Every finding on record at Alpine Health and Rehabilitation of Asheboro

Based on record review, staff, resident and family interviews, the facility failed to protect the residents right to be free from misappropriation of a narcotic medication (Oxycodone) prescribed to treat pain for Resident #46 and Resident #47. This was for 2 of 6 residents reviewed for misappropriation. The findings included: 1a. Resident #46 was admitted on [DATE] with diagnoses of polymyalgia rheummatica (inflammatory disorder that causes muscle pain and stiffness) and osteomyelitis (inflammation of bone tissue that can result in an infection) to his left foot. Review of Resident #46's Physician cumulative orders included an order dated 12/11/23 for Oxycodone 5 milligrams (mg) one tablet four times daily for pain. Review of Resident #46's medication administration record for February 2024 documented he received his Oxycodone as ordered four times daily on 2/6/24. 1b. Resident #47 was admitted on [DATE] with a diagnosis of dementia. Review of Resident #47's cumulative Physician orders included an order dated 12/19/23 for Oxycodone 5 milligrams (mg) I tablet as needed for pain. Review of Resident #47's February medication administration record did not include any documented evidence that she received any Oxycodone during the month of February prior to 2/6/24. An initial allegation report dated 2/6/24 documented that Medication Aide (MA) #1 discovered 3 missing Oxycodone tablets for Resident #46 on audit, 2 missing Oxycodone tablets for Resident #47. The investigation report dated 2/12/24 documented Nurse #1 removed 3 Oxycodone tablets from Resident #46's narcotic bubble pack and 2 Oxycodone tablets from Resident #47's narcotic bubble pack. Both narcotic bubble packs were resealed with scotch tape after replacing what was later determined to be Claritin tablets. The investigation included interviews with nurses and medication aides who worked the week prior leading up to 2/6/24. The investigation read the police and the board of nursing were notified. Nurse #1 was met at the facility on 2/6/24 at the start of her shift by the Director of Nursing (DON) and Unit Manager #1. Nurse #1 was questioned regarding diversion of narcotics discovered on 2/6/24 and requested she perform a drug test. Nurse #1 refused and was terminated at this time. An interview was completed with MA #1 on 2/21/24 at 2:00 PM. She stated she relieved Nurse #1 on 2/6/24 and a narcotic count was completed. There was no evidence of missing narcotics until she was preparing to administer Resident #46's schedule Oxycodone when she noticed the back of the bubble pack had been tampered with. She immediately notified the DON and Administrator. A telephone interview was attempted on 2/21/24 at 2:50 PM with Nurse #1 with no return calls at the time of survey exit. The DON was unavailable for interview during the survey. An interview was completed on 2/22/24 at 9:20 AM with Unit Manager #1. She stated she assisted the DON with a completing narcotic audit on 2/6/24 which included the narcotic count logs, the medication administration records for residents who had narcotics signed out as administered and evidence of tampering of the bubble packs. She stated only two residents were affected. Unit Manager #1 stated she was present on 2/6/24 when Nurse #1 was questioned about the missing narcotics. She stated Nurse #1 denied the allegation and refused to be drug tested with the understanding that she would be terminated. An interview was completed on 2/22/24 at 2:25 PM with Resident #46. He stated he did not have any untreated pain and the medication regime he was prescribed was effective. Resident #46 stated he had been questioned about his pain control earlier this month by the DON and Administrator. An interview was completed on 2/22/24 at 2:40 PM with Resident #47 and a family member. She stated she occasionally experienced back pain but when she told the nurse, she got a pain pill that helped her back. There were no observed signs or symptoms of untreated pain during the interview with Resident #47. The family member stated there were no concerns with Resident #47's care or pain management. An interview was completed on 2/21/24 at 3:20 PM with the Administrator. He stated when he was made aware on 2/6/24 of the tampering of Resident #46's and Resident #47's narcotics, he submitted his initial report and notified the state agency on 2/6/24. He stated the DON and Unit Manager #1 completed an audit of all narcotic medications for the correct medication count and evidence of tapering. He stated it was determined that Nurse #1 was the only staff member who worked both medication carts missing the narcotics in recent days. He stated Nurse #1 refused to submit to a drug test on 2/6/24 and was terminated. The Administrator stated Nurse #1 was hired in October 2023 and had already received disciplinary actions in November and in December 2023 for administering discontinued narcotics to residents. He stated an action plan also included the completion of education with the nurses and the medication aides regarding diversion and proper documentation with ongoing monitoring. He stated the investigation dated 2/12/24 substantiated the diversion of narcotics The facility action plan dated 2/6/24 documented the immediate actions the facility took on 2/6/24 included a complete narcotic audit, interviews and pain assessments with Resident #46 and Resident #47. The action plan also read completion of the initial allegation report was forwarded to the state agency on 2/6/24. The action plan read all nurses and medication aides were interviewed for the week leading up to 2/6/24. He stated the police were also notified and notified the board of nursing. The facility replaced the diverted narcotics for Resident #46 and Resident #47 for a total of .65 cents. The action plan detailed the education was provided by the Staff Development Coordinator (SDC) to all nurses and medication aides staff regarding diversion, narcotics counts to include any evidence of tampering, documentation correctly on narcotics count sheets and medication administration records. This education was completed by 2/9/24. The facility started Quality Monitoring 5 times a week for 4 weeks on 2/6/24 to ensure there was no evidence of narcotic diversion. The audits were to be completed by the DON and SDC to include narcotic count sheets, medication administration records and any evidence of tampering with the narcotic bubble packs. An ad hoc Quality Assurance and Performance Improvement (QAPI) team meeting was completed on 2/6/24 to review and discuss the action plan. The results of the Quality Monitoring will be discussed at the monthly QAPI meeting and further concerns will be addressed by the team. The date of completion was 2/12/24. The action plan was validated by reviewing the education provided to the staff, reviewing the interviews with staff and residents, and reviewing the daily Quality Monitoring documentation. Residents were interviewed during the survey, and none reported untreated pain. Staff were interviewed and they had all received education narcotic diversion. The facility completion date of 2/12/24 was validated.

Based on observation, record review, Nurse Practitioner interview, and staff interview, the facility failed to develop a person centered and individualized care plan which addressed the needs of a resident with dementia and how staff were to provide their care and treatment for 1 of 3 residents (Resident #73) reviewed for dementia care. The findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 ' s cognition was severely impaired and her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #73 was dependent on 2 or more staff for bed mobility and transfers, and dependent on 1 for eating, dressing, personal hygiene, and toileting. She received antipsychotic medication, antianxiety medication, and antidepressant medication on 7 of 7 days during the MDS review period. The cognitive loss/dementia Care Area Assessment (CAA) for the 3/3/21 MDS indicated Resident #73 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The CAA read, Proceed to Care Plan for cues and reminders as needed. A review of active physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #73 ' s active care plan as of 4/21/21 included the following areas related to her dementia Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] - Focus area: Impaired cognitive function/dementia or impaired thought processes related to advanced age and memory deficit. This focus area was initiated on 2/27/21, last revised on 3/16/21, and last reviewed on 3/22/21. The goal indicated Resident #73 would be able to communicate basic needs on a daily basis through the next review date. The interventions read: Ask yes/no questions in order to determine the resident's needs; Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated; and Cue, reorient and supervise as needed. - Focus area: Resident #73 received antipsychotic medications related to senile dementia with behavioral disturbance, delusional disorder Alzheimer's dementia. This focus area was initiated on 3/6/20, last revised on 3/16/21, and last reviewed on 3/22/21. The goal was for Resident #73 to remain free of [CONDITION(S)] drug related complications, including movement disorder, discomfort, [CONDITION(S)], gait disturbance, constipation/impaction or cognitive/behavioral impairment through the next review date. The interventions read: Administer antipsychotic medications as ordered by physician and observe for side effects and effectiveness every shift; Abnormal Involuntary Movement Scale (AIMS) every 6 months and as needed; Consult with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly; Discuss with physician and family the ongoing need for use of medication and review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy; and Observe/document/report as needed any adverse reactions of [CONDITION(S)] medications. This active care plan for Resident #73 had not addressed person centered and individualized approaches to care for Resident #73 related to her dementia diagnosis. An interview was conducted with Nursing Assistant (NA) #7 on 4/21/21 at 12:45 PM. She reported that Resident #73 had some resistance to care that included yelling out or crying. NA #7 stated that Resident #73 had no behavioral symptoms if she was not disturbed by staff. She indicated that non-pharmacological interventions of hand holding, rubbing her head, reassuring words, and talking to her about her mother helped to manage Resident #73 ' s behaviors. During an interview with NA #6 on 4/21/21 at 12:47 PM she confirmed NA #7 ' s interview related to Resident #73 ' s resistance to care that was exhibited by yelling out and/or crying. She stated some of the interventions staff utilized for Resident #73 was to always explain to the resident what care was going to be provided before beginning the care, approach her from the front, speak slowly, and make eye contact. She indicated that those interventions were normally implemented for all residents with cognitive impairment. NA #6 explained that interventions that were specific to Resident #73 included hand holding, rubbing her head or chest, and talking about her family. An observation was conducted on 4/21/21 at 12:52 PM of NA #6 and NA #7 transferring Resident #73 from her geriatric wheelchair to her bed via a mechanical lift. NA #6 approached Resident #73 from the front and informed her that she and NA #7 were going to transfer her to her bed. Resident #73 began yelling when first touched by staff. NA #6 and NA #7 utilized tactile stimulation of rubbing Resident #73 ' s chest, holding her hand, and speaking to her with words of encouragement and support throughout this entire interaction. These interventions were successful in reducing Resident #73 ' s observed behaviors and she was able to be transferred to her bed without incident. An interview was conducted with Nurse Practitioner (NP) #1 on 4/21/21 at 10:26 AM. She reported that Resident #73 had dementia with behaviors and that these behaviors such as yelling out, crying, and swatting with her hands when staff provided care. She indicated that Resident #73 was prescribed [MEDICATION(S)] 50 mg twice daily to manage these behaviors in addition to [MEDICATION(S)] and [MEDICATION(S)] to manage anxiety and agitation. During an interview with the Social Worker (SW) on 4/21/21 at 2:00 PM Resident #73 ' s care plan was reviewed. She revealed that Resident #73 had dementia with behaviors and that these behaviors and the non-pharmacological interventions used to manage the behaviors and to assist staff with caring for the resident were not addressed in the care plan. An interview was conducted with MDS Nurse #1 and MDS Nurse #2 on 4/22/21 at 8:35 AM. They both indicated that Resident #73 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Director of Nursing on 4/22/21 at 11:20 AM she indicated that it was her expectation that residents diagnosed with dementia had care plans developed that were individualized and addressed their care needs in relation to their dementia diagnosis.

Based on record review and interviews with Pharmacy Consultant, Nurse Practitioner, Psychiatric Physician ' s Assistant, and staff, the Pharmacy Consultant failed to identify and address the need for evaluation of [CONDITION(S)] medications for gradual dose reductions (Resident #13) and the need for the facility to identify and monitor target behavioral symptoms for the use of [CONDITION(S)] medications (Residents #73, and #102). In addition, the facility failed to act upon recommendations made by the Pharmacy Consultant (Resident #73). This was for 3 of 5 residents reviewed for unnecessary medications. The findings included: 1a. Resident #73 was admitted to the facility on [DATE] with diagnoses that included dementia and anxiety. A physician ' s order dated 2/28/20 indicated [MEDICATION(S)] (antidepressant medication) 25 milligrams (mg) once daily for anxiety/agitation. A physician ' s order dated 3/1/20 read, Observation: AntiDepressant Medication ([MEDICATION(S)]) - Observe for behavior (sadness). Observe for side effects: [gastrointestinal] upset, [CONDITION(S)], fatigue, dizziness, dry mouth, headache. Document Y if resident is free of side effects. Document N if the resident is NOT free from side effects. If N document [side effect] in the [progress notes]. every shift. This observation and side effect documentation was to be completed 3 times per day (7:00 AM, 3:00 PM, and 11:00 PM). A physician ' s order dated 3/2/20 indicated [MEDICATION(S)] (antianxiety medication) 0.25 mg every 12 hours as needed (PRN) for anxiety or agitation 14 Days (3/16/20 end date). A physician ' s order dated 3/2/20 read, Observation: Antianxiety Medication ([MEDICATION(S)])- Observe for behavior (agitation). Observe for side effects: drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document:'Y' if resident is free of side effects. 'N' if the resident is not free of side effects. If 'N' document [side effects] in the [progress notes]. every shift for 14 Days. This observation and side effect documentation was to be completed 3 times per day (7:00 AM, 3:00 PM, and 11:00 PM). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 ' s cognition was severely impaired. She had no [CONDITION(S)] and no behavioral symptoms. Resident #73 was noted with rejection of care and wandering on 1 to 3 days during the MDS review period. She was administered antianxiety medication on 1 of 7 days and antidepressant medication on 3 of 7 days. A physician ' s order dated 3/5/21 indicated [MEDICATION(S)] (antipsychotic medication) 25 mg once daily at night for sadness. A physician ' s order dated 3/5/20 read, Observation: Antipsychotic Medication ([MEDICATION(S)])- Observe for behavior: (sadness) Observe for side effects: dry mouth, constipation, blurry vision, disorientation/confusion, difficulty urinating, [CONDITION(S)], dark urine, yellow skin, [nausea and vomiting], lethargy, drooling, [extrapyramidal symptoms] (tremors, gait issues, agitation, restlessness, involuntary movement of mouth/tongue.) Document: Y if resident is free of side effects. N if the resident is not free of side effects. If N document [side effects] in the [progress notes]. This observation and side effect documentation was to be completed 3 times per day (7:00 AM, 3:00 PM, and 11:00 PM). A physician ' s order dated 3/16/20 indicated routine [MEDICATION(S)] 0.25 mg every evening for agitation for Resident #73. The previous 3/2/20 order for PRN [MEDICATION(S)] 0.5 mg stopped on 3/16/20. A physician ' s order for Resident #73 dated 3/20/20 indicated an increase in [MEDICATION(S)] from 25 mg to 50 mg once daily for anxiety/agitation. A monthly Medication Regimen Review (MRR) for March 2020 completed by the Pharmacy Consultant (review dated of 3/20/20) was addressed to the physician indicating that Resident #73 was receiving the antipsychotic medication [MEDICATION(S)] but lacked a supporting diagnosis. The Pharmacy Consultant provided the physician with a list of appropriate diagnoses/conditions and requested the physician to circle all that applied to Resident #73. On 3/27/20 the physician signed this MRR and circled the following diagnoses/conditions: delusional disorder and Alzheimer ' s with behavioral disturbance. A physician ' s order dated 12/7/20 indicated an order by NP #1 to increase [MEDICATION(S)] for Resident #73 from 25 mg once daily to 25 mg twice daily for delusional disorder and Alzheimer ' s dementia. A physician ' s order dated 1/13/21 indicated an order by NP #1 to increase [MEDICATION(S)] from 25 mg twice daily to 50 mg twice daily for delusional disorder and Alzheimer ' s dementia. The annual MDS assessment dated [DATE] indicated Resident #73 ' s cognition was severely impaired. She had no mood issues, no [CONDITION(S)], no behaviors, no rejection of care, and no wandering. Resident #73 received antipsychotic medication, antianxiety medication, and antidepressant medication on 7 of 7 days during the MDS review period. A Psychiatric Physician ' s Assistant (PPA) note dated 3/19/21 indicated that Resident #73 ' s [CONDITION(S)] medications included [MEDICATION(S)] 50 mg twice daily, [MEDICATION(S)] 0.25 mg once daily, and [MEDICATION(S)] 50 mg once daily. Staff were to monitor Resident #73 ' s mood and behaviors. A review of Resident #73 ' s March 2020 through 4/20/21 Medication Administration Records (MAR) indicated she received [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] as ordered. The target behavior for [MEDICATION(S)] and [MEDICATION(S)] was listed as sadness and the target behavior for [MEDICATION(S)] was agitation. The MAR included side effect monitoring, but no behavior monitoring. The monthly Medication Regimen Reviews (MRRs) from 3/23/20 through 4/20/21 revealed the Pharmacy Consultant had not identified and addressed the lack of behavior monitoring for the [CONDITION(S)] medications [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The Pharmacy Consultant additionally had not identified that sadness was noted as a target behavior for [MEDICATION(S)] when the medication was prescribed for delusional disorder and Alzheimer ' s dementia and that sadness was also noted as the target behavior for [MEDICATION(S)] when the medication was prescribed for anxiety/agitation. A phone interview was conducted with the Pharmacy Consultant on 4/22/21 at 9:25 AM. She stated that she completed the monthly MRRs at the facility. She was asked if she reviewed the medical records to ensure the facility had appropriately identified target behaviors and monitored these behaviors during her monthly MRRs. The Pharmacy Consultant revealed she had not reviewed target behavior identification or behavior monitoring. She explained that she was not sure where the facility documented target behaviors and behavior monitoring at. The Pharmacy Consultant was unable to explain how she was able to ascertain if the prescribed [CONDITION(S)] medications were effective for managing target behaviors without behavior monitoring being conducted. An interview was conducted with Resident #73 ' s NP (NP #1) on 4/21/21 at 10:26 AM. She stated it was her expectation that target behaviors were accurately identified and that behavior monitoring was completed for the use of [CONDITION(S)] medications. The NP acknowledged that Resident #73 was on multiple [CONDITION(S)] medications and it was essential to have target behaviors identified and behavior monitoring conducted on those target behaviors in order to determine if the medications were effective. A phone interview was conducted with the PPA on 4/22/21 at 10:10 AM. She reiterated NP #1 ' s interview that indicated target behaviors needed to be accurately identified and that these target behaviors must be routinely monitored in order to ascertain if the prescribed medication was effectively treating the behavior/behaviors that the medication was prescribed for. An interview was conducted with the Director of Nursing (DON) on 4/22/21 at 11:20 AM. She stated it was her expectation that appropriate and accurate target behaviors were identified and that behavior monitoring was completed for the use of [CONDITION(S)] medications. She further stated she expected the Pharmacy Consultant to identify and address any missing target behaviors as well as the lack of behavior monitoring for any resident on [CONDITION(S)] medications during the monthly MRR. 1b. Resident #73 was admitted to the facility on [DATE] with diagnoses that included dementia, Alzheimer's disease, and anxiety. A physician ' s order dated 2/28/20 indicated [MEDICATION(S)] (antidepressant medication) 25 milligrams (mg) once daily. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 ' s cognition was severely impaired. She had no [CONDITION(S)] and no behavioral symptoms. Resident #73 was noted with rejection of care and wandering on 1 to 3 days during the MDS review period. She was administered antidepressant medication on 3 of 7 days. A physician ' s order dated 3/5/21 indicated [MEDICATION(S)] (antipsychotic medication) 25 mg once daily. A physician ' s order dated 3/16/20 indicated routine [MEDICATION(S)] (antianxiety medication) 0.25 mg every evening for Resident #73. A physician ' s order for Resident #73 dated 3/20/20 indicated an increase in [MEDICATION(S)] from 25 mg to 50 mg once daily. A psychiatric note dated 9/11/20 completed by the Psychiatric Physician ' s Assistant (PPA) indicated staff reported no mood or behavioral concerns for Resident #73. Her current psychiatric medications were listed as [MEDICATION(S)] 25 mg once daily at night, [MEDICATION(S)] 50 mg once daily, and [MEDICATION(S)] 0.25 mg once daily at night. The PPA wrote that Resident #73 was lying in bed and not responding to her questions. She was noted with significant dementia, no obvious signs of depression or anxiety, and no observed behavioral disturbances. Resident #73 ' s depression was stable and [MEDICATION(S)] was to be continued, dementia with behavioral disturbance was fair, and [MEDICATION(S)] and scheduled [MEDICATION(S)] were treating anxiety. The PPA indicated that Resident #73 had fallen and that [MEDICATION(S)] may need to be discontinued if falls continued. A monthly MRR for September 2020 completed by the Pharmacy Consultant (review dated of 9/22/20) was addressed to the PPA indicating that Resident #73 was on [MEDICATION(S)] 25 mg once daily at night, [MEDICATION(S)] 0.25 mg once daily, and [MEDICATION(S)] 50 mg once daily. The Pharmacy Consultant requested the PPA evaluate the current doses and consider a Gradual Dose Reduction (GDR) to ensure that resident was using the lowest possible effective/optimal dose. There was no indication in the medical record that this recommendation had been responded to and/or acted upon by the PPA or other medical practitioner. A Nurse Practitioner (NP) note for Resident #73 dated 10/8/20 indicated there were no behavioral concerns. Resident #73 was followed by psychiatric services and she was on [MEDICATION(S)] 50 mg once daily, [MEDICATION(S)] 0.25 mg once daily at night, and [MEDICATION(S)] 25 mg once daily at night. A physician note dated 10/17/20 indicated staff reported no concerns and there was no change in Resident #73 ' s plan of care and medications. A psychiatric note dated 10/30/20 completed by the PPA indicated staff reported no mood or behavioral concerns for Resident #73. Her current psychiatric medications were listed as [MEDICATION(S)] 25 mg once daily at night, [MEDICATION(S)] 50 mg once daily, and [MEDICATION(S)] 0.25 mg once daily at night. The PPA wrote that Resident #73 was lying in bed and not responding to her questions. She was noted with significant dementia, no obvious signs of depression or anxiety, and no observed behavioral disturbances. Resident #73 ' s depression was stable and [MEDICATION(S)] was to be continued, dementia with behavioral disturbance was fair, and [MEDICATION(S)] and scheduled [MEDICATION(S)] were treating anxiety. The PPA indicated that Resident #73 had fallen and that she chewed her finger at times. There was no mention in the note of GDR evaluation and/or of GDRs being clinically contraindicated for any of Resident #73 ' s [CONDITION(S)] medications. A physician ' s order dated 12/7/20 indicated an order to increase [MEDICATION(S)] for Resident #73 from 25 mg once daily to 25 mg twice daily. A physician ' s order dated 1/13/21 indicated an order to increase [MEDICATION(S)] from 25 mg twice daily to 50 mg twice daily. The annual MDS assessment dated [DATE] indicated Resident #73 ' s cognition was severely impaired. She had no mood issues, no [CONDITION(S)], no behaviors, no rejection of care, and no wandering. Resident #73 received antipsychotic medication, antianxiety medication, and antidepressant medication on 7 of 7 days during the MDS review period. She was noted with no GDRs of her antipsychotic medication and no physician documentation of a GDR being clinically contraindicated. A PPA note dated 3/19/21 indicated that Resident #73 ' s [CONDITION(S)] medications included [MEDICATION(S)] 50 mg twice daily, [MEDICATION(S)] 0.25 mg once daily, and [MEDICATION(S)] 50 mg once daily. The PPA wrote the goal was to taper next visit. A review of Resident #73 ' s current physician orders on 4/20/21 indicated the 3/20/20 order for [MEDICATION(S)] 50 mg once daily remained active, the 3/16/20 order for [MEDICATION(S)] 0.25 mg once daily remained active, and the 1/13/21 order for [MEDICATION(S)] 50 mg twice daily remained active. A phone interview was conducted with the Pharmacy Consultant on 4/22/21 at 9:25 AM. She stated she expected her recommendations to be responded to by the next MRR the following month. The monthly MRR for September 2020 that requested the psychiatric provider (PPA) evaluate Resident #73 ' s [CONDITION(S)] medications ([MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]) for the appropriateness of a GDR was reviewed. When asked if this recommendation was responded to by the PPA she indicated that she saw a PPA or physician note that indicated medications were to be continued. She acknowledged that there was no physician or PPA documentation that stated that a GDR was clinically contraindicated. A phone interview was conducted with the PPA on 4/22/21 at 10:10 AM. She was unable to recall with certainty the September 2020 MRR that recommended a GDR evaluation. She indicated that her plan was to taper at least one of Resident #73 ' s [CONDITION(S)] medications at her next visit. During an interview with the Director of Transitions on 4/22/21 at 11:18 AM he indicated that the facility had no record of a response from the medical provider (PPA, physician, or NP) for the September 2020 pharmacy recommendation for a GDR evaluation for Resident #73. He explained that there were several changes with management staff over the past several months. He further explained that as a result of the changes the pharmacy recommendation forms from September 2020 were unable to be located. The Director of Transitions acknowledged that there was no indication in the medical record that the September 2020 pharmacy recommendation for Resident #73 was responded to. An interview was conducted with the Director of Nursing (DON) on 4/22/21 at 11:20 AM. She indicated that she just began working at the facility last week. The DON reported that her expectation was for the treating provider to respond to pharmacy recommendations within a month. She further reported that she expected the Pharmacy Consultant to make repeat recommendations if she had not received a response to a previous recommendation. 2. Resident #13 was originally admitted to the facility on [DATE] with multiple diagnoses including [CONDITION(S)]. The annual Minimum Data Set (MDS) assessments dated 2/8/20 and 1/4/21 indicated that Resident #13 had received an antipsychotic medication, had no behavioral symptoms and no gradual dose reduction (GDR) had been attempted. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #13's cognition was intact, and he had received an antipsychotic medication for 7 days during the assessment period and no GDR had been attempted. The assessment further indicated that the resident did not have any behaviors. Resident #13 had a doctor's order dated 12/17/18 for [MEDICATION(S)] (an antipsychotic medication) 2 milligrams (mgs.) in the morning and 3 mgs. at bedtime for [CONDITION(S)]. Resident #13's care plan was reviewed. One of the care plan problems dated 4/5/21 was resident receives antipsychotic medication related to [CONDITION(S)]. The approaches included consult with pharmacy, doctor to consider dosage reduction when clinically appropriate at least quarterly. Resident #13's doctor's progress notes and the psychiatric Nurse Practitioner notes from March 2020 to present were reviewed. The notes did not document that a GDR was clinically contraindicated for the resident and the clinical rationale as to why a GDR attempt would likely impair or exacerbate resident's medical or psychiatric condition. Resident #13's monthly drug regimen reviews (DRR) were reviewed. The monthly DRR from 3/23/20 through 3/25/21 revealed that the pharmacy consultant had not recommended a GDR for the [MEDICATION(S)]. The Pharmacy Consultant was interviewed on 4/22/21 at 9:27 AM. She stated that she did not recommend a GDR for Resident #13 ' s [MEDICATION(S)] since the psychiatric Nurse Practitioner indicated that no GDR was required due to diagnoses of [CONDITION(S)]. The Director of Nursing (DON) was interviewed on 4/22/21 at 11:29 AM. The DON stated that she expected that a GDR be attempted for residents on [CONDITION(S)] medications and the pharmacy consultant was expected to recommend a GDR per the regulations. 3. Resident #102 was admitted on [DATE] with a diagnosis of [CONDITION(S)] Disorder. [CONDITION(S)] Disorder is defined as a mental disorder that can cause unusual shifts in mood, energy, activity levels, concentration and the ability to carry out day-to-day task. Review of Resident #102's quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact and exhibited no behaviors. She was coded for the use of an antipsychotic for 7 of 7 days of the look back period. Review of Resident #102's care plan last revised on 3/9/21 read she received antipsychotic medications related to her [CONDITION(S)] Disorder. Interventions included documenting behavioral symptoms not usual for Resident #102 and observe for side effects. The care plan read to record behaviors. The care plan did not include any target behaviors for staff to observe. Review of Resident #102's April 2021 Physician orders read as follows: *[MEDICATION(S)] (antipsychotic) 0.75 milligrams every night at bedtime for mood stabilizer related to [CONDITION(S)] Disorder *Observation: Antipsychotic Medication ([MEDICATION(S)])-Observe for behavior: (increased mood). Observe for side effects: dry mouth, constipation, blurry vision, disorientation/confusion, difficultly urinating, [CONDITION(S)], dark urine, yellow skin, nausea/vomiting, lethargy, drooling, tremors, gait issues, agitation, restlessness, involuntary movements of mouth and tongue. Document Y (yes) if she was free of side effects and document N (no) if Resident #102 was not free of side effects every shift. Review of Resident #102's Medication Administration Record (MAR) for April 2021 indicated she received her [MEDICATION(S)] as ordered. Also the April 2021 MAR read to document Y indicating she was absent of side effects and N if she was not free of side effects. for the use of Resident # related to side effects. The April 2021 MAR documentation for the side effects of Resident #102's antipsychotic medication all read Y indicating no adverse side effects observed. The MAR did not include any target behavior monitoring. Review of Resident #102's nursing notes from 4/1/21 to 4/21/21 did not include any behavior nursing notes. Review of the monthly Consultant Pharmacist Residents Reviewed Reports read there was no pharmacy recommendations regarding Resident #102 on the following review dates: 10/28/20, 11/25/20, 12/23/20, 1/27/21, 2/26/21 and 3/26/21. Review of Resident #102's psychotherapy initial evaluation completed by the provider social worker dated 3/30/21 read Resident #102 presented the following problems and symptoms: [CONDITION(S)] that it made her sad, occasional worry about her ability to pay for her stay, decreased mood, occasional panic or anxiety, periods of occasional high energy, fatigue and excessive worry. Resident #102's treating diagnosis was moderate [CONDITION(S)] Disorder with the most recent episode of depression and she would benefit from psychotherapy services. Interview on 4/21/21 at 9:10 AM was conducted with Nurse #1. She stated behaviors were documented on Resident #102's MAR. She stated she was not aware her MAR did not include any target behavior monitoring and Resident #102 was only being monitored for side effects of her antipsychotic medication. She stated any behaviors she exhibited related to her [CONDITION(S)] Disorder would be documented in a nursing note. Nurse #1 stated examples of target behaviors for Resident #102' [CONDITION(S)] Disorder would be behaviors related to [CONDITION(S)] or depression. Interview on 4/21/21 at 9:20 AM, Resident #102 was observed sitting up in bed. She appeared groomed and dressed for the day. She endorsed recent depression and felt it was related to the lack of socialization since COVID-19. She stated she felt sad, ruminated about things that happened in her past and experienced [CONDITION(S)]. Interview on 4/21/21 at 10:30 AM was conducted with Nurse Practitioner (NP) #1. She stated it was her expectation that the Consultant Pharmacist identify the need for target behaviors and the need for these behaviors to be monitored for Resident #102. NP #1 explained increased mood meant [CONDITION(S)]. NP #1 stated depression symptoms had not be identified. She stated [CONDITION(S)] and depression symptoms needed to be clarified so the staff knew what to look for when assessing Resident #102. NP #1 stated the Consultant Pharmacist usually wrote a recommendation regarding any concerns for the facility to address. Interview on 4/21/21 at 1:55 PM, Nursing Assistant (NA) #2 stated she had not noticed any behaviors out of the ordinary for Resident #102. She explained her ordinary behaviors were not wanting to get out of the bed or take showers. In a telephone interview on 4/22/21 at 9:30 AM, the Consultant Pharmacist stated she had completing her monthly reviews remotely since COVID-19. She stated she asked the previous Director of Nursing (DON) where the nurses were documenting Resident #102's behaviors and she only recently began reviewing the MAR's for evidence of behavior monitoring. She stated she had planned to address with the facility the need for behavior identification and monitoring on her April 2021 visit. The Consultant Pharmacist stated Resident #102's target behaviors should have been clarified and increased mood was not necessarily the only behavior related to [CONDITION(S)] Disorder. She stated she did not think she made any recommendations regarding the need for the facility to identify Resident #102's target behaviors or behavior monitoring. Interview was conducted with the Director of Nursing (DON) on 4/22/21 at 11:30 AM. The DON stated she started her position earlier this month. She stated she was not aware that the Consultant Pharmacist had not identified the need for Resident #102's target behaviors and behavior monitoring. The DON stated she was not aware that the nurses were only assessing and documenting on Resident #102 for adverse side effects of [MEDICATION(S)]. The DON stated it was her expectation that the Consultant Pharmacist identified the need for Resident #102's target behaviors associated with her [CONDITION(S)] Disease and accurate behavior monitoring.

