Every finding on record at Astoria Place Living & Rehab

Based on interview and record review the facility failed to monitor and supervise 1 of 3 residents (R2) reviewed for elopement. This failure resulted in R2, a cognitively impaired resident, identified as being at risk for elopement, exiting the facility unsupervised on [DATE]. R2 was found at a public laundromat unattended and confused.This was identified as an Immediate Jeopardy.V1 (Administrator), V2 (Director of Nursing) and V65 (Regional Director of Operations) were presented with the immediate jeopardy template on [DATE] at 4:00 PM. The immediate jeopardy began on [DATE] when R2 left the building unattended by staff.The facility presented a plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised plan on [DATE]. The survey team accepted the revised abatement plan on [DATE] and notified the facility upon return to the facility on [DATE]. The immediate jeopardy was removed on [DATE]. However, the deficiency remains out of compliance at Level Two until the facility evaluates the effectiveness of the removal plan.Findings Include:R2 is a [AGE] year-old male admitted to the facility the evening of [DATE] with a diagnosis of Trauma, Person Injured in Unspecified Motor Vehicle Accident, Traumatic Subarachnoid Hemorrhage, Left Humerus Fracture, Multiple Fractures of Pelvis & Ribs, Nasal Bone Fracture, Alcoholic Cirrhosis. Type 2 Diabetes Mellitus.R2's hospital records time stamped [DATE], 1:23 PM documented in part, on page 3/70 discharge diagnosis principle problem: Traumatic Brain Injury with New Neurocognitive Deficit, on page 44/70 on [DATE] 5:45 AM R2 had a witnessed fall and on page 42/70 on [DATE], 9:45 PM Patient attempted to elope from unit. Pulled off all telemetry monitoring and dressed in street clothes and getting out of bed. Attempted to reorient and educate patient on importance of staying the night in the hospital due to recent fall and need for neurological monitoring. Patient not able to be redirected.R2's Nursing Admission/readmission Assessment completed on [DATE] at the facility documents in part, R2 neurological/mental status alert to person and place only and does not have the ability to understand and hear information.R2's Nursing admission Summary Progress Note completed [DATE], 19:56 (7:56PM) by V22 (Registered Nurse) documents in part, this resident ambulates with a [NAME] (cane), observed this resident's gait is unsteady and (V3 - R2's Family Member) at bedside and expresses concerns regarding resident current state of health.On [DATE] at 10:47 AM, V3 (R2's Family Member) stated per telephone interview R2 had been in a motor vehicle accident in early [DATE] and during hospitalization had a fall on [DATE]. V3 stated since this fall R2 was suffering with periods of confusion and hallucinations. V3 stated she was told by the hospital that R2 required 24-hour care and could benefit from rehab. V3 stated prior to this R2 was living on his own in his own apartment. V3 stated when she arrived at the facility with R2 on [DATE] she informed the staff about R2's condition (hallucinating, confusion) and told the nurse that R2 was at risk for wandering and falling and needed to have constant supervision. V3 stated R2 was very confused upon admission thinking the nurses were waitresses. V3 stated she told the nurse she is worried about R2 and that R2 thinks he is still working in a restaurant. V3 stated she told the nurse she was worried R2 might try to leave. V3 stated the nurse just said, yeah, yeah, they will take care of it and she felt the nurse was not taking what she was saying seriously.R2's Psychotropic Medication Consent for Anti-Anxiety medication dated [DATE] documents in part R2's behaviors exhibited or history of anxiety, restlessness, and wandering.R2's Baseline Care Plan dated [DATE] documents in part, resident is at risk for elopement related to disorientation and confusion and intervention include but not limited to Apply personal safety alarm and/or Wander Alert per physician's order.Per R2's EHR (Electronic Health Record) Change in Condition date/time notified [DATE], 11:00 AM documented in part, resident noted with altered mental status, confusion and numbness to the left side of the face. Resident observed talking to himself or non-existing people, unable to answer questions when asked; will begin a conversation but began (begin) to babble. Resident noted lying in fowler's position, confused, hallucinating, babbling, complained of blurred vision and body tremors noted. No facial drooping observed. At around 7:30 AM, during round resident was noticed that he was not in his room nor anywhere in the unit. Code yellow was activated, and the staff searched the entire facility and within the vicinity. At around 8:50 AM, resident's daughter called the facility and resident was transported back to the facility around 9:30 AM.On [DATE] at 11:42 AM, V36 (Certified Nursing Assistant) stated she was covering R2 on the morning of [DATE]. V36 stated when conducting her initial rounds between 7:00 -7:15 AM she did not see R2 in his bed. V36 stated she searched the floor and could not find R2, so she reported this to the nurse on duty. V36 stated no one mentioned anything to her about R2 being at risk for elopement and she does not know anything about R2 needing or wearing an adult electronic monitoring safety device.On [DATE] at 9:12 AM, V25 (Receptionist) stated the receptionist position is responsible for keeping track of residents, staff and visitors coming and going in and out of the facility. V25 stated the receptionists are the last line of defense to watch the doors in case a resident tries to leave. V25 stated the morning of [DATE] was a very busy morning because there were extra housekeeping staff from an outside company coming in and out of the main entrance. V25 stated she was aware that R2 had been admitted to the facility but there was no memo about R2 being a potential elopement and the elopement binder had not been updated. V25 stated she did not see R2 leave and she did not know what R2 looked like. V25 stated sometime between 7:30 - 7:50 AM she was notified by a staff on the unit that R2 was missing so V25 announced a Code Yellow overhead to alert staff there was a missing person. V25 stated if R2 was wearing an adult electronic monitoring safety device he would not have been able to leave the facility because the alarm would have gone off immediately and a staff member would have intervened right away.On [DATE] at 4:33 PM, V1 (Administrator) stated the facility goal is to keep the residents safe and to prevent an elopement from occurring. V1 stated if a resident is at risk of elopement, it would be care planned and individualized interventions would be in place and followed. V1 stated that he watched the video footage on [DATE] and R2 was seen walking out of the main entrance of the facility at 7:30 AM. V1 stated the facility had a lot of maintenance crew going in and out of the front entrance. V1 stated R2 was able to walk out of the building because R2 blended in with the maintenance staff. V1 stated the receptionist did not know who R2 was because R2 was a new admission and had just come in the night before. V1 stated the receptionist had not had any interactions with R2 before, so she did not know that he was a resident. V1 stated the staff did a sweep inside and outside the facility but could not find R2. V1 stated V3 was notified around 8:15-8:30 AM that R2 was missing from the facility. V1 stated V3 called the facility back around 8:30 AM and reported that R2 called V3 from a laundromat and R2 was confused and was trying to go back to R2's apartment. V1 stated he asked V33 (Treatment Aide/Former Certified Nursing Assistant Supervisor) to meet V3 at the laundromat. V1 stated R2 was returned to the facility by V3 and placed on the locked nursing unit.On [DATE] at 11:06 AM, V33 (Treatment Aide/Former Certified Nursing Assistant Supervisor) stated on [DATE] while at work he received a phone call from V1 telling him R2 was with V3 and V1 gave V33 an address to go to. V33 stated he took a bus and (transportation service) to the address which was a laundromat around (street names). V33 stated when he arrived, he went inside the laundromat to look for R2 but he was not inside. V33 stated R2 was in V3's car which was parked in front of the laundromat, and they were waiting for V33 to arrive. V33 stated V3 then drove R2 and himself from the laundromat back to the facility which was about a 15-minute drive in the car. On [DATE] at 11:05 AM, V3 stated via telephone interview V3 stated she received a phone call from R2 on [DATE] around 7:15 AM telling her to pick him up. V3 told R2 to press the call button and the nurse would come to help him. V3 stated R2 kept telling her, no, no and then he hung up the phone. V3 stated around 8:00 AM R2 calls V3 back and asks her where are you? Come pick me up. V3 stated R2 said he was at a laundromat. V3 stated she did not believe R2 until R2 found a woman inside the laundromat and asked the women to talk to V3 for him. V3 stated the woman on the phone said, your dad is at a laundromat and does not look like he's in good condition. V3 stated V1 called her and acknowledged that R2 was not in the facility and that they were trying to find R2. V3 stated she gave V1 the address of where R2 was and then she left work and went to the laundromat. V3 stated when she arrived R2 could barely stand up and R2 was confused saying he was trying to go home to get his belongings from his old apartment so he could bring it back to his new place. V3 stated R2 did not have any money or any identification on him. V3 stated R2 reported he walked out of the building and got on a bus (the bus stop is right in front of the building). V3 reported R2's old apartment was not anywhere near where R2 was found. V3 drove to the laundromat, found R2, and eventually met a staff member and then drove all of them back to the facility and arrived between 9:00-9:30 AM.On [DATE] at 10:28 AM, V30 (Nurse Practitioner) stated on [DATE] he was made aware that R2 had eloped from the building earlier that morning and was found somewhere in the community. V30 stated he was asked to assess R2 because V3 (R2's Family Member) felt there was something off about R2. V30 stated when he entered R2's room he was babbling and not fully coherent, he was not making any sense. V30 stated V3 was reporting that R2 was talking to a deceased family member and was confused. V30 stated R2 was observed to be shaking and complaining of some numbness in his face. V30 stated there was a need to send R2 to the hospital due to altered mental status so R2 was sent out via 911. V30 stated he does not know how long R2 was missing in the community, but it is possible that he could have developed these symptoms when he was out of the building and not under care and he could have hurt himself and not received the help or monitoring he needed.Per R2's EHR (Electronic Medical Record) Medical Professional Progress Note dated [DATE], 12:25 documented in part, patient seen today for concern for altered mental status. Patient seen talking out loud, nonsensical at times. (V3) also reports concern that he (R2) states he feels his face is numb and is more shaky. Discussed with nursing staff with plans to send to the ER (Emergency Room) for further evaluation.R2's emergency room Progress Note dated [DATE], 21:40 (9:40 PM) reads, resident admitted with diagnosis of delirium.On [DATE] at 3:53 PM, V22 (Registered Nurse) who was the nurse assigned to R2 upon admission on the evening of [DATE] stated he does not remember R2. Surveyor showed V22 a picture of R2 from R2's EHR (Electronic Health Record) and V22 stated he does not remember or recognize R2. Surveyor & V22 reviewed R2's Nursing admission Assessments completed by V22 and V22 stated he does not remember R2 but based on V22's documentation R2 was alert and orientated to person and place but not time. V22 stated R2 was determined to be at high fall risk due to unsteady gait. V22 read his progress note dated [DATE] and stated V3 had concerns about R2's current state of health but he does not remember anything specific that V3 mentioned. V22 does not remember R2 having an adult electronic monitoring safety device.On [DATE] at 10:07 AM, V26 (Social Services Designee) stated that sometimes new admissions arrive and they may not be showing any signs of wandering or pacing or have a history of elopement, but they may be confused. V26 stated any new admission that arrives at the facility must be closely monitored since the staff do not know them well. V26 stated the 2nd floor where R2 was admitted to is a rehabilitation floor which is busy and unlocked. V26 stated it would be safer for a resident to be put on the locked unit if there is concern that the resident may be confused and try to elope.On [DATE] at 2:04 PM, V29 (Social Service Director) stated the Social Service Department is the one who manages the adult electronic monitoring safety devices. V29 stated if a resident is admitted and their hospital records say that the resident has a history of wandering or elopement then right away the staff would put an adult electronic monitoring safety device on that resident. V29 stated the adult electronic monitoring safety devices used to be kept at the front desk, but they kept getting lost so that is why she now keeps them in her office. V29 stated the Social Service staff do not work after 5:00 PM, so if a resident admits after 5:00 PM and the nurse determines a resident is at risk for elopement then the staff would have to monitor the resident more closely until Social Service staff come in the next morning and can put an adult electronic monitoring safety device on the resident. V29 was not made aware that R2 needed an adult electronic monitoring safety device. V29 reviewed R2's elopement risk care plan dated [DATE] and stated based on R2's care plan, R2 should have had an adult electronic monitoring safety device in place due to his risk for elopement. V29 stated R2 only came in the night before and he was not recognized by anyone. V29 stated if R2 was wearing an adult electronic monitoring safety device an alarm would have sounded when he tried to leave the building and since the wander guard was not on R2 was able to walk right out the front door.On [DATE] at 2:33 PM, V21 (Social Services Designee) stated interim baseline care plans are generated by the initial nursing assessments completed upon admission. V21 stated a resident should have an adult electronic monitoring safety device if they are an elopement risk. V21 stated V29 (Social Service Director) stores the adult electronic monitoring safety devices in her office and therefore V29 is the one who gives them out to residents if they are needed. V21 stated if the resident is not wearing an adult electronic monitoring safety device that is recommended, then this is a big safety risk for the residents because then they can just walk out of the building without anyone knowing about it or being alerted that they left the building. V21 stated if this happens the residents are on the street and then anything could happen to them. V21 stated they could get hurt or injured. V21 asked, What if they do not know how to cross the street? What if they fall? V21 stated that would be a risk to residents' safety and health, and it is the facilities' responsibility to keep the residents safe. V21 stated she assessed R2's cognitive status on [DATE] after he was returned to the facility by conducting a BIMS (Brief Interview for Mental Status) Assessment and R2 scored 7 out of 15 indicating severe cognitive impairment. V21 stated if R2 had an interim care plan for an adult electronic monitoring safety device upon admission then he should have been wearing one. V21 stated R2 not wearing an adult electronic monitoring safety device placed him at a safety risk and if R2 was wearing an adult electronic monitoring safety device he would not have been able to leave the facility because the alarm would have sounded when he tried to leave.On [DATE] at 9:00 AM, V24 (Licensed Practical Nurse) stated she was the nurse working on [DATE] overnight shift. V24 stated she does not remember R2 being identified as being at risk for elopement. V24 stated R2 was not wearing an adult electronic monitoring safety device.On [DATE] at 1:59 PM, V18 (Licensed Practical Nurse) stated if a resident is at risk for elopement, they may wear an adult electronic monitoring safety device and if a resident has an adult electronic monitoring safety device this would be care planned as an intervention. V18 stated Social Services are the ones who determine whether a resident needs an adult electronic monitoring safety device or not and they are the ones who give it to the resident to wear. V18 stated nursing does not have access to an adult electronic monitoring safety device, only Social Services does. V18 stated if a resident was determined to be at risk for elopement and has an intervention in their care plan to wear an adult electronic monitoring safety device but the resident was not given it to wear then there is a risk the resident could leave the facility and no one would know that they left the building. V18 stated there are a lot of risks to the residents if they leave the building unsupervised including safety, injury, health condition. V18 stated a change of condition could happen to a resident when they are unsupervised, and no one would be monitoring them if they were not in the building. V18 stated the residents who live in the building require 24-hour care and it is the staff's responsibility to make sure they are safe at all times.On [DATE] at 3:31 PM, V2 (Director of Nursing) stated the purpose of the adult electronic monitoring safety device is to identify residents at risk for elopement and to give the staff warning if the resident tries to leave the building. V2 stated a resident would be at risk for elopement based on if they already have a history of elopement, have confusion, impaired cognition, not orientated to place, and if they can walk around. V2 stated the adult electronic monitoring safety devices are kept in the Social Service Director's office, but one adult electronic monitoring safety device is always kept at the reception desk in case it is off hours so there is an adult electronic monitoring safety device available to the nurses. V2 stated it is everyone's responsibility to keep the residents safe. V2 stated if a resident leaves the facility without staff supervision this could potentially lead to a fall or injury.On [DATE] at 3:40 PM, V54 (Licensed Practical Nurse) stated he works on the 3-11 shift, and he does not have access to a wander guard if a resident is admitted after 5:00 PM because the wander guard is given out by Social Services.On [DATE] at 4:03 PM, V55 (Receptionist) stated she has been working at the facility for two years and works the 3-11 shift as a receptionist. V55 stated the wander guards are not kept at the front desk.On [DATE] at 11:24 AM, V56 (Admissions Director) stated via telephone interview the facility's corporate referral program does the clinical review of the resident prior to accepting a new resident which includes reviewing the resident's medical history, hospital records and any risk the facility should look at rush as if the resident is an elopement risk. V56 stated if the resident had an elopement attempt while in the hospital or if the resident is confused or cognitively impaired these are red flags that the resident may be an elopement risk. V56 stated if the resident is determined to be at risk for elopement/wandering then the facility would admit the resident to their locked unit. V56 stated this is important so the facility can prevent that resident from eloping from the facility. V56 stated residents are here because they require 24-hour care and it is the facility's responsibility to keep them safe. V56 stated if a person is determined to need an adult electronic monitoring safety device, then the nurse would have to contact Social Services because they are the ones that have them to give out. V56 stated there was no information about R2 being an elopement risk in his admission packet and there is no one from the facility that looks through R2's hospital records in detail prior to admission. V56 stated the facility is dependent on the corporate referral program and the hospital liaison to screen the resident to look through the hospital records and determine if the resident is at risk for elopement or wandering. V56 stated she was not aware of R2 having had an elopement attempt in the hospital and if she had been made aware of this, she would have admitted R2 to the locked unit. V56 stated if there was not a bed available on the locked unit then the facility would not have accepted R2.On [DATE] at 2:23 PM, V61 (Nurse Practitioner) stated she was assigned to R2 but did not meet R2 prior to his transfer to the hospital and being diagnosed with delirium. V61 stated delirium can occur when a resident is exposed to a different environment which can lead to confusion and disorientation. V61 stated if R2 already had an episode of elopement in the hospital then R2 should have been assigned to a room on the locked unit. R61 stated if a resident has a history of wandering with confusion and is ambulatory then there is a high likelihood that resident will try to do it again. V61 stated no one likes a nursing home at the age of 54 so R2 was trying to leave. V61 stated it is all the staff's responsibility to know where the residents are at all times and to keep them safe. V61 stated that is why it is important to accurately assess the residents prior to admission which should include reading the hospital information to make sure staff at the facility has all the required information they need to assess the resident and to make sure there are proper protocols and interventions in place to prevent something like that from happening.On [DATE] at 8:40 AM, V1 stated their video surveillance erases after seven days so he does not have the video footage from [DATE] to show surveyor.Facility provided policy titled, Elopement dated [DATE] documents in part, it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care.Facility provided policy titled, Pass Privilege Policy dated [DATE] documents in part, those without independent community pass privileges can still go out on pass, as long as there is a responsible part or staff member to accompany them.The immediate jeopardy was removed on [DATE] when the facility took the following steps to remove the immediacy:1. Resident (R2) was located at (street names) on [DATE] at 9:00 am by V33 (Treatment Aide/Former Certified Nursing Assistant Supervisor) and V3 (R2's Family Member) in stable condition. He returned to the facility via private car of V3.2. After returning to the facility, V3 stated this behavior is not in line with R2' baseline and requested to be re-evaluated at the hospital. Resident's Nurse Practitioner (V30) ordered to transfer resident (R2) to the hospital for evaluation on [DATE] at 11:10 am. He was transported via ambulance at 12:45pm and admitted at (Local Hospital) with diagnosis of delirium.3. New admitted residents on [DATE] were assessed by Nursing using the Elopement Risk UDA on [DATE] to identify risk for elopement. Assessment will be based on resident and family interviews, nursing report, and hospital documentation to ensure accuracy. New admissions at risk for elopement will have interventions in place to ensure they cannot elope, which can include adult electronic monitoring safety device placement. Residents identified as not being at risk for elopement, but with confusion will continue to be monitored for wandering behaviors as an identifier if they should be added as elopement risk.4. Effective [DATE], the Social Service Team/Designee will review all residents risk for elopement and the community survival skills using the stand-alone Elopement UDA to identify risk for elopement and Community Survival Skills UDA to determine capacity for independent out on pass and assess elopement risk. There are 140 in-house residents. There are 3 residents at risk for elopement as of [DATE]. Residents identified at risk for elopement's care plan were reviewed on [DATE].5. The facility Elopement Binder was updated on [DATE] on each unit and the front lobby which includes the resident photos, the wander alert /expiration date. This binder will be updated weekly on Fridays and as needed for new admission and discharge of resident identified at risk for elopement. The update is completed by SS/Designee and is ongoing.6. Residents identified at risk for elopement with adult electronic monitoring safety device alert system will be monitored for placement which will be documented by nurses in the monitoring tab every shift. The device functionality will be assessed by social services weekly and logged in the elopement risk binder.7. A 1:1 education was conducted for the receptionist who was assigned to monitor the entrance door using the in and out log to ensure no residents leave the facility without staff knowledge. This was completed on [DATE]. Reception will give shift to shift report to inform incoming receptionist/staff any new admissions. All facility receptionists and receptionist covering personnel were in serviced on [DATE] to monitor the entrance door using the in and out log to ensure no residents leave the facility without staff knowledge. This was completed on [DATE].8. An education was conducted by the DON/SSD/Designee of the facility elopement/missing resident policy, and location of wander guards. This education was initiated on [DATE] and is ongoing until staff are educated. New hires and agency staff will be in-serviced as well before the start of their shift.9. All nurses will be inserviced on ensuring all interim care plan interventions are in place as listed on the baseline care plan. SS will monitor to ensure that care plan interventions related to elopement are in place. Inservicing initiated on [DATE] and continuing. New hires and agency staff will be in-serviced as well before the start of their shift.10. Newly admitted residents at risk for elopement will upon admission be added to the elopement list with binders and pictures updated at the nurses station and reception desk. In-services will be performed by ss/designee when there are changes to the elopement risk list.11. Effective [DATE] extra adult electronic monitoring safety devices were placed at the nursing office in the top drawer of ADON desk labeled (Electronic Monitoring Device) and the reception desk in drawer labeled (Electronic Monitoring Device) SS will replace the adult electronic monitoring safety devices if they are utilized to ensure that there is always a replacement available.12. A QA audit tool was generated to monitor new admissions assessment for elopement risk and community survival skills is completed same day of admit and elopement binder (including photos), wander alert device application and monitoring of functionality, and placement of device and elopement behavior is documented in the monitoring tab. This will be conducted 3x/week x12 weeks.13. A QA audit is generated to monitor compliance of the assigned receptionist in monitoring the entrance door using the in/out log. This audit will be conducted 3x/week x12 weeks.14. The Facility Medical Director was informed & approved of the abatement plan on [DATE].15. The trends and results of the QAPI Audit will be discussed in the monthly QAPI meeting until resolution.On [DATE] the surveyor, via observation, interview and record confirmed the implementation of facility's removal plan.On [DATE] - [DATE] observed reception staff monitoring entrance and exit doors by asking residents for Out on Pass papers signed by the nurse prior to leaving the facility and asking visitors and contractors to sign in and out at the reception desk. Did not observe any residents leaving the facility without staff knowledge. Observed at the reception desk and on each nursing unit an Elopement Binder containing an updated list of residents at risk and using wander guards dated [DATE]. Photos of the residents were also included in the binder and were posted by the front reception desk. Observed extra adult electronic monitoring safety devices in the drawer of the reception desk, in the nursing office and the Social Service Director's Office.During interviews on [DATE] and [DATE], Reception staff (V25, V62) and staff who intermittently cover the front desk when reception staff is on break (V56 - Admissions Director, V63 - Human Resource Director) stated they have been in-serviced on the importance of monitoring the entrance door to ensure no resident leaves the facility unauthorized and all residents who leave either have a signed out on pass form or are supervised by a facility staff member. V25 and V62 stated they give shift to shift reports to each other to inform the incoming receptionist of any new admissions or readmissions, and this is also communicated to the interdisciplinary team via email communication.During interviews on [DATE] nursing staff (V8 - RN, V16 - CNA, V64 - CNA, V66 - LPN) stated they received in-servicing on the elopement policy, use of adult electronic monitoring safety devices including and the importance of closely monitoring residents. V8 and V66 stated they were in-serviced on completing elopement risk assessment interim care plans and reviewing them to make sure all interventions listed are in place. V8 and V66 stated adult electronic monitoring safety devices are kept in the Social Service Office, the front desk and in the nursing office and it is nursing responsibility to check the resident's electronic monitoring safety device every shift to make sure they are being worn. All staff able to show surveyor where the Elopement Binder was on the unit and verbally identify those residents who wear wander guards on their unit.On [DATE] reviewed EHR (Electronic Health Records) for residents admitted to the facility between [DATE] - [DATE] and found nursing had completed elopement risk assessments and social service staff had reviewed residents to determine if they are at risk for elopement/wandering and completed community survival skills and elopement risk assessments.Residents who required adult electronic monitoring safety devices had up to date elopement risk assessments and care plans which specified the use of an electronic monitoring safety device. Resident Electronic Health Records who require adult electronic monitoring safety devices had nursing documentation indicating that they were being monitored every shift by nursing and weekly by Social Services.In-service training records were reviewed and completed including to agency nursing staff.

