Every finding on record at Augusta Nursing and Rehabilitation

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks at bedtime to diabetic residents and snacks to general residents for four of five residents in the survey sample, Residents #2, #5, #3 and #4. The findings include: 1.The facility staff failed to provide snacks for Resident #2 (R2). 5/6/26 at 2:00 PM observation of unit nourishment pantries: Hall 400-no snacks, Hall 300-seven Peanut butter (PB) sandwiches, seven mighty shakes, two vanilla ice cream, Hall 200-four chocolate cakes. 5/7/26 at 7:50 AM, observation of unit nourishment pantries: Hall 400-no snacks, Hall 300- eight packs chocolate cakes, two vanilla ice cream, ten mighty shakes, three one-half peanut butter (PB) sandwiches, Hall 200- eight packs chocolate cakes, seven mighty shakes, five one-half PF sandwiches. R2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Alzheimer's Disease, dementia and rheumatoid arthritis The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/14/26, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for hygiene/bathing; requiring maximal assistance for locomotion/transfer/dressing and independent for eating. A review of the comprehensive care plan dated 12/10/25 revealed, FOCUS: Resident is at risk of altered nutritional status related to ulcer of esophagus with bleeding, hypothyroidism, hiatal hernia and protein calorie malnutrition. INTERVENTIONS: Provide and serve supplements as ordered. Provide, serve diet as ordered. Monitor intake and record every meal. A review of R2's ADL (activities of daily living record) for March 2026 to May 2026 revealed no evidence of snacks being provided or percent (%) of meal intake on the following days: 3/2, 3/5, 3/9, 3/10, 3/13, 3/16, 3/19, 3/20, 3/23, 3/24, 3/28, 3/29, 3/31, 4/7, 4/10, 4/11, 4/14, 4/22, 4/24, 4/25, 5/26, 4/30, 5/1, 5/4, 5/5 and 5/6. An interview was conducted on 5/6/26 at 11:00 AM with R2. Asked if she is provided with snacks between meals and at bedtime, R2 stated, once in a while the staff bring some food in. An interview was conducted on 5/6/26 at 2:35 PM with CNA (certified nursing assistant) #3, who stated snacks are kept in the nourishment pantry. If they are not on the unit, snacks are in the kitchen and are obtained there. Dietary is to stock the pantries with snacks. If there were no snacks, she would pay for something for the resident out of the vending machine. The residents should be getting snacks between meals. An interview was conducted on 5/6/26 at 3:00 PM with the dietary manager. Asked about resident snacks, the dietary manager stated, snacks come from the kitchen twice a day, a tray of snacks is put at the nursing station, and the nursing staff distributes them to the residents. Snacks are mainly PBJ (peanut butter jelly), some turkey/cheese, ham/cheese if I have it on hand, oatmeal cream cookies. This is just for the diabetic residents. The kitchen does not provide snacks for the whole building. An interview was conducted on 5/6/26 at 3:30 PM with CNA #1, asked about resident snacks, CNA #1 stated, residents are offered snacks if they are stocked. The kitchen stocks the nutrition rooms on their units. On night shifts 7PM-7AM, if there were no snacks, and a resident wanted a snack, and there was not any, she would pay for the snack from the vending machine out of money that is hers. In the kitchen, the snacks would be in dry storage area. On 5/6/26 at 3:45 PM, a review of the dry storage area of the kitchen revealed no snack crackers, cookies or any other variation. On 5/7/26 at 8:20 AM, Resident #2 stated, there was no snack last evening. On 5/7/26 at 2:30 PM, the Executive Director and the Director of Clinical Services were made aware of the findings. A review of the facility's Snack policy revealed, Snacks and beverages will be provided as identified in the individual plans of care. Bedtime snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. The Dining Services Department assembles on a daily basis, snack items (food and beverages) for delivery to each resident/patient care area. The Dining Services Department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. No further information was provided prior to exit. 2. The facility staff failed to provide snacks for Resident #5 (R5). 5/6/26 at 2:00 PM observation of unit nourishment pantries: Hall 400-no snacks, Hall 300-seven Peanut butter (PB) sandwiches, seven mighty shakes, two vanilla ice cream Hall 200-four chocolate cakes. 5/7/26 at 5/7/26 7:50 AM, observation of unit nourishment pantries: Hall 400-no snacks, Hall 300- eight packs chocolate cakes, two vanilla ice cream, ten mighty shakes, three one-half peanut butter (PB) sandwiches, Hall 200- eight packs chocolate cakes, seven mighty shakes, five one-half PB sandwiches. R5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus) and pneumonitis due to inhalation of food or vomit. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/13/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being independent for locomotion/transfer/dressing/toileting/bathing/eating and hygiene. A review of the comprehensive care plan dated 12/28/23 revealed, FOCUS: Resident has is at nutritional risk related to Type 2 DM (diabetes mellitus), CKD (chronic kidney disease) and GERD (gastro-esophageal disease). INTERVENTIONS: Provide, serve diet as ordered. Monitor intake and record every meal. Offer substitutes for foods not eaten. A review of R5's ADL (activities of daily living record) for March 2026 to May 2026 revealed no evidence of snacks being provided or percent (%) of meal intake on the following days: 3/2, 3/5, 3/9, 3/10, 3/13, 3/14, 3/16, 3/19, 3/20, 3/24, 3/27, 3/28, 3/29, 3/30, 3/31, 4k/7, 4/10, 4/11, 4/16, 4/20, 4/22, 4/24, 4/25, 4/26, 4/30 and 5/5. An interview was conducted on 5/6/26 at 11:45 AM with R5. Asked if he is provided snacks between meals and at bedtime, R5 stated, No, there are no snacks provided; with diabetes, I should have a bedtime snack, they do not bring it and even if I ask for it, they often do not have snacks. Only snack provided is one half peanut butter sandwich, but no other snacks. An interview was conducted on 5/6/26 at 2:35 PM with CNA (certified nursing assistant) #3, who stated snacks are kept in nourishment pantry. If they are not on the unit, snacks are obtained from the kitchen. Dietary is to stock the pantries with snacks. If there were no snacks, she would pay for something for the resident out of the vending machine. The residents should be getting snacks between meals. An interview was conducted on 5/6/26 at 3:00 PM with the dietary manager. Asked about resident snacks, the dietary manager stated, snacks come from the kitchen twice a day, a tray of snacks is put at the nursing station, and the nursing staff distributes them to the residents. Snacks are mainly PBJ (peanut butter jelly), some turkey/cheese, ham/cheese if I have it on hand, oatmeal cream cookies. This is just for the diabetic residents. Snacks are not provided for the whole building. An interview was conducted on 5/6/26 at 3:30 PM with CNA #1, asked about resident snacks, CNA #1 stated, residents are offered snacks if they are stocked. The kitchen stocks the nutrition rooms on their units. On night shifts 7PM-7AM, there are often no snacks, and a resident wanted a snack, and there was not any, she would pay for the snack from the vending machine. In the kitchen, the snacks would be in dry storage area. On 5/6/26 at 3:45 PM, a review of the dry storage area of the kitchen revealed, no snack crackers, cookies or any other variation. On 5/7/26 at 8:45 AM, Resident #5 stated, there was no snack last evening. On 5/7/26 at 2:30 PM, the Executive Director and the Director of Clinical Services were made aware of the findings. No further information was provided prior to exit. 4. For Resident #3 (R3), facility staff failed to offer snacks. R3 was admitted to the facility with a diagnosis that included but not limited to depression. On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 05/03/2026, R3 scored 15 of 15 on the BIMS (brief interview for mental status), indicating R3 was cognitively intact for making daily decisions. The ADL (activities of daily living) sheet dated May 2026 for R3 documented in part, HS (at hours of sleep) Snack 1900 to 0700 (7:00 p.m-7:00 a.m.). Further review revealed that R3 was not offered a snack during 7:00 p.m-7:00 a.m. in two of six opportunities. On 05/06/2026 at approximately 1:40 p.m. an interview was conducted with R3 regarding snacks. She stated she is not always offered a snack during the day or in the evening. On 05/06/2026 at approximately 2:00 p.m. an observation of the facility's nourishment rooms revealed the following: Unit 200 – four small chocolate snack cakes; Unit 300 - seven peanut butter sandwiches, seven mighty shakes, two vanilla ice cream cups and Unit 400 – no evidence of any snacks. On 05/06/2026 at approximately 3:40 p.m. an observation of the facility's dry storage room failed to evidence a supply of snacks, such as chips, crackers, cookies, etc, for residents. On 05/07/2026 at approximately 7:50 a.m. observation of the facility's nourishment rooms revealed the following: Unit 200 - eight small packs of chocolate snack cakes; Unit 300 - eight small packs of chocolate snack cakes, two vanilla ice cream cups, ten mighty shakes, three one-half peanut butter sandwiches. On 05/06/2026 at approximately 2:58 p.m. interview was conducted with the facility's Dietary Manager regarding the availability of snacks for the facility's residents. He stated that a tray of snacks such as sandwiches, peanut butter and jelly and /or cold cuts, and oatmeal cream cookies, are taken to the nurse's stations at approximately 2:00 and 7:00 p.m. and the nurses distribute them to the diabetic residents. When asked about other types of snacks for the rest of the facility's residents he stated he does not provide snacks for the whole building. On 05/06/2026 at approximately 3:31 p.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding snacks. When asked about snacks for residents who were not diabetics, she stated that residents would receive snacks only if the facility had any snacks and they were kept in nutrition rooms on the hallways. She stated that the facility did not always have snacks for the residents. When asked who stocked the nutrition rooms, she stated the kitchen staff were responsible for stocking the nutrition rooms. She further stated that on the weekends when she worked on during the 7:00 p.m. to 7:00 a.m. shift on Saturdays and Sundays, if a resident wanted a snack and if the nourishment room did not have any and she would check the dry storage room in the kitchen and if there were no snacks there she would get the resident something from the vending machine using her own money. When asked how they evidence a resident is offered a snack she stated that it is documented on the ADL record. On 05/07/2026 at approximately 8:00 a.m. an interview was conducted with CNA #5 regarding snacks. She stated that she works the 7:00 a.m.- 3:00 p.m. shift and had not seen any snacks given out or supplied in the nutrition room on the unit. She further stated if a resident asked for a snack she would go to the kitchen and ask for something or if they had their own snacks in their room she would provide those snacks to the resident. When asked how they evidence a resident is offered a snack she stated that it is documented on the ADL record. On 05/07/2026 at approximately 8:45 a.m. an interview was conducted with the facility's ADCS (Assistant Director of Clinical Services) regarding snacks for residents who are not diabetic. She stated snacks are offered to the residents by the nursing staff twice daily, in the afternoon and evening, around the residents' bedtime usually around 8:00 p.m.to 9:00 p.m. She stated snacks were stocked in the nourishment rooms on each unit by the dietary staff. She further stated if the nourishment room run out of snacks, the staff can access additional snacks in the facility's dry storage room and freezer in the kitchen. At approximately 8:50 a.m. an observation of the inside of the cabinets, drawers, refrigerator and freezer inside the facility's nourishment room on Unit 400 was conducted with ADCS. She stated that there were no snacks or drinks stocked anywhere inside the nourishment room. At approximately 8:52 a.m. an observation of the inside of the cabinets, drawers, refrigerator and freezer inside the facility's nourishment room on Unit 200 was conducted with ADCS. The observation revealed eight packages of chocolate covered rolled cakes with cream filling approximately 3.4 ounces for each package. Further observation within the room failed to evidence any other type of snacks or drinks. When asked if the snacks described above were adequate for the residents ADCS stated no. At approximately 9:00 a.m. an observation of the facility's Dry storage room within the facility kitchen was observed with ADCS. [NAME] examining the stock in the dry storage room ADCS stated that there were no supplies of any type of snacks or snack drinks. ADCS stated that staff could also obtain ice cream for residents as a snack if they preferred it and that the staff could obtain the ice cream from the walk-in freezer in the facility kitchen. Observation of the inside of the walk-in freezer with ADCS revealed a box of vanilla and chocolate individual ice cream cups, three ounces each. After completing the observation stated above, ADCS was asked if there were enough snacks and variety of snacks and drinks to meet the needs of the facility's residents, she stated no. On 05/07/2026 at approximately 12:47 p.m. the facility Executive Director and Director of Clinical Services were made aware of the above findings. No further information was provided prior to exit. 5. For Resident #4 (R4), facility staff failed to offer snacks. R4 was admitted to the facility with a diagnosis that included but not limited to swallowing difficulties. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/06/2026, R4 scored 2 (two) of 15 on the BIMS (brief interview for mental status), indicating R4 was severely impaired of cognition for making daily decisions. On 05/06/2026 at approximately 2:00 p.m. an observation of the facility's nourishment rooms revealed the following: Unit 200 – four small chocolate snack cakes; Unit 300 - seven peanut butter sandwiches, seven mighty shakes, two vanilla ice cream cups and Unit 400 – no evidence of any snacks. On 05/06/2026 at approximately 3:40 p.m. an observation of the facility's dry storage room failed to evidence a supply of snacks, such as chips, crackers, cookies, etc, for residents. On 05/07/2026 at approximately 7:50 a.m. observation of the facility's nourishment rooms revealed the following: Unit 200 - eight small packs of chocolate snack cakes; Unit 300 - eight small packs of chocolate snack cakes, two vanilla ice cream cups, ten mighty shakes, three one-half peanut butter sandwiches. On 05/06/2026 at approximately 2:58 p.m. interview was conducted with the facility's Dietary Manager regarding the availability of snacks for the facility's residents. He stated that a tray of snacks such as sandwiches, peanut butter and jelly and /or cold cuts, and oatmeal cream cookies, are taken to the nurse's stations at approximately 2:00 and 7:00 p.m. and the nurses distribute them to the diabetic residents. When asked about other types of snacks for the rest of the facility's residents he stated he does not provide snacks for the whole building. On 05/06/2026 at approximately 3:31 p.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding snacks for R4. She could not recall R4 receiving snacks. When asked about snacks for residents who were not diabetics, she stated that residents would receive snacks only if the facility had any snacks and they were kept in nutrition rooms on the hallways. She stated that the facility did not always have snacks for the residents. When asked who stocked the nutrition rooms, she stated the kitchen staff were responsible for stocking the nutrition rooms. She further stated that on the weekends when she worked on during the 7:00 p.m. to 7:00 a.m. shift on Saturdays and Sundays, if a resident wanted a snack and if the nourishment room did not have any and she would check the dry storage room in the kitchen and if there were no snacks there she would get the resident something from the vending machine using her own money. When asked how they evidence a resident is offered a snack she stated that it is documented on the ADL record. On 05/07/2026 at approximately 8:00 a.m. an interview was conducted with CNA #5 regarding snacks for R4. She could not recall R4 receiving snacks. She stated that she works the 7:00 a.m.- 3:00 p.m. shift and had seen any snacks given out or supplied in the nutrition room on the unit. She further stated if a resident asked for a snack she would go to the kitchen and ask for something or if they had their own snacks in their room she would provide those snacks to the resident. When asked how they evidence a resident is offered a snack she stated that it is documented on the ADL record. On 05/07/2026 at approximately 8:45 a.m. an interview was conducted with the facility's ADCS (Assistant Director OF Clinical Services) regarding snacks for residents who are not diabetic. She stated snacks are offered to the residents by the nursing staff twice daily, in the afternoon and evening, around the resident's bedtime usually around 8:00 p.m. to 9:00 p.m. She stated snacks were stocked in the nourishment rooms on each unit by the dietary staff. She further stated if the nourishment room run out of snacks, the staff can access additional snacks in the facility's dry storage room and freezer in the kitchen. At approximately 8:50 a.m. an observation of the inside of the cabinets, drawers, refrigerator and freezer inside the facility's nourishment room on Unit 400 was conducted with ADCS. She stated that there were no snacks or drinks stocked anywhere inside the nourishment room. At approximately 8:52 a.m. an observation of the inside of the cabinets, drawers, refrigerator and freezer inside the facility's nourishment room on Unit 200 was conducted with ADCS. The observation revealed eight packages of chocolate covered rolled cakes with cream filling approximately 3.4 ounces for each package. Further observation within the room failed to evidence any other type of snacks or drinks. When asked if the snacks described above were adequate for the residents ADCS stated no. At approximately 9:00 a.m. an observation of the facility's Dry storage room within the facility kitchen was observed with ADCS. [NAME] examining the stack in the dry storage room ADCS stated that there were no suppl of any type of snacks or snack drinks. ADCS stated that staff could also obtain ice cream for residents as a snack if they preferred it and that the staff could obtain the ice cream from the walk-in freezer in the facility kitchen. Observation of the inside of the walk-in freezer with ADCS revealed a box of vanilla and chocolate individual ice cream cups, three ounces each. After completing the observation stated above, ADCS was asked if there were enough snacks and variety of snacks and drinks to meet the needs of the facility's residents, she stated no. On 05/07/2026 at approximately 12:47 p.m. the facility Executive Director and Director of Clinical Services were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, the facility staff failed to prepare food in a sanitary manner in one of one facility kitchens.The findings include:On 05/06/2026 at approximately 9:40 a.m. an observation of the facility's kitchen revealed the Dietary Manager plating and covering slices of caramel apple cake for the resident's dessert and did not have his mustache covered. On 05/06/2026 at approximately 11:08 a.m. an observation of the Dietary Manager making peanut butter protein drinks for the resident's and did not have his mustache covered.On 05/06/2026 at approximately 2:58 p.m. interview was conducted with the facility's Dietary Manager regarding the purpose of hair, beard and mustache guard he stated that they were worn to prevent hair from falling into food. After informed of the above observation he stated he should have had his mustache covered.The facility's policy Staff Attire documented in part, Policy Statement. All employees wear approved attire for the performance of their duties.On 05/07/2026 at approximately 12:47 p.m. the facility Executive Director and Director of Clinical Services were made aware of the above findings.No further information was provided prior to exit.

Based on clinical record review and staff interview, facility staff failed to provide ADL (activites of daily living) care for one of five residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), facility staff failed to ensure independent feeding skills did not dimmish by documenting level of assistance and percentage of food consumed during breakfast, lunch or dinner.R3 was admitted to the facility with a diagnosis that included but not limited to depression.On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 05/03/2026, R3 scored 15 of 15 on the BIMS (brief interview for mental status), indicating R3 was cognitively intact for making daily decisions. Section GG Functional Abilities coded R4 as requiring Setup or Clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following activity.The ADL sheet dated May 2026 for R3 documented in part, Eating. 0900, 1300 and 1800. Further review of the ADL sheet for eating failed to evidence documentation regarding R3's level of assistance, and the percentage of the meal consumed in nine of 19 opportunities.On 05/06/2026 at approximately 3:31 p.m. an interview was conducted with CNA (certified nursing assistant) #1. When asked how they evidence the resident's level of assistance during a meal and the percentage of the meal consumed she stated that it is documented on the ADL record.On 05/07/2026 at approximately 8:00 a.m. an interview was conducted with CNA #5. When asked how they evidence the resident's level of assistance during a meal and the percentage of the meal consumed she stated that it is documented on the ADL record.On 05/07/2026 at approximately 8:20 a.m. an interview was conducted with CNA#6. When asked how they evidence the resident's level of assistance during a meal and the percentage of the meal consumed she stated that it is documented on the ADL record.The facility's policy Activities of Daily Living (ADLs) documented in part, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.On 05/07/2026 at approximately 12:47 p.m. the facility Executive Director and Director of Clinical Services were made aware of the above findings.No further information was provided prior to exit.

