Brookdale Montrose

Based on medical record review, review of shower schedules, review of staff schedules, review of call light audit reports, interviews with residents, interviews with family members, and interviews with staff, the facility failed to ensure sufficient staffing to meet residents needs. This affected three residents (#2, #4, and #11) out of five residents reviewed for staffing and had the potential to affect all residents in the facility. The facility census was 38.

Findings Include:

1. Review of the medical record revealed Resident #2 was admitted to the facility on 03/08/23. Diagnoses included Parkinson's disease, benign prostatic hyperplasia, dementia, neurocognitive disorder with Lewy bodies, hypothyroidism, insomnia, pain, heart failure, and hyperlipidemia.

Review of the Personal Service Assessment dated 03/12/24 revealed Resident #2 had some memory impairment and needed assistance with showering.

Review of the facility shower schedule revealed Resident #2 was scheduled to have a shower on day shift on Mondays and Thursdays.

Review of the Shower Task in Point Click Care (PCC)(an electronic charting system) for December 2024 revealed Resident #2 received a shower on 12/02/24, 12/03/24, 12/05/24, 12/10/24, 12/16/24, and 12/19/24. He had not received a shower on 12/23/24, 12/26/24, or 12/30/24.

Review of the facility's paper shower sheets revealed Resident #2 had a shower on 12/02/24, 12/20/24, 12/13/24 and 12/16/24.

Review of the staffing schedule on 12/23/24 revealed a Caregiver (CG) had called off and there was only one nurse and one Caregiver to assist 15 residents.

Review of the staffing schedule on 12/26/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver to assist 15 residents.

On 12/30/24 at 9:45 A.M. an interview with Caregiver #100 revealed she was not able to get her showers completed when she was the only Caregiver working the unit. She stated she was the only one working today (12/30/24) because the other Caregiver had called off. She stated there was only one Caregiver and one Nurse on the unit.

On 12/30/24 at 11:20 A.M. an interview with Licensed Practical Nurse (LPN) #101 revealed Caregivers just did not show up to work or they would get there at 8:00 A.M. to 8:30 A.M. She stated on this day, they had four Caregivers scheduled, but two called off, and another one of them started in housekeeping on this day and they never took her off the schedule. She stated most days she had to serve the residents their breakfast because they did not have enough staff. She verified showers were not being completed as scheduled.

On 12/31/24 at 8:20 A.M. an interview with CG #102 revealed she tried to get the showers completed when she was working, but it was hard with only one person. She stated there was usually three to four showers to complete per day. She stated they were not completed yesterday (12/30/24) and the residents were already asking if they were going to get them today. She stated the showers were documented on shower sheets and in PCC.

On 12/31/24 at 10:45 A.M. an interview with Family Member #300 revealed Resident #2 never received his shower yesterday (12/30/24) or all last week. She stated the staff were aware and CG #102 was the only person who made sure Resident #2 received his shower.

On 12/31/24 at 1:36 P.M. an interview with Health and Wellness Director #400 confirmed the showers for Resident #2 had not been completed.

2. Review of the medical record revealed Resident #4 was admitted to the facility on 11/10/23. Diagnoses included right breast cancer, depression, tuberculosis of the lung, and insomnia.

Review of the Personal Service Assessment dated 06/13/24 revealed Resident #4 had some memory impairment and needed assistance with showering.

Review of the facility shower schedule revealed Resident #4 was scheduled to have a shower on day shift on Mondays and Thursdays.

Review of the Shower Task in Point Click Care (PCC)(an electronic charting system) for December 2024 revealed Resident #4 received a shower on 12/03/24, 12/10/24, 12/12/24, 12/16/24, and 12/19/24 and 12/24/24. She had not received a shower on 12/26/24 or 12/30/24.

Review of the facility's paper shower sheets revealed Resident #4 had a shower on 12/06/24, 12/10/24, 12/15/24 and 12/16/24.

Review of the staffing schedule on 12/23/24 revealed a Caregiver (CG) had called off and there was only one nurse and one Caregiver working for 15 residents.

Review of the staffing schedule on 12/26/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver working for 15 residents.

On 12/30/24 at 9:45 A.M. an interview with Caregiver #100 revealed she was not able to get her showers completed when she was the only Caregiver working the unit. She stated she was the only one working today (12/30/24) because the other Caregiver had called off. She stated there was only one Caregiver and one Nurse on the unit.

On 12/30/24 at 11:20 A.M. an interview with Licensed Practical Nurse (LPN) #101 revealed Caregivers just did not show up to work or they would get there at 8:00 A.M. to 8:30 A.M. She stated on this day, they had four Caregivers scheduled, but two called off, and another one of them started in housekeeping on this day and they never took her off the schedule. She stated most days she had to serve the residents their breakfast because they did not have enough staff. She verified showers were not being completed as scheduled.

On 12/31/24 at 8:20 A.M. an interview with CG #102 revealed she tried to get the showers completed when she was working, but it was hard with only one person. She stated there was usually three to four showers to complete per day. She stated they were not completed yesterday (12/30/24) and the residents were already asking if they were going to get them today. She stated the showers were documented on shower sheets and in PCC.

Observation on 12/31/24 at 10:47 A.M. revealed Family Member #301 was standing at the nurse's station asking LPN #101 if Resident #4 was going to receive her shower because she had not received it the day before (12/30/24).

On 12/31/24 at 10:50 A.M. an interview with Family Member #301 revealed Resident #4 had not received her shower they day before on 12/30/24.

On 12/31/24 at 1:36 P.M. an interview with Health and Wellness Director #400 confirmed the showers for Resident #4 had not been completed. She stated she was previously aware that Resident #4 had not received her showers last week.

3. Review of the medical record revealed Resident #11 was admitted to the facility on 09/26/24. Diagnoses included anemia, atherosclerotic heart disease, weakness, multiple myeloma, and hypertension.

Review of the Personal Service Assessment dated 09/26/24 revealed Resident #11 had intact cognition and needed assistance with showering.

Review of the facility shower schedule revealed Resident #11 was scheduled to have a shower on the day shift on Mondays and Thursdays.

Review of the Shower Task in Point Click Care (PCC)(an electronic charting system) for December 2024 revealed Resident #11 received a shower on 12/03/24, and 12/16/24, and she refused on 12/12/24 and 12/19/24. She had not received a shower on 12/05/24, 12/23/24, 12/26/24, or 12/30/24.

Review of the facility's paper shower sheets revealed Resident #11 had a shower on 12/02/24, 12/09/24, and 12/16/24.

Review of the staffing schedule on 12/23/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver working for 15 residents.

Review of the staffing schedule on 12/26/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver working for 15 residents.

On 12/30/24 at 9:45 A.M. an interview with Caregiver #100 revealed she was not able to get her showers completed when she was the only Caregiver working the unit. She stated she was the only one working today (12/30/24) because the other Caregiver had called off. She stated there was only one Caregiver and one Nurse on the unit.

On 12/30/24 at 11:20 A.M. an interview with Licensed Practical Nurse (LPN) #101 revealed Caregivers just did not show up to work or they would get there at 8:00 A.M. to 8:30 A.M. She stated on this day, they had four Caregivers scheduled, but two called off, and another one of them started in housekeeping on this day and they never took her off the schedule. She stated most days she had to serve the residents their breakfast because they did not have enough staff. She verified showers were not being completed as scheduled.

On 12/31/24 at 8:20 A.M. an interview with CG #102 revealed she tried to get the showers completed when she was working, but it was hard with only one person. She stated there was usually three to four showers to complete per day. She stated they were not completed yesterday (12/30/24) and the residents were already asking if they were going to get them today. She stated the showers were documented on shower sheets and in PCC.

On 12/31/24 at 10:55 A.M. an interview with Resident #11 revealed she had not received her shower the day before (12/30/24). She stated she was never told why, they just never showed up. She stated she had not received a shower the week before either.

On 12/31/24 at 1:36 P.M. an interview with Health and Wellness Director #400 confirmed the showers for Resident #11 had not been completed.

4. Review of the medical record revealed Resident #2 was admitted to the facility on 03/08/23. Diagnoses included Parkinson's disease, benign prostatic hyperplasia, dementia, neurocognitive disorder with Lewy bodies, insomnia, pain, and hemorrhoids.

Review of the Personal Service Assessment dated 03/12/24 revealed Resident #2 had some memory impairment and needed assistance with dressing and toilet use.

Review of the call light audit report revealed on 12/14/24 Resident #2 turned his call light on at 8:57 A.M. and it was on for 32 minutes. He turned it on again at 9:35 A.M. and it was on for one hour and 25 minutes.

Review of the staff schedule revealed on 12/14/24 the Heatherwood unit had a Caregiver call off for the day so they only had one nurse and the Health and Wellness Director #400 worked as a Caregiver, however she did not start working until 8:30 A.M.

On 12/30/24 at 9:50 A.M. an interview with Family Member #300 revealed on the morning of 12/14/24, the staff left her family member on the toilet for 90 minutes because they were short staffed.

On 12/30/24 at 11:07 A.M. an interview with Family Member #301 revealed he was visiting on 12/14/24 and Resident #2 had to go to the bathroom. He stated the nurse was the only person working. She assisted the resident to the toilet and left him on the toilet for 90 minutes. He stated Resident #2 started yelling out for help so he went and got the nurse because he was still on the toilet.

On 12/30/24 at 12:55 P.M. an interview with Registered Nurse #402 confirmed the call lights should be answered as soon as possible and an hour and 25 minutes was too long. He verified Resident #2's call light was documented for being on for one hour and 25 minutes.

On 12/31/24 at 1:36 P.M. an interview with the Health and Wellness Director #400 revealed she was not scheduled to work on 12/14/24, however she received a telephone call from the nurse working on Heatherwood unit at 7:50 A.M. stating she did not have any Caregivers on the unit and she was the only one working. She stated she got ready and came right in to work as a Caregiver, but she did not get to the facility until around 8:30 A.M. She stated Caregiver #308 was working on the other unit and floated over to Heatherwood unit to help out.

This violation represents noncompliance investigated under Master Complaint Number OH00160680 and Complaint Number OH00160369 and is an example of continued noncompliance from the surveys dated 04/02/24 and 06/07/24.

Based on review of the medical record, review of shower schedules, review of staff schedules, interview with residents, interview with family, and interviews with staff, the facility failed to ensure showers were completed per the residents schedule. This affected three residents (#2, #4, and #11) of three reviewed for assistance with activities of daily living (ADL).

Findings included:

1. Review of the medical record revealed Resident #2 was admitted to the facility on 03/08/23. Diagnoses included Parkinson's disease, benign prostatic hyperplasia, dementia, neurocognitive disorder with Lewy bodies, hypothyroidism, insomnia, pain, heart failure, and hyperlipidemia.

Review of the Personal Service Assessment dated 03/12/24 revealed Resident #2 had some memory impairment and needed assistance with showering.

Review of the facility shower schedule revealed Resident #2 was scheduled to have a shower on day shift on Mondays and Thursdays.

Review of the Shower Task in Point Click Care (PCC)(an electronic charting system) for December 2024 revealed Resident #2 received a shower on 12/02/24, 12/03/24, 12/05/24, 12/10/24, 12/16/24, and 12/19/24. He had not received a shower on 12/23/24, 12/26/24, or 12/30/24.

Review of the facility's paper shower sheets revealed Resident #2 had a shower on 12/02/24, 12/20/24, 12/13/24 and 12/16/24.

Review of the staffing schedule on 12/23/24 revealed a Caregiver (CG) had called off and there was only one nurse and one Caregiver to assist 15 residents.

Review of the staffing schedule on 12/26/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver to assist 15 residents.

On 12/30/24 at 9:45 A.M. an interview with Caregiver #100 revealed she was not able to get her showers completed when she was the only Caregiver working the unit. She stated she was the only one working today (12/30/24) because the other Caregiver had called off. She stated there was only one Caregiver and one Nurse on the unit.

On 12/30/24 at 11:20 A.M. an interview with Licensed Practical Nurse (LPN) #101 revealed Caregivers just did not show up to work or they would get there at 8:00 A.M. to 8:30 A.M. She stated on this day, they had four Caregivers scheduled, but two called off, and another one of them started in housekeeping on this day and they never took her off the schedule. She stated most days she had to serve the residents their breakfast because they did not have enough staff. She verified showers were not being completed as scheduled.

On 12/31/24 at 8:20 A.M. an interview with CG #102 revealed she tried to get the showers completed when she was working, but it was hard with only one person. She stated there was usually three to four showers to complete per day. She stated they were not completed yesterday (12/30/24) and the residents were already asking if they were going to get them today. She stated the showers were documented on shower sheets and in PCC.

On 12/31/24 at 10:45 A.M. an interview with Family Member #300 revealed Resident #2 never received his shower yesterday (12/30/24) or all last week. She stated the staff were aware and CG #102 was the only person who made sure Resident #2 received his shower.

On 12/31/24 at 1:36 P.M. an interview with Health and Wellness Director #400 confirmed the showers for Resident #2 had not been completed.

2. Review of the medical record revealed Resident #4 was admitted to the facility on 11/10/23. Diagnoses included right breast cancer, depression, tuberculosis of the lung, and insomnia.

Review of the Personal Service Assessment dated 06/13/24 revealed Resident #4 had some memory impairment and needed assistance with showering.

Review of the facility shower schedule revealed Resident #4 was scheduled to have a shower on day shift on Mondays and Thursdays.

Review of the Shower Task in Point Click Care (PCC)(an electronic charting system) for December 2024 revealed Resident #4 received a shower on 12/03/24, 12/10/24, 12/12/24, 12/16/24, and 12/19/24 and 12/24/24. She had not received a shower on 12/26/24 or 12/30/24.

Review of the facility's paper shower sheets revealed Resident #4 had a shower on 12/06/24, 12/10/24, 12/15/24 and 12/16/24.

Review of the staffing schedule on 12/23/24 revealed a Caregiver (CG) had called off and there was only one nurse and one Caregiver working for 15 residents.

Review of the staffing schedule on 12/26/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver working for 15 residents.

On 12/30/24 at 9:45 A.M. an interview with Caregiver #100 revealed she was not able to get her showers completed when she was the only Caregiver working the unit. She stated she was the only one working today (12/30/24) because the other Caregiver had called off. She stated there was only one Caregiver and one Nurse on the unit.

On 12/30/24 at 11:20 A.M. an interview with Licensed Practical Nurse (LPN) #101 revealed Caregivers just did not show up to work or they would get there at 8:00 A.M. to 8:30 A.M. She stated on this day, they had four Caregivers scheduled, but two called off, and another one of them started in housekeeping on this day and they never took her off the schedule. She stated most days she had to serve the residents their breakfast because they did not have enough staff. She verified showers were not being completed as scheduled.

On 12/31/24 at 8:20 A.M. an interview with CG #102 revealed she tried to get the showers completed when she was working, but it was hard with only one person. She stated there was usually three to four showers to complete per day. She stated they were not completed yesterday (12/30/24) and the residents were already asking if they were going to get them today. She stated the showers were documented on shower sheets and in PCC.

Observation on 12/31/24 at 10:47 A.M. revealed Family Member #301 was standing at the nurse's station asking LPN #101 if Resident #4 was going to receive her shower because she had not received it the day before (12/30/24).

On 12/31/24 at 10:50 A.M. an interview with Family Member #301 revealed Resident #4 had not received her shower they day before on 12/30/24.

On 12/31/24 at 1:36 P.M. an interview with Health and Wellness Director #400 confirmed the showers for Resident #4 had not been completed. She stated she was previously aware that Resident #4 had not received her showers last week.

3. Review of the medical record revealed Resident #11 was admitted to the facility on 09/26/24. Diagnoses included anemia, atherosclerotic heart disease, weakness, multiple myeloma, and hypertension.

Review of the Personal Service Assessment dated 09/26/24 revealed Resident #11 had intact cognition and needed assistance with showering.

Review of the facility shower schedule revealed Resident #11 was scheduled to have a shower on the day shift on Mondays and Thursdays.

Review of the Shower Task in Point Click Care (PCC)(an electronic charting system) for December 2024 revealed Resident #11 received a shower on 12/03/24, and 12/16/24, and she refused on 12/12/24 and 12/19/24. She had not received a shower on 12/05/24, 12/23/24, 12/26/24, or 12/30/24.

Review of the facility's paper shower sheets revealed Resident #11 had a shower on 12/02/24, 12/09/24, and 12/16/24.

Review of the staffing schedule on 12/23/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver working for 15 residents.

Review of the staffing schedule on 12/26/24 revealed a Caregiver had called off and there was only one nurse and one Caregiver working for 15 residents.

On 12/30/24 at 9:45 A.M. an interview with Caregiver #100 revealed she was not able to get her showers completed when she was the only Caregiver working the unit. She stated she was the only one working today (12/30/24) because the other Caregiver had called off. She stated there was only one Caregiver and one Nurse on the unit.

On 12/30/24 at 11:20 A.M. an interview with Licensed Practical Nurse (LPN) #101 revealed Caregivers just did not show up to work or they would get there at 8:00 A.M. to 8:30 A.M. She stated on this day, they had four Caregivers scheduled, but two called off, and another one of them started in housekeeping on this day and they never took her off the schedule. She stated most days she had to serve the residents their breakfast because they did not have enough staff. She verified showers were not being completed as scheduled.

On 12/31/24 at 8:20 A.M. an interview with CG #102 revealed she tried to get the showers completed when she was working, but it was hard with only one person. She stated there was usually three to four showers to complete per day. She stated they were not completed yesterday (12/30/24) and the residents were already asking if they were going to get them today. She stated the showers were documented on shower sheets and in PCC.

On 12/31/24 at 10:55 A.M. an interview with Resident #11 revealed she had not received her shower the day before (12/30/24). She stated she was never told why, they just never showed up. She stated she had not received a shower the week before either.

On 12/31/24 at 1:36 P.M. an interview with Health and Wellness Director #400 confirmed the showers for Resident #11 had not been completed.

This violation represents noncompliance investigated under Master Complaint Number OH00160680 and Complaint Number OH00160369.

Based on review of the medical record, review of the staffing schedules, interviews with staff, and review of facility policy and procedure, the facility failed to ensure medications were administered as ordered for Resident #1, #2 and #10. This affected three residents (Resident #1, #2 and #10) of five reviewed for physician orders.

Findings included:

1. Review of the medical record revealed Resident #1 was admitted to the facility on 02/29/20. Diagnoses included hyperlipidemia, hypertension, diabetes, kidney disease, pain, osteoarthritis of the knees, gout, insomnia, macular degeneration, glaucoma, atrial fibrillation, and congestive heart failure.