Based on interviews and record reviews, the facility failed to follow orders to continue hospital medications during transition of care for 1 (R3) out of 6 residents reviewed for medications.Findings include: R3's admission Record documents in part an admission date of 7/6/2026. Medical diagnoses include but are not limited to malignant neoplasm of endocervix, severe protein-calorie malnutrition, neoplasm related pain, pulmonary embolism, enterocolitis due to clostridium difficile, and adult failure to thrive. R3's hospital papers (Transfer to External Facility papers) dated 7/6/2026 3:35 PM, documents in part a list of medications to take following discharge from the hospital. These medications include but are not limited to: Acetaminophen (Tylenol) 1000 mg (milligram) by mouth every 8 hours, Apixaban (Eliquis) 5 mg by mouth every 12 hours for pulmonary treatment coverage, and Mirtazapine (Remeron) 15 mg by mouth nightly at bedtime. Per V62's (Receptionist) email, R3 admitted to the facility at 5:45 PM. Documents were scanned and given to Nurse [V31 (Evening Nurse Supervisor)]. V31's progress note dated 7/6/2026 8:59 PM documents in part verifying medications with V53 (Nurse Practitioner). During a telephone interview with V52 (Nurse) on 8/19/2026 at 2:16 PM, V52 recalled R3 admitting to the facility during the evening shift. V52 recalled V23 (R3's Family Member) calling the facility the following day (7/7/2026) to verify that R3's medications were consistent with the ones R3 received at the hospital. V52 recalled the admitting orders missing the Apixaban and Acetaminophen orders. R3's Order Summary Report and Medication Administration Record documents in part that the facility did not order the Apixaban until 7/7/2026. R3 did not receive an evening dose on 7/6/2026. R3's first dose at the facility was at 2:06 PM. Facility did not order Acetaminophen until 7/7/2026. R3 did not receive an evening dose on 7/6/2026 or a morning dose on 7/7/2026. R3's first dose was the one scheduled for 2:00 PM. Facility ordered Mirtazapine on 7/6/2026 but did not start it until 7/7/2026. R3 did not receive a dose at bedtime on 7/6/2026. During a telephone interview with V53 (Nurse Practitioner) on 8/19/2026 at 2:36 PM, V53 stated when a resident admits to the facility, the nurse is to go over all the medications that the resident was on at the hospital with V53. V53 stated it is a case-by-case basis but will continue the medications about 80% of the time during admission. V53 stated does not recall deviating from the hospital orders for R3. V53 stated if [V53] orders to continue all hospital medications, the facility is expected to continue the medication orders as scheduled. V53 stated Apixaban was important to continue because of R3's diagnosis of pulmonary embolism. On 8/20/2026 at 3:00 PM, V31 (Evening Nurse Supervisor) stated receiving the nurse-to-nurse report from the hospital regarding R3. Reviewed V31's Nursing Report Form dated 7/6/2026 with V31. It reads R3 was on Tylenol and on Eliquis for PE (pulmonary embolism). V31 stated using the Transfer to External Facility papers dated 7/6/2026 3:35 PM to go over the hospital orders with V53 (Nurse Practitioner). V31 stated V53 ordered to continue the medications from the hospital. V31 stated V53 did not give any specific orders to hold Apixaban, Acetaminophen, or Mirtazapine. V31 did not know why the medications were not ordered on 7/6/2026 or why the evening doses were not given. Facility's admission and readmission Policy (adopted 5/22/15; last revised 7/3/26) documents in part: It is the policy of this facility to ensure that the facility complies with federal regulations in terms of admission and readmission of resident. Facility staff are to verify orders from the hospital with physician or on-call physician and carry out physician orders. Facility's Physician Orders (adopted 11/10/14; revised 7/8/26) documents in part: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. Upon admission and readmission, the facility will verify transfer orders from the hospital with the resident's attending physician or physician on call. Physician orders will be carried out at a reasonable time.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than 5%. The facility had 2 errors out of a total of 26 medication opportunities resulting in a 7.69% medication error rate.Findings include: R10's admission Report reads diagnoses including but not limited to chronic (congestive) heart failure, hypertensive heart disease with heart failure, and ventricular fibrillation. R10's Care Plan Report documents in part R10's risk for altered cardiovascular status related to recent cardiac arrest, hypertension, atrial fibrillation, and congestive heart failure (initiated 9/01/2020). Intervention includes giving medications as ordered by the doctor (initiated 9/01/2020). R10's Care Plan Report also documents in part R10's risk for nutritional problems due to a history of significant weight loss prior to initial admission, as well as possible medical causes that contributed to a decrease in appetite (initiated 7/09/2026). Intervention includes providing supplements as ordered (initiated 7/09/2026). On 08/18/2026 at 10:50 AM, V8 (Nurse) prepared medications for R10. Medications included Folic Acid, Tamsulosin, Carvedilol, Multivitamin, Vitamin C, Fish Oil, Magnesium Oxide, and Aspirin. R10 swallowed the medications whole at 11:00 AM. V8 stated that completed all R10's morning medications. At 1:27 PM, surveyor reviewed R10's MAR (Medication Administration Record) and Order Summary Report. R10 has an order for Thiamine Hydrochloride 100 MG (milligram) one tablet by mouth one time a day for supplement due during morning medication pass. V8 marked it off as administered on R10's MAR. R10's Medication Admin Audit Report reads that V8 marked it off at 11:03 AM along with the other medications; however, surveyor did not observe this during medication pass observations. At 1:59 PM, R10 stated receiving the medications from the initial medication pass. R10 stated V8 did not administer any additional medications. At 2:00 PM, V8 stated didn't return to R10 for any additional medication administration. Reviewed R10's MAR with V8. V8 stated did not pull Thiamine during morning medication pass. V8 stated did not know it was missed and will administer it to R10. At 2:11 PM, V8 returned to R10's room with medication. V8 apologized and informed R10 that it was Vitamin B (Thiamine) that was missed from the morning. R10's MAR and Medication Admin Audit Report also reads that R10's order for Carvedilol 12.5 MG is to give one tablet every 12 hours. The morning dose is scheduled for 9:00 AM but was not given until 11:00 AM. At 2:05 PM, V8 stated when medications are scheduled for a specific time, nurses have one hour before and one hour after to administer the medications. Facility's Physician Orders policy (adopted 11/10/14; last revised 7/8/26) documents in part: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. Physician orders will be carried out at a reasonable time. Medication orders entered in the POS (Physician Order Sheet) shall be reflected accurately in the MAR (Medication Administration Record). Facility's Medication Pass policy (adopted 1/5/16; last revised 7/7/26) documents in part: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.

Based on interview and record review the facility failed to promote wound healing in one resident (R3); failed to follow their policy to prevent new pressure ulcers from developing in two residents (R1 and R3) and failed to document skin monitoring and/or frequency to observe for skin impairments. This failure resulted in R1 and R3 developing new unstageable pressure ulcers. Findings include: 1. R1 diagnosis include but are not limited to Diabetes, Anemia, Hypertension, Hyperlipidemia, Schizoaffect Disorder, Bilateral Hearing Loss, and has impaired mobility. R1 was transferred to the hospital on [DATE] and did not return to the facility. R1's Wound Assessment Report dated 12/9/25 Left buttock, incontinence associated dermatitis (IAD), partial thickness, acquired in house on 12/8/25, New, 100% epithelial. Cleanse and apply bordered foam daily. R1's Skin Alteration Nursing Evaluation/ dated 12/9/25 notes NEW skin alteration. Left buttock, Other, Length 2.0 x With 1.0, Stage N/A. [This evaluation has no mention of intervention for air mattress.] R1's Wound Assessment Report dated 12/16/25 location: sacrum to buttock, Pressure Ulcer/Injury, unstageable, acquired in house, new, 20% granulation, 80% slough. Cleanse every other day, apply calcium alginate and honey, bordered foam. R1's Progress Notes dated 12/16/25 written by V19, Wound NP, notes the unstageable sacrum to buttock pressure ulcer. States sharp debridement was not performed due to consent for procedure unable to be obtained. Assessment/plan: Unstageable sacrum to buttock is obscured with adherent slough and currently treated with honey. R1's Skin Alteration Nursing Evaluation/ dated 12/22/25 notes sacrum to buttock, 9.0 x 10.0, Unstageable, acquired in house, on 12/16/25. 100% slough. Cleanse every other day, apply calcium alginate with santyl and bordered foam. R1's Skin/Wound Evaluation dated 12/18/2025 documents, in part, an unstageable wound to the sacrum with an onset date of 12/16/2025 with a measurement of Length 8.5 cm Width x 10.00 cm x Depth 0.10 cm. Low Air Loss Mattress on place.repositioning with wedge. R1's Skin Summary Note dated 12/18/2025 documents skin assessment done and noted with multiple arterial ulcers on the feet and new unstageable pressure ulcer of the sacrum as described above. Continue treatment as ordered. Weekly monitoring by wound specialist. Review of R1's Shower/Bathing & Skin Monitoring 12/1/25 – 12/17/25. Response of yes on 12/3/25; 12/7/25; 12/10/25; 12/13/25;12/16/25; and 12/17/25. All other dates are No, except 12/5/25 stated not applicable. [There is no documentation to describe skin condition.] R1's care plan dated 12/31/2025 documents a focus for at risk pressure ulcer development related to a pressure ulcer development related to Braden Score of 9 starting out as a healed MASD (Moisture Associated Skin Damage). #R1's care plan identifies he requires assistance for repositioning and turning in bed and 1 person to partial assist with turning and repositioning while in bed. 2 staff total assist with transfers, may use Mechanical lift. Can not tolerate full bath or shower, prefer sponge bath. [R1's sacral pressure ulcer was first documented on 12/8/25, 24 days prior to care plan changes.] R1's Minimum Data Set Section M dated 10/17/2025 documents R1 is at risk for developing pressure ulcers, number of venous and arterial ulcers present 0, number of stages 1, 2, 3, 4 and unstageable wounds 0. No pressure reducing device for bed is indicated (section M1200b). On 12/8/2025 R1's MDS documents 1 unstageable pressure ulcers, 1 present upon admission/entry or reentry. Pressure reducing device for bed. Section GG identifies R1 requires assistance with hygiene, rolling in bed and is dependent on staff for transfers. [There is a discrepancy in the day the wound was first observed and the day of assessment.] R1's wound care assessment report documented by the wound care nurse practitioner documents a left buttock incontinence associated with dermatitis on 12/8/2025. R1's wound care assessment report documented by the wound care nurse practitioner documents an unstageable wound from sacrum to buttock dated 12/16/2025. R1's Progress notes dated 12/26/25 Noted pressure ulcer to coccyx site worse, large, brown-rusty color unstageable. Had diarrhea. C.diff screening is pending. Assessment plan: ua not suggesting uti, chest x ray not suggesting pna? Pressure ulcer and or diarrhea. C.diff screening result pending. Now on Augmentin. R1's Wound Culture dated 12/30/2025 documents result of ESBL (Escherichia coli) Heavy and Providencia Stuartii- Heavy Growth. R1's progress note dated 12/30/25 Noted to be febrile, temp 101.8 Assessment/Plan: fever: STAT labs, sacrum and chest x-ray, blood cultures x2, sacral wound culture, insert PICC line, start empiric IV Vancomyycin and Ceftriaxone for suspected infection. R1's follow-up question Report dated 12/1/2025 to 12/21/2025 documents, in part, on 12/16/2025 at 9:22 am R1 did take a shower, bath or bed bath. No documentation was found documenting alterations in R1's skin integrity by the Certified Nurse's Assistant, Nurse, or Wound Care Nurse on 12/16/2025. Review of concerns and grievances dated 12/22/25 and 1/2/26 both from R1's family reporting concerns related to R1's wounds. On 2/25/2025 at 3:35 pm, V3 (Director of Nursing) verified the follow-up question report for skin assessment and showers does not document R1's skin integrity. Surveyors requested a policy for Pressure Wound Care and Pressure Wound Prevention and V1 (Administrator), V2 (Director of Nursing), and V3 (Wound Care Coordinator) stated on 2/24/2026 and 2/25/2026 at different times, the facility does not have a policy with the titles of Pressure Wound Care and Pressure Wound Prevention. Surveyor requested documentation of skin integrity observation details and facility unable to provide documentation. On 2/25/25 at 9:54AM V7 (Certified Nurse Assistant-(CNA), stated R1 used a wheelchair and was able to transfer independently in and out of bed; she (V7) performed complete daily skin assessments; R1 required bed care and pull ups and he transitioned from independently transferring to remaining in bed with a gradual decline in condition. V7 said assignments are rotated through care sections weekly, and upon her (V7) returning to R1's section, V7 noticed the presence of a wound. V7 said skin impairments are documented in the electronic record. On 2/25/2026 at 10:26 AM, V8 (Registered Nurse) stated R1 was observed ambulating and by December, I learned he was no longer able to get out of bed; R1 typically showered during the morning shift. V8 said the wound care nurse completes skin assessments, and we notify her immediately of any changes in skin integrity. On 2/25/2026 at 10:51 AM, V9 (Certified Nurse Assistant-(CNA), stated in December R1 could not walk anymore but could still use his call light; she (V9) performs skin assessments daily to monitor for any changes in skin integrity. On 02/25/26 at 11:46am V3 (WCC) stated that she does not have documentation that R3 refused to be placed on an air mattress. Sated R1's skin assessment documented moisture associated skin dermatitis to the sacrum on 12/9/2025. V3 said all nurses may perform skin assessments, but assessments are typically completed when a CNA (Certified Nurse Assistant) reports a skin [NAME]. V3 said skin assessments are done on admission, weekly for four weeks, then monthly and quarterly, unless new changes are reported; new findings are documented as skin observations because they are acquired; the wound care (NP) is notified and performs an assessment. V3 said for high risk residents, interventions such as barrier cream, heel protectors, and turning/repositioning are ordered and documented each shift. On 2/25/2026 at 12:45 pm, V11 (Infection Preventionist) said R1's sacrum wound started as a moisture associated skin damage; R1 began to show signs of drowsy and labs were ordered with results of increased white blood cell count. On 02/25/26 at 3:22pm V2 (Director of Nursing/DON) stated that air mattresses are placed for residents that have been identified to have wounds or if a resident is at risk for skin breakdown. V2 stated that refusal of care should be care planned. V2 said The CNA performs skin checks and documents in the electronic chart. V2 said R1's wound began as moisture associated dermatitis and opened on 12/20 and an air mattress ordered on 12/16, 1 week after identification of a skin impairment. Facility's policy titled Skin Care Regiment and Treatment Formulary revised 07/03/25 documents in part, Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures:. 10. Prevention: c. Use of pressure redistribution mattress. 11. Treatment Protocol: Deep Tissue Injury: Blood-filled blister (intact) keep blister intact. Foam dressing. Relieve pressure Facility's Policy titled Skin Care Integrity and Treatment Formulary dated 7/3/2025 documents, in part, It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Refer any skin breakdown to the skin care team and physician including wound physician/NP for further review and management as indicated. 2. R3's medical diagnoses include but are not limited to malignant neoplasm, essential hypertension, anemia, severe protein calorie malnutrition. R3's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R3's cognition is intact. R3's Braden scale risk scores dated 11/06/25 are an 8, indicating R3 is high risk for skin breakdown. R3 was admitted to the facility on [DATE] with an intact deep tissue injury to R3's sacrum area and skin intact to mid back area. R3's wound assessment dated [DATE] documents in part, Sacrum. Primary Etiology: Pressure Ulcer/Injury. Stage/Severity DTI (Deep Tissue Injury) Wound Status: Present on Admission. Size 6cm (centimeter) x (by) 6cm x 0cm. Wound base 100% intact epithelium with evidence of deeper tissue injury. R3's wound assessment dated [DATE] documents in part, Sacrum. Primary Etiology: Pressure Ulcer/Injury. Stage/Severity DTI (Deep Tissue Injury) Wound Status: Present on Admission. Size 6cm (centimeter) x (by) 6cm x 0cm. Wound base 100% intact epithelium with evidence of deeper tissue injury. Mid back. Primary Etiology: Pressure Ulcer/Injury. Stage/Severity: DTI. Wound Status: New. Size 12cm x 3cm x 0cm. Wound Base: 100% intact epithelium with evidence of deeper tissue injury. R3's wound assessment progress note dated 01/06/26 documents in part, Location: Sacrum. Primary Etiology: Pressure Ulcer/injury. Stage/Severity: Unstageable. Odor Post Cleansing: Malodorous. Size 9cm (centimeter) x (by) 9cm x 0.5cm. Mid back. Primary Etiology: Pressure Ulcer/Injury. Stage/Severity: Unstageable. Wound status: Stalled. Odor Post Cleansing: Malodorous. Size: 16cm x 3 cm x 1cm. wound Base: 100% slough. R3's physician progress note dated 11/12/25 documents in part, Mobility and ADL (Activities of Daily Living) limitations due to debility from esophageal cancer now with need for assistance with personal care and rehab needs:. Risk for skin breakdown r/t (related to) limited mobility: offloading, frequent turns, off load bony prominences, skin checks. R3's wound assessment progress note dated 11/17/25 documents in part, The patient continues on an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus. R3's progress note dated 11/05/25 documents in part, Resident has potential for infection related to: I.V (intravenous line), other.resident will not develop signs and symptoms of infection. assess for signs and symptoms of infection. Initiate proper precautions per facility policy. R3's progress note dated 12/02/25 documents in part, R3 has an actual impairment to skin integrity and is assessed high risk for pressure sore development r/t Braden score 8 and disease process.Apply LAL (Low Air Loss) mattress to bed. Date initiated 12/02/25. Resident is educated regarding importance of offloading and repositioning using supportive surfaces as pillows, wedges and hell protectors. Date initiated 12/17/25. R3's wound culture results with a collection date of 01/06/26 documents in part, Culture Wound: 1. Staphylococcus aureus – MRSA (Methicillin resistant staphylococcus aureus) light growth. 2. Escherichia coli very light growth. On 02/24/26 at 12:30pm V16 (Certified Nursing Assistant) stated that R3 never refused care. V16 stated that R3 was in pain the whole shift and would sometimes ask staff to wait a few minutes before turning him. V16 stated that she would wait a few minutes and then R3 would allow her to take care of him. On 02/24/26 at 1:24pm V4 (Nutritionist) stated that she was informed that R3's wounds were getting worse on 12/18/25. V4 stated that at that time, R3's supplements were increased. On 02/24/26 at 2:08pm V3 (Wound Care Coordinator/WCC) stated that if a resident is admitted with wounds, she orders an air mattress and turning and repositioning. V3 stated that the orders are reflected as interventions on the resident's care plan. V3 stated that R3 acquired pressure wounds in the facility. V3 stated that if a resident refuses care or any interventions, the refusal should be documented and the resident's next of kin should be notified. V3 stated that she offered R3 an air mattress but R3 refused. V3 stated that she did not place an order for an air mattress for R3 and she thinks there is a standing order for an air mattress for everyone. V3 stated that R3 had redness to his sacrum and heels on admission but the areas later opened. V3 stated that R3 was a very high risk for skin breakdown due to R3 being very skinny and malnourished. V3 stated that R3's sacral wound showed signs of infection. On 02/25/26 at 11:46am V3 (WCC) stated that she does not have documentation that R3 refused to be placed on an air mattress. Review of R3's progress notes dated 11/05/25 through 01/08/26 shows one entry of R3 refusing wound care, no other nursing entries of R3 refusing care or refusing air mattress noted. Review of R3's care plans dated 11/05/25 with revision dates of 12/02/25,12/09/25 and 01/06/26show no documentation of refusal of care. On 02/25/26 at 11:30am V6 (Licensed Practical Nurse/LPN) stated that if a resident developed new wounds, the resident would need more interventions. V6 stated that the only way that the staff are aware of a resident's interventions are by looking at the resident's care plan. V6 stated that the staff don't look at the residents' care plans often. On 02/25/26 at 11:55am V10 (Wound Care Nurse) V10 stated that for residents that are at high risk for pressure ulcers, the facility automatically places the resident on a low air loss mattress. V10 stated that R3 refused the low air loss mattress but she did not document R3's refusal. V10 stated that R3 would not refuse wound care dressing changes but sometimes would ask her to come back later. V10 stated that she would change R3's wound dressings early in the morning and he wanted them changed later in the day. V10 stated that R3 wounds started to show signs of infection, and the wounds had an odor. On 02/25/26 at 12:44pm V11 (Infection Preventionist) stated that residents are placed on EBP (Enhanced Barrier Precaution) if they have wounds. V11 stated that EBP requires the use of a gown and gloves when performing direct patient care. V11 stated that the facility does not have to place a physician's order for EBP, but EBP is care planned. V11 stated that when a resident is on EBP staff wear PPE (Personal Protective Equipment) to protect the resident from infection.V11 stated that R3 was sent out to the hospital for abnormal vital signs and was informed that R3's hospital diagnosis was sepsis. V11 stated that she was never informed that R3's wound was showing signs of infection. V11 stated that if she was informed that R3 wound showed signs of infection, she would have reached out to the Infectious Disease Nurse Practitioner (ID NP) to possibly start R3 on antibiotics empirically. On 02/25/26 at 2:27pm V13 (Infectious Disease Nurse Practitioner) stated that she has not seen R3 since 11/19/25. V13 stated usually if wounds are getting worse, the wound care team calls her. V13 stated that she was never informed of R3's wounds worsening or showing signs of infection. On 02/25/26 at 3:21pm V2 (Director of Nursing/DON) stated that air mattresses are placed for residents that have been identified to have wounds or if a resident is at risk for skin breakdown. V2 stated that refusal of care should be care planned. Facility's care plan titled Enhanced Barrier Precaution revised 09/16/25 documents in part, Policy: The facility will use Enhanced Barrier Precautions (EBP) to reduced transmission of multi-drug-resistant organisms in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDROs (multidrug resistant organisms) as well as residents with wounds and/or indwelling medical devices. Procedure: 1. EBP will be used for any resident in the facility: With open wounds whose drainage can be contained by dressing. Has indwelling medical devices. Facility's policy titled Braden Scale revised 06/30/25 documents in part, Policy Statement: It is the policy of this facility to complete the Braden Risk Assessment for all its residents for the following objectives: 1. To be able to assess the resident's potential or risk factors to develop pressure ulcers. 2. To be able to identify each risk factors unique to the resident that can potentially cause for the development of pressure ulcer and properly address them in the resident's care plan interventions. Procedures:. 3. Each risk factor and potential cause should be reviewed individually and addressed in the resident's care plan. 4. Implement interventions per the resident's Braden Score and/or individual risk factors identified as reflected in the care plan. Facility's policy titled Skin Care Regiment and Treatment Formulary revised 07/03/25 documents in part, Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures:. 10. Prevention: c. Use of pressure redistribution mattress. 11. Treatment Protocol: Deep Tissue Injury: Blood-filled blister (intact) keep blister intact. Foam dressing. Relieve pressure.