Based on observations, staff interview and clinical record review, facility staff failed to provide ADL (activities of daily living) for dependent residents for two of five residents in the survey sample, Resident #4 and #1.The finding include:1. For Resident #4 (R4), facility staff failed to ensure independent feeding skills did not dimmish by documenting level of assistance and percentage of food consumed during breakfast, lunch or dinner. R4 was admitted to the facility with a diagnosis that included but not limited to chronic obstructive pulmonary disease (1) and dysphagia (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/06/2026, R4 scored 2 (two) of 15 on the BIMS (brief interview for mental status), indicating R4 was severely impaired of cognition for making daily decisions. Section GG Functional Abilities coded R4 as requiring Setup or Clean-up assistance – Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following activity. The ADL (activities of daily living) sheet dated February 2026 for R4 documented in part, Eating. 0900 (9:00 a.m.), 1300 (1:00 p.m.) and 1800 (6:00 p.m.). Further review of the ADL sheet for eating failed to evidence documentation regarding R4's level of assistance, and the percentage of the meal consumed in 40 of 84 opportunities. The ADL sheet dated March 2026 for R4 documented in part, Eating. 0900, 1300 and 1800. Further review of the ADL sheet for eating failed to evidence documentation regarding R4's level of assistance, and the percentage of the meal consumed in 48 of 93 opportunities. The ADL sheet dated April 2026 for R4 documented in part, Eating. 0900, 1300 and 1800. Further review of the ADL sheet for eating failed to evidence documentation regarding R4's level of assistance, and the percentage of the meal consumed in 25 of 39 opportunities. On 05/06/2026 at approximately 3:31 p.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding R4. CNA #1 stated she worked two times a week and every other weekend and had frequently provided care to R4. When asked about R4's ability to eat she stated R4 usually required verbal prompts to feed herself during breakfast and sometimes required total assistance and would sometimes feed R4. When asked how they evidence the resident's level of assistance during a meal and the percentage of the meal consumed she stated that it is documented on the ADL record. On 05/07/2026 at approximately 8:00 a.m. an interview was conducted with CNA #5 regarding R4. CNA #5 stated she took care of R4 a few times. When asked about R4's ability to eat she stated R4 was dependent on staff to feed R4 but was independent with finger foods (i.e. small sandwiches. The daughter would come in at lunchtime, and the son would come in at dinner time, feed R4 and when they finished feeding R4 they give the tray back after the meal was completed and we (CNAs) would document the level of assistance, and the percentage R4 ate. When asked how they evidence the resident's level of assistance during a meal and the percentage of the meal consumed she stated that it is documented on the ADL record. On 05/07/2026 at approximately 8:20 a.m. an interview was conducted with CNA#6 regarding R4. She stated she provided care on regular bases to R4 during 7:00 a.m. to 7:00 p.m. shift. She stated R4 could eat independently given some prompting and sometimes R4 was dependent on staff to feed her. When asked how they evidence the resident's level of assistance during a meal and the percentage of the meal consumed she stated that it is documented on the ADL record. On 05/07/2026 at approximately 8:38 a.m. an interview was conducted with the ADON (assistant director of nursing) regarding R4. She stated she assist R4 with a few meals and R4 could feed herself with minimal assistance, her food needed to be cut up into bite size piece, assistance with loading the food on a fork or spoon, place it in R4's hand and she would bring it to her mouth to feed self. She stated R4 was independent with finger foods (i.e. sandwiches, cookies, etc ). She stated the family would come in and feed R4 for lunch and dinner every day (seven days a week). When asked how they evidence the resident's level of assistance during a meal and the percentage of the meal consumed she stated that it is documented on the ADL record. The facility's policy Activities of Daily Living (ADLs) documented in part, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. On 05/07/2026 at approximately 12:47 p.m. the facility Executive Director and Director of Clinical Services were made aware of the above findings. No further information was provided prior to exit. Reference: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (2) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. 2. The facility staff failed to provide ADL (activities of daily living) specifically feeding assistance for a dependent resident, Resident #1 (R1). R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited fracture of left ulna, neuropathy and hepatic encephalopathy. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 4/21/26, coded the resident as scoring an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting and hygiene; assistance with meals. A review of the comprehensive care plan dated 4/28/26 revealed, FOCUS: Resident has nutritional problem or potential nutritional problem related to diagnosis of hepatic encephalopathy, metabolic encephalopathy, cirrhosis of liver, fatty liver and significant weight loss. INTERVENTIONS: Provide, serve diet as ordered. Monitor intake and record every meal. A review of the 5/5/26 diet order revealed, Regular diet, Mechanical Soft texture, Regular/Thin liquids consistency. A review of R1's ADL (activities of daily living) record reveals missing evidence of percent eating on following dates: 3/5, 3/7, 3/8, 3/13, 3/15, 3/17, 3/18, 3/26, 3/30, 4/1, 4/2, 4/5, 4/6, 4/8, 4/9, 4/10, 4/12, 4/22, 4/23, 4/24, 4/25, 4/27, 4/28, 4/29, 5/1, 5/3, 5/4, 5/5 and 5/6. A review of the mini nutrition progress note dated 1/23/26 at 8:09 AM revealed, Resident has no decrease in food intake in the last 3 months. Mini Nutrition Score: The score is:11.0 (8 - 11 points: At risk of malnutrition). A review of the mini nutrition progress note dated 4/20/26 at 3:47 PM revealed, Resident has no decrease in food intake in the last 3 months. Weight loss greater than 3kg (6.6 pounds) in the last 3 months. Mini Nutrition Score: The score is:7.0 (0 - 7 points: Malnourished). A review of the progress note dated 5/5/26 at 7:10 PM revealed, Residents' sister POA (power of attorney) in facility and requested residents' diet be changed to mechanical soft- due to risk of aspiration. New order noted, POA made aware, diet slip updated and taken to dietary manager. A review of the LPN (licensed practical nurse) progress note dated 5/6/26 at 9:00 AM revealed, This writer offered resident her breakfast tray, resident refused. This writer offered to feed resident, resident continued to refuse. A review of the LPN progress note dated 5/6/26 at 1:58 PM revealed, This writer offered resident her lunch tray, resident refused. This writer offered to feed resident, resident continued to refuse. On 5/6/26 at approximately 12:00 PM, lunch trays were being passed. R1 was in bed sleeping with no lunch tray on bedside table. The 200-unit nursing station included CNA (certified nursing assistant) #4 and LPN (licensed practical nurse) #1. When asked about R1's lunch tray, LPN #1 stated, the family asked us not to feed the resident, there was a note about it last evening. When asked if there was a physician order, LPN #1 stated, no, the resident is in hospice. When asked who had asked the resident if she wanted to eat, CNA #4 stated, she said no, no, no. She did not want to eat. On 5/7/26 at 8:00 AM, an interview was conducted with CNA #5 who stated, there is a lack of communication about what residents are feeders. It is not clear from nursing staff or in documentation. On 5/7/26 at 9:00 AM, an interview was conducted with R1's sister-POA who stated, My sister cannot use a knife and a fork, that is why I requested a soft diet and for her to be fed. On 5/7/26 at 9:05 AM, an interview was conducted with Assistant Director of Clinical Services, who stated, if a resident refuses a meal, the CNA is to document it as a refusal and tell the nurses who then write a progress note. CNA #4 is on light duty. She would absolutely have access to document a resident meal refusal. In PCC (point click care) there is a section for eating, there are multiple questions, so they will select answer if they what assistance is needed and should be documented for every meal; that is the evidence that they were assisted in some way. On 5/7/26 at 9:55 AM, an interview was conducted with CNA #4 who stated, Meal trays are passed to residents and documentation is in PCC. If the resident refuses a meal tray I deliver, then I document in PCC. Yesterday, R1 stated, no, no, I do not want that when I offered her the lunch tray. On 5/7/26 at 2:30 PM, the Executive Director and the Director of Clinical Services were made aware of the findings. No further information was provided prior to exit.

Based on observations, resident/staff interview facility, document review and clinical record review, it was determined the facility staff failed to implement the care plan for two of five residents in the survey sample, Residents #2 and #5.The findings include: 1.The facility staff failed to implement the comprehensive care plan providing snacks and monitoring meal intake for Resident #2 (R2).R8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Alzheimer's Disease, dementia and rheumatoid arthritisThe most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/14/26, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for hygiene/bathing; requiring maximal assistance for locomotion/transfer/dressing and independent for eating.A review of the comprehensive care plan dated 12/10/25 revealed, FOCUS: Resident is at risk of altered nutritional status related to ulcer of esophagus with bleeding, hypothyroidism, hiatal hernia and protein calorie malnutrition. INTERVENTIONS: Provide and serve supplements as ordered. Provide, serve diet as ordered. Monitor intake and record every meal.A review of R2's ADL (activities of daily living record) for March 2026 to May 2026 revealed no evidence of snacks being provided or percent (%) of meal intake on the following days: 3/2, 3/5, 3/9, 3/10, 3/13, 3/16, 3/19, 3/20, 3/23, 3/24, 3/28, 3/29, 3/31, 4/7, 4/10, 4/11, 4/14, 4/22, 4/24, 4/25, 5/26, 4/30, 5/1, 5/4, 5/5 and 5/6. An interview was conducted on 5/6/26 at 11:00 AM with R2. Asked if she is provided with snacks between meals and at bedtime, R2 stated, once in a while the staff bring some food in.An interview was conducted on 5/6/26 at 2:45 PM with RN (registered nurse) #1. RN #1 described the care plan purpose, as identifying the specific needs and interventions to meet those needs for each resident. Asked if interventions are not followed, has the care plan been implemented, RN #1 stated, no, it was not implemented.On 5/7/26 at 2:30 PM, the Executive Director and the Director of Clinical Services were made aware of the findings. A review of the facility's Comprehensive Care Plan policy revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.No further information was provided prior to exit. 2. The facility staff failed to implement the comprehensive care plan providing snacks and monitoring meal intake for Resident #5 (R5).R5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus) and pneumonitis due to inhalation of food or vomit.The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/13/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being independent for locomotion/transfer/dressing/toileting/bathing/eating and hygiene.A review of the comprehensive care plan dated 12/28/23 revealed, FOCUS: Resident has is at nutritional risk related to Type 2 DM (diabetes mellitus), CKD (chronic kidney disease) and GERD (gastro-esophageal disease). INTERVENTIONS: Provide, serve diet as ordered. Monitor intake and record every meal. Offer substitutes for foods not eaten.A review of R5's ADL (activities of daily living record) for March 2026 to May 2026 revealed no evidence of snacks being provided or percent (%) of meal intake on the following days: 3/2, 3/5, 3/9, 3/10, 3/13, 3/14, 3/16, 3/19, 3/20, 3/24, 3/27, 3/28, 3/29, 3/30, 3/31, 4k/7, 4/10, 4/11, 4/16, 4/20, 4/22, 4/24, 4/25, 4/26, 4/30 and 5/5.An interview was conducted on 5/6/26 at 11:45 AM with R5. Asked if he is provided snacks between meals and at bedtime, R5 stated, No, there are no snacks provided; with diabetes, I should have a bedtime snack, and they do not bring it into me. They may have one half peanut butter sandwich, but no other snacks.An interview was conducted on 5/6/26 at 2:45 PM with RN (registered nurse) #1. RN #1 described the care plan purpose, as identifying the specific needs and interventions to meet those needs for each resident. Asked if interventions are not followed, has the care plan been implemented, RN #1 stated, no, it was not implemented.On 5/7/26 at 2:30 PM, the Executive Director and the Director of Clinical Services were made aware of the findings. No further information was provided prior to exit.

Based on observations, staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment that was free from accident hazards and provide adequate supervision to prevent an avoidable accident/elopement for one resident (Resident #113-R113) in a survey sample of 29 residents. R113, while wearing a wander guard device, eloped from the facility, left the premises, fell , and was unable to get up, which resulted in complaints of back pain, requiring treatment and new order for x-rays, constituting harm. During the survey, the survey team identified that the wander guard system was not consistently functioning properly, and immediate jeopardy was identified. The findings included: The facility staff failed to provide adequate supervision and have a consistently functioning wander guard system to prevent residents with a known elopement risk from the ability to exit the facility without staff knowledge, which resulted in immediate jeopardy. Resident #113, who was a known elopement risk and had a wander guard in place, exited the facility, left facility grounds, fell into a drainage ditch 465.7 feet away from the buidling, was unable to get herself up, and crawled to the edge of the road. After an unknown amount of time, a staff member driving to work saw R113, assisted her off the ground, and drove her to the facility. R113 subsequently complained of pain in her back, requiring new physician orders to be written, which constituted harm. On 10/15/24 at 10:50 a.m. an interview was conducted with R113. R113 said that she walked out to the parking lot and then went on down to the road to smoke a cigarette. R113 said that she stepped into the grass and slid into the mud. R113 said that it took her about half an hour to crawl out of the mud. R113 said that she managed to get out of the mud and back to the side of the road, when an employee saw her, and picked her up in her vehicle. R113 stated. I go outside whenever I want to go out. No signing out or telling anyone. On 10/15/24 and 10/16/24, a clinical record review was conducted. This review revealed that on 9/19/24, according to Resident #113's (R113) care plan, R113 was identified as being at risk for elopement and as a wanderer. R113's care plan included a focus area, which was initiated on 9/24/24, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. Interventions for this focus area, included but were not limited to, an intervention entered 9/24/24, which read, monitor location every 2 hours and prn. That intervention was resolved on 10/2/24. On 10/8/24, a new intervention was added to R113's care plan which read, monitor location every 30 minutes and prn. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m., until 6:30 p.m. R113's hospital discharge summary, dated 8/31/24, noted R113 with confusion, unsteady gait, cognitive decline, and unable to live alone. This summary indicated R113 as being unsafe to live alone because of her poor decision making, and noted an example of her placing a paper plate into a toaster oven to support that assessment. On 9/23/24, an elopement risk assessment was completed by the facility, which determined R113 to be an elopement risk and a wander guard was ordered. On 9/20/24 at 6:38 p.m., a nursing progress note in R113's chart read in part, Resident noted setting [sic] on porch this evening. When staff was leaving the facility, found resident walking next to stop sign on property. Assisted back to porch and this nurse walked resident to her unit. Resident watching tv at this time. Resident also had two cigarettes and a lighter on her person. Cigarettes placed in med cart until further direction. On 10/17/24 at 11:20 a.m., the regional director of clinical services measured the distance the resident had achieved on 9/20/24, with the surveyor and facility administrator observing. Although there was no stop sign noted in the designated area that the facility indicated R113 had been found on 9/20/24, it was measured as being 244.4 feet from the front door of the facility. The closest stop sign found in the area by the surveyor was approximately 0.25 miles or 1320 feet from the facility. On 9/23/24 at 7:02 p.m., a nursing progress note was entered into R113's record that read, Pt [patient] was seen walking outside upon returning inside facility she requested to speak with the speech therapist she informed her that she wants to leave the facility to go home. ADON [assistant director of nursing] was contacted via phone an instructed the writer to conduct an elopement assessment, this was done and pt is an elopement risk. Grand daughter was contacted and informed and message left on phone for Dr [medical director name redacted]. Wander guard place on pts Lt [left] ankle for safety. SIC On 9/24/24, R113's care plan was revised to add an intervention, which read, Monitor location every 2 hours and prn [as needed]. This intervention was discontinued on 10/2/24. On 10/17/24, the facility administration was asked to provide the survey team with evidence of the safety monitoring. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m. 6:30 p.m. On 9/25/25 and 9/26/24, nursing note entries in R113's chart both read in part, .Often wonders outside and off sidewalk. Wonderguard in place . SIC On 10/2/24, a nursing progress note in R113's chart read, Resident had fall outside and was assisted back into facility by [certified nursing assistant #6's name redacted], CNA and no injury noted. Wandergaurd is intact and was let out to set on front porch by receptionist and wanderguard does work. On 10/3/24, a progress note from the nurse practitioner was entered into R113's clinical record, which read in part, Patient presented with complaints of lower back pain following a fall. On examination, pain was noted along the spine in the LS [lumbar spine] region. This pain is consistent with a potential injury to the thoracic spine. Plan: Prescribed Tylenol, 1 gram, twice a day for 7 days, with additional doses as needed for pain management. An x-ray will be ordered to rule out a compression fracture. According to facility documents, on 10/2/24, one of the two statements was by certified nursing assistant #1 (CNA#1) who had spotted R113 lying on the ground and had assisted R113 back to the building. On 10/16/24 at 5:21 p.m., an interview was conducted with CNA #1. CNA #1 stated that she had discovered R113 at 2:45 p.m., while driving to work, lying beside the road. CNA#1 stated that R113 had reported that she had fallen into a drainage ditch, off the facility property, and was unable to get up. CNA#1 stated that she had assisted R113 up off the ground, into her jeep, and took R113 back to the facility. According to CNA#1, R113 was wet, had mud all over her, and required a shower. CNA#1 stated that upon entering the building with R113, she had alerted staff, who had been unaware of R113's absence or how long she was gone, and that there had been no audible alarm sounding when they entered the building. On 10/16/24 at 11:20 a.m., the survey team, facility administrator, and regional nurse consultant measured the distance from the facility's front entrance/exit door to the location where R113 was found on 10/2/24, determining that the distance was 465.7 feet. The width of the ditch the resident fell into was measured at 7.2 feet and 0.87 feet in depth. The distance from the hard surface road to the ditch was measured to be 23.5 feet of grass and rough terrain. On 10/16/24 at 11:24 a.m., during an interview, other staff member #1 (OS #1) reported that frequently the front door wander guard system doesn't function properly. OS#1 said, There are times she has it on and it [the door alarm] doesn't go off, they check it and have to make adjustments. It doesn't always go off. Earlier this week [Resident #109's name redacted] went out and it didn't work. OS #1 reported that on 10/2/24, she was helping with answering the phones but was bouncing around and was not at the front desk/lobby when R113 went outside. OS #1 reported that she was on one of the nursing units helping a resident when R113 was brought back to the facility. OS #1 also stated, She [R113] is a difficult one. We never know when she has a wander guard or not, one day she has it and other days she doesn't. On 10/16/24 at 12:28 p.m., an interview was conducted with Other Staff #2 (OS #2), who worked as a back-up receptionist. OS #2 reported that just a few weeks ago she was working on a Sunday and about 1:10 p.m., when she arrived, R113 was in the parking lot. OS #2 said, Since she had a wander guard on, she wasn't supposed to be outside. I told her she needed to come back inside because she had a fall, and I didn't want her to fall again. OS #2 reported this was about 2-3 weeks ago. According to OS #2's timecard, she had worked 9/22/24, which was prior to R113's fall incident and then worked again on Sunday, 10/6/24. OS #2 went on to state that, They [administration] kept changing their minds. At one time they would let her go out on the porch. Another time they said someone had to be with her. When asked about the door alarm and functioning, OS #2 said, Sometimes the things don't go off. It is really sporadic. On 10/16/24 at approximately 2:00 p.m., R124 was observed by the survey team to be in the lobby, beyond the sensor for the wander guard alarm, past the receptionist desk, and only 8 feet from the exit door. Yet, there was no audible alarm triggered by the wander guard system. R124 was redirected back to his room by facility staff, away from the exit doors. On 10/16/24 at approximately 2:30 p.m., an interview was conducted with the maintenance assistant. The maintenance assistant reported that he checks the door alarms daily, Monday through Friday, and at times the front door's wander guard system doesn't work and they have to make adjustments. On 10/16/24 at 3:27 p.m., an interview was conducted with maintenance director. The maintenance director did report that in his short tenure of a few months that . once in a while, the receptionist will say that when a resident goes out, it doesn't alarm, and we have to make adjustments. On 10/16/24 in the early afternoon, the front door wander guard system was tested with the director of nursing (DON). The DON placed a wander guard into her sock, to mimic the location where the wander guard is placed on resident's ankle. The DON was able to walk through the lobby and open the front door, without the locking mechanism of the wander guard system engaging to lock the door and prevent exit. On 10/16/24, in the late afternoon, the front door was again tested using a wander guard by the maintenance director. Initially when the maintenance director had the device pass through the lobby area, the sensor did not pick up the signal, and made no alarm. On the second attempt, the alarm sounded, and the door locked. On the third attempt, the alarm sounded but the door remained unlocked and a resident could have exited. On 10/16/24 at 5:43 p.m., during an end of day meeting with the facility administrator, director of nursing (DON) and regional director of clinical services (RDCS), the incident on 10/2/24, involving R113 was discussed. The facility administrator reported she was not at the facility and was out of town at the time of the incident. The administrator went on to say that there wasn't a receptionist the day of the incident. When the survey team questioned that the nursing progress note indicated that the receptionist had let the resident out, as well as being noted likewise in the investigation summary, but that both receptionists had denied letting the resident out of the facility on 10/2/24, the Administrator and RDCS both stated they didn't know who had let R113 outside. During the end of day meeting held on 10/16/24, the RDCS provided the survey team with an Action Plan they had implemented following R113's elopement on 10/2/24. According to the action plan residents with a wander guard were reviewed to ensure appropriateness. The RDCS and Administrator stated that they determined R113 was not an elopement risk and was not appropriate to have a wander guard. On 10/17/24 at 9:00 a.m. another interview was conducted with R113. R113 stated, I just went out the front door, the door was unlocked, and people were outside, and no alarm sounded. I would go up sometimes and the alarm would sound, and they would turn it off, and I would go out the door. On 10/17/24 at 9:19 a.m., the facility administrator was asked about the functioning of the wander guard system. The administrator said, I am not aware of an issue. The survey team reported that in staff interviews multiple staff reported that the wander guard system is inconsistent and doesn't always operate properly. It was also reported that during the testing of the system by the DON and by the maintenance director the day prior, the wander guard system had not functioned properly. The administrator stated, This is the first I've heard of it. I always thought there was a mag [magnetic] lock, that if the door isn't closing enough, they may not latch. We just adjust those sensors on the side regularly. There is some sort of sensitivity, different things can affect it. That's usually what's going on. On 10/17/24 at 11:15 a.m. an interview was conducted with the business office assistant (other staff #2, OS2). OS2 verbalized that residents with wander guards were able to go out and sit on the front porch without staff going with them, until R113 fell outside. OS#2 stated, Now, if a resident with a wander guard wants to go outside, staff or a family member had to be with the resident. On 10/17/24 at 9:00 a.m. an interview with R113 was conducted. R113 was complaining of her back hurting from her waist down and that her chest was hurting. The surveyor notified R113's nurse, LPN#6. When notified, the physician ordered an x-ray of R113's lumbar spine on 10/17/24. On 10/17/24 at 3:15 p.m., the survey team identified the facility was in immediate jeopardy (IJ) in the care area of Quality of Care, as confirmed by the state agency. Given the findings that the facility failed to provide adequate supervision and failed to have a consistently functioning wander guard system to prevent residents identified as an elopement risk the ability to exit the facility without staff knowledge, the survey team determined that this noncompliance made the occurrence of serious adverse outcome likely and that the facility needed to take immediate corrective action. The survey team met with the facility administrator, director of nursing, and corporate staff and reviewed the IJ findings. On 10/18/24 at 6:20 p.m., the facility administration provided the survey team with an accepted IJ removal plan. The facility's plan to remove IJ read as follows: At approximately 0930 on 10/17/24 a staff member was posted at the front door to monitor entrance and exit and to ensure residents at risk were not allowed to exit without supervision. A staff member was assigned to relieve the scheduled staff when needed. [NAME] Security Services was contacted and on-site at arrived on site 10/17/24 at approximately 3:00 pm to work on functionality of the door alarming and latching when triggered by the Wander guard alarm. A staff person has been scheduled for 1:1 supervision of the front door for next 24 hours and until maintenance has verified door functionality; staff will be educated on responsibility of supervising the front door. All current staff in the building will be educated on their responsibility of preventing resident elopements beginning 10/17 evening shift and additional staff will be educated at their assigned shift. The facility alleged they would have the IJ removal plan completed on 10/17/24 at 6:30 p.m. On 10/17/24 at 6:20 p.m. the front receptionist was interviewed. The receptionist was able to verbalize that she was not able to leave the desk for any reason, unless someone came to relieve her. The receptionist was able to verbalize that residents with wander guards are not able to exit the front door unless a staff member was with them and also showed the surveyor an elopement book which identified the residents with wander guards. On 10/18/24 at 8:15 am the survey team returned on-site to verify the removal of IJ. A receptionist was sitting at the front desk in the lobby. The receptionist was interviewed and was able to verbalize that residents with wander guards are not permitted to go outside unless accompanied by staff or family. The receptionist also stated that she was not able to leave from monitoring the front desk/door unless someone was present to relieve her. Sign off sheets were verified that since 5 p.m. on 10/17 staff signed every 15 minutes that they were watching the front door, and it was continuously monitored. A statement from the maintenance director indicated that he had worked on the front door on 10/17 and had called a contractor in to work on it. The contractor bill dated 10/17/24 was provided which showed that the lever trim function of the front exterior door had been changed. The facility reported that the front door wander guard system was now operating properly. The survey team verified this with the Director of Nursing, noting that the system alarmed and locked the door when a wander guard approached the door. A copy of the schedule for all departments on 10/17 and 10/18 was received. Staff education sign-in sheets were also received, and a comparison was made to ensure that all staff working in the facility at 6:30 p.m., on 10/17 signed that they were educated on elopement, how to manage elopement risks, etc. Several staff were identified that had worked the evening/night shift that had not signed as having received education. Also identified was a certified nursing assistant (CNA #4) who was currently working who had not signed as having received education. CNA #4 was interviewed and confirmed she had not received any education. A sample of staff across all departments to include therapy, housekeeping, laundry, nursing and dietary were interviewed to ensure that they received training and understood elopement risk, how to respond in the event of a missing resident, and how to respond if the wander guard alarm sounds, etc. On 10/18/24 at 10 a.m., the administrator was asked to come to the conference room. When shown the staff that that had not signed as being educated, the administrator provided additional sign-in sheets that the survey team had not been given. The survey team was able to identify that all staff currently working and who had worked since 6:30 pm on 10/17/24 had received training except for CNA #4. On 10/18/24 at 10:10 a.m., the facility administrator was made aware the survey team had found that a staff member had not been educated. The administrator was notified that the survey team could not verify abatement of IJ until CNA #4 was trained. On 10/18/24 at 10:20 a.m., the facility administrator provided evidence that CNA #4 had been educated. On 10/18/24 at 10:20 a.m., the survey team was able to confirm that the immediacy had been removed. Following the removal of immediate jeopardy the scope and severity was lowered to a level three, isolated, as R113 suffered pain following the elopement incident and fall. No more information was provided.