Based on record review, observation, and interviews with Nurse Practitioner, Psychiatric Physician ' s Assistant, Pharmacy Consultant, and staff, the facility failed to evaluate residents on [CONDITION(S)] medications for gradual dose reductions (Resident #13) and failed to identify and monitor target behavioral symptoms for the use of [CONDITION(S)] medications (Residents #73 and #102). This was for 3 of 5 residents reviewed for unnecessary medications. The findings included: 1. Resident #73 was admitted to the facility on [DATE] with diagnoses that included dementia and anxiety. A physician ' s order dated 2/28/20 indicated [MEDICATION(S)] (antidepressant medication) 25 milligrams (mg) once daily for anxiety/agitation. A physician ' s order dated 3/1/20 read, Observation: AntiDepressant Medication ([MEDICATION(S)]) - Observe for behavior (sadness). Observe for side effects: [gastrointestinal (GI)] upset, [CONDITION(S)], fatigue, dizziness, dry mouth, headache. Document Y if resident is free of side effects. Document N if the resident is NOT free from side effects. If N document [side effect] in the [progress notes]. every shift. This observation and side effect documentation was to be completed 3 times per day (7:00 AM, 3:00 PM, and 11:00 PM). A physician ' s order dated 3/2/20 indicated [MEDICATION(S)] (antianxiety medication) 0.25 mg every 12 hours as needed (PRN) for anxiety or agitation 14 Days (3/16/20 end date). A physician ' s order dated 3/2/20 read, Observation: Antianxiety Medication ([MEDICATION(S)])- Observe for behavior (agitation). Observe for side effects: drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document:'Y' if resident is free of side effects. 'N' if the resident is not free of side effects. If 'N' document [side effects] in the [progress notes]. every shift for 14 Days. This observation and side effect documentation was to be completed 3 times per day (7:00 AM, 3:00 PM, and 11:00 PM). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 ' s cognition was severely impaired. She had no [CONDITION(S)] and no behavioral symptoms. Resident #73 was noted with rejection of care and wandering on 1 to 3 days during the MDS review period. She was administered antianxiety medication on 1 of 7 days and antidepressant medication on 3 of 7 days. A physician ' s order dated 3/5/21 indicated [MEDICATION(S)] (antipsychotic medication) 25 mg once daily at night for sadness. A physician ' s order dated 3/5/20 read, Observation: Antipsychotic Medication ([MEDICATION(S)])- Observe for behavior: (sadness) Observe for side effects: dry mouth, constipation, blurry vision, disorientation/confusion, difficulty urinating, [CONDITION(S)], dark urine, yellow skin, [nausea and vomiting], lethargy, drooling, [extrapyramidal symptoms] (tremors, gait issues, agitation, restlessness, involuntary movement of mouth/tongue.) Document: Y if resident is free of side effects. N if the resident is not free of side effects. If N document [side effects] in the [progress notes]. This observation and side effect documentation was to be completed 3 times per day (7:00 AM, 3:00 PM, and 11:00 PM). A physician ' s order dated 3/16/20 indicated routine [MEDICATION(S)] 0.25 mg every evening for agitation for Resident #73. The previous 3/2/20 order for PRN [MEDICATION(S)] 0.5 mg stopped on 3/16/20. A physician ' s order for Resident #73 dated 3/20/20 indicated an increase in [MEDICATION(S)] from 25 mg to 50 mg once daily for anxiety/agitation. A physician ' s order dated 12/7/20 indicated an order by Nurse Practition (NP) #1 to increase [MEDICATION(S)] for Resident #73 from 25 mg once daily to 25 mg twice daily for delusional disorder and Alzheimer ' s dementia. A physician ' s order dated 1/13/21 indicated an order by NP #1 to increase [MEDICATION(S)] from 25 mg twice daily to 50 mg twice daily for delusional disorder and Alzheimer ' s dementia. The annual MDS assessment dated [DATE] indicated Resident #73 ' s cognition was severely impaired. She had no mood issues, no [CONDITION(S)], no behaviors, no rejection of care, and no wandering. Resident #73 received antipsychotic medication, antianxiety medication, and antidepressant medication on 7 of 7 days during the MDS review period. A Psychiatric Physician ' s Assistant (PPA) note dated 3/19/21 indicated that Resident #73 ' s [CONDITION(S)] medications included [MEDICATION(S)] 50 mg twice daily, [MEDICATION(S)] 0.25 mg once daily, and [MEDICATION(S)] 50 mg once daily. Staff were to monitor Resident #73 ' s mood and behaviors. A review of Resident #73 ' s March 2020 through 4/20/21 Medication Administration Records (MAR) indicated she received [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] as ordered. The target behavior for [MEDICATION(S)] and [MEDICATION(S)] was listed as sadness and the target behavior for [MEDICATION(S)] was agitation. The MAR included side effect monitoring, but no behavior monitoring. An interview was conducted with Nursing Assistant (NA) #7 on 4/21/21 at 12:45 PM. She reported that Resident #73 had some resistance to care that included yelling out or crying. NA #7 stated that Resident #73 had no behavioral symptoms if she was not disturbed by staff. During an interview with NA #6 on 4/21/21 at 12:47 PM she confirmed NA #7 ' s interview related to Resident #73 ' s resistance to care that was exhibited by yelling out and/or crying. An observation was conducted on 4/21/21 at 12:52 PM of NA #6 and NA #7 transferring Resident #73 from her geriatric wheelchair to her bed via a mechanical lift. NA #6 approached Resident #73 from the front and informed her that she and NA #7 were going to transfer her to her bed. Resident #73 began yelling when first touched by staff. NA #6 and NA #7 utilized tactile stimulation of rubbing Resident #73 ' s chest, holding her hand, and speaking to her with words of encouragement and support throughout this entire interaction. These interventions were successful in reducing Resident #73 ' s observed behaviors and she was able to be transferred to her bed without incident. During an interview with Unit Manager (UM) #3 on 4/21/21 at 1:00 PM she stated that behavior monitoring of target behaviors for [CONDITION(S)] medications was completed on the MAR. The active MAR and active physician ' s orders for Resident #73 was reviewed with UM #3. UM #3 revealed she not realized that the physician ' s orders and MAR only required documentation of the presence of side effects and had not required documentation of target behavior monitoring. UM #3 further revealed that the target behavior of sadness identified for [MEDICATION(S)] and [MEDICATION(S)] were not accurate for Resident #73. During a phone interview with the Pharmacy Consultant on 4/22/21 at 9:25 AM she indicated that targeted behaviors were expected to be identified for [CONDITION(S)] medications in order for the facility to be able to track what the medication was being used for, if behaviors were ongoing or were stable, and if the medication was needed or was able to be decreased and/or discontinued. She indicated that identification of targeted behaviors provided a rationale for what the medication was being used to control. An interview was conducted with Resident #73 ' s NP (NP #1) on 4/21/21 at 10:26 AM. She stated it was her expectation that target behaviors were accurately identified and that behavior monitoring was completed for the use of [CONDITION(S)] medications. The NP acknowledged that Resident #73 was on multiple [CONDITION(S)] medications and it was essential to have target behaviors identified and behavior monitoring conducted on those target behaviors in order to determine if the medications were effective. A phone interview was conducted with the PPA on 4/22/21 at 10:10 AM. She reiterated NP #1 ' s interview that indicated target behaviors needed to be accurately identified and that these target behaviors must be routinely monitored in order to ascertain if the prescribed medication was effectively treating the behavior/behaviors that the medication was prescribed for. An interview was conducted with the Director of Nursing (DON) on 4/22/21 at 11:20 AM. She stated it was her expectation that appropriate and accurate target behaviors were identified and that behavior monitoring was completed for the use of [CONDITION(S)] medications. 2. Resident #13 was originally admitted to the facility on [DATE] with multiple diagnoses including [CONDITION(S)]. The annual Minimum Data Set (MDS) assessments dated 2/8/20 and 1/4/21 indicated that Resident #13 had received an antipsychotic medication, had no behavioral symptoms and no gradual dose reduction (GDR) had been attempted. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #13's cognition was intact, and he had received an antipsychotic medication for 7 days during the assessment period and no GDR had been attempted. The assessment further indicated that the resident did not have any behaviors. Resident #13 had a doctor's order dated 12/17/18 for [MEDICATION(S)] (an antipsychotic medication) 2 milligrams (mgs.) in the morning and 3 mgs. at bedtime for [CONDITION(S)]. Resident #13's care plan was reviewed. One of the care plan problems dated 4/5/21 was resident receives antipsychotic medication related to [CONDITION(S)]. The approaches included consult with pharmacy, doctor to consider dosage reduction when clinically appropriate at least quarterly. Resident #13's doctor's progress notes and the psychiatric Nurse Practitioner (NP) notes from March 2020 to present were reviewed. The notes did not document that a GDR was clinically contraindicated for the resident and the clinical rationale as to why a GDR attempt would likely impair or exacerbate resident's medical or psychiatric condition. Resident #13's nurse's notes (March 2020 through April 2021) and the Nursing Assistants notes (January through April 2021) were reviewed. The notes revealed that Resident #13 did not have any behaviors except calling 911 (times 1), calling facility main number and non-compliant with fluid restriction. Interview with the Nurse Practitioner (NP) #2 was conducted on 4/21/21 at 8:58 AM. The NP stated Resident #13 was being followed by the psychiatric (psych) NP for medication management. She added that the psych NP would make a recommendation if a GDR was indicated or not. Interview with the psychiatric NP was conducted on 4/22/21 at 9:40 AM. The NP stated that she was following Resident #13 for medication management of [CONDITION(S)] medication and assessment of mood and behaviors. She revealed that Resident #13 was on [MEDICATION(S)] 2 mgs. in AM and 3 mgs. at bedtime since 2018 due to diagnoses of [CONDITION(S)]. She indicated that she did not recommended a GDR for the [MEDICATION(S)] since Resident #13 has appropriate diagnoses of [CONDITION(S)], and so GDR was not required. The Director of Nursing (DON) was interviewed on 4/22/21 at 11:29 AM. The DON stated that she expected that a GDR be attempted for residents on [CONDITION(S)] medications. 3. Resident #102 was admitted on [DATE] with a diagnosis of [CONDITION(S)] Disorder. [CONDITION(S)] Disorder is defined as a mental disorder that can cause unusual shifts in mood, energy, activity levels, concentration and the ability to carry out day-to-day task. Review of Resident #102's quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact and exhibited no behaviors. She was coded for the use of an antipsychotic for 7 of 7 days of the look back period. Review of Resident #102's care plan last revised on 3/9/21 read she received antipsychotic medications related to her [CONDITION(S)] Disorder. Interventions included documenting behavioral symptoms not usual for Resident #102 and observe for side effects. The care plan read to record behaviors. The care plan did not include any target behaviors for staff to observe. Review of Resident #102's April 2021 Physician orders read as follows: *[MEDICATION(S)] (antipsychotic) 0.75 milligrams every night at bedtime for mood stabilizer related to [CONDITION(S)] Disorder *Observation: Antipsychotic Medication ([MEDICATION(S)])-Observe for behavior: (increased mood). Observe for side effects: dry mouth, constipation, blurry vision, disorientation/confusion, difficultly urinating, [CONDITION(S)], dark urine, yellow skin, nausea/vomiting, lethargy, drooling, tremors, gait issues, agitation, restlessness, involuntary movements of mouth and tongue. Document Y (yes) if she was free of side effects and document N (no) if Resident #102 was not free of side effects every shift. Review of Resident #102's Medication Administration Record (MAR) for April 2021 indicated she received her [MEDICATION(S)] as ordered. Also the April 2021 MAR read to document Y indicating she was absent of side effects and N if she was not free of side effects. for the use of Resident # related to side effects. The April 2021 MAR documentation for the side effects of Resident #102's antipsychotic medication all read Y indicating no adverse side effects observed. The MAR did not include any target behavior monitoring. Review of Resident #102's nursing notes from 4/1/21 to 4/21/21 did not include any behavior nursing notes. Review of the monthly Consultant Pharmacist Residents Reviewed Reports read there was no pharmacy recommendations for the following review dates: 10/28/20, 11/25/20, 12/23/20, 1/27/21, 2/26/21 and 3/26/21. Review of Resident #102's psychotherapy initial evaluation completed by the provider social worker dated 3/30/21 read Resident #102 presented the following problems and symptoms: [CONDITION(S)] that it made her sad, occasional worry about her ability to pay for her stay, decreased mood, occasional panic or anxiety, periods of occasional high energy, fatigue and excessive worry. Resident #102's treating diagnosis was moderate [CONDITION(S)] Disorder with the most recent episode of depression and she would benefit from psychotherapy services. Interview on 4/21/21 at 9:10 AM was conducted with Nurse #1. She stated behaviors were documented on Resident #102's MAR. She stated she was not aware her MAR did not include any target behavior monitoring and Resident #102 was only being monitored for side effects of her antipsychotic medication. She stated any behaviors she exhibited related to her [CONDITION(S)] Disorder would be documented in a nursing note. Nurse #1 stated examples of target behaviors for Resident #102' [CONDITION(S)] Disorder would be behaviors related to [CONDITION(S)] or depression. Interview on 4/21/21 at 9:20 AM, Resident #102 was observed sitting up in bed. She appeared groomed and dressed for the day. She endorsed recent depression and felt it was related to the lack of socialization since COVID-19. She stated she felt sad, ruminated about things that happened in her past and experienced [CONDITION(S)]. Interview on 4/21/21 at 10:30 AM was conducted with Nurse Practitioner (NP) #1. She stated it was her expectation that the facility identify target behaviors and monitor those behaviors for Resident #102. NP #1 explained increased mood meant [CONDITION(S)]. NP #1 stated depression symptoms had not be identified. She stated [CONDITION(S)] and depression symptoms needed to be clarified so the staff knew what to look for when assessing Resident #102. NP #1 stated the facility should have recognized the need for target behaviors and monitoring associated with the use of an antipsychotic medication. Interview on 4/21/21 at 1:55 PM, Nursing Assistant (NA) #2 stated she had not noticed any behaviors out of the ordinary for Resident #102. She explained her ordinary behaviors were not wanting to get out of the bed or take showers. In a telephone interview on 4/22/21 at 9:30 AM, the Consultant Pharmacist stated she had completing her monthly reviews remotely since COVID-19. She stated she asked the previous Director of Nursing (DON) where the nurses were documenting Resident #102's behaviors and she only recently began reviewing the MAR's for evidence of behavior monitoring. She stated she had planned to address with the facility the need for behavior identification and monitoring on her April 2021 visit. The Consultant Pharmacist stated Resident #102's target behaviors should have been clarified and increased mood was not necessarily the only behavior related to [CONDITION(S)] Disorder. She stated she did not think she made any recommendations regarding the need for the facility to identify Resident #102's target behaviors or behavior monitoring. Interview was conducted with the Director of Nursing (DON) on 4/22/21 at 11:30 AM. The DON stated she started her position earlier this month. She stated she was not aware that the facility staff had not identified the need for Resident #102's target behaviors and behavior monitoring. The DON stated she was not aware that the nurses were only assessing and documenting Resident #102 for adverse side effects of [MEDICATION(S)]. The DON stated it was her expectation that the facility identify the need for Resident #102's target behaviors associated with her [CONDITION(S)] Disease and accurate behavior monitoring.

Based on record review, observations, and interviews with resident and staff, the facility failed to honor a resident's choice related to showers. This was for 1 of 3 residents reviewed for choices (Resident #16). The findings included: Resident #16 was originally admitted to the facility on [DATE] with a recent readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was cognitively intact and had no rejection of care. He required extensive assistance for dressing, toileting and personal hygiene and was dependent on staff for bathing. The review of Resident #16's active care plan, last reviewed on 1/27/21, revealed a focus area for Activities of Daily Living (ADL) self-care performance deficit related to right and left below the knee amputations, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included the resident can participate in part to total assist by 1 staff in bathing. A review of Resident #16's medical record revealed he was hospitalized from 3/15/21 through 3/20/21. Scheduled showers were on Monday and Thursday on the 3:00 PM to 11:00 PM sift (2nd shift). A review of the nursing progress notes from 11/1/2020 through 4/21/21 revealed Resident #16 refused a shower on 3/24/21 and 3/31/21 and was provided a bed bath. A review of Resident #16's Nursing Assistant (NA) bathing/shower documentation from 3/24/21 through 4/21/21 indicated Resident #16 had received bed baths in place of showers on his scheduled shower days of Monday and Thursday. An interview was completed with Resident #16 on 4/21/21 at 9:10 AM, who stated he would like to have a shower and shampoo on his scheduled shower days. Resident #16 explained he had been receiving bed baths and shampoos with a cap which left his hair greasy and his scalp flaky and itchy on his scheduled shower days and was told there wasn't enough staff when he inquired about a shower. On 4/21/21 at 1:40 PM, an interview occurred with Nurse Aide (NA) #3 who worked the 7:00 AM to 3:00 PM shift. She explained all residents were scheduled for showers 2 times a week with nail care, shaving and shampoos also rendered. She went onto say if a resident refused their scheduled shower the nurse would be notified so it could be documented in the medical record. NA #3 further stated there was enough staff to provide the necessary care to the residents. The Director of Nursing (DON) was interviewed on 4/21/21 at 3:26 PM and stated it was her expectation for showers to be provided on the scheduled days per the resident's choice. She further stated if a bed bath was provided rather than a shower the NA's documentation should indicate which was provided and the nurse should be made aware so documentation would occur in the electronic medical record as to the reason why. A phone interview occurred with NA #4 on 4/22/21 at 8:45 AM, who was familiar with Resident #16 and worked the 3:00 PM to 11:00 PM shift. She couldn't recall Resident #16 refusing a bath when offered. Resident #16's shower/bath documentation was reviewed and indicated NA #4 was assigned to the resident on 4/1/21, a scheduled shower day. She further stated Resident #16 had been receiving a bed bath on his scheduled shower days because he had been sick. On 4/22/21 at 9:05 AM, an interview occurred with NA #5, who was familiar with Resident #16 and stated she worked 7:00 AM to 7:00 PM most days. NA #5 explained Resident #16 enjoyed his showers and she could not recall him refusing a shower when offered. Resident #16's shower/bath documentation was reviewed and indicated NA #5 was assigned to the resident on 4/8/21, 4/12/21 and 4/15/21, scheduled shower days. NA #5 stated Resident #16 had been in the hospital recently and when things got busy, she would just make sure he had a complete bed bath instead of his scheduled shower.

Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of prognosis (Resident #85), tobacco use (Resident #1), medications (Resident #83), cognition (Resident #25), and oxygen therapy (Resident #59) for 5 of 26 sampled residents. The findings included: 1. Resident #85 was most recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85' s cognition was moderately impaired. He was on hospice services. The MDS assessment indicated Resident #85 had no condition or chronic disease that could result in a life expectancy of less than 6 months. An interview was conducted with MDS Nurse #1 on 4/22/21 at 8:35 AM. She confirmed that she completed the section of Resident #85 ' s 3/11/21 MDS assessment in the area of prognosis. She additionally confirmed that Resident #85 was on hospice services at the time of that MDS assessment. MDS Nurse #1 reported that she was not aware that if a resident was on hospice that they also needed to be coded as having a life expectancy of less than 6 months. She indicated the 3/11/21 MDS assessment for Resident #85 was coded inaccurately for prognosis. During an interview with the Director of Nursing on 4/22/21 at 11:20 AM she indicated that she expected the MDS to be coded accurately. 2. Resident #83 was most recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 ' s cognition was severely impaired. He was coded with 1 injection and 1 insulin injection during the 7 day MDS look back period. A review of Resident #83 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 had received 1 [MEDICATION(S)] injection during this 7 day review period. An interview was conducted with MDS Nurse #1 on 4/22/21 at 8:35 AM. She confirmed that she completed the section of Resident #83 ' s 3/16/21 MDS assessment in the area of medications. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1. MDS Nurse #1 revealed she coded Resident #83 ' s [MEDICATION(S)] injection as an insulin injection in error. She indicated the 3/16/21 MDS assessment for Resident #83 was coded inaccurately and should have indicated he received no insulin injections. During an interview with the Director of Nursing on 4/22/21 at 11:20 AM she indicated that she expected the MDS to be coded accurately. 3. Resident # 1 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 did not use tobacco during the assessment period. Resident #1 had a smoking assessment dated [DATE] and revealed that she was a safe smoker. Resident #1's care plan dated 11/2/20 revealed that she was a smoker. Resident #1 was interviewed on 4/19/21 at 2:00 PM and she reported that she had been smoking since she was admitted to the facility. Nurse #1 was interviewed on 4/21/21 at 10:40 AM. Nurse #1 stated that Resident #1 was a smoker and she completed a smoking assessment when the resident was readmitted on [DATE]. MDS Nurse #2 was interviewed on 4/22/21 at 8::35 AM. MDS Nurse #2 verified that Resident #1 was a smoker and she acknowledged that she coded the significant change in status MDS assessment dated [DATE] incorrectly. She added that she would complete a modification assessment to reflect that Resident #1 have used tobacco during the assessment period. The Director of Nursing (DON) was interviewed on 4/22/21 at 11:29 AM. The DON stated that she expected the MDS assessment to be coded accurately. 4) Resident #59 was originally admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact and oxygen use in the facility was not coded. A review of Resident #59's active care plan, last reviewed on 2/24/21 revealed a focus area of oxygen therapy continuously for shortness of breath. During an interview with the MDS Nurse #2 on 4/21/21 at 3:44 PM, she confirmed she was aware Resident #59 received oxygen therapy continuously and oxygen was not marked on the MDS assessment dated [DATE]. She stated it was an oversight. An interview was conducted with the Director of Nursing on 4/22/21 at 11:22 AM, and stated it was her expectation for the MDS to be coded accurately. 5) Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS), dated [DATE], and recent discharge MDS dated , 1/24/2021, coded the resident as not being in a persistent vegetative state under section B. All MDS assessments prior to 1/15/2021 had Resident #25 coded as persistent vegetative state. The resident's most recent comprehensive care plan, dated 4/7/2021, indicated Resident #25 has an activity of daily living (ADL) self-care deficit related to [CONDITION(S)] [CONDITION(S)], trauma, and persistent vegetative state. On 4/19/2021 at 10:37am Resident #25 was observed to be awake but unable to respond to verbal stimuli or interact with his environment in a meaningful way. On 4/21/2021 at 3:02pm an interview was conducted with MDS #1 and MDS nurse #2. Both MDS nurses reviewed the quarterly MDS dated [DATE] and the discharge MDS dated [DATE]. MDS #1 stated there was no change in the resident's cognition, the coding was done in error. MDS#2 stated she coded both the 1/15/2021 and the 1/24/2021 assessments and the resident should have been coded as persistent vegetative state in Section B. She further stated, it was an error. In an interview with the Director of Nursing (DON) on 4/22/21at 11:20am, she stated it was her expectation that MDS be coded correctly.

