reported to the Administrator, the Administrator, Director of Nursing, and Social Services Director or their designee will immediately initiate an investigation. 2. An immediate investigation will be conducted referring the appropriate protocol for abuse, neglect, exploitation, misappropriation, injury of unknown source, or reasonable suspicion of a crime .4. Witnesses and others with knowledge of the concern will make reports in writing. Reports contain date, time, and signature. A summary of all of the reports will be compiled .
R1 was admitted to the facility on [DATE] with diagnoses that include Dementia, Major Depressive Disorder, mixed receptive-expressive language disorder (difficulty understanding and speaking language), and a history of TIAs (mini stroke).
R1's most recent Minimum Data Set (MDS) dated [DATE] states that R1 has a Brief Interview of Mental Status (BIMS) of 3 out of 15, indicating that R1 has severe cognitive impairment. R1's MDS also indicates that she ambulates with a walker with supervision of 1 staff member.
R1 has a guardian that makes decisions for her due to her severe cognitive impairment.
R2 was admitted to the facility on [DATE], with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction (stroke), adjustment disorder with depressed mood, heart failure, and left below knee amputation.
R2's most recent MDS (Minimum Data Set) dated 6/15/23 states that R2 has a BIMS of 11 out of 15, indicating that R1 has moderately impaired cognition. R2's MDS indicates that he requires extensive assistance from 1 staff member for transferring but can self-propel in his wheelchair, as observed by Surveyors.
On 7/10/23, at approx. 2:05 PM a CNA D (Certified Nursing Assistant) observed R1 and R2 sitting outside, R2 had his hand under R1's shirt and on her breast. As the CNA approached, R2 removed his hand, the CNA asked what he was doing and R2 stated he was enjoying the day. The CNA went into the facility and reported the incident to the PM shift CNAs and then left the facility.
The facility obtained a written statement from CNA D stating: On July 10, 2023, at about 2:05 pm, I was leaving the building after my shift. When I got to the outside sliding doors, I saw R2 cupping the underneath left breast of R1 under the shirt. I said R2 what are you doing? he said, just enjoying the day. I went and told (CNA Name) quick what was happening, and she reported it to the nurse. Then when I went to leave again after telling (CNA Name), I saw him touch her left breast through from the outside of her shirt. He stopped as soon as he saw me both times.
It is important to note that CNA D's statement does not have a date or time that it was written, nor does it contain the CNA's signature. Additionally, the facility did not interview or obtain statements from the afternoon (PM) shift CNAs that this incident was reported to, or the nurse that was working at that time. The facility did not interview or gather statements from any other staff.
On 7/17/23 at 3:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A what their process was for investigating allegations of abuse, NHA A stated that it should be reported to the nurse, then to the Social Worker or DON, and then to herself. Surveyor asked NHA A if she interviewed other staff when she was investigating this incident, NHA A reported that they obtained a statement from the CNA that witnessed the incident and spoke with the med tech but did not interview other staff. NHA A stated that they provided education to all staff but did not interview them. Surveyor asked NHA A if she was aware of a third incident that occurred the same day, NHA A stated no. Surveyor told NHA A that a staff member reported to Surveyors that he told the med tech that he observed R2 with his hand up R1's pant leg, NHA A stated that staff did not report that to them and that she would investigate it. Surveyor asked NHA A if they performed skin checks on non interviewable residents, NHA A stated that she didn't even think to do that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents (R) were free from sexual abuse by a resident (R2). R2 had been observed touching R1 in an inappropriate manner.
On 7/10/23, R2 was observed by facility staff to be touching R1's left breast on 2 occasions and had his hand up R1's pant leg on another occasion. The facility failed to separate the residents, perform an assessment on R1, monitor both residents when they were together, and ensure R1's safety. The facility failed to prevent sexual abuse to a non-consenting female resident. The facility failed to protect the female resident after sexual incident occurred, failed to complete a thorough investigation, failed to complete skin checks on non-verbal/non-interviewable residents, and failed to provide adequate supervision to prevent potential reoccurrence.