Based on observation, interview, and record review the facility failed to practice infection control measures during a wound care dressing change on a resident. This failure affected 1 (R2) of 3 residents reviewed for wound care. Findings include:On 2/24/2026 at 10:45 am, V3 (Wound Care Coordinator) began preparing wound care supplies; without performing hand washing or hand sanitizing measures and opening/touching the treatment cart drawers; opened the surgical drape touching with her (V3's) bare hands; touched her glasses and with same hand and began typing on her laptop reading the wound care order; opened another drawer and removed a stack of gauze with her bare hands; and V3 used hand sanitizer and removed other supplies from the cart.On 2/24/2025 at 10:48 am, V3 stated she (V3) should practice handwashing and infection control practices before, between, and after wound care. V3 verified using hand sanitizer after opening the surgical drape and preparing other wound care supplies. V3 stated the purpose of infection control practices such as hand washing/sanitizing is to prevent infection to the wound. On 2/25/2026 at 12:45 pm, V11 (Infection Preventionist) stated for a clean procedure, the nurse should wash his/her hands; gather your equipment; wash your hands again; put on your Protective Personal Equipment; and complete the wound care. V11 stated the outside of the wound care treatment cart is considered dirty; hand hygiene should be done when touching the outside the cart and then opening wound care dressing supplies; and hand hygiene should be performed whether sterile or clean when handling wound care supplies. Facility Policy titled infection control 7/5/2016 revised 6/30/2025 documents, in part, 17: Hand hygiene will be performed by staff and contracted workers before and after direct patient contact and after each situation that necessitates hand hygiene. Alcohol-based hand rubs or hand washing x 20 seconds will be used.

Based on interview and record review, the facility failed to implement their abuse prohibition policy by failing to immediately report an allegation of staff to resident sexual abuse to the abuse the coordinator. The facility also failed to report suspicion of a crime to local law enforcement. These failures affect 1 resident (R1) of 5 reviewed for abuse.Findings include:R1 was admitted to the facility on [DATE] for therapy due to left knee surgery. R1's medical diagnoses include mood disorder, schizoaffective disorder, bipolar disorder, major depressive disorder and generalized anxiety disorder. On 10/23/2025 at 08:16 AM, V3 (Community Case Worker/Social Worker) stated that he worked with R1 before R1 was admitted in the facility as her social worker. V3 stated that R1 was admitted in the facility on the evening of 10/21/2025. During that time V5 (Certified Nursing Assistant) gave her a sponge bath feeling her body and her breast leaning tried to kiss R1, Making pass to go to bed. V3 stated that R1 told V5, No. And V5 backed off. V3 stated that R1 struggles with anxiety and depression. V3 said, R1 is a nervous lady but super honest and lucid. V3 stated that R1 went to the hospital last night (10/22/2025) and went back to facility on the same night. V3 stated that he did not see R1 after admission [DATE]) in the facility, but all information was made known by R1 to him (V3) through text messages.On 10/23/2025 at 10:27 AM, R1 stated that she went to the hospital because somebody sexually molested her. R1 stated that she was given a sponge bath and was touched by towelette in her genital area. R1 described towelette as a disposable wipe. R1 said, He (V5) was wiping my genitals, and he was really digging into them with fingers and stuff with a towelette. And at one point he was kind of wiggling my clitoris. I did not say anything and trying to figure out what was he doing down there. I don't think I was overreacting this was a real thing. R1 stated that it happened the same evening she was admitted (10/21/2025) around 07:00 PM to 08:00 PM after dinner. R1 continued stating that V5 rubbed her body, it's okay at first then V5 started massaging her breast telling her Does it feel good? R1 stated, I said that's enough, and he (V5) stopped. He was bending over the bed kissed me touched everything on my lips tongue entered my mouth. R1 stated that at that point she told V5, What's the matter with you stop it. He (V5) goes oh okay and he stopped. And that's it. R1 said, I felt creepy not good. When I realized what he (V5) was doing to me my heart was beginning to beat fast. R1 stated that she reported it to the female nurse the next morning. R1 cannot recall the nurse saying, My memory sometimes blurry. R1 stated that she went to the hospital, the doctor told her that she was okay. While she was in the hospital, police spoke to her and report was done. On 10/23/2025 at 12:49 PM V5 (Certified Nursing Assistant) stated that he worked and was assigned to R1 on 10/21/2025. According to V5 he did not perform sponge bath or bed bath but changed R1 twice. First around 07:45 PM to 08:00 PM because R1 had been incontinent. V5 stated that he took off or removed hospital blanket that was around R1. R1 needs to be turn facing left and facing right. During turning R1 was struggling with pain that he (V5) needs to be slow. During that time, V5 stated that R1 informed him that she has surgery. V5 stated that after cleaning R1, he put a new brief, changed R1's gown because it was wet on the back and changed the pad on the bed. V5 stated that the second time he performed bedside care was around 10:30 PM before the end of his shift. V5 stated that he changed R1's brief and pad again because it was wet. V5 stated that he used disposable wipes that is provided to the staff/Certified Nursing Assistant for incontinent care. During incontinent care with R1 he cleaned around the perineal area maybe around 1 or 2 times using the wipes and then cleaned the back area or anus or rectum area. V5 denies cleaning R1's breast area, denies asking R1 if she feels good and denies kissing or trying to kiss R1. V5 stated that R1 did not tell her about any concerns during those encounters. V5 said, No protests have been made but she was grimacing pain during turning. On 10/23/2025 at 01:40 PM, V7 (Wound Care Nurse/LPN) stated that during wound assessment of R1 with V18 (Wound Nurse Practitioner) and another wound nurse. She/V7 overheard R1 speaking on the phone talking that a CNA asking her are you feeling good while cleaning her breast. And CNA bent over almost kissed her/R1. After R1 finished her phone conversation, V7 asked R1 where it happened? R1 replied that it happened in the facility. V7 told R1 she must report it to V1 (Administrator). V7 stated that when she asked R1 if she feels uncomfortable? R1 said yes. V7 said that she then reported it to V1 and performed another assessment. The facility's Abuse Initial Report dated 10/22/2025, V7 was the staff who first became aware of the incident. R1 was alleged as a victim. And V5 was alleged as perpetrator. Report allegation reads, R1 reported that while cleaning the resident (R1). Certified Nursing Assistant V5 touched her inappropriately. On 10/24/2025 at 01:20 PM, V13 (Registered Nurse) stated that she was the morning nurse of R1 on 10/22/2025. V13 stated that during endorsement from the night shift nurse, R1 stated that she was assaulted by one of the CNA (Certified Nursing Assistant). V13 said that the report was given around 8:00 AM by V17 (Agency Registered Nurse). V13 stated that she was also informed the second time by V7 (Wound Care Nurse/Licensed Practical Nurse) about the incident. V13 stated that V17 told her that it happened overnight. And it was a male CNA, but there was no male CNA who worked during nightshift. On 10/24/2025 at 02:02 PM, V17 (Agency Registered Nurse) was made aware that during change of shift report with morning nurse it was mentioned that R1 had an incident. V17 stated that three of them, her/V17 with V13 the morning nurse and V15 the night nurse assigned to R1 were talking about the incident at the nurse station. V17 stated R1 was saying that V5 was trying to kiss her and trying to touch her sexually. V17 stated that she did not believe R1 because she is not in her sound mind. And per R1's admission report from the hospital, R1 has Schizophrenia. Although V17 stated that personally she did not spoke to R1 during the whole shift. Per V17, R1 statements can also be true but she knows V5 that is why she does not believe R1's statement. V17 stated that she did not report to V1 abuse coordinator because she did not know that she needs to report the incident. And that she was not assigned to R1 during that time. V17 said, I am sorry about that, I should have reported it. On 10/28/2025 at 08:02 AM, V15 (Licensed Practical Nurse) stated that she was assigned and took care of R1 on 10/22/2025 11:00 PM to 07:00 AM shift. V15 stated that R1 mentioned to her that male CNA (Certified Nursing Assistant) assaulted her. V15 stated that she did not ask R1 about the assault of a male CNA because she was sleepy. V15 stated that allegation of sexual abuse needs to be reported right away to the administrator as the abuse coordinator. V15 said, I should have reported it. V15 stated that she knows that she can call or contact V1 (Administrator) anytime. On 10/23/2025 11:19 AM, V2 (Director of Nursing) stated that regarding incident of R1, it was wound care nurse, either V4 or V7 who notified V1 around 09:00 AM on 10/22/2025. V1 started initial investigation, V9 (Medical Doctor) ordered R1 to transfer to hospital to be check. V5 alleged perpetrator was made aware by R1 that he will be suspended pending investigation.On 10/24/2025 at 02:29 PM, V1 (Administrator) stated that he was informed by V7 (Wound Nurse/Licensed Practical Nurse) the first time. V7 told him that during assessment, R1 reported that CNA touched her inappropriately while cleaning her. V1 stated that R1 told him that when she was getting bath, or clean it felt sexually inappropriate. V1 said, Yes, it falls under definition of sexual abuse. She said it was sexually inappropriate. V1 stated that R1 reported to V7 giving description and gave V5's name. V1 stated facility did not report alleged sexual abuse to the police because R1 refused it. Per V1, hospital reported it, but facility did not. V1 said, They should have reported it to me if they knew about it. Abuse policy dated 06/26/2025:It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. The facility follows federal guidelines dedicated to prevention of abuse and timely thorough investigations of allegations. Sexual abuse is defined as non-consensual contact of any type with a resident. Even if there is capacity to give consent, consent obtained through intimidation, coercion or fear is considered sexual abuse. It includes unwanted touching of the breast or perineal area. A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal or non-verbal cues. A report will be made to the local police department immediately and not exceeding 2 hours after or within 24 hours of the allegation being made, forming suspicion or allegation of sexual abuse.All allegations and/or suspicions of abuse must be reported to the Administrator immediately. Abuse policy incorporate elements of the 1150B of Social Security Act to report reasonable suspicion of crimes. Both abuse policy and 1150B of Social Security Act outlines the procedure on reporting to law enforcement by long term care facility. The facility shall report to law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime (as defined by the law of the applicable political subdivision) against any individual who is a resident of, or is receiving care from, the facility. Per policy example of a crime in all political subdivision (city, township, or village) include sexual abuse.

Based on interview and record review the facility failed to ensure that a resident's medications were documented as administered, as ordered by the physician. This failure affects one resident (R1) out of three residents reviewed for quality of care.Findings include:On 08/12/2025 at 12:30pm V2 (DON/Director of Nursing) presented R1's MARs (medication administration records) to the surveyor, which were reviewed. There were missing entries of nurses' signatures/initials or codes on the MARs for June 2025 (6/1/2025 to 6/30/2025).R1's diagnoses include Dementia, Asthma, Bipolar Disorder, Chronic Diastolic Heart Failure, and Major Depressive Disorder.There were missing entries of nurses' signatures/initials or codes on R1's medication administration record for the following medications, dates, and times:On 06/08/2025 at 6:00am Levothyroxine Sodium (Hormone) 50 mcg (microgram) tablet- Give 1 Tablet by mouth in the morning.On 06/08/2025 at 6:00am Pantoprazole Sodium (Antiulcer) Oral Tablet Delayed Release 40 mg (milligrams)- Give 1 tablet by mouth in the morning.On 06/08/2025 at 6:00am Advair Diskus (Corticosteroid) Aerosol Powder Breath Activated 100-50 mcg/dose-1 inhalation inhale orally every 12 hours.On 8/12/2025 at 1:37pm V4 (ADON (Assistant Director of Nursing)/RN (Registered Nurse) stated the nurses are responsible for administering the medications to the residents. The nurse is to document in the electronic medication administration record that the medication was administered to the resident. V4 stated there are codes the nurses can use on the electronic medication administration record when a resident refuses the medication, or the resident is out of the facility on pass. V4 stated if a there is a blank space on the medication administration record for a scheduled dose of medication to be administered to the resident on a certain date and time in my professional opinion this would indicate that the medication was not administered to the resident.On 8/12/2025 at 3:00pm V2 (DON/Director of Nursing) stated the nurse are responsible for administering the medications to the residents. The nurses are to document on the electronic medication administration record after a medication is administered to the resident. There are codes the nurses can use on the electronic medication record when a resident refuses the medication or if the resident is out on pass from the facility or hospitalized . Reviewed the Facility's Policy titled Medication Pass which documents, 7. After medication is administered to each resident, sign MAR (medication administration record) that it was given.Reviewed facility's Registered Nurse Job Description, which documents, in part, 16. Completes medical records documenting care provided and other information in accordance with nursing policies while maintaining strict confidentiality.