Based on observations, staff and resident interviews and record review, the facility failed to assist activities of daily living (ADLs) dependent residents with nail care (Resident # 214, Resident #102 and Resident #80) and facial hair (Resident #214). This was for 3 of 8 residents reviewed for ADLs. Findings included: 1. Resident #214 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] His admission Minimum Data Set (MDS) dated [DATE] was in progress and indicated he was cognitively intact and exhibited no behaviors. Resident #214's baseline care plan dated 4/8/21 read he required physical staff assistance with his personal hygiene. Interview and observation was conducted with Resident #214 on 4/19/21 at 10:20 AM. He appeared disheveled. He stated he was receiving wound care to his right elbow due to an infection. His fingernails appeared long, dirty and jagged. His facial hair was unkept at his side [CONDITION(S)] and grown out approximately 2 inches sticking straight out. He stated he needed his fingernails cleaned and trimmed and stated nobody had offered to assist with his nail care. He stated he normally wore his beard growth just around his mouth and chin (circle style) and keep his side [CONDITION(S)] shaven. He stated nobody at the facility had mentioned his beard but he would really like to have a shave to wear his beard in the way he was accustomed. A second observation was conducted on 4/19/21 at 3:14 PM. His fingernails were still dirty, long and jagged. His beard was still unkept. Resident #214 stated nobody had asked him about cutting his fingernails or beard. He stated he mentioned it earlier today but was unsure who he talked too. Review of a nursing note dated 4/21/21 at 8:13 AM read Resident #214's nail care was completed. Review of a nursing note dated 4/20/21 at 3:15 PM read Resident #214 allowed staff to trim his beard to his preferred length. Interview was conducted with Unit Manager (UM) #1 on 4/21/21 at 8:45 AM. She stated it was the responsibly of the floor nurses to cut and clean the fingernails of diabetic residents. She stated she was not aware of any ADL refusals by Resident #214. She stated on occasion he would tell the staff to come back later then comply. She stated nail care should be done weekly and usually completed after a shower. Interview was conducted with Nurse #1 on 4/21/21 at 9:10 AM. She stated she was not aware of any refusals and that Resident #214 was cooperative. Nurse #1 stated the floor nurses were responsible for trimming the fingernails of all diabetic residents. Observation on 4/21/21 at 9:45 AM revealed a therapist in his room having a discussion. His beard was noted to be trimmed in the circle style. Interview on was conducted on 4/21/21 at 1:55 PM with Nursing Assistant (NA) #2. She stated Resident #214 required assistance with his ADLs and she was not aware of any refusals. She stated the floor nurses were responsible for trimming fingernails for diabetic residents. During a wound care observation on 4/21/21 at 2:00 PM, Unit Manager (UM) #1 asked Resident #214 if his beard trimmed yesterday. Resident #214 stated yes, it was getting shabby. I'm happy it was trimmed. He also stated someone did his fingernails earlier today and he was also happy about that too. Interview was conducted on 4/21/21 at 4:00 PM, NA #1 stated Resident #214 does not refuse any care and he was very cooperative. Review of the facility policy titled Care of Fingernails revised on February 2018 read licensed nurses will trim the fingernails of diabetic residents. Review of Resident #214's nursing notes included one refusal of a shower on 4/21/21 in preference for a bed bath that was completed on 4/12/21. Review of Resident #214's NA documentation from 4/9/21 to 4/21/21 for ADLs and behaviors, did not include any rejection of care behaviors and he required extensive to total assistance with his personal hygiene. Interview with the Director of Nursing (DON) was conducted on 4/22/21 at 11:30 AM. She stated it was her expectation that ADL dependent residents be assisted with personal hygiene to include nail care and shaving facial hair. The DON stated it was her expectation that diabetic residents nail care be completed by licensed nurses. 2. Resident #102 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #102's quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact and exhibited no behaviors. She was coded for extensive assistance with her personal hygiene and impairment on one side of her upper extremities. Review of Resident #102's care plan revised on 3/9/21 indicated she had an activities of daily living self-care deficient. Interview and observation was conducted on 4/19/21 at 2:45 PM with Resident #102. She was sitting up in a wheelchair in her room. She appeared clean and groomed. Her fingernails appeared long and dirty. She stated her fingernails had not been trimmed in a long time and she needed them cut and cleaned. In a second observation on 4/19/21 at 4:40 PM, Resident # 102 was observed sitting in bed. She fingernails were still long and dirty. She stated nobody had asked her about trimming her fingernails in weeks. Resident #102 stated she did not like going to the shower room and preferred bed baths. Interview on 4/21/21 at 8:45 AM was conducted with Unit Manager (UM) #1. She stated it was the responsibly of the floor nurses to cut and clean the fingernails of diabetic residents. UM #1 stated Resident #102 was known to frequently refuse showers and preferred bed baths. She stated she was not aware of any ADLs refusals except showers. She stated nail care should be done weekly and usually completed after a shower. Interview was conducted with Nurse #1 on 4/21/21 at 9:10 AM. She stated she was not aware of any refusals of nail care but was aware that Resident #102 preferred bed baths and refused showers. Nurse #1 stated the floor nurses were responsible for trimming the fingernails of all diabetic residents. In an observation and interview on 4/21/21 at 10:10 AM, Resident #102 was sitting up in bed with a warm washcloth on her hands. She stated someone was getting ready to cut her fingernails and put the washcloth over her hands to soften her fingernails. She stated she took a shower on 4/20/21 but her fingernails had still not been trimmed. Nurse #2 entered the room and stated she was preparing to cut Resident #102's fingernails and confirmed that the floor nurses were responsible for cutting the fingernails of all diabetic residents. Observation and interview was conducted with Resident #102 on 4/22/21 at 9:20 AM. She presented her hands. Her fingernails were trimmed and clean. She stated her hands felt and looked a lot better. Interview was conducted on 4/21/21 at 1:55 PM with Nursing Assistant (NA) #2. She stated Resident #102 refused a bed bath today because she took a shower yesterday. NA #2 stated she was not aware of ant refusals of nail care but added the nurses were supposed to cut fingernails of all diabetic residents. Review of the facility policy titled Care of Fingernails revised on February 2018 read licensed nurses will trim the fingernails of diabetic residents. Review of Resident #102's nursing notes from 4/1/21 to 4/21/21 did not include any behavior nursing notes. Review of Resident #102's NA documentation from 3/1/21/21 to 4/21/21 for ADLs and behaviors, did not include any rejection of care behaviors and she required extensive to total assistance with her personal hygiene. Interview with the Director of Nursing (DON) was conducted on 4/22/21 at 11:30 AM. She stated it was her expectation that ADL dependent residents be assisted with personal hygiene to include nail care. The DON stated it was her expectation that diabetic residents nail care be completed by licensed nurses. 3) Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #80 had severe cognitive impairment. He required extensive assistance with dressing and was dependent on staff for toileting, personal hygiene, and bathing. A review of the active care plan, last reviewed on 3/23/21, revealed a focus area for Resident #80 being at risk for activities of daily living self-care performance related to mental status, history of a stroke, [CONDITION(S)] and moderate to severe protein calorie malnutrition with a new feeding tube placement. The interventions included to provide total assistance of 1 to 2 staff members with personal hygiene. A review of the nursing progress notes from 2/3/21 to 4/19/21 revealed no refusals for nail care documented. During observations on 4/19/21, and 4/21/21, Resident #80 was observed to have medium length nails and a dark substance under fingernails to both hands. On 4/21/21 at 9:26 AM, an interview occurred with Unit Manager #3 who explained nurse aides (NA's) completed nail care on scheduled shower days and during personal care tasks. They were to visualize the fingernails and clean/trim/file as needed. If the resident was a diabetic the nurse was to cut their nails. An interview was completed with NA #3 on 4/21/21 at 1:40 PM, who stated both the NA's and nurses completed nail care as needed. The NA explained during showers and personal care, aides were to observe nails and provide assistance to clean/trim nails or alert a nurse if the resident was a diabetic. The Director of Nursing (DON) was interviewed on 4/21/21 at 3:26 PM and indicated NA's could clean under all resident's nails and cut fingernails for all residents except those with diabetes. Diabetic residents had their fingernails cut by the nurse or treatment nurse. She stated it was her expectation for the aides to monitor, clean and trim nails during personal care, retrieving a nurse for any diabetic nail care that was needed. On 4/21/21 at 3:40 PM, an interview occurred with NA #5 who stated both the NA's and nurses completed nail care as needed. NA #5 further stated during scheduled showers and personal care, aides were to observe fingernails and provide assistance to clean/trim nails or alert the nurse if the resident was a diabetic.

Based on observations, interviews, record reviews, and staff interviews, the facility failed to implement planned fall interventions for 1 of 7 sampled residents (Resident #87) reviewed for accidents. Resident #87 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] with behavioral disturbances and cerebral vascular accident (stroke). The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired, required extensive assistance for all activities of daily living (ADLs) and personal hygiene. The resident was coded as not having any falls during the assessment period. The resident's most recent comprehensive care plan dated 3/30/2021 revealed a focused area for falls. Interventions included keeping the bed in low position. On 4/19/2021 at 10:04am Resident #87 was observed sitting in a wheelchair on the 400 hall. The resident was observed to have a black, blue, and yellow bruise under his left eye. When asked how he bruised his eye, the resident gave multiple accounts of how he got the bruise. Record review of revealed Resident #87 had an unwitnessed accident in his room on 3/13/2020 in which he was found on the floor to the left side of his bed with a red area on his forehead, redness and bruising to left thigh, and red and swollen left shoulder. Resident was transported to local hospital for care. Interventions added to care plan included fall mats while resident was in bed and staff ensuring bed was kept in low position. Record review of incident/accident report dated 8/27/2020 revealed Resident #87 had an unwitnessed accident around 11:30pm in which he was found on floor bedside his bed with redness to right occipital area and guarding his left arm. Care plan interventions included keeping bed in low position. Resident was transported to local hospital for care. An incident report dated 4/13/2021 indicated Resident #87 was found in his bed with the left side of his head resting on a bedside dresser. The resident was noted to have a small bruise under his left eye at the time of the incident report. The incident report indicated the bed was not in low position at the time the resident was found. On 4/21/2021 at 9:40am an interview was conducted with Nurse #3. She stated she was assigned to Resident #87 on 4/14/2020. Nurse #3 stated shortly after she reported to her shift, nurse assistant (NA) #10 reported Resident #87 was asleep on his bedside table and had a small red area under his left eye. She stated the nurse practitioner (NP) was in the facility and assessed the resident at that time. She further stated she completed a risk assessment per the facility policy and notified the resident's family. Nurse #3 stated she was not certain who left the resident's bed raised or why it had been left in the raised position. When asked if the resident could have raised the bed, she stated the resident's bed control is kept at the foot of the bed so he would not have been able to reach it. An interview was conducted with NA#10 on 4/21/2021 at 9:49am. She stated on 4/14/2021 she started her rounds at 6:45am and noticed an odor at the top of the 400 hall near the nurse's station. She asked NA #6, to check residents at the top of the 400 hall. NA #10 stated she then completed her rounds in another area. When she conducted her rounds again at 9:00am she noticed Resident #87 was in his bed asleep with his head resting on the bedside dresser and the bed was not in low position. She further stated the resident had a small red bruise under his left eye at that time. Later in the day the bruise became larger. She stated she did not leave the resident's bed raised and she was not certain who did. When asked if the resident could have raised the bed, she stated she did not think the resident could reach the bed control that was at the foot of the bed. An interview was conducted with the Director of Nursing (DON) on 4/22/2021 at 11:20am. She stated she expected all interventions for falls/accidents to be implemented.

Based on record reviews, observations and staff interviews, the facility failed to administer water flushes via a feeding tube at the physician ordered flow rate for 1 of 4 sampled residents who received tube feedings (Resident #80). The findings included: Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #80's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #80 had severe cognitive impairment and received 51% or more of his total calories through tube feedings and an average fluid intake of 501 cubic centimeters (cc) per day or more by tube feeding. Review of Resident #80's active care plan, last reviewed on 3/23/21, revealed a focus area for tube feeding as ordered due to dysphagia, nothing by mouth (NPO) and moderate to severe protein-calorie malnutrition. The interventions included to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A nutritional note dated 4/8/21 read Resident #80 was NPO with 100% nutrition and hydration received via a feeding tube. His enteral feeding (feeding tube formula) was at 65 ml per hour and water flush of 120 ml every 4 hours. An observation of Resident #80 on 4/19/21 at 9:59 AM, revealed his feeding tube was connected to a continuous bag of formula running at 65 ml per hour with a standby bag of water running at 30 ml every hour on the pump. On 4/21/21 at 9:15 AM, an observation of Resident #80 occurred. He was connected to a continuous bag of tube feed formula running at 65 ml per hour with a standby bag of water running at 30 ml every hour on a pump. An interview occurred with Unit Manager #3 on 4/21/21 at 1:56 PM. She reviewed the current order for Resident #80's tube feeding formula to run at 65 ml per hour with a water flush of 120 ml every 4 hours. An observation was made with the Unit Manager #3 on 4/21/21 at 2:05 PM of Resident #80's water flush setting for the tube feeding. Unit Manager #3 acknowledged the rate was at 30 ml per hour and should have been set as 120 ml every 4 hours. She was unable to state why the rate was different than the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/21/21 at 3:26 PM, an interview was conducted with the Director of Nursing who stated she was unsure why the water flush rate was different from the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record reviews, observations, resident and staff interviews, the facility failed to administer oxygen at the prescribed rate (Residents #16, #59 and #67) and failed to clarify an oxygen order (Resident #67). This was for 3 of 4 residents reviewed for respiratory. The findings included: 1) Resident #16 was originally admitted to the facility on [DATE] with a recent readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was cognitively intact. He required extensive to total assistance from staff for Activities of Daily Living (ADL's) and used oxygen. A review of Resident #16's active care plan, last reviewed on 1/27/21 revealed a focus area for oxygen use related to [CONDITION(S)]. The interventions included oxygen settings at 3 liters via nasal cannula as ordered. Review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/21 at 12:20 PM, an observation was made of Resident #16 which revealed the oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed horizontally at eye level. On 4/21/21 at 9:10 AM, an observation was made of Resident #16 while he was sitting up in bed. The oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed at horizontal, eye level. An observation was made with Unit Manager #3 of Resident #16's oxygen concentrator on 4/21/21 at 1:56 PM, who stated the oxygen regulator on the concentrator was set at 3 liters when standing over the machine, looking down. Unit Manager #3 stated when she observed the regulator horizontally at eye level, she could see the flow was set at 2.5 liters. Unit Manager #3 adjusted the flow to administer 3 liters of oxygen. During an interview with the Director of Nursing on 4/21/21 at 3:26 PM, she indicated it was her expectation for oxygen to be delivered at the ordered rate. 2) Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 was cognitively intact, required extensive to total assistance with Activities of Daily Living (ADL's) and used oxygen. A review of Resident #59's active care plan, last reviewed on 2/24/21, revealed a focus area for oxygen therapy continuous for shortness of breath. The interventions included to administer oxygen as ordered. An interview was conducted with Resident #59 on 4/19/21 at 11:58 AM, who stated he wore 2 liters of oxygen at all times. The oxygen regulator on the concentrator was observed at 2.5 liters flow by nasal cannula when viewed at horizontal, eye level. On 4/21/21 at 9:20 AM, an observation was made of Resident #59 as he was sitting up in bed. The oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed horizontally at eye level. An observation was made with Unit Manager #3 of Resident #59's oxygen concentrator on 4/21/21 at 1:56 PM, who stated the oxygen regulator on the concentrator was set at 2 liters when standing over the machine, looking down. Unit Manager #3 stated when she observed the regulator horizontally at eye level, she could see the flow was set at 2.5 liters. Unit Manager #3 adjusted the flow to administer 2 liters of oxygen. During an interview with the Director of Nursing on 4/21/21 at 3:26 PM, she indicated it was her expectation for oxygen to be delivered at the ordered rate. 3a) Resident #67 was originally admitted to the facility on [DATE] with a recent readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 was cognitively intact and used oxygen. A review of Resident #67's active care plan, last reviewed on 3/15/21, revealed a focus area for use of oxygen related to [CONDITION(S)], [CONDITION(S)] and heart failure. The interventions included oxygen settings at 3 liters via nasal cannula. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - An order dated 3/14/21 for oxygen at 4 liters via nasal cannula to keep oxygen saturations above 90%. - An order dated 3/17/21 for oxygen at 3 liters via nasal cannula every shift. On 4/19/21 at 12:07 PM, an interview occurred with Resident #67 who stated he used 3 liters of oxygen at all times. An interview occurred with Unit Manager (UM) #3 on 4/21/21 at 1:44 PM. She reviewed the active orders for Resident #67 revealing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview UM #3 spoke with the facility Nurse Practitioner and was told Resident #67 should be on 3 liters of oxygen at all times. The UM #3 stated it appeared the order for 4 liters of oxygen was not discontinued when the new order for 3 liters of oxygen was obtained on 3/17/21. UM #3 corrected the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing was interviewed on 4/21/21 at 3:26 PM and stated she would expect the nursing staff to ensure an order was discontinued prior to initiating a new order pertaining to the same medical treatment. 3b) Resident #67 was originally admitted to the facility on [DATE] with a recent readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 was cognitively intact and used oxygen. A review of Resident #67's active care plan, last reviewed on 3/15/21, revealed a focus area for use of oxygen related to [CONDITION(S)], [CONDITION(S)] and heart failure. The interventions included oxygen settings at 3 liters via nasal cannula. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Resident #67 on 4/19/21 at 12:07 PM, who stated he used 3 liters of oxygen at all times. The oxygen regulator on the concentrator was observed at 2.5 liters flow by nasal cannula when viewed at horizontal, eye level. On 4/21/21 at 11:45 AM, an observation was made of Resident #67. The oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed horizontally at eye level. An observation was made with Unit Manager #3 of Resident #67's oxygen concentrator on 4/21/21 at 1:56 PM, who stated the oxygen regulator on the concentrator was set at 3 liters when standing over the machine, looking down. Unit Manager #3 stated when she observed the regulator horizontally at eye level, she could see the flow was set at 2.5 liters. Unit Manager #3 adjusted the flow to administer 3 liters of oxygen. During an interview with the Director of Nursing on 4/21/21 at 3:26 PM, she indicated it was her expectation for oxygen to be delivered at the ordered rate.

Based on record review and staff interview, the facility failed to ensure residents medical records were complete and accurate for 2 of 26 sampled residents reviewed (Residents #1 & #13). Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1's cognition was intact, and she had 2 venous/arterial ulcers. Resident #1 had a doctor's order dated 4/9/21 to clean right plantar foot with normal saline and to apply Santyl ointment (helps remove non-living tissue from the wound) and calcium alginate (highly absorbent dressing) and wrap with dry dressing daily until healed. Resident #1's Treatment Administration Records (TARs) were reviewed for February, March and April 2021. The TARs revealed that the treatment to the right plantar foot was not signed off by the Treatment Nurse/nurses to indicate that the treatment was provided on 2/15/21, 2/17/21, 2/19/21, 2/20/21, 2/26/21, 3/1/21, 3/6/21, 3/8/21, 3/12/21, 3/15/21, 3/17/21, 3/18/21, 3/19/21, 4/12/21, 4/14/21, and 4/16/21. The Treatment Nurse was interviewed on 4/21/21 at 12:50 PM. The Treatment Nurse indicated that she works Monday though Friday to provide treatments to residents. She stated she had provided the treatment to Resident #1's right plantar foot Monday through Friday. She verified that she had not consistently signed off the TARs to indicate that she had provided the treatment since she was not familiar with the point click care (PCC) computer system. She added that she just received an in-service today (4/21/21) on how to properly document on the TARs in PCC after the treatments were completed. The Director of Nursing (DON) was interviewed on 4/22/21 at 11:29 AM. The DON stated that she expected resident's medical records to be complete and accurate. She also expected the licensed nurses including the Treatment Nurse to mark off/sign off the TARs after the treatments were completed. 2. Resident #13 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #13 had an indwelling urinary catheter. Resident #13's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13 was observed on 4/19/21 at 9:56 AM. He was in bed with an indwelling urinary catheter. Resident #13 stated that he had the indwelling urinary catheter since he was discharged from the hospital. Unit Manager (UM) #2 was interviewed on 4/21/21 at 10:15 AM. She verified that Resident #13 had an indwelling urinary catheter but did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . UM #2 reported that she reinstated the order for the indwelling urinary catheter today (4/21/21). The Director of Nursing (DON) was interviewed on 4/22/21 at 11:29 AM. The DON stated that she expected resident's medical records to be complete and accurate by ensuring residents with an indwelling urinary catheter have a doctor's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review interviews with staff, resident representative, and physician, the facility failed to do neurological checks (neurochecks) after an unwitnessed fall (Resident #1) for 1 of 3 residents reviewed for accidents. Findings included: Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had an incident report documented that revealed an unwitnessed fall on 9/4/19 at 10:20 pm. The resident was found lying flat (back) on the floor next to her bed. The resident denied any pain and range of motion of the four extremities were intact. The resident was noted to be confused. Staff communication form (SBAR) and progress note dated 9/4/19 at 10:20 pm documented vital signs and resident records reviewed. The resident's primary [DIAGNOSES REDACTED]. There were medication changes in the past week. Blood pressure was 180/72 and pulse was 106. Oxygen saturation on room air was 92%. Suspected problem that contributed to the fall was left blank. The resident appeared to by lying on her back on the floor with no complaints of pain and range of motion was completed without complications. The plan was to monitor vital signs. Resident was able to state, I need the toilet in the bathtub (bathroom). Resident representative and attending physician were notified at 9/4/19 at 10:20 pm. The form was signed by Nurse #1. A review of the resident's nurses' note for 9/7/19 did not reveal any documentation. On 9/30/19 at 3:30 pm an interview was conducted with Nurse #1 who was assigned to the resident on 9/7/19 and 9/8/19 and was the nurse in charge (weekend). Nurse #1 was not aware that the resident had a fall on 9/4/19. Nurse #1 commented that when there is an unwitnessed fall the resident would be assessed for potential injury after the fall and neuro checks would be done. Nurse #1 would normally assess the resident for 3 days, especially if there was pain or they hit their head. He also commented that this would be documented, and he believed this was the facility standard. Nurse #1 commented that he did not assess the resident for injury post fall while assigned on 9/7/19. On 8/30/19 at 2:40 pm an interview was conducted with Nurse #2 who was assigned to Resident #1 the night she fell on [DATE]. Nurse #2 stated that the resident was found on the floor in her room between the bed and the wall. The resident was wet and trying to get to the toilet. The resident denied pain. Range of motion to extremities were within normal limits. There was no obvious injury. Nurse #2 indicated that the resident had dementia and could be confused. The resident was educated to use the call light and added additional supervision on his shift. Nurse #2 stated that he believed the facility expectation for an unwitnessed resident fall would be to assess the resident for injury to include neurological checks. He commented the assessment would include observation for deformity and bruising and new onset of pain. Nurse #2 believed that the timeframe was 3 days and would be documented. There was no evidence that the neurochecks were done for three days after the resident's fall. On 10/1/19 at 8:45 am an interview was conducted with the attending Physician for the Resident #1. The Physician stated he was informed the resident was found lying on the floor in her room and it was believed that the resident had fallen (unwitnessed). The Physician also expected facility staff to assess the resident after her fall for three days and document. The Director of Nursing (DON) was interviewed on 10/1/19 at 11:30 am who stated that she was not aware that nursing did not document post fall assessments for Resident #1 after her fall on 9/4/19 and after her change in assessment of chest pain on 9/5/19 and after. The DON stated that her expectation from staff for a resident unwitnessed fall would be to assess the resident for three days or as ordered and document to include a neurological check.

Based on resident interview, observation, record review and staff interview, the facility failed to serve food and coffee at breakfast meals that was palatable and at an appetizing temperature to four of seven sampled residents reviewed for food palatability (Residents #2, #4, #5 and #7). Findings included: 1.Interviews with residents on 9/30/19, revealed four of seven residents interviewed voiced concerns about the temperature of food and coffee they were served at breakfast being too cold. a. Resident #2's Minimum Data Set (MDS) Quarterly Review (QR) completed on 7/10/19 revealed the resident was alert and oriented. Interview with Resident #2 on 9/30/19 at 10:28 AM and revealed she had concerns that the breakfast was usually cold. She said she called the Food Service Account Manager when things were not right with the food. On 10/01/19 at 12:13 PM, she said the breakfast was not hot or cold, the temperature was medium, and the pancakes were a little hard around the edges. b. Resident #4's admission MDS completed on 8/15/19 revealed the resident was alert and oriented. Interview with Resident #4 on 09/30/19 at 10:30 AM revealed he occasionally received cool eggs and coffee at breakfast. The resident said he was tired of asking for his food to be reheated. c. Resident #5's admission MDS dated [DATE] revealed he was alert and oriented. Interview with Resident #5 on 09/30/19 at 4:10 PM revealed he frequently received cold food at breakfast, and he had not asked for his food to be reheated. d. Resident #7's MDS QR dated 8/16/19 revealed she understood and understands, had clear speech and intact cognition. Interview with Resident #7 on 9/30/19 at 2:30 PM revealed she periodically was served cold eggs and coffee at breakfast. She believed staff were aware of her concern because she had asked for her food to be reheated. On 10/1/19 at 7:30 AM, the kitchen tray line was observed. The breakfast meal service was in progress. Many residents' trays were observed prepared from the kitchen tray line intermittently between 7:30 AM on 8:00 AM on 10/1/19. Observations of staff preparing resident breakfast meals revealed they would obtain a plate from a plate warmer, place food from the tray line onto the plate and then set the plate of food on a resident's breakfast tray. On 10/01/19 at 8:06 AM the kitchen's plate warmer, which was used to heat plates to keep foods served on resident meal trays hotter, was noted not to be turned on and the unit that held the plates was at room temperature. Interview with the Food Service Account Manager on 10/1/2019 at 8:06 AM revealed he did not realize the plate warmer had not been turned on. He said he was involved with the Resident Council Group and he had not received a lot of food complaints.

Based on observations, staff interviews and review of facility records, the facility failed to 1) air dry dishes (cups), 2) store cold/frozen foods in a closed container (pancakes, lettuce), with a date of opening (lettuce, ham, diced potatoes), at least 41 degrees Fahrenheit (F) or below on the tray line (Cesar salad), and 3) maintain the chemical sanitizing concentration in the 3 compartment sink between 150 - 400 parts per million (PPM), per manufacturer recommendations. The findings included: 1. An observation of the lunch meal tray line occurred on 04/01/19 at 12:20 PM and revealed the following items were stored wet: - 6 clear plastic cups were stored wet and ready for use on resident lunch meal trays - 18 clear plastic cups were stored wet and ready for use on the tray line An interview with the certified dietary manager (CDM) on 04/01/19 at 12:20 PM revealed new cups were implemented into the facility's dish rotation that day. The CDM stated the cups were washed that day around 11:00 AM or 11:30 AM which did not allow sufficient time for the cups to air dry before use. He stated that the tray line typically started around 11:15 AM. The CDM further stated that the cups should have been washed in sufficient time to allow them to air dry before use. 2. An observation of the walk-in freezer occurred on 04/01/19 at 12:32 PM, an observation of the walk-in refrigerator occurred on 04/01/19 at 12:33 PM and an observation of the lunch meal tray line occurred on 04/04/19 at 12:02 PM. The observations revealed the following cold foods stored open to air, stored without a date of opening, or stored on the tray line above 41 degrees F: · Freezer- approximately 12 pancakes were stored in a plastic bag that was open to air · Refrigerator- Shredded lettuce was stored in a plastic bag that was open to air and without a date of opening, ham was stored wrapped in plastic wrap without a date of opening, and diced potatoes were stored in a plastic bag without a date of opening · Temperature monitoring of Cesar salad (Romaine lettuce mixed with parmesan cheese and an egg and dairy based dressing) stored on the lunch meal tray line revealed a temperature range of 43 - 45.8 degrees F. The instructions on the bottle of dressing recorded shelf stable, refrigerate after opening. The CDM stated on 04/01/19 at 12:33 PM that cold foods should be stored in closed containers, not exposed to air and with a label that recorded the date of opening. He stated that the cold storage units had just been monitored for items stored, but he could not explain how these items were missed. An interview on 04/04/19 at 12:02 PM with the CDM and district dietary manager (DDM) revealed that although the salad dressing was shelf stable until opened, once opened and mixed with the salad, temperature monitoring was required and the Cesar salad should have been maintained at least 41 degrees F or below. 3. An observation of the 3 compartment manual hand washing sink, while in use, occurred on 04/01/19 at 12:42 PM. Dietary staff (DS) #1 was observed to place serving utensils into the sink with a chemical sanitizing solution. The chemical sanitizing solution was observed to be 500 PPM. The utensils were removed and stored ready for use without rinsing. DS #1 stated on 04/01/19 at 12:43 PM that he set up the manual hand washing sink that morning, but did not recall what time. He stated that he did not check the concentration of sanitizing solution at the time he set up the sink and had not checked the concentration since he started using the sink again. DS #1 further stated it was not his practice to check the chemical concentration of the sanitizing sink before use. He stated he was not certain what the concentration of sanitizing solution should be, but thought it should be either 200 PPM or 400 PPM, but that he was not certain. Interviews occurred on 04/01/19 at 12:44 PM with the CDM and DDM. The DDM stated in interview that the chemical concentration of the sanitizing solution should be at least 200 PPM. The CDM stated that the chemical concentration of the sanitizing sink at 500 PPM was correct. Follow up interviews and an observation of the manual hand washing sink, while in use, occurred on 04/04/19 at 11:49 AM. The chemical concentration of the manual hand washing sink was 400 PPM. During the interview a review of manufacturer recommendations revealed the concentration of chemical sanitizer should be 150 - 400 PPM. The DDM stated he was unaware that the chemical concentration could be too strong with the potential of leaving chemical residue on dishes if the dishes were not rinsed after sanitizing. An interview with Administrator #1 and Administrator #2 occurred on 04/04/19 at 1:17 PM and revealed they expected cold foods to be stored in closed containers, with a date of opening, on the tray line at appropriate temperatures and the sanitizing sink to have the correct chemical concentration.

Based on record review and staff interviews, the facility failed to resubmit for Level II Preadmission Screening and Resident Review for 1 of 3 residents reviewed for Preadmission Screening and Resident Review (Resident #18). Findings included: Resident #18 was admitted on [DATE]. Resident #18's medical [DIAGNOSES REDACTED]. Review of the last quarterly minimum data set ((MDS) dated [DATE] revealed Resident #18 was moderately cognitively impaired. During an interview with the Social Worker (SW) #1 on 4/3/19 at 11:00 AM, SW #1 stated she was responsible for resubmitting for Level II Preadmission Screening and Resident Review (PASARR). SW #1 stated the facility's administration had given her a list of residents in the facility to review for PASARR on 2/27/19. SW #1 reported she was in the process of reviewing the medical record of residents on the list. SW #1 stated she was informed by the facility's administration on 4/2/19 that Resident #18 was on the list she received on 2/27/19 to screen for Level II services due to a new [DIAGNOSES REDACTED]. On 4/3/19 at 12:12 PM, Administrator #2 stated his expectation was SW #1 should have completed a screening for Level II services and referred Resident #18 for evaluation. During an interview with Administrator #1 on 04/03/19 at 12:50 PM, she stated the facility was actively identifying residents with mental health [DIAGNOSES REDACTED]. The Administrator stated her expectation was Resident #18 with a new mental health [DIAGNOSES REDACTED].