Evidenced by:
The facility's policy titled Resident/ Client Physical, Mental, or Sexual Abuse, Neglect, or Misappropriation revised on 1/3/17, states in part: Policy: All allegations of resident/ client physical, mental or sexual abuse, neglect, mistreatment, injuries of unknown origin or misappropriation of property are to be reported to ones [sic] supervisor immediately .Purpose: To ensure that each resident is safe and treated with dignity and respect. To ensure that each resident is free from all forms of abuse, neglect, misappropriation, or exploitation. Definitions: .Sexual Abuse- Non-consensual sexual contact of any type with a resident .5. Investigation, Protection, and Reporting: 1. If there is an allegation or belief that a resident/ client has/ or could be harmed, staff shall immediately take action to endure the resident/ clients are free from physical and emotional harm. Staff shall immediately notify their supervisor of the allegation when sure the resident/ client is safe. 2. The Supervisor will take the following actions as appropriate to situation: a. Provide protection from the alleged abuser. b. Check on resident to see if medical intervention is necessary (if sexual abuse do not clean up resident). c. Provide needed medical care and notify physician, if appropriate .
R1 was admitted to the facility on [DATE] with diagnoses that include Dementia, Major Depressive Disorder, mixed receptive-expressive language disorder (difficulty understanding and speaking language), and a history of TIAs (mini stroke).
R1's most recent Minimum Data Set (MDS) dated [DATE] states that R1 has a Brief Interview of Mental Status (BIMS) of 3 out of 15, indicating that R1 has severe cognitive impairment. R1's MDS also indicates that she ambulates with a walker with supervision of 1 staff member.
R1 has a guardian that makes decisions for her due to her severe cognitive impairment.
R2 was admitted to the facility on [DATE], with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction (stroke), adjustment disorder with depressed mood, heart failure, and left below knee amputation.
R2's most recent MDS dated [DATE] states that R2 has a BIMS of 11 out of 15, indicating that R1 has moderately impaired cognition. R2's MDS indicates that he requires extensive assistance from 1 staff member for transferring but can self-propel in his wheelchair, as observed by Surveyors.
R2 is his own person and decision maker.
On 7/10/23, at approximately 2:05 PM, a Certified Nursing Assistant (CNA) observed R1 and R2 sitting outside, R2 had his hand under R1's shirt and on her breast. As the CNA approached, R2 removed his hand, the CNA asked what he was doing and R2 stated he was enjoying the day. The CNA went into the facility and reported the incident to the PM shift CNAs and then left the facility. As she was leaving, she noticed that R2 had his hand on R1's breast outside of her shirt. As the CNA approached, he again moved his hand. The CNA did not report the 2nd incident to the facility.
The facility initiated an investigation and submitted a report to the State Agency.
On 7/10/23 at approximately 4:00 PM, per CNA interview two CNAs observed R2 with his hand up the inside of R1's pant leg. One of the CNAs reported the incident to the Medication Technician (Med Tech/Med Aide), who did not report the incident to the facility's NHA or Director of Nursing (DON). Of note, the NHA and DON were not aware of this 3rd incident until Surveyors reported to them.
On 7/17/23 at 1:28 PM, Surveyor interviewed CNA D, CNA D indicated on 7/10/23 at 2:05 PM CNA D walked out the sliding doors because CNA D's shift was over for the day. CNA D indicated she saw R1 and R2 outside, R2's hand was under R1's shirt and touching left breast. CNA D indicated she asked R2, What are you doing? R2 replied, Just enjoying the day . R2 then stopped touching R1's breast. CNA D indicated she immediately went inside and reported this incident to the two PM shift CNA's. CNA D indicated she then went to leave again and observed R2's hand over R1's shirt touching R1's breast. R2 moved his hand from R1's breast when he saw CNA D. CNA D indicated it was the end of her shift and she left the facility. CNA D indicated she did not separate the two residents after either of the incidents. CNA D indicated the last couple of weeks R1 and R2 seem to be in a relationship, and they sit outside and hold hands. CNA D indicated it's usually after lunch they will sit outside, hold hands, and CNA D has observed R2 with his hand on R1's leg. CNA D indicated this is common knowledge and everyone knows this. CNA D indicated she thought both residents were their own person and that it was consensual because they both were enjoying it. CNA D indicated the only reason she reported this incident is because it is not appropriate to touch someone's breast in a public setting. CNA D indicated she received education after the incident and now knows that R1 can't consent.