Review of the Personal Service Assessment dated 04/01/24 revealed Resident #1 had intact cognition and required assistance with her medications.

Review of the December 2024 Medication Administration Record (MAR) revealed no documentation that Resident #1 received her physician ordered Tylenol 1000 milligram (mg) for pain, Latanoprost Ophthalmic drops 0.005% for macular degeneration, Trazodone 100 mg for insomnia, Ferrous Sulfate 325 mg for iron deficiency anemia, and Metoprolol Tartrate 50 mg for hypertension on 12/24/24 at 8:00 P.M. and Hydralazine 30 mg for hypertension on 12/25/24 at 12:00 A.M.

Review of the employee timecards revealed Licensed Practical Nurse (LPN) #403 had worked on 12/24/24 from 7:00 A.M. to 9:00 P.M. and Registered Nurse (RN) #402 had worked on 12/24/24 from 8:30 P.M. until 9:30 A.M. on 12/25/24.

On 12/31/24 at 1:20 P.M. an interview with RN #402 revealed on 12/24/24 there was no nurse scheduled for 7:00 P.M. to 7:00 A.M. and LPN #403 had worked 12/24/24 from 7:00 A.M. to 9:00 P.M. He stated he went into work on 12/24/24 at 8:30 P.M. until 12/25/24 at 9:30 A.M. He verified he had not administered any medication while he was on shift working. He verified there was no documentation that medications were given at bedtime on 12/24/24 for Resident #1 or on 12/25/24 at 12:00 A.M. for Resident #1. He stated he thought LPN #403 had administered all the bedtime medications.

Review of the facility policy titled, Medications and Treatment-Administration Assistance

Based on review of the medical record, review of the incident log, and interview with staff, the facility failed to ensure the incident log was complete and accurate. This affected one resident (Resident #1) of three reviewed for falls.

Findings included:

Review of the medical record revealed Resident #1 was admitted to the facility on 02/29/20. Diagnoses included hypertension, diabetes, kidney disease, pain, osteoarthritis of the knees, gout, insomnia, macular degeneration, glaucoma, atrial fibrillation, and congestive heart failure.

Review of the Personal Service Assessment dated 04/01/24 revealed Resident #1 had intact cognition, required assistance with mobility, and used a mobility aide. The assessment indicated she had fallen in the past 12 months.

Review of the progress note dated 10/12/24 at 11:50 A.M. revealed the nurse observed Resident #1 lying flat on her back in front of her recliner with her head at the foot of the chair.

Review of the incident log from 10/01/24 to 12/30/24 revealed no documentation of Resident #1's fall on 10/12/24.

On 12/31/24 at 8:30 A.M. an interview with the Executive Director confirmed the incident log was not complete and there was no evidence of Resident #1's fall on 10/12/24.

Based on review of the medical record, review of call light reports, interview with family, and interview with staff, the facility failed to ensure call lights were answered timely for Resident #2. This affected one resident (Resident #2) of three reviewed for timely call light response time. In addition, based on review of the medical record and interview with staff, the facility failed to ensure daily weights were completed per physician orders for Resident #1. This affected one resident (Resident #1) of five reviewed for physician orders.

Findings included.

1. Review of the medical record revealed Resident #1 was admitted to the facility on 02/29/20. Diagnoses included hyperlipidemia, hypertension, diabetes, kidney disease, pain, osteoarthritis of the knees, gout, insomnia, macular degeneration, glaucoma, atrial fibrillation, and congestive heart failure.

Review of the Personal Service Assessment dated 04/01/24 revealed Resident #1 had intact cognition and required assistance with her medications.

Review of the weights in Point Click Care (the electronic charting system) revealed Resident #1 weighed 166.6 pounds on 11/01/24, 175.4 pounds on 11/18/24 and 162.4 pounds on 11/28/24.

Review of the progress note dated 11/25/24 at 5:52 P.M. revealed Resident #1 had a new order for daily weights to be completed.

Review of the physician's order dated 11/25/24 revealed Resident #1 had an order for daily weights in the mornings for seven days for edema.

Review of the November 2024 Medication Administration Record (MAR) revealed no documentation that daily weights were obtained as ordered for Resident #1.

Review of the Nurse Practitioner progress note dated 12/02/24 revealed Resident #1 had a new order from 11/25/24 for daily weights for seven days for the edema in her arms and legs. Her left hand and wrist were much improved and she had no further complaints of pain. Staff were asked to obtain daily weights, however they were not completed.

On 12/31/24 at 12:05 P.M. an interview with Licensed Practical Nurse (LPN) #101 revealed they put all monthly weights in Point Click Care and the daily weights were to be placed on the MAR. She stated Resident #1 had gone out to the hospital for pneumonia and when she came back, she was not on Lasix (an antidiuretic medication) and developed edema in her arms and legs. She stated evidently the resident received an order for daily weights and the order never was placed on the MAR. She confirmed the daily weights were never completed.

2. Review of the medical record revealed Resident #2 was admitted to the facility on 03/08/23. Diagnoses included Parkinson's disease, benign prostatic hyperplasia, dementia, neurocognitive disorder with Lewy bodies, insomnia, pain, and hemorrhoids.

Review of the Personal Service Assessment dated 03/12/24 revealed Resident #2 had some memory impairment and needed assistance with dressing and toilet use.

Review of the call light audit report revealed on 12/14/24 Resident #2 turned his call light on at 8:57 A.M. and it was on for 32 minutes. He turned it on again at 9:35 A.M. and it was on for one hour and 25 minutes.

Review of the staff schedule revealed on 12/14/24 the Heatherwood unit had a Caregiver call off for the day so they only had one nurse and the Health and Wellness Director #400 worked as a Caregiver, however she did not start working until 8:30 A.M.

On 12/30/24 at 9:50 A.M. an interview with Family Member #300 revealed on the morning of 12/14/24, the staff left her family member on the toilet for 90 minutes because they were short staffed.

On 12/30/24 at 11:07 A.M. an interview with Family Member #301 revealed he was visiting on 12/14/24 and Resident #2 had to go to the bathroom. He stated the nurse was the only person working. She assisted the resident to the toilet and left him on the toilet for 90 minutes. He stated Resident #2 started yelling out for help so he went and got the nurse because he was still on the toilet.

On 12/30/24 at 12:55 P.M. an interview with Registered Nurse #402 confirmed the call lights should be answered as soon as possible and an hour and 25 minutes was too long. He verified Resident #2's call light was documented for being on for one hour and 25 minutes.

On 12/31/24 at 1:36 P.M. an interview with the Health and Wellness Director #400 revealed she was not scheduled to work on 12/14/24, however she received a telephone call from the nurse working on Heatherwood unit at 7:50 A.M. stating she did not have any Caregivers on the unit and she was the only one working. She stated she got ready and came right in to work as a Caregiver, but she did not get to the facility until around 8:30 A.M. She stated Caregiver #308 was working on the other unit and floated over to Heatherwood unit to help out.

This violation represents noncompliance investigated under Master Complaint Number OH00160680 and Complaint Number OH00160369.

Based on record review and interview, the facility failed to adequately effectively manage Resident #50's disruptive behaviors to ensure Resident #99 was free from abuse. This finding affected one (Resident #99) of three residents reviewed for abuse.

Findings include:

1. Review of Resident #99's medical record revealed the resident was admitted on 07/26/24 with diagnoses including Alzheimer's disease, constipation and essential hypertension. The resident's medical record revealed the resident had a guardian (Guardian #807).

Review of Resident #99's Montreal Cognitive Assessment (MOCA) tool dated 07/17/24 revealed the resident scored a 7 out of 30. (A MOCA score of 26 or below was often considered an indicator of cognitive impairment, which could include conditions like mild cognitive impairment or dementia.)

Review of Resident #99's progress notes dated 08/09/24 at 1:40 P.M. authored by Licensed Practical Nurse (LPN) #808 revealed the nurse observed the resident sitting at another table this morning. The resident stated he did not want to be around a particular resident near him related to a prior incident when another resident put a hand in his shirt and inappropriately touched his breast while he was sleeping on the patio.

Review of Resident #99's progress note dated 08/09/24 at 2:30 P.M. authored by Director of Clinical Services Specialist (DCS) #809 indicated the resident reported that another male resident had touched him several times and he did not like it. The other resident was talked to about his behavior and asked not to touch other residents. The two men were separated. An hour later, the other resident sought out Resident #99 and proceeded to approach and touch him again. Resident #99 became very angry and told the other resident that he would lay him out if he did not leave him alone. The nurse talked with the son and explained the situation. The son stated the guardian was looking for an assisted living and the other family was notified.

Review of Resident #99's progress note dated 08/10/24 at 8:46 A.M. (late entry) authored by DCS #809 indicated a caregiver stated she witnessed Resident #50 approach Resident #99 in the dining area. She stated she heard Resident #99 say get this MF away from me and then removed a butter knife from his shoe and pointed it at Resident #50 stating if you come near me, I will stab you with this knife. Resident #99 then got up from the table and went out to the patio outside of the dining area.

Review of Resident #99's progress note dated 08/10/24 at 12:27 P.M. authored by DCS #809 revealed the resident was angry with Resident #50 because he followed him and tried to touch him again. Resident #99 stated to this nurse that he was going to hurt Resident #50 if he approached him again. The nurse contact Resident #50's wife and explained the situation. The family planned to pick up Resident #50 and take him out of the facility for the weekend. Resident #99's guardian would be contacted to get an updated on assisted living (AL) plans.

Review of Resident #99's progress note dated 08/10/24 at 3:22 P.M. authored by LPN #808 indicated the resident was sitting in the back of the dining room when the nurse observed another resident stood up and started towards this resident. The nurse spoke with the other resident and asked him to stay away from Resident #99. Resident #99 stated to the nurse that he had reported that the resident better stay away from him and stop talking to him. Resident #99 showed a butter knife and stated if the other resident wanted to play then they would play. The nurse redirected Resident #99 and updated the new behavior to the administration staff.

Review of Resident #99's progress note dated 08/11/24 at 7:01 P.M. indicated the resident was sitting in the dining room at lunch talking with staff and commenting about the other resident who was on LOA. He continued to come up to the nurse and report the other resident was going to get a butter knife in his throat. The administration staff was updated.

Review of Resident #99's progress note dated 08/12/24 at 2:40 P.M. authored by DCS #809 indicated the resident continued to be upset and threatening to hurt another resident. The nurse contacted the resident's guardian to discuss having the resident evaluated for aggression and behaviors. Emergency services (EMS) was called and arrived at the facility at 2:15 P.M.

Review of Resident #99's progress note dated 08/13/24 at 12:15 A.M. revealed the resident returned with no new orders.

Review of Resident #99's progress note dated 08/13/24 at 3:37 P.M. authored by DCS #809 revealed a caregiver was in the dining room and noticed Resident #99 on the patio outside the dining room. Resident #50 went out on the patio with resident #99, walked over to the resident and proceeded to put his left hand in Resident #99's shirt which startled him. Resident #99 became angry, and the two residents were separated. Resident #99 stated if Resident #50 touched him again I will kill him. Both families were notified. One-to-one supervision had been initiated at this time.

Review of Resident #99's progress note dated 08/23/24 at 11:13 A.M. revealed the resident's one-to-one supervision had been discontinued at this time.

An interview was conducted on 09/27/24 at 8:03 A.M. with Resident #99 revealed Resident #50 kept wanting to touch his shoulder. When questioned, he felt Resident #50 fondled people, and he did not feel safe. He confirmed the administrative staff were aware. He stated he did not want to move into another facility and just wanted Resident #50 to stay away from him. He stated he called Resident #50 an expletive name and stated he was not gay and felt Resident #50 was making inappropriate moves to him. Resident #99 stated when the incident occurred, he was sleeping, and Resident #50 unbuttoned his top two buttons of his shirt and touched his chest, and this was the only incident that occurred regarding dignity and respect or abuse.

Interview on 09/27/24 at 8:34 A.M. with the Administrator indicated approximately three weeks ago Resident #99 had reported that Resident #50 touched him inappropriately. During the investigation, it was determined Resident #50 touched Resident #99 at his collar bone above a t-shirt when the resident was sleeping on the patio. The Administrator confirmed Resident #99 became upset, but no physical altercation occurred. The Administrator stated the residents were immediately separated and both residents had a sitter but Resident #50's sitter remained in effect for an indefinite period. The Administrator confirmed psych services adjusted both resident's medications and Resident #50's wife was called who felt the resident was bored during the day. The Administrator stated they are going to have home health care come in and engage the resident with activities during the day so the resident would not be bored. The Administrator stated this had not occurred prior to this incident and he denied concerns with dignity and respect or abuse.

Interview on 09/27/24 at 9:23 A.M. with the Health and Wellness Coordinator (HWD) indicated it was his understanding that Resident #99 was out on the patio when Resident #50 went out and touched him on his chest. He stated the facility had kept them separated and Resident #50 was someone who had to touch people. He denied abuse and stated he was not sure why it occurred. The HWD indicated both residents were assessed by Geriatric NP #810 and neither resident was assessed by psych services.

A telephone interview was conducted on 09/27/24 at 9:33 A.M. of Resident #99's guardian (Guardian #807) with the HWD in attendance and Guardian #807 revealed he had reported to the facility that Resident #99 told him that he was being physically assaulted by another resident in the facility. Guardian #807 stated the facility called and told him that he would need to move Resident #99 from the facility, and he stated he was not moving the resident because the resident defended himself against another resident who was inappropriately touching him.

Interview on 09/27/24 at 10:28 A.M. with Geriatric NP #810 indicated she had increased Resident #50's Seroquel antipsychotic medication from 25 milligrams (mg) daily to 25 mg twice daily and she had ordered psych services to assess Residents #50 and #99. She confirmed Resident #50 required one-to-one supervision but could not state when the supervision started.

2. Review of Resident #50's medical record revealed the resident was admitted on 05/23/24 with diagnoses including chronic pain, hyperlipidemia and unspecified dementia without behavioral disturbance.

Review of Resident #50's MOCA dated 07/12/24 revealed the resident scored 23 out of 30.

Review of Resident #50's progress note dated 08/08/24 at 9:54 A.M. authored by LPN #801 indicated the resident had been told numerous times to stop touching and bother other residents. The resident had been bothering a certain resident who did not like him. The power-of-attorney (POA) and staff were made aware.

Review of Resident #50's progress note dated 08/09/24 at 4:30 P.M. authored by DCS #809 indicated Resident #99 was observed on the patio outside of the dining area putting his hand down the shirt of another male resident. The male resident was sleeping and woke up startled and angry. The male resident was cussing and yelling at Resident #50 and told him if he touched him again, he would hurt him. The two men were separated.

Review of Resident #50's medical record revealed no evidence of new interventions in place to manage Resident #50's disruptive behavior.

Review of Resident #50's progress note dated 08/13/24 at 6:24 A.M. authored by LPN #811 indicated the resident remained restful in his room with one with one-to-one supervision provided by a caregiver.

Per Resident #50's medical record, Resident #50's wife took the resident on a leave of absence (LOA) from 08/09/24 to 08/12/24.

Review of Resident #50's progress note dated 08/13/24 at 9:52 A.M. revealed the caregiver stated she witnessed Resident #50 approaching Resident #99 in the dining area. The caregiver stated she heard Resident #99 say get the MF away from me and then he removed a butter knife from his shoe and pointed it at Resident #50 and stated, if you come near me, I will stab you with a knife. The resident then got up from the table and went out to the patio outside to the dining area. One-to-one supervision was initiated at this time.

Review of Resident #50's medical record did not reveal evidence of the second resident-to-resident incident which occurred on 08/13/24 at 3:37 P.M.

Review of Resident #50's Geriatric Nurse Practitioner (NP) note dated 09/09/24 at 7:00 P.M. revealed the resident was standing by another female resident after dinner talking then it turned into a kiss on each cheek and then on the lips. The caregiver and the nurse stopped what was going on. The resident went back to his room after the incident and the resident continued with one-to-one staff supervision.

Review of Resident #50's Geriatric NP note dated 09/16/24 at 10:15 A.M. revealed the POA came in to speak with Resident #50 about his behavior and asked the nurse to be present when the resident retold the conversation. The nurse reiterated what was said about how the resident was interrupting the unit and upsetting other residents, having them misbehave by being aggressive with behaviors. On 09/15/24 Resident #50's Seroquel antipsychotic was increased, and the staff were waiting on psychiatry to evaluate.

Interview on 09/27/24 at 7:41 A.M. revealed Resident #50 stated he was aware Resident #99 did not like to be touched. He denied concerns with dignity and respect or abuse and stated he did not know why Resident #99 was aggressive to him. When questioned, he stated he did not remember touching Resident #50 at any point. He was sitting in the main dining room waiting for the breakfast meal. The sitter (Caregiver Agency #806) was adjacent to the resident sitting on the edge of the dining room in a chair.

Interview on 09/27/24 at 7:46 A.M. with Caregiver Agency #806 (sitter) indicated she had been sitting with Resident #50 for approximately three weeks because she was told the resident touched the shoulder of Resident #99 who did not like it. Caregiver Agency #806 denied concerns with dignity and respect or abuse.

An interview was conducted on 09/27/24 at 8:03 A.M. with Resident #99 revealed Resident #50 kept wanting to touch his shoulder. When questioned, he felt Resident #50 fondled people, and he did not feel safe. He confirmed the administrative staff were aware. He stated he did not want to move into another facility and just wanted Resident #50 to stay away from him. He stated he called Resident #50 an expletive name and stated he was not gay and felt Resident #50 was making inappropriate moves to him. Resident #99 stated when the incident occurred, he was sleeping, and Resident #50 unbuttoned his top two buttons of his shirt and touched his chest, and this was the only incident that occurred regarding dignity and respect or abuse.

Interview on 09/27/24 at 8:34 A.M. with the Administrator indicated approximately three weeks ago Resident #99 had reported that Resident #50 touched him inappropriately. During the investigation, it was determined Resident #50 touched Resident #99 at his collar bone above a t-shirt when the resident was sleeping on the patio. The Administrator confirmed Resident #99 became upset, but no physical altercation occurred. The Administrator stated the residents were immediately separated and both residents had a sitter but Resident #50's sitter remained in effect for an indefinite period. The Administrator confirmed psych services adjusted both resident's medications and Resident #50's wife was called who felt the resident was bored during the day. The Administrator stated they are going to have home health care come in and engage the resident with activities during the day so the resident would not be bored. The Administrator stated this had not occurred prior to this incident and he denied concerns with dignity and respect or abuse.

Interview on 09/27/24 at 9:23 A.M. with the HWD indicated it was his understanding that Resident #99 was out on the patio when Resident #50 went out and touched him on his chest. He stated the facility had kept them separated and Resident #50 was someone who had to touch people. He denied abuse and stated he was not sure why it occurred. The HWD indicated both residents were assessed by Geriatric NP #810 and neither resident was assessed by psych services.