Based on observations, staff interviews, and review of manufacturer recommendations, the facility failed to 1) store medications with a date of expiration (laxative), 2) store medications upright (nasal spray) and 3) remove loose pills and debris from 2 of 3 medication carts; additionally the facility failed to 4) store medications refrigerated 36 - 46 degrees Fahrenheit for 1 of 2 medication storage rooms. The findings included: 1 a. An observation and interview with Nurse #1 of a medication cart for the ,[DATE] halls occurred on [DATE] at 10:13 AM and revealed the following: - One [MEDICATION NAME] 10 mg suppository was observed stored outside of original packaging. There was no date of expiration. Nurse #1 stated during the observation that she was uncertain why the suppository was stored on the medication cart outside of original packaging and she did not know when it expired. She further stated that the medication cart was last checked/cleaned one day last week. An interview occurred on [DATE] at 11:07 AM with unit coordinator #1 (UC#1). UC #1 stated all nurses were responsible to check medication carts at least twice weekly for improperly stored medications and to check daily while the cart was in use. UC #1 stated all medications should be stored with a date of expiration. An interview with the Director of Nursing (DON) occurred on [DATE] at 03:21 PM and revealed medications should be stored per manufacturer guidelines. The DON stated that nursing staff should monitor the medication carts twice weekly to ensure medications were stored per manufacturer guidelines and with a date of expiration. An interview with Administrator #1 and Administrator #2 occurred on [DATE] at 04:05 PM. Both Administrators stated that the medication carts and storage rooms should be checked twice per week for medications stored outside of manufacturer guidelines and should include a date of expiration. 1 b. An observation and interview with Nurse #2 of a medication cart for the 100 hall occurred on [DATE] at 10:35 AM and revealed the following: - Flucticasone Propionate, 120 metered nasal spray was stored on its side. Manufacturer guidelines recorded on the bottle recommended to store upright. - Twelve [MEDICATION NAME] 10 mg suppositories were observed stored outside of original packaging. There was no date of expiration. - 9 loose pills (different sizes, shapes and colors), 4 half pills (different sizes, shapes and colors), and debris Nurse #2 stated during the observation that the nasal spray should be stored upright and was usually stored in a cup to keep the nasal spray upright. Nurse #2 stated that she did not know that the suppositories were stored on the medication cart and she did not know when they expired. Nurse #2 stated she could not identify the loose pills or explain the debris. An interview with the DON occurred on [DATE] at 10:57 AM and revealed that the nasal spray should be stored upright per manufacturer recommendations. She stated all medications should be stored with a date of expiration. The DON stated that any loose pills found on the medication cart should be destroyed and that nursing staff should monitor the medication carts to ensure medications were not stacked too tightly to prevent pills from coming out of the medication cards. An interview occurred on [DATE] at 11:07 AM with UC#1. UC #1 stated all nurses were responsible to check medication carts at least twice weekly for improperly stored medications and cleanliness and to check daily while the cart was in use. UC #1 stated all medications should be stored with a date of expiration and all loose pills should be discarded. UC #1 further stated nurses should dispense medications into a cup and store medication cards loosely to minimize the loss of pills. An interview with Administrator #1 and Administrator #2 occurred on [DATE] at 04:05 PM. Both Administrators stated that the medication carts and storage rooms should be checked twice per week for medications stored outside of manufacturer guidelines and include a date of expiration. 2. An observation of Station #1 medication storage room with UC #1 occurred on [DATE] at 11:14 AM. The refrigeration temperature was 49 degrees Fahrenheit. The following medications were stored with manufacturer instructions to Refrigerate, store 36 - 46 degrees Fahrenheit: - One unopened vial of Purified Protein Derivative (vaccine used to test for [MEDICAL CONDITION]). - Four prefilled 5 ml pens of [MEDICATION NAME] (insulin). - Four prefilled 5 ml pens of [MEDICATION NAME] (insulin). - Five, 1 ml vials of [MEDICATION NAME] (antianxiety) - 1 unopened multi-dose vial of Influenza (flu vaccine) An interview with UC #1 during the observation and review of the (MONTH) 1 - 3, 2019 temperature log for the refrigerator revealed temperatures were recorded between 42 - 46 degrees Fahrenheit. UC #1 stated that the refrigeration temperatures were checked nightly by nursing staff and that the items stored in refrigeration should be stored 36 -46 degrees Fahrenheit. A follow up observation of the refrigerator in the medication storage room of Station #1 and interview with UC #1 occurred on [DATE] at 11:31 AM and revealed a temperature of 51 degrees. The same items were stored. The UC #1 stated that it could not be determined how long the items stored in refrigeration were stored above 46 degrees so the items would be discarded and re-ordered. An interview with the DON occurred on [DATE] at 03:21 PM and revealed medications should be stored per manufacturer guidelines. The DON stated that if medications were stored outside of manufacturer temperature guidelines, the medications should be not be administered, but rather discarded and re-ordered. The DON stated the refrigerators in the medication storage rooms should be checked nightly to monitor for correct temperatures. An interview with Administrator #1 and Administrator #2 occurred on [DATE] at 04:05 PM. Both Administrators stated that the medication carts and storage rooms should she checked twice per week for medications stored outside of manufacturer guidelines.

Based on observations, staff interviews, and review of menus, the facility failed to serve ½ cup serving of corn per the menu to 4 residents for 1 of 2 tray line observations. The findings included: An observation of the lunch meal tray line occurred on 04/01/19 from 12:17 PM until 12:30 PM. During the observation, dietary staff (DS) #2 was observed at 12:30 PM to plate corn for Residents #5, #95, #97, and #98. DS #2 was observed to plate corn from a 4 ounce (1/2 cup) serving utensil, but only filled the serving utensil approximately half full for Residents #5, #95, #97 and #98. An additional pan full of corn was observed stored on the stove. Review of the menu revealed residents were to receive ½ cup portion of corn. A half cup portion was not plated. During the observation, DS #2 stated that she was attempting to serve the remaining corm left in the pan before she began serving from the second pan of corn. The surveyor brought this observation to the attention of the certified dietary manger (CDM) on 04/01/19 at 12:31 PM. The CDM stated all residents should receive portions of food per the menu. He stated that he monitored the tray line when he was in the kitchen but due to additional responsibilities he did not always have an opportunity to monitor the tray line for correct portions served. The CDM was observed to instruct DS #2 to plate a full serving of each food item to residents. An interview with Administrator #1 and Administrator #2 occurred on 04/04/19 at 1:17 PM. During the interview both Administrators stated they expected residents to receive portions of food per the menu. A telephone interview occurred on 04/05/19 at 12:51 PM with the registered dietitian (RD). During the interview, the RD stated she rounded in the facility weekly, but had not noticed concerns with residents receiving incorrect portions of food. The RD stated she expected dietary staff to provide residents portions of food according to the menu.

Based on observations, record reviews, resident, staff, and Medical Doctor interviews, the facility failed to administer pain medication when requested for 1 of 3 residents (Resident #4) reviewed for pain management. Failure to provide Resident #4 with pain medication when she requested, resulted in the resident experiencing prolonged pain and discomfort. The findings included: Resident #4 was admitted to the facility on [DATE] following a hospitalization for injuries suffered in a motor vehicle accident (MVA). The resident's [DIAGNOSES REDACTED]. Review of Resident #4s orders dated 08/10/18 revealed she was on the following medications for pain: [MEDICATION NAME] tablet - give 1000 milligrams (mg) by mouth (po) every 6 hours for pain for 21 days (ending 08/31/18). Review of the most comprehensive Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was cognitively intact for daily decision making and required extensive assistance of 1 to 2 persons with most activities of daily living. The MDS also revealed Resident #4 received scheduled and as needed (prn) pain medications for frequent pain assessed at a level of 7. Review of Resident #4s orders dated 08/18/18 revealed she was on the following medication for pain: [MEDICATION NAME] (HCl) tablet 15 mg po every 6 hours as needed for pain. Review of Resident #4s pain Care Area Assessment (CAA) dated 08/22/18 revealed she had actual pain related to impaired mobility, multiple fractures, surgical incisions, anxiety and depression. The CAA noted they would proceed to care plan due to her actual pain related to the above diagnoses. Review of Resident #4s care plan dated 08/22/18 revealed she was care planned for pain related to multiple fractures. The goal was for Resident #4s pain to be managed to the greatest extent possible so it did not affect her day to day activities. The interventions included notifying the physician if interventions were unsuccessful or if the current compliant was a significant change from the residents past experience of pain and the resident preferred to have pain controlled by pain medications. An observation and interview on 08/24/18 at 8:10 AM with Resident #4 revealed she was in bed with her gown on and stated she came to the facility for rehabilitation following a MVA. Resident #4 stated she was in pain all the time from all her fractures and her pain was usually at a 7 to 8 on a pain scale of 10 and was currently at a pain level of 7. The resident was noted to grimace and complain when moving in the bed. She stated she was supposed to get her pain medication around 8:30 AM in the morning when she woke up and asked for it. The resident stated for the past several days it had been closer to 11:00 AM or 11:30 AM before the nurse gave it to her. Resident #4 stated she had different nurses every day administering her medications and had received her pain medication almost 2 to 3 hours after she had asked for it. She stated she didn't think the staff understood how bad she was hurting having to lay in the bed all day every day with metal in her body. She stated she had to have metal plates placed in the back of her head, her right upper arm and screws put in her knees to repair some of her fractures. Resident #4 stated she was on bed rest and could only have her head elevated a small amount due to healing the fracture in her neck and in her back. She stated she had asked the nurse assistant (NA) to tell the nurse around 8:30 AM when she woke up that she needed something for pain. Resident #4 stated she knew the NA had told the nurse because the NA came back and told her she had told them she wanted her pain medication. Resident #4 stated she had the same NA Monday through Thursday of this week but had different nurses every day giving her medications. Review of the Medication Administration Record [REDACTED]. On Wednesday, 08/22/18 at 10:43 AM the MAR indicated [REDACTED]. On Monday, 08/20/18 at 11:53 AM the MAR indicated [REDACTED]. A phone interview on 08/24/18 at 10:43 AM with MA #1 revealed she had worked on Thursday, 08/23/18 from approximately 9:00 AM to 12:30 PM as the MA for the hall Resident #4 resided on and had passed the morning medications. She stated she had been at a room down the hall when NA #6 had told her that Resident #4 wanted pain medication. She stated she was administering meds to a resident in room [ROOM NUMBER] and when she was finished she took the pain medication in to Resident #4. MA #1 stated it was soon after NA #6 had told her Resident #4 wanted something for pain and after she had given medications to the resident in room [ROOM NUMBER]. MA #1 stated the resident was complaining of pain when she have her the medication at 11:42 and stated her pain was at a level 8 out of 10 scale. Review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. According to the documentation on the MAR indicated [REDACTED]. A phone interview on 08/24/18 at 1:38 PM with the family member revealed she wished the facility would do a better job with keeping Resident #4 comfortable. The family member stated they had taken her off of the pain medications from the hospital and had not given her pain medication at the facility when she requested. She stated she had to wait sometimes 2 and 3 hours for her medication and stated she had a lot of pain from her fractures. Review of the schedule for the week of 08/20/18 through 08/23/18 revealed Resident #4 had the same NA for all four days. A phone interview on 08/24/18 at 2:00 PM with NA #6 revealed she had taken care of Resident #4 Monday, 08/20/18 through Thursday, 08/23/18. NA #6 stated she had told the Medication Aide (MA) each day around 9:00 AM when Resident #4 had asked for her pain medication. NA #6 stated Resident #4 had asked her a couple of times each day about her pain medication and each time she stated she had gone to the MA and told her Resident #4 had asked for pain medication. NA #6 stated she could not remember or didn't know how long Resident #4 had to wait for her pain medication but stated she had to ask the MA more than once each time about the resident's pain medication. A phone interview was attempted with MA #3 and MA #4 with no return calls. Review of the MAR indicated [REDACTED]. This was 1 hour and 43 minutes after she first requested her pain medication which was given by Nurse #2. Review of the MAR indicated [REDACTED]. According to the documentation on the MAR, the pain medication was given 2 hours and 53 minutes after it was first requested. An interview on 08/24/18 at 2:32 PM with Nurse #2 revealed she had given pain medication to Resident #4 when it was reported to her that she needed the medication. She stated that usually the MA will let the nurse know when a resident had requested pain medication and they would assess the pain level and administer the medication or the MA would administer the medication. Nurse #2 stated she was not sure when Resident #4 had first requested pain medication but stated her pain was at a level 7 out of a scale of 10 and she stated she was hurting bad from her fractures. An interview on 08/24/18 at 5:18 PM with the Medical Director (MD) revealed when Resident #4 was stating she was in pain to him, her body was not telling him her pain level was that high. He stated her heart rate, respirations and blood pressure were not elevated like you would typically see in someone in pain. The MD stated because of her history, he had not wanted to schedule pain medication for her and stated her prn medications should take care of any pain she was having now. The MD stated it was his expectation that residents receive their prn pain medication within 30 minutes of requesting the medication. An interview on 08/24/18 at 5:30 PM with the DON revealed it was her expectation that residents receive their pain medication within 30 minutes of their request or less.

Based on observations, record review, resident, and staff interviews, the facility failed to provide a complete bed bath to a dependent resident by not washing a resident's feet when requested for 1 of 3 residents (Resident #4) reviewed for activities of daily living (ADL) care, specifically bathing. The findings included: Resident #4 was admitted to the facility on [DATE] following a hospitalization for injuries suffered in a motor vehicle accident (MVA). The resident's [DIAGNOSES REDACTED]. Review of the most comprehensive Minimum Data Set ((MDS) dated [DATE] and export ready revealed Resident #4 was cognitively intact for daily decision making and required extensive assistance of 1 to 2 persons with most activities of daily living except eating. The MDS revealed Resident #4 was totally dependent with the assistance of 1 person with bathing. Review of Resident #4s Care Area Assessment (CAA) dated 08/22/18 for ADL revealed she had an actual ADL functional impairment due to multiple fractures, impaired mobility, weakness and pain. Review of Resident #4s care plan dated 08/22/18 revealed she was care planned for an ADL self-care performance deficit related to multiple fractures, impaired mobility, weakness and pain. The goal was for the resident to maintain current level of function or increase level of function through the next review date. The interventions included complete bed bath with assistance until resident is allowed to be up for showers, encourage active participation in tasks as resident is able, ensure effective pain management prior to ADL activities, gather and provide needed supplies, provide total assistance of 1 staff with complete bed bath as scheduled, provide assistance with dressing and undressing, provide extensive to total assistance of 1 staff with personal hygiene, provide total assistance of 1-2 staff with toileting, encourage resident to discuss feelings regarding self-care deficit and praise all efforts at self-care. An observation on 08/24/18 at 11:48 revealed Nursing Assistant (NA) #5 was in the process of giving Resident #4 a bed bath. NA #5 proceeded to wash the resident's back and bottom and then dumped out her bath water. NA #6 stated she had rinsed the wash cloth off at the sink and rinsed the resident rather than using 2 pans. NA #5 was changing Resident #4s bed linens and the resident asked NA #5 if she was going to wash her feet. NA #5 kept changing the linens and when she was done took out the soiled linen. NA #5 did come back in the room with a drink the resident had requested but did not take her socks off and wash her feet. An interview on 08/24/18 at 2:56 PM with Resident #4 revealed NA #5 had not been back into her room and taken her socks off and washed her feet. The resident stated this was not the first time this had happened with NA #5. The resident stated she had bathed her before and had not washed her feet and changed her socks. An interview on 08/24/18 at 3:00 PM with the Director of Nursing (DON) and NA #5 revealed a complete bed bath included washing the resident's entire body including their feet. During the interview, the DON asked NA #5 if she had given Resident #4 a bed bath and NA #5 stated that she had. The DON then asked her if she had washed the resident's feet and NA #5 laughed and stated no she had not and went on to say the resident had asked her about it while she was changing her linens. The DON told NA #5 washing a resident's feet was part of a complete bed bath and should be done every time she was bathed. An interview on 08/24/18 at 3:15 PM with the DON revealed it was her expectation that a resident's entire body be washed, including their feet, when they were given a complete bed bath.

Based on staff interviews and record reviews, the facility failed to accurately record the correct personnel administering controlled pain medication for 1 of 3 residents (Resident #4) reviewed for pain management. The findings included: Resident #4 was admitted to the facility on [DATE] following a hospitalization for injuries suffered in a motor vehicle accident (MVA). The resident's [DIAGNOSES REDACTED]. Review of Resident #4's orders dated 08/18/18 revealed she had an order to receive [MEDICATION NAME] (HCl) tablet 15 milligrams (mg) and the orders read to give 1 tablet every 6 hours as needed for pain. Review of the Medication Administration Record [REDACTED]. Review of the nurse and nurse assistant (NA) schedules revealed MA #2 was not assigned to work on Thursday, 08/23/18. The MA working that day on the assignment of Resident #4s hall was MA #1. A phone interview on 08/24/18 at 10:43 AM with MA #1 revealed she had worked on Thursday, 08/23/18 from approximately 9:00 AM to 12:30 PM as the MA for the hall Resident #4 resided on and had passed the morning medications. She stated she had passed medications under MA #2s sign in because she did not have one of her own and the scheduler had instructed her to use MA #2s sign in. A phone interview on 08/24/18 at 2:16 PM with MA #2 revealed she had not worked on Thursday, 08/23/18 at the facility. MA #2 stated she was not aware that MA #1 was giving medications under her login and name but stated that was the way the scheduler had instructed them to do the login during training. MA #2 stated she would have to change her password the next time she was scheduled to work. An interview on 08/24/18 at 2:32 PM with the nurse supervising MA #1 on Thursday, 08/23/18 revealed she was not aware MA #1 was giving medications under MA #2s login until she looked at the MAR indicated [REDACTED]. An interview on 08/24/18 at 2:46 PM with the scheduler revealed she had been doing schedules at the facility for about 6 years. She stated she did schedules for the nurses, MAs and NAs including their orientation/training schedules. She stated each employee was scheduled with a preceptor in their discipline and signed in the computer under their preceptor until they completed training. The scheduler stated once employees completed training they were given their own login and password. She stated this had been the process for the past 6 years since she had been doing scheduling. An interview on 08/24/18 at 5:30 PM with the Administrator and DON revealed they would expect each individual working to have their own login and password and for them to work under their own identifying login. They both stated it was not acceptable for an employee to pass medications under another employee's login. The Administrator stated MA #1 had her own login and password but stated it must not have been given to her prior to Thursday, 08/23/18 when she worked.

Based on record review, Nurse Practitioner (NP) interview, and staff and resident interviews, the facility neglected to implement interventions in place to address the resident's refusal of daily showers which were ordered by the physician to treat 1 of 2 residents for having maggots on her body. Resident #2 experienced a second occurrence of maggots growing on her body which required continued treatment at the facility. Immediate jeopardy began on 6/22/18 when Resident #2 refused showers and the facility failed to implement any interventions to address the resident's refusal of showers. Maggots were found again in her abdominal folds. Immediate Jeopardy was removed on 7/06/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service. Findings included: Resident #2 was admitted on to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's care plan dated 4/27/18 revealed goals and interventions for dependent on staff for emotional and social needs, self-care deficit, desired to return to home, fluid volume deficit, poor oral hygiene, diabetes, at risk for falls, bowel incontinence, [MEDICAL CONDITION], potential for pressure ulcer, and actual impairment to skin integrity. The quarterly Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, and was understood and understands. The resident had an intact cognition. The resident required extensive assistance of 2 persons for all transfers, bed mobility, and locomotion. Dressing and personal care required 2 staff members limited assistance. A Nurses' note dated 6/19/18 at 3:31 pm revealed the resident had maggots in the abdominal folds. The Nurse Practitioner was notified and an order was obtained for an anti-bacterial wash every day. Review of Resident #2's physician orders [REDACTED]. Further review of the physician orders [REDACTED].#2 to receive a shower each day. Review of a nurses' note dated 6/22/18 revealed the resident felt a shower every day was too much. A Physician order [REDACTED].#2. Review of a nurses' note dated 6/30/18 revealed the resident had refused some of her every day showers and had requested to go back to the twice a week schedule. On 7/3/18 at 9:45 am an interview was conducted with the Treatment Nurse (TN) who stated that Resident #2 had maggots on her body and in her bed. The TN stated she observed that Resident #2 had several maggots in her bed with food debris and two in the skin folds of her lower abdomen about 6/20/18. The Nurse Practitioner (NP) was notified and daily showers with anti-bacterial wash were ordered. By about day 3 the resident refused her showers and the nursing assistants provided a bed bath with anti-bacterial wash. Nursing staff was not notified of the refusal. On day 5 the resident had a few maggots again in the same area of her abdominal fold. The TN stated that the maggot issue information was passed verbally during shift change. The staff was verbally directed to look for maggots during routine care. On 7/3/18 at 11:45 am an interview was conducted with the Assistant Director of Nursing (ADON) who stated that Resident #2 had maggots found on her body shortly after another resident was found to have maggots. The resident was found to have maggots in the folds of her lower abdominal skin. The ADON stated the TN identified the maggots during treatment and was not sure if there was tissue injury. The resident was always dressed and it was unclear how maggots were able to get under her clothing. The NP was called and an order for [REDACTED]. The ADON expected the treatment nurse assigned for that day to inform her if there were any maggots. The ADON stated that the maggots were mentioned in the Monday morning meeting but not discussed for prevention or new process. The staff were directed to kill any flies. On 7/3/18 at 5:45 pm an interview was conducted with Resident #2 who stated there was a quick increase in the number of flies in her room about 1 to 2 weeks ago. The resident stated about a week ago there were maggots on her stomach and in her bed which caused her anxiety. The NP ordered anti-bacterial wash and showers every day which were still in place at this time. The resident stated that during the first five days of the showers there were additional maggots that had hatched. The resident preferred a bed bath and when she refused and had a bed bath instead of a shower the maggots returned. The resident informed the staff that she did not need a shower. The resident stated she was informed by the NP her lymph [MEDICAL CONDITION] can attract flies and cause maggots and agreed to have a shower. On 7/5/18 at 8:05 am an interview was conducted with the NP who was very familiar with Resident #2. The resident was alert and oriented and able to make her own decisions. The resident was her own resident representative. The resident was known to resist personal care and preferred a bed bath. Resident #2 had maggots to her right lateral lower abdominal fold and maggots in the bed. The NP stated she ordered daily showers and cleanse with anti-bacterial wash. The resident agreed to daily showers and education was provided why showers were needed. After the first three days the resident started to complain to the nursing assistant that a daily shower was too much for her and began to inform personal care staff that the NP informed the resident she no longer needed a daily shower. The NP stated that the resident manipulated staff. The staff did not inform the NP of the resident's refusal on day three of the order for daily showers and by day five the resident had maggots again in her abdominal folds, same place. The showers were more effective at washing the lymph [MEDICAL CONDITION] and any potential fly eggs. The resident did not like to transfer via the mechanical lift because of her size and fear of falling which contributed to the shower refusal. The resident had lymph [MEDICAL CONDITION] which wept fluid continuously and put the resident at increased risk for maggots. The NP stated that when a resident refused care or treatment her expectation was for staff to re-educate the resident to obtain compliance and if the refusal continued to inform her. The NP has attempted to get resident cooperation to make better choices by explaining why and the consequences. This method had been repeated and sometimes it worked and sometimes it had not. On 7/5/18 at 10:45 am an interview was conducted with Resident #2 who stated that the resident had a shower this morning and was made aware by the NP the importance of the need for a shower versus her preferred bed bath. The staff used the shower gurney to transfer the resident to the shower and that worked better than the mechanical lift. The resident stated that it was over a five-day period that she had maggots and was very concerned about their returning. The resident had received her usual, daily ant-anxiety medication. The resident commented that the flies were better. On 7/5/18 at 12:15 pm an interview was conducted with Nursing Assistant (NA) #1 who stated that she was assigned to Resident #2 who received a shower or complete bed bath every day. The resident preferred a bed bath and had to be coaxed to take her shower when it was ordered. NA #1 was aware of the maggots and had seen flies in the resident's room, but not more than usual. When the NP ordered for the resident to take a shower, the resident refused and said she did not need a shower anymore. NA #1 provided a bed bath and later learned that the shower order continued. NA #1 indicated that she would inform the nurse if the resident refused a shower. On 7/5/18 at 11:00 am an interview was conducted with the Director of Nursing (DON) who stated that Resident #2 sometimes refused her ordered shower and the staff at times had called the resident's family member to influence the resident to take a shower, which was effective. The resident was in agreement that her family member was called. On day three of the ordered daily shower the resident refused to have a shower and the nursing assistant gave the resident a bed bath. The family member was not called as an intervention. The resident did not receive a shower for two days of the ordered daily shower and maggots appeared again. The DON's expectation was for nursing assistants to inform the nurses of resident refusals and confirmed that the nursing assistants did not inform the nurses of the refused showers, the NP was not aware, and maggots were again observed on the resident on 6/23/18. The Administrator, Assistant Administrator, Corporate Nurse Consultant and Director of Nursing were notified of the Immediate Jeopardy on 7/5/18 at 12:32 pm. On 7/6/18 the facility provided an acceptable credible allegation for immediate jeopardy removal that included the following: The plan of correcting the specific deficiency including the processes that lead to the deficiency cited: Resident #2 was admitted to center on 7/28/17 with [DIAGNOSES REDACTED]. On 6/15/18 a Weekly Skin Assessment was performed with no findings noted. On 6/19/18 Resident #2 was noted to have maggots to her abdominal folds. Resident #2 Nurse Practitioner was notified with orders for anti-bacterial wash received. On 6/20/18 Resident #2 Nurse Practitioner ordered Daily Showers. Resident #2 refused showers on 6/22/18, 6/25/18, 6/26/18, 6/27/18 and 6/29/18. After review of the medical record for Resident #2 noting the number of refusals of care related to showers, the center failed to implement specific interventions to encourage the resident to comply with the physician's orders [REDACTED].#2 had a skin evaluation assessment performed by the Charge Nurse assigned to Resident#2 on 7/6/18; there were no signs of maggots noted. On 7/6/18 the Unit Coordinator interviewed Resident #2 regarding her bed baths. Resident #2 stated she receives good bed baths and denied having any concerns with bed baths. A Root Cause Analysis was conducted by the Interdisciplinary Team (IDT) including the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers and Social Services Director on 7/5/18 and it was determined that there was not a resident specific plan of care for alternate interventions to offer the resident to help promote the likelihood the resident will comply with showers per physician orders. The IDT determined the center did not educate the resident on the risks of refusals of showers including risk of maggots. The facility audit of the current residents was reviewed on 7-5-18 and did not reveal any other residents with physician orders [REDACTED]. An additional Root Cause identified by the IDT was the Certified Nursing Assistants lacked knowledge of how to identify maggots. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: Residents who refuse bed baths and showers who are not offered specific interventions to encourage the resident to comply have been identified as having the potential to be affected. All residents in the center had a head to toe skin assessment completed on 7/4/18 by the Unit Coordinators, Unit Managers, Wound Care Nurse, Treatment Nurse and Assistant Director of Nursing. No other residents were identified as having maggots. On 7/5/18 the Director of Nursing completed an audit for refusals of physician's orders [REDACTED]. On 7/5/18 identified residents had their care plans updated to include resident specific interventions to attempt when refusals of showers or bed baths occur. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, 11-7 Supervisor, Unit Managers, and Unit Coordinators re-educated licensed nurses and Certified Nursing Assistants on Abuse and Neglect Prevention beginning on 7/5/18. Beginning 7/6/18 No Licensed Nurses and no Certified Nursing Assistants will be allowed to work until the training is complete. This education also included ensuring staff awareness that failure to provide showers or bed baths as ordered by the physician can constitute resident neglect. The Licensed Nurses will document interventions offered and if the interventions were accepted or refused on the Treatment Administration Record and or the Resident Progress Notes. The NHA and DON will have a no tolerance approach to any deviation from the policy. Newly hired Licensed Nurses will be educated on Abuse and Neglect Prevention by the Staff Development Coordinator, Director of Nursing, Assistant Director of Nursing, Unit Managers and / or Unit Coordinators during their classroom orientation prior to providing care to residents. Of the 48 Licensed Nurses, 30 of the Licensed Nurses have received the education for F600. Six of the Licensed Nurses who have not yet received the education work on an as needed basis. Three of the Licensed Nurses who has yet to receive the education are currently on vacation. One of the Licensed Nurses who has yet to receive the education is on Family Medical Leave Act (FMLA). Each of the Licensed Nurses who have not yet received the education will not be permitted to work until the education is received. Of 57 the 83 Certified Nursing Assistants have received the education for F600. 21 of the Certified Nursing Assistants who have not yet received the education work on an as needed basis, 7 of the Certified Nursing Assistants who have yet to receive the education are currently on vacation. Three of the Certified Nursing Assistants who has yet to receive the education is on Family Medical Leave Act (FMLA). Each of the Certified Nursing Assistants who have not yet received the education will not be permitted to work until the education is received. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and / or in compliance with the regulatory requirements. Daily Monday - Friday in the Clinical Morning Meeting for 12 weeks, the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers will audit Treatment Administration Records of residents who refuse showers and bed baths to validate showers and bed baths are offered as needed based on resident preference, and offered specific interventions to encourage the resident to comply with the physician's orders [REDACTED]. The Director of Nursing will present the results of the audits to the Quality Assessment and Performance Improvement Committee monthly for six months for recommendations including new interventions to assure compliance is sustained ongoing. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor began education for the Nursing Assistants that if resident refuses a bed bath or shower that the charge nurse is to be informed of the refusal. The Nursing Assistants were also provided education on what maggots look like. Beginning 7/6/18 no Nursing Assistant will be allowed to work until the training is complete. The Title of the person responsible for implementing the acceptable plan of correction: Nursing Home Administrator will be responsible for implementing this acceptable plan of correction. Immediate Jeopardy removal date: 7/6/18 Validation: Immediate Jeopardy (IJ) was removed on 7/6/18 at 4:15 pm validation was completed of the credible allegation for IJ removal as evidenced by interviews of one licensed and one nursing assistant for each of the 7 facility halls for evidence of in-service completion. Pest control and maintaining a clean facility in-service was completed for 123 staff members on 7/2/18 and 56 staff members on 7/3/18. On 7/6/18 an outside professional pest control was observed to treat the facility grounds with a liquid spray. On 7/6/18 the Administrator stated that the facility and grounds were treated for [REDACTED].