Based on resident interviews, staff interviews, observations, and facility documentation, the facility staff failed to ensure multiple residents on 2 of 2 units had the opportunity to exercise autonomy regarding voting interests and preferences. The findings included: 1. The facility staff failed to ensure that multiple residents were able to pursue an activity that was important them. On 10/15/24 at 11:15 am, during the initial tour of the facility, Resident #114 (R114) and Resident #123 (R123) asked the surveyor if they were allowed to vote. R114 and R123 both stated that no one from the facility had talked with them about voting. R114 stated, I want to vote and need to know what to do. R123 stated, I have a voter's card and would like to vote. Also during this tour, no signage with voting information was observed. On 10/15/24 at 11:40 am, an interview was conducted with the social service director. The social service director said she had only been in this position since 9/26/24. The social service director said, If the resident is not registered to vote, then we will get them registered. When asked about the lack of posted voting information, the social service director stated, I will have the information hung up before the end of the day for the residents to see. When questioned further, the social service director said that she had not contacted the register's office but would do so that day. On 10/15/24 at 11:50 a.m., an interview was conducted with the administrator. The administrator said that the preparation for voting should begin the month of September. The administrator stated, Generally social services does the prep for voting but I didn't have anyone in social services for one month. The administrator said, If the residents are not registered, then we would fill out the registration forms so they can vote. When questioned about the lack of observable voting information, the administrator said that the information for the right to vote should be posted. The administrator stated, Residents can do an absentee ballot if they wanted to or go to the polls, we would take them there. On 10/15/24 at 4:30 p.m. an observation was conducted for voting information. This surveyor observed signs posted that read, If a resident was interested in voting to see the social service director ASAP [as soon as possible]. These signs were posted in common areas on each unit at the bulletin boards at the nurse's station, outside the dining room, and in the vending machine area. On 10/16/24 at 9:00 a.m., a follow-up interview was conducted with R114 and R123. R114 and R123 verbalized that no one from the facility had talked with them about voting and that they wanted to vote. On 10/16/24 at 12:10 p.m. an interview was conducted with Resident #103 (R103). R103 stated that over a month ago, I asked the activity assistant about voting and I didn't get a response. R103 said that she wanted to vote and was registered in another county to vote, so she was not sure how that worked. R103 said no one from the facility had discussed voting with her. R103 stated, If you don't vote, you are part of the problem. When the surveyor asked about being transported to the location where she is registered to vote, R103 stated that it was 2 hours away. On 10/16/24 at 12:20 p.m., an interview was conducted with Resident #106 (R106). R106 stated, I didn't know I could vote but I would like to. On 10/16/24 at 12:25 p.m., an interview was conducted with Resident #111 (R111). R111 said no one had spoken with her about voting from the facility. R111 said that she was registered, wanted to vote, and would like to do an absentee ballot. On 10/16/24 at 12:30 p.m., an interview was conducted with Resident #113 (R113). R113 said that she was not registered to vote and does not know how to register. R113 said she would like to vote in this election. On 10/16/24 at 12:35 p.m. an interview was conducted with Resident #108 (R108). R108 said she wanted to vote and was registered to vote in another county. On 10/16/24 at 12:38 p.m. an interview was conducted with Resident #102 (R102). R102 said that no facility staff had spoken with him about voting. R102 said he was registered and wanted to vote. On 10/16/24 at 12:50 p.m., a telephone call was placed to the voter registration office in the locality where the facility was located. The registrar reported that the deadline for non-registered voters to register ended at 5 p.m. on 10/15/24. As for the residents who are registered at other locations, the registrar stated that it would be up to the registrar at each locality as to whether the resident would be able submit an absentee ballot there or not. The registrar reported that the deadline for absentee ballots is that they must be received in the local office by 5pm on Thursday, October 24, 2024. On 10/16/24 at 3:00 p.m., an interview was conducted with the social services director. The social services director said that she called the register's office yesterday and was told if the resident is registered, an absentee ballot can be completed, but must be mailed out by Monday. The social worker director said, If the resident is not registered, then we have missed that deadline. The cutoff date was yesterday. The surveyor asked how the residents would see the notice about voting if they do not come out of their rooms and the social worker director said, We will go room to room and ask each resident about voting. On 10/16/24 at approximately 5:00 p.m., the administrator provided a document titled, Center for Clinical Standards and Quality, which was a CMS (Centers for Medicare and Medicaid services) guidance for nursing home policies. The administrator stated, We have no voting policy. This is all we have. The CMS document read in part, .certified long-term care facilities affirm and support the right of residents to vote. Nursing homes should have a plan to ensure residents can exercise their right to vote, whether in person, by mail, absentee ballot, or other authorized process. Assistance in registering to vote, requesting an absentee ballot or completing a ballot from an agent of the resident's choosing. No other information was provided prior to survey exit.

Based on resident interviews, staff interviews, observations and facility documentation the facility staff failed to allow the residents to exercise their rights as a citizen of the United States for multiple residents residing on 2 of 2 units and failed to treat residents with and provide an environment that promoted respect and dignity for residents on 1 of 2 nursing units. The findings included: 1. The facility staff failed to ensure the resident right regarding voting was upheld, affecting multiple residents on 2 of 2 units. On 10/15/24 at 11:15 am during the initial tour of the facility nursing units Resident #114 (R114) and Resident #123 (R123) asked the surveyor if they were allowed to vote. R114 and R123 both stated that no one from the facility had talked with them about voting. R114 stated, I want to vote and need to know what to do. R123 stated, I have a voter's card and would like to vote. On 10/15/24 at 11:40 am an interview was conducted with the social service director. The social service director said she had only been in this position since 9/26/24. She stated that if the resident is not registered to vote, then we will get them registered. The social service director stated, I will have the information hung up before the end of the day for the residents to see. The social service director said that she had not contacted the register's office but would do that today. On 10/15/24 at 11:50 a.m. an interview was conducted with the administrator. The administrator said that the preparation for voting should begin the month of September. The administrator stated, generally social services does the prep for voting but I didn't have anyone in social services for one month. The administrator said if the residents were not registered, then we would fill out the registration forms so they can vote. The administrator said the information for the right to vote should be posted. She stated, do an absentee ballot if they wanted to or go to the polls, we would take them there. On 10/15/24 at 4:30 p.m. an observation was conducted. This surveyor observed signs posted that read, if a resident was interesting in voting to see the social service director ASAP [as soon as possible]. The signs were posted only in common areas on each unit at the bulletin boards at the nurse's station, outside the dining room and in the vending machine area. On 10/16/24 at 9:00 a.m. a follow-up interview was conducted with R114 and R123. R114 and R123 verbalized that no one from the facility had talked with them about voting and they wanted to vote. On 10/16/24 at 12:10 p.m. an interview was conducted with Resident #103 (R103). R103 stated that over a month ago, I asked the activity assistant about voting and I didn't get a response. R103 said she wanted to vote and was registered in another county to vote so she was not sure how that worked. R103 said no one from the facility had discussed voting with her. R103 stated, if you don't vote, you are part of the problem. When the surveyor asked about being transported to the location where she is registered to vote, R103 stated that it was 2 hours away. On 10/16/24 at 12:20 p.m. an interview was conducted with Resident #106 (R106). R106 stated, I didn't know I could vote but would like to vote. On 10/16/24 at 12:25 p.m. an interview was conducted with Resident #111 (R111). R111 said no one had spoken with her about voting from the facility. She said she was registered, wanted to vote and would like to do absentee ballot. On 10/16/24 at 12:30 p.m. an interview was conducted with Resident #113 (R113). R113 said that she was not registered to vote and does not know how to register. R113 said she would like to vote in this election. On 10/16/24 at 12:35 p.m. an interview was conducted with Resident #108 (R108). R108 said she wanted to vote and was registered to vote in another county. On 10/16/24 at 12:38 p.m. an interview was conducted with Resident #102 (R102). R102 said that no facility staff had spoken with him about voting. R102 said he was registered and wanted to vote. On 10/16/24 at 12:50 p.m., a telephone call was placed to the voter registration office in the locality where the facility was located. The registrar reported that the deadline for non-registered voters to register was yesterday by 5 p.m. As for residents who are registered at other locations, it would be up to the registrar at that locality as to if the resident can do an absentee ballot there or not. The registrar reported that the deadline for absentee ballots is that they must be received in their office by 5pm on Thursday, October 24, 2024, at 5 pm. On 10/16/24 at 3:00 p.m. an interview was conducted with the social service director. The social service director said she called the register's office yesterday and if the resident is registered that an absentee ballot can be completed and must be mailed out by Monday. The social worker director stated, that if the resident is not registered that we have missed that deadline, and the cutoff date was yesterday. The surveyor asked how the residents would see the notice about voting if they do not come out of their rooms and the social worker director said, we will go room to room and ask each resident about voting. On 10/16/24 at approximately 5:00 p.m. the administrator provided a document titled, Center for Clinical Standards and Quality, that was a CMS (Centers for Medicare and Medicaid services) document, and she stated, we have no voting policy this is all we have. The CMS document read in part, .certified long-term care facilities affirm and support the right of residents to vote. Nursing homes should have a plan to ensure residents can exercise their right to vote, whether in person, by mail, absentee ballot, or other authorized process. Assistance in registering to vote, requesting an absentee ballot or completing a ballot from an agent of the resident's choosing. 2. The facility staff failed to provide residents with an environment to promote dignity on 1 of 2 units. On 10/15/24 at 2:30 p.m. an interview was conducted with Resident #104 (R104). R104 said she feels safe now and staff is good except some arguing. R104 said this morning that the unit manager was at the door screaming at the aide that was in the room with my roommate. R104 stated, I yelled to get out of here, close the door because it makes me anxious, and it bothers me. On 10/15/24 at 4:30 p.m. an interview was conducted with a licensed practical nurse, unit 3 manager, LPN# 5 (LPN5). LPN5 said that this morning she had words with certified nursing assistant, CNA #3 (CNA3). LPN#5 said that CNA3 started screaming at me. LPN5 said she told CNA3 it was her responsibility to chart on residents and CNA3 began arguing and LPN5 stated, I told her to stop I was not going to argue with her. LPN5 said she told CNA3 to clock out, leave and called the director of nursing (DON). LPN5 said CNA3 was in the resident's room and yelling, you have no control of me. LPN5 said CNA3 continued to work until her shift was done. On 10/16/24 at 4:45 an interview was conducted with the regional director of clinical services (RDCS). The RDCS said that they interviewed the resident after the incident, and we did not have anyone that stated they were fearful. On 10/15/24 at 5:00 p.m. an interview was conducted with the director of nursing (DON). The DON said that CNA3 worked until I came in this morning about 7:10 a.m. I had a conversation with CNA3 and CNA# 2 (CNA2), because she was a witness to the incident, and we had the conversation with the human resource director. On 10/15/24 at 5:20 p.m. an interview was conducted with the treatment nurse, LPN#7 (LPN7). LPN#7 said, at about 6:15 a.m. I don't know the aides name, but aide (CNA2) came up said I changed the resident and LPN#5 said you can tell me he had feces on his brief, but did you chart it, if not care has not been done. LPN7 said, then the other aide (CNA3) said I cannot get in to chart, and we told you a week ago and [LPN5's name redacted] said advocate for yourself, and it looks like you did not do your job. [LPN5's name redacted] said I am not human resources I cannot help you. Then, LPN5 said I am not going to argue with you and the aide (CNA3) said I don't know why you have such an attitude. The aide CNA3) went to the resident's room, had the door opened, was not closed all the way, and LPN5 and the aide (CNA3) were loud. LPN7 said she was just stepping in trying to calm the situation and support another manager. LPN7 said she had never witnessed other arguments on the floor but had heard that it happens. On 10/15/24 at 7:15 p.m. an interview was conducted with CNA#2. CNA2 said that she was getting CNA3 to help her with a resident's care. CNA2 reported that CNA3 went to the resident's room and opened the door and CNA3 yelled up to the nurse's station asking LPN5 why she was screaming at her. CNA2 said that LPN5 stood up out of her chair and began screaming at CNA3 to clock out. CNA2 reported that R104 yelled out for CNA3 to close the door and do that outside the door not in my room. CNA3 closed the door and she and LPN5 kept yelling and then finally they stopped and CNA3 came into the room with me to help me with Resident #122's (R122) care. While we were doing incontinence care for R122, LPN5 opened the resident's door and demanded CNA3 to come out of the room. CNA3 said to LPN5 I am providing care for a resident now and LPN5 just kept yelling for CNA3 to come out of the room and was getting louder and louder. CNA2 said R104 was sleeping when this argument started, and the resident appeared agitated. CNA2 said that R122 looked uncomfortable and all she could do was apologize to both residents. On 10/16/24 at 9:25 a.m. an interview was conducted with R104. R104 said that she was shocked by all the yelling. She said it made her anxious and agitated. R104 stated, an almost fist throwing happened about 2 weeks ago. R104 said the staff should be more respectful because it scares us! On 10/16/24 at 9:30 a.m. an interview was conducted with R122. R122 stated, they were talking loudly over me and saying come out here now. I could hear them arguing until [roommate's name redacted] told them to get out and shut the door. R122 said, It was a rough morning. I didn't like it, and it made me uncomfortable. It didn't involve me, so take it elsewhere. On 10/16/24 at 5:43 p.m. an end of day meeting was conducted with the administrator, director of nursing and regional director of clinical services. The above concerns were discussed. The facility administrator stated, we didn't know what was going on until you said something. The RDCS and administrator said that the reason they were not aware of the staff arguing, was that the DON was on a medication cart and then you all (surveyors) walked into the building, and it was forgotten. The RDCS and the administrator said it had been taken care of and reported they had suspended the employees involved, reported the incident as an allegation of abuse and are investigating. The administrator stated that R104 had been interviewed. When asked about the other resident, R104's roommate, the administrator stated, she wasn't interviewable. The facility administrator was made aware that according to R122's clinical record, she had a brief interview for mental status (BIMS) score of 15 out of 15 and had been able to communicate and answer questions with the surveyor. The survey team explained that R122 had been the resident staff were providing care to when the altercation had taken place. The facility administrator stated they would go talk with her immediately following the meeting/discussion with the survey team and that they were unaware R122 was involved. The facility reported that they did not have a facility policy with regards to staff interactions in resident care areas. The facility did provide the survey team with a document titled, Employee Guidebook, and on page 16 it read in part, Professional Courtesy and Customer Service . The company is committed in our efforts to provide a high standard of resident/patient care and excellent customer service, and in the communication that takes place during the workday. You are also expected to approach customers, clients, residents, patients and families in a professional, courteous and efficient manner . The facility also provided a document titled, Code of Ethics. Within that document excerpts read, The company will not tolerate: . Any other conduct that creates an intimidating or hostile work environment . The facility provided a policy titled, Resident Rights, read in part .ensure that residents right are known to staff. Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations. No additional information was provided.

Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to administer the facility in a manner to effectively maintain the highest practicable well-being of each resident, having the potential to affect many residents on 2 of 2 nursing units. The findings included: 1. The facility administration failed to effectively administer/manage the facility to provide adequate supervision and a consistently functioning wander management system, to prevent residents with a known elopement risk the ability to exit the facility and facility grounds. According to multiple staff interviews, the facility administration was aware and had permitted residents identified as a wandering risk to exit the facility routinely. The administrator failed to ensure adequate supervision although it was known that the wander guard system didn't operate properly, which also permitted residents at risk for wandering to exit the facility without staff knowledge. On 10/15/24 and 10/16/24, an interview was conducted with R113. R113 reported to the surveyor that she used to go outside, sit on the porch and would at times walk off the facility premises to smoke. R113 also verbalized during the interview that she wanted to leave the facility and return home to live. On 10/15/24 and 10/16/24, a clinical record review was conducted. This review revealed several nursing note entries related to R113 going outside unassisted and unsupervised. The entries were on the following dates: 9/20/24, 9/23/24, 9/25/24, 9/26/24, and 10/2/24. On 10/2/24, R113 exited the facility, left the facility premises, fell into a drainage ditch, and crawled out of the ditch to the side of the road, where she was seen by a staff member who was driving to work, assisted off the ground, and driven back to the facility. On 10/16/24 at 12:24 p.m., an interview was conducted with licensed practical nurse #9 (LPN #9) who had written the nursing note dated 9/20/24, referenced above. LPN #9 was asked about the incident on 9/20/24 with R113. LPN #9 said, The CNA told me they thought she was out, as I was going down, the business office manager said, I just got [R113's name redacted] from the stop sign. They also handed me 2 cigarettes they had taken away. LPN #9 reported she was not sure how far R113 had gotten or the specific location she was retrieved from but had been told that R113 was at the end of the driveway. LPN #9 reported that at that time, R113 did not have a wander guard in place. On 10/16/24 at 11:19 a.m., an interview was conducted with registered nurse #3 (RN #3) who was the author of the nursing note dated 9/23/24. During the interview, RN #3 stated, I was in my car getting my blood pressure equipment and she [R113] was in the parking lot. I raised the concern, as I had heard she was an elopement risk, and I asked the other nurse when I came back in with her, since I am only part-time. She [R113] had told the nutrition lady she wanted to leave, she told her not to tell me, she wanted to go home and wanted to leave without permission. On 10/16/24 at 11:24 a.m., during an interview with other staff member #1 (OS #1), she reported that frequently the front door wander guard system doesn't function properly. OS #1 said, There are times she [R113] has it on and it [ the door] doesn't go off, they check it, and have to make adjustments. It doesn't always go off. Earlier this week [resident #109's name redacted] went out and it didn't work. OS #1 reported that on 10/2/24, she was helping with answering the phones but was bouncing around and was not at the front desk/lobby when R113 went outside. OS #1 reported that she was on one of the nursing units helping a resident when R113 was brought back. OS #1 also stated, She [R113] is a difficult one, we never know when she has a wander guard or not. One day she has it and other days she doesn't. When asked if the administrator was aware that the wander guard was not functioning properly, OS #1 stated that the administrator was aware. On 10/16/24 at 12:28 p.m., an interview was conducted with Other Staff #2 (OS #2), who worked as a back-up receptionist. OS #2 reported that just a few weeks ago she was arriving about 1:10pm on a Sunday and saw R113 in the parking lot. OS #2 said, Since she [R113] had a wander guard on, she wasn't supposed to be outside. I told her she needed to come back inside because she had a fall, and I didn't want her to fall again. OS #2 reported that this was about 2-3 weeks ago. According to OS #2's timecard, she had worked 9/22/24, which was prior to R113's fall incident, and then worked again on Sunday, 10/6/24. OS #2 went on to state, They [administration] kept changing their minds, at one time they would let her go out on the porch, another time they said someone had to be with her. When asked about the door alarm and functioning OS #2 said, Sometimes the things don't go off; it is really sporadic. On 10/16/24 at 1:02 p.m., an interview was conducted with registered nurse #1 (RN #1). RN #1 was the nurse that wrote the progress note dated 10/2/24, regarding R113's fall while outside. RN #1 stated that she was told by CNA #6 that she brought her back in. RN #1 also stated that the RDCS had told her the same thing and reported that the receptionist had let the resident out. RN #1 reported that the resident was covered in mud, she had a wander guard on, and the receptionist turned the alarm off and let her out. I don't remember who told me that. Corporate said they are allowed to go out and whoever lets them out should go with the resident. On 10/16/24 at approximately 2:30 p.m., an interview was conducted with the maintenance assistant about the wander guard system. The maintenance assistant reported that he checks the door alarms daily and at times the front door's wander guard system doesn't work and they must make adjustments. On 10/16/24 at 3:27 p.m., an interview was conducted with the maintenance director about issues with the wander guard system. The maintenance director reported that in his short tenure of a few months that .once in a while the receptionist will say that when a resident goes out it doesn't alarm, and we have to make adjustments. On 10/16/24, the front door wander system was tested with the director of nursing (DON). The DON placed a wander guard into her sock, to mimic the location where the wander guard is placed on resident's ankle. The DON was able to walk through the lobby and open the front door, without the locking mechanism engaging to lock the door and prevent exit. On 10/16/24, in the late afternoon, the front door was again tested using a wander guard by the maintenance director. Initially when the maintenance director had the device pass through the area, the sensor did not pick up the signal and made no alarm. On the second attempt, the alarm sounded, and the door locked. On the third attempt, the alarm sounded but the door remained unlocked, and a resident could have exited. On 10/16/24 at 5:43 p.m., during an end of day meeting with the facility administrator, director of nursing (DON), and regional director of clinical services (RDCS), the incident on 10/2/24, involving R113 was discussed. The facility administrator reported that she was not at the facility and was out of town at the time of the incident. When questioned further, the administrator went on to say that there wasn't a receptionist the day of the incident. When the survey team questioned that the nurse progress note indicated that the receptionist let the resident out, as well as the investigation summary, but both receptionists denied having done so, the Administrator and RDCS stated that they didn't know who had let R113 outside. On 10/17/24 at 9:19 a.m., the facility administrator was asked about the wander guard system. The administrator said, I am not aware of an issue. The survey team informed the administrator that multiple staff had reported that the wander guard system is inconsistent and doesn't always operate properly. The administrator was also informed that during the testing by the DON and maintenance director the day prior, the wander guard system had not functioned properly. The administrator then said, This is the first I've heard of it. I always thought there was a mag [magnetic] lock, if the door isn't closing enough, they may not latch. We just adjust those sensors on the side regularly. There is some sort of sensitivity, different things can affect it. That's usually what's going on. 2. The facility administration failed to ensure the resident's right to vote was being upheld, knowing a presidential election was upcoming. On 10/15/24 at 11:15 am, during the initial tour of the facility nursing units, Resident #114 (R114) and Resident #123 (R123) asked the surveyor if they were allowed to vote. R114 and R123 both stated that no one from the facility had talked with them about voting. R114 said, I want to vote and need to know what to do. R123 stated, I have a voter's card and would like to vote. On 10/15/24 at 11:40 am, an interview was conducted with the social service director. The social service director said she had only been in this position since 9/26/24. The social service director stated, If the resident is not registered to vote, then we will get them registered. When questioned about the lack of posted voting information, the social service director said, I will have the information hung up before the end of the day for the residents to see. When questioned about voting eligibility, the social service director stated that she had not contacted the register's office but would do so that day. On 10/15/24 at 11:50 a.m. an interview was conducted with the administrator. The administrator stated that the preparation for voting should begin the month of September. The administrator stated, Generally social services does the prep for voting but I didn't have anyone in social services for one month. The administrator stated if the residents were not registered, then we would fill out the registration forms so they can vote. The administrator stated the information for the right to vote should be posted. The administrator said, The residents can do an absentee ballot if they wanted to or go to the polls, we would take them there. On 10/15/24 at 4:30 p.m. an observation of the common areas was conducted. The survey team observed signs posted that read, If a resident was interesting in voting to see the social service director ASAP [as soon as possible]. The signs were posted in common areas on each unit at the bulletin boards at the nurse's station, outside the dining room, and in the vending machine area. On 10/16/24 at 9:00 a.m. a follow-up interview was conducted with R114 and R123. R114 and R123 verbalized that no one from the facility had talked with them about voting and that they wanted to vote. On 10/16/24 at 12:10 p.m. an interview was conducted with Resident #103 (R103). R103 stated that over a month ago, I asked the activity assistant about voting and I didn't get a response. R103 said that she wanted to vote and was registered in another county to vote, so she was not sure how that worked. R103 said no one from the facility had discussed voting with her. R103 stated, If you don't vote, you are part of the problem. When the surveyor asked about being transported to the location where she is registered to vote, R103 stated that it was 2 hours away. On 10/16/24 at 12:20 p.m. an interview was conducted with Resident #106 (R106). R106 stated, I didn't know I could vote but would like to vote. On 10/16/24 at 12:25 p.m. an interview was conducted with Resident #111 (R111). R111 said that no one had spoken with her about voting from the facility. R111 said that she was registered, wanted to vote, and would like to do absentee ballot. On 10/16/24 at 12:30 p.m. an interview was conducted with Resident #113 (R113). R113 said that she was not registered to vote and does not know how to register. R113 said that she would like to vote in this election. On 10/16/24 at 12:35 p.m. an interview was conducted with Resident #108 (R108). R108 said she wanted to vote and was registered to vote in another county. On 10/16/24 at 12:38 p.m. an interview was conducted with Resident #102 (R102). R102 said that no facility staff had spoken with him about voting. R102 said that he was registered and wanted to vote. On 10/16/24 at 12:50 p.m., a telephone call was placed to the voter registration office in the locality where the facility was located. The registrar reported to the surveyor that the deadline for non-registered voters to register was 5 p.m. yesterday, 10/15/24. As for residents who are registered at other locations, it would be up to the registrar at that locality as to whether the resident could do an absentee ballot there or not. The registrar reported that the deadline for absentee ballots is that they must be received in the local office by 5pm on Thursday, October 24, 2024, On 10/16/24 at approximately 5:00 p.m. the administrator provided a document titled, Center for Clinical Standards and Quality, that was a CMS (Centers for Medicare and Medicaid services) guidance for nursing home policies, and stated, We have no voting policy. This is all we have. This CMS document read in part, .certified long-term care facilities affirm and support the right of residents to vote. Nursing homes should have a plan to ensure residents can exercise their right to vote, whether in person, by mail, absentee ballot, or other authorized process. Assistance in registering to vote, requesting an absentee ballot or completing a ballot from an agent of the resident's choosing. 3. The facility administrator denied being aware of a disruptive staff argument that took place on the nursing unit, that continued into the room of two residents, with yelling and raised voices that awoke one resident and alarmed them both, until being notified by the survey team. On 10/15/24 at approximately 11 a.m., during an interview with Resident #104 (R104), the resident reported to the surveyor that she had been awakened by yelling that morning. I told them [the staff] to get out of my room, shut the door, and take it elsewhere! When questioned how the incident had made her feel, R104 reported that she had gotten anxious and didn't like it. On 10/15/24, during an end of day meeting, the facility administrator, director of nursing, and regional director of clinical services were made aware of Resident #104 reporting that staff had an argument that morning, which took place out on the unit and then continued into the resident's room. The facility administrator stated that was the first she was hearing of the incident. On 10/15/24 at 7:20 p.m., staff interviews were conducted with certified nursing assistants #2 and #3 (CNA #2 and CNA #3). Both CNA #2 and CNA #3 confirmed that on the morning of 10/15/24 at approximately 6:30-6:45 a.m., a disagreement had taken place at the nursing station between them and the unit manager/licensed practical nurse #5 (LPN #5). CNA #3 reported that she walked away and went to provide care to Resident #122 and that LPN #5 came to the room and started calling her to come out of the room with a raised voice. CNA #2 confirmed that LPN #5 had come to the resident's room and in a loud voice kept yelling for CNA #3 to exit the room. CNA #2 went on to report that R104 was awakened by the incident and shouted for them to get out & shut the door. CNA#2 stated that R#122 had looked very uncomfortable and that she had apologized to both residents. On the morning of 10/16/24 at approximately 8:40 a.m., an interview was conducted with R122. R122 reported that the CNA#2 and CNA#3 were providing care for her, when another staff member [LPN #5] had come to the room door and was yelling at CNA #3. On 10/16/24 at 5:43 p.m., during an end of day meeting, the facility administrator, director of nursing, and regional director of clinical services were asked what they had done with regards to the staff conflict. The facility administrator stated, We didn't know what was going on until you said something. We have suspended the employees involved, reported the incident as an allegation of abuse, and are conducting an investigation. The administrator stated that R104 had been interviewed. When asked about the other resident, R104's roommate, the administrator stated, she wasn't interviewable. When asked why she felt that R#122 was not interviewable, the administrator did not respond. The facility administrator was made aware that according to R122's clinical record, she had a brief interview for mental status (BIMS) score of 15 out of 15, indicating intact cognition, and had been able to communicate and answer questions appropriately with the surveyor. The survey team also informed the administrator that R122 was the resident to whom staff were providing care when the altercation had taken place. The facility administrator stated that they would go talk with her immediately following the meeting with the survey team and that they were unaware the roommate was involved. According to the facility job description of the Executive Director 1 (Administrator), which read in part, . The primary purpose of the Executive Director is to direct the day-to-day functioning of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times . You will also provide leadership to all facility staff in meeting the goal of providing quality resident care . No other information was provided prior to exit.

Based on resident interviews, staff interviews, observations and facility documentation the facility staff failed to allow the residents to exercise their rights as a citizen of the United States for multiple residents residing on 2 of 2 units and failed to treat residents with and provide an environment that promoted respect and dignity for residents on 1 of 2 nursing units. The findings included: 1. The facility staff failed to ensure the resident rights regarding voting was upheld, affecting multiple residents on 2 of 2 units. On 10/15/24 at 11:15 am during the initial tour of the facility nursing units Resident #114 (R114) and Resident #123 (R123) asked the surveyor if they were allowed to vote. R114 and R123 both stated that no one from the facility had talked with them about voting. R114 stated, I want to vote and need to know what to do. R123 stated, I have a voter's card and would like to vote. On 10/15/24 at 11:40 am, an interview was conducted with the social service director. The social service director said she had only been in this position since 9/26/24. The social service director said, If the resident is not registered to vote, then we will get them registered. When asked about the lack of posted voting information, the social service director stated, I will have the information hung up before the end of the day for the residents to see. When questioned further, the social service director said that she had not contacted the register's office but would do so that day. On 10/15/24 at 11:50 a.m., an interview was conducted with the administrator. The administrator said that the preparation for voting should begin the month of September. The administrator stated, Generally social services does the prep for voting but I didn't have anyone in social services for one month. The administrator said, If the residents are not registered, then we would fill out the registration forms so they can vote. When questioned about the lack of observable voting information, the administrator said that the information for the right to vote should be posted. The administrator stated, Residents can do an absentee ballot if they wanted to or go to the polls, we would take them there. On 10/15/24 at 4:30 p.m., an observation was conducted for voting information. This surveyor observed signs posted that read, if a resident was interested in voting to see the social service director ASAP [as soon as possible]. These signs were posted in common areas on each unit at the bulletin boards at the nurse's station, outside the dining room, and in the vending machine area. On 10/16/24 at 9:00 a.m., a follow-up interview was conducted with R114 and R123. R114 and R123 verbalized that no one from the facility had talked with them about voting and they wanted to vote. On 10/16/24 at 12:10 p.m., an interview was conducted with Resident #103 (R103). R103 stated that over a month ago, I asked the activity assistant about voting and I didn't get a response. R103 said she wanted to vote and was registered in another county to vote so she was not sure how that worked. R103 said no one from the facility had discussed voting with her. R103 stated, if you don't vote, you are part of the problem. When the surveyor asked about being transported to the location where she is registered to vote, R103 stated that it was 2 hours away. On 10/16/24 at 12:20 p.m., an interview was conducted with Resident #106 (R106). R106 stated, I didn't know I could vote but I would like to. On 10/16/24 at 12:25 p.m., an interview was conducted with Resident #111 (R111). R111 said no one had spoken with her about voting from the facility. R111 said that she was registered, wanted to vote, and would like to do absentee ballot. On 10/16/24 at 12:30 p.m. an interview was conducted with Resident #113 (R113). R113 said that she was not registered to vote and does not know how to register. R113 said she would like to vote in this election. On 10/16/24 at 12:35 p.m., an interview was conducted with Resident #108 (R108). R108 said she wanted to vote and was registered to vote in another county. On 10/16/24 at 12:38 p.m., an interview was conducted with Resident #102 (R102). R102 said that no facility staff had spoken with him about voting. R102 said he was registered and wanted to vote. On 10/16/24 at 12:50 p.m., a telephone call was placed to the voter registration office in the locality where the facility was located. The registrar reported that the deadline for non-registered voters to register ended at 5 p.m. on 10/15/24. As for the residents who are registered at other locations, the registrar stated that it would be up to the registrar at each locality as to whether the resident would be able submit an absentee ballot there or not. The registrar reported that the deadline for absentee ballots is that they must be received in the local office by 5pm on Thursday, October 24, 2024. On 10/16/24 at 3:00 p.m., an interview was conducted with the social services director. The social services director said that she called the register's office yesterday and was told if the resident is registered, an absentee ballot can be completed, but must be mailed out by Monday. The social worker director said, If the resident is not registered, then we have missed that deadline. The cutoff date was yesterday. The surveyor asked how the residents would see the notice about voting if they do not come out of their rooms and the social worker director said, We will go room to room and ask each resident about voting. On 10/16/24 at approximately 5:00 p.m. the administrator provided a document titled, Center for Clinical Standards and Quality, that was a CMS (Centers for Medicare and Medicaid services) document, and she stated, We have no voting policy. This is all we have. The CMS document read in part, .certified long-term care facilities affirm and support the right of residents to vote. Nursing homes should have a plan to ensure residents can exercise their right to vote, whether in person, by mail, absentee ballot, or other authorized process. Assistance in registering to vote, requesting an absentee ballot or completing a ballot from an agent of the resident's choosing. 2. The facility staff failed to provide residents with an environment that promotes dignity on 1 of 2 units. On 10/15/24 at 2:30 p.m. an interview was conducted with Resident #104 (R104). R104 said she feels safe now and staff is good except some arguing. R104 said this morning that the unit manager was at the door screaming at the aide that was in the room with my roommate. R104 stated, I yelled to get out of here, close the door because it makes me anxious, and it bothers me. On 10/15/24 at 4:30 p.m. an interview was conducted with a licensed practical nurse, unit 3 manager, LPN# 5 (LPN5). When asked about the earlier altercation on the unit, LPN5 said that this morning she had words with certified nursing assistant, CNA #3 (CNA3). LPN#5 said, [CNA3 name redacted] started screaming at me. LPN5 said that she told CNA3 it was her responsibility to chart on residents and CNA3 began arguing and LPN5 stated, I told her to stop, I was not going to argue with her. LPN5 said that she told CNA3 to clock out and leave, then called the director of nursing (DON). LPN5 said that CNA3 was in the resident's room and yelling, You have no control of me! LPN5 said that CNA3 continued to work until her shift was done. On 10/15/24 at 5:00 p.m. an interview was conducted with the director of nursing (DON). The DON said that CNA3 worked until I came in this morning about 7:10 a.m. I had a conversation with CNA3 and CNA# 2 (CNA2), who was a witness to the incident, and we had the conversation with the human resource director. On 10/15/24 at 5:20 p.m. an interview was conducted with the treatment nurse, LPN#7 (LPN7). When asked about the staff altercation that happened that morning, LPN#7 said, At about 6:15 a.m., the aide [indicating CNA2] came up and said I changed the resident and then [LPN#5's name redacted] said you can tell me he had feces on his brief, but did you chart it, if not care has not been done. LPN7 said, Then the other aide [indicating CNA3] said, 'I cannot get in to chart, and we told you a week ago' and then [LPN5's name redacted] said 'advocate for yourself; it looks like you did not do your job. [LPN5's name redacted] said I am not human resources; I cannot help you.' Then [LPN5] said 'I am not going to argue with you and the aide [CNA3) said 'I don't know why you have such an attitude.' The aide [CNA3] went into the resident's room, had the door opened, it wasn't closed all the way, but [LPN5] and the aide [CNA3] were loud. LPN7 said that she had just stepped in, trying to calm the situation. LPN7 said that she had never witnessed other arguments on the floor but had heard that arguments do happen among the staff. On 10/15/24 at 7:15 p.m. an interview was conducted with CNA#2. CNA2 said that she was getting CNA3 to help her with R122's care. CNA2 reported that CNA3 went to the resident's room, opened the door, and yelled up to the nurse's station asking LPN5 why she was screaming at her. CNA2 said that LPN5 stood up out of her chair and began screaming at CNA3 to clock out. CNA2 reported that R104 had yelled out to CNA3, Close the door! Do that outside the door, not in my room! CNA2 stated that CNA3 closed the door but that she and LPN5 had kept yelling. CNA2 stated that when they finally stopped, CNA3 came into the room with me to help me with Resident #122's name redacted] care. While we were doing incontinence care for R122, LPN5 opened the resident's door and demanded CNA3 to come out of the room. CNA3 said to LPN5 I am providing care for a resident now and LPN5 just kept yelling for CNA3 to come out of the room and was getting louder and louder. When asked about the residents' response, CNA2 said that R104 had been sleeping when this argument started, and after being awakened like that, R104 appeared agitated. CNA2 said that R122 had looked uncomfortable and that all she could do was apologize to both residents. On 10/16/24 at 9:25 a.m. an interview was conducted with R104. When asked about yesterday's disruption, R104 said that she was shocked by all the yelling. When asked how it made her feel, R104 said that it made her feel anxious and agitated. When asked about the frequency of these types of disturbances, R104 stated, An almost fist throwing happened about 2 weeks ago. R104 said, the staff . should be more respectful because it scares us! On 10/16/24 at 9:30 a.m. an interview was conducted with R122. R122 stated, They were talking loudly over me and saying come out here now. I could hear them arguing until [roommate's name redacted] told them to get out and shut the door. R122 said, It was a rough morning! I didn't like it, and it made me uncomfortable! It didn't involve me, so take it elsewhere. On 10/16/24 at 4:45 an interview was conducted with the regional director of clinical services (RDCS). The RDCS said, We interviewed the resident after the incident, and we did not have anyone that stated they were fearful. On 10/16/24 at 5:43 p.m. an end of day meeting was conducted with the administrator, director of nursing and regional director of clinical services. When the above concerns were discussed, the facility administrator stated, We didn't know what was going on until you said something. The RDCS and administrator said that the reason they were not aware of the staff arguing was that the DON was on a medication cart . and then you all [surveyors] walked into the building, and it was forgotten. The RDCS and the administrator said that the altercation had been taken care of and reported, that they had suspended the employees involved, reported the incident as an allegation of abuse, and are investigating. The administrator stated that R104 had been interviewed. When asked about the other resident, R104's roommate, the administrator stated that she wasn't interviewable. The administrator was then made aware that according to R122's clinical record, R122 had a brief interview for mental status (BIMS) score of 15 out of 15 (indicating no cognitive impairments) and that R122 had answered questions when interviewed by the surveyor. The survey team explained that R122 had been the resident staff were providing care to when the altercation had taken place. The facility administrator stated that they would go talk with R122 immediately following the meeting/discussion with the survey team and that they were unaware R122 was involved. During this same meeting, facility staff reported that they did not have a facility policy with regards to staff interactions in resident care areas. The facility did provide the survey team with a document titled, Employee Guidebook, and on page 16 it read in part, Professional Courtesy and Customer Service . The company is committed in our efforts to provide a high standard of resident/patient care and excellent customer service, and in the communication that takes place during the workday. You are also expected to approach customers, clients, residents, patients and families in a professional, courteous and efficient manner . The facility also provided a document titled, Code of Ethics. Within that document excerpts read, The company will not tolerate: . Any other conduct that creates an intimidating or hostile work environment . The facility provided a policy titled, Resident Rights, read in part .ensure that residents rights are known to staff. Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations. No additional information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of care during medication administration for two residents (Resident #111- R111 and resident #121- R121) in a survey sample of 29 residents. The findings included: 1. For R111, the facility nurse failed to follow professional standards of practice during medication administration by not observing the resident to take the medications before exiting the room. On 10/15/24 at 11:10 a.m., R111 was observed sitting in a wheelchair at the bedside. R111 had an over bed table in front of her and on the table was a cup of medication that included two round, white tablets. When asked what it was, R111 stated she didn't know. A visitor in the room, told R111, that's your morning medications, you need to take those. Upon the surveyor exiting the room, licensed practical nurse (LPN #4) was in the hallway at the medication cart. When asked about mediation administration and R111 having 2 white tablets in a cup in her room. LPN #4 identified that the medication was sodium bicarbonate. When asked if she normally leaves medications at the bedside for a resident to take, LPN #4 said, I don't normally, I had just given them to her and came back to the cart to get insulin. When asked what the accepted practice is, LPN #4 stated, To watch to make sure they take them and don't drop them or whatever. On 10/15/24, a review of R111's clinical record revealed an active physician's order for Sodium Bicarbonate Oral Tablet 325 MG (Sodium Bicarbonate (Antacid)) Give 2 tablet by mouth four times a day for CKD [chronic kidney disease]. There were no orders indicating the resident could self-administer medications. On 10/15/24, at approximately 1 p.m., the facility administrator provided the survey team with a listing of residents who had been determined and had an order that they were permitted to self-administer medications. R111 was not on the list. 2. For R121, the facility nurse left medications in the room at the bedside for the resident to self-administer versus staying with the resident to ensure and observe the medications being taken. On 10/15/24, at approximately 1 p.m., the facility administrator provided the survey team with a listing of residents who had been determined and had an order that they were permitted to self-administer medications. R121 was not on the list. On 10/15/24 at 2:06 p.m., R121 was visited in his room. While talking with R121, it was noted that on the over bed table was a medication cup with two large tablets. When the resident was asked about the medication, the resident stated, it was tums that had had been given that morning to take since I got the ulcer. On 10/15/24 at 2:11 p.m., an interview was conducted with registered nurse #2 (RN #2). RN #2 confirmed she was R121's nurse. When asked about the pills at the bedside, RN #2 said, I don't recall, I will have to look. On 10/15/24, in the afternoon a clinical record review was conducted. This review revealed that R121 did not have any physician orders in his clinical record, nor any record of any medications being administered. On 10/15/24 at approximately 2:20 p.m., an interview was conducted with the unit manager, who was a licensed practical nurse (LPN #4). LPN #4 confirmed that there had been a problem with R121's physician orders and said she did not give R121 the medications that were observed at the bedside. On 10/15/24 at 2:35 p.m., an interview was conducted with the Director of Nursing (DON). When asked about her expectation when nurses are administering mediations, the DON stated, during administration they should pull up the medication administration record (MAR) and follow the five rights of medication administration. They should not leave the patient until the pills are consumed and watch to make sure they take them. According to the facility policy titled, Medication- Oral Administration of it read in part, . Chart on nurse's notes: pertinent observations after administration. Education provided to resident or family regarding medication. On 10/15/24 at 5:30 p.m., during an end of day meeting, the facility administrator, director of nursing and regional director of clinical services were made aware of the above findings.