Based on interview and record review, the facility failed to provide pain management in accordance with the resident's comprehensive care plan, the resident's goals for care and preferences. This failure affects one (R1) resident of four residents reviewed for pain in the sample of seven. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: multiple sclerosis, encounter for palliative care, malignant neoplasm of colon, unspecified, unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing. R1's MDS/Minimum Data Set, dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R1 is cognitively intact. R1's physician order set documents in part R1 has an active order for HYDROmorphone HCl (Hydrochloride) Tablet 4 MG (milligrams) Give 1.5 tablet by mouth every 6 hours for Pain since 02/25/2025. R1's physician order set documents in part R1 has an active order for Morphine Sulfate (Concentrate) Solution 20 MG/ML (milliliter), give 0.25 ml sublingually every 1 hours as needed for Pain/difficulty breathing since 02/11/2025. R1's physician order set documents in part R1 has an active order for Morphine Sulfate (Concentrate) Solution 20 MG/ML, give 0.25 ml sublingually every 2 hours as needed for pain/difficulty breathing since 02/11/2025. R1's current care plan (date initiated 12/06/2024) documents in part R1 is at risk for tremors, damage to motor and sensory control centers, damage to motor nerve tracts, damage to sensory tracts, pain, related to the diagnosis of multiple sclerosis. R1 will remain free of complications or discomfort related to Multiple Sclerosis. Interventions include give medication as ordered. Monitor/document for side effects and effectiveness (date Initiated: 12/06/2024). On 05/23/2025, at 10:23 AM, R1 stated that one time the nurses told R1 that the HYDROmorphone HCl (Dilaudid) Tablet was not available. They waited until the hospice nurse came to tell R1 that he had one tablet left. R1 stated that it affected him and it agitates R1 because the pain medication helps R1 feel less pain. On 5/23/2025, at 10:31 AM, V4 (Certified Nursing Assistant) stated He (R1) does have pain. He pulls the light for that every time he calls. I'll call the nurse and the nurse will go see him. On 05/23/2025, at 10:41 AM, V5 (Registered Nurse) stated that R1 has multiple sclerosis (MS) and has a lot of pain issues. On 05/27/2025, at 9:42 AM, V6 (Licensed Practical Nurse) stated that she doesn't work too often with R1. V6 stated that R1 would not feel alright if he didn't receive his scheduled Dilaudid medication. Sometimes if he is sleeping at 12:00 PM, V6 will return at 1:00 PM. V6 will give R1 the Dilaudid because R1 will tell V6 that he is in pain. V6 stated that the emergency medication box is located on the second floor. V6 stated that she is not sure if Dilaudid is available in the emergency medication box. V6 stated that she gave the Morphine PRN (as needed) pain medication in the morning. V6 did not offer it to R1 at 12:00 PM because V6 stated that she was expecting the Dilaudid to be delivered during her shift. V6 stated that she didn't check if there was Dilaudid in the emergency medication box because the medication was pending to be delivered. V6 stated that pain management is important because it is important to make sure the resident is not feeling pain and do whatever we can to manage his pain. On 5/27/25, at 2:51 PM, V3 (Assistant Director of Nursing) stated that the nurses on the floor should be refilling/reordering medications when there is 8 tablets/capsules left. V3 stated that means it is time to reorder. V3 stated for residents that are under hospice care, usually the hospice doctor provides the prescriptions. V3 stated that for R1's Dilaudid and Morphine medication refill prescriptions, the nurse on duty should be reaching out to the hospice provider to notify that they have 8 tablets left. V3 stated the hospice nurse will take care of refilling the medication through the pharmacy that the hospice company uses. The pharmacy will deliver that medication to the facility. V3 stated that purpose of a PRN (as needed) pain medication, is to address the patient's breakthrough pain, or if the resident does not have routine pain medication. If they ask for pain medication, that's when they give it. V3 stated that if the scheduled pain medication is not available then the nurses should offer it. V3 stated that R1's conditions which may cause R1 to have pain is malignancy cancer, unspecified fracture, and multiple sclerosis. V3 stated that it is important to administer pain medication to a resident experiencing pain because if not, it may affect their quality of life. On 05/27/2025, at 3:51 PM, V8 (Hospice Registered Nurse) stated that V8 visited R1 on 04/29/2025. V8 called the pharmacy to refill the Dilaudid medication. V8 stated that he was informed by the nurse on duty that R1 had three more tablets. V8 stated that this was around 3:00 PM. V8 stated that if the pharmacy does not deliver it the same day, then they will deliver it the next morning. V8 stated that the nursing staff did not notify V8 that R1 was running low on Dilaudid prior to 04/29/2025. V8 stated if the nurses call the hospice 24-hour service line, on the weekend or on Monday, then it can be refilled. V8 stated that if the Dilaudid medication is not available, then the Morphine can be offered. V8 stated that R1 has multiple sclerosis and generalized chronic constant pain and missing a scheduled pain medication can affect him and make him have more pain and agitation. V8 stated that V8 saw R1 several times already. R1 informed him that R1 missed some Dilaudid doses because staff didn't wake him up during night. V8 stated that sometimes R1 would call V8 at night. V8 stated that he informed V2 (Director of Nursing) and that is why there is an order for R1 to be awaken at night to be given the scheduled pain. On 05/28/2025, at 1:47 PM, via telephone V9 (Registered Nurse) stated that she worked the night shift on 4/29/25, going to 4/30/25, in the morning. V9 stated that they were waiting for pharmacy to deliver R1's Dilaudid medication. V9 stated that she administered Morphine to R1. V9 stated I told R1 that he didn't have the Dilaudid. R1 had another option for pain relief. R1 said yes I will take that. V9 stated I gave the Morphine to R1 twice that shift. V9 stated that she endorsed it to the next shift. V9 stated that she is aware that Dilaudid is available in the emergency medication box. V9 stated that she didn't have access to it since V9 works through agency. V9 stated I believe nobody had access that night. V9 stated that she endorsed to the morning nurse, that they are waiting for hospice to deliver Dilaudid and to just give R1 liquid Morphine until it gets here. V9 stated that R1 told V9 that the morphine helped him. V9 stated that she mistakenly documented that she administered the Dilaudid to R1 and she is sorry for that. V9 stated I just clicked it, but I'm sorry I shouldn't have documented it if I didn't administer it. R1's controlled substance record for HYDROmorphone HCl (Dilaudid) tablet medications documents in part 04/29 at 6:00PM amount remaining is 0 (zero). R1's controlled substance record for HYDROmorphone HCl (Dilaudid) tablet medications documents in part dated received 04/30, quantity received 60. 04/30 at 6:00 PM amount remaining is 58.5. R1's medication administration note dated 04/30/2025 1:00 PM documents HYDROmorphone HCl Tablet 4 MG (milligrams), give 1.5 tablet by mouth every 6 hours for Pain on order, awaiting from pharmacy. R1's April 2025 medication administration record documents in part R1 did not receive scheduled HYDROmorphone HCl (Dilaudid) medication order on 04/30/2025 at 12:00PM. R1's April 2025 medication administration record documents in part R1 received Morphine Sulfate (Concentrate) Solution 20 MG/ML, 0.25 ml sublingually on 04/30/2025 at 08:42 AM. Reviewed list of medications in the emergency box stock and it documents that HYDROmorphone HCl Tablet 2 MG (milligrams) max (maximum) 4 tablets available. Facility document dated 01/30/2025, titled pain documents in part it is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. Facility document not dated titled resident rights for people in long-term care facilities documents in part you have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based upon observation, interview, and record review the facility failed to follow facility polices and procedures, failed to ensure that residents are assessed for signs/symptoms of pain, failed to obtain physician orders, failed to follow physician orders, and failed to ensure that physician orders are transcribed on the MAR (Medication Administration Record). The facility also failed to administer pain medication timely to three of four residents (R1,R2, R4) reviewed for pain. These failures resulted in R2 crying due to experiencing excruciating pain. Findings include: 1. R2 was admitted on [DATE] (9 months ago) with cervical radiculopathy (pinched or irritated nerve in the neck causing pain radiating into the chest or arm). R2's (7/12/24) care plan states resident is at risk for pain related to cervical radiculitis, interventions: monitor and record/report to Nurse any signs/symptoms of non-verbal pain. Resident will be able to tell you how much pain is experienced and tell you what increases or alleviates pain. Administer pain medication per request. R2's (April 2025) POS (Physician Order Sheets) exclude pain medication. R2's (2/7/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 4/16/25 at 2:05pm, surveyor inquired about concerns at the facility R2 stated I (R2) have debilitating RA (Rheumatoid Arthritis) that's in my hands and shoulders [R2's fingers were notably misaligned]. I have tried on multiple occasions to get them (facility staff) to prescribe me lidocaine patches because I've been on them for years. I can't get them here and I've sat here in excruciating pain, on a scale of 1 to 10 it's been 20. Surveyor inquired if R2 has prescribed pain medication R2 responded I should but no one's giving me one. There are times when the pain is so horrific, I will cry out for hours. Surveyor inquired about R2's current pain level R2 replied Right now, it's only about a 5. Surveyor inquired if R2 receives Tylenol R2 stated It doesn't do diddly, so I don't take it. It's like putting a bandaid on a sliced wound. Surveyor inquired if facility staff assess R2's pain level every shift R2 responded Oh, h*** no, they're (staff) very incompetent here (facility) in many respects. On 4/16/25 at 2:29pm, V8 (Registered Nurse) affirmed that she's assigned to R2. Surveyor inquired if a Lidocaine patch is prescribed for R2 V8 stated I'm looking through the orders, no I (V8) don't see any Lidocaine patch. Surveyor inquired if R2 is prescribed pain medication V8 responded No, no pain medication. Surveyor inquired why R2's physician orders exclude pain medication if she has pain related to RA V8 replied I'm gonna have to follow-up with the doctor for that. Surveyor inquired if R2's pain is assessed every shift V8 stated Yeah, I'm doing pain assessments on her. Surveyor inquired about R2's pain assessment conducted today V8 accessed R2's EMR (Electronic Medical Record) and responded, Today at 1:46, it was zero. Surveyor advised that R2 is currently experiencing pain and returned to the resident's room (with V8). Surveyor inquired if R2 reported that her pain level was zero today R2 replied That's not true, nobody's ever asked me about it and V8 failed to request R2's pain level at this time. Surveyor inquired why R2's pain was rated zero today (per EMR) V8 stated That was at 1:46am (over 12 hours ago), I haven't documented for my shift. I was gonna document it at 2:30 (7.5 hours after V8's shift started). R2's (4/16/25) dayshift (7am-3pm) pain assessment (documented by V8) states 0 however this assessment was entered after surveyor record review/interview and clearly incongruent with actual findings. On 4/17/25 at 11:29am, V2 (Director of Nursing) stated We got orders for (R2) for the lidocaine patch. R2's (April 2025) MAR affirms that 4% Lidocaine patch orders were received (the following day); start date 4/17/25. R2's Lidocaine patch was administered on 4/17/25 at 8am (roughly 17.5 hours after V8 was made aware of R2's reported pain) and 4% Lidocaine patches are (over the counter) facility floor stock therefore readily available. 2. R4's diagnoses include dementia, chronic peptic ulcer, and encounter for palliative care. R4's (3/17/25) care plan states resident is at risk for pain. R4's (3/20/25) BIMS determined that resident is rarely/never understood and altered level of consciousness is continuously present. R4's POS includes (3/17/25) pain assessment every shift. Acetaminophen (Analgesic) 650mg (milligrams) every 4 hours as needed for pain (pain scale 1-3). (3/19/25) Hydromorphone (Narcotic) 4mg tablet give 0.25ml (milliliters) every 2 hours as needed for moderate pain. R4's (March 2025) monitoring record affirms pain assessments were not documented on (dayshift) 3/21, 3/23, 3/25, (evenings) 3/21, 3/28 and (nights) 3/17, the entries are blank. On 4/15/25 at 2:27pm, R4 was observed lying in bed in a fetal position. R4 was noted to be grimacing and both hands were grasping the right shin. R4's right foot appeared severely bruised (dark purple) and notably edematous. Surveyor inquired if R4 was in pain however R4 did not respond. On 4/15/25 at 2:29pm, V4 (LPN/Licensed Practical Nurse) affirmed that she was assigned to R4. Surveyor inquired about R4's cognitive and functional status V4 stated He's bed bound, alert x1, and Yugoslavian speaking. Surveyor inquired how staff communicate with R4 V4 responded We have a service posted the language help desk, then we have a staff (V5/CNA-Certified Nursing Assistant) 5 days a week in the morning. Surveyor inquired if R4 injured his right foot V4 replied He came like this, he's here for 1 or 2 weeks [R4 was admitted on [DATE], roughly 1 month ago]. V4 subsequently assessed R4's right foot (as requested) and stated, Looks swollen, it's maybe looks like +4, we elevate with the pillow. Surveyor inquired if R4's foot also appeared bruised V4 responded Yeah, discolored. When V4 touched R4's right foot he jerked it away from V4 and placed it over the edge of the mattress (out of reach). Surveyor inquired if R4 has pain medication prescribed V4 replied He has Acetaminophen and Hydromorphone. Surveyor inquired if R4 received pain medication today V4 stated Hydromorphone was not recently taken. Surveyor inquired if R4 received Acetaminophen today V4 responded Not given today. During the assessment, V4 failed to utilize the language help desk and/or staff to determine R4's pain level. On 4/15/25 at 2:35pm, surveyor inquired what language R4 speaks V5 (CNA) stated Bosnian and affirmed that she's able to communicate with R4. V5 inquired if R4 was experiencing pain however received no verbal response and he was motioning towards his ears. Surveyor inquired if R4 is hard of hearing V5 responded He has a little bit hearing problem. V5 inquired (again) in a louder voice if R4 was experiencing pain R4 raised both hands in the air, shrugged his shoulders and appeared perplexed as if he didn't understand what was asked and/or didn't hear the question. Surveyor inquired if R4's foot appeared bruised V5 responded Probably, but like a little bit swollen however failed to determine R4's pain level. On 4/15/25 at 2:45pm, surveyor inquired when R4 was last medicated for pain V4 reviewed the EMR (Electronic Medical Records) and stated, Hydromorphone he never got, 3/21/25 was the Acetaminophen (several weeks ago). R4's (4/15/25) MAR affirms at 11:24pm (roughly 9 hours after V4's assessment) R4 received Acetaminophen 650mg for pain rated 4 however Acetaminophen was prescribed for pain scale 1-3 [Hydromorphone should have been administered]. 3. R1's diagnoses include dislocation of right hip, pain in left leg, and sciatica right side. R1 was discharged from the facility on 4/10/25. R1's (3/20/25) care plan affirms resident is at risk for pain, intervention: provide analgesic as ordered. R1's POS includes (3/20/25) Pain assessment every shift. (3/24/25) Lidocaine Patch 4% apply to right hip in the morning for pain. R1's (2025) monitoring record affirms pain assessments were not documented on 3/22, 3/26, 3/27, and 4/6 (dayshift). R1's MAR affirms the prescribed Lidocaine Patch was marked UV (Unavailable) on 4/5/25. On 4/21/25 at 3:16pm, surveyor inquired what UV indicates on the MAR V10 (Registered Nurse) replied I believe it's unavailable. The (2/28/25) resident counsel concern/response form includes the following: residents state they are having to wait a long time when requesting pain medication, in-service done however the (undated) pain medication administration in-service/training sign in sheet includes only 9 staff signatures. The pain policy (revised 1/30/25) states it is the policy to ensure that all residents are assessed for pain in every situation where there is a potential for pain. For pain complaints and for situations/incidents that might result to pain, the nursing staff may document it in any part of the resident's medical record that may include Nurses notes, incident report, medication record, etc. Upon admission, the nurse will assess resident for pain. For those identified with pain upon admission/readmission assessment, an order for pain medication will be obtained from the physician. Pain medication ordered will be administered to the resident as soon as possible. The physician orders policy (revised 8/16/24) states the facility shall ensure to follow physician orders as it is written in the POS.

Based upon interview and record review the facility failed to follow policy procedures, failed to ensure that floor stock medication was available, failed to ensure that floor stock medication was transcribed on the MAR (Medication Administration Record), failed to ensure that prescribed medication was transcribed correctly, and/or failed to administer medication as ordered for four of four residents (R1, R2, R3, R4) reviewed for medication administration. Findings include: 1. R1's diagnoses include dislocation of right hip, pain in left leg, and sciatica right side. R1 was discharged from the facility on 4/10/25. R1's (3/20/25) care plan includes risk for pain, intervention: provide analgesic as ordered. R1's (3/24/25) POS (Physician Order Sheets) includes Lidocaine Patch 4% apply to right hip in the morning for pain. On 4/15/25 at 3:11pm, V6 (Registered Nurse) affirmed that the 4% lidocaine patch is a facility house stock (over the counter) medication. On 4/16/25 at 2:46pm, surveyor inquired about the facility (house stock) 4% Lidocaine patch availability V7 (Central Supply) stated I order every Monday and the supply comes on Friday. There's some occasions where the supplier doesn't have them and their on backorder. So, we (facility) take petty cash, go to (Drug Store) and buy the patches so there's always patches all the time available. R1's MAR affirms the prescribed Lidocaine Patch was marked UV (Unavailable) on 4/5/25. On 4/21/25 at 3:16pm, surveyor inquired what UV indicates on the MAR V10 (Registered Nurse) replied I believe it's unavailable. 2. R2's diagnoses include type II diabetes mellitus. R2's (7/12/24) care plan includes diabetes mellitus, interventions: diabetes medication as ordered by doctor. R2's (9/8/24) POS includes Glargine (Insulin) 15 units at bedtime. R2's (2/7/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 4/16/25 at 2:05pm, surveyor inquired if R2's insulin is administered as ordered R2 stated Not to me and my blood sugars are poorly controlled. The Nurses give me insulin sometimes and sometimes they don't. R2's (March 2025) MAR does not document R2's Glargine insulin was administered on 3/8/25, the entry is blank. 3. R3's diagnoses include age related nuclear cataracts, osteoarthritis and neuropathy. R3's (4/8/15) care plan states resident is at risk for pain administer analgesia as per orders. R3's (4/4/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 4/15/25 at 2:54pm, surveyor inquired about concerns with medication administration R3 stated I (R3) requested a medication patch, she (Nurse) looked at my page and said you have nothing on the order for a pain patch. She gave me my (oral) medication but not the eye drops. I asked her about the eye drops, she said I don't have your eye drops. R3's POS includes Latanoprost 0.005% 1 drop both eyes at bedtime for glaucoma (start date: 2/17/25). (4/9/25) Lidocaine patch 4% apply to affected skin every 12 hours as needed for pain. R3's (February 2025) MAR affirms Latanoprost administration was not documented on 2/17/25, the entry is blank. R3's (April 2025) MAR excludes the prescribed Lidocaine patch. On 4/17/25 at 3:08pm, surveyor inquired about the requirements for entering physician orders V9 (ADON/Assistant Director of Nursing) stated It automatically populates to the MAR when entered under POS and should be entered by the pharmacy. Surveyor inquired if R3's (April 2025) MAR includes the 4% Lidocaine patch (prescribed 4/9/25) V9 stated No, I don't see it here. Usually, we (staff) put in the POS and the pharmacy give us (staff) a reminder for the 4% to be entered because it's a floor stock and affirmed that facility staff are required to enter the 4% Lidocaine patch orders on the MAR. 4. R4's diagnoses include dementia and encounter for palliative care. R4's (3/17/25) care plan states resident is at risk for pain related to dementia. R4's (3/20/25) BIMS determined that resident is rarely/never understood and altered level of consciousness is continuously present. R4's (3/19/25) POS includes Hydromorphone (Narcotic) 4mg (milligram) tablet give 0.25ml (milliliters) every 2 hours as needed for moderate pain and Hydromorphone 4mg tablet give 0.5ml every 2 hours as needed for severe pain. On 4/17/25 at 2:54pm, surveyor inquired about concerns with R4's Hydromorphone orders V9 (ADON) stated Hydromorphone 4 milligrams, oh I think it's a tablet and uh the dispensation is dispense as liquid. On 4/21/25 at 2:36pm, surveyor inquired if medication tablets are dispensed in milliliters V11 (Medical Director) responded No. The Physician Orders policy (revised 8/16/24) states it is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. Medication orders entered in the POS shall be reflected accurately in the MAR.

Based on interviews and record review, the facility failed to ensure the safety of one resident (R3) as two Certified Nurse Assistants prepared to transfer resident from chair to bed. This failure resulted in R3 falling and sustaining a laceration to the forehead requiring hospitalization and stitches. Findings include: R3 is [AGE] year old with diagnosis including but not limited to: history of falling, presence of artificial right hip joint, other osteoporosis and fracture of unspecified part of right femur. During investigation on 3/24/25 at 12:53 PM, R3 was observed lying in bed with a scar on her forehead. On 3/24/25 at 12:53 PM, V7 (CNA/ Certified Nurse Assistant) said that R3 had fallen from her geri-chair (geriatric chair) while she (V7) and V6 (CNA) were preparing to transfer R3 to her bed. V7 said, V6 (CNA) and I were working together to transfer her (R3) because she is a total care patient. R3 was sitting up in her chair by the bed and I went to go and get the mechanical lift. V6 was standing on the other side of the bed at that time when R3 leaned forward and fell . I (V7) could not try to catch her (R3) because I was too far from her. On 3/24/25 at 12:55 PM, V6 (CNA) said that she (V6) was on the side of the bed when R3 fell and could not reach her (R3) in enough time to stop her from falling from the chair. At that time, V6 pointed to the side of R3's bed near the window and said that this is where she (V6) was standing during R3's fall. V6 then pointed to the position where R3 was sitting at the time of her fall, which was at the foot of R3's bed. Surveyor asked if R3 was reclined or sitting up in the geri chair at the time of her fall. On 3/24/25 at 12:55 PM, V6 (CNA) said that at the time of R3's fall, R3's chair was not reclined, yet in an upward position. Surveyor asked if a staff member should be standing close to R3 in preparation to transfer R3 from her geri chair to the bed. On 3/24/25 at 1:18 PM, V5 (RN/ Registered Nurse) said, R3 has poor trunk support and usually leans from side to side in the geri (geriatric) chair. R3 also sometimes slides in the chair and is unable to sit up straight. It is unsafe for her (R3), which is why she is usually reclined in her geri chair. If a staff member was with R3, the fall may have been prevented. On 3/24/2025 at 2:30 PM, V8 (Restorative Nurse) said, R3 has a tendency to slouch and slide in the chair because she has poor trunk control. Upon inquiry of the process of transferring from bed to chair, V8 said, One person should be with R3 and applying the slings or guiding the patient, the other CNA is controlling the lift. Once the patient is in the sling during the transfer, one CNA is guiding the patient and the other CNA is maneuvering the machine. Surveyor asked if was safe for R3 to sit upward in a geri chair alone. V8 said that if a CNA (Certified Nurse Assistant) was standing near R3 prior to the transfer, it would decrease the chances of her falling due to R3's poor trunk control. On 3/26/25 at 3:15 PM, V14 (CNA) said that during a patient transfer to bed, a CNA should be within arms reach of the patient for safety and to prevent the patient from falling. Surveyor asked if it would be easier for a patient to lean forward in a geriatric chair if the chair is not reclined. On 3/27/25 at 12:55 PM, V12 (NP/ Nurse Practitioner) said, a patient with poor trunk control can definitely sit up and lean forward in a geri- chair depending on how weak or strong the patient is. Surveyor asked if a fall with head injury may be detrimental to a geriatric patient. On 3/27/25 at 12:55 PM, V12 (NP) said, Sure, yes it can. R3's Care plan documents, R3 uses reclining wheelchair for proper body alignment, comfort and positioning due to poor trunk control; R3 is at high risk for falls; staff instructed to use tactile cueing, holding on R3's shoulder when R3 is seated on geri chair during showers days, to lower risk of R3 rocking forward. Section GG- Functional Abilities assessment documents, R3 is dependent on staff for chair to bed transfers. Facility Incident Report dated 3/4/25 documents, R3 had an observed fall with injury in resident's room; CNA reported to the Nurse on duty that R3 leaned forward and fell on the floor; CNA was unable to reach R3 to stop her from falling; R3 was taken to the hospital and returned to the facility with ten sutures on the right frontal head. R3's Hospital visit summary dated 3/4/25 documents, diagnosis: Fall, injury of head and facial laceration. Facility policy titled Mechanical lift transfers documents, there will always be two staff to assist the resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface.

Based on observation, interview, and record review the facility failed to ensure prepared foods stored in the walk-in cooler were properly dated, labeled and discarded on the use by date. These failures have the potential to affect 154 residents in the facility who are receive an oral diet. Findings Include: On 11/19/24 at 9:08 AM during the initial kitchen tour in the kitchen with V23 (Cook), there was a food cart with trays of prepared foods such as ham sandwich, vanilla pudding, chocolate pudding, cups of fruits, and pitchers of lemonade. The prepared foods on the tray had no labels when they were prepared. The plastic cover covering the food cart had no label. V23 called V22 (Dietary Aide) and entered the main cooler. V22 stated that the plastic cover should have a date labeled when they were made to know when the food should be discarded. Surveyor and V22 also found a bag of opened grated parmesan cheese with the label that reads prepared date 11/9/24 and used by 11/16/24 (no manufacturer's expiration date noted). V22 stated prepared date is the same as opened date on the label. There was also a tray of pie crust inside a clear bag with no label. On 11/19/24 at 11:38 AM, interviewed V24 (Dietary Manager) and stated, We keep everything for 7 days after opening 7 days we throw it out. Dry goods after opening good for 6 months. If it says used by, we wait for few more days. If it's not in the box and no expiration date, we go by the used by date. All prepared foods should be labeled and dated. They are good for 7 days. We discard on the 7th day. If prepared foods are in the cart, the cart should be covered with plastic cover and labeled and dated whatever day it was prepared. The facility's Receiving policy dated 10/19 documents in part: All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. The facility's roster dated 11/19/24 documents 156 residents residing in the facility with 2 residents who are NPO (Nothing by Mouth).

Based on observation, interview and record review the facility failed to follow their infection prevention and control policy by failing to don proper personal protective equipment, failing to handle soiled linen properly and failing to perform hand hygiene after handling soiled linen. These failures have the potential to affect all 45 residents residing on the one residental floor at the facility. Findings include: On 11/19/24 at 11:45 AM, there was orange signage for Enhanced Barrier Precautions (EBP) posted on the outside of R77's door. On 11/19/24 at 11:47 AM, V12 (Certified Nursing Assistant) viewed the orange signage for Enhanced Barrier Precautions posted outside R77's room and stated that sign tells V12 that R77 is on Enhanced Barrier Precautions which means that when V12 goes into R77's room to provide direct resident care V12 wears a gown and gloves. V12 stated if V12 is only going into the room to drop something off such as R77's food tray and V12 is not going to touch the resident then V12 only has to use hand sanitizing solution before and after entering the room, no gown or gloves are required. V12 stated if R77 was on contact isolation, then there would be a different type of sign posted outside R77's room and then anytime V12 enters R77's room V12 would have to put on a gown, and gloves whether V12 is providing direct care or not. On 11/19/24 at 12:10 PM, V13 (Certified Nursing Assistant) stated V13 reads the infection control signs posted outside the resident's rooms to see what type of isolation the resident is on. V13 stated R77 is on Enhanced Barrier Precautions. V13 stated when V13 is doing any activities of daily living requiring V13 to touch R77, then V13 puts on gloves and a gown but if V13 is only entering the room to deliver R77's meal tray or is not going to touch R77 then V13 does not need to put on any personal protective equipment, only hand hygiene before and after entering the room. On 11/19/24 at 12:27 PM, V13 entered R77's room carrying R77's lunch tray. V13 did not have on a gown or gloves. On 11/19/24 at 12:47 PM, V4 (Infection Preventionist Nurse) stated R77 is on Contact Isolation precautions for Extended-Spectrum Beta-Lactamases (ESBL) in wound. V4 viewed the orange Enhanced Barrier Precaution sign posted outside R77's room and stated that is not the correct sign. It should be the Contact Isolation Precautions sign. V4 stated V4 has confirmed with wound care that R77 is still having draining from R77's wound despite completing course of antibiotics and that R77's wound was re-cultured to make sure the ESBL is gone. V4 stated the results of the culture is not back yet and therefore R77 is still on Contact Isolation precautions until the wound cultures results get back. V4 stated staff should be wearing a gown and gloves anytime they are entering R77's room. V4 stated if the staff is not wearing the appropriate PPE the potential problem is the infection can spread to other residents. R77's diagnoses inlcude Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Other Specified Symptoms And Signs Involving The Circulatory And Respiratory Systems, Chronic Embolism And Thrombosis Of Right Femoral Vein, Vascular Dementia, Moderate, With Other Behavioral Disturbance, Chronic Systolic (Congestive) Heart Failure, Vitamin D Deficiency, Dysphagia, Insomnia, Morbid (Severe) Obesity Due To Excess Calories, Aphasia Following Cerebral Infarction, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Type 2 Diabetes Mellitus, Hypertension, Diabetes Mellitus Due To Underlying Condition With Diabetic Neuropathy, Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition, Major Depressive Disorder, Recurrent, Moderate, Cellulitis. R77's Order Summary Report dated 11/08/24 documents in part, Isolation-Contact precautions. Reason for isolation: ESBL in wound. R77's Lab Results Report collected 11/05/24, report date 11/08/24 documents in part, wound positive for ESBL. R77's progress note in electronic health record (EHR) dated 11/08/24, 11:20 documents in part, (R77) wound culture positive for ESBL. R77's infection control care plan dated 11/08/24 documents in part, (R77) is on contact isolation related to positive ESBL to back wound with interventions including to maintain contact isolation precautions in accordance with Centers for Disease Control (CDC) guidelines. The facility policy titled Infection Prevention and Control dated 07/31/24 documents, 1.) A sign will be provided outside the room for residents on transmission-based precaution indicating the type of the precaution (Contact, Droplet, or EBP). 2.) Hand hygiene will be performed by staff before and after direct patient contact and after each situation that necessitates hand hygiene. Alcohol-based hand rubs or hand washing x 20 seconds will be used. 3.) Standard Precaution - based on principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membrane may contain transmissible infectious agents. Infection prevention practices include hand hygiene, use of gloves, gown, or mask depending on anticipated exposure, and safe injection practices. 4.) Contact Precaution - intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment and use of gown and gloves is necessary prior to room entry. U.S. Department of Health and Human Services Center for Disease Control and Prevention sign titled, Contact Precautions documents in part, Providers and Staff Must Also: 1.) Put on gloves before room entry. Discard gloves before room exit. 2.) Put on gown before room entry. Discard gown before room exit. 45110 On 11/19/24 at 11:01 AM surveyor observed V12 [Certified Nurse Assistant] walking down the hallway and passes the nursing station holding soiled linen hanging down with yellow, brownish stains next to her uniform with bare hands and went into the soiled utility room. V12 came immediately out of the soiled utility room and entered the clean supply room and came out with an under brief and towel in her hands. On 11/19/24 at 11:02 AM, V12 stated I removed soiled linen from a resident's bed that had urinated on the sheets and took the linen into the soiled utility room. Then I went into the clean supply room for an under brief and towel. I did not wash my hands I was rushing and forgot. I was supposed to place the soiled linen in a plastic bag, soon as I removed them from the bed and washed my hands. I should not have walked down the hallway with the soiled linen, due to infection control. I will go a wash my hands now. On 11/20/24 at 2:00 PM, V2 [Director of Nursing] stated, My expectation for handling soiled linen is when the linen is removed from the bed, the nursing staff should immediately place the linen into a plastic bag, then take the back to the soiled utility room. Then staff then should immediately wash their hands to prevent the spread of infection and or cross contamination between the soiled linen and clean linen from one resident to another. On 11/22/24 at 110:59 AM, V2 [Director of Nursing] via email said, the facility does not have policy for nursing staff handling linen. Policy: Infection Prevention and Control dated 7/31/24. Standard precautions Based on principle that all blood, body fluids, secretions, excretions, may contain transmissible infectious agents. Infection prevention practices include hand hygiene, use of gloves, gown, mask.