Based on record review, resident interview, and Nurse Practitioner and staff interviews, the facility failed to provide basic care and cleanliness for 2 of 2 sampled residents reviewed for maggots (Residents #1 and #2). Maggots were found in Resident #1's right lower extremity wound and in Resident #2's abdominal folds. Resident #1 was sent to the hospital for treatment and Resident #2 received treatment for [REDACTED]. Immediate jeopardy (IJ) began on 6/14/18 when for Resident #1 was not provided basic care and cleanliness by staff and live maggots were found in his right lower extremity wound. IJ began on 06/19/18 for Resident #2 when she was not provided with basic care and cleanliness by staff and live maggots were found in her abdominal folds. The Immediate Jeopardy was removed on 7/6/18 when the facility implemented a credible allegation of IJ removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service. Findings included: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was discharged back to the hospital on [DATE] and remained in the hospital during this survey. The resident's [DIAGNOSES REDACTED]. A nurses' note dated 6/12/18 revealed Resident #1 was started on an antibiotic for treatment of [REDACTED]. The first dose of [MEDICATION NAME] 600 milligrams every 12 hours for 14 days was administered. Resident went LOA (leave of absence) on 6/13/18 twice in his motorized wheelchair going to town. Both LOAs the resident returned with his right lower leg/foot dressing missing. When the resident returned to the facility the second time, blood was dripping onto the floor (from the resident's right lower extremity wound) of the facility hall way. The resident was reminded that it was not safe for him to continue to injure his foot. A nurses' note dated 6/13/18 revealed the resident continued to be non-compliant with treatments and refused to have wound dressings changed. The reason for the resident's refusal was not documented. A review of the out of facility release of responsibility form revealed Resident #1's last out of building was on 6/13/18. The resident left the facility almost every day for the past 3 months. Resident #1's care plan dated review date 6/14/18 revealed goals and interventions for daily care decisions at times refuses wound treatment, independent with smoking, activities of daily living self-care deficit, resistive to care related to [MEDICAL CONDITION], at risk for falls, at risk for infection, antidepressant and antipsychotic medication, nutritional deficit, [MEDICAL CONDITION], multiple PUs, altered skin integrity, and [MEDICAL CONDITION] of the right lower extremity. The only intervention for wound care non-compliance was to encourage the resident. Resident #1's quarterly Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, and understood and understands. He had intact cognition, no [MEDICAL CONDITION], and no behaviors. The resident required one-person extensive assistance for bed mobility and total dependence of two for transfer. Locomotion on and off the unit was supervision set-up only. Dressing, personal hygiene, and toileting was one-person physical assistance and set up was for meals. A nurses' note dated 6/14/18, written by the treatment nurse, revealed Resident #1 complained of increased pain to his wounds. During dressing change of the right lower extremity wound revealed there was a large amount thick, brown drainage with foul odor and white objects were moving in the wound. The NP was notified and ordered for the wounds to be open to air and to send the resident to the hospital. 911 was called and the resident was immediately transferred. The hospital discharge summary dated 6/24/18 revealed Resident #1 was admitted on [DATE] and his [DIAGNOSES REDACTED]. Burkett [MEDICAL CONDITION] rendered the resident paralyzed due to spinal invasion. The resident was treated for [REDACTED]. A nurses' note dated 6/24/18 revealed Resident #1 returned to the facility with no pain and a [DEVICE] to his new AKA and several areas of open skin. Resident returned with orders for antibiotic administration to treat a urinary tract infection. On 7/3/18 at 9:45 am an interview was conducted with the Treatment Nurse (TN) who stated that two residents on Hall 700 had maggots. Resident #1 had white moving bugs that were believed to be maggots coming out of his lower right extremity/foot wound with 100% necrotic tissue with recent [DIAGNOSES REDACTED]. The resident also had a planned above the knee amputation pending which was performed on his last hospital admission. The resident was known to frequently leave the facility by motorized wheelchair in the extreme heat and go as far as 2 miles away to the store. There were times when the resident dragged his right foot while outside and his dressing came off and there were times when the resident refused to have his dressing changed putting him at higher risk for infection. The dressing to the right lower extremity was dressed as ordered and no other form of securing the dressing was done by the TN. The resident had to have his dressing redressed frequently due to falling off and drainage. The TN stated that the maggot issue information was passed verbally during shift change. On 7/5/18 at 8:05 am an interview was conducted with the facility Nurse Practitioner (NP) who stated she was very familiar with Resident #1. The resident was frequently non-compliant with wound care dressing change. The resident preferred his dressing changes while still in bed before he got up to his motorized wheelchair (WC). The NP stated from what she observed the resident would request to get up to his WC at various times and the dressing change time was not always altered to meet this schedule. The resident was alert and oriented. NP stated on 6/13/18 she evaluated the resident ' s wound and the dressing was soaked through and the drainage was like mud. The NP stated that the resident had a recent doppler test (an observation of arteries and veins) of his lower extremities and [MEDICAL CONDITIONS] was found. The NP commented that [MEDICAL CONDITION] can cause slow or non-healing of wounds. The resident refused to go to the Emergency Department (ED) so the NP ordered a broad-spectrum antibiotic for concerned infection and labs and the wound care was completed. The NP commented that she was surprised the resident was not septic. On 6/14/18 when the Treatment Nurse removed the resident's right lower extremity wound dressing there were white moving objects in the wound believed to be maggots. The resident was transferred to the ED with his wound open to air kill the maggots. The resident was informed and re-educated as to the seriousness of his right leg infection and then agreed to the plan of treatment. The resident had an above the knee amputation planned which was performed during this hospitalization . The resident had an intact cognition and stable [MEDICAL CONDITION]. The NP stated that the resident made poor choices. The resident's only significant other was in the facility and was estranged from his family. The NP witnessed the resident's right lower extremity dressing was soaked through from drainage and smelled foul. All staff involved would talk to the resident and reeducate him when there were refusals. The NP stated she felt the resident understood the consequences of refusal. The resident was oriented enough he would most likely not be deemed incompetent but was not aware if there was a competency evaluation. The resident was his own representative. The NP stated the resident was safe to leave the building and had always returned. On 7/5/18 at 11:00 am an interview was conducted with the Director of Nursing (DON) who stated that Resident #1 had a long history of refusing wound and personal care. The resident preferred to be up in his motorized wheelchair (WC) and wanted the dressings to be changed before he got into his WC. The resident did not want to get back into the bed for wound care. Removal of the resident's WC for behavior caused the resident's non-compliance to increase. The resident contracted for safe WC use, the WC was returned and his wound care compliance was 100% for a while. Staff tried changing the resident's dressing on night shift while in bed and that worked for a while with return of refusal. The resident would change the time he wanted his wound dressing changed depending on his needs and how he felt which caused communication breakdown between the shifts and whether the resident should be offered wound care before getting up to his WC. At times the resident would ask the night staff to place him in the WC before his dressing were changed by day shift. Once up in the WC the resident would not allow dressing changes unless he had a problem. The resident was alert and oriented and his own resident representative. The resident was asked each day if he would allow wound care. The DON stated that the current interventions were not always effective for this resident and some of them were not care planned. The DON stated a psychiatrist was not obtained to evaluate the resident's non-compliance and competency. The resident had refused psychiatry services in the past. 2. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's care plan dated 4/27/18 revealed goals and interventions for dependent on staff for emotional and social needs, self-care deficit, desired to return to home, fluid volume deficit, poor oral hygiene, diabetes, at risk for falls, bowel incontinence, [MEDICAL CONDITION], potential for pressure ulcer, and actual impairment to skin integrity. The quarterly Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, and was understood and understands. The resident had an intact cognition. The resident required extensive assistance of 2 persons for all transfers, bed mobility, and locomotion. Dressing, bathing, and personal care required 2 staff members limited assistance. A nurses' note dated 6/19/18 at 3:31 pm, written by the treatment nurse, revealed the resident had maggots in the abdominal folds. A Nurse Practitioner (NP) order dated 6/19/18 revealed anti-bacterial wash every day. A Nurse Practitioner order dated 6/20/19 revealed an order for [REDACTED]. A nurses' note dated 6/22/18 revealed the resident felt a shower every day was too much. A nurses' note dated 6/30/18 revealed the resident had refused some of her every day showers and had requested to go back to the twice a week schedule. On 7/3/18 at 9:45 am an interview was conducted with the Treatment Nurse (TN) who stated that Resident #2 had maggots on her body and in her bed. The TN stated she observed that Resident #2 had several maggots in her bed with food debris and two in the skin folds of her lower abdomen about 6/20/18. The Nurse Practitioner (NP) was notified and daily showers with anti-bacterial wash were ordered. By about day 3 the resident refused her showers and the nursing assistants provided a bed bath with anti-bacterial wash. Nursing staff was not notified of the refusal. On day 5 the resident had a few maggots again in the same area of her abdominal fold. The TN stated that the maggot issue information was passed verbally during shift change. The staff was verbally directed to look for maggots during routine care. On 7/3/18 at 11:45 am an interview was conducted with the Assistant Director of Nursing (ADON) who stated that Resident #2 had maggots found on her body shortly after another resident was found to have maggots. The resident was found to have maggots in the folds of her lower abdominal skin. The ADON stated the TN identified the maggots during treatment and was not sure if there was tissue injury. The resident was always dressed and it was unclear how maggots were able to get under her clothing. The NP was called and an order for [REDACTED]. The ADON expected the treatment nurse assigned for that day to inform her if there were any maggots. The ADON stated that the maggots were mentioned in the Monday morning meeting but not discussed for prevention or new process. The staff were directed to kill any flies. On 7/3/18 at 5:45 pm an interview was conducted with Resident #2 who stated there was a quick increase in the number of flies in her room about 1 to 2 weeks ago. The resident stated about a week ago there were maggots on her stomach and in her bed which caused her anxiety. The NP ordered anti-bacterial wash and showers every day which were still in place at this time. The resident stated that during the first five days of the showers there were additional maggots that had hatched. The resident preferred a bed bath and when she refused and had a bed bath instead of a shower the maggots returned. The resident informed the staff that she did not need a shower. The resident stated she was informed by the NP her lymph [MEDICAL CONDITION] can attract flies and cause maggots and agreed to have a shower. On 7/5/18 at 8:05 am an interview was conducted with the NP who was very familiar with Resident #2. The resident was alert and oriented and able to make her own decisions. The resident was her own resident representative. The resident was known to resist personal care and preferred a bed bath. Resident #2 had maggots to her right lateral lower abdominal fold and maggots in the bed. The NP stated she ordered daily showers and cleanse with anti-bacterial wash. The resident agreed to daily showers and education was provided why showers were needed. After the first three days the resident started to complain to the nursing assistant that a daily shower was too much for her and began to inform personal care staff that the NP informed the resident she no longer needed a daily shower. The NP stated that the resident manipulated staff. The staff did not inform the NP of the resident's refusal on day three of the order for daily showers and by day five the resident had maggots again in her abdominal folds, same place. The showers were more effective at washing the lymph [MEDICAL CONDITION] and any potential fly eggs. The resident did not like to transfer via the mechanical lift because of her size and fear of falling which contributed to the shower refusal. The resident had lymph [MEDICAL CONDITION] which wept fluid continuously and put the resident at increased risk for maggots. The NP stated that when a resident refused care or treatment her expectation was for staff to re-educate the resident to obtain compliance and if the refusal continued to inform her. The NP has attempted to get resident cooperation to make better choices by explaining why and the consequences. This method had been repeated and sometimes it worked and sometimes it had not. On 7/5/18 at 10:45 am an interview was conducted with Resident #2 who stated that the resident had a shower this morning and was made aware by the NP the importance of the need for a shower versus her preferred bed bath. The staff used the shower gurney to transfer the resident to the shower and that worked better than the mechanical lift. The resident stated that it was over a five-day period that she had maggots and was very concerned about their returning. The resident had received her usual, daily ant-anxiety medication. The resident commented that the flies were better. On 7/5/18 at 12:15 pm an interview was conducted with Nursing Assistant (NA) #1 who stated that she was assigned to Resident #2 who received a shower or complete bed bath every day. The resident preferred a bed bath and had to be coaxed to take her shower when it was ordered. NA #1 was aware of the maggots and had seen flies in the resident ' s room, but not more than usual. When the NP ordered for the resident to take a shower, the resident refused and said she did not need a shower anymore. NA #1 provided a bed bath and later learned that the shower order continued. NA #1 indicated that she would inform the licensed nurse if the resident refused a shower. On 7/5/18 at 11:00 am an interview was conducted with the Director of Nursing (DON) who stated that Resident #2 sometimes refused her ordered shower and the staff at times had called the resident's family member to influence the resident to take a shower, which was effective. The resident was in agreement that her family member was called. On day three of the ordered daily shower the resident refused to have a shower and the nursing assistant gave the resident a bed bath. The family member was not called as an intervention. The resident did not receive a shower for two days of the ordered daily shower and maggots appeared again. The DON's expectation was for nursing assistants to inform the nurses of resident refusals and confirmed that the nursing assistants did not inform the nurses of the refused showers, the NP was not aware, and maggots were again observed on the resident on 6/23/18. The Administrator, Assistant Administrator, Corporate Nurse Consultant and Director of Nursing were notified of the Immediate Jeopardy on 7/5/18 at 12:32 pm. On 7/6/18 the facility provided an acceptable credible allegation for immediate jeopardy removal that included the following: The plan of correcting the specific deficiency including the processes that lead to the deficiency cited: 1. a. Resident #1 was admitted to Randolph Health and Rehabilitation on 8/10/17 due to [MEDICAL CONDITION] secondary to Burkitt's [MEDICAL CONDITION]. He was assessed as having a Brief Interview Mental Status (BIMS) score of 15 on the following Minimum Data Set (MDS) Assessments with assessment reference dates of: 8/17/17, 8/24/17, 9/7/17, 10/20/17, 11/7/17, 2/7/18, 3/7/18, 6/14/18 and 6/27/18. A BIMS score of 15 indicates the resident is cognitively intact. The BIMS scale goes from 0-15, with 15 being the highest possible score. Resident #1 is alert and oriented to time, person and place. Resident #1 was issued an order by the attending physician on 8/10/17 that he can leave the center on Leave of Absence (LOA) per the resident's discretion. Resident #1 is currently at the hospital. Resident #1 was care planned on 8/23/17 for declination of care including refusing of going to bed, wound care and personal hygiene. Resident #1 went on LOA on 6/1/18, 6/2/18, 6/3/18, 6/4/18, 6/5/18, 6/6/18, 6/8/18 two times, 6/9/18 two times, 6/10/18 three times, 6/11/18, 6/12/18, two times and 6/13/18. On 6/3/18, 6/4/18, 6/5/18, 6/7/18, 6/8/18, 6/9/18, 6/10/18, 6/11/18 and 6/13/18. Resident #1 was out of the center and did not allow Licensed Nursing to perform his treatment. On 6/8/18 Nurse Practitioner documented in progress note that Resident #1 was evaluated for Venous Stasis Ulcer of leg; per progress note Resident #1 was being evaluated by the surgeon for a right lower leg amputation. On 6/11/18 a Weekly Head to Toe Skin Assessment was completed by a Licensed Nurse with no abnormal findings per the resident ' s baseline. On 6/13/18 the center Wound Nurse evaluated Resident #1's wound to the right ischium stage IV pressure ulcers 4.x5.25x0.1 100% [MEDICATION NAME], no undermining, pink wound bed, scant serous drainage, no odor, surrounding skin normal, no pain, Nurse Practitioner made aware of wound status on 6/13/18. On 6/13/18 the center Wound Care Nurse assessed Resident #1 ' s Right perineum wound Stage IV 4x5.75.1.2 100% granulation tissue, red wound bed, small serous drainage, normal edges, no pain; Nurse Practitioner was made aware of wound status on 6/13/18. On 6/12/18 the center Wound Care Nurse assessed Resident #1 Arterial Wound to the right lower extremity as 19.0x7x3.0cm, 100% black necrotic tissue, strong odor present, heavy brown purulent drainage; Nurse Practitioner was notified and intramuscular antibiotic ordered. On 6/14/18 Resident #1 was noted by charge nurse to have moving objects in his arterial wound to his right lower leg. Resident #1 attending Physician was contacted and resident was immediately sent to the Emergency Department for evaluation of the wound. Resident #1 returned to the center on 6/24/18 with right lower leg amputation. Resident #1 was sent to the Emergency Department on 6/27/18 and was admitted with [DIAGNOSES REDACTED]. Resident #1 is currently in the hospital. The facility Interdisciplinary Team (IDT) including the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers and Social Services Director met on 7/4/18 to review of the medical record of Resident #1 to determine the root cause of the processes that lead to the deficiency cited. The team reviewed the number of LOAs and the number of refusals of care related to treatments of the right lower extremity, the center determined that Resident #1's right lower leg arterial wound could have come into contact with the maggots during his thirteen plus incidence of being absent from the facility . The center identified that resident had refused wound treatments to the right lower leg multiple times from (MONTH) 1-13, (YEAR). During interviews with the facility staff, it was determined that the center failed to coordinate Resident #1's wound treatment to resident preference. The facility IDT also identified right lower leg wound dressing had fallen off while outside of the facility on 6-10-18 and that facility did not reinforce the right lower wound dressing prior to resident leaving the facility. b. Resident #2 was admitted to center on 7/28/17 with [DIAGNOSES REDACTED]. Resident #1 BIMS on 5/24/18 was 15. Resident #1 BIMS on 4/5/18 was 15. On 6/15/18, a Weekly Skin Assessment was performed with no findings noted. On 6/19/18 Resident #2 was noted to have maggots to her abdominal folds. Resident #2's Nurse Practitioner was notified with orders for anti-bacterial wash received. On 6/20/18, Resident #2's Nurse Practitioner ordered daily showers for Resident #2. Resident #2 refused showers on 6/22/18, 6/25/18, 6/26/18, 6/27/18 and 6/29/18. After review of the medical record for Resident #2, noting the number of refusals of care related to showers, the center failed to implement specific interventions to get the resident to shower. The facility Interdisciplinary Team met on 7/5/18 to review of the medical record of Resident #2 to determine the root cause of the processes that lead to the deficiency cited. A Root Cause Analysis was conducted by the Interdisciplinary Team (IDT) on 7/5/18 and it was determined that there was not a resident specific plan of care for alternate interventions to offer the resident to help promote the likelihood the resident will comply with showers per physician orders. The IDT determined the center did not educate the resident on the risks of refusals of showers including risk of maggots. Resident #2 had a skin evaluation assessment performed by the Charge Nurse assigned to Resident#2 on 7/6/18; there were no signs of maggots noted. On 7/6/18 the Unit Coordinator interviewed Resident #2 regarding her bed baths. Resident #2 stated she receives good bed baths and denied having any concerns with bed baths. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: · On 7/4/18 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor conducted medical record audits to determine any residents who routinely leave the center on LOA and do not receive treatments due to the LOA. · On 7/5/18 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor will contact the attending physician and orders will be requested to offer treatments to be scheduled as needed based on resident preference. · On 7/4/18 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor begin in-servicing the facility nurses regarding reinforcing wound dressing as needed when resident going on leave absences to protect the wound bed. · On 7/5/18 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor conducted medical record audits to determine any residents who refuse showers and bed baths per physician order. On 7/5/18 the attending physician will be contacted by the Director of Nursing, Assistant Director of Nursing, Unit Coordinators and Unit Managers for clarification of any residents with physician orders [REDACTED]. All residents in the center had a head to toe skin assessment completed on 7/4/18 by the Unit Coordinators, Unit Managers, Wound Care Nurse, Treatment Nurse and Assistant Director of Nursing; no other residents were identified as having maggots. Beginning 7/5/18 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor educated the licensed nurses to seek a physician's orders [REDACTED]. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor educated the licensed nurses beginning 7/5/18 to reinforce dressings as needed when residents go on LOA due to risk of dressing being removed. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor educated the licensed nurses beginning 7/5/18 to evaluate the status of the treatment or dressing when residents return from LOA and document any abnormal findings in Resident Progress Notes. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor educated the licensed nurses beginning 7/5/18 that if an as needed dressing change is indicated, the licensed nurse will perform the dressing change and document the status of the wound in the Resident Progress Notes if changes in the wound bed or amount of drainage are noted. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor educated the licensed nurses beginning 7/5/18 if an as needed dressing change is indicated, the licensed nurse will document the treatment or dressing change on the Treatment Administration Record. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor educated the licensed nurses beginning 7/5/18 that if changes in the wound bed or drainage are noted, the attending physician will be notified of any changes with the notification documented in the Resident Progress Notes. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor educated the licensed nurses beginning 7/5/18 related to complying with physician's orders [REDACTED]. No Licensed Nurse will be permitted to work without first receiving the education. The Nursing Assistants were re-educated by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers, 3-11 Nurse Supervisor and 11-7 Nurse Supervisor beginning 7/4/18 regarding if a resident refuses a bed bath or shower that the Charge Nurse is to be informed of the refusal. Beginning 7/5/18 no Nursing Assistants will be allowed to work without first receiving the education. Of the 48 Licensed Nurses, 30 of the Licensed Nurses have received the education for F684. Six of the Licensed Nurses who have not yet received the education work on an as needed basis. Three of the Licensed Nurses who has yet to receive the education are currently on vacation. One of the Licensed Nurses who has yet to receive the education is on Family Medical Leave Act (FMLA). Each of the Licensed Nurses who have not yet received the education will not be permitted to work until the education is received. Newly hired Licensed Nurses will be educated by the Staff Development Coordinator during their classroom orientation to: to seek a physician's orders [REDACTED]. [REDACTED]. in the Resident Progress Notes if changes in the wound bed or amount of drainage are noted; if changes in the wound bed or drainage are noted, the attending physician will be notified of any changes with the notification documented in the Resident Progress Notes. Upon return to the center, Resident #1's attending physician will be contacted to request a physician's orders [REDACTED]. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and / or in compliance with the regulatory requirements. Daily Monday - Friday in the Clinical Morning Meeting for 12 weeks, the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Coordinators, Unit Managers will audit Treatment Administration Records of residents identified as routinely going on LOA, and / or residents who routinely refuse treatments. If concerns, such as not offering treatments at times suitable to meet the preference of the resident are identified, the affected resident will be interviewed to determine any change in preferred time, physician's orders [REDACTED]. If concerns such as non-compliance are identified alternative (TRUNCATED)

Based on observations, record review, Nurse Practitioner (NP) interview, resident and staff interviews the facility failed to implement an effective pest control program to contain the presence of flies in the rooms of four (4) of twelve (12) sample residents. (Residents #1, #2, #3, and #5). Residents #1 had live maggots develop in his right lower extremity wound and Resident #2 had live maggots develop in her abdominal folds. Resident #1 was transferred to the hospital for treatment of [REDACTED].#2 received treatment for [REDACTED]. Immediate jeopardy (IJ) began on 6/14/18 when Resident #1 was found with live maggots in his right lower extremity wound. Immediate Jeopardy began on 6/19/18 for Resident #2 when live maggots were found on her abdomen. The facility failed to implement an effective pest control program to control flies in the facility to prevent the development of maggots on Resident #1 ' s wound and on Resident #2 ' s abdomen. The Immediate Jeopardy was removed on 7/6/18 when the facility implemented a credible allegation of IJ removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service. Findings included: 1a. Resident #1's quarterly Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, and understood and understands. He had intact cognition, no [MEDICAL CONDITION], and no behaviors. A nurses' note dated 6/14/18, written by the Treatment Nurse (TN), revealed Resident #1 was observed to have white moving objects coming out of his right lower extremity wound. The NP was informed and an order to transfer the resident to the hospital and to leave the wound open to air was obtained. Another nurses' note dated 6/14/18 revealed Resident #1 was hosptalized on [DATE] for right lower extremity wound infection and white moving objects in his wound. The Nurse Practitioner (NP) ordered for the resident's right lower extremity dressing to be removed and left open to air and transfer to the hospital. The resident was transported by Emergency Medical Services. A Hospital discharge summary dated 6/24/18 revealed Resident #1 was admitted on [DATE] for an infection to his right lower extremity and had an above the knee amputation. On 7/3/18 at 9:45 am an interview was conducted with the TN. The TN stated that on 6/14/18 during wound care of Resident #1's right lower extremity white moving objects were observed coming out of the wound which staff and the NP believed to be maggots. The resident was sent immediately to the hospital. Record review revealed Resident #1 was re-hosptalized on [DATE] and was not available for interview or observation during the survey. 1b. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had adequate hearing, clear speech, and was understood and understands. The MDS specified the resident had an intact cognition. A nurses' note dated 6/19/18 at 3:31 pm, written by the treatment nurse, revealed the resident had maggots in her abdominal folds. On 7/3/18 at 9:45 am an interview was conducted with the Treatment Nurse (TN) who stated that on 6/19/18 she went to place [MEDICATION NAME] powder to Resident #2's abdominal folds and noticed 2 maggots in the skin fold of her lower right lateral abdomen and 10 maggots in the bed. The TN stated she informed the NP who ordered daily showers with an antibacterial wash to remove the maggots and kill fly eggs. The TN was not aware of any pest control service visit for the flies after identifying the maggots. On 7/3/18 at 5:45 pm an interview was conducted with Resident #2 who stated recently there was a quick increase in the number of flies in her room about 1 to 2 weeks ago. The resident was killing three at a time with a fly swatter and would ask the nursing assistants to assist. The number of flies in her room was an increase. The resident stated other than the fly swatter she was not offered any other method to control the flies in her room. The resident stated that she complained to the nursing assistants on more than one occasion. The resident stated about a week ago there were maggots on her stomach and in her bed. The resident stated that she had a daily shower with an antibacterial wash to prevent any further maggots or hatching of eggs and no longer had maggots. She further stated that maintenance staff did not approach her to inquire about the flies, check her window or provide any other form of pest control other than what was already in place. 1c. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had adequate hearing, clear speech, and was understood and understands. The MDS specified the resident had an intact cognition. On 7/2/18 at 9:45 am an observation of Resident #3's room (room [ROOM NUMBER]) was completed. The resident's bed was next to the window. There were a few flies noted flying around the resident. The room and the resident were both clean and there was no odor. The flies were observed to land on the bed and the resident's hand and face. The resident was observed to have limited mobility and no ability to swat the flies away. On 7/2/18 at 9:45 am an interview was conducted with Resident #3 who stated he did not like the flies and believed they were coming in the window where the 2 sliding window glass pieces met. The fly increase in flies in his room was recent. The resident stated he could not use a fly swatter. On 7/2/18 at 9:55 am an interview was conducted with Nurse #1 who was assigned to Resident #3. Nurse #1 stated that last Tuesday she informed maintenance about the flies and the residents were offered a fly swatter. Nurse #1 did not believe that a fly swatter was effective for a resident who did not have the ability to use the swatter such as Resident #3. Nurse #1 noted that flies were in Resident #3's room and in the hallway during the interview. On 7/3/18 at 8:55 am an interview was conducted with Resident #3 who stated that maintenance had been in to evaluate his window, did something to the window and killed some flies. The flies were better 1d. Review of a quarterly Minimum (MDS) data set [DATE] revealed Resident #5 had adequate hearing, clear speech, and was understood and understands. The MDS specified the resident had an intact cognition. On 7/2/18 at 11:40 am an interview was conducted with Resident #5. Resident #5 stated that he had several flies in his room and he did not like flies. He further stated that the increase in flies in his room was recent and he did not know why. The resident stated he was not able to swat the flies. On 7/2/18 at 11:40 am an observation was done of room [ROOM NUMBER] (Resident #5's room) and 2 flies were observed in the room. The window was not closed completely and light from outside could be seen at the window's edge. On 7/2/18 at 10:10 am an interview was conducted with the Housekeeping Manager (HM) who stated that housekeeping was required to report concerns of flies. The HM stated that there were the usual number of flies in the facility and no concerns were reported. On 7/3/18 at 8:30 am an interview was conducted with the Maintenance Manager (MM) who stated on 6/20/18 he was alerted to flies on Hall #400 and investigated. MM stated he found all measures to control flies operational and intact and no new interventions were added. Pest control was scheduled monthly and returned when called on an as needed basis. MM stated on 6/20/18 that he killed flies with a swatter when informed of the flies and provided swatters to residents that were able to use the swatter. MM felt that the entry for the flies were the entry/exit doors for staff and visitors and that there was a recent heavy rain with increase in temperature and humidity that caused an increase in flies to enter the facility. MM stated that staff were not allowed to use chemicals, the hired pest control provided that service. MM stated he did not call for pest control to provide service to the facility. He explained that one particular root cause was not identified. All potentials that MM was aware of were evaluated and the only one identified was the entry/exit doors. MM stated outside pest control will be evaluating the fly issue today as a result of inquiry. The fly issue was a quick change. MM stated that the resident in room [ROOM NUMBER] complained of flies and MM swatted and killed the flies, not sure the total amount. MM commented that Hall #700 had more flies than the other halls. On 7/3/18 at 10:30 am an interview was conducted with MM who stated after disclosure of known maggots that he was informed by the Administrator of two separate occasions where two residents had maggots over the past 2 weeks and to evaluate for potentially more flies relating to residents. MM stated he heard staff discuss maggots on residents, but felt it was hearsay. MM stated that on hall #7 there were more flies than on other halls in the facility. MM changed the sticky paper in the bug light and decided not to call for the outside pest control. MM stated he requested HM to have the resident with maggot's room deep cleaned. MM stated that he observed for flies and did not see any more than usual and that was why he did not request for the outside pest control company to provide service. MM's plan was to abate flies that come in the door and kill the flies in the facility by fly swatter. MM commented that the facility cannot use chemicals or sprays but pest control can. MM commented that he did not think the situation warranted pest control. Pest control treated the facility once a month for prevention that was not specific to flies. MM stated that he felt the facility's current fly control measures could manage the concerns. MM then stated that after the Administrator informed him of the second resident with maggots the circumstance was urgent, but still did not employ the outside pest control to service the facility. MM stated that pest control management was his responsibility. On 7/3/18 at 11:30 am an interview was conducted with the Assistant Director of Nursing (ADON) who was aware of two residents with maggots on their bodies. The NP was notified and one resident was transferred to the hospital. That resident ' s room was cleaned and no maggots were observed. The staff were informed to kill flies. Staff rounds were required to notify management of any fly concerns and to inform maintenance. The Administrator, Assistant Administrator, Corporate Nurse Consultant and Director of Nursing were notified of the Immediate Jeopardy on 7/5/18 at 12:32 pm. The facility provided an acceptable credible allegation for immediate jeopardy removal on 7/6/18 which included the following: The plan of correcting the specific deficiency including the processes that lead to the deficiency cited: On 6/14/18 at approximately 11:30 am, the Maintenance Director was notified of maggots in the wound of Resident #1. He immediately went to the room and visually checked for any signs of maggots. At that time none were identified. A physician order [REDACTED].#1 was sent to the hospital for evaluation. On 6/14/18 the Maintenance Director notified the Housekeeping Supervisor of the need to deep clean Resident #1 ' s room as an added precaution. The room was thoroughly deep cleaned on 6/14/18 with no signs of maggots identified. Pest Control came to center on 6/14/18. On 6/19/18 Resident #2 was noted to have maggots on her abdomen. At that time her room was deep cleaned as there was spoiled food noted on her over bed table as well as food not properly stored. Resident #2 was provided storage bags to secure her food. Resident #2 was admitted to center on 7/28/17 with [DIAGNOSES REDACTED]. On 6/15/18 a Weekly Skin Assessment was performed with no findings noted. On 6/19/18 Resident #2 was noted to have maggots to her abdominal folds. Resident #2 Nurse Practitioner was notified with orders for [MEDICATION NAME] 4% received. On 6/20/18 Resident #2 Nurse Practitioner ordered Daily Showers. Resident #2 refused showers on 6/22/18, 6/25/18, 6/26/18, 6/27/18 and 6/29/18. After review of the medical record for Resident #2 noting the number of refusals of care related to showers, the center failed to implement specific interventions to encourage the resident to comply with the physician's order [REDACTED]. The breakdown in the process occurred because the Maintenance Director was not aware that the Pest Control Company treated flies. Additionally, the Maintenance Director was not aware that maggots are fly larva. On 7/5/18 the Nursing Home Assistant Administrator provided a one to one in-service education for the Maintenance Director regarding services provided by the Pest Control Company and that maggots are fly larva that can potentially mature to flies. The Interdisciplinary Care Team (IDT) including the Nursing Home Administrator, the Director of Nursing, Maintenance Director, Minimum Data Set Coordinators, Social Workers and Evening Nurse Supervisor met on 7/5/18 and determined the root causes the pest control program breakdown. One of the Root Cause determined by the IDT was there was a delay of the Maintenance Director notifying the Pest Control Company to perform pest services on 6/19/18 or again on 6/22/18 when maggots were noted in the center. Another Root Cause determined by the IDT was flies entered the center due to staff using the 700 hall exit door, which does not have an air curtain. The staff is using the 700 Hall Exit Door to come and go in and out of the facility after 5:00 PM. The Nursing Home Administrator educated the Maintenance Director and one of two Maintenance Assistants on 7/5/18 to notify the Pest Control to come do a center visit and treatment as indicated when any observations or notifications of pests occur. On 7/5/18 the Maintenance Director activated an alarm on the 700 Hall exit door to alert if when the door is utilized for non-emergencies. Another of the Root Cause determined was flies entered the center through tears in the window screens. The Assistant Administrator conducted a 100% facility audit for screen integrity on 7/2/18. On 7/2/18 the Maintenance Director and Maintenance Assistants repaired or replaced the window screens noted with tears. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: The Nursing Home Administrator educated the Maintenance Director and one of two Maintenance Assistants on 7/5/18 to notify the Pest Control to come do a center visit and treatment as indicated when any observations or notifications of pests occur. The Nursing Home Administrator educated the Maintenance Director and one of two Maintenance Assistants on 7/5/18 that fly sticky paper should be checked and changed as needed twice monthly for three months and monthly thereafter, or as indicated. The remaining Maintenance Assistant is on vacation and is scheduled to return to work on 7/10/18. On 7/10/18 the remaining Maintenance Assistant will be educated to notify the Pest Control to come do a center visit and treatment as indicated when any observations or notifications of pests occur and that fly sticky paper should be checked and changed as needed twice monthly for three months and monthly thereafter, or as indicated. The Pest Control Company treated the interior and exterior of the center with pesticide and bait on 7/6/18. On 7/6/18 the Pest Control Company added monthly exterior bait service for flies. Pest Control visits and treats the center on a monthly basis and will visit and treat as needed per monitoring regimen. Pest Control will monthly visits will not have a gap in treatment more 35 days. · Residents residing on the 700 hall have the potential to be affected. On 6/20/18, the Maintenance Director noticed a fly in two resident rooms on his Ambassador Rounds. He went to obtain a fly-swatter and returned to the rooms and killed both flies. The Ambassador Program is designed to enhance customer satisfaction and responsiveness through biweekly contact with residents by facility staff. Responsibilities of the Ambassador include: - Reaching out proactively to residents to address concerns and answer questions two times a week or more frequently if needed - Ambassadors are advocates for our residents and perform resident visits as well as room observations two times a week or more frequently if needed. On 7/5/18 Room observations were added to the Ambassador Rounds for cleanliness, safety and pests. If the Ambassador notes concerns, they will be documented on a concern form and / or work order as needed for follow up / resolution. On 6/21/18, Maintenance Director completed inspection on all fly fans and operations were normal. Additionally, the Maintenance Director checked all fly lights for proper function and installed new fly sticky paper, which was not effective because of reoccurrence of maggots for Resident#2. On 6/28/18, room inspections identified two flies in one room. Maintenance staff eliminated both flies and a fly swatter was provided for residents in the room per their request. A visual sweep of the halls was completed with no additional signs of flies on 6/28/18. A 100% audit was completed on facility windows for closure, screen integrity, and quality. Three window screens were repaired on 7/2/18. On 7/3/18, Pest control arrived and performed a facility assessment. On 7/5/18, Pest Control was called and requested to come back to the facility for assessment with treatment of [REDACTED]. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and / or in compliance with the regulatory requirements. Beginning 7/5/18, during the Ambassador Rounds conducted by Assistant Director of Nursing, Staff Development Coordinators, Minimum Data Set Coordinators, Social Workers, Medical Records Coordinator, Business Office Director, Admissions Coordinator, Maintenance Director, Human Resources Coordinator, Unit Managers, Unit Coordinators, Transportation Director, Activities Assistants, Scheduler, the staff will perform two random observations for flies twice weekly for 12 weeks in resident care areas. If flies or maggots are noted, the Ambassador will attempt to eradicate as appropriate, notify the Charge Nurse and complete a work order. Fly sticky paper will be checked and changed by the Maintenance Director as needed twice monthly for three months and monthly thereafter, or as indicated. Maintenance Director will observe fly sticky paper weekly during the summer months to determine if fly sticky paper needs to be changed. Maintenance Director or Assistant Administrator will accompany Pest Control Technician during monthly and as needed visits / treatments for a minimum of three months to validate services rendered. Beginning 7/5/18 all staff education provided by the Staff Development Coordinator, 3- 11 Nurse Supervisor, 11-7 Nurse Supervisor, Unit Coordinators, Unit Managers, Assistant Director of Nursing, Dietary Manager, Rehab Manager, Housekeeping Manager was initiated to educate staff they are not to enter or exit through the 700 Hall door, complete a work order for torn window screens and to attempt to eradicate, notify the Charge Nurse and complete a work order if flies, maggots or pests are noted. Results of the audits will be presented by the Nursing Home Administrator for review in the Quality Assurance and Performance Improvement Committee monthly for a minimum of three months to validate success of the interventions and recommendations of Quality Assurance and Performance Improvement Committee to assure compliance is sustained ongoing. The Title of the person responsible for implementing the acceptable plan of correction: The Nursing Home Administrator is responsible for the implementation of the plan of correction. Immediate Jeopardy removal date: 7/6/18 Validation: Immediate Jeopardy (IJ) was removed on 7/6/18 at 4:15 pm validation was completed of the credible allegation for IJ removal as evidenced by interviews of one licensed and one nursing assistant for each of the 7 facility halls for evidence of in-service completion. Pest control and maintaining a clean facility in-service was completed for 123 staff members on 7/2/18 and 56 staff members on 7/3/18. On 7/6/18 outside professional pest control was observed to treat the facility grounds with a liquid spray. On 7/6/18 the Administrator stated that the facility and grounds were treated for [REDACTED].