Interview on 09/27/24 at 10:28 A.M. with Geriatric NP #810 indicated she had increased Resident #50's Seroquel antipsychotic medication from 25 mg daily to 25 mg twice daily and she had ordered psych services to assess Residents #50 and #99. She confirmed Resident #50 required one-to-one supervision but could not state when the supervision started.

A second interview on 09/27/24 at 11:45 A.M. with the HWD confirmed Resident #50's wife took the resident on a LOA on 08/09/24 and returned on 08/12/24. The HWD confirmed that he was unaware if Residents #50 and #99 were assessed by psych services and psych services only came once per month. The HWD confirmed the facility did not put interventions in place to prevent the second resident to resident confrontation between Residents #50 and #99 on 08/13/24. The HWD confirmed one to one supervision was initiated for both residents on 08/13/24 following the second resident to resident involving Residents #50 and #99.

Review of the Abuse, Neglect and Exploitation Policy revised 05/2021 revealed the facility was committed to maintaining a safe environment for each resident, visitor and employee. Instance or allegations of abuse, neglect or exploitation should be treated seriously and must be reported to the Executive Director or the supervisor on duty for and appropriate follow-up.

This violation represents non-compliance investigated under Complaint Number OH00157964 and is an example of continued non-compliance from the survey dated 04/02/24.

Based on interviews and record review the facility failed to ensure narcotic medication was administered in accordance with accepted standards of practice and only by persons authorized by law to administer narcotic medication to Former Resident (FR) #40. This affected one resident (#40) of three residents reviewed for medication administration. The census was 35.

Findings include:

Review of the medical record for FR #40 revealed an admission date of 6/30/24. Discharge was on 07/04/24. Diagnoses included malignant pleural effusion, chronic obstructive pulmonary disease and type two diabetes mellitus.

Review of the July 2024 physician orders revealed FR #40 was on hospice care. She had orders for Morphine Sulfate (MS) Oral (by mouth) Solution 10 mg/5 ml-give 0.5 mg by mouth every two hours for pain/shortness of breath and Ativan oral tablet 0.5mg give 0.5mg every four hours as needed for anxiety/restlessness.

Review of the hospice note dated 07/03/24 at 8:30 A.M. revealed the daughter of FR #40 stated the facility nurse gave her prefilled oral syringes of morphine and the Ativan and instructed her she could give it every two hours (Ativan order was for every four hours). The note said the hospice nurse educated the nurse on duty about rounding frequently and a nurse should be administering medications.

Review of a text message sent to Licensed Practical Nurse (LPN) #150 from FR #40's daughter sent on 07/03/24 at 9:22 P.M. revealed she had been waiting for LPN #300 to medicate her mother. The text said she was appalled the nurse would give a shower while the aides watched television. She then stated This is the same nurse last night that gave me the morphine to give when I felt needed. The morphine was left with me in the room.

Interview on 08/06/24 at 2:20 P.M. with LPN #150 revealed he was aware of the allegation of narcotics being left in the room with FR #40 overnight on 07/02/24 into 07/03/24. He stated he received a text from the daughter with her concern about the situation so he came in on 07/03/24 and spent some time with daughter. LPN #150 reported the allegation to the Executive Director (ED) who directed him to contact the District Nurse.

Interview on 08/06/24 at 2:37 P.M. with FR #40's daughter revealed on the evening of 07/02/24 going into 07/03/24 her mom needed morphine. She stated LPN #300 asked her if she was comfortable administering to her mom herself. The daughter stated to surveyor I didn't know any better. I was not sure how much but I did administer it twice. The syringe was thrown away in the room. Hospice told me the medications should not have been left in the room. It was difficult to find the nurse at night the few days she was there. I did not understand why LPN #300 was giving a shower and not the caregiver who was on phone or watching television.

Interview on 08/06/24 at 4:45 P.M. with Regional Nurse #500 revealed the facility was aware of the allegation of the situation with the medications. She stated it would not be standard practice to leave medications unattended. She stated it was brought up about termination of the nurse and it was escalated to the district level.

Interview on 08/06/24 at 4:53 P.M. with the Executive Director (ED) revealed LPN #150 did report to him about the allegation and the ED asked him to report it directly to the District Nurse on 07/03/24.

Phone interview on 08/06/24 at 6:20 P.M. with LPN #300 revealed LPN #300 stated she was confused about the situation. She stated FR #40 was only in the facility for a few days and said I was covering two floors. She stated she told the daughter to tell the caregivers and they would get her to give the medication when needed. She stated she medicated FR #40. LPN #300 initially said it was never the case the medication was left out. I am very confused. She later stated I forgot the Ativan so I did leave the morphine syringe in the room while I got the Ativan. That's on me. No timeframe was given regarding how long she left the morphine in the room. When asked if she asked if the daughter was comfortable administering the medications LPN #300 responded not that I remember. LPN #300 stated when she would go to offer to medicate FR #40 there were times when the daughter would say Not right now. She stated she could not recall the times of medication administration for the morphine or Ativan.

In a subsequent phone interview on 08/07/24 at 11:42 A.M. initiated by LPN #300, she revealed she said she had a caregiver with her everytime she went into FR #40's room stating the caregiver would hold the resident's head while she administered the medications. She stated it was Caregiver #310.

Interview on 08/07/24 at 12:33 P.M. with Agency LPN #530, the nurse who followed LPN #300's shift on 07/03/24, stated it was a last minute shift and she arrived after 8:00 A.M. FR #40 was actively dying. She stated she saw the hospice nurse outside the resident's room who stopped her stating please don't do what the nurse last night did. Giving the medication to the family. She stated the orders were not right in the system as she still had orders for all medications which would normally be discontinued when actively dying. She stated the morphine and Ativan orders were not in the system. She later found them written down and with help of hospice nurse clarified them. She said the hospice nurse said they were changed the day before. When she went to FR #40's room LPN #530 stated she did not see medication in the room but she collected the syringe from the trash. Family told the hospice nurse that LPN #300 did not have time to come in and out because she was covering two floors and told the family to use their judgement. LPN #530 stated she reported the incident to the office as LPN #150 was not there.

Interview on 08/07/24 at 12:45 P.M. with Hospice Nurse Manager (HNM) #520 stated the case manager visited FR #40 on 07/03/24 around 8:30 A.M. She indicated the family were given syringes by LPN #300 per family. The family reported last medicating FR #40 by family was around 1:00 A.M. HNM #520 stated a hospice aide was present starting at 9:00 A.M. on 07/03/24 as they were now providing even more care where there was a hospice staff with FR #40 until she passed away on 07/04/24 at 3:30 A.M. HNM #520 stated the case manager did speak to the on-coming nurse how medication should be administered by nurse and not the family. HNM #520 stated the family said LPN #300 said the Ativan could be given every two hours (the order was for every four hours as needed). Hospice marked it as a potential medication error. The case manager was unavailable for interview as she was on vacation. It was unclear if she saw the medication in the room or not.

Interview on 08/07/24 at 2:24 P.M. with Caregiver #200 revealed it was reported to her on 07/03/24 by Agency LPN #530 that narcotics were left in a room overnight. Caregiver #200 reported it to ED.

Phone interview on 08/08/24 at 7:15 A.M. initiated by Caregiver #310 revealed she was with LPN #300 everytime in FR #40's room. Caregiver #310 verified LPN #300 left the morphine syringe in the room while she went to get additional medication.

A subsequent phone interview on 08/08/24 at 9:30 A.M. with LPN #150 revealed Caregiver #310 was not in the room each time LPN #300 was in there as he was in another area of the apartment at one point on 07/03/24 unbeknownst to LPN #300 and no other staff was present with her.

This violation represents non-compliance investigated under Complaint Number OH00155989.

Based on interviews and record reveiws the facility failed to ensure administered medications were accurately documented as administered per physician orders on the Medication Administration Record (MAR) for Former Resident (FR) #40. This affected one resident (#40) of three residents reviewed for medication administration. The census was 35.

Findings include:

Review of the medical record for FR #40 revealed an admission date of 6/30/24. Discharge was on 07/04/24. Diagnoses included malignant pleural effusion, chronic obstructive pulmonary disease and type two diabetes mellitus.

Review of the July 2024 orders revealed FR #40 had an order for Ativan oral tablet 0.5 milligrams (mg), give 0.5 mg every four hours as needed for anxiety/restlessness.

Review of the July 2024 MAR revealed Licensed Practical Nurse (LPN) #300 documented she administered Ativan oral tablet 0.5 mg every four hours as needed on 07/03/24 at 9:30 P.M. and on 07/03/24 at 10:30 P.M.

Review of the narcotic log for FR #40 for Lorazepam (Ativan) 0.5 mg, one tab by mouth every four hours as needed was signed off by LPN #300 on 07/03/24 at 9:30 P.M. and on 07/04/24 at 1:30 A.M. There was no documentation Ativan was administered on 07/03/24 at 10:30 P.M.

Interview on 08/07/24 at 1:45 P.M. with Licensed Practical Nurse (LPN) #150 revealed the MAR did not match the narcotic log. He verified there was no progress note to explain the discrepancy. He verified it was LPN #300's signature and electronic identifier.

This violation represents non-compliance investigated under Complaint Number OH00155989.

Based on record reviews and interviews the facility failed to ensure a safe, clean environment was maintained related to bed bugs for Resident #18. This affected one resident (#18) of three residents reviewed for physical environment and had the potential to affect all 35 residents.

Findings include:

Record review of Resident #18 revealed an admission date of 05/10/21. Diagnoses included osteoarthritis of right knee, repeated falls and muscle weakness. Review of the progress notes revealed nothing regarding bed bugs.

Interview on 08/06/24 from 11:12 A.M. through 11:30 A.M. with Caregiver #405 and #410 and Licensed Practical Nurse (LPN) #415 revealed they were uncertain of exact date bed bugs were seen in Resident #18's apartment. They stated Resident #18's room mate (Resident #19) was moved on the same date as discovery however Resident #18 remained in the room for two to three more days. They did not believe the facility had a sense of urgency about the situation. They stated treatment for Residents #18's apartment did not start immediately.

Interview on 08/06/24 at 11:40 A.M. with the Maintenance Director #430 revealed the expectation was to move residents immediately when bed bugs were suspected and to treat as soon as possible. He stated they would call the pest control company on the same date. He did not recall, nor did he track, the dates of when bed bugs were discovered in Residents #18''s apartment or when they were moved.

Interview on 08/06/24 at 11:43 A.M. with Resident #18 revealed she was unaware why her roommate (Resident #19) was moved out but started to suspect it was due to bed bugs. She stated she remained in the apartment for two to three more nights before being moved. She was uncertain of date but stated housekeepers went to her room and asked her why she was still in the apartment. She stated that was the first she knew about the bed bugs. She could not recall the exact day she moved but it was the same day the housekeepers spoke to her. She stated she had not received any updates on when she could return to apartment.

Interview on 08/06/24 at 11:47 A.M. with Housekeeper #450 revealed she and another housekeeper (#460) saw Resident #18 was still in her apartment days after her room mate was found to have bed bugs. She stated they asked the resident why she was still in there. The resident did not know. Housekeeper #450 stated resident was moved that day. She believed the resident moved on 07/09/24. She started packing up items and closed the door until treatment. Interview on 08/07/24 at 12:23 P.M. with Housekeeper #460 confirmed information.

Interview on 08/06/24 at 1:17 P.M. with Caregiver #200 revealed she contacted pest control via text on 07/06/24 after she was made aware by staff member of bed bugs. She stated pest control came in on 07/08/24 to assess. She stated the Executive Director (ED) was made aware on the weekend (7/6) of the bed bug issue but did not believe Resident #18 had to move because the issue was found on Resident #19's side of their apartment. Caregiver #200 stated the ED was made aware on 07/08/24 by pest control the treatment could not be started until resident was moved out and room was packed. She believed Resident #18 moved on 07/09/24. The room still had too many personal belongings as of 7/17/24 and pest control notified the ED again.

Interview on 08/06/24 at 2:13 P.M. with LPN #150 revealed they were made aware of bed bugs on 07/06/24 and helped shower, clean and move Resident #19. Resident #18 did not move as the ED told them she did not have to move since the bed bugs were found on Resident #19's side.

Interview on 08/06/24 at 2:40 P.M. with ED revealed he did not initially move Resident #18 as he wanted to confirm there were bedbugs first. He stated he did have a discussion with Resident #18 after the pest control company confirmed they saw bed bug activity. In a subsequent interview on 08/06/24 at 3:20 P.M. ED stated they had no pest control policy. An interview on 08/07/24 at 3:13 P.M. revealed how he did not believe he needed to move Resident #18 because the bed bugs were found on Resident #19's side of the apartment. He stated Resident #18 was emotional and the move could be upsetting to her. In addition he stated moving her to another apartment would take up an available apartment for a potential new resident. He stated Resident #18 had many belonging in her apartment and he felt overwhelmed stating they did not have the staff to dedicate to packing up the apartment. He stated he tried to hire an outside company but they declined. He stated the pest control company quoted $50/hour per person but he said that was too expensive.

Interview on 08/07/24 at 9:40 A.M. with the Regional Nurse revealed the company had bed bug policies.

Review of the pest control receipts revealed the initial assessment of bed bugs for Residents #18 and #19's apartment was done on 07/08/24. Treatment was started on other vacated rooms on 07/08/24 but not started on Resident #18 and #19's room until 7/24/24. Treatment was on-going.

Review of the facility policy titled Bed Bugs Policy-IC-7

Based on record review, review of schedules and punch details, interviews with staff and agency staff the facility failed to provide sufficient staff to meet resident needs including the Memory Care Unit (MC). This affected 23 of 23 residents (#328, #330, #332, #333, #334, #335, #336, #337, #338, #339, #340, #344, #345, #346, #350, #351, #352, #353, #354, #356, #357, #358, #359) on MC reviewed for staffing and had the potential to affect all 42 residents in the facility.

Findings include:

Review of the medical records for Residents #328, #330, #332, #333, #334, #335, #336, #337, #338, #339, #340, #344, #345, #346, #350, #351, #352, #353, #354, #356, #357, #358 and #359 revealed medications due at 8:00 A.M., 9:00 A.M. and 7:00 P.M. were not administered on 05/29/24.

Interview on 06/07/24 at 9:30 A.M. with Caregiver (CG) #201 revealed there has not been a Director of Nursing (DON) for a couple of months. She stated they do not see corporate in the building very often. Stated they were here today but the last time was about three weeks ago.

Interview on 06/07/24 at 10:40 A.M. with Resident #354 revealed he stated he received morning medication on 05/29/24 however did not receive any nighttime medication. He stated he had to search for his nurse but he never found her. He specifically mentioned Depakote and Seroquel stating he did not sleep well that night.

Interview on 06/07/24 from 10:34 A.M. to 2:09 P.M. with residents (#2362, #252 and #253) revealed overall concerns with staffing. They noted there was no DON.

Interview on 06/07/24 at 1:22 P.M. with the Executive Director (ED) revealed there was an incident on 05/29/24 where Resident #354 was able to leave the Memeory Care Unit (MC) on his own. Per the ED the resident's explanation was he was looking for the nurse to administer his medications.

Interviews on 06/07/24 from 9:30 A.M to 10:30 A.M. with Caregiver (CG) #200, CG #201, CG #204 and #205 revealed concerns with staffing. CG #201 described the schedule as a nightmare stating there were multiple call-offs or no-shows and not enough nursing. CG #200, CG #204 and CG #205 stated they often only worked with one CG on each floor even though they believed there should be two on each floor. They mentioned there were times when a third CG would float between the two floors. They stated the MC did not always have a nurse present which meant there was possibly only one staff member on the unit for 23 residents. CG #204 and #205 revealed the new schedule was out for the following week but there were no nurses listed on 06/12/24. They mentioned Wednesdays being particularly bad for nursing. She showed the schedule from her phone and emailed a copy to surveyor.

Interviews on 06/07/24 at 3:45 P.M. with the District Director of Clinical Services (DDCS) #214 revealed there were two nurses on dayshift in the building on 05/29/24 and three caregivers. She confirmed there was no DON or other nursing management in the building that day. The two nurses were agency nurses, Agency Licensed Practical Nurse (LPN) #219 and LPN #221. She stated they did not need two nurses for 42 residents. She stated LPN #221 could have passed medications on both units had she known it needed done. When asked how she would have known she stated any staff (activities, caregivers, office staff) could have told her. DDCS #214 felt it was more of a communication issue than staffing issue. DDCS #214 verified MC did not have a nurse on the unit on 05/29/24 from 7:00 A.M. until 11:27 A.M.

Interview on 06/07/24 at 4:23 P.M. with Agency LPN (LPN) #219 revealed she picked up the shift when she saw it posted at 10:45 A.M. on the agency website on 05/29/24 arriving to the facility at 11:27 A.M. She stated by the time she got access to the computer it was closer to 12:00 P.M. She stated she saw the morning (9:00 A.M) medications were not administered. She stated she attempted to contact the physicians to get orders to administer medications since it was now out of the range. She did not receive any return calls. She stated she administered the medications due during her shift (12:00 P.M. to 6:00 P.M.). LPN #219 revealed there was only another agency nurse in the building that day. LPN #219 was not given any instructions by any clinical management as she said no one was in the building that fit that description. She stated she later learned the facility expected the dayshift nurse to pass the 7:00 P.M. medications at 6:00 P.M. rather than leaving them for the nightshift. She stated she let the next shift know about the medication issue.

Review of the working schedule on 05/29/24 revealed for dayshift there were two nurses (7:00 A.M.-7:00 P.M.) with their names with a line through them and agency written beside them. There were two CGs (7:00 A.M.-3:00 P.M.) listed for Assisted Living (AL). There were two CGs listed for MC but both names had a line through them. One was marked as no show and the other one had a replacement name. On the evening shift (3:00 P.M.-11:00 P.M.) one of the two CGs was marked late and the other was a call-off for AL; one was marked late and the other a no-show for MC. The nightshift schedule (nurse was 7:00 P.M.-7:00 A.M. and CG was 11:00 P.M. to 7:00 A.M.) revealed a nurse for AL and two CGs (one left around 20 minutes early); on MC there was no nurse with two CGs however one called off and the replacement was marked as a no-show.

Review of the invoice from the staffing agency revealed on 05/29/24 LPN #219 worked from 11:27 A.M. to 7:56 P.M and LPN #221 worked 6:58 A.M. to 7:51 P.M.