Based on observations, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to complete a thorough and accurate investigation of a serious elopement incident involving one resident (Resident #113-R113), in a survey sample of 29 residents. The findings included: On 10/15/24 at 10:50 a.m., an interview was conducted with R113 regarding her 10/2/24 fall outside. R113 said that she walked out to the parking lot and then went on down to the road to smoke a cigarette. R113 said that she stepped in the grass and slid into the mud. R113 said that it took her about half an hour to crawl out of the mud. R113 said that she managed to get out of the mud and to the side of the road, when an employee saw her and picked her up in her vehicle. R113 stated. I go outside whenever I want to go out. No signing out or telling anyone. On 10/16/24 at 10:10 a.m., an interview was conducted with the administrator. The administrator said that education for the wander guards was conducted with the administration staff and the clinical staff. The administrator said that R113 would go out and off the property to smoke, she felt the wanderguard was a restraint. The administrator said that she had physical therapy to evaluate R113 and had the nurse practitioner to see R113 to see if she needed the wanderguard. The administrator said that they were trying to find another facility for R113 to go to so she can smoke because she likes to smoke. The administrator said the day that R113 went out the front door that a receptionist was not working that day. The administrator stated, The receptionist letting resident out was all we could come up with that made sense. Then the administrator said that the receptionist that was there that day was no longer with the company. On 10/16/24, a clinical record review was conducted. On 10/2/24, a nursing progress note written read, Resident had fall outside and was assisted back into facility by [certified nursing assistant #6's name redacted], CNA and no injury noted. Wandergaurd is intact and was let out to set on front porch by receptionist and wanderguard does work. (SIC) On 10/16/24, during a clinical record review, R113's care plan was reviewed. According to R113's care plan, a focus area was initiated on 9/24/24, which remained active at the time of the 10/2/24 elopement and at the time of the survey, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. On 10/16/24 at 10:30a.m., an interview was conducted with certified nursing assistant #6 (CNA6). CNA6 stated, I did not find her outside and I did not have anything to do with it. I saw her standing outside in the circle and reported it to the social service director. CNA6 verbalized that if residents sign out, they can go outside, off the property to smoke. On 10/16/24 at 10:55 a.m. an interview was conducted with the regional traveling director of nursing (DON). The regional traveling DON said that R113 fell outside the facility near the circle and was found by an employee that was coming to work and the employee brought R113 back to the building. The regional traveling DON verbalized that she had a statement from the former receptionist, other staff #1 (OS1), that she didn't let R113 out of the facility. The regional traveling DON stated, Someone let her out of the facility. The regional traveling DON was unable to identify who had allowed R113 to leave the facility. On 10/16/24 at 11:25 a.m., an interview was conducted with the social worker assistant (OS1), who was previously the receptionist. OS1 verbalized that she was on unit 2 helping two residents and was not at the receptionist desk when R113 left the building. OS1 verbalized that the staff did not know when the wanderguard was on R113 because sometimes she had it on and other times it had been removed. OS1 verbalized that there were times when R113 came up to the front door and the alarm did not sound off, with the wanderguard on the resident. OS1 verbalized that she had seen R113 sitting in the chair in the lobby, after being brought back inside, and that she went to the unit to get her nurse to come down to the lobby to assess the resident. On 10/16/24 at 1:02 p.m., an interview was conducted with registered nurse #1 (RN #1). RN #1 was the nurse that wrote the progress note dated 10/2/24, regarding R113 having fallen while outside. RN #1 stated that she was told by CNA #6 that she brought her back in. RN #1 also stated that the RDCS (regional director of clinical services) had told her the same thing and reported that the receptionist had let the resident out. RN #1 reported that R113 was . covered in mud, she had a wander guard on, and the receptionist turned the alarm off and let her out. I don't remember who told me that. Corporate said they are allowed to go out and who ever lets them out should go with the resident. On 10/16/24 in the early afternoon, the front door wander guard system was tested with the director of nursing (DON). The DON placed a wander guard into her sock, to mimic the location where the wander guard is placed on resident's ankle. The DON was able to walk through the lobby and open the front door, without the locking mechanism of the wander guard system engaging to lock the door and prevent exit. On 10/16/24 at approximately 2:30 p.m., an interview was conducted with the maintenance assistant. The maintenance assistant reported that he checks the door alarms daily, Monday through Friday, and at times the front door's wander guard system doesn't work and they have to make adjustments. On 10/16/24 at 3:27 p.m., an interview was conducted with maintenance director. The maintenance director reported that in his short tenure of a few months that . once in a while, the receptionist will say that when a resident goes out, it doesn't alarm, and we have to make adjustments. On 10/16/24, in the late afternoon, the front door was again tested using a wander guard by the maintenance director. Initially when the maintenance director had the device pass through the lobby area, the sensor did not pick up the signal, and made no alarm. On the second attempt, the alarm sounded, and the door locked. On the third attempt, the alarm sounded but the door remained unlocked, and a resident with a wanderguard could have exited. On 10/16/24 at 5:21 p.m., a telephone interview was conducted with certified nursing assistant #1 (CNA#1), who had found R113 and assisted her back into the facility on [DATE]. On 10/16/24, CNA #1 stated that she had discovered R113 at 2:45 p.m., while driving to work, lying beside the road, off the facility property, unable to get up. CNA#1 stated that she had assisted Resident #113 up off the ground, into her jeep, and took Resident #113 back to the facility. According to CNA#1, Resident #113 was wet, had mud all over her, and required a shower. CNA#1 stated that upon entering the building with R113 she alerted staff, who had been unaware of R113's absence or how long she was gone. CNA #1 also reported that there was no door alarm sounding when she assisted R113 back into the facility. On 10/16/24 at 5:43 p.m., during an end of day meeting with the facility administrator, director of nursing (DON) and regional director of clinical services (RDCS), the incident on 10/2/24, involving R113 was discussed. The facility administrator reported she was not at the facility and was out of town at the time of the incident. The administrator went on to say that there wasn't a receptionist the day of the incident. When the survey team questioned the accuracy of the nurse's progress note that indicated that the receptionist let the resident out, as well as the facility synopsis of the incident, but that both receptionists had denied doing so, the Administrator and RDCS both acknowledged that they didn't know who had let R113 outside. On 10/17/24 at 8:30 a.m., an interview was conducted with the social service director. The social service director said, I saw [R113's name redacted] standing at the front door, and she was wet. I had her sit down in a chair and had the social worker assistant go up to the unit and get a nurse. The social service director said, No alarm was sounding when the resident came back into the facility and I don't remember an alarm sounding earlier, because we always jump up when the alarm goes off and I don't remember any of us doing that. On 10/17/24 at 9:00 a.m., an interview was conducted with R113. R113 stated, I just went out the front door, the door was unlocked, and people were outside, and no alarm sounded. I would go up sometimes and the alarm would sound, and they would turn it off and I would go out the door. On 10/17/24 at 9:19 a.m., the facility administrator was asked about the functioning of the wander guard system. The administrator said, I am not aware of an issue. The survey team reported to the administrator that during staff interviews multiple staff reported that the wander guard system is inconsistent and doesn't always operate properly. It was also reported that during the testing of the system by the DON and by the maintenance director the day prior, the wander guard system had not functioned properly. The administrator stated, This is the first I've heard of it. I always thought there was a mag [magnetic] lock, that if the door isn't closing enough, they may not latch. We just adjust those sensors on the side regularly. There is some sort of sensitivity, different things can affect it. That's usually what's going on. On 10/17/24 at 11:15 a.m., an interview was conducted with the business office assistant (other staff #2, OS2), who was the back-up receptionist. OS2 verbalized that residents with a wanderguard were able to go out and sit on the front porch without staff going with them, until R113 fell outside. OS2 said, Now, if a resident with a wanderguard wants to go outside, staff or a family member had to be with the resident. On 10/17/24 at 3:35 p.m., an interview was conducted with the regional director of clinical services (RDCS). The RDCS verbalized that she took R113 to the receptionist desk earlier on 10/17/24 to identify if CNA#6 was the person that let her out on 10/2/24. The RDCS stated that R113 verbalized that the receptionist was not the one at the desk on 10/2/24. When questioned about R113's prior statements, the RDCS reported that the facility staff had not interviewed R113 prior to 10/17/24 or during the investigation. When this was questioned, the RDCS stated that they had concluded that R113 was not appropriately assessed for elopement risk and had determined that the incident was not an elopement. On 10/18/24 10:50 a.m., an interview was conducted with the administrator. The administrator stated, I feel like [name redacted] business office assistant let her out and won't say that she did. They all have become quiet and only say we were told they could go out and sit on the porch. The administrator also stated that until the incident involving R113 on 10/2/24, the facility staff had permitted residents with a wanderguard to go outside unsupervised. On 10/18/24, a review was conducted of the facility's synopsis of the incident, which read in part, . Through the investigation it was discovered that the receptionist allowed the resident to exit the alarmed door due to the resident stating she wanted to sit on front porch Conclusion: clinical staff has been re-educated on completing elopement assessments accurately and objectively to determine proper use of wander guard. Staff will be educated that residents with wander guards will not be allowed to exit the center unattended . The only statements within this synopsis file were from OS1, whose statement contradicted the synopsis findings, and CNA #1, who had brought R113 back to the facility. The facility's synopsis referenced a receptionist that administration was unable to accurately identify and focused on who allowed the resident to exit the building without interviewing R113 about the incident. The facility's synopsis did not provide any evidence that the wanderguard that R113 had been wearing at the time of her elopement had been tested for appropriate function. The facility synopsis did not reference the wanderguard system as a possible causative factor in the elopement and included no evidence of the facility evaluating if the wander guard system was functioning properly, although it was known to malfunction. On 10/18/24, a facility documentation review was conducted. A policy titled, Elopement/Wandering Risk Guideline, read in part .evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. A facility document was reviewed titled, Release of Responsibility for Leave of Absence, which indicated that prior to any leave of absence from the facility, residents must first sign out. No other information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement the comprehensive care plan interventions for one resident (resident #113- R113) in a survey sample of 29 residents. The findings included: For R113, who had a care plan intervention for staff to monitor location every 30 minutes and prn [as needed], the facility staff failed to implement this intervention. On 10/15/24, in the afternoon, R113 was visited in her room. During the interview, R113 verbalized a desire to leave the facility and return home to live. On 10/15/24 and 10/16/24, at varying times, multiple observations were conducted of R113. There was no indication that facility staff were providing any type of monitoring of the resident every thirty minutes. On 10/16/24, during a clinical record review, R113's care plan was reviewed. According to the care plan, a focus area was initiated on 9/24/24, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. Interventions for this focus area, included but were not limited to, an intervention entered 9/24/24, read, monitor location every 2 hours and prn. That intervention was resolved on 10/2/24. On 10/8/24, a new intervention was added to R113's care plan which read, monitor location every 30 minutes and prn. On 10/17/24, the facility administration was asked to provide the survey team with evidence of the safety monitoring. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m. 6:30 p.m. On 10/17/24, attempts were made to interview the care plan nurse that had entered the interventions of monitoring R113's location. However, that employee was no longer employed at the facility and therefore was not available for interview. On 10/17/24, in the afternoon, an interview was conducted with licensed practical nurse (LPN #6), who was also a care plan nurse. LPN #6 was unaware that R113 had a current intervention to monitor the resident's location every 30 minutes. LPN #6 was shown the active care plan. LPN #6 stated she would attempt to find out why this intervention was put into place for R113. LPN #6 was asked by the survey team to provide a copy of the resident's current care plan as well as all resolved items. On 10/17/24, in the afternoon, the survey team was provided a copy of R113's care plan. The care plan provided at that time noted the focus area that indicated R113 was an elopement risk and had every 30-minute safety checks, was resolved on 10/17/24 by the regional director of clinical services. According to the facility policy titled, Plans of Care, it read in part, . The individualized person-centered plan of care may include but is not limited to the following: . individualized interventions that honor the resident's preferences and promote achievement of the resident's goals, interdisciplinary approaches that maintain and/or build upon resident abilities, strengths and desired outcomes . On 10/18/24, during a meeting held with the facility administrator and regional director of clinical services, they were made aware of the above concern that R113's interventions with regards to safety checks had not been implemented. No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise the care plan for one resident (resident #113- R113) in a survey sample of 29 residents. The findings included: For R113, who the facility staff identified was no longer an elopement risk, the facility staff failed to review and revise the care plan to indicate this. On 10/15/24, in the afternoon and on multiple occasions on 10/16/24, R113 was visited in her room. During the interviews, R113 verbalized a desire to leave the facility and return home to live. On 10/16/24, during a clinical record review, R113's care plan was reviewed. According to the care plan, a focus area was initiated on 9/24/24, which remained active at the time of survey that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. On 10/2/24, according to a nursing note and facility documentation, it captured that certified nursing assistant #1 (CNA#1) had found Resident #113, who had been wearing a wander guard, lying on the ground and had assisted R#113 back to the building. On 10/16/24, during an interview with CNA #1, CNA #1 stated that she had discovered R113 at 2:45 p.m., while driving in to work, lying on the edge of the road, off the facility property, unable to get up. CNA#1 stated that she had assisted Resident #113 up off the ground, into her jeep, and took Resident #113 back to the facility. According to CNA#1, which had been stated earlier by RN#1 and the regional of clinical services, Resident #113 was wet, had mud all over her, and required a shower. CNA#1 stated that upon entering the building with R113 she alerted staff, who had been unaware of R#113's absence or how long she was gone, and that there had been no audible alarm sounding at that time. On 10/16/24 at 11:20 a.m., the survey team, facility administrator, and regional nurse consultant measured the distance from the facility's front entrance/exit door to the location where the resident was found on 10/2/24, determining that the distance was 465.7 feet. The width of the ditch the resident fell into was measured at 7.2 feet and 0.87 feet in depth. The distance from the hard surface road to the ditch was measured to be 23.5 feet of grass and rough terrain. On 10/16/24, during an interview with the facility administrator and regional director of clinical services (RDCS), the RDCS stated that they determined R113 was not appropriately assessed for elopement. The RDCS stated that another wandering/elopement assessment was conducted and identified that R113 was not an elopement risk. According to the assessment tab of R113's chart on 9/23/24 and 10/7/24, R113 had been assessed to be a risk for elopement. Then on 10/8/24, another assessment was conducted which noted R113 was no longer a risk for elopement. R113's care plan was not reviewed and revised to indicate the change in status as it noted at the time of survey that R113 remained a risk for elopement. On 10/17/24, in the afternoon, the survey team was provided a copy of R113's care plan. The care plan provided at that time noted the focus area that indicated R113 was an elopement risk, was resolved on 10/17/24 by the regional director of clinical services. According to the facility policy titled, Plans of Care, it read in part, . Review, update and/or revise the comprehensive care plan based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment, and as needed . On 10/18/24, during a meeting held with the facility administrator and regional director of clinical services, they were made aware of the above concern that R113's care plan had not been reviewed and revised. No additional information was provided.