On 7/17/23 at 2:10 PM, CNA I indicated he was one of the staff that CNA D reported the incident to on 7/10/23. CNA, I indicated the first incident occurred at shift change at 2:00 PM. The incident was reported to MA H. CNA I indicated after the first incident staff were told to monitor both residents. CNA I indicated the two residents were not separated. CNA I indicated on 7/10/23 at 4:00 PM R1 and R2 were sitting outside unsupervised. CNA I and CNA J went outside and observed R2's hand all the way up R1's pants leg. CNA I indicated R2 had a guilty look on his face and that R1 had a blank expression on her face and appeared to not be bothered. CNA I indicated they did not separate the residents and they reported the incident to MA H. CNA J indicated to Surveyor that the above incident was accurate, and that CNA J observed the incident as well. CNA I indicated R1 was pursuing R2 just as much as R2 was pursuing R1. CNA I indicated that around 5:30-6:00 PM on 7/10/23, DON B told CNA I the two residents cannot be by each other until further notice. CNA I indicated now the two residents have no contact with each other and the dining room is set up differently, so they don't sit next to each other. CNA I indicated he thought R1's guardian gave approval and was fine with it all. CNA I indicated he has not received any education recently regarding consent/sexual abuse. CNA J indicated she has not received any education regarding this. CNA I indicated that he is not aware of R2 touching any other residents, but that he has heard of R2 saying and touching female staff inappropriately. CNA I indicated this is why when he is working, he is the one that will assist R2.
On 7/17/23 at 1:45 PM, MA H (Medical Assistant) indicated CNA J reported to her on 7/10/23 that R2 grabbed R1's breast in a public area. MA H indicated she called DON B (Director of Nursing) shortly after the incident being reported to her. MA H did not separate the two residents until DON B directed her to do so. MA H indicated shortly after the incident R2's daughter came in and sat with him. MA H indicated they now must keep the two residents separated, they cannot be in bedrooms alone together, R1 is supposed to wear a bra, and they should be checked on at least every two hours. MA H indicated that previously there were two other residents who were in a relationship and MA H thinks maybe R1 and R2 saw that and wanted to be in a relationship.
On 7/17/23 at 2:30 PM, Surveyor asked MA H if CNA I reported the incident of R2 putting his hand up R1's pants leg. MA H indicated CNA I did report this, but that MA H didn't hear anything more about it. MA H indicated it sounded like CNA I wasn't confident and that it might not have been 100% witnessed. MA H indicated CNA I reported this incident around 4:00 PM. Surveyor asked MA H if MA H reported this incident to the DON or NHA. MA H stated, No.
Based on the incident the facility implemented temporary care plans for R1 and R2. They are as follows:
R1 dated 7/10/23:
Problem: Residents potential inability to consent to sexual activity, touch.
Goal: To keep resident free from sexual activity, touch while determining residents [sic] ability to consent.
Approaches: Staff monitoring residents [sic] interactions and contacts. Resident did NOT have any unsupervised visits with male resident.
7/12/23:
Problem: Resident is deemed unable to provide consent to sexual activity or touch.
Approaches: Attempt to provide structured activities and/ or supervised visits as available and appropriate.
R2 dated 7/10/23:
Problem: Resident touched another resident in a sexual manner.
Goals: Resident will not touch another resident in a sexual manner.
Approaches: Resident will not have unsupervised interactions with female residents.
7/12/23:
Problem: Resident was unaware of specific resident did/ does not have ability to provide consent to sexual activity or touch.
Goals: Educate resident on other residents [sic]ability to consent and verbalize understanding.
Approaches: Resident was provided with education, information and was able to verbalized [sic] understanding.
It is important to note that the temporary care plans were not implemented into R1 and R2's comprehensive care plans found in their Electronic Health Record (EHR). The temporary care plans were only found with the investigation.
On 7/11/23 the facility assessed R1 using Sexuality Screen Tool. The results state, in part: .It is the teams [sic] belief that R1 is not in a position to provide consent for acts of a sexual nature.
On 7/11/23, facility staff interviewed the 14 other residents that live on the same floor as R1 and R2. The facility asked residents Do you feel safe at the facility and Has anyone ever tried to touch you in an inappropriate way. Except for 2 residents who were unable to answer, all other residents answered yes to the first question and no to the second question.
It is important to note that the resident roster provided to Surveyors indicated that only 6 residents on that unit were interviewable. The facility did not perform skin checks on the residents that were not interviewable.
On 7/12/23, the facility provided education for staff to read and sign. The education gave definitions for sexual contact, intimacy, and consent. The education did not address sexual assault or sexual abuse. The facility has 83 employees that work in the health center, not including the DON and NHA. Out of the 83 employees, only 30 staff members have signed off on reading the education.