Review of the punch details on 05/29/24 dayshift revealed CG #204 worked 6:50 A.M. to 3:43 P.M., CG #200 worked 7:40 A.M. to 3:43 P.M on AL. CG #222 worked 8:57 A.M. to 3:20 P.M. on MC. On evening shift CG #207 worked 3:10 P.M. to 11:19 P.M. on MC and CG #203 worked 5:18 P.M. to 6:42 A.M. on AL.

Review of the Resident Council minutes for January, February and April 2024 revealed residents voiced concerns with call light response times stating taking too long to answer call lights, nightshift is spread too thin and call lights taking awhile.

Review of the facility policy titled Medication and Treatment-General Guidelines for Medication Administration/Assistance

Based on record review and interviews with agency and facility staff, the facility failed to administer medications as ordered. This affected 23 of 23 residents (#328, #330, #332, #333, #334, #335, #336, #337, #338, #339, #340, #344, #345, #346, #350, #351, #352, #353, #354, #356, #357, #358, #359) reviewed for medications. The census was 42.

Findings include:

1. Review of the medical record for Resident #354 revealed an admission date of 04/21/23. Diagnoses included bipolar disorder, type 2 diabetes mellitus, Alzheimer's Disease, insomnia and hypertension.

Review of the service plan for Resident #354 revealed he needed assistance with medication.

Review of Resident #354's medication orders revealed Resident #354 had orders including Divalproex sodium (medication taken for seizures) 500 milligrams (mg) one tablet at 7:00 P.M., Losartan Potassium (medication taken for hypertension) 50 mg one tablet at 9:00 A.M., Melatonin (medication taken for insomnia) 3 mg one tablet at 7:00 P.M., Metformin (medication for diabetes mellitus) 1000mg one tablet at 9:00 A.M., and Seroquel (medication for bipolar) 100 mg 1.5 tablet at 7:00 P.M.

Review of the Medication Administration Record (MAR) revealed on 05/29/24 the A.M. medications were marked as other/see nurses note and the P.M. medications were left blank.

Review of the progress noted dated 05/29/24 and timed at 12:52 P.M. authored by Agency Licensed Practical Nurse (LPN) #800 revealed unable to administer.

Interview on 06/07/24 at 10:40 A.M. with Resident #354 revealed he stated he received morning medication on 05/29/24 however did not receive any nighttime medication. He specifically mentioned Depakote and Seroquel stating he did not sleep well that night.

Interview on 06/07/24 at 1:22 P.M. with Executive Director revealed he was aware of the issue with medications on 05/29/24 when he learned Resident #354 was searching for the nurse. He did not investigate the reason why the medications were not given.

2. Review of the medical record for Resident #328 revealed an admission date of 06/26/21. Diagnoses included polyneuropathy, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, essential hypertension and hypothyroidism.

Review of Resident #328's medication orders revealed Resident #328 had orders including Levothyroxine (thyroid medication) 75 mcg one tablet daily at 8:00 A.M., Zoloft (antidepressant medication) 25 mg at 7:00 P.M.

Review of the MAR on 05/29/24 revealed the A.M. medications were marked as other/see nurses note and the P.M. medications were left blank.

Review of the progress note dated 05/29/24 and timed 12:50 P.M. and authored by LPN #800 revealed unable to administer.

3. Review of the medical record for Resident #330 revealed an admission date of 05/05/23. Diagnoses include unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Parkinson's Disease, major depressive disorder, epilepsy and chronic obstructive pulmonary disorder.

Review of Resident #330's medication orders revealed Resident #330 had orders including Cozaar (medication to treat hypertension) 25 mg one tablet daily at 9:00 A.M., Synthroid (medication to treat thyroid) 75 mcg one tablet daily at 9:00 A.M., Lamictal (medication to treat epilepsy) one tablet 25 mg daily at 9:00 A.M. and 7:00 P.M., Melatonin 3 mg one tablet at 7:00 P.M.

Review of the MAR on 05/29/24 revealed the A.M. medications were marked as other/see nurses note and the P.M. medications were blank.

Review of the nurse's note dated 05/29/24 and timed for 12:45 P.M. authored by LPN #800 revealed a note that was struck out stating unable to administer replaced with declined order.

4. Review of the medical record for Resident #332 revealed an admission date of 05/23/24. Diagnoses included unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, other insomnia and essential hypertension.

Review of Resident #332's medication orders revealed Resident #332 had orders including Lisinopril (medication for hypertension) 2.5 mg one tablet at 9:00 A.M., Melatonin (mediation for insomnia) 3 mg one tablet at 7:00 P.M., Meloxicam (medication for pain) 7.5 mg 1 tablet at 8:00 A.M., Seroquel (medication for dementia) 25 mg 0.5 tablet at 7:00 P.M., Sertraline (medication for major depression) 50 mg one tablet at 7:00 P.M.

Review of the MAR on 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 1:01 P.M. authored by LPN #800 revealed unable to administer.

5. Review of the medical record for Resident #333 revealed an admission date of 10/11/23. Diagnoses included Alzheimer's Disease early onset, major depressive disorder, anxiety disorder and hypertension.

Review of Resident #333's medication orders revealed Resident #333 had orders including Lisinopril (medication for hypertension) 2.5 mg one tablet at 9:00 A.M., donepezil HCI (medication for Alzheimer's Disease) 10 mg one tablet at 7:00 P.M., Sertraline HCI (medication for anxiety) 50 mg 1.5 tablets at 9:00 A.M., Mirtazapine (medication for Alzheimer's Disease) 7.5 mg one tablet at 7:00 P.M., Hydroxyzine HCI (medication for anxiety/agitation) 25mg two times a day at 9:00 A.M. and 7:00 P.M., Memantine HCI (medication for behaviors related to Alzheimer's Disease) 10 mg 1 tablet at 9:00 A.M. and 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:59 P.M. authored by LPN #800 revealed unable to administer.

6. Review of the medical record for Resident #334 revealed an admission date of 06/02/23. Diagnoses included unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, hypertension, other anxiety disorders and osteoarthritis.

Review of Resident #334's medication orders revealed Resident #334 had orders including Amlodipine Besylate (medication for hypertension) 5 mg 1 tablet at 9:00 A.M. and Triamterene-HCTZ (medication for hypertension) 25mg one capsule at 9:00 A.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note.

Review of the nurse's note dated 05/29/24 and timed for 12:55 P.M. authored by LPN #800 revealed unable to administer.

7. Review of the medical record for Resident #335 revealed an admission date of 03/27/21. Diagnoses included essential hypertension, hypertensive retinopathy bilateral, anxiety disorder and unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety.

Review of Resident #335's medication orders revealed Resident #335 had orders including Citalopram (medication for anxiety) 20 mg one tablet at 9:00 A.M., Lorazepam (medication for anxiety) 0.5 mg one tablet at 9:00 A.M. and Donepezil (medication for dementia) 10 mg one tablet at 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:51 P.M. authored by LPN #800 revealed unable to administer.

8. Review of the medical record for Resident #336 revealed an admission date of 09/19/22. Diagnoses included essential hypertension, Alzheimer's Disease, chronic obstructive pulmonary disease and type 2 diabetes mellitus.

Review of Resident #336's medication orders revealed Resident #336 had orders including Norvasc (medication for hypertension) 10 mg one tablet at 9:00 A.M., Losartan (medication for hypertension) 50 mg one tablet at 9:00 A.M. and 5:00 P.M. and Seroquel (medication for Alzheimer's Disease) 50 mg 1 tablet at 9:00 A.M. and 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note. The 5:00 P.M. medication was administered. The 7:00 P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:58 P.M. authored by LPN #800 revealed unable to administer.

9. Review of the medical record for Resident #337 revealed an admission date of 02/23/22. Diagnoses included unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, unspecified atrial fibrillation, Alzheimer's Disease and hypertension.

Review of Resident #337's medication orders revealed Resident #337 had orders including Digoxin (medication for atrial flutter) 125 mcg 1 tablet at 9:00 A.M., Melatonin (medication for insomnia) 10 mg one tablet at 7:00 P.M., Synthroid (medication for hypothyroidism) 125 mcg one tablet at 9:00 P.M., Xarelto (Medication to thin blood) 15 mg one tablet at 7:00 P.M., Diltiazem HCI ER (medication for hypertension) 180 mg one capsule twice a day at 9:00 A.M. and 7:00 P.M. and Losartan (medication for hypertension) 50 mg one tablet twice a day at 9:00 A.M. and 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 1:07 P.M. authored by LPN #800 revealed unable to administer.

10. Review of the medical record for Resident #338 revealed an admission date of 09/14/2022. Diagnoses included essential hypertension, Alzheimer's Disease and major depressive disorder. Review of Resident #338's medication orders revealed Resident #338 had orders including Lexapro (medication for depression) 10 mg one tablet at 9:00 A.M., Lisinopril (medication for hypertension) 10-12.5 mg one tablet at 9:00 A.M., Seroquel (medication for anxiety and agitation) 25 mg three times a day at 9:00 A.M., 1:00 P.M. and 7:00 and Melatonin (medication for insomnia) 10 mg one tablet at 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:56 P.M. authored by LPN #800 revealed unable to administer.

11. Review of the medical record for Resident #339 revealed an admission date of 03/28/24. Diagnoses included unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, hypothyroidism and Guillain-Barre Syndrome.

Review of Resident #339's medication orders revealed Resident #339 had orders including Synthroid (medication for hypothyroidism) 50 mcg two tablets every Monday, Tuesday, Wednesday, Thursday and Friday at 8:00 A.M.

Review of the MAR on 05/29/24 revealed the A.M. medication was marked as other /see nurses note.

Review of the nurse's note dated 05/29/24 and timed for 1:07 P.M. authored by LPN #800 revealed unable to administer.

12. Review of the medical record for Resident #340 revealed an admission date of 02/02/23. Diagnoses included essential hypertension, unspecified atrial fibrillation, dementia in other diseases classified elsewhere, mild with psychotic disturbance and insomnia.

Review of Resident #340's medication orders revealed Resident #340 had orders including Metoprolol Succinate ER (medication for hypertension) 25 mg one tablet at 9:00 A.M., Mirtazapine (medication for depression) 15 mg one tablet at 7:00 P.M., Eliquis (medication for atrial fibrillation) 5 mg one tablet twice a day at 9:00 A.M. and 7:00 P.M., Flecainide Acetate (medication for atrial fibrillation) 50 mg twice a day at 9:00 A.M. and 7:00 P.M. and Seroquel (medication for behaviors) 25mg twice a day at 9:00 A.M. and 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:58 P.M. authored by LPN #800 revealed unable to administer.

13. Review of the medical record for Resident #344 revealed an admission date of 10/04/23. Diagnoses included Alzheimer's Disease, urinary tract infection, unspecified dementia unspecified severity with agitation.

Review of Resident #344's medication orders revealed Resident #344 had orders including Amlodipine Besylate (medication for hypertension) 5 mg one tablet at 9:00 A.M., Melatonin (medication for insomnia) 3 mg at 7:00 P.M., Sertraline (medication for dementia/agitation) 50 mg one tablet at 9:00 A.M., Bactrim DS 800 (medication for urinary tract infection) 160 mg one tablet at 8:00 A.M. and 7:00 P.M., Depakote (medication for dementia/agitation) 125 mg one capsule twice a day at 8:00 A.M. and 7:00 P.M.

Review of the MAR revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:51 P.M. authored by LPN #800 revealed unable to administer.

14. Review of the medical record for Resident #345 revealed an admission date of 10/14/19. Diagnoses included mild cognitive impairment of uncertain or unknown etiology, essential hypertension and major depressive disorder.

Review of Resident #345's medication orders revealed Resident #345 had orders including Amlodipine (medication for hypertension) 5 mg one tablet at 7:00 P.M., Levothyroxine (medication for hypothyroidism) 88 mcg one tablet at 7:00 P.M. and escitalopram (medication for depression) 10 mg one tab at 9:00 A.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:53 P.M. authored by LPN #800 revealed unable to administer.

15. Review of the medical record for Resident #346 revealed an admission date of 10/30/23. Diagnoses included unspecified dementia unspecified severity without behavioral disturbance mood disturbance and anxiety, type 2 diabetes mellitus and angina pectoris.

Review of Resident #346's medication orders revealed Resident #346 had orders including Amlodipine Besylate (medication for hypertension) 2.5 mg one tablet at 9:00 A.M., Melatonin (medication used as a sleep aid) 3 mg one tablet at 7:00 P.M. and Metformin HCI (medication for diabetes) 500 mg one tablet at 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:57 P.M. authored by LPN #800 revealed unable to administer.

16. Review of the medical record for Resident #350 revealed an admission date of 02/26/21. Diagnoses included Alzheimer's Disease, cachexia and mild cognitive impairment.

Review of Resident #350's medication orders revealed Resident #350 had orders including Donepezil HCI (medication for dementia) 5 mg two tablets at 7:00 P.M.

Review of the MAR for 05/29/24 revealed the P.M. medication was left blank. There was no progress related to missing night time medication.

17. Review of the medical record for Resident #351 revealed an admission date of 6/26/22 and was at the hospital during the survey. Diagnoses included generalized anxiety disorder, essential hypertension, chronic obstructive pulmonary disease and unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety.

Review of Resident #351's medication orders revealed Resident #351 had orders including Melatonin (medication for insomnia) 3 mg one tablet at 7:00 P.M., Sertraline HCI (medication for depression) 100 mg one tablet at 9:00 A.M., Verelan Oral Capsule Extended Release (medication for hypertension) 240 mg 1 capsule at 7:00 P.M., Apixaban (medication for atrial fibrillation) 2.5 mg one tablet twice a day at 9:00 A.M. and 7:00 P.M., Cipro Oral (medication for a urinary tract infection) 500 mg one tablet twice a day at 8:00 A.M. and 7:00 P.M., Sinemet Oral (medication for Parkinson's Disease) 100 mg one tablet three times a day at 8:00 A.M., 2:00 P.M. and 7:00 P.M.

Review of the MAR for 05/29/24 revealed the 9:00 A.M. were marked as other/see nurses note and the 7:00 P.M. medication was left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:50 P.M. authored by LPN #800 revealed unable to administer.

18. Review of the medical record for Resident #352 revealed an admission date of 03/26/22. Diagnoses included essential hypertension, type 2 diabetes mellitus and unspecified dementia.

Review of Resident #352's medication orders revealed Resident #352 had orders including Amlodipine Besylate (medication for hypertension) 5 mg one tablet at 9:00 A.M., Gilmepiride (medication for diabetes) four mg one tablet at 9:00 A.M., Hydrochlorothiazide (medication for hypertension) 25 mg one tablet at 9:00 A.M., Levothyroxine Sodium (medication for hypothyroidism) 88 mcg one tablet at 9:00 A.M., Lisinopril (medication for hypertension) 40 mg one tablet at 9:00 A.M., Melatonin (medication for insomnia) 5 mg one tablet at 7:00 P.M. and Metformin HCI ER (medication for diabetes) 500 mg one tablet twice a day at 9:00 A.M. and 7:00 P.M.

Review of the MAR revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:53 P.M. authored by LPN #800 revealed unable to administer.

19. Review of the medical record for Resident #353 revealed an admission date of 01/26/24. Diagnoses included unspecified sequelae of cerebral infarction, vascular dementia, essential hypertension and presence of cardiac pacemaker.

Review of Resident #353's medication orders revealed Resident #353 had orders including Lisinopril oral (medication for hypertension) 2.5 mg one table at 9:00 A.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note. Review of the nurse's note dated 05/29/24 and timed for 12:57 P.M. authored by LPN #800 revealed unable to administer.

20. Review of the medical record for Resident #356 revealed an admission date of 06/27/23. Diagnoses included type 1 diabetes mellitus, unspecified dementia, nonrheumatic mitral prolapse and irritable bowel syndrome.

Review of Resident #356's medication orders revealed Resident #356 had orders including Byetta 10 MCG Pen Subcutaneous Solution Pen Injector (medication for diabetes) inject 10 units subcutaneously at 8:00 A.M., Lantus Subcutaneous Solution 100 Unit/ML (medication for diabetes) inject 15 units subcutaneously at 7:00 P.M., Lisinopril (medication for hypertension) 20 mg one tablet at 9:00 A.M., Singulair (medication for asthma) 10 mg one tablet at 7:00 P.M. and Synthroid (medication for hypothyroidism) 50 mcg one tablet at 9:00 A.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:53 P.M. authored by LPN #800 revealed unable to administer.

21. Review of the medical record for Resident #357 revealed an admission date of 02/10/23. Diagnoses included Alzheimer's Disease, cerebral infarction, essential hypertension and type 2 diabetes mellitus.

Review of Resident #357's medication orders revealed Resident #357 had orders including Metformin HCI (medication for diabetes) 500 mg one tablet at 9:00 A.M., Sertraline HCI (medication for major depressive disorder) 50 mg one tablet at 9:00 A.M., Amlodipine Besylate (medication for hypertension) 5 mg one tablet twice a day at 9:00 A.M. and 7:00 P.M., Carvedilol (medication for hypertension) 25 mg one tablet twice a day at 9:00 A.M. And 7:00 P.M. and Losartan Potassium (medication for hypertension) 25 mg one tablet twice a day at 9:00 A.M. and 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:52 P.M. authored by LPN #800 revealed unable to administer.

22. Review of the medical record for Resident #358 revealed an admission date of 01/06/20. Diagnoses included essential hypertension, hypothyroidism, unspecified dementia and major depressive disorder.

Review of Resident #358's medication orders revealed Resident #358 had orders including Levothyroxine (medication for hypothyroidism) 50 mcg one tablet at 9:00 A.M., Meloxicam (medication for pain) 7.5 mg one tablet at 9:00 A.M. and Memantine (medication for dementia) 5 mg one tablet twice a day at 9:00 A.M. and 7:00 P.M.

Review of the MAR for 05/29/24 revealed the A.M. medications were marked as other /see nurses note and the P.M. medications were left blank.

Review of the nurse's note dated 05/29/24 and timed for 12:52 P.M. authored by LPN #800 revealed unable to administer.

23. Review of the medical record for Resident #359 revealed an admission date of 12/17/19. Diagnoses included essential hypertension, hypothyroidism, dementia, , anxiety disorder and major depressive disorder.

Review of Resident #359's medication orders and MAR for 05/29/24 revealed Resident #359 had orders including Percocet (medication for pain) 325 mg one tablet at 7:00 P.M. and the P.M. medications were left blank.

Interview and observation on 06/07/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #215 revealed his computer screen showing the MAR on 5/29/24. The screen was pink. LPN #215 explained it meant the medication was not given. He confirmed the agency nurse who worked on 05/29/24 had access to their system. He checked a binder with printed MARs for when there was no computer access. There were only two dates printed which were 05/13/24 and 05/26/24. LPN #215 showed the screen for current medication pass which was either white or green indicating it was due or was given.