Based on record review, resident interview, and staff interview, the facility failed to safely transfer a resident when one staff utilized a mechanical lift to transfer a resident who required the extensive assistance of 2 staff members for transfers. The unsafe transfer resulted in the resident (Resident #58) sustaining a hematoma and laceration to the head and a fracture to her right arm for 1 of 4 residents reviewed for accidents. The findings included: Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated Resident #58 ' s cognition was moderately impaired. She was assessed with [REDACTED]. Resident #58 required the extensive assistance of 2 or more staff for transfers. She required the extensive assistance of 1 staff for bed mobility, dressing, and personal hygiene. Resident #58 was dependent on 1 staff with toileting and bathing. She was not steady on her feet and was only able to stabilize with staff assistance, she had impairment on one side of the upper and lower extremities, and she utilized a wheelchair. Resident #58 was indicated to always be incontinent of bowel and bladder. She had no falls noted. The plan of care for Resident #58 included the focus area of an ADL self-care performance deficit related dementia, [MEDICAL CONDITION], and stroke. This focus area was initiated on 7/5/17 and last revised on 11/17/17. The interventions included the extensive assistance of two staff to move between surfaces. The plan of care for Resident #58 also included the focus area of high risk for falls related to gait/balance problems, [MEDICAL CONDITION], incontinence, [MEDICAL CONDITION] medication, and being unaware of safety needs. This focus area was initiated on 7/6/17 and last revised 11/17/17. The goal was for Resident #58 not to sustain a serious injury. A hard copy Incident/Accident Report, completed by Nurse #1, indicated Resident #58 had an unwitnessed fall in her room on 1/27/18 at 10:05 AM. Resident #58 sustained a head injury. The description of the incident indicated Resident #58 was observed laying on the floor in her room beside the bed on her back. Resident #58 was noted vomiting when Nurse #1 entered the room. Bleeding was observed to the right side of Resident #58 ' s head. Equipment was noted to be involved in the incident/accident. The outcome to Resident #58 was noted as pain, bleeding, and head trauma. The Nurse Practitioner was notified at 10:10 AM and the Responsible Party (RP) was notified at 10:20 AM. Resident #58 was transferred to the emergency room (ER) by Emergency Medical Services (EMS) at 10:45 AM. An electronic SBAR (Situation, Background, Assessment, Recommendation) form was completed on 1/27/18 for Resident #58 related to a change in condition. The form indicated Resident #58 was observed on the floor in her room on her back, bleeding and vomiting. Resident #58 was noted as appearing to be in distress with complaints of pain and bleeding from the right side of her head with a hematoma observed. A physician's order [REDACTED].#58 to be sent to the ER for evaluation and treatment related to a fall. A hard copy Incident/Accident Investigation Follow Up Report dated 1/27/18 and completed by Nurse Unit Manager (UM) #1 and signed by the Administrator and Director of Nursing (DON) was reviewed. The description of the incident was a fall with injury that occurred on 1/27/18 for Resident #58. The summary of the investigation/reasonable conclusion indicated Resident #58 was sitting on the side of her bed when Nursing Assistant (NA) #1 walked around to pull her back. Resident #58 leaned forward and fell to the floor. Recommendations/new interventions included staff education. The care plan was noted as updated on 1/27/18. The interventions for Resident #58 ' s plan of care related to ADLs was updated on 1/27/18 to indicate she required the total assistance of 2 staff with a mechanical lift for transfers between surfaces. An electronic Interdisciplinary Post Fall Review form was completed on 1/27/18. The form indicated Resident #58 had an unwitnessed fall on 1/27/18 at 10:05 AM. Resident #58 was observed laying on her back on the floor in her room vomiting when staff arrived to check on her. Resident #58 was transferred to the ER for a hematoma to the head and a 3 centimeter (cm) gash noted with bleeding. The form indicated the environmental factor of equipment was present at the time of the fall. The hospital ER records dated 1/27/18 related to Resident #58 ' s fall were reviewed. The records indicated Resident #58 presented to the ER by EMS with complaints of an unwitnessed fall with laceration on the right side of her head and right shoulder pain. Resident #58 was noted to not remember the fall. Resident #58 was indicated to have had a hematoma to the head, a laceration to the head that was sutured with a staple, and she was assessed with [REDACTED]. An electronic Transfer Evaluation form was completed by Nurse UM #1 on 1/27/18 at 6:05 PM. The form indicated Resident #58 was dependent on staff for 100% of transfers. Resident #58 was assessed as non-ambulatory and unable to sit on bedside without full back and head support. She was also noted with an arm fracture. A physician's order [REDACTED].#58 indicated the following: - Follow up appointment was to be scheduled with orthopedic physician for right arm fracture. - Staples were to be removed from right scalp in 10 days (2/7/18). The interventions for Resident #58 ' s plan of care related to falls were updated on 1/30/18 to indicate she transferred with a mechanical lift and 2 staff assist. During an interview with Resident #83 on 1/29/18 at 3:00 PM he reported he witnessed Resident #58 fall in the room across the hall on 1/27/18 in the morning. He indicated the NA, unable to recall her name, utilized a mechanical lift without another staff member and Resident #58 fell , busted her head, and went to the hospital. (Record review indicated Resident #83 was most recently readmitted to the facility on [DATE] and his 11/28/17 quarterly MDS indicated his cognition was fully intact.) An interview was attempted with Resident #58 on 1/29/18 at 3:20 PM. Resident #58 was alert with confusion. She was able to recall she hit her head and hurt her arm, but was unable to provide any details about how she fell . An interview was conducted with the Social Services Director (SSD) on 1/30/18 at 1:10 PM. She stated NA #1 and Nurse #1 were assigned to Resident #58 at the time of her fall on 1/27/18. An interview was conducted with Nurse #2 on 1/30/18 at 2:00 PM. She stated Resident #58 was not a fall risk although she had a fall over the past weekend. She was unable to provide any details on the fall that Resident #58 had on 1/27/18. She reported Resident #58 required a mechanical lift and 2 staff assistance for transfers. She indicated the facility utilized two types of mechanical lifts and 2 staff were required for the use of both types of lifts. During this interview, Nurse #2 stated Resident #83 was alert, oriented, and reliable with his statements. An interview was conducted with NA #2 on 1/30/18 at 2:10 PM. She reported Resident #58 was not a fall risk although she had a fall over the past weekend. She stated she was not working at the time of Resident #58 ' s fall on 1/27/18 and she was unable to provide any details on the fall. She indicated Resident #58 required a mechanical lift for transfers and 2 staff assistance. She reported the facility utilized two types of mechanical lifts and 2 staff were required for the use of both types of lifts. During this interview, NA #2 stated Resident #83 was alert, oriented, and reliable with his statements. A phone interview was attempted with NA #1 on 1/30/18 at 2:24 PM. The phone number provided was not in service. A phone interview was conducted with Nurse #1 on 1/30/18 at 2:25 PM. She stated she was an agency nurse and she confirmed she was assigned to Resident #58 at the time of her fall on 1/27/18. She indicated she was in the process of completing her medication administration when NA #1 came up to her and said she needed her to come now as Resident #58 had fallen off the bed. Nurse #1 reported she immediately stopped what she was doing and went to Resident #58 ' s room. She stated Resident #58 was laying on her back, bleeding from the head, vomiting, and complaining of pain. Nurse #1 indicated she asked NA #1 how Resident #58 had fallen off the bed and she stated Resident #58 tried to get up on her own without assistance and she fell . Nurse #1 reported that Resident #58 had no history of trying to get up without assistance. This phone interview with Nurse #1 continued. She indicated after she had assessed Resident #58 she contacted the physician, the RP, EMS and completed the Incident/Accident Report form. She stated the Assistant Director of Nursing (ADON) was the one who had completed the investigation into the fall. Nurse #1 revealed she was later informed by another NA and a medication aide, unable to recall their names, that Resident #83 had observed NA #1 use the mechanical lift with Resident #58 without another staff present. Nurse #1 confirmed she had observed the mechanical lift in Resident #58 ' s room when she assessed the resident after the fall. Nurse #1 additionally confirmed NA #1 had left Resident #58 in the room to come and get her for assistance. An alternative phone number was requested from the SSD for NA #1 on 1/30/18 at 2:50 PM as the previous number that was provided was not in service. She indicated she was going to ask Human Resources (HR) for an alternative number. An interview was conducted with the ADON on 1/30/18 at 2:51 PM. She stated she was working in her office at the time of Resident #58 ' s fall on 1/27/18. She indicated an NA, unable to recall the name, came into her office and said Resident #58 had fallen. She reported she went to Resident #58 ' s room and she was laying on the floor, blood from her head area, and it appeared she had vomited on herself. She indicated NA #1 was assigned to Resident #58 at that time. She stated following the fall an NA, the ADON was unable to recall the name, reported to her the resident across the hall (Resident #83) had observed the mechanical lift in Resident #58 ' s room at the time of her fall. The ADON indicated she then interviewed Resident #83. She stated Resident #83 informed her the door to Resident #58 ' s room was open and the curtain was pulled at the time of her fall. He confirmed he saw the mechanical lift in Resident #58 ' s room at the time her fall, but he was unable to see exactly what happened as the curtain was partially blocking his view. This interview with the ADON continued. She stated she and the Weekend Nurse Supervisor then interviewed NA #1 and asked her what had happened. NA #1 admitted to utilizing the mechanical lift without another staff member ' s assistance. She stated she was putting Resident #58 back to bed. She reported she had gotten her out of the mechanical lift and seated on the side of her bed. She indicated she then walked around to other side of the bed to position Resident #58, but during that time Resident #58 fell forward and hit the floor. The ADON indicated NA #1 had not provided a reason as to why she used the mechanical lift without another staff member, but she confirmed she had. She stated she suspended NA #1 that day as she had violated the facility ' s policy of using 2 staff assistance with all mechanical lifts. She indicated NA #1 was currently suspended as the investigation was still pending. On 1/30/18 at 3:20 PM the SSD indicated HR had no alternative phone number for NA #1. This resulted in NA #1 being unable to be reached for interview. An interview was conducted with the DON on 2/1/18 at 12:25 PM. She verified the facility ' s policy was for two staff to utilize mechanical lifts. She indicated she expected staff to follow the policy. She additionally indicated she expected staff to consistently implement the plan of care interventions related to transfers.

Based on record review and staff interview, the facility ' s Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and to monitor the interventions that the committee put into place in February 2017. This was for eight (8) recited deficiencies (self- determination, Minimum Data Set (MDS) accuracy, Activities of daily living (ADL) care for dependent residents, increase/ prevent decrease in range of motion/ mobility, drug regime free from unnecessary drugs, free from unnecessary [MEDICAL CONDITION] medications, free of medication error rate of 5% or more) which were originally cited on 2/9/17 during the recertification/ complaint investigation survey and on the current recertification/ complaint investigation survey on 2/1/18. There was also one recited deficiency (free of accident hazards) that was originally cited during the complaint investigation of 7/23/17 and on the current recertification/ complaint investigation of 2/1/18. The continued failure of the facility during the two federal surveys of record and complaint investigation show a pattern of the facility ' s inability to sustain an effective QAPI program. The findings included: This tag is cross referred to: 1. F561—self-determination: Based on record review, observations and resident, staff and family interviews, the facility failed to honor the resident ' s preference to communicate in Spanish resulting in the staff ' s inability to assess him and determine his needs. This was evidenced by 1 of 1 residents reviewed for communication/sensory (Resident #3). During the recertification survey 0f 2/9/17, the facility was cited F242 for failure to honor a resident ' s choice in bathing. 2. F 641—Accuracy of assessments: Based on record review, observation, and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of physical restraints (Residents #98 and #128) and behaviors (Residents #9 and #57) for 4 of 35 residents reviewed. During the recertification survey of 2/9/17, the facility was cited F278 for failure to code the MDS accurately in the areas of Preadmission Screening and Resident Review level 2, behaviors and discharge status. 3. F 677—ADL care provided for dependent residents: Based on record review, observation and staff interview, the facility failed to provide incontinent care and nail care upon request for 2 of 4 sampled residents reviewed for activities of daily living (ADL) (Residents # 9 & #111). During the recertification survey of 2/9/17, the facility was cited F312 for failure to provide personal care and hygiene including showers and nail care. 4. F 688—Increase/ prevent decrease in range of motion/ mobility: Based on record review, observation and staff and resident interview, the facility failed to provide treatment to prevent further decrease in range of motion for 1 of 4 sampled residents reviewed for range of motion (Resident #75). During the recertification survey of 2/9/17, the facility was cited F318 for failure to apply splints as ordered by the physician. 5. F 689—Free of Accident Hazards/Supervision/ Devices: Based on record review, resident interview, and staff interview, the facility failed to safely transfer a resident when one staff utilized a mechanical lift to transfer a resident who required the extensive assistance of 2 staff members for transfers. The unsafe transfer resulted in the resident (Resident #58) sustaining a hematoma and laceration to the head and a fracture to her right arm for 1 of 4 residents reviewed for accidents. During the complaint investigation of 7/23/17, the facility was cited F323 for failure to safely transfer one of one residents resulting in a fracture. 6. F 757—Drug regime free from unnecessary drugs: Based on record review and staff and Nurse Practitioner (NP) interview, the facility failed to follow doctor's order to discontinue a medication for 1 of 7 sampled residents reviewed for unnecessary medications (Resident #92). During the recertification survey of 2/9/17, the facility was cited F329 for failure to follow the Nurse Practitioner orders and monitor potassium medication. 7. F 758—Free from unnecessary [MEDICAL CONDITION] meds/ as needed use: Based on record review and staff and physician interviews, the facility failed to ensure there was a 14-day limit/stop date in place for as needed [MEDICAL CONDITION] medication for 3 of 6 residents reviewed for unnecessary medication (Residents #3, #80, and #86). During the recertification survey of 2/9/17, the facility was cited F329 for failure to follow the Nurse Practitioner orders and monitor potassium medication. 8. F 759—Free of medication error rates of 5% or more: Based on record review, observation and staff interview, the facility failed to maintain a medication error rate at 5% or less by not administering medications as ordered and not following the manufacturer's specification for [MEDICATION NAME] coated and extended release medications. There were five errors out of 25 opportunities observed. The medication error rate was 20% (Resident #316, #123 & #10). During the recertification survey of 2/9/17, the facility was cited F332 for failure to maintain medication error rate at 5% or below as evidenced by 2 errors out of 28 opportunities resulting in 7.14$ med error rate. 9. F 761—Label/ store drugs/biologicals: Based on record review, observation and staff interview, the facility failed to date multi dose medications when opened and failed to discard expired medications in 1 (300 hall) of 2 medication rooms and 3 (100, 600 and 700 hall medication carts) of 4 medication carts observed. During the recertification survey of 2/9/17, the facility was cited F431 for failure to date multi-dose vials of injectable medications after opening in 2 of 3 medication storage refrigerators. On 2/1/18 at 1:54 PM, an interview was conducted with the Administrator. The Administrator stated that the facility has a QAPI committee that consisted of the Medical Director, Administrator, Director of Nursing, Pharmacy Consultant and all the department heads. The committee met monthly. She said there had been a lot of areas that the facility had been working on and corrected successfully since the Administrator and Director of Nursing came in May 2017. The following areas had been identified and continued to be reviewed—complaints about cold food, call light response had improved and continued to be monitored, falls, pressure ulcers, weight loss, MDS accuracy, care plans and abuse. Regarding the repeat citations, the Administrator said the facility has continued to build a cohesive team that could monitor and correct deficiencies. They have had increased meeting as needed for falls and any areas that might need increased attention and the plan might need to be adjusted sooner than monthly. She said the QAPI committee had adjusted and changed plans and it continued to be an ongoing process to reach, attain and maintain compliance with all the issues identified.

Based on resident and staff interviews the facility failed to safely transfer 1 of 1 (#1) residents resulting in a fracture. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set assessment completed 4/18/17 revealed a score of 15 on the brief interview of mental status indicating that the resident has good memory and cognition. The resident required assistance with bed mobility and had not transferred or walked during the review period. Review of the care plan 4/24/17 revealed a goal for the resident to maintain her current level of functioning through the next review date. The care plan stated that the resident was totally dependent on staff for transfer by 2 staff with a mechanical lift. The care plan included an intervention for the physical therapy to evaluate and treat the resident as ordered. Review of physical therapy progress note 5/3/17 revealed that Resident #1 had the following impairments: balance deficits, decreased dynamic balance, decreased safety awareness, decreased functional activity tolerance, decreased static balance, and strength impairments. Physical Therapy Encounter Note 5/5/17 written by the Physical Therapy Assistant stated, worked on standing and partial pivot with walker, sit to stand SBA (stand by assist) from elevated bed to walker, pivot was CGA (contact guard assist) to minimum assist for walker and cures when to move walker and feet, patient went to sit on bed and did not get completely on it, wen to lower bed for patient and during this time patient slide off bed and down to the floor, patient also had a silky gown on, grabbed for patient to help prevent any hard landing and to prevent head from hitting floor. Occupational Therapy Treatment Encounter Note 5/5/17 stated, that Resident #1 sat down half way on the bed and was educated on scooting back to decrease fall risk. The resident stated she couldn ' t and started to slide down to the floor and was lowered to the floor. Review of the facility Incident/Accident report 5/5/17 stated, Called to room by therapy with report they were transferring resident to bed when bed too high for resident and she slid onto floor. Found lying on back at bed with therapy at bedside. Complained of right leg pain and says her leg is broken. Hospital emergency department notes 5/5/17 stated, [AGE] year old female with multiple comorbidities including HTN (hypertension), DM (Diabetes Mellitus, COPD (Chronic Obstructive Pulmonary Disease) and morbid obesity who presents as a transfer from Randolph for evaluation of RLE (Right lower extremity) tib/fib (tibia/fibula) fracture that occurred during rehab at her facility. Plain films demonstrated comminuted distal right tibial shaft fracture along with proximal, distal shafts of right fibula. Neurovascularly intact on exam. Review of the hospital operative report 5/8/17 revealed a pre-operative [DIAGNOSES REDACTED]. The resident ' s fracture was repaired with surgical management. Review of the resident assessment completed 7/3/17 revealed that the resident scored 15 on the brief interview of mental status indicating that she had no problem with memory and was cognitively intact. During interview with Resident #1 at 5:15 PM on 7/23/17 she stated that she got out of the wheelchair and staff told her to pivot backwards and move until her legs hit the bed then to sit down. The resident said she did and sat on the edge of the bed. There was one staff down near the closet and one at the head of the bed. After she sat down the therapy staff member raised the bed causing her to fall and break her leg. Resident #1 stated that her feet came off the floor, she began falling and she heard her leg snap. She also reported that staff usually come to her to get her legs up. She said that she had pain in her knee, hands, arms, ankle and toes prior to the fall due to neuropathy. It felt like wearing a sock all the time and now it felt painful and sharp from her knee to her ankle. The resident said that she had pivoted before and there was someone there holding her arm or a walker. She stated, I told them it wore me out. She stated that she had the walker that day but someone moved it out of her reach. The resident stated that the staff did not use a safety belt. The resident reported that the OT (occupational therapy) staff told her that it was their fault. Interview with the PT (Physical Therapy) staff at 9:15 PM on 7/23/17 revealed that she was standing right next to Resident #1 next to the bed on the right hand side. The resident sat on the bed but not far enough. The resident had on a slippery gown and slid to the floor. The staff stated she was hanging onto the walker and I was standing next to her. The OT staff was trying to get the remote to lower the bed but she could not really reach the remote because it was on the opposite side at the foot of the bed if I recall. She stated that the bed was at the height needed for the resident to stand up. She was said the resident was so nervous and want to sit. She was rushing, doing it so quickly sat down too soon. The bed height had not been a problem in the past. She stated they were working on moving from the bed to the wheelchair and the resident had already turned back and took a little step backwards to get back to the bed. She was practicing sitting down. Her back was to the bed and she needed to go 5-6 inches with her feet. She stated it happened so fast, not rushing would have prevented the fall. She stated that she had not seen Resident #1 since her return from the hospital. During interview with the OT staff at 9:25 PM on 7/23/17 she stated, Myself and PT were working with her to safely transfer to the wheelchair. We stood her up bed raised and she did her half turn. She told her to sit when she felt the back of the bed behind her. She sat halfway. Then told her to stand up so that we could get her on the bed, that ' s when she fell . The bed was the same height as when she got out of bed. When she tried to get back on the bed we braced her feet and tried to lower the bed but couldn ' t get to the remote in time. The resident said I ' m going down, I ' m going down. The other staff was in front of the resident bracing her feet. The PT staff said that she was on the resident ' s right side (closet side) and the remote was on the resident ' s left side. The physical therapist was in front of the resident. The walker was right in front of her and the legs went up a little bit when she fell . Interview with the rehabilitation manager at 9:06 PM revealed that she in-serviced her staff regarding using gait belts and safe transfers. She did not take any written statements from the staff. The rehabilitation manager stated the staff told her they were using a gait belt. Interview with a nursing assistant at 9:30 PM on 7/23/17 revealed that Resident #1 is alert and oriented. Interview with Resident #1 at 9:45 PM on 7/23/17 revealed that the physical therapy staff was at the head of the bed with her back turned and OT staff was standing in the corner. The resident said that she was sitting pretty good but she was not all the way on the bed. Interview with the OT (occupational therapy) staff at 1:49 PM on 7/24/17 revealed that they did not use a gait belt because it hurt the resident more. During interview with the PT (physical therapist) at 2:04 PM on 7/24/17 she stated that they did not use a gait belt. The one she had with her would not fit. The resident is a large woman. Interview with a nurse on the resident ' s hall at 4:01 Pm on 7/24/17 revealed that the resident was alert and oriented and if the resident said something happened, it ' s true.