Based on observation, interview, and record review, the facility failed to properly date opened multi-dose respiratory inhalers and nasal spray, failed to store unopened multi-dose eye drop solution and discard expired multi dose medications for 6 residents (R38, R58, R75, R103, R111, R125) from 3 of 6 medication carts reviewed for medication storage and labeling. Findings include: R38's admission record showed admitted on [DATE] with diagnoses including Type 2 diabetes mellitus with unspecified diabetic retinopathy, Primary open-angle glaucoma bilateral, Age-related nuclear cataract bilateral. R58's admission record showed admitted on [DATE] with diagnoses including Diabetes mellitus, Legal blindness, Chronic obstructive pulmonary disease, Essential (primary) hypertension. R75's admission record showed admitted on [DATE] with diagnoses including Other sequelae of nontraumatic intracerebral hemorrhage, Thyrotoxicosis, Essential (primary) Chronic obstructive pulmonary disease. R103's admission record showed admitted on [DATE] with diagnoses inlcuding Spondylosis without myelopathy or radiculopathy lumbar region, Essential (primary) hypertension, Chronic obstructive pulmonary disease. R111's admission record showed admitted on [DATE] with diagnoses including Type 2 diabetes mellitus, Epilepsy, Personal history of Covid-19, Chronic diastolic (congestive) heart failure, Essential (primary) hypertension. R125'a admission record showed admitted on [DATE] with diagnoses including Displaced fracture of base of neck of right femur, Osteonecrosis due to previous trauma right femur, Paroxysmal atrial fibrillation, Chronic diastolic (congestive) heart failure, Nonrheumatic mitral (valve) stenosis, Essential (primary) hypertension. On [DATE] at 11:05 AM A Medication cart was inspected with V7 (Registered Nurse / RN), found R38's Latanoprost ophthalmic solution sealed / unopen inside the medication cart. Pharmacy label indicated refrigerate unopened, store opened at room temperature. Discard after 6 weeks. V7 said unopen Latanoprost eyedrops should be refrigerated. At 11:17 AM A Medication cart was inspected V8 (Licensed Practical Nurse / LPN) and found the following inside the medication cart: 1. R58's Latanoprost ophthalmic solution sealed / unopen. Pharmacy label indicated Refrigerate unopened, store opened at room temperature. Discard after 6 weeks. 2. R58's Latanoprost ophthalmic solution date opened [DATE]. Pharmacy label indicated Refrigerate unopened, store opened at room temperature. Discard after 6 weeks. V8 stated medication should have been discarded 6 weeks after opening. 3. R75's Symbicort inhaler date opened [DATE]. Pharmacy label indicated Discard within 3 months after opening. V8 said it should have been discarded in June. 4. R103's Symbicort inhaler opened, no open date. Pharmacy label indicated Discard within 3 months after opening. 5. R111's Fluticasone 50mcg nasal spray opened with no open date. 6. R125's Albuterol Sulfate Inhaler opened with no open date. Pharmacy label indicated Discard 12 months after removal from pouch. V8 said medication should have an open date once opened to know when to discard. She said medication has an expiration don't want to give expired meds. Stated Latanoprost ophthalmic solution should be refrigerated when not opened. On [DATE] At 10:43am V2 (Director of Nursing / DON) has been working in the facility for almost 3 years. She said nurses are expected to date when medication is opened including inhaler, nasal spray, etc. Medications should be labeled and dated once opened so there is awareness when to dispose the medication. V2 said if medication is used when it should have been discarded It will affect the effectivity of the medication. She said Latanoprost eyedrop should be kept in fridge when not in use. Could potentially affect the potency of the medication if not stored properly. She said if expired medication was not discarded could potentially use the medication and have an adverse reaction to the resident. R38's physician order summary (POS) report dated [DATE] showed an active order for Latanoprost solution 0.005% instill 1 drop in both eyes at bedtime for glaucoma. R58's POS report dated [DATE] showed active order for Latanoprost ophthalmic emulsion 0.005% instill 1 drop in both eyes at bedtime. R75's POS report dated [DATE] showed active order for Symbicort inhalation Aerosol ,d+[DATE].5mcg (micrograms)/act (actuator) 1 puff inhale orally two times a day for SOB (shortness of breath) / wheezing. R103's POS report dated [DATE] showed active order for Symbicort inhalation Aerosol ,d+[DATE].5mcg/act 2 inhalation inhale orally every 12 hours for asthma rinse mouth after every application. R111's POS report dated [DATE] showed active order for Fluticasone Propionate nasal suspension 50mcg 1 spray in each nostril two times a day for treatment. R125's POS report dated [DATE] showed active order for Albuterol Sulfate HFA Inhalation Aerosol solution 108mcg/act 1 puff inhale orally one time a day for SOB / Chronic obstructive lung disease. Facility medication storage, labelling and disposal policy dated [DATE] documented in part: It is the facility's policy to comply with federal regulations in storage, labeling and disposal of medications. Medications will be stored safely under appropriate environmental controls. Follow pharmacy recommendation as to when the medication should be discarded after opening.

Based on observations, interviews, and record reviews, the facility failed to follow R95 and R110's care plans by not administering the ordered oxygen flow rates, label R40's oxygen tubing, store R86's oxygen tubing while not in use and have oxygen signage for R399 for five out of a total sample of 31 residents. Findings include: R40's Admission Record documents in part a primary diagnosis of chronic respiratory failure with hypoxia (low oxygen content in the blood). R40's Order Summary Report documents in part orders to change oxygen tubing every night shift every [Sunday] for infection control (active 10/03/2024) and oxygen continuous 2 [liters per minute] via nasal cannula every shift (active 10/03/2024). On 11/19/2024 at 11:18 AM, R40 was sitting in the common/dining room reading. R40 received 2 liters of oxygen via nasal cannula. The nasal cannula was not labeled and R40 did not recall the last time staff changed it. On 11/20/2024 at 10:42 AM, V2 (Director of Nursing) stated the nasal cannula should be changed weekly or as needed. V2 stated whoever changes the nasal cannula should also label it. Reviewed facility's Oxygen Therapy and Administration policy, last revised on 8/16/2024. Under Procedure, it documents in part: Date your equipment. 47304 The findings include: R86's admission record showed admitted on 1/4/2021 with diagnoses not limited to Chronic respiratory failure with hypoxia, Other emphysema, Generalized anxiety disorder, Other specified symptoms and signs involving the circulatory and respiratory systems, Personal history of covid-19, Chronic obstructive pulmonary disease. R399's admission record showed admitted on 11/13/2024 with diagnoses not limited to Other specified chronic obstructive pulmonary disease, Other pericardial effusion, Unspecified right bundle-branch block , Generalized anxiety disorder, Solitary pulmonary nodule, Acute respiratory failure with hypoxia, Bronchiectasis, Unspecified atrial flutter, Single subsegmental thrombotic pulmonary embolism without acute cor pulmonale, Paroxysmal atrial fibrillation. On 11/19/24 at 10:17 AM Observed R86 sitting on the side of the bed, alert, and oriented x 3, verbally responsive, with oxygen tank and Oxygen tubing hanging on it, not stored properly. R86 said he is using oxygen at 3L/min as needed. He uses it almost daily. On 11/19/24 at 10:38AM Observed R399 lying in bed, alert and verbally responsive. With oxygen inhalation via nasal cannula at 4Lmin. No oxygen signage by the door entrance. V6 (Licensed Practical Nurse / LPN) requested by R399's doorway and stated there should have a signage for oxygen in use by the room entrance / door. On 11/20/24 At 10:43am V2 (Director of Nursing / DON) said has been working in the facility for almost 3 years. Stated Oxygen cannula / tubing should be stored properly not the touching the floor. If O2 tubing is not being used should be kept inside a clear bag to maintain cleanliness and prevent contamination. V2 said signage should be posted by the doorway for a warning for everyone to be aware that oxygen is in use. R86's order summary report dated 11/19/24 with active order not limited to Oxygen at 3liter/min via nasal cannula as needed for SOB (shortness of breath). R399's order summary report dated 11/19/24 with active order not limited to Oxygen continuous 3-4 L/min via nasal cannula every shift. Baseline care plan dated 11/15/2024 documented in part: R399 has Oxygen Therapy related to COPD, Emphysema, Atrial fibrillation. Give oxygen as ordered by the physician - continuous oxygen at 3-4L/min/nasal cannula. Facility's Oxygen storage policy dated 8/16/24 documented in part: It is the policy of the facility to store oxygen safely and properly. 44103 On 11/19/24 at 10:36 AM, Surveyor observed R95 lying in bed and using oxygen (O2) via nasal cannula (NC). R95 was not interviewable. R95's oxygen flow rate was set to 4 liters per minute (LPM). At 10:38 AM, Surveyor asked V20 (Agency Registered Nurse) to check R95's oxygen setting. V20 entered R95's room and verified R95's oxygen flow rate was set to 4LPM. On 11/19/24 at 10:55 AM, Surveyor observed R110 lying in bed and was using oxygen via nasal cannula. R110's oxygen flow rate was set to 4 LPM. R110 stated [R110] has sleep apnea and uses oxygen to help [R110] breath better. R110 stated R110 does not walk and needs staff assistance to get up from bed. At 10:59 AM, Surveyor asked V21 (Registered Nurse) to check R110's oxygen setting. V21 entered R110's room and verified R110's oxygen flow rate was set to 4LPM. V21 stated that R110's oxygen should be set to 3LPM. On 11/20/24 at 10:33 AM, interviewed V2 (Director of Nursing) and stated that the nurses are supposed to be monitoring that the resident's oxygen is in the right setting. V2 stated that O2 setting is based on the physician's order and should be followed for the effective use of the oxygen on the resident. R95's clinical records show an admitted [DATE] with included diagnoses but not limited to Chronic Respiratory Failure with Hypoxia. R95's Minimum Data Set (MDS) dated [DATE] shows R95 has memory problem and dependent on staff with transfers. R95's physician orders read in part: Oxygen continuous 2-3L/min via nasal cannula every shift for sob [shortness of breath] (ordered 3/09/24). R95's care plan documents in part: R95 has order for oxygen secondary to diagnosis of Chronic Obstructive Pulmonary Disease (date initiated 10/10/22) with one intervention that reads, Give oxygen as ordered by the physician. Administer 2-3 L/NC continuous. R110's clinical records show an admitted [DATE] with included diagnoses but not limited to Obstructive Sleep Apnea and Chronic Respiratory Failure with Hypoxia. R110's MDS dated [DATE] shows R110 is cognitively intact and requires substantial/maximal assistance with bed mobility. R110's physician orders read in part: Apply oxygen 2-3 lpm to keep O2 sat greater than or equal to 90% as needed (ordered 10/16/24). R110's care plan documents in part: R110 is at risk for altered respiratory status/difficulty breathing related to Sleep Apnea and Chronic Respiratory Failure (dated initiated 1011/24) with one intervention that reads, Give oxygen as ordered by the physician. Oxygen at 2-3 LPM/NC as needed. The facility's Oxygen Therapy and Administration policy dated 8/16/24 reads in part: Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Procedure: Confirm order from physician (this should include liter flow, FiO2 and delivery device).

Based on observation, interview and record review, the facility failed to ensure medication was administered and not left at bedside for 1 (R113) resident reviewed for medication administration in a sample of 31. Findings include: R113's admission record showed admitted on 6/24/2023 with diagnoses including Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Occlusion and stenosis of left carotid artery, Other sequelae of cerebral infarction, Other specified arthritis multiple sites, Deficiency of other vitamins, Thyrotoxicosis, Nicotine dependence cigarettes, Chronic obstructive pulmonary disease, Essential (primary) hypertension, Other psychoactive substance abuse, Chronic viral hepatitis C. On 11/19/24 at 10:31 AM Observed R113 sitting on the side of the bed, alert and verbally responsive. Observed 1 white round pill inside the medication clear cup at bedside table. R113 stated he does not know what medication it was. Requested V5 (Registered Nurse/RN) in R113's room and said it could be a thyroid medication from 11-7 shift nurse. She said medication should not be left at bedside. R113 stated nobody told me nothing, I don't know what it is. On 11/20/24 At 10:43am V2 (Director of Nursing / DON) said has been working in the facility for almost 3 years. Stated nurses are expected to administer medications as ordered by the doctor. Nurses are expected to make sure that resident took the medication before leaving the room. Nurse is not supposed to leave the medication at bedside that is a standard nursing practice. V2 said unless resident is able to self-administer medication then it could be left at bedside but it should have an order, an assessment that resident is able to self-administer. R113's physician order summary report dated 11/19/24 showed active order not limited to Methimazole Tablet 5 MG Give 1 tablet by mouth one time a day for hyperthyroidism scheduled at 6am. Order does not reflect R113 may self-administer medication. No assessment for self-administration evaluation found in R113's electronic health record. MDS (Minimum Data Set) dated 9/17/24 showed R113's cognition was moderately impaired. Facility's medication pass policy dated 8/16/24 documented in part: It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures. Facility's medication storage, labeling and disposal policy dated 8/16/24 documented in part: Medications will be secured in locked storage area. Facility's Nurse job description (undated) documented in part: Administer medications.

Based on observation, interview and record review the facility failed to distinguish between a behavior slide versus a fall, and failed to follow their fall occurrence policy for one [R119] resident reviewed for falls on the sample list of 31 residents. Findings include: R119 's clinical record indicates the follow in part; R119 was admitted the medical diagnosis of cerebral infarction with hemiplegia and hemiparesis affecting left dominant side, coronary angioplasty, ventricular tachycardia, cardiac implants, major depressive disorder, generalized weakness, anxiety, and alcohol abuse with withdrawal. R119's Minimum Data Set [MDS] section [ C] Brief interview Mental Status he scored [04] indicates R119 is moderately impaired. R119's care plan indicates the following: 8/9/24- R119 demonstrate cognitive impairment related to psychiatric disorder, history of substance abuse, impaired decision making, poor logic and poor ability to understand cause and effect. Poor judgement and awareness. 6/17/24- R119 has an impaired mobility. 8/6/23- R119 is at high risk for falls related to cognitive deficit, poor balance, limited mobility. 11/19/24- R119 has behavior of sliding onto the floor when experiencing any abdominal discomfort. [Behavior Care Plan was entered after care plan was requested by the state survey agency] On 11/19/24 at 10:43 AM, during initial interview with R82 in his room behind his privacy curtain by the window, surveyor heard a noise. Surveyor observed R82's roommate R119 on the floor next to his bed, with his head resting on the wheelchair's leg rest. Surveyor called for R119's nurse, V8 [Licensed Practical Nurse]. Surveyor explained to V8 that she heard a noise and observed R119 on the floor with his head on top of the wheelchair leg rest. On 11/19/24 at 10:45 AM, V8 [Licensed Practical Nurse] entered the room and moved the wheelchair off the mat to reach R119. V8 stated, I am not sure who placed the wheelchair next to R119's bed on his floor mat. I see his head was resting on the wheelchair leg. V8 asked surveyor if R119 hit his head on the wheelchair leg. Surveyor said, she did not witness the fall, but observed R119 head on top of the wheelchair's leg rest. V8 asked R119 if he hit his head, R119 did not respond. On 11/19/24 at 10:55 AM V8 stated, R119 has a behavior of sliding out of the bed. R119 did not fall out of bed, he slides out of bed. Surveyor asked V8, because the occurrence was not witnessed, how do she [V8] know it was a slide versus a fall. V8 stated, V2 [Director of Nursing] told the nursing staff that R119 has a behavior of sliding out of the bed, so it is not treated as a fall, it is documented as a behavior. Anytime R119 is observed on the floor, it is automatically documented as behavior slide. I will take R119 vital signs and notify the nurse practitioner and family member. R119 is confused and he is not able to communicate his needs. Nursing staff make frequent rounds on R119. Sometimes R119 responds to my questions, but I am not sure the answer is true, because R119 is very confused. R119 is not answering me today.' Reviewed R119's progress note indicates in part: 11/19/24 at 10:53 V8 [ Licensed Practical Nurse] Note. R119 continues to slide out of bed onto the landing pad located on the floor next to his bed. R119 was removed from the floor by the certified nurse assistant and placed back in bed. R119 was redirected, re-oriented and re-educated on the importance of staying in bed and pressing his call button when needing assistance. Writer assessed R119, and he was clean and dry, vital signs within normal limits. Nurse practitioner and R119's family made aware. [There was no information regarding R119's head was on top of the wheelchair's leg, and no neurological assessment noted.] On 11/21/24 at 11:00 AM, V16 [Restorative Director/Registered Nurse] stated, I assist with fall interventions along with the director of nursing [V2]. A fall means rather if the resident intentionally or unintentionally falls on the floor. A fall is sometimes considered a change of plane. R119 is very confused and is a high fall risk. R119 has a behavior of sliding out of bed. If R119 is observed on his floor mat and he intentionally place himself there, then it is not a fall. R119 is very confused with a BIMS sore of 4, but he can make an intentional decision to get on the floor. If R119 is on the floor, it is always a behavior slide, the floor mat helps to reduce the risk of injury, it does not 100% eliminate injury. On 11/20/22 at 11:34 AM, V2 [Director of Nursing] stated, A fall is a change of plane. However, that rule does not apply to R119, because he slides out of bed, and it was considered a behavior. During the Behavior Committee Meeting on 1/18/24. The interdisciplinary team decided R119 had a behavior. The difference from a fall and a behavior slide is that the behavior slide is usually witness, but when R119 is observed on the floor, and no one witnesses him sliding to the floor, it is usually still a behavior slide. It is a fall when R119 is observed off the floor mat then it should consider a fall. R119 have not had any documented falls since 12/12/23 but had several bed slides. If R119 was observed on the floor next to his bed with his head resting on the wheelchair footrest, then V8 should have documented and treated the incident as a fall not a behavior slide. V8 should have started neurological assessments and completed risk management fall incident report. R119 needs a sitter by his bed side 24 hours per day. The facility is not able to provide a sitter. R119's family member cannot afford a sitter as well. Maybe this is not the right facility for R119, because we cannot provide one to one monitoring that he needs. I will in-service the staff between the difference between a fall versus a behavior slide. R119's care plan was updated on 11/19/24, that's why you don't see the behavior care plan dated for 1/18/24. I am not sure what happened to the original behavioral care plan. Policy: Fall Occurrence dated 7/26/24. If a resident had fallen, the resident is automatically considered a high risk for falls. An incident report will be completed by the nurse each time a resident fall. The incident may be written in the nurse note or other parts of the resident's medical record that will remain accessible to any person who has the right to access the residents record.

Based on observation, interview, and record review, the facility failed to ensure a low air loss mattress device was on the correct weight setting for one dependent resident (R105) of two residents with pressure ulcers on a sample list of 31 residents. Findings Include: R105's clinical records show an admitted [DATE] with included diagnoses not limited to Multiple Sclerosis and Stage 4 Pressure Ulcer. R105's physician orders read: Low Air Loss (LAL) Mattress ordered on 10/27/24. R105's skin care plan date initiated on 10/27/24 reads in part: R105 has a pressure injury on the sacral area with one intervention that reads, Check air mattress if functioning properly every shift and prn [as needed]. R105's weight shows 180 lbs dated 11/15/24. R105's Skin Risk assessment dated [DATE] shows a score of 10 (High Risk in developing a pressure ulcer). On 11/19/24 at 10:24 AM, R105's lying in bed alert and able to verbalize needs. Surveyor observed R105's low air loss mattress weight setting was set to 180 pounds (lbs). R105 stated [R105] has a wound above the tail bone area and is being seen by the wound care team. On 11/20/24 at 9:06 AM, V18 (Wound Care Coordinator/Registered Nurse) and V19 (Treatment Nurse/Licensed Practical Nurse both stated R105 came in with a stage 4 sacral pressure ulcer with wound treatment daily. Both stated R105's wound assessment scale (a tool used to assess risks of developing pressure ulcer) dated 11/11/24 is 10 which means R105 is high risk in developing pressure ulcer. Both stated R105 is on a low air loss mattress and supplements for wound healing. At 9:23 AM, R105's wound dressing was observed with V18 and V19. R105's wound dressing on the sacral area was intact. R105's low air loss mattress machine was observed set to 210 lbs. V18 stated that the purpose of the low air loss mattress is to offload the pressure point and alternates the weight of the resident to promote wound healing and prevention of developing pressure ulcer. V18 stated that the low air loss mattress should be set correctly and is based on the current weight of the resident. V18 stated nurses and wound care team should be monitoring and making sure that the low air loss mattress is in the correct setting and if it's in the wrong setting, the mattress could be so hard or so soft. For example, if it's in a low setting it's not doing its purpose and the resident will sink. At 9:33 AM, V18 checked R105's current weight recorded in the electronic health record and showed R105 weighed 180 lbs dated 11/15/24. V18 stated that R105's low air loss mattress weight setting should be set to 180 lbs. The facility's Specialized Mattress and Appropriate Layers of Padding policy dated 8/19/24 reads in part: use specialized air mattresses like Low Air Loss Mattress on residents with stage 3 and 4 pressure sores to ensure moisture, heat, and friction control.