Interviews on 06/07/24 at 3:45 P.M. with the District Director of Clinical Services (DDCS) #214 revealed she did not know the extent of the medication issue until today. She believed the facility thought it was only one resident affected (Resident #354).

Interview on 06/07/24 at 4:23 P.M. with Agency LPN (LPN) #219 revealed she picked up the shift when she saw it posted at 10:45 A.M. on the agency website on 05/29/24 arriving at 11:27 A.M. She stated by the time she got access to the computer it was closer to 12:00 P.M. She stated she saw the morning (9:00 A.M) medications were not administered. She stated she attempted to contact the physicians to get orders to administer medications since it was now out of the range. She did not receive any return calls. She stated she administered the medications due during her shift (12:00 P.M.-6:00 P.M.). She stated she later learned the facility expected the dayshift nurse to pass the 7:00 P.M. medications at 6:00 P.M. rather than leaving them for the nightshift. She stated she let the next shift know about the medication issue.

Review of the facility policy titled Medication and Treatment-General Guidelines for Medication Administration/Assistance

Based on interview and record review, the facility failed to ensure there was enough staff to meet the needs of the residents. This affected one of three residents reviewed, Resident #38. Facility census was 47.

Findings include:

Review of the medical record for Resident #38 revealed an admission date of 08/04/23. Diagnoses included dementia without behavioral disturbance, hypothyroidism, and hypokalemia.

Review of the Montreal Cognitive Assessment Test (MoCA) dated 10/15/23 revealed Resident #38 was moderately cognitively impaired.

Review of physician's orders for March 2024 revealed Resident #38 was ordered one to one supervision with staff member until further notice every day and night.

Review of the electronic medication administration record (eMAR) note dated 03/09/24 timed at 7:46 P.M. revealed one to one with staff member for Resident #38 did not occur due to not enough staff.

Review of the eMAR note dated 03/10/24 timed at 7:43 P.M. revealed one to one with staff member for Resident #38 did not occur due to no staff available.

Review of eMAR note dated 03/12/24 timed at 8:16 P.M. revealed one to one with staff member for Resident #38 did occur on second shift but not on third shift due to not enough staff.

Interview on 03/14/24 at 6:45 A.M. with Licensed Practical Nurse (LPN) #210 revealed staffing could be better. If they had three aides, it was okay but when they only had one aide in memory care (MC) and one aide in assisted living (AL) it was hard to complete their work as assigned and meet the needs of the residents. LPN #210 said Resident #38 was supposed to have one to one staff supervision but that did not occur because there was not enough staff.

Interview on 03/14/24 at 6:52 A.M. with Caregiver (CG) #220 revealed staffing could be better. If they only had one aide in MC, it was hard to meet the needs of the residents in a timely manner. CG #220 felt there should be two aides in MC to ensure that the ordered one on one supervision could be done for Resident #38.

During an interview on 03/14/24 at 2:30 P.M. with Registered Nurse Corporate Care Manager and Health and Wellness Director (HWD) #296, HWD #296 verified the eMAR notes indicated the one on one supervision for Resident #38 was not being consistently implemented.

This violation represents non-compliance investigated under Complaint Number OH00152078, OH00152003 and OH00150774.

Based on observation, medical record review, policy review and interview, the facility failed to ensure a key was available and readily accessible at all times in the memory care unit to open Resident #47's door which staff were locking while Resident #47 was in the room to prevent another resident from entering the room. This affected one (Resident #47) of three residents reviewed for abuse. The census was 47.

Finding include:

Review of the medical record for Resident #47 revealed an admission date of 12/17/19 with diagnoses of dementia without behavioral disturbance, major depressive disorder, anxiety disorder, and amnesia. Resident #47 was on hospice services and resided on the third-floor, secured memory care unit.

Review of the Montreal Cognitive Assessment Test (MoCA) dated 10/15/23 revealed that Resident #47 was severely cognitively impaired.

Review of the Personal Service Assessment dated 12/04/23 revealed Resident #47 wandered requiring redirection, had difficulty with orientation to person, place or time and had difficultly communicating needs and preferences (verbally and nonverbally).

Review of Resident #47's service plan updated 12/04/23 revealed there was no evidence Resident #47's room door was to be locked.

Review of the nurses' notes dated 03/05/24 timed at 6:50 P.M. revealed Resident #38 tried coaxing Resident #47 into his room several times after dinner and the nurse had to keep redirecting him. At one point he seemed to hide around the comer wailing for Resident #47 to come down and then tried to go into her room. Resident #47 became agitated, made the motion no with her hands then grabbed her own breasts. The nurse continued to monitor the situation until Resident #47 was ready for bed. The nurse then locked Resident #47's door to prevent Resident #38 from entering and Resident #38 finally went to the living room to watch television. Health and Wellness Director ( HWD) #296 was made aware and the oncoming shift was advised to continue monitoring throughout the night.

Observation on 03/26/24 at 7:25 A.M. revealed upon arriving at Resident #47's room the door was closed and locked so that it could not be entered from the outside. Interview, at the time of the observation, with LPN #275, Caregiver #300 and Caregiver #218 revealed none of the staff on the secured memory unit had a master key to open Resident #47's door. They confirmed Resident #47 was in the room. They indicated the night shift nurse (LPN #242) had the master key and she was currently on the second floor. LPN #275 said there were always caregivers on the secured memory care unit during the night, but the night shift nurse had shared duties of the assisted living on the second floor and the memory care on the third floor during the night and was not always present on the secured memory care unit. The door had been locked to prevent Resident #38 from entering the room.

Interview on 03/26/24 at 8:05 A.M. with Caregiver #311 revealed the staff had been locking Resident #47's room at night so Resident #38 could not get to her because Resident #38 sought out Resident #47.

Interview on 03/26/24 at 8:15 A.M. with LPN #242 revealed the staff locked Resident #47's door at night for Resident #47's safety since Resident #38 was entering her room.

Interview on 03/26/24 at 8:25 A.M. with Caregiver #310 revealed she assisted Resident #47 getting up in the morning and going to bed at night. The staff locked her door from the outside so Resident #38 could not enter her room however Resident #47 could still exit the room.

Interview on 03/26/24 at 10:35 A.M. with HWD #296 with Registered Nurse Corporate Care Manager (RNCCM) #312 present revealed caregivers did not have master keys to open the doors to resident rooms. HWD #296 and RNCCM #312 said Resident #47's door should not be locked.

Observation on 03/26/24 at 10:55 A.M. with LPN #275 revealed Resident #47's door was locked. LPN #275 used a key to unlock and open the door. Resident #47 was lying in bed, sleeping.

Review of the facility's Room Access policy dated June 2021 revealed doors to resident bedrooms or suites would remain unlocked unless the resident requested it to be locked and the resident was able to demonstrate the independent use of a key. Resident room access would comply with local fire department regulations. Entry door to resident rooms would remain unlocked unless the resident was on hospice, unable to ambulate and either he/she or the responsible party had requested the door to be locked for reasons of solitude or privacy. Associates should have access at all times to residents' room and should carry a universal key to facilitate entry. The community should contact the district team and the Divisional Dementia Care Manager (DDCM) for additional accommodations requested outside this policy. Documentation should be placed in the resident's record /service plan specifying the resident/responsible party's request for locking of resident's door and resident's ability to demonstrate they could navigate a key in the care plan. The community was to contact the DDCM, District Director of Clinical Service (DDCS) and the District Director of Operations for discussion of those residents who were not engaged and evidence a wandering behavior that had been disruptive.

Based on observation, interview, review of medical records, review of local Police Department report, and review of the facility's policies and procedures for Sexuality and Intimacy, Room Access, and Abuse, Neglect and Exploitation, the facility failed to ensure cognitively impaired female Resident #47 was free from sexual abuse by a sexually aggressive, cognitively impaired male resident, Resident #38. Residents #47 and #38 resided on the secured memory care unit. In addition, the facility failed to implement the facility's Sexuality and Intimacy policy and procedure, update the residents' service plans to reflect sexual behaviors, conduct an interdisciplinary team (IDT) meeting with the residents' representatives, notify the residents' physicians and/or nurse practitioner of repeated intimate contact and Resident #47's negative reactions to the contact, ensure one-to-one supervision which was implemented for the safety of female residents was consistently implemented, and prevent staff from resorting to locking Resident #47's door after she retired for the night to keep Resident #38 from entering. This resulted in Real and Present Danger and negative psychosocial outcome for Resident #47 and had the potential for serious harm, injuries and/or negative health outcomes when on 02/20/24 at approximately 7:30 P.M. Resident #38 began displaying sexually aggressive behaviors towards Residents #40 and #47 then began to target Resident #47 consistently over the next several weeks without appropriate action being taken to identify Resident #47's ability to consent and protect Resident #47 from continued sexual abuse/sexually aggressive advances and contact. This affected one resident (#47) and had the potential to affect all 22 female residents (Residents #20, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #44, #45, #46 and #47) residing in the facility memory care unit. The census was 47.

On 03/25/24 at 3:58 P.M., the Administrator, Health and Wellness Director (HWD) #296, Registered Nurse Corporate Care Manager (RNCCM) #312 and Registered Nurse Area Nurse Manager (RNANM) #314 were notified Real and present Danger began on 02/17/24 at approximately 7:30 P.M. when Resident #38, who was cognitively impaired and resided in the secured memory unit, began displaying sexually aggressive behaviors towards female residents, specifically Residents #40 and #47, who were also cognitively impaired and resided in the secured memory care unit. Resident #38 was observed kissing Resident #40 on the lips and Resident #38 was observed coaxing Resident #47 into his room. Resident #47 was found in Resident #38's room on multiple occasions with Resident #38 kissing Resident #47, sucking on Resident #47's fingers, and with his pants below his knees. Resident #47's medical record included documentation indicating Resident #47 had negative reactions related to the contact and was noticeably fearful when the hospice chaplain visited.

The Real and Present Danger was abated on 04/01/24 when the facility implemented the following corrective actions:

On 03/25/24, one-to-one staff supervision for Resident #38 was restarted. HWD #296/designee confirmed compliance with one-to-one supervision by auditing the nursing schedule each shift daily. At this time, the schedule was made through 03/27/24 at 3:00 P.M. and Resident #38's representative approved the facility to utilize a staffing agency to ensure one-to-one supervision was maintained if needed.

On 03/25/24 at 4:30 P.M., a conference call was held to discuss, formulate and implement a corrective action plan. This conference call was led by District Director of Operations (DDO) #320 with the Administrator, HWD #296, Associate General Counsel #321, Vice President of Operations East Division #322, RNANM #314, Division Director of Clinical Operations (DDCO) #323 and Vice President of Clinical Services (VPCS) #324.

On 03/26/24 at 12:30 P.M., a conference call was held with the Administrator, HWD #296, RNCCM #312, RNANM #314, DDO #320, DDCO #323, Associate General Counsel #321 and the Division Dementia Care Manager (DDCM) #325 to further discuss the corrective action plan and implementation.

On 03/26/24, HWD #296/designee audited nursing progress notes from February 2024 to March 2024 for all the other female residents residing on the secured memory unit. The facility audit concluded no other females were affected by sexual abuse.

On 03/27/24, DDO #320 educated the Administrator and HWD #296 on the facility's Sexuality and Intimacy policy and Abuse, Neglect and Exploitation policy.

On 03/27/24, HWD #296 and the Administrator reviewed the daily communication log for reports of physical intimacy between memory care residents. The review would continue weekly for four weeks. All reports of physical intimacy would be evaluated and responded to in accordance with the facility's Sexuality, and Intimacy and Abuse, Neglect and Exploitation policies.

Between 03/28/24 and 04/01/24, HWD #296 completed skin checks on all female residents with no concerns noted from the checks.

By 03/29/24, the Administrator, HWD #296, RNCCM #312 and RNANM #314 held care conferences with Residents #38 and #47's representatives to discuss the sexual intimacy and obtain their input.

On 03/29/24, the Administrator, HWD #296 and Resident #38's physician made the decision to continue the one-to-one supervision for Resident #38.

By 03/31/24, the Administrator/designee had re-educated all staff on the facility's Sexuality and Intimacy policy. Review of the policy revealed it was comprehensive and provided appropriate and sound direction to staff which would ensure the rights and safety of all residents.

By 03/31/24, the Administrator/designee re-educated all staff on the facility's Abuse, Neglect and Exploitation policy.

By 03/31/24, the Administrator/designee re-educated all staff assigned the secured memory care unit on the facility's Room Access policy and not to lock resident rooms.

On 04/01/24, the Administrator and HWD #296 contacted the physician for Resident #38 and the NP for Resident #47 to further discuss and review the resident's needs.

On 04/01/24, based on assessments, care conferences, discussions with Resident #38's physician, and Resident #47's NP, the decision was made to issue an immediate discharge notice to Resident #38 and Resident #38's son/POA once an appropriate safe and secure memory care unit and/or facility was located and accepted Resident #38. Resident #38, Resident #38's son/POA, the local ombudsman and physician would be involved in the decision regarding discharge location and appropriateness to meet Resident #38's needs. Until a safe discharge was arranged and carried out, one-to-one supervision would continue for Resident #38. HWD #296/designee would continue to ensure compliance with one-to-one supervision by making a staff schedule in advance and auditing the nursing schedule every shift.

On 04/01/24, HWD #296 updated the Service Plans for Residents #38 and #47.

By 04/05/24, HWD #296/designee would review and revise Service Plans for all female resident's residing on the secured memory unit.

Although the Real and Present danger was abated on 04/01/24, the violation remained as the facility was in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.

Findings include:

Review of the medical record for Resident #47 revealed an admission date of 12/17/19 with diagnoses of dementia without behavioral disturbance, major depressive disorder, anxiety disorder, and amnesia. Resident #47 was on hospice services and resided on the secured memory care unit.

Review of the Montreal Cognitive Assessment (MoCA) dated 10/15/23 revealed Resident #47 was severely cognitively impaired. Review of the service plan dated 12/04/23 revealed Resident #47 had behaviors of dressing or undressing in inappropriate places and was exit seeking.

Review of the Personal Service Assessment dated 12/04/23 revealed Resident #47 wandered requiring redirection, had difficulty with orientation to person, place or time and had difficultly communicating needs and preferences (verbally and nonverbally).

Review of the psychiatry nurse practitioner progress note dated 01/24/24 revealed Resident #47 was nonsensical and confused and had episodes of agitation. Resident #47 was alert to name only, had disorganized thought process, poor short-term and long-term memory, poor insight, and poor judgment.

Review of the nurse progress notes dated from 10/02/23 through 02/17/24 revealed Resident #47 was anxious, refused care, had behaviors of pouring liquids on food at mealtimes, was exit seeking and asked for late husband at times.

Review of the hospice nurse progress note dated 02/20/24 timed at 5:12 P.M. revealed staff reported that Resident #47 was mistaking one of the residents for her late husband and was often coerced into his room or chased by him (resident not identified) and it gave her more anxiety. The note indicated staff were monitoring the situation.

Review of the nurse's progress note dated 03/06/24 timed at 6:38 P.M. revealed Resident #47 was found in Resident #38's bed. Resident #38 was kissing her, and his pants were down to his knees. The nurse removed Resident #47 from the situation and Resident #38 continued to seek her out. Resident #47 became tearful at dinner and did not eat. HWD #296 advised caregivers to monitor throughout the night.

Review of the nurse's progress note dated 03/07/24 timed at 12:31 P.M. revealed the power of attorney (POA) for Resident #47 was notified about Resident #47's and Resident #38's current relationship and behaviors. The note indicated the POA was excited for her mother and stated, GO MOM, how awesome is that, at her age and state. I am happy for her. The note included the nurse explained Resident #47 had been in Resident #38's bed and gave full details. The daughter stated, She has my blessings and consent. Please keep me updated on this budding romance.

Review of the nurse's progress note dated 03/08/24 timed at 6:59 P.M. revealed Resident #38 repeatedly asked Resident #47 to come to his room and she repeatedly resisted. Resident #47 became visibly upset and would not go down the hallway near Resident #38. The nurse escorted her to her room where she was changed and then laid down. This nurse stayed with Resident #47 for a while as she stated, Please don't leave me. The note further indicated at the time of the entry Resident #47 was resting and all parties had been notified.

Review of the nurse's progress note dated 03/08/24 timed 8:30 P.M. revealed a local police officer was at the facility. The officer indicated he was following up on a call to from the Area Agency on Aging (AAA) and he needed to speak with Resident #47 to determine/establish the baseline cognition status. The nurse escorted the officer to Resident #47's room and remained present while he asked questions. There was no other information in the progress notes to indicate why the AAA asked for the assessment or why such an assessment would be conducted by the local police.

Review of the Police Department Investigative Report for a Welfare Check dated 03/08/24 authored by Police Officer (PO) #316 revealed, on 03/08/24 at approximately 8:12 P.M., the PO responded to the facility for a sex offence report. On scene at facility, the PO made contact over the phone with Adult Protective Services (APS) Supervisor #315. APS Supervisor #315 stated that APS received a complaint from a nurse that worked at the facility about a male resident possibly interacting inappropriately with a female resident. After speaking with APS Supervisor #315, the PO went into the facility and was able to make contact with both Resident #38 and Resident #47. Both residents were found to be staying in the facility's memory care lock down unit. While on scene, the PO spoke with the nurse working night shift [LPN #242] and she stated that she was aware of the situation, and they were keeping a close eye on the two residents due to the accusations. The caller stated that she contacted the State Ombudsman to make a report and have them investigate the incident. APS Supervisor #315 requested a welfare check on the female resident for the evening and that the incident be documented.

Review of the Police Department Investigative Report Supplement dated 03/08/24 authored by PO #316 revealed, on scene at facility, the PO was able to make contact with Resident #47 first. Resident #47 was found in her bedroom with the door locked. Staff at the facility was able to PO #316 in the room where PO #316 made contact with Resident #47. Resident #47 was found to be incoherent. Resident #47 was unable to communicate any concerns or issues that she had. Resident #47 was unable to answer any questions PO #316 asked. While speaking with Resident #47, the on-duty nurse, [LPN #242], arrived at the room and stated that she was aware of the allegations. The nurse stated that Resident #47's current mental status was normal for her. The nurse stated that this had been an ongoing issue over the last month or so. She said that on 03/07/24 Resident #38 had Resident #47 in his room and both were in his bed. Resident #38 was found with no clothing on from the waist down. The nurse said the incidents had been documented with the facility but at the time neither of the residents had been moved or placed on a special regulations. The nurse and PO #316 made contact with Resident #38 at his room. Resident #38 was asleep at the time but awoke to speak with PO #316. PO #316 asked Resident #38 simple questions like what the current date was and about what time it was. Resident #38 was unable to answer those questions. PO #316 also asked Resident #38 for his birthdate and names of any friends that he had in the facility, but he was unsure. The nurse stated that Resident #38 was in the memory care unit but still seemed very intelligent. She did not believe he had been diagnosed with a memory loss disease. PO #316 was informed by the nurse and APS Supervisor #315 that Resident #47's daughter who was the POA was notified of the incident and did not seem concerned. The report further indicated APS Supervisor #315 and the nurse made sure to tell PO #316 they were not sure how much information was given to the daughter because the daughter thought it was cute that her mom made a boyfriend. PO #316 noted at the time, there was no allegation of sexual assault. A matter of record was documented due to the circumstances.