Based on record review, observation and staff, resident and physician interview, the facility failed to protect 2 (Residents # 2 & # 7) of 2 sampled residents from abuse. Resident #2, who was cognitively impaired, was witnessed by residents and staff being sexually abused by Resident #1, who was cognitively intact. Resident #7, who was cognitively intact, was verbally abused by Nurse #2. Immediate jeopardy began on 5/11/17 for Resident #2 when he was sexually abused by Resident #1. It was witnessed by NA #1 and NA #1 did not remove Resident # 2 from the situation. Immediate jeopardy was removed on 5/18/17 when an acceptable credible allegation was provided. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) for example #2, Resident #7 and to ensure all staff members are in-serviced and interventions put in place are effective. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. He was assessed as Preadmission Screening Resident Review (PASRR) level II. Resident #2 was discharged to an assisted living facility on 5/12/17. Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] indicated that he had impaired cognition. The Care Area Assessment (CAA) indicated triggered for cognition related to Brief Interview for mental status (BIMS) score of 08/15. [DIAGNOSES REDACTED]. Able to verbalize needs. Had prior placement in group home setting but cannot return. Currently receiving skilled therapy. Displays behaviors which are not of new onset. Has support from family. Resident #2's care plan dated 4/26/17 was reviewed. One of the care plan problems was (name of Resident #2) has impaired cognitive function and impaired thought processes related to MR, Anxiety disorder, cognitive impairment, polysubstance abuse and [MEDICAL CONDITION]. The goal was Resident #2 will be able to communicate basic needs on a daily basis and have minimal risk of injury related to cognitive impairment through the review date. The approaches included to identify self at each interaction, face resident when speaking and make eye contact, reduce any distractions and to try to provide consistent care givers as much as possible in order to decrease confusion. List of abuse investigations since the last survey (March 2017 to present time) was requested from the Administrator. The Administrator provided folders containing written statements from residents and staff. There were 2 incidents were staff and residents were alleging abuse. One of the two incidents was for Resident #2. The staff and residents alleged that Resident #2 was sexually abused by Resident #1. Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His quarterly MDS assessment dated [DATE] indicated that he had intact cognition. Resident #1's nurse's notes were reviewed. The notes dated 5/11/17 at 9:07 PM revealed at approximately 7:15 PM this nurse was called to the resident's smoking area because Resident #1 was touching Resident #2 inappropriately. When I got to the smoking area I noted Resident #1 trying to put his hand back into Resident #2's pants. I stated to Resident #1 that he needed to stop what he was doing right now. Resident #1 then replied I can jerk him off he likes it. I told him he can't do that in the open for all to see. Considering other residents and family members were outside looking. After I started talking to Resident #2 and make sure his penis was in his underwear and not hanging out I realized he may not understand what was going on. At that time Resident #1 says He's a grower not a shower. I told Resident #1 that Resident #2 may not understand and he said I'm going to suck his d--- in his room tonight I'm getting me some d--- honey. I tried to redirect the conversation by asking Resident #1 what was he doing and he had a boyfriend he stated We mad at each other he won't f--- me. An aide brought Resident #2 back into the building and took him to the social worker. A nursing Assistant asked Resident #1 what was he doing and he stated Molesting this little boy. Resident #1 then came inside and said at the nurses station out loud it's nothing you all can do I'm going to get me some of that d--- and my old man upset. We immediately began 1 on 1 care for Resident #1 to monitor his behavior. At 7:20 PM, the administrator and Director of Nursing (DON) were contacted. At 7:30 PM, I called on call physician and he returned the call at 7:45 PM. (Name of physician) ordered for Resident #1 to be sent to the emergency room (ER) to have a psych evaluation. The responsible party (RP) of Resident #1 was contacted and made aware of the new order and expressed that she understood. At 8:00 PM, contacted county Police department and at 8:15 PM (name of Officer) came to the building to do the police report. I explained to him what happened. I also showed him the area the incident happened in as well. At 8:30 PM, we both interviewed Resident #2 and we asked what happened and if he gave Resident #1 permission to touch him on his penis. Resident #2 said that Resident #1 had touched his penis and he told him to stop 3x (times) and Resident #1 did not. That he was not like that (meaning gay) like Resident #1. Resident #1 kept doing it and Resident #2 said that Resident #1 had kissed him 2x before in the mouth. Resident #2 also said he didn't want Resident #1 around him anymore. He wanted the police to tell Resident #1 this as well and that next time he'll testify against him. But right now he didn't want Resident #1 to go to jail. At 8:45 PM we interviewed Resident #1 who said that Resident #2 wanted to be touched and liked it. But he had learned his lesson this time. (Name of Officer) explained to Resident #1 the consequences of his actions and he acknowledged the fact that he understood what the officer was stating to him. At 9:00 PM, nonemergency transport picked up Resident #1 and transported him to the emergency room (ER) for the psych evaluation. Called and gave report to ER at 9:15 PM. Resident #1 left in stable condition. Tried to interview Nurse #1, author of the nurse's notes dated 5/11/17 but not available. Review of the EMS report dated 5/11/17 revealed that a non- emergency transport was dispatched to (the name of facility). The nurse at the facility stated that they had caught Resident #1 performing sexual acts on another resident (Resident #2) and he was transported to the ER for psychiatric evaluation. The report further stated that Resident #1 was able to walk from stretcher to the wheelchair without assistance. Review of the ER notes dated 5/11/17 revealed that Resident #1 presented in ER via EMS from the (name of facility) for psychiatric evaluation. Resident #1 stated that he was caught masturbating another patient (Resident #2) that was mentally disabled. Resident #1 also stated that well, he (Resident #2) told me he liked it until we got caught. The notes revealed that Resident #1 denied suicidal ideation/homicidal ideation or hallucinations. Denies any previous charges/convictions for sexual assault. Resident #1 was diagnosed with [REDACTED]. Review of the Police report dated 5/11/17 revealed Nurse reported that some of the staff had observed a male patient (Resident #1) at the facility masturbating another male patient (Resident #2). Nurse stated that the person (Resident #2) being masturbated did not have the mental capacity to consent to such activity. The report further indicated that the Police and the Nurse interviewed the alleged victim (Resident #2). He stated that the offender (Resident #1) kissed him on the mouth and masturbated him. He indicated that he told the offender (Resident #1) to stop on 3 different occasions but he did not until staff interrupted the incident. The report revealed that while interviewing the victim (Resident #2), he appeared to be cognitively aware of everything that happened and appeared to use normal reasoning skills. The victim (Resident #2) told me and the Nurse that he did not want to pursue charges at this time however he did want me to speak to the offender (Resident #1) and make him aware that if anything like this ever occur again he would pursue charges. The report also revealed that the Police had spoken with the offender (Resident #1) who denied that the victim (Resident #2) ever told him to stop. The written statement from the SW dated 5/11/17 was reviewed. The statement was an interview with Resident #1. The statement indicated that when the SW questioned Resident #1 what happened, he stated that he had asked Resident #2 if he could touch his d--- and he said he could. Resident #1 also indicated that he asked Resident #2 if he was in his right mind and he said he was. Resident #1 then stated that he asked him if he could feel it, and he said he could. SW asked him if he touched Resident #2 and he said yes. SW also revealed that Resident #1 smelled alcohol and had a styro foam cup with him. The cup was empty but smelled of beer. When asked if he was drinking and he replied yes. When he was leaving the office Resident #1 stated that the facility could not stop him from smoking, drinking or doing anything he wanted. The written statement from the SW dated 5/11/17 was reviewed. The statement was an interview with Resident #2. The statement indicated that Resident #2 stated that he was not a gay but he thought that Resident #1 was. He indicated that Resident #1 had told him that he wanted to do him in his b--- h--- and then he kissed him. Resident #2 stated that Resident #1 wanted him as a boyfriend because he was little. He denied Resident #1 touching him. The written statement from the SW dated 5/11/17 was reviewed. The statement was an interview with Resident #8. Resident #8 stated that he was in the smoking area when he saw Resident #1's taking his hands out of top of Resident #2's waistband. The written statement from the SW dated 5/12/17 was reviewed. This statement was from an interview with Resident #11. Resident #11 reported to the SW that Resident #1 and the guy (Resident #2) were out in the smoking area. The resident stated that Resident #1 got in the guy's pants and he said that he was making it hard then they kissed on the mouth. Resident #11 was not available for interview. The written statement from NA #1 dated 5/12/17 was reviewed. The statement revealed that she was in the smoking area when she saw the hands of Resident #1 down in Resident #2's pants. NA #1 indicated that she told them this was not the appropriate area because there were other people out there. She told Resident #1 to stop but he would not stop. She went to get the nurse. The written statement from the SW dated 5/12/17 was reviewed. This statement was an interview with Resident #9. Resident #9 informed the SW that they were all smoking in the smoking area. It just happened that she looked and saw Resident #1's hands down the boy's pants (Resident #2). She yelled at him asking him what he was doing and he replied was playing with the guy's d----. Then Resident #1 yelled saying you b---- mind your own business. NA #1 was there and she went to get the nurse. While the NA was gone, Resident #1 lifted Resident #2's shirt up and was playing with his chest. He asked him for a kiss and the boy gave him a pop kiss on the lips. The written statement from the SW dated 5/12/17 was reviewed. This statement was an interview with Resident #10. Resident #10 stated that they were all smoking in the smoking area when Resident #9 yelled at Resident #1 asking him what the h-- he was doing. Resident #10 turned and saw Resident #1 playing with the guy. Resident #1 stated that he was about to play with the guy's d---. Resident #10 asked Resident #1 if he was serious, it was very disrespect with woman out there. Resident #1 replied b----- mind your own business. Resident #1's doctor's progress notes dated 5/15/17 was reviewed. The progress notes revealed that the Nurse Practitioner had seen Resident #1 following an alleged sexual assault. The notes indicated that Resident #1 was reported to have sexually assaulted another resident (Resident #1). The other resident (Resident #2) was a male who was intellectually challenged. A brief tour of the facility was conducted on 5/16/17 at 11:40 AM. Resident #1, who was cognitively intact, was observed in his room. Patient Care Assistant (PCA) #1 was observed outside of Resident #1's room. At 11:45 AM, PCA #1 was interviewed. She stated that Resident #1 was on 1:1 monitoring because he had grabbed a resident's private area (Resident #2). On 5/16/17 at 1:55 PM, the Social Worker (SW) was interviewed. She stated that she was at the facility when the incident happened. The staff members informed her that Resident #1 had inappropriately touched Resident #2. She interviewed both residents and had written statements. She also called the Administrator. The SW added that when she interviewed Resident #1, he was holding a cup that was empty. The cup smelled of beer. On 5/16/17 at 2:00 PM, the Administrator was interviewed. She stated that she received a call from the facility on 5/11/17 at 7:21 PM informing her of the situation regarding Resident #1 and Resident #2. The Nurse assigned to Resident #1 was no longer employed at the facility. The Police was called and staff and residents were interviewed. The Administrator stated that after the interview with Resident #2 who denied being inappropriately touched by Resident #1 and after talking to the Police, the kissing between Resident #1 and #2 was consensual, so she didn't implement the abuse policy. The Administrator had provided a copy of the timeline of the incident and the written statements from the staff. The timeline included: 1. 7:21 PM, received a call from facility nurse that there was a situation in which Resident #1 had inappropriately touched Resident #2 2. Resident #2 was removed from smoke area and placed on 15 minute checks to ensure there was no emotional distress displayed. 3. Resident #1 was brought inside the facility and placed on 1:1 monitoring. 4. Resident #2 interviewed by the SW at this time. 5. Resident #1 interviewed by SW 6. Follow up interviews with staff and residents present at the time of incident. 7. Physician notified and Police called. New orders obtained to send Resident #1 out for psychiatric evaluation. 8. Resident #1's RP notified at 7:30 PM. Resident #2's guardian notified by Administrator via telephone. Message left to please return call. 9. 8:30 PM, Police into facility and spoke to both residents at different times. Then spoke to Administrator stating that no crime has been committed here and that Resident #2 was very alert and coherent and could explain everything that happened, but didn't want Resident #1 around him anymore. No arrest where made at this time. 10. Resident #1 out of facility via EMS for evaluation. 11. Resident #1 returned to facility 5/12/17 at 10:23 AM from ER with significant other. Resident sat outside in the car and significant other brought paperwork in from the hospital and signed Resident #1 out on leave of absence (LOA). On 5/16/17 at 2:05 PM, Resident #8, who has intact cognition, was interviewed. He stated that he was in the smoking area the evening of 5/11/17 smoking. Several other residents including Resident #9 and #10 were there smoking. He heard Resident #9 screaming, he turned around and saw Resident #1 pulling his hands out of Resident #2's pants. Resident #2 was a young guy who was mentally challenged and he acted as if nothing had happened. A telephone interview was conducted on 5/16/17 at 2:40 PM with Resident #2. He stated that Resident #1 had kissed him on his lips 2-3 times in the past. He indicated that he reported it to the nurse (didn't know name) and the Administrator. He added that he didn't like him kissing him and told him to stop. Resident #2 was unable to remember the incident on 5/11/17 in the smoking area. On 5/16/17 at 3:44 PM, Nursing Aide (NA) #1 was interviewed. She indicated that she had known Resident #2 and he was alert but confused at times. She also stated that she had known Resident #1. His cognition was intact and he was able to walk but preferred to use a wheelchair. NA #1 reported that she was outside smoking with other residents including Resident #1, #8, #9 and #10 the evening of 5/11/17. Resident #2 came and sat beside Resident #1. Few minutes later, she observed Resident #1 put his hands inside the pants of Resident #2. Resident #2 didn't say a word. She didn't hear Resident #1 asking permission from Resident #2 if he could touch him. She told Resident #1 that this was a wrong place for him to do it and he responded you b---- if you didn't like it turn your head away. She then went to get the nurse. On 5/16/17 at 4:25 PM, the smoking area was observed. Resident #1, #8, #9 and #10 were observed smoking in the smoking area. A staff member was also observed. There was no unusual behavior observed. On 5/16/17 at 4:45 PM, Resident #9, who has intact cognition, was interviewed. She stated that she was outside in the smoking area smoking with other residents the evening of 5/11/17. She indicated that Resident #2 came in the door and sat beside Resident #1. Later on, she saw Resident #1 with his hands inside the pants of Resident #2. She yelled at Resident #1 saying what the h-- are you doing to that boy? Resident #1 replied playing with his d----. You b----, mind your own business. The NA who was in the smoking area saw it and she went to get the nurse. Resident #9 indicated that Resident #2 was mentally challenged and he didn't know what Resident #1 was doing to him. On 5/16/17 at 5:00 PM, Resident #10, who has intact cognition, was interviewed. He stated that he was outside in the smoking area smoking the evening of 5/11/17. He saw Resident #2 came in the door and later on he observed Resident #1's hands in Resident #2's pants. When he asked Resident #1, he responded getting ready to play with his d----. Resident #10 stated that he was so mad and wanted to hit him. He indicated that Resident #2 has a mind of a 5 year old. On 5/16/17 at 5:10 PM, Resident #1 was interviewed. He stated that he remembered the incident with Resident #2 in the smoking area. He stated that he was just playing with his d---. He added that it was not a big deal as Resident #2 was okay with it. On 5/1617 at 8:39 PM, the Police called back and was interviewed. He stated that the only information he could share was he handled the case the way the alleged victim wants it to be handled. On 5/17/17 at 1:40 PM, the previous Administrator was interviewed. She stated that nobody had reported to her that Resident #2 had been kissed by Resident #1. On 5/18/17 at 11:30 AM, the physician of Resident #1 and Resident #2 was interviewed. He stated that the facility had called and informed him about Resident #1 kissing Resident #2. He was also informed that the Police was contacted and there was no harm done to Resident #2. He indicated that he came to facility to assess Resident #2. He asked him about the kiss and he acknowledged that Resident #1 had kissed him. He didn't ask him about inappropriate touching because he was not informed by the facility that he was also inappropriately touched by Resident #1. The physician also shared that he went to the assisted living facility where Resident #2 was currently residing to interview him. He asked him again and he remembered about the kissing and he was embarrassed about the situation. He didn't asked him about the inappropriate touching because nobody had told him about it. The physician also indicated that Resident #2 had told him that he liked woman and not man. The physician stated that Resident #2 can make simple decision but not complex decision and he considered giving a consent for fondling was a complex decision to make. A telephone interview on 5/23/17 at 10:15 AM was conducted with NA #1. NA #1 stated that when she observed Resident #1 touching Resident #2 inappropriately, she tried to remove Resident #2 away from Resident #1 but Resident #2 had refused. Then she tried to remove Resident #1 but he locked his wheelchair so she could not move it. So she left the smoking area to get the nurse. The administrator was notified of immediate jeopardy on 5/17/17 at 2:21 PM. Credible Allegation: 1. On 5/11/17 at 7:21pm the Social Services Director notified the Administrator via phone of an event occurring in the smoking area where Resident #1 allegedly touched the penis of Resident #2. Resident #1 and Resident #2 were immediately separated by the Smoking Supervisor and Resident #1 was placed with one on one supervision. Resident #2 was placed on every 15 minute checks by the Charge Nurse with emotional support provided by the Services Director until discharge from the Facility on 5/12/17. Resident #1 and Resident #2 were interviewed separately by the Social Services Director on 5/11/17 immediately following the event and both indicated the event that occurred was consensual in nature when interviewed. The Police were notified immediately by the Charge Nurse and came to the facility at 8:30pm 5/11/17 to interview Resident #1 and Resident #2 During the course of this interview both parties reported a consensual kiss occurred and denied other physical contact. The Police determined and communicated to the Administrator that no crime was committed. Staff and Residents present when the event occurred were interviewed as part of the investigation, on 5/11/17 results of these interviews showed varying descriptions of the event that spanned from observations of a Resident #1 kissing Resident #2 to observations of Resident #1 touching the outside of Resident #2's pants and another that described Resident #1 placing his hands in the pants of Resident #2. The Physician of Resident #1 and Resident #2 was notified by the Administrator on 5/11/17 at 7:30pm. The Administrator attempted to notify the Guardian for Resident #2 via phone message on 5/11/17 at 8:15pm, the message stated that the Administrator needed to discuss the event that occurred at the facility on 5/11/17. The Administrator attempted again to notify the Guardian for Resident #2 at 4:00pm on 5/12/17 prior to his discharge. On 5/18/17 at 1:00pm the Administrator and the Social Services Director made a third attempt to contact the Guardian for Resident #2 and left the same message as previous. Resident #1 is responsible for his own affairs. Resident #1 was transported to the emergency room for Psych and Medical evaluation, where he was diagnosed with [REDACTED]. Resident #1 sat outside in the car while He was signed out of the facility for a leave of absence by his friend on 5/12/17 and returned from the leave of absence on 5/16/17 and one on One Supervision was immediately restarted. One on One Supervision will be discontinued when the Interdisciplinary team agrees it is appropriate based on Psych and Medical evaluations to be completed by 5/23/17. Resident #2 was assessed by the Charge Nurse on 5/11/17 following the event, according to the Charge Nurse this assessment was within normal limits but was not documented in the medical record. The Social Services Director completed a Health Questionnaire and BIMS (Cognitive assessment) with score of 8 on 5/12/17. On 5/12/17 Resident #2 was discharged to an Assisted Living Facility as previously planned prior to this event. 2. Current residents have the potential to be affected by this alleged deficient practice. The Social Services Director, Social Services Assistant, Activities Director, and Nurse Managers conducted audits of current residents with a BIMS score of 8-15. This audit was completed on 5/18/17. This audit include one on one interviews by questioning each resident to determine any other residents who have been approached in an inappropriate way by any other resident or made to feel uncomfortable. For Residents who's BIMS score is below 8 the same audit and interview was conducted with their Responsible Party. No new allegations of abuse or residents who have been approached in an inappropriate way by any other resident or made to feel uncomfortable were identified as a result of these audits completed on 5/18/17. On 5/18/17, the Administrator, Social Services Director, Director Clinical Services and Nurse Managers completed interviews with all facility staff to verify no other unreported allegations of abuse occurred. No new allegations were identified as a result of the interviews conducted by 5/18/17. No facility staff shall return to work until interviews are completed. The Facility's Abuse Prohibition Policy was reviewed by the District Director of Clinical Services, the Director of Nursing and the Administrator and all required components related to F 223 were present. 1. Resident #2 received a planned discharge to an Assisted Living Facility on 5/12/17. Resident #1 remains on One on One Supervision in the Facility until the Interdisciplinary Team agrees to remove based on Psych services and Medical evaluations by 5/23/17. The Administrator and Director of Nursing were immediately re-educated by the District Director of Clinical Services regarding Abuse Prohibition to include the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect 5/17/17 On 5/18/17 facility staff, the Nursing Department, Therapy, Housekeeping, Dietary, Maintenance, Business Office and Administration were re-educated by the Director of Nursing, Nurse Managers, and Staff Development Coordinator regarding; The definition of Abuse: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. Immediate intervention to stop No tolerance for abuse Beginning 5/18/17 no Facility staff including Nursing, Therapy, Housekeeping, Dietary, Maintenance, Business Office and Administration shall work prior to receiving this education. All new employees and any agency will be educated on the above prior to working in resident care area by the Administrator, Director of Nursing or Staff Development Coordinator. Facility Staff will be provided this education at least annually via the Administrator, Director of Nursing or Staff Development Coordinator. This education will be included in the facility's new hire orientation and newly hired Facility Staff will not be permitted to assume their floor responsibilities until they have completed this education The credible allegation was verified on 5/18/17 at 5:00 PM as evidenced by staff interviews on abuse policy and procedures, different types of abuse, what to do if a resident displayed aggressive behaviors and actions to be taken if abuse was observed and/or suspected, reporting and resident assessments. Alert and oriented residents were also interviewed to assess if any other residents were affected. Review of in-service records revealed 142 facility staff (licensed nursing staff, unlicensed nursing staff, administrative staff, activities, social worker) had been in-serviced by 5/18/17 and staff who did not have the in-service will be in-serviced prior to working on floor. Review of list of alert and oriented residents and list of families who were interviewed to assess if any other residents were affected. 2. Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident #7's quarterly MDS assessment dated [DATE] indicated that his cognition was intact and he had no behavior. Review of Resident #7's nurse's notes dated 3/28/17 revealed resident was highly upset with his nurse because he had not had his [MEDICATION NAME] (narcotic pain medication) patch changed yet. He was threatening his nurse's job because she had to prioritize her care for woman who had fallen. When I asked him to calm down, he shouted at me F-you. I asked him why is he swearing at me and he repeated F-you faggot and wanted me to swing at him. I told him I wasn't that stupid. He then said he has a friend coming to visit and he would take care of me. The author of the nurse's notes dated 3/28/17 was Nurse #2 and he was not available for interview. Review of Nurse #2's personnel records revealed that he was terminated on 4/5/17 due to no call no show. List of abuse investigations since the last survey (March 2017 to present time) was requested from the Administrator. The Administrator provided folders containing written statements from residents and staff. There were 2 incidents were staff and residents were alleging abuse. One of the two incidents was for Resident #7. Review of the statement written on 3/28/17 by Nurse #3 revealed at approximately 4:30 PM I was in a room giving a resident medications when a Certified Medication Aide (CMA) came into the room with a look of fear on her face and said I need you now. I went out in the hall and I could hear 2 people arguing and cursing very loudly. When I got over to station 3, Nurse #2 and Resident #7 were in verbal altercation. I tried to stop the verbal altercation and Resident #7 became very angry calling Nurse #2 a faggot and cursing him. Resident #7 jumped at Nurse #2 and 2 Resident Care Assistants (RCA) grabbed him and another RCA was trying to get Nurse #2. This is when Nurse #2 began shouting to Resident #7 hit me M-F---!! over and over. I was unable to stop this from happening and the RCA and the Activity Assistant were able to get Resident #7 to his room. This yelling and cursing between Nurse #2 and Resident #7 lasted probably 5 minutes while I was there. Review of the statement written on 3/29/17 by CMA revealed around 5:30 PM on 3/28/17 I heard a loud altercation coming from around the corner on station 3 between Resident #7 and Nurse #2. Both were cursing and arguing with one another. Resident #7 was threatening Nurse #2. Nurse #2 was telling Resident #7 go ahead and hit me, come on, f-me, f-you. I got Nurse #3 to see if she could help the confrontation. Like I said it was so sudden and off guard there was a lot of shouting and cursing between both individuals. A telephone interview with the previous Administrator was conducted on 5/17/17 at 1:40 PM. She indicated that she remembered the incident with Resident #7 and Nurse #2. She acknowledged that she had read the written statements from the staff members. She revealed that she had interviewed Resident #7 and Nurse #2 and they both denied verbal abuse and so she did not proceed to follow the abuse policy. She also indicated that she did not document her interview with Resident #7 and Nurse #2. An interview with the current Administrator was conducted on 5/17/17 at 1:45 PM. The current Administrator read the 3 written statements from the staff members and stated that this was a verbal abuse. 5/17/17 at 2:05 PM, Resident # 7 was interviewed. He remembered the incident with Nurse # 2. He was very mad at him (Nurse #2). He went to the nurse's station to ask his nurse for his pain medication as it was already late. His nurse was explaining as to why his medication was late