Based on observation, interview, and record review, the facility failed to provide privacy and promote dignity for one of one resident [R105] reviewed for urinary catheter use on the sample list of 31. Findings included: On 11/19/24 at 10:24 AM, R105's urinary catheter bag was hanging on the side of R105's bed, half filled with urine and visible from the hallway. The urinary catheter bag did not have a protective cover over the bag. R105 stated the [R105] is on the urinary catheter bag because of [R105's] wound. On 11/20/24 at 10:33 AM, interviewed V2 (Director of Nursing) and stated that urinary catheter bag placement should not be facing the door, and if it's facing the door, it should be inside of a bag for privacy. V2 stated that if the urinary catheter bag is exposed, it can potentially cause a dignity issue. R105's physician orders document in part: Indwelling Catheter Type: (urinary) Catheter Size: 16 FR, 10 cc (cubic centimeter) balloon Reason for use: Neurogenic Bladder (ordered 10/27/24). The facility's Privacy and Dignity policy dated 8/16/24 documents in part: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Urine bags will be covered with the use of privacy bags.

Based on interview and record review, the facility failed to affirm the rights of a resident to be free from abuse. This failure affects one (R1) of three residents reviewed for abuse. Findings Include: R1's electronic health records (EHR) documents R1 was initially admitted to the facility on [DATE] with listed diagnoses not limited to but including Unspecified Dementia, Alzheimer's Disease, Dysphagia, Moderate Protein Calorie Malnutrition, Anorexia, Chronic Kidney Disease Stage 4, Repeated Falls, Type 2 Diabetes Mellitus. R1 was admitted under hospice services on 05/04/23 for end-of-life support. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severely impaired cognition and requires substantial/maximal assistance with Activities of Daily Living (ADLs). R2's EHR documents R2 was initial admitted to the facility on [DATE] with listed diagnoses not limited to but including Alzheimer's Disease Late Onset, Dysarthria and Anarthria, Major Depressive Disorder, Unspecified Mood Affective Disorder, Alcohol Abuse, Psychoactive Substance Abuse, Nontraumatic Chronic Subdural Hemorrhage, History of Falling. R2's MDS dated [DATE] documents R2 has severely impaired cognition and requires partial/moderate assistance with ADLs. R2 does not use a wheelchair or scooter and is able to walk 50 feet with supervision. R1's EHR indicates R1 and R2 have been roommates since 10/09/24. R1's Change in Condition assessment dated [DATE] at 10:32 AM completed by V2 (Assistant Director of Nursing/Registered Nurse) documents in part, skin alteration on his (R1) right arm observed after his (R1) roommate grabbed him on his arm and skin evaluation identified as skin tear with scant amount of bleeding. R2's Change in Condition assessment dated [DATE] at 9:50 AM completed by V2 documented in part, resident (R2) is verbally and physically aggressive toward his roommate and the resident exhibited an increased in anger and irritability towards others, CNA witnessed that (R2) is within his roommate's territory and was yelling and cursing him, he (R2) is also saying verbally inappropriate things towards his roommate. As per his roommate (R1) he (R2) just suddenly stands in front of him (R1) and grabs his (R1) right arm and becomes verbally aggressive toward him. As per (R2), (R2) got angry because his roommate (R1) keeps on changing the television channel. Per R2's EHR R2 was sent to (hospital) via Involuntary Petition to prevent further harm to others. On 11/03/24 at 12:40 PM, observed R1 lying in bed eating lunch meal with steri-strips intact on R1's right arm near inside of wrist. R1 pointed to the empty bed next to R1 and stated, he grabbed my hand rough, and then R1 said, I don't know why. R1 did not remember the name of the resident who grabbed R1's hand. R1 stated he hurt me and stated look! and pointed to R1's arm where steri-strip was. On 11/03/24 at 11:52 AM, V4 (Agency Certified Nursing Assistant) stated around 9:30-10:00 AM on 10/26/24 V4 was providing ADL care to another resident when V4 heard a resident (R3) holler at V4 to come to a room because help was needed. V4 stated when V4 entered the room R1 was lying in bed and R2 was standing over R1 pointing his finger aggressively yelling you are a racist! MF***er, MF***er! my TV, my TV, you're a racist! V4 stated R2 was very mad and angry and was still yelling at R1 racist, MF***er, MF***er! even after V4 separated R1 and R2. V4 stated R2 reported that R1 was changing R2's television with R1's remote on purpose. V4 stated V4 did not see R2 grabbing R1's arm when V4 entered the room but after V4 separated R1 and R2, R1 lifted up R1's right hand and pointed at R1's right hand with his left finger to show V4 R1's arm. V4 stated that there was an opened area the size of nickel, where the skin was pulled back on R1's right arm, near R1's wrist area and it was red from a little bleeding, and it appeared to be a fresh wound. On 11/03/24 at 12:35 PM, R3 stated on 10/26/24 sometime in the morning R3 was walking down the hallway to buy an item at the vending machine and from the hallway saw R2 shaking R1 by the arm and R2 was yelling and swearing at R1 as R2 stood over R1. R3 stated R2 likes to get into with people over small stuff and can go off on people sometimes. On 11/03/24 at 5:50 PM, via phone interview V15 (Registered Nurse) stated V15 was working on 10/26/24 and was called into R1/R2's room around 9:30-10:00 AM. V15 stated V15 immediately went into R1/R2's room and saw that V4 (CNA) had already separated R1 and R2. V15 stated V15 could see R2 was sitting on R2's bed but R2 was upset and getting more and more agitated, V15 stated R2 kept talking and talking in a very angry tone and looked very upset and was still pointing at R1 and swearing and threatening R1. V15 stated R2 was immediately removed from the room and put under supervision with another staff member. V15 stated R1 told V15 that R2 came over and grabbed R1's arm and then R1 pointed to the cut on R1's arm. V15 stated V15 could see a cut on R1's right arm near the wrist and there was some bleeding. V15 stated the cut was a skin tear. V15 stated R1 appeared angry but not scared and told V15 R1 did not want to stay in the room with R2. V15 stated V15 reassured R1 that R1 is safe and R2 would not be allowed back into the room. V15 stated R2 was not allowed back into the room and was taken off the unit and kept busy until the ambulance came to pick R2 up which was around 1:00 PM. On 11/03/24 at 5:00 PM, via phone V12 (Maintenance Director) stated V12 was working last Saturday, 10/26/24 and was asked to do a 1:1 with R2. V12 stated initially R2 was growling, grumbling, muttering under his breath F*** these F******* people. V12 stated V12 asked R2 Is everything okay? and R2 responded with F*** these people and F*** everyone in here. On 11/03/24 at 5:21 PM, via phone interview V13 (Nursing Supervisor/Registered Nurse) stated V13 was the nursing supervisor working on 10/26/24 and when V13 entered R1's room R1 told V13 that R1 did not know why R2 was so mad and why R2 was standing over R1 saying words to R1 that R1 did not know. V13 stated R1 told V13 that R2 grabbed R1 's arm. V13 stated V13 saw a skin altercation on R1's right arm, near wrist area with minimal bleeding. V13 stated R1 was upset about the incident. V13 stated R1 denied pain and discomfort. R1's doctor, family and hospice company was notified. V13 stated V13 went to talk to R2 who had already been removed from the room and when V13 approached R2, R2 was so mad, and frustrated that R1 was changing R2's television with R1's remote and that is why R2 got so mad at R1. V13 stated V13 could still see that R2 was still frustrated by the way R2 was talking about the situation and seemed to be getting more agitated, so V13 stopped asking questions to prevent further escalation. V13 stated R2's psych nurse practitioner and primary doctor was notified, and the recommendation was to send R2 out for further evaluation, so the facility initiated an involuntary petition. V13 stated R2 was sent out for verbally and physical aggression toward R1 and to prevent other injury or danger to other residents including himself and staff. On 11/03/24 at 5:08 PM, via phone interview V14 (Wound Care Nurse/Licensed Practical Nurse) stated V14 was told R1's roommate had attacked R1 and V14 was needed to conduct a skin assessment. V14 stated V14 observed R1 to have an open skin tear on R1's right forearm with minimal bleeding. V14 stated V14 cleaned the wound with normal saline and put a dry dressing on it to protect the area. On 11/03/24 at 4:05 PM, V1 (Administrator) stated V1 is the Abuse Coordinator for the facility and the goal of our abuse program is to keep all the residents free from abuse and to make sure they have a safe and comfortable place to live. V1 stated it is the resident's right to be free from abuse while they are living in the facility. V1 stated all residents are at risk for abuse and it is everyone's responsibility to prevent abuse. V1 stated the meaning of abuse is the willful or intentional act of harming someone. V1 stated V1 was made aware of the situation on 10/26/24 and an investigation was opened and submitted to Illinois Department of Health on 10/26/24 within the two-hour window. V1 stated R2 grabbing R1's arm caused harm to R1 by giving R1 a skin tear and that a skin tear is an injury. V1 stated R2 pointing R2's finger and yelling at R1 could be considered verbal abuse. V1 stated R2 was sent out because R2 continued to make verbally inappropriate comments and could not calm down so R2's doctor gave the order to send R2 to the hospital rather than to keep R2 here and potentially have another situation/outburst. Ombudsman Resident Rights for People in Long Term Care Facilities undated documents in part, your rights to safety. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Facility policy titled Abuse & Neglect dated 07/12/24 documents in part, it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires mental attention. Examples include hitting, slapping, kicking, squeezing, grabbing, pinching, poking twisting, and roughly handling. Verbal abuse includes but not limited to the use of oral, written, or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples include name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs etc.

Based on observation, interview and record review, the facility failed to follow their policies and ensure identification, monitoring, assessment, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 developing a left heel wound that progressed to [CONDITION(S)]. As result of the infection, R1 could not receive a prosthesis for the right leg. This failure also resulted in the delay of R1's placement on the Renal Transplant List due to an infection and open wound on the left heel. Doctor's current prognosis is to continue treatment as a palliative heel. This situation was identified as an immediate jeopardy on 4/26/2021. The administrator was notified on 08/12/2021. The surveyor confirmed by observation, interview, and record review the immediate jeopardy was removed on 08/18/2021. Findings include: Current Face Sheet documents R1's is a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Minimum Data Sheet (MDS) dated [DATE] documents R1's mental status was intact as noted in the Brief Interview for Mental Status (BIMS) score of 12 out of 15. MDS documents R1 requiring one-person physical assist with most Activities of Daily Living. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with R1 on 8/3/2021 at 12:31 PM, R1 states he only had the wound from the right BKA(below the knee amputation) when he was admitted to the facility. R1's Hospital discharge records dated 3/23/2021 is absent of any mention of a left heel/foot ulcer. Documentation is as follows: Left foot, wash with antiseptic spray, and apply A&D Crème. Review of facility's Treatment Administration Record (TAR) documents the following Physician order: to start on 3/24/2021: Vitamin A & D Ointment (house stock)/ABD/Kerlix/ACE wrap every day shift every other day for preventive measures. Left Lower Leg: NSS Cleanse. Pat dry. Apply Vitamin A&D ointment. Abdominal pad on the heel. Kerlix wrap. Secure with [MEDICATION(S)]. V15 (Physician Assistant) progress note dated 3/25/2021 documents the following: Major rehabilitation goals: Return to pre-morbid functional status of independence for ADLs, transfers, speech/cognition, independence for swallowing. Goals for ambulation currently are only pre-prosthetic training. Once he gets a prosthesis, ambulation goals will be added. V15 (PA/Physician Assistant) Progress notes dated 4/13/2021 documents the following: Indications for rehabilitation: The patient needs to be assessed for [CONDITION(S)], skin breakdown, any change in mental condition, [CONDITION(S)], respiratory failure, and cardiopulmonary decompensation. On 8/6/2021 at 3:21 PM V15 (PA/Physician Assistant) states he was consulting for rehab. Goals for rehab were to allow transfer in and out wheelchair. Goal: prosthetic fitting and training. Complication developed with left leg so focused on transfers, bed mobility, and ADLs. The left leg wound inhibited therapy. Resident became non-weight bearing. Initially much more functionality noted. The facility had to stop because R1 became non-weight bearing on the left leg because of the heel wound. R1 needed to be weight bearing on the left leg to be fitted for the right leg prosthetic and for prosthetic On 8/03/2021, R1 states that two weeks after being in the facility, R1 found a wound on his left heel and V6 (Wound care nurse) wrapped it for him that day. R1 states every day after that for 1 week and 3 days, he went to the front desk to ask staff to change his dressing on the left heel. They would say, I will send someone. I will send the wound care nurse, but no one came for 1 week and 3 days. After this time, V6 came to room and changed the bandage. R1 states V6 (Wound Nurse) saw the drainage that had leaked through the dressing. V6 began squeezing the area, believing it was a blister. R1 stated I told him to stop squeezing it because it hurt too bad to be a blister. I told V6 I was going to go see my wound care doctor on Monday, and I made an appointment. After being diagnosed with [CONDITION(S)], R1 states it made him feel really bad that he cannot receive his prosthesis and was taken off the renal transplant list. R1 stated I thought I was going to be walking when I left the facility. They were going to make my prosthetic while I was at the facility, and I would come home with it. It's a double shot. I have no prosthetic and not I'm not able to get on a transplant list because of this. I thought I would be walking, and I can't do it now. It was the end of April/beginning of May that I went to see the wound doctor. During an interview with V11 (Podiatrist/Wound Care Clinic) on 8/4/2021 at 1:15 PM, surveyor read the above order, regarding application of Vitamin A&D ointment, to V11. V11 stated that the treatment read to him was not wound care treatment, it was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They need to work up the wound, do culture tests, apply wound care products, have x-ray done and more. On 8/5/2021 3:59 - 4:19 PM ,V11 stated The goal now that the wound is open and chronic and blood flow is not best, we want to keep the wound infection free. This is more of a palliative heel. Two weeks ago we looked up a super-specialist to see if they can vascularize his foot to [NAME] what he has. We have been trying everything on it, IV and Oral antibiotics . We are trying antibiotic via graft/mesh to minimize the side effects with chronic oral and IV antibiotic use. V11 (Podiatrist) note dated 4/26/2021 documents V11 performed sharp excisional debridement of left heel lateral aspect ulcer. The following is on physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Ace wrap to left lower leg. Change dressing every other day and PRN. Offload heel always, use Prevalon boot or equivalent. On 8/11/2021 at 9:45 AM, V3 (DON) states Someone has to physically put an order in the TAR. The wound care nurses are responsible for transcribing the order into the TAR. The wound care nurses do it for the most part. Floor nurses can put the orders on the TAR, if they are capable of doing it. Wound care nurse checks for orders daily. They can do their own listing report to select new orders. If the resident went to an appointment, the wound care nurse will follow up to see if there are any orders. That is my expectation. Surveyor asked V3 to explain how a Doctor's order could not make it onto the TAR. can you explain how a doctor's order does not make it to the TAR. V3 replied, It can happen if it's not put in the usual way, or a honest mistake. The first document of R1's wound in the nurses progress notes are from V9 (RN) Health status note dated 4/26/2021. Documents the following: Received a call from V12 (RN Wound Center) and told NOD (nurse on duty) that resident came to wound center at the Hospital after his hemodialysis treatment due to left foot blister. Wound care team made aware and Primary Care MD made aware and okay with consult. On 8/4/2021 at 10:08 AM, V9 confirms he wrote the above note. V9 states he does not remember R1 having any wounds other than the wound on the right stump. On 8/4/2021 at 4:22 PM, V12 (RN, Wound Care Clinic) states the first time R1 was seen by them, after the right leg below the knee amputation (BKA), was on 4/26/2021. V12 states he believes R1 called to make the appointment and R1 was seen weekly after 4/26/2021. The first documentation of an issue with R1's left foot is from a Shower sheet dated 4/22/2021. There is a scribble (unclear writing) notation regarding area of the ankle on the left foot. Physical Therapy note dated 5/6/2021 (service dates 4/30/2021 - 5/6/201) documents for the first time the identification of R1's left foot wound and the precaution to off load. No documented wound assessment to the left heel wound was done during that week nor was update to care plan done. There are no orders transcribed to R1's TAR for the left heel/foot wound are until 5/19/2021. even though wound was identified and debrided by V11 on 4/26/2021. The first documentation of R1's left heel wound by a wound care nurse was on the Weekly wound assessments dated 5/16/2021 by V6 (Wound Nurse). Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/4/2021 at 1:30 PM , V4 (Regional Nurse Consultant) hands surveyor a stack of Wound Assessment Details Reports and states that the left lateral heel wound was identified on 5/16/2021 and that V6 put the date identified on the form as 3/23/21. The correct date wound was identified is 5/16/2021. On 8/4/2021 at 11:20 AM V6 (Wound Care Nurse) states he did not learn of the wound until 6/1/2021 when the resident came from the podiatrist with orders. Review of all wound assessment sheets from 3/24/2021 until the 5/16/21 assessment is absent of any mention the left heel/foot wound. Review of resident's Care plan reveals no update to reflect a plan of care for left heel wound that was identified by the facility on 5/16/2021. 5/16/2021 Wound Assessment details report done by V6 documents: Full thickness wound to left lateral Heel. 20% pink or red tissue, 80% slough non-adherent with scant serous exudate. Review of all of R1's TAR's document nurses signing off on the TAR that the above treatments were done every other day from 3/24/2021 through 6/10/2021 (except 3 days in April [3rd, 15th, and 25th]) and confirmed by nurses Interviews: On 8/4/2021 at 12:17 PM, V8 (LPN) states I remember R1 but not that much. I don't remember anything about R1 heel/foot wound. Surveyor showed V8 her initials on R1's TAR and R1 states she signed, but she did not do the treatment. V8 states she referred treatment to the wound nurse. V8 signed off on it but did not do the treatment. V8 reported to V5( Wound Care Nurse) that it needed to be done. V8 is unsure whether the treatment is then completed. Surveyor showed her the TAR for April 2021. V8 stated every time there was a wound care to be done, it was reported to the wound care nurse to be completed. She signed off, but did not complete the treatment. V8 never confirmed the treatments were completed. Surveyor showed V8 the TAR in May with Santyl order. V8 (LPN) stated, I believe all nurses do the same thing. I never see the wound because I don't change the dressing. Surveyor asks V8 who directed her to sign the TAR and then ask the wound care nurse to do the treatment. V8 states she learned it from working at the facility. That is how it is done. Surveyor asks if she follows up with wound care to see if treatment was done and V8 said no. Surveyor asks if V8 does daily skin assessments. V8 states No, the wound care nurse does it weekly. On 8/4/2021 at 12:40 PM, V9 (RN) states, The wound care nurse does the wound treatments. We just sign off on it. This is the practice of all the nurses. Surveyor showed V9 his initials on R1's TAR and V9 said he signs off and the wound nurse does the treatments. Review of the TARs for R1 from admission to discharge has the initials of multiple nurses including the V8, V9, and V13 who stated they did not do treatments. On 8/5/2021 at 10:11 AM, V13 (Former RN) states., The wound treatment nurse would use their own computer to sign off for wound treatments they provided to the resident. I'm not sure how they process it on their side. Once I click the TAR, I would inform the wound care nurse that they needed a treatment. It is the policy and practice of the facility to sign off on the TAR and inform wound care nurse. V13 states direction to do it that way came from management. V13 said, I learned it in orientation. I don't remember exactly who told me to do it that way. On 8/5/2021 at 5:39 PM V6 (Wound Care Nurse) asks the process for completing wound treatments. V6 states he has a computer. V6 said, I go to the TAR, the TAR tells me the treatment to do. I go to patient name and it shows treatment. Usually, it is yellow before I do it. After I do the treatment, I check it and it turns green. V6 said, Sometimes the nurse signs it, but they ask me if I did it first, then they sign it. Surveyor asks V6 of he also assesses everyone who is not listed as having wounds. V6 stated, Yes, on admission we do skin assessment. We just treat once a resident is diagnosed with a wound. We do weekly wound assessment and document in wound rounds. Wound care treatment and computer process observed by surveyor on 8/4/2021 at 10:24 AM with V7 (Wound Care Nurse , PRN). On 8/5/2021 at 1:09 PM, the surveyor asks V2 (ADON), if the nurse signs the TAR then who does the treatment? V2 said, Wound treatments are done by the wound care nurse. Surveyor clarified, If V8 (Nurse) signs the TAR, the wound care nurse does the treatment? V2 said, The wound care nurse does the treatment. It is not actually our policy. It is our practice. The nurse asks the wound care nurse if it is done, then the nurse signs off that it was done. Surveyor inquires who instructs the nurses to sign TAR on something they did not do? V2 stated, It is ensuring documentation is done. The nurses sees wound care nurse and ask if it is done and then the nurse signs off that it was done. Surveyor asks V2 if there is knowledge that the nurses are signing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] ? V2 said, There are no instructions. That is our practice. We sign off if treatment is done by wound care. On 8/17/2021 at 1:39 PM V26 (Renal office RN) states R1 is not on the transplant list because they are waiting for the wound to heal. Getting on the list was put on hold because of infection. There can be no open wounds before the evaluation On 8/17/2021 at 1:42 PM V24 (Social Worker) and V25 (Renal Doctor) states the goal for R1 was to rehab at the nursing home then do the transplant work up to get on the transplant list. R1 got an infection in the left heel, so he is no longer on the transplant list at this time. Braden Scale Assessment is a predictor of pressure ulcer risk. R1's Braden score on admitted d 3/23/2021 documents a score of 20. A score of 20 is considered high risk. Facility's wound care program care guidelines dated 7/3/2019 documents the following: The goal of this policy is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The purpose of the prevention recommendations is to guide evidence-based care to prevent development of pressure ulcers and the purpose of the treatment focused recommendations is to provide evidence-based guidance on the most effective strategies to promote pressure injury/ulcer healing. Procedures: Timely identification of residents assessed to be at risk for skin breakdown. Each risk factor and potential cause (s) identified should be reviewed individually and addressed into the resident's care plan. Proper Identification of Risk factors that can impact in the development of unavoidable ulcer or may impede with the healing process if resident does have an ulcer. The following are the risk factors for review: Contractures, decreased mobility or Bedfast, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Prevention of skin bread includes but not limited to; Inspection of the skin every shift with care for signs of breakdown. Moisturize skin with lotion to keep the skin soft and pliable. Documentation a. Wound Rounds system - using phone device connected to the internet that allows nursing staff to effectively evaluate, monitor, tract and treat residents and/or patients at risk for pressure ulcers while providing one-step wound assessment documentation. The care plan shall be evaluated and revised based on resident's response to treatment; treatment goals and outcomes. The resident's skin alteration/breakdown (pressure ulcer, arterial, diabetic, venous ulcers and etc .) shall be documented in the clinical records in accordance to the facility's policy and in compliance to current regulatory standards. Pressure Ulcer Treatment: Initiate wound care treatment upon identification of the wound with physicians order. Develop a care plan with appropriate interventions. Timely referral to facility's Wound Care Specialist for State III/IV pressure ulcers and/or any recalcitrant wounds. Quality Assurance and Performance Improvement. The facility may utilize the QAPI Process for implementing skin and wound care program. Abatement Plan accepted on 8/18/2021: 1). Facility to ensure that nurses are educated to follow physician treatment orders. A. On 8/12/2021, an in-service was conducted by Regional Nurse Consultant (RNC), DON, ADON and Administrator for all nurses to ensure that nurses are educated to follow physician treatment orders including any orders from outside Physician appointments or consultations. In-service was conducted in person and via telephone. (In-service sheets will indicate via phone if they were in-serviced via the phone. We have no staff that are on leave of absence or vacation. We use the same staff for weekdays and weekends. We do not use agency. All nurses have been in-serviced. ( In-service on following physician treatment orders including those from outside physicians) B. On 8/12/2021, a QA was started to be conducted twice a week for 4 weeks and weekly for 8 weeks to look at 10 residents to ensure physician treatment orders are being followed by the treatment nurse. 2) Ensure nurses are signing off on treatments that they provide. C. On 8/12/2021, an in-service was conducted for all nurses by Regional Nurse Consultant and Administrator that discussed nurses are only to sign off on treatments that he or she provides. In -service was conducted in person and via telephone. We have no staff that are on leave of absence or vacation. We use the same staff for weekdays and weekends. We do not use agency. All nurses have been in-serviced. On 8/12/2021, a QA was started to be conducted twice a week for 4 weeks and weekly for 8 weeks to ensure that 10 residents with wound treatments are being provided by the actual treatment nurses and being signed off on the corresponding TARs. D. On 8/12/2021, an audit was conducted by MDS Coordinator of all Treatment Administration Records (TAR) of each resident with wounds to identify if there are treatments not written in the TAR and are being signed off by nurses other than those who actually provided the treatments. The wound care nurses are doing the treatments as ordered and signing the medical record themselves upon completion. The wound care treatment policy was reviewed and revised as of 8/12/21 and includes treatments documented on the clinical record by treating nurse. 3) Ensure that weekly skin rounds are comprehensive and reflect the actual state of wound(s). E. On 8/12/2021, a house wide skin sweep of all residents with and without wounds were audited by ADON, Restorative Nurse and Wound Care Nurse to identify any individual with skin breakdown or open areas that were not previously identified, assessed, referred, provided treatment, or care planned and reflect accurate status of any wound(s). Skin sweep was carried out by nurses and c.n.a.'s for every resident, a census of 146 residents. Wounds identified during the above audit were entered in 1 resident record, including Wound Rounds and referred to the attending physician for appropriate treatment. F. On 8/12/2021, a QA was started to be conducted twice a week for 4 weeks and weekly for 8 weeks to look at 10 residents with wounds to ensure that each wound has comprehensive assessment showing the actual state of the wound. 4) Ensure comprehensive wound assessments are done upon identification of a wound. G. Newly identified wounds will be included in the Interdisciplinary Team daily meeting to ensure that they are all communicated upon identification and that comprehensive wound assessments are completed. H. On 8/12/2021, a comprehensive wound assessment was completed upon identification of a wound for 1 resident. On 8/12/2021, a QA was started to be conducted twice a week for 4 weeks and weekly for 8 weeks to look at 10 random high- risk residents to ensure that they don't have unidentified and undocumented wounds or wounds that have not been referred to the physician or wounds without comprehensive assessment or treatment orders. 5) Ensure physician is notified of any change in condition. I. On 8/12/2021, an in-service was conducted by RNC/ADON/DON/Administrator for all nurses to ensure that the physician is notified of any change in condition and to send a referral of all wounds to the primary care physician, and wound care specialist as appropriate, for notification and to obtain treatment orders, including outside consultations. In -service was conducted in person and via telephone. We have no staff that are on leave of absence or vacation. We use the same staff for weekdays and weekends. We do not use agency. All nurses have been in-serviced. On 8/12/2021, a QA was started to be conducted twice a week for 4 weeks and weekly for 8 weeks to look at 10 residents with wounds to ensure that each wound has comprehensive assessment showing the actual state of the wound, that each wound was referred to the physician, that each wound has a corresponding treatment order, including outside consultations. 6) Update wound care plans to reflect individualized plan of care. J. On 8/12/2021,a physical assessment of the resident, and the care plans of all residents identified with wounds were audited to identify if their wounds and the corresponding treatments are reflected in their care plans. Audit shows that all residents with wounds have in their care plans all their wounds identified with their corresponding individualized/person-centered treatments. K. On 8/12/2021, an in-service to all nurses was conducted by DON that all wound treatments are performed based on physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In -service was conducted in person and via telephone. We have no staff that are on leave of absence or vacation. We use the same staff for weekdays and weekends. We do not use agency. All nurses have been in-serviced. 7) Establish communication protocol or policy to ensure staff/interdisciplinary team are aware of status of wound and plan of care. On 8/12/2021, a weekly wound log was started to record all wounds, including new wounds identified during the week, so that the staff and Interdisciplinary Team are aware of status of wound and plan of care. Log is reviewed and passed out during the weekly meeting. L. On 8/12/2021, an in-service was conducted by Regional Nurse Consultant (RNC)for all direct care staff/IDT that there is a new weekly wound log started to record all wounds, including new wounds identified during the week, so that the staff and IDT are aware of status of wound and plan of care. 8) Identify and assess residents that are high risk for skin conditions and monitor closely. M. On 8/12/2021, a house wide physical assessment in the form of a skin sweep of all residents with and without wounds were audited by DON, ADON and Wound Care Nurse to also identify all residents at high risk for skin conditions who need to be closely monitored. There were 19 identified residents at high risk for skin breakdown N. On 8/12/2021, an in-service was conducted for all direct care staff and nurses by DON and ADON that discussed who are identified as high risk for skin conditions, to monitor for daily regular skin check including during showers, and to implement preventative skin care interventions based on the individualized plan of care. In -service was conducted in person and via telephone. We have no staff that are on leave of absence or vacation. We use the same staff for weekdays and weekends. We do not use agency. All nurses have been in-serviced. On 8/12/2021, a QA was started to be conducted twice a week for 4 weeks and weekly for 8 weeks to look at 10 random high- risk residents to ensure that they don't have unidentified and undocumented wounds or wounds that have not been referred to the physician or wounds without comprehensive assessment or treatment orders