Based on observation, resident and staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure medications were stored in a secure manner for two residents (Resident #114-R114 and Resident #126-R126) in a survey sample of 29 residents. The findings included: 1. For R114, the facility staff failed to ensure Vicks vapor rub, which was at the bedside unsecured, was stored appropriately. On 10/15/24 at approximately 10:45 a.m., during a tour of the resident, R114 was observed to have Vicks vapor rub at the bedside. When R114 was asked about the Vicks, the resident stated she applied it under her nose every night to prevent her nose from getting stopped up. On 10/15/24 at 2:20 p.m., an interview was conducted with registered nurse (RN #3). RN #3 was asked about R114's medications and stated, we give her, her medications. RN #3 went on to say that no medications should be at the patient's bedside. When asked about the Vicks vapor rub, RN #3 said, I can't speak to that, I don't leave medication at the bedside. RN #3 accompanied the surveyor to R114's room, observed the Vicks vapor rub and removed it. On 10/15/24 at approximately 2:25 p.m., RN #3 took the Vicks vapor rub to the nursing station, where the unit manager/licensed practical nurse #5 (LPN #5) was, told LPN #5 about it and LPN #5 stated, it has to come out, we have to find out where she is using it and if appropriate there is an assessment that has to be done for her to self-administer and it has to be done every three months. On 10/15/24, during a clinical record review of R114's chart, it was noted that there was no physician order for the use or administration of Vicks vapor rub. On 10/15/24, in the afternoon, during an interview with the director of nursing, when asked about medication storage, the DON stated that all medications should be stored securely in the medication cart. According to the facility policy titled, Medication Storage Guidance, provided to the survey team, it read in part on page 11, . safe and secure storage includes abiding by proper temperature controls as well as maintaining appropriate light and humidity exposure . On 10/15/24, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided. 2. For R126, who had medication at the bedside, the facility staff failed to remove the medication and/or provide the resident with a means to securely store medications. On 10/17/24 at 4:43 p.m., R126's room was observed, noting that a 120 ml bottle of Ketoconazole Shampoo 2%, which had a pharmacy label, was on the bedside table On 10/17/24 at approximately 4:50 p.m., the director of nursing (DON), facility administrator, and a regional director of clinical services accompanied the surveyors to R126's room. The facility administration confirmed the medication at the bedside and stated that it should not be stored at the bedside, which could be accessible to anyone entering the room and they removed it. On 10/15/24, in the afternoon, during an interview with the director of nursing, when asked about medication storage, the DON stated that all medications should be stored securely in the medication cart. According to the facility policy titled, Medication Storage Guidance, provided to the survey team, it read in part on page 11, . safe and secure storage includes abiding by proper temperature controls as well as maintaining appropriate light and humidity exposure . On 10/18/24, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to report suspicion of physical abuse/mistreatment for one of 7 residents (Resident #203) and failed to report suspicion of physical abuse/mistreatment timely for one of 7 residents (Resident #207) to the state agency. The Findings Include: 1. The facility did not report suspicion of physical abuse/mistreatment for resident #203 (R203). According to the clinical record, diagnoses for R203 included Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24. R203 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R203's clinical record documented a social workers note dated 12/3/24 that indicated a certified nursing assistant (CNA) had been rude and rough during care (when turning R203) and indicated that R203 was not feeling safe during the provided care. On 12/9/24 at 1:50 p.m., R203 was interviewed regarding the incident. R203 verbalized asking for help to turn in bed, CNA #1 came into the room to assist and turned R203 abruptly and roughly, scaring R203 to the point R203 felt like CNA #1 was going to [NAME] her out the bed. R203 was asked if she felt CNA #1 was intending to harm her and if R203 felt safe around CNA #1. R203 verbalized not feeling that CNA #1's intended to harm her but just didn't feel safe while being turned. R203 went onto say that in general CNA #1 seems to be in a hurry, doesn't really speak while providing care, and seems rude. R203 verbalized trying to speak with CNA #1 and thanking her for helping but usually there is no response. Provided by the facility, a witness statement from R203 was reviewed and indicated that CNA #1 is rough when handling R203, grabbed the pad to turn R203 and felt like being flung on her side. R203 goes on to state that CNA #1 is rushing and feels that CNA #1 does not like her (R203). R203 states that she doesn't feel that CNA #1 would intentionally hurt but doesn't feel safe when CNA #1 works with her (R203). On 12/9/24 at 3:25 p.m., the administrator and the director of nursing (DON) were interviewed regarding not reporting this to state agency. The DON verbalized that R203 had reported the incident to the wound nurse and the wound nurse had then reported the incident to the DON and administrator. The administrator verbalized the incident was investigated at the time and talking with R203 (along with the DON), had done a skin assessment, which indicated no concerns, and interviewed R203 which did not indicate CNA #1 was intentional in her actions and felt that it was more of a customer service concern. The administrator verbalized that education was planned for CNA #1 however, CNA #1 does not work full time and has not worked since the incident. On 12/9/24 at 3:45 p.m. R203 was interviewed again. R203 verbalized, in general CNA #1 seems rude, does not talk, and seems to be in a rush. R203 said that she has tried talking with CNA #1 and thanking her for the help to show kindness but CNA #1 does not converse when providing care. R203 verbalized not feeling that CNA #1 would intentionally harm her, but that particular day felt that CNA #1 would've thrown R203 out of the bed if she thought she (CNA #1) could get away with it. When asked if she (R203) felt that 'CNA #1 would throw her out of bed, if CNA #1 could get away with it' sounds intentional, R203 responded I guess so, I wasn't looking at it like that. R203 again verbalized, This is just how CNA #1 made me feel at the time. On 12/10/24 at 8:45 a.m., an interview was conducted with license practical nurse (LPN #1), to whom R203 reported the allegation. LPN #2 verbalized R203 reported the incident and LPN #1 wrote a witness statement and reported the concern to the DON. LPN #1 said that while talking with R203, it came across that the CNA didn't do anything intentional, but just did not want that particular CNA working with R203. On 12/10/24 at 9:00 a.m. the social worker was interviewed (other staff, OS #1). OS #1 said that after the incident had been reported and the DON and administrator had assessed R203, she also assessed and talked with R203. During the conversation between R203 and OS #1, OS #1 verbalized R203 said this was the first time this had happened. OS #1 was asked about her notation in the progress notes, OS #1 reviewed the note and agreed that the note does indicate R203 not feeling safe around CNA #1. On 12/10/24 at 10:00 a.m. The DON was interviewed. After reviewing the information, the DON verbalized that it should have been reported, but went onto say we did do an investigation which did not yield anything was intentional and there was no physical evidence to indicate suspicion of abuse. On 12/10/24 at 11:25 a.m. the administrator was interviewed. The administrator verbalized CNA #1 has not worked since this incident and is currently suspended pending investigation. No other information was presented prior to exit conference on 12/10/24. The Findings Include: 2. The facility did not report suspicion of physical abuse/mistreatment for resident #207 (R207) timely. Diagnoses for R207 included: Dementia, diabetes, hemiplegia, and anxiety. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 10/3/24. R207 was assessed with a cognitive score of 11 indicating moderately cognitively intact. Review of current Facility Reported Incidents (FRI's) indicated hat the facility had reported an allegation of abuse/mistreatment on 12/9/24. The FRI indicated that the incident date was 12/6/24. Review of R207's clinical record documented a social workers note dated 12/6/24 that indicated R207 was upset due to missing drinks and chips were stale after coming back from a leave of absence and was blaming a CNA (identified as CNA #2), and CNA #2 was pointing her finger in R207's face. On 12/10/24 at 8:30 a.m. R207 was interviewed regarding the incident. R207 verbalized feeling that the CNA #2 did point her fingers in R203's face but is aware that CNA #2 has been noted to talk with her hands. When asked if R207 felt safe, R207 verbalized feeling safe and went onto verbalized knowing how to handle herself. R207 also said that the CNA #2 has not worked with her since. On 12/10/24 at 9:10 a.m. the social worker (OS #1) was interviewed. OS #1 explained that during a conversation with R207, R207 reported CNA #2 had pointed her finger in R207's face. OS #1 said at the time of the discussion with R207 the social worker assistant (OS #2) was present and wrote the note and also talked with CNA #2. OS #1 was asked who reported the incident and who was the incident reported to. OS #1 verbalized she (OS #1 reported the incident on 12/6/24 and it was reported to the regional administrator as the DON was not in the facility that day. OS #1 then left the room and returned a few minutes later and verbalized she was not a 100 percent sure that she reported to the regional administrator, but verbalized it was reported on 12/6/24. On 12/10/24 at 10:00 a.m. the DON and regional administrator was interviewed. The DON verbalized not working the day of the incident. The regional administrator verbalized she was not aware of anyone reporting the incident to her on 12/6/24 and she became aware of the incident on 12/9/24 after her and the DON were reviewing progress notes and reports. The regional administrator also verbalized that on 12/9/24 the DON had found a typed note in her mail box from the social worker reporting an incident, but then realized that was a different incident. The regional administrator verbalized after reviewing everything, the FRI should have been sent within 24 hours of the incident. On 12/10/24 at 11:25 a.m. the administrator was interviewed. The administrator verbalized this incident is still being investigated but the CNA in question has been terminated due to unrelated concerns regarding call outs. Review of the facilities abuse policy read in part: [ .] Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment [ .] is obligated to report such information immediately, but no later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials [ .]. Once the allegation is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that the reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations. No other information was presented prior to exit conference on 12/10/24.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were clinically appropriate to self-administer medications, before being permitted to do so for three residents (Resident #111- R111, Resident #114- R114, and Resident #121-R121) in a survey sample of 29 residents. The findings included: 1. For R111, the facility nurse provided the resident with medications and left them at the bedside for the resident to self-administer, when the resident had not been assessed to be appropriate for self-administration of medications. On 10/15/24 at 11:10 a.m., R111 was observed sitting in a wheelchair at the bedside. R111 had an over bed table in front of her and on the table was a cup of medication that contained two round, white tablets. When asked what it was, R111 stated that she didn't know. A visitor in the room, told R111, that's your morning medications, you need to take those. Upon the surveyor exiting the room, licensed practical nurse (LPN #4) was observed in the hallway at the medication cart. When asked about mediation administration and R111 having 2 white tablets in a cup in her room, LPN #4 identified that the medication was sodium bicarbonate. When asked if she normally leaves medications at the bedside for a resident to take, LPN #4 said, I don't normally, I had just given them to her, and came back to the cart to get insulin. When asked what the accepted practice is, LPN #4 stated, To watch, to make sure they take them and don't drop them or whatever. On 10/15/24, a review of R111's clinical record revealed an active physician's order for Sodium Bicarbonate Oral Tablet 325 MG (Sodium Bicarbonate (Antacid)) Give 2 tablet by mouth four times a day for CKD [chronic kidney disease]. There were no orders indicating that R111 could self-administer medications. On 10/15/24, at approximately 1 p.m., the facility administrator provided the survey team with a listing of residents who had been determined safe to self-administer and had an order that they were permitted to self-administer medications. R111 was not on the list. According to R111's assessment tab of the clinical record, there was no assessment of the resident's ability to self-administer medications found. According to R111's care plan, there was no indication of self-administration of medications. 2. For R114, the facility staff permitted the resident to have Vick's vapor rub at the bedside to self-administer, when the resident did not have an order for the medication and had not been determined clinically appropriate to self-administer medications. On 10/15/24 at approximately 10:45 a.m., during a tour of the unit, R114 was observed to have Vicks vapor rub at the bedside. When R114 was asked about the Vicks, the resident stated that she applied it under her nose every night to prevent her nose from getting stopped up. On 10/15/24, at approximately 1 p.m., the facility administrator provided the survey team with a listing of residents who had been determined safe to self-administer and had an order that they were permitted to self-administer medications. R114 was not on the list. On 10/15/24 at 2:12 p.m., R114's room was observed and again the Vicks vapor rub was noted at the bedside. On 10/15/24 at 2:20 p.m., an interview was conducted with registered nurse (RN #3). RN #3 was asked about R114's medications and stated, We give her her medications. RN #3 went on to say, No medications should be at the patient's bedside. When asked about the Vicks vapor rub, RN #3 said, I can't speak to that. I don't leave medication at the bedside. RN #3 accompanied the surveyor to R114's room, observed the Vicks vapor rub, and removed it. On 10/15/24 at approximately 2:25 p.m., RN #3 took the Vicks vapor rub to the nursing station, where the unit manager/licensed practical nurse #5 (LPN #5) was informed about it. LPN #5 stated, It has to come out, we have to find out where she is using it and if appropriate, there is an assessment that has to be done for her to self-administer, and it has to be done every three months. On 10/15/24, during a clinical record review of R114's chart, it was noted that there was no physician order for the use or administration of Vicks vapor rub. According to R114's assessment listing, no assessment had been conducted to determine if R114 was clinically appropriate to self-administer medications. According to R114's care plan, there was no indication that the interdisciplinary team had determined R114 was appropriate to self-administer medications. 3. For R121, the facility nurse left medications in the room at the bedside for the resident to self-administer, when the resident had not been assessed for the ability to self-administer medications. On 10/15/24, at approximately 1 p.m., the facility administrator provided the survey team with a listing of residents who had been determined to safely self-administer and had an order that they were permitted to self-administer medications. R121 was not on the list. On 10/15/24 at 2:06 p.m., R121 was visited in his room. While talking with R121, it was noted that on the over bed table was a medication cup with two large tablets. When the resident was asked about the medication, R121 stated that it was tums that had been given that morning to take, . since I got the ulcer. On 10/15/24 at 2:11 p.m., an interview was conducted with registered nurse #2 (RN #2). RN #2 confirmed she was R121's nurse. When asked about the pills at the bedside, RN #2 said, I don't recall, I will have to look. On 10/15/24, in the afternoon a clinical record review was conducted. This review revealed that R121 did not have any physician orders in his clinical record, nor any record of any medications being administered. There was also no indication that R121 had been assessed for the ability to self-administer medication. On 10/15/24 at approximately 2:20 p.m., an interview was conducted with the unit manager, who was a licensed practical nurse (LPN #4). LPN #4 confirmed that there had been a problem with R121's physician orders and said she did not give R121 the medications that were observed at the bedside. On 10/15/24 at 2:35 p.m., an interview was conducted with the Director of Nursing (DON). When asked about her expectation when nurses are administering medications, the DON stated, Medications are to be stored in the medication cart. The DON went on to say, During administration, they should pull up the medication administration record (MAR) and follow the five rights of medication administration. They should not leave the patient until the pills are consumed and watch to make sure they take them. According to the facility policy titled, Self-Administration of Medication at Bedside it read in part, Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete Self-administration of Medications Evaluation. The interdisciplinary team will review the evaluation and will document Section III. Approval granted must be checked yes or no. Interdisciplinary team member signs the evaluation section . Complete the care plan for approved self-administered drugs . On 10/15/24 at 5:30 p.m., during an end of day meeting, the facility administrator, director of nursing and regional director of clinical services were made aware of the above findings. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement abuse policies for two of seven residents, Resident #'s 203 and 207. The Findings Include: 1. The facility did not implement facility abuse policy in regards to reporting suspicion of physical abuse/mistreatment for Resident #203 (R203). According to the clinical record, diagnoses for R203 included, Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24, which assessed R203 with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R203's clinical record documented a social workers note, dated 12/3/24, that indicated a certified nursing assistant (CNA) had been rude and rough during care (when turning R203) and alluded to R203 not feeling safe during the care provided. On 12/9/24 at 1:50 p.m., R203 was interviewed regarding the incident. R203 verbalized asking for help to turn in bed, CNA #1 came into the room to assist and turned R203 abruptly and roughly. R203 stated that it scared her to the point that it felt like CNA #1 was going to [NAME] her out the bed. When asked if she felt CNA #1 was intending to harm her and if R203 felt safe around CNA #1, R203 verbalized not feeling that CNA #1's intended to harm her but just didn't feel safe while being turned. R203 went onto say that in general CNA #1 seems to be in a hurry, doesn't really speak while providing care, and seems rude. R203 verbalized trying to speak with CNA #1 and thank her for helping but that usually there is no response. A witness statement from R203 was reviewed and indicated CNA #1 was rough when handling R203, grabbed the pad to turn R203 and felt like R203 was being flung on her side. The witness statement documented that R203 goes on to state that CNA #1 is rushing and feels that CNA #1 does not like her (R203). The witness statement also documented that R203 stated that she doesn't feel that CNA #1 would intentionally hurt but doesn't feel safe when CNA #1 works with her (R203). On 12/9/24 at 3:25 p.m., the administrator and the director of nursing (DON) were interviewed regarding not reporting the above allegations to state agency. The DON verbalized that R203 had reported the incident to the wound nurse and the wound nurse had then reported the incident to the DON and administrator. The administrator verbalized that the incident was investigated at the time, along with a skin assessment and talking with R203 (along with the DON), indicated no concerns. The administrator stated that the interview with R203 did not indicate CNA #1 was intentional in her actions and felt that it was more of a customer service concern. The administrator verbalized that education was planned for CNA #1, but that CNA #1 does not work full time and has not worked since the incident. On 12/9/24 at 3:45 p.m., R203 was interviewed again. R203 verbalized, in general CNA #1 seems rude, does not talk, and seems to be in a rush. R203 said that she has tried talking with CNA #1 and thanking her for the help to show kindness but CNA #1 does not converse when providing care. R203 verbalized not feeling that CNA #1 would intentionally harm her, but that particular day felt that CNA #1 would've thrown R203 out of the bed if she thought she (CNA #1) could get away with it. When asked if she (R203) felt that 'CNA #1 would've thrown her out of bed, if CNA #1 could get away with it' sounds intentional, R203 responded, I guess so, I wasn't looking at it like that. R203 then verbalized, This is just how [CNA #1's name redacted] made me feel at the time. On 12/10/24 at 8:45 a.m., an interview was conducted with licensed practical nurse (LPN #1), to whom R203 reported the allegation. LPN #2 verbalized that R203 reported the incident and LPN #1 wrote a witness statement and reported the concern to the DON. LPN #1 said that while talking with R203, it came across that she didn't do anything intentional, but just did not want that particular CNA working with R203. On 12/10/24 at 9:00 a.m., the social worker was interviewed (other staff, OS #1). OS #1 said that after the incident had been reported and the DON and administrator had assessed R203, the OS #1 also assessed and talked with R203. During the conversation with R203, OS #1 verbalized that R203 said this was the first time this had happened. When OS #1 was asked about her notation in the progress notes, OS #1 reviewed the note and agreed that the note does indicate R203 not feeling safe around CNA #1. On 12/10/24 at 10:00 a.m. The DON was interviewed. After reviewing the information, the DON verbalized that it should have been reported, but went onto say, We did do an investigation, which did not yield anything was intentional, and there was no physical evidence to indicate suspicion of abuse. On 12/10/24 at 11:25 a.m., the administrator was interviewed. The administrator verbalized that CNA #1 has not worked since this incident and is currently suspended pending investigation. No other information was presented prior to exit conference on 12/10/24. 2. The facility did not implement facility abuse policy in regards to timely reporting for suspicion of physical abuse/mistreatment for Resident #207 (R207). According to the clinical record, diagnoses for R207 included: Dementia, diabetes, hemiplegia, and anxiety. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 10/3/24 assessed R207 with a cognitive score of 11 out of 15, indicating moderately cognitively intact. Review of facility documentation indicated that the facility had reported an allegation of abuse/mistreatment on 12/9/24, with the incident date of 12/6/24. Review of R207's clinical record documented a social workers note dated 12/6/24 that indicated R207 was upset due to missing drinks and chips were stale after coming back from a leave of absence and was blaming a CNA (identified as CNA #2), and CNA #2 was pointing her finger in R207's face. On 12/10/24 at 8:30 a.m. R207 was interviewed regarding the incident. R207 verbalized feeling that the CNA #2 did point her fingers in R203's face but is aware that CNA #2 has been noted to talk with her hands. When asked if R207 felt safe, R207 verbalized feeling safe and went onto verbalized knowing how to handle herself. R207 also said that the CNA #2 has not worked with her since. On 12/10/24 at 9:10 a.m. the social worker (OS #1) was interviewed. OS #1 explained that during a conversation with R207, R207 reported CNA #2 had pointed her finger in R207's face. OS #1 said at the time of the discussion with R207 the social worker assistant (OS #2) was present and wrote the note and also talked with CNA #2. OS #1 was asked who reported the incident and who was the incident reported to. OS #1 verbalized she (OS #1 reported the incident on 12/6/24 and it was reported to the regional administrator as the DON was not in the facility that day. OS #1 then left the room and returned a few minutes later and verbalized she was not 100 percent sure that she reported to the regional administrator, but verbalized it was reported on 12/6/24. On 12/10/24 at 10:00 a.m., the DON and regional administrator was interviewed. The DON verbalized not working on the day of the incident. The regional administrator verbalized that she was not aware of anyone reporting the incident to her on 12/6/24, and that she became aware of the incident on 12/9/24, while reviewing progress notes and reports with the DON. The regional administrator also verbalized that on 12/9/24 the DON had found a typed note in her mail box from the social worker reporting an incident, but then realized that was a different incident. The regional administrator verbalized that after reviewing everything, the incident should have been sent within 24 hours of the incident. On 12/10/24 at 11:25 a.m., the administrator was interviewed. The administrator verbalized that this incident was still being investigated, but the CNA in question had been terminated due to unrelated concerns regarding call outs. Review of the facilities abuse policy read in part: [ .] Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment [ .] is obligated to report such information immediately, but no later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials [ .]. Once the allegation is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that the reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations. No other information was presented prior to exit conference on 12/10/24.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement abuse policies for two of seven residents, Resident #'s 203 and 207. The Findings Include: 1. The facility did not implement facility abuse policy in regards to reporting suspicion of physical abuse/mistreatment for Resident #203 (R203). According to the clinical record, diagnoses for R203 included, Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24, which assessed R203 with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R203's clinical record documented a social workers note, dated 12/3/24, that indicated a certified nursing assistant (CNA) had been rude and rough during care (when turning R203) and alluded to R203 not feeling safe during the care provided. On 12/9/24 at 1:50 p.m., R203 was interviewed regarding the incident. R203 verbalized asking for help to turn in bed, CNA #1 came into the room to assist and turned R203 abruptly and roughly. R203 stated that it scared her to the point that it felt like CNA #1 was going to [NAME] her out the bed. When asked if she felt CNA #1 was intending to harm her and if R203 felt safe around CNA #1, R203 verbalized not feeling that CNA #1's intended to harm her but just didn't feel safe while being turned. R203 went onto say that in general CNA #1 seems to be in a hurry, doesn't really speak while providing care, and seems rude. R203 verbalized trying to speak with CNA #1 and thank her for helping but that usually there is no response. A witness statement from R203 was reviewed and indicated CNA #1 was rough when handling R203, grabbed the pad to turn R203 and felt like R203 was being flung on her side. The witness statement documented that R203 goes on to state that CNA #1 is rushing and feels that CNA #1 does not like her (R203). The witness statement also documented that R203 stated that she doesn't feel that CNA #1 would intentionally hurt but doesn't feel safe when CNA #1 works with her (R203). On 12/9/24 at 3:25 p.m., the administrator and the director of nursing (DON) were interviewed regarding not reporting the above allegations to state agency. The DON verbalized that R203 had reported the incident to the wound nurse and the wound nurse had then reported the incident to the DON and administrator. The administrator verbalized that the incident was investigated at the time, along with a skin assessment and talking with R203 (along with the DON), indicated no concerns. The administrator stated that the interview with R203 did not indicate CNA #1 was intentional in her actions and felt that it was more of a customer service concern. The administrator verbalized that education was planned for CNA #1, but that CNA #1 does not work full time and has not worked since the incident. On 12/9/24 at 3:45 p.m., R203 was interviewed again. R203 verbalized, in general CNA #1 seems rude, does not talk, and seems to be in a rush. R203 said that she has tried talking with CNA #1 and thanking her for the help to show kindness but CNA #1 does not converse when providing care. R203 verbalized not feeling that CNA #1 would intentionally harm her, but that particular day felt that CNA #1 would've thrown R203 out of the bed if she thought she (CNA #1) could get away with it. When asked if she (R203) felt that 'CNA #1 would've thrown her out of bed, if CNA #1 could get away with it' sounds intentional, R203 responded, I guess so, I wasn't looking at it like that. R203 then verbalized, This is just how [CNA #1's name redacted] made me feel at the time. On 12/10/24 at 8:45 a.m., an interview was conducted with licensed practical nurse (LPN #1), to whom R203 reported the allegation. LPN #2 verbalized that R203 reported the incident and LPN #1 wrote a witness statement and reported the concern to the DON. LPN #1 said that while talking with R203, it came across that she didn't do anything intentional, but just did not want that particular CNA working with R203. On 12/10/24 at 9:00 a.m., the social worker was interviewed (other staff, OS #1). OS #1 said that after the incident had been reported and the DON and administrator had assessed R203, the OS #1 also assessed and talked with R203. During the conversation with R203, OS #1 verbalized that R203 said this was the first time this had happened. When OS #1 was asked about her notation in the progress notes, OS #1 reviewed the note and agreed that the note does indicate R203 not feeling safe around CNA #1. On 12/10/24 at 10:00 a.m. The DON was interviewed. After reviewing the information, the DON verbalized that it should have been reported, but went onto say, We did do an investigation, which did not yield anything was intentional, and there was no physical evidence to indicate suspicion of abuse. On 12/10/24 at 11:25 a.m., the administrator was interviewed. The administrator verbalized that CNA #1 has not worked since this incident and is currently suspended pending investigation. No other information was presented prior to exit conference on 12/10/24. 2. The facility did not implement facility abuse policy in regards to timely reporting for suspicion of physical abuse/mistreatment for Resident #207 (R207). According to the clinical record, diagnoses for R207 included: Dementia, diabetes, hemiplegia, and anxiety. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 10/3/24 assessed R207 with a cognitive score of 11 out of 15, indicating moderately cognitively intact. Review of facility documentation indicated that the facility had reported an allegation of abuse/mistreatment on 12/9/24, with the incident date of 12/6/24. Review of R207's clinical record documented a social workers note dated 12/6/24 that indicated R207 was upset due to missing drinks and chips were stale after coming back from a leave of absence and was blaming a CNA (identified as CNA #2), and CNA #2 was pointing her finger in R207's face. On 12/10/24 at 8:30 a.m. R207 was interviewed regarding the incident. R207 verbalized feeling that the CNA #2 did point her fingers in R203's face but is aware that CNA #2 has been noted to talk with her hands. When asked if R207 felt safe, R207 verbalized feeling safe and went onto verbalized knowing how to handle herself. R207 also said that the CNA #2 has not worked with her since. On 12/10/24 at 9:10 a.m. the social worker (OS #1) was interviewed. OS #1 explained that during a conversation with R207, R207 reported CNA #2 had pointed her finger in R207's face. OS #1 said at the time of the discussion with R207 the social worker assistant (OS #2) was present and wrote the note and also talked with CNA #2. OS #1 was asked who reported the incident and who was the incident reported to. OS #1 verbalized she (OS #1 reported the incident on 12/6/24 and it was reported to the regional administrator as the DON was not in the facility that day. OS #1 then left the room and returned a few minutes later and verbalized she was not 100 percent sure that she reported to the regional administrator, but verbalized it was reported on 12/6/24. On 12/10/24 at 10:00 a.m., the DON and regional administrator was interviewed. The DON verbalized not working on the day of the incident. The regional administrator verbalized that she was not aware of anyone reporting the incident to her on 12/6/24, and that she became aware of the incident on 12/9/24, while reviewing progress notes and reports with the DON. The regional administrator also verbalized that on 12/9/24 the DON had found a typed note in her mail box from the social worker reporting an incident, but then realized that was a different incident. The regional administrator verbalized that after reviewing everything, the incident should have been sent within 24 hours of the incident. On 12/10/24 at 11:25 a.m., the administrator was interviewed. The administrator verbalized that this incident was still being investigated, but the CNA in question had been terminated due to unrelated concerns regarding call outs. Review of the facilities abuse policy read in part: [ .] Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment [ .] is obligated to report such information immediately, but no later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials [ .]. Once the allegation is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that the reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations. No other information was presented prior to exit conference on 12/10/24.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to report suspicion of physical abuse/mistreatment for one of 7 residents (Resident #203) and failed to report suspicion of physical abuse/mistreatment timely for one of 7 residents (Resident #207) to the state agency. The Findings Include: 1. The facility did not report suspicion of physical abuse/mistreatment for resident #203 (R203). According to the clinical record, diagnoses for R203 included Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24. R203 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R203's clinical record documented a social workers note dated 12/3/24 that indicated a certified nursing assistant (CNA) had been rude and rough during care (when turning R203) and indicated that R203 was not feeling safe during the provided care. On 12/9/24 at 1:50 p.m., R203 was interviewed regarding the incident. R203 verbalized asking for help to turn in bed, CNA #1 came into the room to assist and turned R203 abruptly and roughly, scaring R203 to the point R203 felt like CNA #1 was going to [NAME] her out the bed. R203 was asked if she felt CNA #1 was intending to harm her and if R203 felt safe around CNA #1. R203 verbalized not feeling that CNA #1's intended to harm her but just didn't feel safe while being turned. R203 went onto say that in general CNA #1 seems to be in a hurry, doesn't really speak while providing care, and seems rude. R203 verbalized trying to speak with CNA #1 and thanking her for helping but usually there is no response. Provided by the facility, a witness statement from R203 was reviewed and indicated that CNA #1 is rough when handling R203, grabbed the pad to turn R203 and felt like being flung on her side. R203 goes on to state that CNA #1 is rushing and feels that CNA #1 does not like her (R203). R203 states that she doesn't feel that CNA #1 would intentionally hurt but doesn't feel safe when CNA #1 works with her (R203). On 12/9/24 at 3:25 p.m., the administrator and the director of nursing (DON) were interviewed regarding not reporting this to state agency. The DON verbalized that R203 had reported the incident to the wound nurse and the wound nurse had then reported the incident to the DON and administrator. The administrator verbalized the incident was investigated at the time and talking with R203 (along with the DON), had done a skin assessment, which indicated no concerns, and interviewed R203 which did not indicate CNA #1 was intentional in her actions and felt that it was more of a customer service concern. The administrator verbalized that education was planned for CNA #1 however, CNA #1 does not work full time and has not worked since the incident. On 12/9/24 at 3:45 p.m. R203 was interviewed again. R203 verbalized, in general CNA #1 seems rude, does not talk, and seems to be in a rush. R203 said that she has tried talking with CNA #1 and thanking her for the help to show kindness but CNA #1 does not converse when providing care. R203 verbalized not feeling that CNA #1 would intentionally harm her, but that particular day felt that CNA #1 would've thrown R203 out of the bed if she thought she (CNA #1) could get away with it. When asked if she (R203) felt that 'CNA #1 would throw her out of bed, if CNA #1 could get away with it' sounds intentional, R203 responded I guess so, I wasn't looking at it like that. R203 again verbalized, This is just how CNA #1 made me feel at the time. On 12/10/24 at 8:45 a.m., an interview was conducted with license practical nurse (LPN #1), to whom R203 reported the allegation. LPN #2 verbalized R203 reported the incident and LPN #1 wrote a witness statement and reported the concern to the DON. LPN #1 said that while talking with R203, it came across that the CNA didn't do anything intentional, but just did not want that particular CNA working with R203. On 12/10/24 at 9:00 a.m. the social worker was interviewed (other staff, OS #1). OS #1 said that after the incident had been reported and the DON and administrator had assessed R203, she also assessed and talked with R203. During the conversation between R203 and OS #1, OS #1 verbalized R203 said this was the first time this had happened. OS #1 was asked about her notation in the progress notes, OS #1 reviewed the note and agreed that the note does indicate R203 not feeling safe around CNA #1. On 12/10/24 at 10:00 a.m. The DON was interviewed. After reviewing the information, the DON verbalized that it should have been reported, but went onto say we did do an investigation which did not yield anything was intentional and there was no physical evidence to indicate suspicion of abuse. On 12/10/24 at 11:25 a.m. the administrator was interviewed. The administrator verbalized CNA #1 has not worked since this incident and is currently suspended pending investigation. No other information was presented prior to exit conference on 12/10/24. The Findings Include: 2. The facility did not report suspicion of physical abuse/mistreatment for resident #207 (R207) timely. Diagnoses for R207 included: Dementia, diabetes, hemiplegia, and anxiety. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 10/3/24. R207 was assessed with a cognitive score of 11 indicating moderately cognitively intact. Review of current Facility Reported Incidents (FRI's) indicated hat the facility had reported an allegation of abuse/mistreatment on 12/9/24. The FRI indicated that the incident date was 12/6/24. Review of R207's clinical record documented a social workers note dated 12/6/24 that indicated R207 was upset due to missing drinks and chips were stale after coming back from a leave of absence and was blaming a CNA (identified as CNA #2), and CNA #2 was pointing her finger in R207's face. On 12/10/24 at 8:30 a.m. R207 was interviewed regarding the incident. R207 verbalized feeling that the CNA #2 did point her fingers in R203's face but is aware that CNA #2 has been noted to talk with her hands. When asked if R207 felt safe, R207 verbalized feeling safe and went onto verbalized knowing how to handle herself. R207 also said that the CNA #2 has not worked with her since. On 12/10/24 at 9:10 a.m. the social worker (OS #1) was interviewed. OS #1 explained that during a conversation with R207, R207 reported CNA #2 had pointed her finger in R207's face. OS #1 said at the time of the discussion with R207 the social worker assistant (OS #2) was present and wrote the note and also talked with CNA #2. OS #1 was asked who reported the incident and who was the incident reported to. OS #1 verbalized she (OS #1 reported the incident on 12/6/24 and it was reported to the regional administrator as the DON was not in the facility that day. OS #1 then left the room and returned a few minutes later and verbalized she was not a 100 percent sure that she reported to the regional administrator, but verbalized it was reported on 12/6/24. On 12/10/24 at 10:00 a.m. the DON and regional administrator was interviewed. The DON verbalized not working the day of the incident. The regional administrator verbalized she was not aware of anyone reporting the incident to her on 12/6/24 and she became aware of the incident on 12/9/24 after her and the DON were reviewing progress notes and reports. The regional administrator also verbalized that on 12/9/24 the DON had found a typed note in her mail box from the social worker reporting an incident, but then realized that was a different incident. The regional administrator verbalized after reviewing everything, the FRI should have been sent within 24 hours of the incident. On 12/10/24 at 11:25 a.m. the administrator was interviewed. The administrator verbalized this incident is still being investigated but the CNA in question has been terminated due to unrelated concerns regarding call outs. Review of the facilities abuse policy read in part: [ .] Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment [ .] is obligated to report such information immediately, but no later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials [ .]. Once the allegation is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that the reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations. No other information was presented prior to exit conference on 12/10/24.

Based on observations, staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment that was free from accident hazards and provide adequate supervision to prevent an avoidable accident/elopement for one resident (Resident #113-R113) in a survey sample of 29 residents. R113, while wearing a wander guard device, eloped from the facility, left the premises, fell, and was unable to get up, which resulted in complaints of back pain, requiring treatment, and new order for x-rays, constituting harm. During the survey, the survey team identified that the wander guard system was not consistently functioning properly, and immediate jeopardy was identified. The findings included: The facility staff failed to provide adequate supervision and have a consistently functioning wander guard system to prevent residents with a known elopement risk from the ability to exit the facility without staff knowledge, which resulted in immediate jeopardy. Resident #113, who was a known elopement risk and had a wander guard in place, exited the facility, left facility grounds, fell into a drainage ditch 465.7 feet away from the buidling, was unable to get herself up, and crawled to the edge of the road. After an unknown amount of time, a staff member driving to work saw R113, assisted her off the ground, and drove her to the facility. R113 subsequently complained of pain in her back, requiring new physician orders to be written, which constituted harm. On 10/15/24 at 10:50 a.m. an interview was conducted with R113. R113 said that she walked out to the parking lot and then went on down to the road to smoke a cigarette. R113 said that she stepped into the grass and slid into the mud. R113 said that it took her about half an hour to crawl out of the mud. R113 said that she managed to get out of the mud and back to the side of the road, when an employee saw her, and picked her up in her vehicle. R113 stated. I go outside whenever I want to go out. No signing out or telling anyone. On 10/15/24 and 10/16/24, a clinical record review was conducted. This review revealed that on 9/19/24, according to Resident #113's (R113) care plan, R113 was identified as being at risk for elopement and as a wanderer. R113's care plan included a focus area, which was initiated on 9/24/24, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. Interventions for this focus area, included but were not limited to, an intervention entered 9/24/24, which read, monitor location every 2 hours and prn. That intervention was resolved on 10/2/24. On 10/8/24, a new intervention was added to R113's care plan which read, monitor location every 30 minutes and prn. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m., until 6:30 p.m. R113's hospital Discharge summary, dated [DATE], noted R113 with confusion, unsteady gait, cognitive decline, and unable to live alone. This summary indicated R113 as being unsafe to live alone because of her poor decision making, and noted an example of her placing a paper plate into a toaster oven to support that assessment. On 9/23/24, an elopement risk assessment was completed by the facility, which determined R113 to be an elopement risk and a wander guard was ordered. On 9/20/24 at 6:38 p.m., a nursing progress note in R113's chart read in part, Resident noted setting [sic] on porch this evening. When staff was leaving the facility, found resident walking next to stop sign on property. Assisted back to porch and this nurse walked resident to her unit. Resident watching tv at this time. Resident also had two cigarettes and a lighter on her person. Cigarettes placed in med cart until further direction. On 10/17/24 at 11:20 a.m., the regional director of clinical services measured the distance the resident had achieved on 9/20/24, with the surveyor and facility administrator observing. Although there was no stop sign noted in the designated area that the facility indicated R113 had been found on 9/20/24, it was measured as being 244.4 feet from the front door of the facility. The closest stop sign found in the area by the surveyor was approximately 0.25 miles or 1320 feet from the facility. On 9/23/24 at 7:02 p.m., a nursing progress note was entered into R113's record that read, Pt [patient] was seen walking outside upon returning inside facility she requested to speak with the speech therapist she informed her that she wants to leave the facility to go home. ADON [assistant director of nursing] was contacted via phone an instructed the writer to conduct an elopement assessment, this was done and pt is an elopement risk. Grand daughter was contacted and informed and message left on phone for Dr [medical director name redacted]. Wander guard place on pts Lt [left] ankle for safety. SIC On 9/24/24, R113's care plan was revised to add an intervention, which read, Monitor location every 2 hours and prn [as needed]. This intervention was discontinued on 10/2/24. On 10/17/24, the facility administration was asked to provide the survey team with evidence of the safety monitoring. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m. 6:30 p.m. On 9/25/25 and 9/26/24, nursing note entries in R113's chart both read in part, .Often wonders outside and off sidewalk. Wonderguard in place . SIC On 10/2/24, a nursing progress note in R113's chart read, Resident had fall outside and was assisted back into facility by [certified nursing assistant #6's name redacted], CNA and no injury noted. Wandergaurd is intact and was let out to set on front porch by receptionist and wanderguard does work. On 10/3/24, a progress note from the nurse practitioner was entered into R113's clinical record, which read in part, Patient presented with complaints of lower back pain following a fall. On examination, pain was noted along the spine in the LS [lumbar spine] region. This pain is consistent with a potential injury to the thoracic spine. Plan: Prescribed Tylenol, 1 gram, twice a day for 7 days, with additional doses as needed for pain management. An x-ray will be ordered to rule out a compression fracture. According to facility documents, on 10/2/24, one of the two statements was by certified nursing assistant #1 (CNA#1) who had spotted R113 lying on the ground and had assisted R113 back to the building. On 10/16/24 at 5:21 p.m., an interview was conducted with CNA #1. CNA #1 stated that she had discovered R113 at 2:45 p.m., while driving to work, lying beside the road. CNA#1 stated that R113 had reported that she had fallen into a drainage ditch, off the facility property, and was unable to get up. CNA#1 stated that she had assisted R113 up off the ground, into her jeep, and took R113 back to the facility. According to CNA#1, R113 was wet, had mud all over her, and required a shower. CNA#1 stated that upon entering the building with R113, she had alerted staff, who had been unaware of R113's absence or how long she was gone, and that there had been no audible alarm sounding when they entered the building. On 10/16/24 at 11:20 a.m., the survey team, facility administrator, and regional nurse consultant measured the distance from the facility's front entrance/exit door to the location where R113 was found on 10/2/24, determining that the distance was 465.7 feet. The width of the ditch the resident fell into was measured at 7.2 feet and 0.87 feet in depth. The distance from the hard surface road to the ditch was measured to be 23.5 feet of grass and rough terrain. On 10/16/24 at 11:24 a.m., during an interview, other staff member #1 (OS #1) reported that frequently the front door wander guard system doesn't function properly. OS#1 said, There are times she has it on and it [the door alarm] doesn't go off, they check it and have to make adjustments. It doesn't always go off. Earlier this week [Resident #109's name redacted] went out and it didn't work. OS #1 reported that on 10/2/24, she was helping with answering the phones but was bouncing around and was not at the front desk/lobby when R113 went outside. OS #1 reported that she was on one of the nursing units helping a resident when R113 was brought back to the facility. OS #1 also stated, She [R113] is a difficult one. We never know when she has a wander guard or not, one day she has it and other days she doesn't. On 10/16/24 at 12:28 p.m., an interview was conducted with Other Staff #2 (OS #2), who worked as a back-up receptionist. OS #2 reported that just a few weeks ago she was working on a Sunday and about 1:10 p.m., when she arrived, R113 was in the parking lot. OS #2 said, Since she had a wander guard on, she wasn't supposed to be outside. I told her she needed to come back inside because she had a fall, and I didn't want her to fall again. OS #2 reported that this was about 2-3 weeks ago. According to OS #2's timecard, she had worked 9/22/24, which was prior to R113's fall incident and then worked again on Sunday, 10/6/24. OS #2 went on to state that, They [administration] kept changing their minds. At one time they would let her go out on the porch. Another time they said someone had to be with her. When asked about the door alarm and functioning, OS #2 said, Sometimes the things don't go off. It is really sporadic. On 10/16/24 at approximately 2:00 p.m., R124, who wears a wander guard, was observed by the survey team to be in the lobby, beyond the sensor for the wander guard alarm, past the receptionist desk, and only 8 feet from the exit door. Yet, there was no audible alarm triggered by the wander guard system. R124 was redirected back to his room by facility staff, away from the exit doors. On 10/16/24 at approximately 2:30 p.m., an interview was conducted with the maintenance assistant. The maintenance assistant reported that he checks the door alarms daily, Monday through Friday, and at times the front door's wander guard system doesn't work and they have to make adjustments. On 10/16/24 