Based on record review, observation and staff, resident and physician interview, it was determined that the facility failed to operationalize abuse policies and procedures in the areas of identification (immediately assessing if other residents could have been affected) and reporting (notifying the state agency and adult protective services) for 2 (Resident #2 & #7) of 2 sampled residents reviewed for abuse. Immediate jeopardy began on 5/11/17 for Resident #2 when other residents were not assessed for potential abuse and the allegation of abuse was not reported to the state agency and adult protective services after Resident #2 was sexually abused by Resident #1. Immediate jeopardy was removed on 5/18/17. An acceptable credible allegation was provided on 5/23/17. The facility remains out at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) for example #2, Resident #7 and to ensure all staff are in-serviced on abuse and the monitoring systems put into place are effective. Findings included: The facility's abuse policy and procedure dated January 2017 was reviewed. The policy under Identification read in part The facility Quality Assurance and Performance Improvement (QAPI) Committee will review available data to identify patterns and trends that may indicate the presence of abuse, neglect, injuries of unknown origin or misappropriate of resident property. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression. The policy under Reporting and Response read in part The facility will report all allegation and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of property to the administrator, State Survey Agency, Law Enforcement officials and adult protective services (where state law provides for jurisdiction in long term care facilities) in accordance with State Law through established procedures. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. He was assessed as Preadmission Screening Resident Review (PASRR) level II. Resident #2 was discharged to an assisted living facility on 5/12/17. Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] indicated that he had impaired cognition. The Care Area Assessment (CAA) indicated triggered for cognition related to Brief Interview for mental status (BIMS) score of 08/15. [DIAGNOSES REDACTED]. Able to verbalize needs. Had prior placement in group home setting but cannot return. Currently receiving skilled therapy. Displays behaviors which are not of new onset. Has support from family. Resident #2's care plan dated 4/26/17 was reviewed. One of the care plan problems was (name of Resident #2) has impaired cognitive function and impaired thought processes related to MR, Anxiety disorder, cognitive impairment, polysubstance abuse and [MEDICAL CONDITION]. The goal was Resident #2 will be able to communicate basic needs on a daily basis and have minimal risk of injury related to cognitive impairment through the review date. The approaches included to identify self at each interaction, face resident when speaking and make eye contact, reduce any distractions and to try to provide consistent care givers as much as possible in order to decrease confusion. List of abuse investigations since the last survey (March 2017 to present time) was requested from the Administrator. The Administrator provided folders containing written statements from residents and staff. There were 2 incidents were staff and residents were alleging abuse. One of the two incidents was for Resident #2. The staff and residents alleged that Resident #2 was sexually abused by Resident #1. Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His quarterly MDS assessment dated [DATE] indicated that he had intact cognition. Resident #1's nurse's notes were reviewed. The notes dated 5/11/17 at 9:07 PM revealed at approximately 7:15 PM this nurse was called to the resident's smoking area because Resident #1 was touching Resident #2 inappropriately. When I got to the smoking area I noted Resident #1 trying to put his hand back into Resident #2's pants. I stated to Resident #1 that he needed to stop what he was doing right now. Resident #1 then replied I can jerk him off he likes it. I told him he can't do that in the open for all to see. Considering other residents and family members were outside looking. After I started talking to Resident #2 and make sure his penis was in his underwear and not hanging out I realized he may not understand what was going on. At that time Resident #1 says He's a grower not a shower. I told Resident #1 that Resident #2 may not understand and he said I'm going to suck his d--- in his room tonight I'm getting me some d--- honey. I tried to redirect the conversation by asking Resident #1 what was he doing and he had a boyfriend he stated We mad at each other he won't f--- me. An aide brought Resident #2 back into the building and took him to the social worker. A nursing Assistant asked Resident #1 what was he doing and he stated Molesting this little boy. Resident #1 then came inside and said at the nurses station out loud it's nothing you all can do I'm going to get me some of that d--- and my old man upset. We immediately began 1 on 1 care for Resident #1 to monitor his behavior. At 7:20 PM, the administrator and Director of Nursing (DON) were contacted. At 7:30 PM, I called on call physician and he returned the call at 7:45 PM. (Name of physician) ordered for Resident #1 to be sent to the emergency room (ER) to have a psych evaluation. The responsible party (RP) of Resident #1 was contacted and made aware of the new order and expressed that she understood. At 8:00 PM, contacted county Police department and at 8:15 PM (name of Officer) came to the building to do the police report. I explained to him what happened. I also showed him the area the incident happened in as well. At 8:30 PM, we both interviewed Resident #2 and we asked what happened and if he gave Resident #1 permission to touch him on his penis. Resident #2 said that Resident #1 had touched his penis and he told him to stop 3x (times) and Resident #1 did not. That he was not like that (meaning gay) like Resident #1. Resident #1 kept doing it and Resident #2 said that Resident #1 had kissed him 2x before in the mouth. Resident #2 also said he didn't want Resident #1 around him anymore. He wanted the police to tell Resident #1 this as well and that next time he'll testify against him. But right now he didn't want Resident #1 to go to jail. At 8:45 PM we interviewed Resident #1 who said that Resident #2 wanted to be touched and liked it. But he had learned his lesson this time. (Name of Officer) explained to Resident #1 the consequences of his actions and he acknowledged the fact that he understood what the officer was stating to him. At 9:00 PM, nonemergency transport picked up Resident #1 and transported him to the emergency room (ER) for the psych evaluation. Called and gave report to ER at 9:15 PM. Resident #1 left in stable condition. Tried to interview Nurse #1, author of the nurse's notes dated 5/11/17 but not available. The written statement from the SW dated 5/11/17 was reviewed. The statement was an interview with Resident #1. The statement indicated that when the SW questioned Resident #1 what happened, he stated that he had asked Resident #2 if he could touch his d--- and he said he could. Resident #1 also indicated that he asked Resident #2 if he was in his right mind and he said he was. Resident #1 then stated that he asked him if he could feel it, and he said he could. SW asked him if he touched Resident #2 and he said yes. The written statement from the SW dated 5/11/17 was reviewed. The statement was an interview with Resident #2. The statement indicated that Resident #2 stated that he was not a gay but he thought that Resident #1 was. He indicated that Resident #1 had told him that he wanted to do him in his b-h--- and then he kissed him. Resident #2 stated that Resident #1 wanted him as a boyfriend because he was little. He denied Resident #1 touching him. The written statement from the SW dated 5/11/17 was reviewed. The statement was an interview with Resident #8. Resident #8 stated that he was in the smoking area when he saw Resident #1's taking his hands out of top of Resident #2's waistband. The written statement from the SW dated 5/12/17 was reviewed. This statement was from an interview with Resident #11. Resident #11 reported to the SW that Resident #1 and the guy (Resident #2) were out in the smoking area. The resident stated that Resident #1 got in the guy's pants and he said that he was making it hard then they kissed on the mouth. Resident #11 was not available for interview. The written statement from NA #1 dated 5/12/17 was reviewed. The statement revealed that she was in the smoking area when she saw the hands of Resident #1 down in Resident #2's pants. NA #1 indicated that she told them this was not the appropriate area because there were other people out there. She told Resident #1 to stop but he would not stop. She went to get the nurse. The written statement from the SW dated 5/12/17 was reviewed. This statement was an interview with Resident #9. Resident #9 informed the SW that they were all smoking in the smoking area. It just happened that she looked and saw Resident #1's hands down the boy's pants (Resident #2). She yelled at him asking him what he was doing and he replied was playing with the guy's d----. Then Resident #1 yelled saying you b----- mind your own business. NA #1 was there and she went to get the nurse. While the NA was gone, Resident #1 lifted Resident #2's shirt up and was playing with his chest. He asked him for a kiss and the boy gave him a pop kiss on the lips. The written statement from the SW dated 5/12/17 was reviewed. This statement was an interview with Resident #10. Resident #10 stated that they were all smoking in the smoking area when Resident #9 yelled at Resident #1 asking him what he was doing. Resident #10 turned and saw Resident #1 playing with the guy. Resident #1 stated that he was about to play with the guy's d---. Resident #10 asked Resident #1 if he was serious, it was very disrespect with woman out there. Resident #1 replied b----- mind your own business. Resident #1's doctor's progress notes dated 5/15/17 was reviewed. The progress notes revealed that the Nurse Practitioner had seen Resident #1 following an alleged sexual assault. The notes indicated that Resident #1 was reported to have sexually assaulted another resident (Resident #1). The other resident (Resident #2) was a male who was intellectually challenged. A brief tour of the facility was conducted on 5/16/17 at 11:40 AM. Resident #1, who was cognitively intact, was observed in his room. Patient Care Assistant (PCA) #1 was observed outside of Resident #1's room. At 11:45 AM, PCA #1 was interviewed. She stated that Resident #1 was on 1:1 monitoring because he had grabbed a resident's private area (Resident #2). On 5/16/17 at 1:55 PM, the Social Worker (SW) was interviewed. She stated that she was at the facility when the incident happened. The staff members informed her that Resident #1 had inappropriately touched Resident #2. She interviewed both residents and had written statements. She also called the Administrator. On 5/16/17 at 2:00 PM, the Administrator was interviewed. She stated that she received a call from the facility on 5/11/17 at 7:21 PM informing her of the situation regarding Resident #1 and Resident #2. The Nurse assigned to Resident #1 was no longer employed at the facility. The Police was called and staff and residents were interviewed. The Administrator stated that after the interview with Resident #2 who denied being inappropriately touched by Resident #1 and after talking to the Police, the kissing between Resident #1 and #2 was consensual, so she didn't implement the facility's abuse policy. The Administrator had provided a copy of the timeline of the 5/11/17 incident and the written statements from the staff. The timeline did not indicate that assessment of other residents was completed to identify other residents who might be affected by the abuse nor the allegation of abuse was reported to the state agency and adult protective services. The timeline included: 1. 7:21 PM, received a call from facility nurse that there was a situation in which Resident #1 had inappropriately touched Resident #2 2. Resident #2 was removed from smoke area and placed on 15 minute checks to ensure there was no emotional distress displayed. 3. Resident #1 was brought inside the facility and placed on 1:1 monitoring. 4. Resident #2 interviewed by the SW at this time. 5. Resident #1 interviewed by SW 6. Follow up interviews with staff and residents present at the time of incident. 7. Physician notified and Police called. New orders obtained to send Resident #1 out for psychiatric evaluation. 8. Resident #1's RP notified at 7:30 PM. Resident #2's guardian notified by Administrator via telephone. Message left to please return call. 9. 8:30 PM, Police into facility and spoke to both residents at different times. Then spoke to Administrator stating that no crime has been committed here and that Resident #2 was very alert and coherent and could explain everything that happened, but didn't want Resident #1 around him anymore. No arrest where made at this time. 10. Resident #1 out of facility via EMS for evaluation. 11. Resident #1 returned to facility 5/12/17 at 10:23 AM from ER with significant other. Resident sat outside in the car and significant other brought paperwork in from the hospital and signed Resident #1 out on leave of absence (LOA). On 5/16/17 at 2:05 PM, Resident #8, who has intact cognition, was interviewed. He stated that he was in the smoking area the evening of 5/11/17 smoking. Several other residents including Resident #9 and #10 were there smoking. He heard Resident #9 screaming, he turned around and saw Resident #1 pulling his hands out of Resident #2's pants. Resident #2 was a young guy who was mentally challenged and he acted as if nothing had happened. A telephone interview was conducted on 5/16/17 at 2:40 PM with Resident #2. He stated that Resident #1 had kissed him on his lips 2-3 times in the past. He indicated that he reported it to the nurse (didn't know name) and the Administrator. He added that he didn't like him kissing him and told him to stop. Resident #2 was unable to remember the incident on 5/11/17 in the smoking area. On 5/16/17 at 3:44 PM, Nursing Aide (NA) #1 was interviewed. She indicated that she had known Resident #2 and he was alert but confused at times. She also stated that she had known Resident #1. His cognition was intact and he was able to walk but preferred to use a wheelchair. NA #1 reported that she was outside smoking with other residents including Resident #1, #8, #9 and #10 the evening of 5/11/17. Resident #2 came and sat beside Resident #1. Few minutes later, she observed Resident #1 put his hands inside the pants of Resident #2. On 5/16/17 at 4:25 PM, the smoking area was observed. Resident #1, #8, #9 and #10 were observed smoking in the smoking area. A staff member was also observed. There was no unusual behavior observed. On 5/16/17 at 4:45 PM, Resident #9, who has intact cognition, was interviewed. She stated that she was outside in the smoking area smoking with other residents the evening of 5/11/17. She indicated that Resident #2 came in the door and sat beside Resident #1. Later on, she saw Resident #1 with his hands inside the pants of Resident #2. She yelled at Resident #1 saying what the h-- are you doing to that boy? Resident #1 replied playing with his d----. You b----, mind your own business. The NA who was in the smoking area saw it and she went to get the nurse. Resident #9 indicated that Resident #2 was mentally challenged and he didn't know what Resident #1 was doing to him. On 5/16/17 at 5:00 PM, Resident #10, who has intact cognition, was interviewed. He stated that he was outside in the smoking area smoking the evening of 5/11/17. He saw Resident #2 came in the door and later on he observed Resident #1's hands in Resident #2's pants. When he asked Resident #1, he responded getting ready to play with his d----. Resident #10 stated that he was so mad and wanted to hit him. He indicated that Resident #2 has a mind of a 5 year old. On 5/16/17 at 5:10 PM, Resident #1 was interviewed. He stated that he remembered the incident with Resident #2 in the smoking area. He stated that he was just playing with his d---. He added that it was not a big deal as Resident #2 was okay with it. On 5/17/17 at 1:40 PM, the previous Administrator was interviewed. She stated that nobody had reported to her that Resident #2 had been kissed by Resident #1. The administrator was notified of immediate jeopardy on 5/17/17 at 2:21 PM. Credible Allegation: 1. On 5/11/17 at 7:21pm the Social Services Director notified the Administrator via phone of an event occurring in the smoking area where Resident #1 allegedly touched the penis of Resident #2. Resident #1 and Resident #2 were immediately separated by the Smoking Supervisor and Resident #1 was placed with one on one supervision. Resident #2 was placed on every 15 minute checks by the Charge Nurse with emotional support provided by the Services Director until discharge from the Facility on 5/12/17. Resident #1 and Resident #2 were interviewed separately by the Social Services Director on 5/11/17 immediately following the event and both indicated the event that occurred was consensual in nature when interviewed. The Police were notified immediately by the Charge Nurse and came to the facility at 8:30pm 5/11/17 to interview Resident #1 and Resident #2 During the course of this interview both parties reported a consensual kiss occurred and denied other physical contact. The Police determined and communicated to the Administrator that no crime was committed. Staff and Residents present when the event occurred were interviewed as part of the investigation, on 5/11/17 results of these interviews showed varying descriptions of the event that spanned from observations of a Resident #1 kissing Resident #2 to observations of Resident #1 touching the outside of Resident #2's pants and another that described Resident #1 placing his hands in the pants of Resident #2. The Physician of Resident #1 and Resident #2 was notified by the Administrator on 5/11/17 at 7:30pm. The Administrator attempted to notify the Guardian for Resident #2 via phone message on 5/11/17 at 8:15pm, the message stated that the Administrator needed to discuss the event that occurred at the facility on 5/11/17. The Administrator attempted again to notify the Guardian for Resident #2 at 4:00pm on 5/12/17 prior to his discharge. On 5/18/17 at 1:00pm the Administrator and the Social Services Director made a third attempt to contact the Guardian for Resident #2 and left the same message as previous. Resident #1 is responsible for his own affairs. Resident #1 was transported to the emergency room for Psych and Medical evaluation, where he was diagnosed with [REDACTED]. Resident #1 sat outside in the car while He was signed out of the facility for a leave of absence by his friend on 5/12/17 and returned from the leave of absence on 5/16/17 and one on One Supervision was immediately restarted. One on One Supervision will be discontinued when the Interdisciplinary team agrees it is appropriate based on Psych and Medical evaluations to be completed by 5/23/17. Resident #2 was assessed by the Charge Nurse on 5/11/17 following the event, according to the Charge Nurse this assessment was within normal limits but was not documented in the medical record. The Social Services Director completed a Health Questionnaire and BIMS (Cognitive assessment) with score of 8 on 5/12/17. On 5/12/17 Resident #2 was discharged to an assisted Living Facility as previously planned prior to this event. On 5/23/17 the Administrator completed a 24 hour report outlining the events occurring on 5/11/17 and will complete a 5 day report with details of the investigation on 5/26/17. On 5/23/17 the Administrator reported the events occurring on 5/11/17 to Adult Protective Services. 2. Current residents have the potential to be affected by this alleged deficient practice. The Social Services Director, Social Services Assistant, Activities Director, and Nurse Managers conducted audits of current residents with a BIMS score of 8-15. This audit was completed on 5/18/17. This audit include one on one interviews by questioning each resident to determine any other residents who have been approached in an inappropriate way by any other resident or made to feel uncomfortable. For Residents who's BIMS score is below 8 the same audit and interview was conducted with their Responsible Party. No new allegations of abuse or residents who have been approached in an inappropriate way by any other resident or made to feel uncomfortable were identified as a result of these audits completed on 5/18/17. On 5/18/17, the Administrator, Social Services Director, Director Clinical Services and Nurse Managers completed interviews with all facility staff to verify no other unreported allegations of abuse occurred. No new allegations were identified as a result of the interviews conducted by 5/18/17. No facility staff shall return to work until interviews are completed. The Facility's Abuse Prohibition Policy was reviewed by the District Director of Clinical Services, the Director of Nursing and the Administrator and all required components related to F 223 were present. 1. Resident #2 received a planned discharge to an Assisted Living Facility on 5/12/17. Resident #1 remains on One on One Supervision in the Facility until the Interdisciplinary Team agrees to remove based on Psych services and Medical evaluations by 5/23/17. The Administrator and Director of Nursing were immediately re-educated by the District Director of Clinical Services regarding Abuse Prohibition to include the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect 5/17/17. On 5/18/17 facility staff, the Nursing Department, Therapy, Housekeeping, Dietary, Maintenance, Business Office and Administration were re-educated by the Director of Nursing, Nurse Managers, and Staff Development Coordinator regarding; The definition of Abuse: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. Immediate intervention to stop No tolerance for abuse Beginning 5/18/17 no Facility staff including Nursing, Therapy, Housekeeping, Dietary, Maintenance, Business Office and Administration shall work prior to receiving this education. All new employees and any agency will be educated on the above prior to working in resident care area by the Administrator, Director of Nursing or Staff Development Coordinator. Facility Staff will be provided this education at least annually via the Administrator, Director of Nursing or Staff Development Coordinator. This education will be included in the facility's new hire orientation and newly hired Facility Staff will not be permitted to assume their floor responsibilities until they have completed this education. The credible allegation was verified on 5/18/17 at 5:00 PM as evidenced by staff interviews on abuse policy and procedures, different types of abuse, what to do if a resident displayed aggressive behaviors and actions to be taken if abuse was observed and/or suspected, reporting and resident assessments. Alert and oriented residents were also interviewed to assess if any other residents were affected. Review of in-service records revealed 142 facility staff (licensed nursing staff, unlicensed nursing staff, administrative staff, activities, social worker) had been in-serviced by 5/18/17 and staff who did not have the in-service will be in-serviced prior to working on floor. Review of list of alert and oriented residents and list of families who were interviewed to assess if any other residents were affected. Review of the 24 hour report to the state agency and a letter that the APS was informed of the incident 5/11/17 with Resident #2 and interview with the Administrator was conducted. 2. Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident #7's quarterly MDS assessment dated [DATE] indicated that his cognition was intact and he had no behavior. Review of Resident #7's nurse's notes dated 3/28/17 revealed resident was highly upset with his nurse because he had not had his [MEDICATION NAME] (narcotic pain medication) patch changed yet. He was threatening his nurse's job because she had to prioritize her care for woman who had fallen. When I asked him to calm down, he shouted at me F-you. I asked him why is he swearing at me and he repeated F-you faggot and wanted me to swing at him. I told him I wasn't that stupid. He then said he has a friend coming to visit and he would take care of me. The author of the nurse's notes dated 3/28/17 was Nurse #2 and he was not available for interview. Review of Nurse #2's personnel records revealed that he was terminated on 4/5/17 due to no call no show. List of abuse investigations since the last survey (March 2017 to present time) was requested from the Administrator. The Administrator provided folders containing written statements from residents and staff. There were 2 incidents were staff and residents were alleging abuse. One of the two incidents was for Resident #7. Review of the statement written on 3/28/17 by Nurse #3 revealed at approximately 4:30 PM I was in a room giving a resident medications when a Certified Medication Aide (CMA) came into the room with a look of fear on her face and said I need you now. I went out in the hall and I could hear 2 people arguing and cursing very loudly. When I got over to station 3, Nurse #2 and Resident #7 were in verbal altercation. I tried to stop the verbal altercation and Resident #7 became very angry calling Nurse #2 a faggot and cursing him. Resident #7 jumped at Nurse #2 and 2 Resident Care Assistants (RCA) grabbed him and another RCA was trying to get Nurse #2. This is when Nurse #2 began shouting to Resident #7 hit me M-F---!! over and over. I was unable to stop this from happening and the RCA and the Activity Assistant was able to get Resident #7 to his room. This yelling and cursing between Nurse #2 and Resident #7 lasted probably 5 minutes while I was there. Review of the statement written on 3/29/17 by CMA revealed around 5:30 PM on 3/28/17 I heard a loud altercation coming from around the corner on station 3 between Resident #7 and Nurse #2. Both were cursing and arguing with one another. Resident #7 was threatening Nurse #2. Nurse #2 was telling Resident #7 go ahead and hit me, come on, f-me, f-you. I got Nurse #3 to see if she could help the confrontation. Like I said it was so sudden and off guard there was a lot of shouting and cursing between both individuals. A telephone interview with the previous Administrator was conducted on 5/17/17 at 1:40 PM. She indicated that she remembered the incident with Resident #7 and Nurse #2. She acknowledged that she had read the written statements from the staff members. She revealed that she had interviewed Resident #7 and Nurse #2 and they both denied verbal abuse and so she did not proceed to follow the facility's abuse policy. She also indicated that she did not document her interview with Resident #7 and Nurse #2. An interview with the current Administrator was conducted on 5/17/17 at 1:45 PM. The current Administrator read the 3 written statements from the staff members and stated that this was a verbal abuse and the facility's abuse policy should have been implemented. She further indicated that she could not find any documentation to indicate that this allegation had been investigated nor reported to the state agency or adult protective services. She also stated that she could not find information to indicate that other residents were assessed to identify other residents who might have been verbally abused. The current Administrator indicated that she started as administrator of the facility on May 2017. On 5/17/17 at 2:05 PM, Resident # 7 was interviewed. He remembered the incident with Nurse # 2. He was very mad at him (Nurse #2). He went to the nurse's station to ask his nurse for his pain medication as it was already late. His nurse was explaining as to why his medication was late and Nurse #2 stepped in. He was so mad and acknowledged that he did scream at his nurse. Then Nurse #2 started screaming at him back. He was also so mad to him (Nurse #2) for stepping in, he was not his nurse. Resident #7 did not remember what Nurse #2 had told him because he was very mad at him. An interview with the Activity Assistant (AA) was conducted on 5/17/17 at 2:13 PM. The AA stated that she was at the nurse's station and heard Resident #7 asking for his medication. The Nurse assigned to Resident #7, responded to him it's only 2 hours late and you are not going to die. Resident #7 went back to his room and asked for a concern form. She went to get a concern form for Resident #7. When she came back she observed Nurse #2 screaming and cursing saying F---, M-F-words several times to Resident #7. The AA indicated that the Director of Nursing (DON) was informed and she requested to write a statement. She stated that the response from the nurse to the resident was inappropriate. An interview with Nurse #3 was conducted on 5/18/17 at 8:00 AM. She stated that she was on the medication cart on the other station passing medications. She could hear the screaming and cussing on station 3. A staff member (CMA) came and told her to come now. When she arrived at station 3, Resident #7 and Nurse #2 were arguing and cursing very loudly. She tried to stop the verbal altercation. Staff members tried to stop both of them, when Nurse #2 began shouting to Resident #7 hit me, hit me m-f-over and over again. The verbal altercation lasted for 5 minutes while she was there. An interview with CMA was conducted on 5/18/17 at 9:04 AM. The CMA indicated that she was on another station working and she could hear a loud altercation from station 3. She went to station 3 and observed Resident #7 and Nurse #2 were cursing at each other. Resident #7 was threatening Nurse #2. Nurse #2 responded to Resident #7 hit me, come on, f-me, f-you. She went to get Nurse #3.

Based on record review, observation and staff, residents and physician interview, the administration failed to oversee and enforce the facility's abuse policy and procedures to ensure 2 of 2 sampled residents (Residents #2 and #7) were free from abuse. Resident #2 was sexually abused by Resident #1. Resident #7 was verbally abused by Nurse #2. Immediate jeopardy began on 5/11/17 for Resident #2 when he was sexually abused by Resident #1. Immediate jeopardy was removed on 5/18/17. An acceptable credible allegation was provided on 5/23/17. The facility remains out at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) for example #2, Resident #7 and to ensure all staff are in-serviced on abuse and the monitoring systems put into place are effective. The findings included: 1. Cross Refer to F223: Based on record review, observation and staff, resident and physician interview, the facility failed to protect 2 (Residents # 2 & # 7) of 2 sampled residents from abuse. Resident #2, who was cognitively impaired, was witnessed by residents and staff, being sexually abused by Resident #1, who was cognitively intact. Resident #7, who was cognitively intact, was verbally abused by Nurse #2. 2. Cross Refer to F226: Based on record review, observation and staff, resident and physician interview, it was determined that the facility failed to operationalize abuse policies and procedures in the areas of identification (immediately assessing if other residents could have been affected) and reporting (notifying the state and adult protective services) for 2 (Resident #2 & #7) of 2 sampled residents reviewed for abuse. The facility Administrator and Director of Nursing were informed of Immediate Jeopardy on 5/17/17 at 2:21 PM. The facility provided a credible allegation of compliance: 1. On 5/11/17 at 7:21pm the Social Services Director notified the Administrator via phone of an event occurring in the smoking area where Resident #1 allegedly touched the penis of Resident #2. Resident #1 and Resident #2 were immediately separated by the Smoking Supervisor and Resident #1 was placed with one on one supervision. Resident #2 was placed on every 15 minute checks by the Charge Nurse with emotional support provided by the Services Director until discharge from the Facility on 5/12/17. Resident #1 and Resident #2 were interviewed separately by the Social Services Director on 5/11/17 immediately following the event and both indicated the event that occurred was consensual in nature when interviewed. The Police were notified immediately by the Charge Nurse and came to the facility at 8:30 pm 5/11/17 to interview Resident #1 and Resident #2 During the course of this interview both parties reported a consensual kiss occurred and denied other physical contact. The Police determined and communicated to the Administrator that no crime was committed. Staff and Residents present when the event occurred were interviewed as part of the investigation, on 5/11/17 results of these interviews showed varying descriptions of the event that spanned from observations of a Resident #1 kissing Resident #2 to observations of Resident #1 touching the outside of Resident #2's pants and another that described Resident #1 placing his hands in the pants of Resident #2. The Physician of Resident #1 and Resident #2 was notified by the Administrator on 5/11/17 at 7:30 pm. The Administrator attempted to notify the Guardian for Resident #2 via phone message on 5/11/17 at 8:15 pm, the message stated that the Administrator needed to discuss an event that occurred at the facility on 5/11/17. The Administrator attempted again to notify the Guardian for Resident #2 at 4:00 pm on 5/12/17 prior to his discharge. On 5/18/17 at 1:00 pm the Administrator and the Social Services Director made a third attempt to contact the Guardian for Resident #2 and left the same message as previous. Resident #1 is responsible for his own affairs. Resident #1 was transported to the emergency room for Psych and Medical evaluation, where he was diagnosed with [REDACTED]. Resident #1 sat outside in the car while he was signed out of the facility for a leave of absence by his friend on 5/12/17 and returned from the leave of absence on 5/16/17 and one on one supervision was immediately restarted. One on One Supervision will be discontinued when the Interdisciplinary team agrees it is appropriate based on Psych and Medical evaluations to be completed by 5/23/17. Resident #2 was assessed by the Charge Nurse on 5/11/17 following the event, according to the Charge Nurse this assessment was within normal limits but was not documented in the medical record. The Social Services Director completed a Health Questionnaire and BIMS (Cognitive assessment) with score of 8 on 5/12/17. On 5/12/17 Resident #2 was discharged to an Assisted Living Facility as previously planned prior to this event. On 5/23/17 the Administrator completed a 24 hour report outlining the events occurring on 5/11/17 and will complete a 5 day report with details of the investigation on 5/26/17. On 5/23/17 the Administrator reported the events occurring on 5/11/17 to Adult Protective Services. 1. Current residents have the potential to be affected by this alleged deficient practice. The Social Services Director, Social Services Assistant, Activities Director, and Nurse Managers conducted audits of current residents with a BIMS score of 8-15. This audit was completed on 5/18/17. This audit include one on one interviews by questioning each resident to determine any other residents who have been approached in an inappropriate way by any other resident or made to feel uncomfortable. For Residents who's BIMS score is below 8 the same audit and interview was conducted with their Responsible Party. No new allegations of abuse or residents who have been approached in an inappropriate way by any other resident or made to feel uncomfortable were identified as a result of these audits completed on 5/18/17. 1. On 5/18/17, the Administrator, Social Services Director, District Director of Clinical Services and the Nurse Managers completed interviews with all facility staff to verify no other unreported allegations of abuse occurred. No new allegations were identified as a result of the interviews conducted by 5/18/17. No facility staff shall return to work until interviews are completed. The Facility's Abuse Prohibition Policy was reviewed by the District Director of Clinical Services, the Director of Nursing and the Administrator and all required components related to F 226 were present. 2. On 5/18/17 the District Director of Clinical Services re-educated the Administrator and the Director of Nursing on the Facility's Policy for Abuse Prohibition , the Elder Justice Act, reporting guidelines for the 24 Hour and 5 Day Reports to the NC Health Care Personnel, and her responsibilities to coordinate an effective investigation by ensuring timely interviews and assessments, reviewing results and findings, and determining interventions according to opportunities identified during the investigation as well as assessment of all other residents that might be affected. 3. On 5/18/16 facility staff, the Nursing Department including Nursing Assistants, Therapy, Housekeeping, Dietary, Maintenance, Business Office and Administration were re-educated by the Director of Nursing, Nurse Managers, and Staff Development Coordinator regarding; 4. The definition of Abuse: 5. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. 6. Immediate intervention to stop 7. No tolerance for abuse 8. Maintaining a professional relationship with residents and families and the Resident's Right to live in the facility free from abuse and neglect. The facility will not tolerate abuse and will follow the policy for Abuse Prohibition to investigate all allegations of abuse or neglect thoroughly 9. The Facility Staff will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the Administrator, State Survey Agency, and law enforcement officials according to the required timeline as follows: If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation; or If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation; 10. In accordance with the Elder Justice Act, the facility will report to law enforcement agencies and to the state agency any reasonable suspicion of a crime against any individual who is a resident of, or receives care from the facility 11. Beginning 5/18/17 no Facility staff including Nursing and Nursing Assistants, Therapy, Housekeeping, Dietary, Maintenance, Business Office and Administration shall work prior to receiving this education. All new employees and any agency will be educated on the above prior to working in resident care area. Facility Staff will be provided this education at least annually via the Director of Nursing or Staff Development Coordinator. This education will be included in the facility's new hire orientation and newly hired Facility Staff will not be permitted to assume their floor responsibilities until they have completed this education. 12. The Administrator and Director of Nursing will complete a root cause analysis by 5/19/17 regarding abuse reporting and investigation within the facility. 13 The Administrator and Director of Nursing will hold weekly staff meetings to review and re-educate Facility staff on Abuse Prohibition. During these meetings the Administrator will reinforce the Resident's Right to remain free from abuse and neglect. 14. It is the responsibility of the Administrator, as the Abuse Coordinator within the facility to ensure Facility staff are trained regarding the policy for abuse prohibition, to ensure staff and residents understand the process and are comfortable reporting allegations of abuse, to investigate allegations of abuse, and to complete timely 24 hour and 5 day reports to the State agency. The Division Director of Clinical Services will provide weekly support and education to the Administrator regarding her responsibilities to Abuse prohibition in the Facility. 15. On 5/18/17 the Administrator and Director of Nursing implemented a new system to monitor the management of abuse allegations by reviewing all events with the Division Director of Clinical Services (DDCS) daily to ensure adherence to the Facility Policy on Abuse Prohibition and conduct a weekly focus call to further review events occurring throughout the week to review completion of investigations and reporting as required. The credible allegation was verified on 5/18/17 at 5:00 PM as evidenced by staff interviews on abuse policy and procedures, different types of abuse, what to do if a resident displayed aggressive behaviors and actions to be taken if abuse was observed and/or suspected, reporting and resident assessments. Alert and oriented residents were also interviewed to assess if any other residents were affected. Review of in-service records revealed 142 facility staff (licensed nursing staff, unlicensed nursing staff, administrative staff, activities, social worker) had been in-serviced by 5/18/17 and staff who did not have the in-service will be in-serviced prior to working on floor. Review of list of alert and oriented residents and list of families who were interviewed to assess if any other residents were affected. Review of the 24 hour report to the state agency and a letter that the APS was informed of the incident 5/11/17 with Resident #2 and interview with the Administrator was conducted.