Based on observations, interviews, and record reviews, the facility failed to ensure that one of two sample residents (R20 and R3) were free from sexual abuse by staff, by: not making sure a thorough investigation was done, and R20 was able to communicate to staff her allegations of sexual assault (which she said occurred over two days). R20 reported being in fear from being repeatedly sexually assaulted and unable to communicate with staff. As a resulted there was a delay of 3 to 5 day of a thorough investigation into her allegations of sexual assault. This had the potential to prevent evidence into her allegation of her sexual abuse from being discovered, and put all 129 residents in the facility at risk for abuse. On 10/12/2010 at 12:26 PM, E1 (administrator) was informed of the Immediate Jeopardy involving R20, staff's failure to implement policy and procedures when the resident made an allegation of abuse, as well as need to develop quality assessments/tools to ensure this failure is addressed. The Immediate Jeopardy was determined to have begun on 9/20/2010, when R20's family reported an allegation of sexual abuse and no immediate action was taken to ensure the police were called or a thorough medical examination was done. While the Immediate Jeopardy was removed on 9/22/2010, the facility remained out of compliance at severity level 2 because the facility has yet to: Assess all possible affected residents Inservice all staff on every shifts Fully implement and evaluate the effectiveness of the new plan of care Implement and evaluate effectiveness of new assessment tools Findings include: Review of the R20's Resident Abuse Investigation Report Form documented the following: "Name: R20 Date Incident Occurred: 9/18/10 and 9/19/10. Time: Exact time unknown. Date Reported: 9/2010 Time: 6:45 PM Incident Reported By: Family Member... Relationship to resident: Son... Resident injury: Medical Doctor assessed on 9/24/10. Nurses assessed on 9/20/10... Name of person accused: E9 (Certified Nurses Aid/CNA)... Summary of interview with person reporting the incident (use additional paper as necessary): Son reported on 9/20/10 to administrator that CNA touched resident by inserting his finger in her genital area and touching her breast. Claims this occurred on 9/18/10 and 9/19/10... Summary of interview with resident... Resident reported to family on 9/19/10 and family reported to staff on 9/20/10 that CNA inserted his finger in her genital area and touched her breast." Review of R20's Resident Admission Information Form documented that R20 is a [AGE] year old Asian female, who primary language was Cantonese, and had [DIAGNOSES REDACTED]. A Psychiatric Evaluation of R20 was done on 9/25/2010, with the help of R20's granddaughter as interpreter. The psychiatrist documented the following in his evaluation of R20: "Asked to evaluate this elderly female at this time secondary to an incident that occurred over last weekend... Upon examination and through the interpreter, she is able to relate the story on a pretty consistent basis as compared to previous times that she has told that as well. On further testing, she dose demonstrate some mild cognitive impairment such as she is not fully oriented, which is most likely secondary to her prior stroke... She does not present with any hallucinatory symptoms... Plan: She has not been taking any [MEDICAL CONDITION] medications. She does not appear to require any at this time. She appears to be consistent regarding the allegations that are presented..." Review of R20's Nursing Notes documented that she sustained emotional trauma after the incident on 9/18/10 and 9/19/10. The Nursing Notes document: "10/03/10 at 10 PM R20 was bought to her room by... CNA, but refused to go to bed. Saying "No No No." Kept saying "hello, hello" I went in the room and tried to encourage her to go to bed but we figured out that she thinks (CNA) was a man and... I think she's scared of man." The facility's Policy on Prevention of Abuse/Neglect documented the following procedures for staff to implement when an allegation of abuse is made: "This organization follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines included compliance with the seven federal regulations.... If abuse/neglect is suspected the organization will: 1) Take immediate steps to assure the protection the of the resident. This may involve... provision of medical care... 4) Notify law enforcement authorities and press charges, as appropriate..." However, the facility failed to follow and implement this policy and procedure by not immediately calling the police and making them aware of R20's allegations of sexual abuse. Once informed of R20's allegations, the facility waited approximately 2 days before ensuring a criminal investigation was started. The facility also delayed in ensuring that R20 received a thorough medical examination to confirm if sexual abuse had occurred. Review to the facility's Abuse Prevention Information for Residents documented that the following will be done to prevent resident's abuse: "You have the right to be free from abuse, neglect, misappropriation of property... This facility prohibits mistreatment and has attempted to establish a sensitive and secure environment. To maintain a safe environment this facility: ...-orients and trains employees on how to deal with stress/difficult situations, how to recognize and report potential mistreatment, neglect and abuse -promptly investigates reports and allegations of mistreatment, and makes changes to prevent future occurrences -files accurate and timely investigative reports." However, the facility's staff display limited knowledge and ability to communicate with R20 to ensure her concerns or complaints of possible mistreated were being communicated. The staff kept a communication book at her bedside only of limited words involving care. Unless her family was presented, R20 did not have a voice/method to communicate her concerns to staff. Until the surveyor team questioned facility ' s staff, there was no evidence of facility staff trying to recognize or identify factors that could lead to residents not be able to report being mistreatment. The police detective that conducted the investigation into R20's allegation of abuse was interviewed by phone on 10/12/10 at 12:35 PM. Z1 told surveyor that E9 was arrested and charged with "Criminal Sexual Assault " based on the investigation of R20's complaint. Z1 said a court hearing was conducted on 10/06/10. When asked, Z1 told surveyor that the facility staff did not call the police department until around noon on 9/22/10. Z1 stated, "...if we (the police) are not called right away evidence (of a crime) can be loss." On 10/08/10 at 3 PM, the facility's administrator and corporate staff (E16) were interviewed. E1 reported that R20's son told him that she (R20) complained that a CNA inserted a finger into her genital area and touched her breast. When asked E1 reported that he did informed the police department of R20's allegation of sexual abuse until 2 days later. E1 said the facility was investigating R20's allegations. E1 told surveyors that R20's physician was called, but he wanted two female nurses to examine the resident. E1 said a physician did not examine R20 until 9/22/10. E1 reported that the CNA (E9) was arrested. He said that a court hearing involving R20's allegation was conducted on 10/06/10, and R20 presented as a creditable witness. During this meeting the team expressed concerns that R20's allegations were not reported to the police in a timely manner nor R20 given thorough medical examination. E1 update his abuse policy in response to the survey team concerns. But, E1 provided no evidence that anything else was done to ensure this did not happen again. Surveyor attempted to interview R20 on 10/08/10. R20 was alert and talkative. But R20's ability to speak English was limited. Surveyor interviewed R20's son (Z2) by phone on 10/13/10. Z1 told surveyor: "My mother said he put her to bed and came back later. Her roommate was sick in the hospital. He came into her room and pulled up her gown. She said he put his finger into her vagina, and pull it out.... She complained she was angry and yelling. She can only speak Cantonese and could not tell anybody. She tried to fight off the guy. She tried to move, but she can't because of the stroke. She said he came back later ... She was afraid... and starts yelling loudly. My mother says a female CNA came in and asked something. She said she could not give her the details. She could only tell her (the female CNA) she was cold. She could not tell her what she wanted to say. He (E9) worked only to 11 PM shift. He (E9) came back the next night (on Sunday). My mother said he (E9) put his finger into her again on Sunday night. My mother can't sleep. She's always up at night and looking around. On Monday (9/20/10), my sister went to visit her. My mother told my sister what happen. My sister's English is not so good, but I told her to talk with the administrator. Then, the administrator called me. She went to court on Wednesday (10/06/10) and testified before a judge. The judge asked her; with the help of an interpreter did she see the man who did these things to her in the court. She told the judge yes, and pointed to the CNA (E9). A nurse (E10) responsible for R20's care was interviewed on 10/08/10. E10 reported that R20 maybe alert, but he did not speak her language, so he could not tell. When asked how he communicated with R20, E10 reported he used a communication board. E10 also told surveyor that they relied on the resident's family to act as interpreter. Review of the communication board at R20 ' s bedside only addressed concerns regarding R20's personal care. E13 (The nurse that examined R20 on 9/20/10) was interviewed by phone on 10/12/10. E13 said, "I was not her nurse. She had a male nurse. The male nurse told me the administrator asked me to check her. I and the CNA brought her back to her room. We put her on the bed. She had an adult incontinent pad on. We took it off. I separated her legs... and looked." When asked if she had any training to examine residents for signs of sexual abuse, E13 responded: "No. I had no training in looking at sexual abuse victims. I never did it before... I never worked in the emergency room ." Because the resident alleged that E9 inserted his finger into her genital area, surveyor asked E13 did she examine R20 for internal injuries of the genital area. E13 stated: "It's possible she could have internal injuries, we could not see from the surface." However, E13 did not report that R20 received any other examination than checking for bruising and swelling of the skin. Surveyor also asked E13 how she communicated with R20 on 9/20/10. E13 told surveyor: "It ' s hard to talk with her because she does not speak English. I used a lot of gestures. Her children were not there. No interpreter was called... We didn't ' know what time the children would be coming... A lot of time we do rely on the (R20's) children. The CNA (E12), who went to R20's room on 9/20/10 was interviewed on 10/08/10 and 10/12/10. E12 reported that she also could not communicate with R20. E12 said she just observed E13 do a visual check of R20 on 9/20/10. These are the steps that the facility took to remove the immediacy from this alleged deficient practice: 1. All Employees were re-in-serviced on the Facility's Abuse Policy and Procedure on but not limited to the Facility's Abuse Policy, Abuse Coordinator, types of abuse, addendum to Policy in regards to sexual allegations, reporting and investigation process on 10/06/10, 10/07/10, 10/08/10, 10/11/10, and repeated again on 10/12/10. 2. The Facility's Abuse Policy was revised on 10/08/10 to include that residents involved in allegations of sexual abuse will be sent to the emergency room for an evaluation. Policy was reviewed by the Medical Director and interdisciplinary Team on 10/08/10. 3. The Administrator, Director of Nursing and Assistant Director of Nursing were in-serviced by the Regional Director on 10/12/10 regarding but not limited to the Abuse Policy, investigation and Reporting Procedures. 4. All Attending Physicians were notified regarding the Facility's revision to Abuse Policy on 10/0810. 5. All Residents were re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 6. Resident involved was re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 7. Care plans were reviewed and updated for Residents that scored above a low risk for presentation of abuse and/or neglect on 10/12/10 by the Social Service Department. 8. All Residents were in-serviced by the Social Service Department on 10/12/10 on but not limited to the Facility's Abuse Policy and Procedures. 9. Additional signage was posted throughout the facility to notify Residents, Employees, Visitors and Families of the Facility Abuse Policy and how and who to report abuse to. 10. All Employees were given an Abuse Prevention quiz on 1012/10. 11. The Facility's Abuse Policy was revised on 10/08/10 to include that residents involved in allegations of sexual abuse will be sent to the emergency room for an evaluation. Policy was reviewed by the Medical Director and Interdisciplinary Team on 10/08/10. 12. The Administrator, Director of Nursing and Assistant Director of Nursing were in-serviced by the Regional Director on 10/12/10 regarding but not limited to the Abuse Policy, Investigation and Reporting Procedures. 13. All Attending Physicians were notified regarding the Facility ' s revision to Abuse Policy on 10/08/10. 14. All Residents were re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 15. Resident involved was re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 16. Care plans were reviewed and updated for Residents that scored above a low risk for presentation of abuse and/or neglect on 10/12/10 by the Social Service Department. 17. All Residents were in-serviced by the Social Service Department on 10/12/10 on but not limited to the facility's Abuse Policy and Procedures. 18. Additional signage was posted throughout the facility to notify Residents, Employees, Visitors and Families of the Facility Abuse Policy and how and who to report abuse to. 19. All Employees were given an Abuse Prevention quiz on 10/12/10. 20. Communication Books were updated and provided to all Residents that do not speak English as a primary language on 10/12/10. 21. All Employees were in-service on 10/12/10 regarding but not limited to the interpreter services that the facility's has available and how to locate them. 22. The facility conducted a quality assurance audit to ensure all Residents had communications Books on 10/12/10. Quality assurance audit on an on-going weekly basis conducted by the Activity Director and/or Designee and discussed at the Facility's Quality Assurance Committee Meeting. 23. The Facility conducted a quality assurance audit to ensure all abuse investigations conducted have been accurately completed and reported. This audit was conducted on 10/12/10, and will be conducted weekly on an on-going basis by the Abuse Coordinator/Facility Administrator. Results will be discussed at the Facility's Quality Assurance Committee Meeting. 24. An interpreter phone service will be available for nurses to use to communicate with the resident each shift. The phone number will be maintain on the front of the resident's clinical record.