On 7/17/23 at 8:22 AM, Surveyor observed R1 go outside. Staff did not observe R1 go outside. R1 returned to the facility at 8:26 AM.
On 7/17/23 at 8:47 AM, Surveyor observed R1 returning from being outside; facility staff was not with her.
On 7/17/23 at 9:07 AM, Surveyor interviewed CNA C. CNA C reported to Surveyor that R2 mobilizes independently in his wheelchair and that once he is up in his wheelchair, he goes outside before staff realize it, and R1 ambulates with her walker by herself and goes outside.
On 7/17/23 at 9:20 AM, CNA E (Certified Nursing Assistant) indicated if CNA E observed a resident touching another resident or any altercation between two residents CNA E would immediately report to the nurse. CNA E indicated she would report to nurse and nurse would direct what to do from there. CNA E indicated she does not believe she has received any education recently regarding this.
On 7/17/23 at 9:40 AM, Surveyor asked CNA F if there were any residents that needed frequent checks or any extra supervision. CNA F did not indicate that R1 and R2 need frequent checks or extra supervision.
On 7/17/23 at 10:48 AM, Surveyor observed R1 sitting outside on the bench, no staff members were around. Surveyor attempted to interview R1, but her answers were mostly nonsensical and gibberish. Surveyor asked R1 if any of the residents had touched her inappropriately, R1 stated not that she knew of, and then spoke in unintelligible words.
On 7/17/23 at 12:57 PM, Surveyor observed R1 and R2 sitting on the patio alone. Surveyor observed R2 reach for R1 but due to positioning, was unable to see where he reached or touched. R1 and R2 were alone on the patio for approximately 3 minutes prior to staff arriving.
On 7/17/23 at 1:00 PM, Surveyor interviewed CNA C. Surveyor asked CNA C how she was made aware that R1 and R2 were outside together, CNA C reported that she saw the residents sitting outside through the windows and so she came out to sit with them. Surveyor asked CNA C how often they check in on R1, CNA C reported that they don't document anything, but try to round on her every 15-30 minutes. CNA C also reported that R1's accutech used to help let them know when she was going outside, but she doesn't have that anymore.
On 7/17/23 at 1:00 PM, LPN G (Licensed Practical Nurse) indicated R1 and R2 are allowed intimacy like holding hands. LPN G indicated when staff see R1 and R2 together they are to monitor them to ensure no sexual contact occurs. LPN G indicated there are times that the two get together and we don't see it. LPN G indicated she is aware of the incident between the two residents. LPN G indicated, as far as I know we are watching them the best we can. LPN G indicated the facility provided education to R2 and that they are to encourage R1 to participate in activities. LPN G indicated the staff are to provide frequent checks on both residents. LPN G indicated frequent checks means every 15 minutes to a half an hour. LPN G indicated there is no documentation showing this.
On 7/17/23 at 1:11 PM, CNA C indicated R1 and R2 have been holding hands for the last couple of weeks. CNA C indicated she believes that the facility talked to the guardians regarding the relationship. CNA C indicated staff monitor the two residents the best they can and basically, they have one to one staffing with them.
On 7/17/23 at 1:48 PM, Surveyor observed R1 ambulate outside. R1 went to the edge of the parking lot and appeared to be looking for someone or something and then returned to the bench. There was no staff around watching or monitoring R1.
On 7/17/23 at 3:20 PM, Surveyor interviewed NHA A. Surveyor asked NHA A what their process was for investigating allegations of abuse, NHA A stated that it should be reported to the nurse, then to the Social Worker or DON, and then to herself. Surveyor asked NHA A if she interviewed other staff when she was investigating this incident, NHA A reported that they obtained a statement from the CNA that witnessed the incident and spoke with the med tech but did not interview other staff. NHA A stated that they provided education to all staff but did not interview them. Surveyor asked NHA A if she was aware of a third incident that occurred the same day, NHA A stated no. Surveyor told NHA A that a staff member reported to Surveyors that he told the med tech that he observed R2 with his hand up R2 pant leg, NHA A stated that staff did not report that to them and that she would investigate it. Surveyor asked NHA A if they performed skin checks on non interviewable residents, NHA A stated that she didn't even think to do that.
R1 is unable to consent to sexual contact, the facility failed to ensure R1 was free from sexual abuse when R2 touched R1 on the breast. Facility staff failed to immediately intervene and ensure R1's safety which allowed R2 to touch R1 on the breast a second time and place his hand up R1's pant leg.