Review of the nurse's progress note dated 03/11/24 timed at 11:22 A.M. authored by HWD #296 revealed Resident #47 was walking halls with other residents, staff and by herself that morning. HWD #296 assisted Resident #47 in room. HWD #296 asked Resident #47 who the man was she was walking with, and Resident #47 stated her boyfriend and provided a first name which was not Resident #38's first name. HWD #296 asked Resident #47 if she was afraid or uncomfortable and Resident #47 stated no. Resident #47 stated she wanted to put a bra on and handed the nurse a bra. HWD #296 explained to Resident #47 she already had a bra on. Resident #47 stated, This one will make them look nicer for him. The nurse asked Resident #47, what she would do you do if someone said and did something she did not like and Resident #47 stated, I leave. I just get up and go and say NO! The note indicated Resident #47 showed no signs of discomfort or distress. HWD #296 redirected Resident #47 to activities and she went willingly.

Review of the nurse's progress note dated 03/11/24 timed at 1:41 P.M. revealed Program Coordinator #208 observed Resident #47 exiting out of a male resident's room without her coat or rollator and was walking fast up to the nurse and stated, I hope he dies. Staff recovered her coat and rollator. Resident #47 stayed by the Activities Director's side until activities started.

Review of the nurse's progress note dated 03/12/24 timed at 5:11 P.M. revealed Resident #47 was angry and withdrawn today. Resident #47 would not allow anyone to touch her. Resident #47 became more like herself in the late afternoon but still refused personal care. Resident #47 set off door alarms twice and when redirected she stated, I'm going to kill him. Resident #47 was unable to verbalize anything sensical. Resident #47 eventually allowed the nurse to change her and wash her face and hands and she was currently resting.

Review of the hospice chaplain's progress note dated 03/13/24 timed at 2:13 P.M. revealed the chaplain went to see Resident #47 in the facility to provide spiritual care in the form of conversation and companionship. The chaplain checked with the charge nurse before he connected with Resident #47 for the visit. The charge nurse indicated that Resident #47 had been very anxious and at times aggressive during the day so far. The chaplain found Resident #47 wandering the hallway without her walker. The chaplain noted Resident #47 was fearful and appeared to be trying to get away from something. Notably there was one man in the unit that she appeared to fear. Resident #47's speech was unintelligible, only portions of phases were understandable. The chaplain engaged in a ministry of presence, sitting with Resident #47 in different areas after she walked. The chaplain sought to de-escalate Resident #47 regarding her fears. Resident #47 appeared to be hallucinating and struggled to communicate what her fears really were. While with Resident #47 the chaplain prayed quietly for peace for Resident #47.

Review of the nurse's progress note dated 03/16/24 timed at 7:08 P.M. revealed Resident #47 was sitting in the hallway and refused to go to the dining room for lunch. The nurse and caregiver eventually got her to go but when Resident #47 stood she said, no kissy kissy. HWD #296 notified by caregiver and advised to keep Resident #47 separate from Resident #38.

Review of the nurse's progress note dated 03/17/24 timed at 8:22 P.M. revealed the caregiver was looking for Resident #47 to check for incontinence and change and Resident #47 was found in Resident #38's bed and he was kissing her. The nurse told Resident #47 it was time to get ready for bed and she said, I don't want to be with him. Resident #47 was taken to her room, changed and was in bed resting. Staff advised to continue monitoring.

Review of a general progress note dated 04/01/24 at 2:31 P.M. revealed the nurse asked the nurse practitioner if the resident (Resident #47) was able to consent to intimate encounters. The note documented the NP replied no.

Review of the medical record for Resident #40 revealed an admission date of 06/26/22 with diagnoses of dementia, generalized anxiety disorder, Parkinson's disease, and weakness. Resident #40's daughter was her POA. Resident #40 resided on the secured memory care unit.

Review of the Personal Service assessment dated 01/09/24 revealed Resident #40 had memory loss or cognitive impairment, needed help such as structure, attention, or assistance to accomplish and/or participate in daily routines due to memory loss or cognitive impairment and had difficulty with orientation to person, place, or time.

Review of the MoCA assessment dated 11/13/23 revealed Resident #40 was moderately cognitively impaired.

Review of the nurse progress notes from 02/20/24 to present revealed there was no documentation of Resident #40 being kissed by a male resident.

Review of the medical record for Resident #38 revealed an admission date of 08/04/23 with diagnoses including dementia without behavioral disturbance, memory loss, hypothyroidism, and hypokalemia.

Review of the Personal Service Assessment dated 10/11/23 revealed Resident #38 had memory loss or cognitive impairment and needed help such as structure, attention, or assistance to accomplish and/or participate in daily routines due to memory loss or cognitive impairment.

Review of the MoCA assessment dated 02/27/24 revealed Resident #38 was moderately cognitively impaired. Resident #38 resided on the secured memory care unit.

Review of the nurse's note dated 02/17/24 timed at 7:30 P.M. revealed Resident #38 was walking in the hallway with a female resident (resident not identified). Both residents entered Resident #38's room. The nurse followed both residents into the room and kindly thanked the male resident for looking after the female resident, but that the nurse needed to take her along with her at this time. The male resident continued to try and get the female resident to stay in his room anyway, but the nurse explained that the female resident was coming with her for the night. The female resident agreed and willingly exited Resident #38's room along with the nurse.

Review of the nurse's note dated 02/18/24 timed at 6:31 P.M. revealed Resident #38 was walking with another resident (resident not identified) up and down hallways. Resident #38 was redirected twice during the shift from entering other resident rooms. Resident #38 denied any pain and understood he could not go into a female resident's room. Resident #38 was easy to redirect.

Review of the nurse's note dated 02/20/24 timed at 7:37 P.M. revealed Resident #38 was observed attempting to take a nonverbal resident into his room (resident not identified). Resident #38 was distracted, and the nurse took the female nonverbal resident to her room. The nurse was later informed by an aide that Resident #38 kissed Resident #40 on the mouth. Resident #40 stated she liked it very much. Resident #38 was advised of inappropriate touching of resident; he went to his room and went to sleep.

Review of the nurse's note dated 02/21/24 timed at 12:52 P.M. revealed Resident #38 was trying to take nonverbal resident (specific not identified) of opposite sex to his bedroom. Staff intervened and explained to Resident #38 he could not take the resident into his room. Resident #38 verbalized understanding. The female resident was taken to living room by staff.

Review of the nurse's note dated 02/23/24 timed at 12:23 P.M. revealed Resident #38 approached female resident (resident not identified) while she was sitting in dining room chair, he hugged her and as staff intervened, he tried to kiss her on her lips. Resident #38 was answering to the female's late husband's name, so the female resident believed Resident #38 was her husband. Resident #38 was told by staff that he could not physically touch other residents. Resident #38 was upset and muttered something as he walked away. The nurse was unable to hear what the resident muttered.

Review of Resident #38's service plan with revision date of 02/15/24 revealed Resident #38 had neurological concerns due to dementia with an intervention of notifying the resident's provider of any indictors of decline. In addition, the service plan indicated Resident #38 had cognitive impairment concerns related to dementia and the resident needed help, such as structure, attention, or assistance to accomplish and/or participate in daily routine due to memory loss or cognitive impairment. Resident #38 needed reminders and cueing for daily routines including dressing/grooming, showering/bathing, bathroom help and resident programs. There was no information included in the plan to address Resident #38 being sexually abusive, sexually aggressive and/or targeting a female resident.

Review of the nurse's note dated 02/26/24 timed at 4:30 P.M. revealed Resident #38's brother returned a call to thank the staff for finding out about his urinary tract infection and getting the antibiotic to treat the infection. HWD #296 explained Resident #38 was found in bed with another resident (resident not identified). Both were fully clothed. The residents were awakened and taken to supper.

Review of the nurse's note dated 03/05/24 timed at 6:50 P.M. revealed Resident #38 tried coaxing Resident #47 into his room several times after dinner. The nurse kept redirecting him. At one point he seemed to hide around the corner waiting for the female resident to come down and then tried to go into her room. Resident #47 became agitated, made the motion no with her hands and then grabbed her own breasts. The nurse continued to monitor the situation until Resident #47 was ready for bed. The nurse then locked Resident #47's door to prevent Resident #38 from entering and Resident #38 finally went to the living room to watch television. HWD #296 was notified, and the oncoming shift was advised to continue monitoring throughout the night.

Review of the nurse's note dated 03/06/24 timed at 6:33 P.M. revealed Resident #38 had been trying to coax Resident #47 into his room repeatedly. At approximately 3:00 P.M. Resident #47 was found in Resident #38's bed. Resident #38 was kissing her with his pants down to his knees. The nurse immediately stated that Resident #47 could not be in his room, and he became upset. Resident #38 continued to follow Resident #47 and attempted to get her back into his room. Resident #47 was tearful throughout dinner time. HWD #296 was notified, and caregiver advised to monitor throughout the night.

Review of the nurse's note dated 03/08/24 timed at 7:00 A.M. revealed one to one with staff member and resident (#38) remained in place for the duration of the shift without incident.

Review of the physician progress note dated 03/08/24 timed at 12:15 P.M. revealed Licensed Practical Nurse (LPN) #285 called to report Resident #38 was exhibiting some sexual behavior and had become interested in another resident, following her around and going into her room. The resident (Resident #47) had a bit more progressive dementia than Resident #38. Currently, he (Resident #38) was able to be redirected but LPN #285 was worried that the behavior may escalate and become more unmanageable. The facility pharmacist had recommended a trial of the medication, Tagamet 400 mg twice a day to start. The note further indicated This should provide an antiandrogenic effect that may hopefully reduce this behavior so we will start this medicine and LPN #285 would keep me posted on Resident #38's progress.

Review of the nurse's note dated 03/08/24 timed at 6:56 P.M. revealed Resident #38 repeatedly tried to get Resident #47 into his room, she repeatedly refused and became visibly upset. Resident #38 then eventually went to his room alone. All parties were notified.

Review of the electronic medication administration (e-MAR) note dated 03/08/24 revealed Resident #38 was to always have one- to- one with a staff member until further notice.

Review of the nurse's note dated 03/08/24 timed at 11:45 P.M. revealed a staff member always remained one-to-one with Resident #38. Resident #38 left his room from time to time for a brief walk up and then back down the main hall. Resident #38 was with a staff member during the brief walks. The note indicated the walks were a common occurrence that Resident #38 engaged in nightly. Resident #38 said that he did not like it when the police officer visited him earlier. The nurse reassured him that the police officer was friendly, helpful, and was just there to check on resident safety. Resident #38 replied, I don't buy that. Resident #38 was easily redirected by staff, when needed, and returned to his room without episode.

Review of the e-MAR note dated 03/09/24 timed at 7:46 P.M. revealed one to one with staff member for Resident #38 did not occur due to not enough staff.

Review of the e-MAR note dated 03/10/24 timed at 7:43 P.M. revealed one to one with staff member for Resident #38 did not occur due to no staff available.

Review of the nurse's notes dated 03/11/24 timed at 11:13 A.M. revealed HWD #296 spoke with Resident #38's brother during the shift. HWD #296 explained Resident #38's recent behaviors with female resident. Resident #38's brother stated, As long as he is happy. Please keep me updated and let me know if there is any trouble. HWD #296 stated that Resident #38 started Tagamet. The note further indicated Resident #38 was tolerating the medication well and they would continue to monitor behaviors.

Review of the Behavioral Review with Divisional Dementia Care Manager (DDCM) assessment dated 03/11/24 authored by HWD #296 revealed Resident #38 had been following female residents and touching female residents (hugs, kisses) throughout the day with one female resident in the halls, living room and bedroom. The section of the note titled Solutions indicated Resident #38 was started on Tagamet 400 mg twice a day, currently being treated for a urinary tract infection and test urine again on 03/14/24.

Review of the Survey of Discomfort in Dementia assessment dated 03/11/24 authored by HWD #296 revealed Resident #38 was following and touching female resident throughout the day in the living room, halls and bedroom which had been increasing during the last few weeks. Follow up actions included monitoring per family and physician orders.

Review of the nurse's note dated 03/12/24 timed at 7:05 P.M. revealed Resident #38 was to have one-to-one supervision until further notice. Resident #38 continued to seek out Resident #47 several times a day.

Review of the e-MAR note dated 03/12/24 timed at 8:16 P.M. revealed one-to-one with staff member for Resident #38 did occur on second shift but not on third shift due to not enough staff.

Review of the nurse's progress note for Resident #38 dated 03/17/24 timed 8:31 P.M. revealed the caregiver was looking for Resident #47 to check incontinence brief and change and resident was found in Resident #38's bed and he was kissing her. The nurse told Resident #47 it was time to get ready for bed and she said, I don't want to be with him. Resident #47 was then taken to her room. Resident #38 became frustrated and threw his hands up then began rapidly pacing the halls. Night shift advised to continue to monitor until further notice.

Review of the physician's orders for March 2024 revealed an order dated 03/08/24 for Resident #38 to remain one-to-one with staff member until further notice every day and night for increased observation of resident. The order was discontinued on 03/19/24. Further review of physician orders revealed an order dated 03/11/24 for one tablet of Tagamet 400 mg two times a day for increased libido.

Interview on 03/14/24 at 6:45 A.M. with LPN #210 revealed the police had been at the facility regarding Resident #47. LPN #210 had a concern with Resident #38's actions towards Resident #47 because Resident #47 was not capable of making decisions. LPN #210 stated, the boss told her that Resident #38 must have a need. Resident #38 was supposed to have one to one supervision but that did not occur because there were not enough staff.

Interview on 03/14/24 at 6:52 A.M. with Caregiver #220 revealed she had a concern with Resident #38's actions towards Resident #47 because Resident #47 was not capable of making decisions. Caregiver #220 stated that she observed Resident #47 playing in her own feces and sometimes she was jumpy when they completed perineal care. Caregiver #220 stated she had not personally observed inappropriate contact between Resident #47 and Resident #38.

Interview on 03/14/24 at 7:15 A.M. with Housekeeping Supervisor (HS) #290 revealed one day (date not provided) Resident #47 came running out of Resident #38's room and grabbed HS #290's hand and stated that she didn't want to do anything and left her rollator in Resident #38's room. HS #290 reported this to HWD #296 who said that the family was fine with it, and don't worry about it. She stated, the boss told her that Resident #38 must have a need. HS #290 said Resident #38 was supposed to have one to one supervision but that was not occurring because there was not enough staff.

Observation and interview on 03/14/24 at 8:35 A.M. with Resident #47 revealed she was sitting at the breakfast counter eating breakfast. Resident #47 knew her name and stated she liked it at the facility. No additional information was provided or available during the interview due to the resident's cognitive impairment.

Observation on 03/14/24 at 8:40 A.M. revealed Resident #38 was sitting at a table eating breakfast. Resident #40 came into the dining room and sat with Resident #38.

Observation and interview on 03/14/24 at 8:43 A.M. revealed Resident #47 walking down the hallway towards her room. When asked, Resident #47 stated she was never touched by a man except her husband.

Interview on 03/14/24 at 8:49 A.M. with LPN #285 revealed Resident #47's dementia was progressing. LPN #285 stated Resident #38 chased Resident #47 at times and Resident #47 chased Resident #38 at other times. LPN #285 indicated Resident #47 could hold somewhat of a conversation at times but could not consent to anything. LPN #285 described Resident #38 as being in a hypersexual stage of dementia, but stated he did not feel the resident appeared to be predatory. LPN #285 stated he had spoken to Resident #38's physician on 03/08/24 about considering an order for Tagamet 400 mg two times a day for increased libido because based on his previous experience he knew it could be effective in managing hypersexual behavior and the physician agreed to try the medication.

On 03/14/24 at 9:43 A.M. a telephone interview with Resident #47's daughter/POA revealed she lived in another state and did not routinely see her mother but received weekly updates from Sales Manager #251 about her mother. The POA revealed she was aware her mother was declining, and stated she did not have an issue with her mother being with a male resident because she believed it was for companionship. The POA felt if her mother did not want to do something, she would not do it.

On 03/14/24 at 9:56 A.M. a telephone interview with Resident #38's POA revealed the facility called him and he was told that his father had a behavior of hanging around females lately. The POA stated he was recently informed Resident #38 was hanging around with an older woman and that he found it amusing.

On 03/14/24 at 10:06 A.M. a telephone interview with LPN #275 revealed she worked a lot on the memory care unit. She stated Resident #38 was showing interest in Resident #47 back in February 2024. LPN #275 stated she was concerned, and she brought the concerns up to HWD #296. HWD #296 told LPN #275 that she talked with the POA for Resident #47 and the POA was fine with the situation. LPN #275 stated they were recently educated regarding the situation and HWD #296 stated staff were told it was just human nature and even babies put their hands down their diapers. LPN #275 stated Resident #47 was seen with Resident #38 on 03/06/24; Resident #47 was in his (Resident #38's) bed and Resident #38 had his pants down to his knees.

Observation and interview on 03/14/24 at 12:35 P.M. with Resident #38 revealed he was sitting in the television room watching Animal Planet. Resident #38 stated that he felt safe, and he had plenty of girlfriends. Resident #38 stated that he was a nice guy.

Interviews on 03/14/24 from 6:25 A.M. through 2:00 P.M. with Caregiver #243, LPN #210, LPN #218, Caregiver #220, LPN #275, Program Coordinator #208, Housekeeper #235, Housekeeping Supervisor #290, and LPN #285 revealed Resident #38 had been seen with Resident #47 but each staff member denied observing nudity or sexual touching except kissing. The staff interviewed did voice they were concerned it could escalate and felt management was not being truthful (regarding the situation). The staff reported they had seen Resident #38 with Resident #47 and Resident #40, but not with any other female residents.

Observation of the facility secured memory care unit and review of the facility census revealed there were 22 female residents, Resident #20, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #44, #45, #46 and #47 who currently resided on the unit.