Based on observations, interviews, and record reviews, the facility failed to follow and implement their abuse policy and procedure by not immediately informing the local police department when one resident (R20 in a sample of two residents, who reported allegations of abuse) made an allegation of sexual abuse, and did not ensure she was given a timely and thorough medical evaluation. The facility also failed to ensure that R20, whose primary language was not English, had a method in place to report allegation of abuse directly to staff. This failure resulted in a delay in the start of the facility's abuse and the police criminal investigation, which had the potential to prevent evidence of a criminal sexual assault from being discover, and putting the 129 residents in the facility at risk for abuse. On 10/12/2010 at 12:26 PM, E1 (administrator) was informed of the Immediate Jeopardy involving R20, staff's failure to implement policy and procedures when the resident made an allegation of abuse, as well as need to develop quality assessments/tools to ensure this failure is addressed. The Immediate Jeopardy was determined to have begun on 9/20/2010, when R20's family reported an allegation of sexual abuse and no immediate action was taken to ensure the police were called or a thorough medical examination was done. While the Immediate Jeopardy was removed on 9/22/2010, the facility remained out of compliance at severity level 2 because the facility has yet to: Assess all possible affected residents Inservice all staff on every shifts Fully implement and evaluate the effectiveness of the new plan of care Implement and evaluate effectiveness of new assessment tools Findings include: Review of the R20's Resident Abuse Investigation Report Form documented the following: "Name: R20 Date Incident Occurred: 9/18/10 and 9/19/10. Time: Exact time unknown. Date Reported: 9/2010 Time: 6:45 PM Incident Reported By: Family Member... Relationship to resident: Son... Resident injury: Medical Doctor assessed on 9/24/10. Nurses assessed on 9/20/10... Name of person accused: E9 (Certified Nurses Aid/CNA)... Summary of interview with person reporting the incident (use additional paper as necessary): Son reported on 9/20/10 to administrator that CNA touched resident by inserting his finger in her genital area and touching her breast. Claims this occurred on 9/18/10 and 9/19/10... Summary of interview with resident... Resident reported to family on 9/19/10 and family reported to staff on 9/20/10 that CNA inserted his finger in her genital area and touched her breast." Review of R20's Resident Admission Information Form documented that R20 is a [AGE] year old Asian female, who primary language was Cantonese, and had [DIAGNOSES REDACTED]. A Psychiatric Evaluation of R20 was done on 9/25/2010, with the help of R20's granddaughter as interpreter. The psychiatrist documented the following in his evaluation of R20: "Asked to evaluate this elderly female at this time secondary to an incident that occurred over last weekend... Upon examination and through the interpreter, she is able to relate the story on a pretty consistent basis as compared to previous times that she has told that as well. On further testing, she dose demonstrate some mild cognitive impairment such as she is not fully oriented, which is most likely secondary to her prior stroke... She does not present with any hallucinatory symptoms... Plan: She has not been taking any [MEDICAL CONDITION] medications. She does not appear to require any at this time. She appears to be consistent regarding the allegations that are presented..." Review of R20's Nursing Notes documented that she sustained emotional trauma after the incident on 9/18/10 and 9/19/10. The Nursing Notes document: "10/03/10 at 10 PM R20 was bought to her room by... CNA, but refused to go to bed. Saying "No No No." Kept saying "hello, hello" I went in the room and tried to encourage her to go to bed but we figured out that she thinks (CNA) was a man and... I think she's scared of man." The facility's Policy on Prevention of Abuse/Neglect documented the following procedures for staff to implement when an allegation of abuse is made: "This organization follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines included compliance with the seven federal regulations.... If abuse/neglect is suspected the organization will: 1) Take immediate steps to assure the protection the of the resident. This may involve... provision of medical care... 4) Notify law enforcement authorities and press charges, as appropriate..." However, the facility failed to follow and implement this policy and procedure by not immediately calling the police and making them aware of R20's allegations of sexual abuse. Once informed of R20's allegations, the facility waited approximately 2 days before ensuring a criminal investigation was started. The facility also delayed in ensuring that R20 received a thorough medical examination to confirm if sexual abuse had occurred. Review to the facility's Abuse Prevention Information for Residents documented that the following will be done to prevent resident's abuse: "You have the right to be free from abuse, neglect, misappropriation of property... This facility prohibits mistreatment and has attempted to establish a sensitive and secure environment. To maintain a safe environment this facility: ...-orients and trains employees on how to deal with stress/difficult situations, how to recognize and report potential mistreatment, neglect and abuse -promptly investigates reports and allegations of mistreatment, and makes changes to prevent future occurrences -files accurate and timely investigative reports." However, the facility's staff display limited knowledge and ability to communicate with R20 to ensure her concerns or complaints of possible mistreated were being communicated. The staff kept a communication book at her bedside only of limited words involving care. Unless her family was presented, R20 did not have a voice/method to communicate her concerns to staff. Until the surveyor team questioned facility ' s staff, there was no evidence of facility staff trying to recognize or identify factors that could lead to residents not be able to report being mistreatment. The police detective that conducted the investigation into R20's allegation of abuse was interviewed by phone on 10/12/10 at 12:35 PM. Z1 told surveyor that E9 was arrested and charged with "Criminal Sexual Assault " based on the investigation of R20's complaint. Z1 said a court hearing was conducted on 10/06/10. When asked, Z1 told surveyor that the facility staff did not call the police department until around noon on 9/22/10. Z1 stated, "...if we (the police) are not called right away evidence (of a crime) can be loss." On 10/08/10 at 3 PM, the facility's administrator and corporate staff (E16) were interviewed. E1 reported that R20's son told him that she (R20) complained that a CNA inserted a finger into her genital area and touched her breast. When asked E1 reported that he did informed the police department of R20's allegation of sexual abuse until 2 days later. E1 said the facility was investigating R20's allegations. E1 told surveyors that R20's physician was called, but he wanted two female nurses to examine the resident. E1 said a physician did not examine R20 until 9/22/10. E1 reported that the CNA (E9) was arrested. He said that a court hearing involving R20's allegation was conducted on 10/06/10, and R20 presented as a creditable witness. During this meeting the team expressed concerns that R20's allegations were not reported to the police in a timely manner nor R20 given thorough medical examination. E1 update his abuse policy in response to the survey team concerns. But, E1 provided no evidence that anything else was done to ensure this did not happen again. Surveyor attempted to interview R20 on 10/08/10. R20 was alert and talkative. But R20's ability to speak English was limited. Surveyor interviewed R20's son (Z2) by phone on 10/13/10. Z1 told surveyor: "My mother said he put her to bed and came back later. Her roommate was sick in the hospital. He came into her room and pulled up her gown. She said he put his finger into her vagina, and pull it out.... She complained she was angry and yelling. She can only speak Cantonese and could not tell anybody. She tried to fight off the guy. She tried to move, but she can't because of the stroke. She said he came back later ... She was afraid... and starts yelling loudly. My mother says a female CNA came in and asked something. She said she could not give her the details. She could only tell her (the female CNA) she was cold. She could not tell her what she wanted to say. He (E9) worked only to 11 PM shift. He (E9) came back the next night (on Sunday). My mother said he (E9) put his finger into her again on Sunday night. My mother can't sleep. She's always up at night and looking around. On Monday (9/20/10), my sister went to visit her. My mother told my sister what happen. My sister's English is not so good, but I told her to talk with the administrator. Then, the administrator called me. She went to court on Wednesday (10/06/10) and testified before a judge. The judge asked her; with the help of an interpreter did she see the man who did these things to her in the court. She told the judge yes, and pointed to the CNA (E9). A nurse (E10) responsible for R20's care was interviewed on 10/08/10. E10 reported that R20 maybe alert, but he did not speak her language, so he could not tell. When asked how he communicated with R20, E10 reported he used a communication board. E10 also told surveyor that they relied on the resident's family to act as interpreter. Review of the communication board at R20 ' s bedside only addressed concerns regarding R20's personal care. E13 (The nurse that examined R20 on 9/20/10) was interviewed by phone on 10/12/10. E13 said, "I was not her nurse. She had a male nurse. The male nurse told me the administrator asked me to check her. I and the CNA brought her back to her room. We put her on the bed. She had an adult incontinent pad on. We took it off. I separated her legs... and looked." When asked if she had any training to examine residents for signs of sexual abuse, E13 responded: "No. I had no training in looking at sexual abuse victims. I never did it before... I never worked in the emergency room ." Because the resident alleged that E9 inserted his finger into her genital area, surveyor asked E13 did she examine R20 for internal injuries of the genital area. E13 stated: "It's possible she could have internal injuries, we could not see from the surface." However, E13 did not report that R20 received any other examination than checking for bruising and swelling of the skin. Surveyor also asked E13 how she communicated with R20 on 9/20/10. E13 told surveyor: "It ' s hard to talk with her because she does not speak English. I used a lot of gestures. Her children were not there. No interpreter was called... We didn't ' know what time the children would be coming... A lot of time we do rely on the (R20's) children. The CNA (E12), who went to R20's room on 9/20/10 was interviewed on 10/08/10 and 10/12/10. E12 reported that she also could not communicate with R20. E12 said she just observed E13 do a visual check of R20 on 9/20/10. These are the steps that the facility took to remove the immediacy from this alleged deficient practice: 1. All Employees were re-in-serviced on the Facility's Abuse Policy and Procedure on but not limited to the Facility's Abuse Policy, Abuse Coordinator, types of abuse, addendum to Policy in regards to sexual allegations, reporting and investigation process on 10/06/10, 10/07/10, 10/08/10, 10/11/10, and repeated again on 10/12/10. 2. The Facility's Abuse Policy was revised on 10/08/10 to include that residents involved in allegations of sexual abuse will be sent to the emergency room for an evaluation. Policy was reviewed by the Medical Director and interdisciplinary Team on 10/08/10. 3. The Administrator, Director of Nursing and Assistant Director of Nursing were in-serviced by the Regional Director on 10/12/10 regarding but not limited to the Abuse Policy, investigation and Reporting Procedures. 4. All Attending Physicians were notified regarding the Facility's revision to Abuse Policy on 10/0810. 5. All Residents were re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 6. Resident involved was re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 7. Care plans were reviewed and updated for Residents that scored above a low risk for presentation of abuse and/or neglect on 10/12/10 by the Social Service Department. 8. All Residents were in-serviced by the Social Service Department on 10/12/10 on but not limited to the Facility's Abuse Policy and Procedures. 9. Additional signage was posted throughout the facility to notify Residents, Employees, Visitors and Families of the Facility Abuse Policy and how and who to report abuse to. 10. All Employees were given an Abuse Prevention quiz on 1012/10. 11. The Facility's Abuse Policy was revised on 10/08/10 to include that residents involved in allegations of sexual abuse will be sent to the emergency room for an evaluation. Policy was reviewed by the Medical Director and Interdisciplinary Team on 10/08/10. 12. The Administrator, Director of Nursing and Assistant Director of Nursing were in-serviced by the Regional Director on 10/12/10 regarding but not limited to the Abuse Policy, Investigation and Reporting Procedures. 13. All Attending Physicians were notified regarding the Facility ' s revision to Abuse Policy on 10/08/10. 14. All Residents were re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 15. Resident involved was re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 16. Care plans were reviewed and updated for Residents that scored above a low risk for presentation of abuse and/or neglect on 10/12/10 by the Social Service Department. 17. All Residents were in-serviced by the Social Service Department on 10/12/10 on but not limited to the facility's Abuse Policy and Procedures. 18. Additional signage was posted throughout the facility to notify Residents, Employees, Visitors and Families of the Facility Abuse Policy and how and who to report abuse to. 19. All Employees were given an Abuse Prevention quiz on 10/12/10. 20. Communication Books were updated and provided to all Residents that do not speak English as a primary language on 10/12/10. 21. All Employees were in-service on 10/12/10 regarding but not limited to the interpreter services that the facility's has available and how to locate them. 22. The facility conducted a quality assurance audit to ensure all Residents had communications Books on 10/12/10. Quality assurance audit on an on-going weekly basis conducted by the Activity Director and/or Designee and discussed at the Facility's Quality Assurance Committee Meeting. 23. The Facility conducted a quality assurance audit to ensure all abuse investigations conducted have been accurately completed and reported. This audit was conducted on 10/12/10, and will be conducted weekly on an on-going basis by the Abuse Coordinator/Facility Administrator. Results will be discussed at the Facility's Quality Assurance Committee Meeting. 24. An interpreter phone service will be available for nurses to use to communicate with the resident each shift. The phone number will be maintain on the front of the resident's clinical record.

Based on interviews and record reviews, the facility's administrative staff failed to effectively implement the facility's abuse policy and procedures, for one of two residents (R20), when she made an allegation of abuse. The facility's failure resulted in the R20's allegation of sexual assault not being investigated timely because the police were not called until 2 days later, and the staff failed to have a method in place for R20 to communicate to staff immediately, when she was mistreated over two days. This failure left 129 residents at risk for sexual abuse. On 10/12/2010 at 12:26 PM, E1 (administrator) was informed of the Immediate Jeopardy involving R20, staff's failure to implement policy and procedures when the resident made an allegation of abuse, as well as need to develop quality assessments/tools to ensure this failure is addressed. The Immediate Jeopardy was determined to have begun on 9/20/2010, when R20's family reported an allegation of sexual abuse and no immediate action was taken to ensure the police were called or a thorough medical examination was done. While the Immediate Jeopardy was removed on 9/22/2010, the facility remained out of compliance at severity level 2 because the facility has yet to: Assess all possible affected residents Inservice all staff on every shifts Fully implement and evaluate the effectiveness of the new plan of care Implement and evaluate effectiveness of new assessment tools Findings include: Review of the R20's Resident Abuse Investigation Report Form documented the following: "Name: R20 Date Incident Occurred: 9/18/10 and 9/19/10. Time: Exact time unknown. Date Reported: 9/2010 Time: 6:45 PM Incident Reported By: Family Member... Relationship to resident: Son... Resident injury: Medical Doctor assessed on 9/24/10. Nurses assessed on 9/20/10... Name of person accused: E9 (Certified Nurses Aid/CNA)... Summary of interview with person reporting the incident (use additional paper as necessary): Son reported on 9/20/10 to administrator that CNA touched resident by inserting his finger in her genital area and touching her breast. Claims this occurred on 9/18/10 and 9/19/10... Summary of interview with resident... Resident reported to family on 9/19/10 and family reported to staff on 9/20/10 that CNA inserted his finger in her genital area and touched her breast." Review of R20's Resident Admission Information Form documented that R20 is a [AGE] year old Asian female, who primary language was Cantonese, and had [DIAGNOSES REDACTED]. A Psychiatric Evaluation of R20 was done on 9/25/2010, with the help of R20's granddaughter as interpreter. The psychiatrist documented the following in his evaluation of R20: "Asked to evaluate this elderly female at this time secondary to an incident that occurred over last weekend... Upon examination and through the interpreter, she is able to relate the story on a pretty consistent basis as compared to previous times that she has told that as well. On further testing, she dose demonstrate some mild cognitive impairment such as she is not fully oriented, which is most likely secondary to her prior stroke... She does not present with any hallucinatory symptoms... Plan: She has not been taking any [MEDICAL CONDITION] medications. She does not appear to require any at this time. She appears to be consistent regarding the allegations that are presented..." Review of R20's Nursing Notes documented that she sustained emotional trauma after the incident on 9/18/10 and 9/19/10. The Nursing Notes document: "10/03/10 at 10 PM R20 was bought to her room by... CNA, but refused to go to bed. Saying "No No No." Kept saying "hello, hello" I went in the room and tried to encourage her to go to bed but we figured out that she thinks (CNA) was a man and... I think she's scared of man." The facility's Policy on Prevention of Abuse/Neglect documented the following procedures for staff to implement when an allegation of abuse is made: "This organization follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines included compliance with the seven federal regulations.... If abuse/neglect is suspected the organization will: 1) Take immediate steps to assure the protection the of the resident. This may involve... provision of medical care... 4) Notify law enforcement authorities and press charges, as appropriate..." However, the facility failed to follow and implement this policy and procedure by not immediately calling the police and making them aware of R20's allegations of sexual abuse. Once informed of R20's allegations, the facility waited approximately 2 days before ensuring a criminal investigation was started. The facility also delayed in ensuring that R20 received a thorough medical examination to confirm if sexual abuse had occurred. Review to the facility's Abuse Prevention Information for Residents documented that the following will be done to prevent resident's abuse: "You have the right to be free from abuse, neglect, misappropriation of property... This facility prohibits mistreatment and has attempted to establish a sensitive and secure environment. To maintain a safe environment this facility: ...-orients and trains employees on how to deal with stress/difficult situations, how to recognize and report potential mistreatment, neglect and abuse -promptly investigates reports and allegations of mistreatment, and makes changes to prevent future occurrences -files accurate and timely investigative reports." However, the facility's staff display limited knowledge and ability to communicate with R20 to ensure her concerns or complaints of possible mistreated were being communicated. The staff kept a communication book at her bedside only of limited words involving care. Unless her family was presented, R20 did not have a voice/method to communicate her concerns to staff. Until the surveyor team questioned facility ' s staff, there was no evidence of facility staff trying to recognize or identify factors that could lead to residents not be able to report being mistreatment. The police detective that conducted the investigation into R20's allegation of abuse was interviewed by phone on 10/12/10 at 12:35 PM. Z1 told surveyor that E9 was arrested and charged with "Criminal Sexual Assault " based on the investigation of R20's complaint. Z1 said a court hearing was conducted on 10/06/10. When asked, Z1 told surveyor that the facility staff did not call the police department until around noon on 9/22/10. Z1 stated, "...if we (the police) are not called right away evidence (of a crime) can be loss." On 10/08/10 at 3 PM, the facility's administrator and corporate staff (E16) were interviewed. E1 reported that R20's son told him that she (R20) complained that a CNA inserted a finger into her genital area and touched her breast. When asked E1 reported that he did informed the police department of R20's allegation of sexual abuse until 2 days later. E1 said the facility was investigating R20's allegations. E1 told surveyors that R20's physician was called, but he wanted two female nurses to examine the resident. E1 said a physician did not examine R20 until 9/22/10. E1 reported that the CNA (E9) was arrested. He said that a court hearing involving R20's allegation was conducted on 10/06/10, and R20 presented as a creditable witness. During this meeting the team expressed concerns that R20's allegations were not reported to the police in a timely manner nor R20 given thorough medical examination. E1 update his abuse policy in response to the survey team concerns. But, E1 provided no evidence that anything else was done to ensure this did not happen again. Surveyor attempted to interview R20 on 10/08/10. R20 was alert and talkative. But R20's ability to speak English was limited. Surveyor interviewed R20's son (Z2) by phone on 10/13/10. Z1 told surveyor: "My mother said he put her to bed and came back later. Her roommate was sick in the hospital. He came into her room and pulled up her gown. She said he put his finger into her vagina, and pull it out.... She complained she was angry and yelling. She can only speak Cantonese and could not tell anybody. She tried to fight off the guy. She tried to move, but she can't because of the stroke. She said he came back later ... She was afraid... and starts yelling loudly. My mother says a female CNA came in and asked something. She said she could not give her the details. She could only tell her (the female CNA) she was cold. She could not tell her what she wanted to say. He (E9) worked only to 11 PM shift. He (E9) came back the next night (on Sunday). My mother said he (E9) put his finger into her again on Sunday night. My mother can't sleep. She's always up at night and looking around. On Monday (9/20/10), my sister went to visit her. My mother told my sister what happen. My sister's English is not so good, but I told her to talk with the administrator. Then, the administrator called me. She went to court on Wednesday (10/06/10) and testified before a judge. The judge asked her; with the help of an interpreter did she see the man who did these things to her in the court. She told the judge yes, and pointed to the CNA (E9). A nurse (E10) responsible for R20's care was interviewed on 10/08/10. E10 reported that R20 maybe alert, but he did not speak her language, so he could not tell. When asked how he communicated with R20, E10 reported he used a communication board. E10 also told surveyor that they relied on the resident's family to act as interpreter. Review of the communication board at R20 ' s bedside only addressed concerns regarding R20's personal care. E13 (The nurse that examined R20 on 9/20/10) was interviewed by phone on 10/12/10. E13 said, "I was not her nurse. She had a male nurse. The male nurse told me the administrator asked me to check her. I and the CNA brought her back to her room. We put her on the bed. She had an adult incontinent pad on. We took it off. I separated her legs... and looked." When asked if she had any training to examine residents for signs of sexual abuse, E13 responded: "No. I had no training in looking at sexual abuse victims. I never did it before... I never worked in the emergency room ." Because the resident alleged that E9 inserted his finger into her genital area, surveyor asked E13 did she examine R20 for internal injuries of the genital area. E13 stated: "It's possible she could have internal injuries, we could not see from the surface." However, E13 did not report that R20 received any other examination than checking for bruising and swelling of the skin. Surveyor also asked E13 how she communicated with R20 on 9/20/10. E13 told surveyor: "It ' s hard to talk with her because she does not speak English. I used a lot of gestures. Her children were not there. No interpreter was called... We didn't ' know what time the children would be coming... A lot of time we do rely on the (R20's) children. The CNA (E12), who went to R20's room on 9/20/10 was interviewed on 10/08/10 and 10/12/10. E12 reported that she also could not communicate with R20. E12 said she just observed E13 do a visual check of R20 on 9/20/10. These are the steps that the facility took to remove the immediacy from this alleged deficient practice: 1. All Employees were re-in-serviced on the Facility's Abuse Policy and Procedure on but not limited to the Facility's Abuse Policy, Abuse Coordinator, types of abuse, addendum to Policy in regards to sexual allegations, reporting and investigation process on 10/06/10, 10/07/10, 10/08/10, 10/11/10, and repeated again on 10/12/10. 2. The Facility's Abuse Policy was revised on 10/08/10 to include that residents involved in allegations of sexual abuse will be sent to the emergency room for an evaluation. Policy was reviewed by the Medical Director and interdisciplinary Team on 10/08/10. 3. The Administrator, Director of Nursing and Assistant Director of Nursing were in-serviced by the Regional Director on 10/12/10 regarding but not limited to the Abuse Policy, investigation and Reporting Procedures. 4. All Attending Physicians were notified regarding the Facility's revision to Abuse Policy on 10/0810. 5. All Residents were re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 6. Resident involved was re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 7. Care plans were reviewed and updated for Residents that scored above a low risk for presentation of abuse and/or neglect on 10/12/10 by the Social Service Department. 8. All Residents were in-serviced by the Social Service Department on 10/12/10 on but not limited to the Facility's Abuse Policy and Procedures. 9. Additional signage was posted throughout the facility to notify Residents, Employees, Visitors and Families of the Facility Abuse Policy and how and who to report abuse to. 10. All Employees were given an Abuse Prevention quiz on 1012/10. 11. The Facility's Abuse Policy was revised on 10/08/10 to include that residents involved in allegations of sexual abuse will be sent to the emergency room for an evaluation. Policy was reviewed by the Medical Director and Interdisciplinary Team on 10/08/10. 12. The Administrator, Director of Nursing and Assistant Director of Nursing were in-serviced by the Regional Director on 10/12/10 regarding but not limited to the Abuse Policy, Investigation and Reporting Procedures. 13. All Attending Physicians were notified regarding the Facility ' s revision to Abuse Policy on 10/08/10. 14. All Residents were re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 15. Resident involved was re-assessed by the Social Service Department on 10/12/10 to determine the presentation of abuse and/or neglect. 16. Care plans were reviewed and updated for Residents that scored above a low risk for presentation of abuse and/or neglect on 10/12/10 by the Social Service Department. 17. All Residents were in-serviced by the Social Service Department on 10/12/10 on but not limited to the facility's Abuse Policy and Procedures. 18. Additional signage was posted throughout the facility to notify Residents, Employees, Visitors and Families of the Facility Abuse Policy and how and who to report abuse to. 19. All Employees were given an Abuse Prevention quiz on 10/12/10. 20. Communication Books were updated and provided to all Residents that do not speak English as a primary language on 10/12/10. 21. All Employees were in-service on 10/12/10 regarding but not limited to the interpreter services that the facility's has available and how to locate them. 22. The facility conducted a quality assurance audit to ensure all Residents had communications Books on 10/12/10. Quality assurance audit on an on-going weekly basis conducted by the Activity Director and/or Designee and discussed at the Facility's Quality Assurance Committee meeting. 23. The Facility conducted a quality assurance audit to ensure all abuse investigations conducted have been accurately completed and reported. This audit was conducted on 10/12/10, and will be conducted weekly on an on-going basis by the Abuse Coordinator/Facility Administrator. Results will be discussed at the Facility's Quality Assurance Committee Meeting.