On 03/14/24 at 2:30 P.M. interview with RNCCM #312 and HWD #296 revealed Resident #38's behavior changed recently, and tests showed that he had a urinary tract infection. Resident #47 had been declining cognitively and physically since a fall. HWD #296 stated Resident #47 could carry a conversation at times and other times she could only make a sentence. HWD #296 stated that she contacted Resident #47's and #38's POAs and they had no issues with them being together. HWD #296 stated that she in-serviced the staff regarding the situation and abuse.

Interview on 03/19/24 at 5:20 P.M. with APS Supervisor #318 revealed the APS hotline received two referrals regarding Resident #38 and #47. Since both residents resided at the assisted living, APS referred the case to the State Agency and Ombudsman. APS #318 spoke to Ombudsman Supervisor #319 regarding the referrals.

Observation on 03/25/24 at 7:40 A.M. revealed Resident #38 sitting in the dining room on the memory care unit with two other residents; none of the residents were speaking to each other. Resident #38 was feeding himself breakfast. Caregivers #239 and #272 were assisting with breakfast and LPN #272 was standing at the medication cart facing into the dining room. Interview, during the observation, with LPN #272 revealed he had not observed any sexual behaviors from Resident #38; however, LPN #272 was aware that Resident #38 was recently started on medication to tame down the sexual behaviors.

On 03/25/24 at 7:45 A.M. interview with Caregiver #239 revealed she was told in nursing report recently that Resident #47 was found naked and covered in feces in Resident #38's bed. The caregiver revealed Resident #38 followed Resident #47 everywhere. At times, Resident #47 would say to Resident #38, no, go, go and motion him away. Caregiver #239 took Resident #47 to the bathroom in her room yesterday (03/24/24) and Resident #38 followed Caregiver #239 and Resident #47 to Resident #47's room and stood outside the bedroom door until Resident #47 exited the room. Caregiver #239 reported the staff were told Resident #47's daughter was okay with the relationship between Residents #38 and #47 so the staff let it go. Caregiver #239 reported Resident #47 had not been wanting to get out of bed recently and was nonverbal. Caregiver #239 also stated that Resident #38 was very touchy with staff and other residents, rubbing shoulders, arms, and backs.

On 03/25/24 at 8:35 A.M. interview with Ombudsman Supervisor #319 revealed the ombudsman's office was notified about a situation (involving Resident #47 and Resident #38) from APS. The situation involved a nurse who found a female resident and Resident #38 in Resident #38's bed. Ombudsman Supervisor #319 revealed staff from the ombudsman's office continued to visit the facility to monitor the situation. Ombudsman Supervisor #319 revealed staff from the ombudsman office had not spoken to the local police department and had not reviewed Resident #47's nurse notes in the medical record. Ombudsman Supervisor #319 also stated the ombudsman staff were wondering if Resident #47's daughter/POA had been told the full truth about the situation.

A follow up interview on 03/25/24 at 9:25 A.M. with LPN #275 revealed at the beginning of March 2024, LPN #275 observed Resident #47 lying side-by-side with Resident #38 leaning over kissing her, and Resident #38's pants were down to his knees with his penis exposed. LPN #275 was unsure if Resident #38's penis was erect or not. The week of 03/18/24 the staff could not find either Resident #38 or #47 and when they did find the residents, Resident #47 was in Resident #38's bed, fully clothed with Resident #38 sucking on her fingers with feces underneath Resident #38's fingernails. LPN #275 spoke to Resident #47's daughter once and felt the daughter did not know her mother's current condition/state. Resident #47's hospice nurses agreed Resident #47 was unable to consent due to advanced dementia. LPN #275 stated Resident #47 would wait at the end of the hall for Resident #38 and initially, Resident #47 would go with him because she went with anyone; however, Resident #47 began resisting care especially with a male caregiver at night. Resident #47 would sit in the alcove in the hallway and not come down the hallway if Resident #38 was there. When Resident #47 walked past Resident #38's room, Resident #47 said I'm going to kill him. LPN #275 reported Resident #47 did not seek out Resident #38 and it was only Resident #38 seeking out Resident #47 and trying to coax her into his room.

A follow up interview on 03/25/24 at 10:10 A.M. with Resident #47's daughter/POA revealed HWD #296 had reported Resident #38 and #47 seemed to get along very well, they had been in each other's room; however, she was mainly in his room and that no one was worried about their relationship. HWD #296 told the daughter that as soon as anyone observed anything of concern, we will step in. Program Director #208 told the daughter that, if this really is a bother to your mother, we will separate them. Resident #47's daughter had spoken to LPN #275, HWD #296, the Administrator, Program Director #208, and Sales Manager #251 and no one had reported any concerns to her about Resident #38 and #47's relationship. Resident #47's daughter/POA reported Resident #47 was not able to speak on the phone to the daughter and did not recognize the daughter anymore. The daughter lived 1,000 miles away in a different state and the last time she saw her mom (Resident #47) was a year ago. Resident #47's other daughter lived in another state as well and that daughter and Resident #47 were estranged. The daughter revealed that Resident #47 was not aware her husband passed away. The daughter felt if someone was doing something to Resident #47 that the resident did not like, Resident #47 would let that person know. When the daughter was made aware of the documentation in the nursing progress notes from 03/06/24, 03/07/24, 03/08/24 and 03/11/24, the daughter replied, holy cow, what? Resident #47's daughter/POA verified she was not aware that Resident #47 was displaying resistive behaviors toward the male resident's sexual advances.

On 03/25/24 at 10:30 A.M. interview with Sales Manager (SM) #251 revealed SM #251 used to be the Program Manager on the memory care unit until 2020 and then assisted Resident #47 and Resident #47's husband in the move from the Independent Living to the memory care unit. Resident #47 was like a grandma to SM #251 and SM #251 spoke to Resident #47's daughter here and there. SM #251 stated she told Resident #47's daughter that she felt that Resident #38 didn't have any ill intention toward Resident #47.

On 03/25/24 at 10:35 A.M. interview with Nurse Practitioner (NP) #313 revealed Resident #47 did not have the ability to consent to sexual activity due to end stage dementia, the resident's moods waxed and waned and in the past three to six months, the resident's dementia had gotten much worse, and it had been harder to redirect her. NP #313 stated Resident #47 was not able to answer questions like she used to. Last Monday (03/18/24), NP #313 stated she was told about Resident #47 and a male resident, and the staff had discouraged and been upset with what was going on between the two residents. NP #313 was aware the police were at the facility to check on Resident #47. NP #313 was told about the documentation in the nurse's notes describing Resident #47 being visibly upset, stating, don't leave me after the male resident was trying to coax her into his room. NP #313 stated she had not observed that, nor was NP #313 aware Resident #47 was not accepting of the male resident's sexual advances.

On 03/25/24 at 11:05 A.M. interview with Caregiver #272 revealed she had observed Resident #38 follow and guide Resident #47 and had observed Resident #47 in his room. Regarding whether Resident #47 was accepting of Resident #38's advances, Caregiver #272 said it depends on the day. Somedays Resident #47 was accepting and other days she said no, no and waved her arms in a no motion, would give him a look and step to the side.

Observation of the secured memory care unit on 03/25/24 at 11:07 A.M. revealed Resident #47 walking up the hall towards the dining room with her walker where she sat down in dining room chair. At 11:10 A.M., Resident #38 was observed sitting in the common area watching a concert on television with a group of residents. Resident #38 stood up and walked independently into the dining room. Resident #38 then walked up to Resident #40 and #47 in the dining room standing next to them for a couple of seconds without speaking. At 11:15 A.M., Resident #38 left the dining room and walked down the hallway toward his room. Caregivers #239 and #272 were present throughout the observation.

On 03/25/24 at 11:30 A.M. interview with HWD #296 with the Administrator and RNCCM #312 present revealed the one-to-one supervision was a nursing intervention that was implemented for Resident #38 for a couple of days then discontinued when District Director of Clinical Services (DDCS) #317 visited the building and observed Resident #47 approaching Resident #38. Because of that observation DDCS #317 felt there were not any concerns especially since Resident #47 was leaving her room at night and Resident #38 was not leaving his room. HWD #296 said when she spoke to Resident #47's daughter she told the daughter Resident #47 and Resident #38 were observed in the male resident's room multiple times together, they were observed kissing with the male resident's pants down, and the residents would kiss in the hallway. She stated she told the daughter Resident #47 was not yelling or screaming and if she did, the staff would intervene. HWD #296 felt Resident #47 was accepting as well as resistive to Resident #38's sexual behaviors. HWD #296 verified she did not provide full details of the interaction between the residents. HWD #296 verified an interdisciplinary team (IDT) meeting with Resident #47's daughter/POA was not conducted to discuss Resident #47's ability to consent. HWD #296 verified Resident #38's and #47's service plans had not been updated to reflect the recent onset of sexual behaviors. The Administrator said the facility should have implemented the facility's Sexuality and Intimacy policy and procedure. The Administrator, HWD #296 and RNCCM #312 also verified the NP was not aware of the resistive actions displayed by Resident #47, and that the one-to-one supervision was not consistently implemented then discontinued.

On 03/25/24 at 3:55 P.M. interview with the Administrator verified the incidents between Residents #38, #40 and #47 had not been investigated as potential/actual incidents of sexual abuse.

Observation on 03/26/24 at 7:25 A.M. revealed upon arriving at Resident #47's room the door was closed and locked so that it could not be entered from the outside. Interview, at the time of the observation, with LPN #275, Caregiver #300 and Caregiver #218 revealed none of the staff on the secured memory unit had a master key to open Resident #47's door. They confirmed Resident #47 was in the room. They indicated the night shift nurse (LPN #242) had the master key and she was currently on the second floor. LPN #275 said there were always caregivers on the secured memory care unit during the night, but the night shift nurse had shared duties of the assisted living on the second floor and the memory care on the third floor during the night and was not always present on the secured memory care unit. The door had been locked to prevent Resident #38 from entering the room.

On 03/26/24 at 8:05 A.M. interview with Caregiver #311 revealed she assisted Resident #47 to get up in the morning and go to bed at night. Caregiver #311 had observed Resident #38 guide Resident #47 with her arm towards his room. Caregiver #311 redirected Resident #47 away from Resident #38 and his room and Resident #47 said to Caregiver #311, thank god for getting me away from him. Caregiver #311 said the staff were locking Resident #47's room at night so Resident #38 could not get to her. Resident #38 sought out Resident #47 but Resident #47 did not seek out Resident #38. Resident #47 was not aware her husband passed away. Resident #38's and her husband's name sounded alike to Resident #47 and Resident #38's face resembled Resident #47's husband. Resident #38 answered when Resident #47 called him by her deceased husband's name. Caregiver #311 was told Resident #38 was also found in Resident #40's room kissing Resident #40 and Resident #40 and Resident #40's daughter both stated Resident #38 was a pervert.

On 03/26/24 at 8:15 A.M. interview with LPN #242 revealed the staff locked Resident #47's door at night for Resident #47's safety since Resident #38 was entering her room.

On 03/26/24 at 8:25 A.M. interview with Caregiver #310 revealed she assisted Resident #47 to get up in the morning and go to bed at night. The staff locked her door from the outside so Resident #38 could not enter her room; however, the door was not locked from the inside and the caregiver stated Resident #47 could still exit the room. Caregiver #310 had witnessed a change in Resident #47's behavior which included not wanting to get out of bed, and being curled up in a ball saying, don't let him in.

On 03/26/24 at 2:30 P.M. interview with RNANM #314 verified there was no documentation in Resident #40's medical record of Resident #40 being kissed by a male resident on 02/20/24 nor was there evidence of Resident #40's family being notified of the intimate contact.

Review of the facility's Room Access policy dated June 2021 revealed doors to resident bedrooms or suites would remain unlocked unless the resident requested the door to be locked and the resident was able to demonstrate the independent use of a key. Resident room access would comply with local fire department regulations. Entry door to resident rooms would remain unlocked unless the resident was on hospice, unable to ambulate and either he/she or the responsible party had requested the door to be locked for reasons of solitude or privacy. Associates were to always have access to residents' room and should carry a universal key to facility entry. The community was to contact the district team and the Divisional Dementia Care Manager (DDCM) for additional accommodations requested outside this policy. Documentation was to be placed in the resident's record /service plan specifying the resident/responsible party's request for locking of resident's door and resident's ability to demonstrate they could navigate a key in the care plan. The community was to contact the DDCM, District Director of Clinical Service (DDCS) and the District Director of Operations for discussion of those residents who were not engaged and evidence of wandering behavior that had been disruptive.

Review of the facility's Sexuality and Intimacy policy revised May 2023 revealed the following scenarios to consider:

Scenario #2 was regarding if one or both of the older adults engaged in a physically intimate relationship. If one or both adults were cognitively impaired as previously determined by a licensed healthcare provider or there was documented diagnosis of dementia, there was no documented plan/agreement about the relationship, and there was a mutual agreement with no signs of distress or discomfort. Associates were to take measures to respectfully separate the individuals, in as discrete of a manner as possible while maintaining dignity for the purpose of evaluating the adult's response to the relationship. The associates were to promptly report the incident to the Executive Director (ED) or designee, HWD or supervisor in charge so that the ED or designee could begin an evaluation as soon as possible. The ED/Designee response was to include contacting the resident's legally responsible party/involved family and physician/healthcare provider (HP), completing an incident report, and completing an evaluation. The evaluation was to include a conversation with each resident to explore the resident's thoughts and feelings related to the encounter, documenting the conversation including in the resident's record. The ED/HWD was to set up a meeting with the team to discuss next steps and notify the district leadership (Divisional Dementia Care Manager (DDCM) and the District/Regional Director of Clinical Services). Issues for discussion could include but were not limited to what was the physician/HCP response to this issue, did the issue require reporting to the State, should the ombudsman be notified. A plan was to be determined in conjunction with leadership, DDCM and Legal. The plan was to be discussed with resident(s) and the discussion documented. A meeting was to be set up with the legally responsible party/involved family for discussion of the agreed upon plan/interventions. The cognitively impaired resident's Personal Service Plan was to be updated to reflect the outcome of the ED/designee's discussion with the involved parties.

Scenario #4 indicated in some instances, such as when one of the parties was exhibiting or vocalizing signs of distress, discomfort or had been harmed, the facility was to discern whether the act could be considered abuse and was reportable according to facility's policy and applicable state regulations. Associate response indicated the associates had an important obligation to protect the vulnerable and musty notify the ED or supervisor in charge so that the legally responsible party/involved family for residents could by fully informed of the physical/intimate relationship(s).

Review of facility policy titled Abuse, Neglect and Exploitation Policy

Based on observation and interview, the facility failed to ensure food was served and held in a manner that protected it against contamination. This affected 24 residents that did not reside in memory care. Facility census was 51.

Findings include:

Observation on 12/28/23 at 8:55 A.M. revealed staff were entering and exiting a kitchenette leaving all breakfast food items (waffles, eggs, grits, sausage) uncovered and unattended. The food had been transported from the central kitchen in an insulated meal cart and then the food containers were placed in a serving buffet with attached roll top lids. The roll top lids were not closed leaving the food exposed. This observation was confirmed by the Wellness Director who was present at the time of the initial observation.

Interview on 12/28/23 at 10:22 A.M. with the Dietary Manager (DM) revealed the DM was aware of staff leaving food which was left unattended uncovered but was receiving resistance from serving staff to cover unattended food. The DM revealed staff had been verbally educated on serving and storage measures to minimize contamination but failed to implement them on a consistent basis. The DM disposed of the remaining food to ensure it would not be served to any other residents.

Based on review of the medical record, review of the Self-Reported Incident and staff interviews the facility failed to ensure a thorough investigation was completed and documented in the resident's medical record for Resident #16 after an allegation of physical abuse by an employee. This affected one resident (Resident #16) of three residents reviewed for Abuse. It had the potential to affect all 24 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, 12, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) on the 200 hallway. Findings included: Review of the medial record revealed Resident #16 was admitted to the facility on 12/07/22. Diagnoses included hypertension, atherosclerotic heart disease, congestive heart failure, benign prostatic hyperplasia, glaucoma, osteoarthritis, and spinal stenosis. Review of the personal service assessment dated 01/12/23 revealed Resident #16 did not have any memory loss and had no difficulties with orientation to person place or time. He had no behaviors. Review of the progress notes from 01/20/23 to 02/01/23 revealed no documentation of the allegation of physical abuse or a skin assessment was completed for Resident #16. Review of Self-Reported Incident #231507 revealed on 01/26/23 Resident #17, wife of Resident #16, claims when the nurse came in to give her husband his medications, she hit him in the arm and when she told her not to do that to her husband, she hit him again. The investigation determined at 8:25 P.M. on 01/26/23 Resident #17 was present and reported the incident. She stated the nurse came into their room to give them medication and Resident #16 was asleep. She stated the nurse hit him in his left arm with a closed fist. Resident #17 told the nurse to not do that to him, the nurse balled up her fist and hit him even harder. She stated Resident #16 opened his eyes, took his medications and the nurse left the room. The Caregivers (CG) entered the found Resident #17 very upset. She explained to them what had happened. Resident #16 experienced night terrors and was emotionally disturbed due to the incident. The incident was substantiated and the nurse was reported to the Ohio Board of Nursing. Further review of Self-Reported Incident #231507 revealed no documentation of interviews with Resident #16 or Resident #17. Review of the investigation summary report revealed on 01/26/23 at 8:30 P.M. an unnamed Caregiver had called the Health and Wellness Director stating Resident #17 told her Licensed Practical Nurse (LPN) #111 had punched her husband, Resident #16, in the arm. Resident #17 told LPN #111 to not do that to him and LPN #111 punched him a second time in the same arm. Health and Wellness Coordinator proceeded to the facility to investigate. On 01/26/23 at 8:30 A.M. CG# 122 and CG #123 were interviewed and they stated they had gone into the room of Resident #16 and #17 and found Resident #17 very upset. CG #122 asked Resident #17 what was wrong and she stated to them the heavy-set nurse hit Resident #16 and when she asked her not to do it, she hit him again. LPN #111 was interviewed and she stated she went into give Resident #16 his medication and he was very sleepy and she tapped him on his left shoulder which was covered by a pillow. She stated she did not hit him. She stated he did not respond so she spoke louder to wake him up to take his medication. After being escorted from the facility, LPN #111 called to state she had hit his pillow but not his arm. LPN #111 was escorted from the facility within 20 minutes of the incident. Resident #16's skin check was clear however the resident was experiencing night terrors after the event. Review of the incident log from 12/06/23 to 02/02/23 revealed no documentation of the incident. On 02/03/23 at 9:45 P.M. an interview with Health and Wellness Coordinator #100 revealed she received a call from Health and Wellness Director #99 on 01/26/23 around 8:30 P.M. to come into the facility because there was an incident with one of the residents. She stated she was the closest to the facility. She stated when she got the facility Resident #16 and his wife were visibly upset. Health and Wellness Coordinator #100 indicated Resident #17 stated to her the nurse LPN #111 had come into the room to give her husband his evening medications. She stated he had been sleeping. She stated Resident #17 told her LPN #111 hit her husband in the shoulder to get him away, Resident #17 had told the nurse to not do that and she had hit him again. She stated she immediately had LPN #111 leave the building. She stated Resident #17 was alert and oriented and did not make up stories. She stated she had done a skin assessment and did not see any marks on his arm or bruising. On 02/03/23 at 10:00 A.M. interview with Resident #17 revealed on 01/26/23 at around 8:30 P.M. LPN #111 came into their room to give her husband his medications. She stated her husband was sleeping. She stated the nurse hit him in the left arm with a closed fist. She stated she told the nurse to not hit him in the arm because he had a bad left shoulder and she did it again even harder. She stated the nurse had never hit them before but she was a little rough at times. She stated she told the staff working and then the next day she told the nurse working what had happen. She stated they had fired her within 30 minutes of the incident happening. She stated her and her husband were having some trouble sleeping. She also stated he did not get a bruise that she could see. On 02/03/23 at 10:05 A.M. interview with Resident #16 revealed the nurse had hit him in the left shoulder and it had hurt. He was unable to explain when it happened or who the nurse was. On 02/03/23 at 1:48 P.M. an interview with Health Wellness Coordinator #100 verified there was no documentation of the incident of physical abuse to Resident #16 in his medical record or on the incident log. She indicated she was not aware the incident needed to be documented in the resident record. On 02/03/23 at 2:15 P.M. an interview with the Administrator verified the facility had substantiated the allegation of physical abuse by an employee and there was no documentation of a skin assessment completed for Resident #16 at the time of the incident. Review of the facility policy titled, Abuse, Neglect and ExploitationBased on review of the medical record, review of the Self-Reported Incident and staff interviews the facility failed to ensure a thorough investigation was completed and documented in the resident's medical record for Resident #16 after an allegation of physical abuse by an employee. This affected one resident (Resident #16) of three residents reviewed for Abuse. It had the potential to affect all 24 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, 12, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) on the 200 hallway.

Findings included:

Review of the medial record revealed Resident #16 was admitted to the facility on 12/07/22. Diagnoses included hypertension, atherosclerotic heart disease, congestive heart failure, benign prostatic hyperplasia, glaucoma, osteoarthritis, and spinal stenosis.

Review of the personal service assessment dated 01/12/23 revealed Resident #16 did not have any memory loss and had no difficulties with orientation to person place or time. He had no behaviors.

Review of the progress notes from 01/20/23 to 02/01/23 revealed no documentation of the allegation of physical abuse or a skin assessment was completed for Resident #16.

Review of Self-Reported Incident #231507 revealed on 01/26/23 Resident #17, wife of Resident #16, claims when the nurse came in to give her husband his medications, she hit him in the arm and when she told her not to do that to her husband, she hit him again. The investigation determined at 8:25 P.M. on 01/26/23 Resident #17 was present and reported the incident. She stated the nurse came into their room to give them medication and Resident #16 was asleep. She stated the nurse hit him in his left arm with a closed fist. Resident #17 told the nurse to not do that to him, the nurse balled up her fist and hit him even harder. She stated Resident #16 opened his eyes, took his medications and the nurse left the room. The Caregivers (CG) entered the found Resident #17 very upset. She explained to them what had happened. Resident #16 experienced night terrors and was emotionally disturbed due to the incident. The incident was substantiated and the nurse was reported to the Ohio Board of Nursing.

Further review of Self-Reported Incident #231507 revealed no documentation of interviews with Resident #16 or Resident #17.

Review of the investigation summary report revealed on 01/26/23 at 8:30 P.M. an unnamed Caregiver had called the Health and Wellness Director stating Resident #17 told her Licensed Practical Nurse (LPN) #111 had punched her husband, Resident #16, in the arm. Resident #17 told LPN #111 to not do that to him and LPN #111 punched him a second time in the same arm. Health and Wellness Coordinator proceeded to the facility to investigate. On 01/26/23 at 8:30 A.M. CG# 122 and CG #123 were interviewed and they stated they had gone into the room of Resident #16 and #17 and found Resident #17 very upset. CG #122 asked Resident #17 what was wrong and she stated to them the heavy-set nurse hit Resident #16 and when she asked her not to do it, she hit him again. LPN #111 was interviewed and she stated she went into give Resident #16 his medication and he was very sleepy and she tapped him on his left shoulder which was covered by a pillow. She stated she did not hit him. She stated he did not respond so she spoke louder to wake him up to take his medication. After being escorted from the facility, LPN #111 called to state she had hit his pillow but not his arm. LPN #111 was escorted from the facility within 20 minutes of the incident. Resident #16's skin check was clear however the resident was experiencing night terrors after the event.

Review of the incident log from 12/06/23 to 02/02/23 revealed no documentation of the incident.

On 02/03/23 at 9:45 P.M. an interview with Health and Wellness Coordinator #100 revealed she received a call from Health and Wellness Director #99 on 01/26/23 around 8:30 P.M. to come into the facility because there was an incident with one of the residents. She stated she was the closest to the facility. She stated when she got the facility Resident #16 and his wife were visibly upset. Health and Wellness Coordinator #100 indicated Resident #17 stated to her the nurse LPN #111 had come into the room to give her husband his evening medications. She stated he had been sleeping. She stated Resident #17 told her LPN #111 hit her husband in the shoulder to get him away, Resident #17 had told the nurse to not do that and she had hit him again. She stated she immediately had LPN #111 leave the building. She stated Resident #17 was alert and oriented and did not make up stories. She stated she had done a skin assessment and did not see any marks on his arm or bruising.

On 02/03/23 at 10:00 A.M. interview with Resident #17 revealed on 01/26/23 at around 8:30 P.M. LPN #111 came into their room to give her husband his medications. She stated her husband was sleeping. She stated the nurse hit him in the left arm with a closed fist. She stated she told the nurse to not hit him in the arm because he had a bad left shoulder and she did it again even harder. She stated the nurse had never hit them before but she was a little rough at times. She stated she told the staff working and then the next day she told the nurse working what had happen. She stated they had fired her within 30 minutes of the incident happening. She stated her and her husband were having some trouble sleeping. She also stated he did not get a bruise that she could see.

On 02/03/23 at 10:05 A.M. interview with Resident #16 revealed the nurse had hit him in the left shoulder and it had hurt. He was unable to explain when it happened or who the nurse was.

On 02/03/23 at 1:48 P.M. an interview with Health Wellness Coordinator #100 verified there was no documentation of the incident of physical abuse to Resident #16 in his medical record or on the incident log. She indicated she was not aware the incident needed to be documented in the resident record.

On 02/03/23 at 2:15 P.M. an interview with the Administrator verified the facility had substantiated the allegation of physical abuse by an employee and there was no documentation of a skin assessment completed for Resident #16 at the time of the incident.

Review of the facility policy titled, Abuse, Neglect and Exploitation

Based on review of the medical record, review of the Self-Reported Incident and staff interviews the facility failed to ensure Resident #16 was protected from physical abuse from a facility employee. This affected one resident (Resident #16) of three residents reviewed for Abuse. It had the potential to affect all 24 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, 12, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) on the 200 hallway. Findings included: Review of the medial record revealed Resident #16 was admitted to the facility on 12/07/22. Diagnoses included hypertension, atherosclerotic heart disease, congestive heart failure, benign prostatic hyperplasia, glaucoma, osteoarthritis, and spinal stenosis. Review of the physician's orders revealed Resident #16 had an order for Voltaren gel (pain gel) to be applied to the left shoulder two times daily for pain dated 12/07/22. Review of the personal service assessment dated 01/12/23 revealed Resident #16 did not have any memory loss and had no difficulties with orientation to person place or time. He had no behaviors. Review of the progress notes from 01/20/23 to 02/01/23 revealed no documentation of the allegation of physical abuse or a skin assessment was completed for Resident #16. Review of Self-Reported Incident #231507 revealed on 01/26/23 Resident #17, wife of Resident #16, claims when the nurse came in to give her husband his medications, she hit him in the arm and when she told her not to do that to her husband, she hit him again. The investigation determined at 8:25 P.M. on 01/26/23 Resident #17 was present and reported the incident. She stated the nurse came into their room to give them medication and Resident #16 was asleep. She stated the nurse hit him in his left arm with a closed fist. Resident #17 told the nurse to not do that to him, the nurse balled up her fist and hit him even harder. She stated Resident #16 opened his eyes, took his medications and the nurse left the room. The Caregivers (CG) entered the found Resident #17 very upset. She explained to them what had happened. Resident #16 experienced night terrors and was emotionally disturbed due to the incident. The incident was substantiated and the nurse was reported to the Ohio Board of Nursing. Review of the investigation summary report revealed on 01/26/23 at 8:30 P.M. an unnamed Caregiver had called the Health Wellness Director (HWD) stating Resident #17 told her Licensed Practical Nurse (LPN) #111 had punched her husband, Resident #16, in the arm. Resident #17 told LPN #111 to not do that to him and LPN #111 punched him a second time in the same arm. Health and Wellness Coordinator (HWC) proceeded to the facility to investigate. On 01/26/23 at 8:30 A.M. CG# 122 and CG #123 were interviewed and they stated they had gone into the room of Resident #16 and #17 and found Resident #17 very upset. CG #122 asked Resident #17 what was wrong and she stated to them the heavy-set nurse hit Resident #16 and when she asked her not to do it, she hit him again. LPN #111 was interviewed and she stated she went into give Resident #16 his medication and he was very sleepy and she tapped him on his left shoulder which was covered by a pillow. She stated she did not hit him. She stated he did not respond so she spoke louder to wake him up to take his medication. After being escorted from the facility, LPN #111 called to state she had hit his pillow but not his arm. LPN #111 was escorted from the facility within 20 minutes of the incident. Resident #16's skin check was clear however the resident was experiencing night terrors after the event. Review of the signed statement dated 01/27/23 by CG #123 revealed she was told by Resident #17 that the lady passing medication came in and punched Resident #16 in the arm. Resident #17 stated she asked her not to do that and she did it again. Resident #16 told CG #123 it was the heavy-set lady and she was mean. CG #123 told Resident #17 she needed to report it to HWD in the morning. Review of the signed statement dated 01/26/23 at 9:40 P.M. LPN #111 stated she had gone into the room of Resident #16 to give him is medications, he was very sleepy so she tapped him on his left shoulder area which was covered by a pillow. She stated Resident#17 told her to not hit him so she did not respond she just spoke louder to get him to wake up to take his medications, Review of the undated signed statement from CG #122 revealed her and CG #123 had went into the room of Resident #16 and #17. Resident #17 was upset and she stated the heavy set woman was means and hit Resident #16 once and when Resident #17 told her to please not do that she hit him again. CG #122 stated she would call the HWD because she knew there were allegation of LPN #111 yanking another resident up. On 02/03/23 at 9:45 P.M. an interview with HWC #100 revealed she received a call from HWD #99 on 01/26/23 around 8:30 P.M. to come into the facility because there was an incident with one of the residents. She stated she was the closest to the facility. She stated when she got the facility Resident #16 and his wife were visibly upset. HWC #100 indicated Resident #17 stated to her the nurse. LPN #111 had come into the room to give her husband his evening medications. She stated he had been sleeping. She stated Resident #17 told her LPN #111 hit her husband in the shoulder to get him away, Resident #17 had told the nurse to not do that and she had hit him again. She stated she immediately had LPN #111 leave the building. She stated Resident #17 was alert and oriented and did not make up stories. She stated she had done a skin assessment and did not see any marks on his arm or bruising. On 02/03/23 at 10:00 A.M. interview with Resident #17 revealed on 01/26/23 at around 8:30 P.M. LPN #111 came into their room to give her husband his medications. She stated her husband was sleeping. She stated the nurse hit him in the left arm with a closed fist. She stated she told the nurse to not hit him in the arm because he had a bad left shoulder and she did it again even harder. She stated the nurse had never hit them before but she was a little rough at times. She stated she told the staff working and then the next day she told the nurse working what had happen. She stated they had fired her within 30 minutes of the incident happening. She stated her and her husband were having some trouble sleeping. She also stated he did one get a bruise that she could see. On 02/03/23 at 10:05 A.M. interview with Resident #16 revealed the nurse had hit him in the left shoulder and it had hurt. He was unable to say when it happened or who the nurse was. On 02/03/23 at 2:15 P.M. an interview with the Administrator verified he facility had substantiated the allegation of physical abuse by an employee and there was no documentation of a skin assessment completed for Resident #16 at the time of the incident. Review of the facility policy titled, Abuse, Neglect and ExploitationBased on review of the medical record, review of the Self-Reported Incident and staff interviews the facility failed to ensure Resident #16 was protected from physical abuse from a facility employee. This affected one resident (Resident #16) of three residents reviewed for Abuse. It had the potential to affect all 24 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, 12, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) on the 200 hallway.

Findings included:

Review of the medial record revealed Resident #16 was admitted to the facility on 12/07/22. Diagnoses included hypertension, atherosclerotic heart disease, congestive heart failure, benign prostatic hyperplasia, glaucoma, osteoarthritis, and spinal stenosis.

Review of the physician's orders revealed Resident #16 had an order for Voltaren gel (pain gel) to be applied to the left shoulder two times daily for pain dated 12/07/22.

Review of the personal service assessment dated 01/12/23 revealed Resident #16 did not have any memory loss and had no difficulties with orientation to person place or time. He had no behaviors.

Review of the progress notes from 01/20/23 to 02/01/23 revealed no documentation of the allegation of physical abuse or a skin assessment was completed for Resident #16.

Review of Self-Reported Incident #231507 revealed on 01/26/23 Resident #17, wife of Resident #16, claims when the nurse came in to give her husband his medications, she hit him in the arm and when she told her not to do that to her husband, she hit him again. The investigation determined at 8:25 P.M. on 01/26/23 Resident #17 was present and reported the incident. She stated the nurse came into their room to give them medication and Resident #16 was asleep. She stated the nurse hit him in his left arm with a closed fist. Resident #17 told the nurse to not do that to him, the nurse balled up her fist and hit him even harder. She stated Resident #16 opened his eyes, took his medications and the nurse left the room. The Caregivers (CG) entered the found Resident #17 very upset. She explained to them what had happened. Resident #16 experienced night terrors and was emotionally disturbed due to the incident. The incident was substantiated and the nurse was reported to the Ohio Board of Nursing.

Review of the investigation summary report revealed on 01/26/23 at 8:30 P.M. an unnamed Caregiver had called the Health Wellness Director (HWD) stating Resident #17 told her Licensed Practical Nurse (LPN) #111 had punched her husband, Resident #16, in the arm. Resident #17 told LPN #111 to not do that to him and LPN #111 punched him a second time in the same arm. Health and Wellness Coordinator (HWC) proceeded to the facility to investigate. On 01/26/23 at 8:30 A.M. CG# 122 and CG #123 were interviewed and they stated they had gone into the room of Resident #16 and #17 and found Resident #17 very upset. CG #122 asked Resident #17 what was wrong and she stated to them the heavy-set nurse hit Resident #16 and when she asked her not to do it, she hit him again. LPN #111 was interviewed and she stated she went into give Resident #16 his medication and he was very sleepy and she tapped him on his left shoulder which was covered by a pillow. She stated she did not hit him. She stated he did not respond so she spoke louder to wake him up to take his medication. After being escorted from the facility, LPN #111 called to state she had hit his pillow but not his arm. LPN #111 was escorted from the facility within 20 minutes of the incident. Resident #16's skin check was clear however the resident was experiencing night terrors after the event.

Review of the signed statement dated 01/27/23 by CG #123 revealed she was told by Resident #17 that the lady passing medication came in and punched Resident #16 in the arm. Resident #17 stated she asked her not to do that and she did it again. Resident #16 told CG #123 it was the heavy-set lady and she was mean. CG #123 told Resident #17 she needed to report it to HWD in the morning.

Review of the signed statement dated 01/26/23 at 9:40 P.M. LPN #111 stated she had gone into the room of Resident #16 to give him is medications, he was very sleepy so she tapped him on his left shoulder area which was covered by a pillow. She stated Resident#17 told her to not hit him so she did not respond she just spoke louder to get him to wake up to take his medications,

Review of the undated signed statement from CG #122 revealed her and CG #123 had went into the room of Resident #16 and #17. Resident #17 was upset and she stated the heavy set woman was means and hit Resident #16 once and when Resident #17 told her to please not do that she hit him again. CG #122 stated she would call the HWD because she knew there were allegation of LPN #111 yanking another resident up.

On 02/03/23 at 9:45 P.M. an interview with HWC #100 revealed she received a call from HWD #99 on 01/26/23 around 8:30 P.M. to come into the facility because there was an incident with one of the residents. She stated she was the closest to the facility. She stated when she got the facility Resident #16 and his wife were visibly upset. HWC #100 indicated Resident #17 stated to her the nurse. LPN #111 had come into the room to give her husband his evening medications. She stated he had been sleeping. She stated Resident #17 told her LPN #111 hit her husband in the shoulder to get him away, Resident #17 had told the nurse to not do that and she had hit him again. She stated she immediately had LPN #111 leave the building. She stated Resident #17 was alert and oriented and did not make up stories. She stated she had done a skin assessment and did not see any marks on his arm or bruising.

On 02/03/23 at 10:00 A.M. interview with Resident #17 revealed on 01/26/23 at around 8:30 P.M. LPN #111 came into their room to give her husband his medications. She stated her husband was sleeping. She stated the nurse hit him in the left arm with a closed fist. She stated she told the nurse to not hit him in the arm because he had a bad left shoulder and she did it again even harder. She stated the nurse had never hit them before but she was a little rough at times. She stated she told the staff working and then the next day she told the nurse working what had happen. She stated they had fired her within 30 minutes of the incident happening. She stated her and her husband were having some trouble sleeping. She also stated he did one get a bruise that she could see.

On 02/03/23 at 10:05 A.M. interview with Resident #16 revealed the nurse had hit him in the left shoulder and it had hurt. He was unable to say when it happened or who the nurse was.

On 02/03/23 at 2:15 P.M. an interview with the Administrator verified he facility had substantiated the allegation of physical abuse by an employee and there was no documentation of a skin assessment completed for Resident #16 at the time of the incident.

Review of the facility policy titled, Abuse, Neglect and Exploitation