at 3:27 p.m., an interview was conducted with maintenance director. The maintenance director did report that in his short tenure of a few months that . once in a while, the receptionist will say that when a resident goes out, it doesn't alarm, and we have to make adjustments. On 10/16/24 in the early afternoon, the front door wander guard system was tested with the director of nursing (DON). The DON placed a wander guard into her sock, to mimic the location where the wander guard is placed on resident's ankle. The DON was able to walk through the lobby and open the front door, without the locking mechanism of the wander guard system engaging to lock the door and prevent exit. On 10/16/24, in the late afternoon, the front door was again tested using a wander guard by the maintenance director. Initially when the maintenance director had the device pass through the lobby area, the sensor did not pick up the signal, and made no alarm. On the second attempt, the alarm sounded, and the door locked. On the third attempt, the alarm sounded but the door remained unlocked and a resident could have exited. On 10/16/24 at 5:43 p.m., during an end of day meeting with the facility administrator, director of nursing (DON) and regional director of clinical services (RDCS), the incident on 10/2/24, involving R113 was discussed. The facility administrator reported she was not at the facility and was out of town at the time of the incident. The administrator went on to say that there wasn't a receptionist the day of the incident. When the survey team questioned that the nursing progress note indicated that the receptionist had let the resident out, as well as being noted likewise in the investigation summary, but that both receptionists had denied letting the resident out of the facility on 10/2/24, the Administrator and RDCS both stated they didn't know who had let R113 outside. During the end of day meeting held on 10/16/24, the RDCS provided the survey team with an Action Plan they had implemented following R113's elopement on 10/2/24. According to the action plan residents with a wander guard were reviewed to ensure appropriateness. The RDCS and Administrator stated that they determined R113 was not an elopement risk and was not appropriate to have a wander guard. On 10/17/24 at 9:00 a.m. another interview was conducted with R113. R113 stated, I just went out the front door, the door was unlocked, and people were outside, and no alarm sounded. I would go up sometimes and the alarm would sound, and they would turn it off, and I would go out the door. On 10/17/24 at 9:19 a.m., the facility administrator was asked about the functioning of the wander guard system. The administrator said, I am not aware of an issue. The survey team reported that in staff interviews multiple staff reported that the wander guard system is inconsistent and doesn't always operate properly. It was also reported that during the testing of the system by the DON and by the maintenance director the day prior, the wander guard system had not functioned properly. The administrator stated, This is the first I've heard of it. I always thought there was a mag [magnetic] lock, that if the door isn't closing enough, they may not latch. We just adjust those sensors on the side regularly. There is some sort of sensitivity, different things can affect it. That's usually what's going on. On 10/17/24 at 11:15 a.m. an interview was conducted with the business office assistant (other staff #2, OS2). OS2 verbalized that residents with wander guards were able to go out and sit on the front porch without staff going with them, until R113 fell outside. OS#2 stated, Now, if a resident with a wander guard wants to go outside, staff or a family member had to be with the resident. On 10/17/24 at 9:00 a.m. an interview with R113 was conducted. R113 was complaining of her back hurting from her waist down and that her chest was hurting. The surveyor notified R113's nurse, LPN#6. When notified, the physician ordered an x-ray of R113's lumbar spine on 10/17/24. On 10/17/24 at 3:15 p.m., the survey team identified the facility was in immediate jeopardy (IJ) in the care area of Quality of Care, as confirmed by the state agency. Given the findings that the facility failed to provide adequate supervision and failed to have a consistently functioning wander guard system to prevent residents identified as an elopement risk the ability to exit the facility without staff knowledge, the survey team determined that this noncompliance made the occurrence of serious adverse outcome likely and that the facility needed to take immediate corrective action. The survey team met with the facility administrator, director of nursing, and corporate staff and reviewed the IJ findings. On 10/18/24 at 6:20 p.m., the facility administration provided the survey team with an accepted IJ removal plan. The facility's plan to remove IJ read as follows: At approximately 0930 on 10/17/24 a staff member was posted at the front door to monitor entrance and exit and to ensure residents at risk were not allowed to exit without supervision. A staff member was assigned to relieve the scheduled staff when needed. [NAME] Security Services was contacted and on-site at arrived on site 10/17/24 at approximately 3:00 pm to work on functionality of the door alarming and latching when triggered by the Wander guard alarm. A staff person has been scheduled for 1:1 supervision of the front door for next 24 hours and until maintenance has verified door functionality; staff will be educated on responsibility of supervising the front door. All current staff in the building will be educated on their responsibility of preventing resident elopements beginning 10/17/24 evening shift and additional staff will be educated at their assigned shift. The facility alleged they would have the IJ removal plan completed on 10/17/24 at 6:30 p.m. On 10/17/24 at 6:20 p.m. the front receptionist was interviewed. The receptionist was able to verbalize that she was not able to leave the desk for any reason, unless someone came to relieve her. The receptionist was able to verbalize that residents with wander guards are not able to exit the front door unless a staff member was with them and also showed the surveyor an elopement book which identified the residents with wander guards. On 10/18/24 at 8:15 am the survey team returned on-site to verify the removal of IJ. A receptionist was sitting at the front desk in the lobby. The receptionist was interviewed and was able to verbalize that residents with wander guards are not permitted to go outside unless accompanied by staff or family. The receptionist also stated that she was not able to leave from monitoring the front desk/door unless someone was present to relieve her. Sign off sheets were verified that since 5 p.m. on 10/17/24 staff signed every 15 minutes that they were watching the front door, and it was continuously monitored. A statement from the maintenance director indicated that he had worked on the front door on 10/17/24 and had called a contractor in to work on it. The contractor bill dated 10/17/24 was provided which showed that the lever trim function of the front exterior door had been changed. The facility reported that the front door wander guard system was now operating properly. The survey team verified this with the Director of Nursing, noting that the system alarmed and locked the door when a wander guard approached the door. A copy of the schedule for all departments on 10/17/24 and 10/18/24 was received. Staff education sign-in sheets were also received, and a comparison was made to ensure that all staff working in the facility at 6:30 p.m., on 10/17/24 signed that they were educated on elopement, how to manage elopement risks, etc. Several staff were identified that had worked the evening/night shift that had not signed as having received education. Also identified was a certified nursing assistant (CNA #4) who was currently working who had not signed as having received education. CNA #4 was interviewed and confirmed she had not received any education. A sample of staff across all departments to include therapy, housekeeping, laundry, nursing and dietary were interviewed to ensure that they received training and understood elopement risk, how to respond in the event of a missing resident, and how to respond if the wander guard alarm sounds, etc. On 10/18/24 at 10 a.m., the administrator was asked to come to the conference room. When shown the staff that that had not signed as being educated, the administrator provided additional sign-in sheets that the survey team had not been given. The survey team was able to identify that all staff currently working and who had worked since 6:30 pm on 10/17/24 had received training except for CNA #4. On 10/18/24 at 10:10 a.m., the facility administrator was made aware the survey team had found that a staff member had not been educated. The administrator was notified that the survey team could not verify abatement of IJ until CNA #4 was trained. On 10/18/24 at 10:20 a.m., the facility administrator provided evidence that CNA #4 had been educated. On 10/18/24 at 10:20 a.m., the survey team was able to confirm that the immediacy had been removed. Following the removal of immediate jeopardy the scope and severity was lowered to a level three, isolated, as R113 suffered pain following the elopement incident and fall. No more information was provided.

Based on observations, staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment that was free from accident hazards and provide adequate supervision to prevent an avoidable accident/elopement for one resident (Resident #113-R113) in a survey sample of 29 residents. R113, while wearing a wander guard device, eloped from the facility, left the premises, fell , and was unable to get up, which resulted in complaints of back pain, requiring treatment, and new order for x-rays, constituting harm. During the survey, the survey team identified that the wander guard system was not consistently functioning properly, and immediate jeopardy was identified. The findings included: The facility staff failed to provide adequate supervision and have a consistently functioning wander guard system to prevent residents with a known elopement risk from the ability to exit the facility without staff knowledge, which resulted in immediate jeopardy. Resident #113, who was a known elopement risk and had a wander guard in place, exited the facility, left facility grounds, fell into a drainage ditch 465.7 feet away from the buidling, was unable to get herself up, and crawled to the edge of the road. After an unknown amount of time, a staff member driving to work saw R113, assisted her off the ground, and drove her to the facility. R113 subsequently complained of pain in her back, requiring new physician orders to be written, which constituted harm. On 10/15/24 at 10:50 a.m. an interview was conducted with R113. R113 said that she walked out to the parking lot and then went on down to the road to smoke a cigarette. R113 said that she stepped into the grass and slid into the mud. R113 said that it took her about half an hour to crawl out of the mud. R113 said that she managed to get out of the mud and back to the side of the road, when an employee saw her, and picked her up in her vehicle. R113 stated. I go outside whenever I want to go out. No signing out or telling anyone. On 10/15/24 and 10/16/24, a clinical record review was conducted. This review revealed that on 9/19/24, according to Resident #113's (R113) care plan, R113 was identified as being at risk for elopement and as a wanderer. R113's care plan included a focus area, which was initiated on 9/24/24, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. Interventions for this focus area, included but were not limited to, an intervention entered 9/24/24, which read, monitor location every 2 hours and prn. That intervention was resolved on 10/2/24. On 10/8/24, a new intervention was added to R113's care plan which read, monitor location every 30 minutes and prn. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m., until 6:30 p.m. R113's hospital discharge summary, dated 8/31/24, noted R113 with confusion, unsteady gait, cognitive decline, and unable to live alone. This summary indicated R113 as being unsafe to live alone because of her poor decision making, and noted an example of her placing a paper plate into a toaster oven to support that assessment. On 9/23/24, an elopement risk assessment was completed by the facility, which determined R113 to be an elopement risk and a wander guard was ordered. On 9/20/24 at 6:38 p.m., a nursing progress note in R113's chart read in part, Resident noted setting [sic] on porch this evening. When staff was leaving the facility, found resident walking next to stop sign on property. Assisted back to porch and this nurse walked resident to her unit. Resident watching tv at this time. Resident also had two cigarettes and a lighter on her person. Cigarettes placed in med cart until further direction. On 10/17/24 at 11:20 a.m., the regional director of clinical services measured the distance the resident had achieved on 9/20/24, with the surveyor and facility administrator observing. Although there was no stop sign noted in the designated area that the facility indicated R113 had been found on 9/20/24, it was measured as being 244.4 feet from the front door of the facility. The closest stop sign found in the area by the surveyor was approximately 0.25 miles or 1320 feet from the facility. On 9/23/24 at 7:02 p.m., a nursing progress note was entered into R113's record that read, Pt [patient] was seen walking outside upon returning inside facility she requested to speak with the speech therapist she informed her that she wants to leave the facility to go home. ADON [assistant director of nursing] was contacted via phone an instructed the writer to conduct an elopement assessment, this was done and pt is an elopement risk. Grand daughter was contacted and informed and message left on phone for Dr [medical director name redacted]. Wander guard place on pts Lt [left] ankle for safety. SIC On 9/24/24, R113's care plan was revised to add an intervention, which read, Monitor location every 2 hours and prn [as needed]. This intervention was discontinued on 10/2/24. On 10/17/24, the facility administration was asked to provide the survey team with evidence of the safety monitoring. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m. 6:30 p.m. On 9/25/25 and 9/26/24, nursing note entries in R113's chart both read in part, .Often wonders outside and off sidewalk. Wonderguard in place . SIC On 10/2/24, a nursing progress note in R113's chart read, Resident had fall outside and was assisted back into facility by [certified nursing assistant #6's name redacted], CNA and no injury noted. Wandergaurd is intact and was let out to set on front porch by receptionist and wanderguard does work. On 10/3/24, a progress note from the nurse practitioner was entered into R113's clinical record, which read in part, Patient presented with complaints of lower back pain following a fall. On examination, pain was noted along the spine in the LS [lumbar spine] region. This pain is consistent with a potential injury to the thoracic spine. Plan: Prescribed Tylenol, 1 gram, twice a day for 7 days, with additional doses as needed for pain management. An x-ray will be ordered to rule out a compression fracture. According to facility documents, on 10/2/24, one of the two statements was by certified nursing assistant #1 (CNA#1) who had spotted R113 lying on the ground and had assisted R113 back to the building. On 10/16/24 at 5:21 p.m., an interview was conducted with CNA #1. CNA #1 stated that she had discovered R113 at 2:45 p.m., while driving to work, lying beside the road. CNA#1 stated that R113 had reported that she had fallen into a drainage ditch, off the facility property, and was unable to get up. CNA#1 stated that she had assisted R113 up off the ground, into her jeep, and took R113 back to the facility. According to CNA#1, R113 was wet, had mud all over her, and required a shower. CNA#1 stated that upon entering the building with R113, she had alerted staff, who had been unaware of R113's absence or how long she was gone, and that there had been no audible alarm sounding when they entered the building. On 10/16/24 at 11:20 a.m., the survey team, facility administrator, and regional nurse consultant measured the distance from the facility's front entrance/exit door to the location where R113 was found on 10/2/24, determining that the distance was 465.7 feet. The width of the ditch the resident fell into was measured at 7.2 feet and 0.87 feet in depth. The distance from the hard surface road to the ditch was measured to be 23.5 feet of grass and rough terrain. On 10/16/24 at 11:24 a.m., during an interview, other staff member #1 (OS #1) reported that frequently the front door wander guard system doesn't function properly. OS#1 said, There are times she has it on and it [the door alarm] doesn't go off, they check it and have to make adjustments. It doesn't always go off. Earlier this week [Resident #109's name redacted] went out and it didn't work. OS #1 reported that on 10/2/24, she was helping with answering the phones but was bouncing around and was not at the front desk/lobby when R113 went outside. OS #1 reported that she was on one of the nursing units helping a resident when R113 was brought back to the facility. OS #1 also stated, She [R113] is a difficult one. We never know when she has a wander guard or not, one day she has it and other days she doesn't. On 10/16/24 at 12:28 p.m., an interview was conducted with Other Staff #2 (OS #2), who worked as a back-up receptionist. OS #2 reported that just a few weeks ago she was working on a Sunday and about 1:10 p.m., when she arrived, R113 was in the parking lot. OS #2 said, Since she had a wander guard on, she wasn't supposed to be outside. I told her she needed to come back inside because she had a fall, and I didn't want her to fall again. OS #2 reported that this was about 2-3 weeks ago. According to OS #2's timecard, she had worked 9/22/24, which was prior to R113's fall incident and then worked again on Sunday, 10/6/24. OS #2 went on to state that, They [administration] kept changing their minds. At one time they would let her go out on the porch. Another time they said someone had to be with her. When asked about the door alarm and functioning, OS #2 said, Sometimes the things don't go off. It is really sporadic. On 10/16/24 at approximately 2:00 p.m., R124, who wears a wander guard, was observed by the survey team to be in the lobby, beyond the sensor for the wander guard alarm, past the receptionist desk, and only 8 feet from the exit door. Yet, there was no audible alarm triggered by the wander guard system. R124 was redirected back to his room by facility staff, away from the exit doors. On 10/16/24 at approximately 2:30 p.m., an interview was conducted with the maintenance assistant. The maintenance assistant reported that he checks the door alarms daily, Monday through Friday, and at times the front door's wander guard system doesn't work and they have to make adjustments. On 10/16/24 at 3:27 p.m., an interview was conducted with maintenance director. The maintenance director did report that in his short tenure of a few months that . once in a while, the receptionist will say that when a resident goes out, it doesn't alarm, and we have to make adjustments. On 10/16/24 in the early afternoon, the front door wander guard system was tested with the director of nursing (DON). The DON placed a wander guard into her sock, to mimic the location where the wander guard is placed on resident's ankle. The DON was able to walk through the lobby and open the front door, without the locking mechanism of the wander guard system engaging to lock the door and prevent exit. On 10/16/24, in the late afternoon, the front door was again tested using a wander guard by the maintenance director. Initially when the maintenance director had the device pass through the lobby area, the sensor did not pick up the signal, and made no alarm. On the second attempt, the alarm sounded, and the door locked. On the third attempt, the alarm sounded but the door remained unlocked and a resident could have exited. On 10/16/24 at 5:43 p.m., during an end of day meeting with the facility administrator, director of nursing (DON) and regional director of clinical services (RDCS), the incident on 10/2/24, involving R113 was discussed. The facility administrator reported she was not at the facility and was out of town at the time of the incident. The administrator went on to say that there wasn't a receptionist the day of the incident. When the survey team questioned that the nursing progress note indicated that the receptionist had let the resident out, as well as being noted likewise in the investigation summary, but that both receptionists had denied letting the resident out of the facility on 10/2/24, the Administrator and RDCS both stated they didn't know who had let R113 outside. During the end of day meeting held on 10/16/24, the RDCS provided the survey team with an Action Plan they had implemented following R113's elopement on 10/2/24. According to the action plan residents with a wander guard were reviewed to ensure appropriateness. The RDCS and Administrator stated that they determined R113 was not an elopement risk and was not appropriate to have a wander guard. On 10/17/24 at 9:00 a.m. another interview was conducted with R113. R113 stated, I just went out the front door, the door was unlocked, and people were outside, and no alarm sounded. I would go up sometimes and the alarm would sound, and they would turn it off, and I would go out the door. On 10/17/24 at 9:19 a.m., the facility administrator was asked about the functioning of the wander guard system. The administrator said, I am not aware of an issue. The survey team reported that in staff interviews multiple staff reported that the wander guard system is inconsistent and doesn't always operate properly. It was also reported that during the testing of the system by the DON and by the maintenance director the day prior, the wander guard system had not functioned properly. The administrator stated, This is the first I've heard of it. I always thought there was a mag [magnetic] lock, that if the door isn't closing enough, they may not latch. We just adjust those sensors on the side regularly. There is some sort of sensitivity, different things can affect it. That's usually what's going on. On 10/17/24 at 11:15 a.m. an interview was conducted with the business office assistant (other staff #2, OS2). OS2 verbalized that residents with wander guards were able to go out and sit on the front porch without staff going with them, until R113 fell outside. OS#2 stated, Now, if a resident with a wander guard wants to go outside, staff or a family member had to be with the resident. On 10/17/24 at 9:00 a.m. an interview with R113 was conducted. R113 was complaining of her back hurting from her waist down and that her chest was hurting. The surveyor notified R113's nurse, LPN#6. When notified, the physician ordered an x-ray of R113's lumbar spine on 10/17/24. On 10/17/24 at 3:15 p.m., the survey team identified the facility was in immediate jeopardy (IJ) in the care area of Quality of Care, as confirmed by the state agency. Given the findings that the facility failed to provide adequate supervision and failed to have a consistently functioning wander guard system to prevent residents identified as an elopement risk the ability to exit the facility without staff knowledge, the survey team determined that this noncompliance made the occurrence of serious adverse outcome likely and that the facility needed to take immediate corrective action. The survey team met with the facility administrator, director of nursing, and corporate staff and reviewed the IJ findings. On 10/18/24 at 6:20 p.m., the facility administration provided the survey team with an accepted IJ removal plan. The facility's plan to remove IJ read as follows: At approximately 0930 on 10/17/24 a staff member was posted at the front door to monitor entrance and exit and to ensure residents at risk were not allowed to exit without supervision. A staff member was assigned to relieve the scheduled staff when needed. [NAME] Security Services was contacted and on-site at arrived on site 10/17/24 at approximately 3:00 pm to work on functionality of the door alarming and latching when triggered by the Wander guard alarm. A staff person has been scheduled for 1:1 supervision of the front door for next 24 hours and until maintenance has verified door functionality; staff will be educated on responsibility of supervising the front door. All current staff in the building will be educated on their responsibility of preventing resident elopements beginning 10/17/24 evening shift and additional staff will be educated at their assigned shift. The facility alleged they would have the IJ removal plan completed on 10/17/24 at 6:30 p.m. On 10/17/24 at 6:20 p.m. the front receptionist was interviewed. The receptionist was able to verbalize that she was not able to leave the desk for any reason, unless someone came to relieve her. The receptionist was able to verbalize that residents with wander guards are not able to exit the front door unless a staff member was with them and also showed the surveyor an elopement book which identified the residents with wander guards. On 10/18/24 at 8:15 am the survey team returned on-site to verify the removal of IJ. A receptionist was sitting at the front desk in the lobby. The receptionist was interviewed and was able to verbalize that residents with wander guards are not permitted to go outside unless accompanied by staff or family. The receptionist also stated that she was not able to leave from monitoring the front desk/door unless someone was present to relieve her. Sign off sheets were verified that since 5 p.m. on 10/17/24 staff signed every 15 minutes that they were watching the front door, and it was continuously monitored. A statement from the maintenance director indicated that he had worked on the front door on 10/17/24 and had called a contractor in to work on it. The contractor bill dated 10/17/24 was provided which showed that the lever trim function of the front exterior door had been changed. The facility reported that the front door wander guard system was now operating properly. The survey team verified this with the Director of Nursing, noting that the system alarmed and locked the door when a wander guard approached the door. A copy of the schedule for all departments on 10/17/24 and 10/18/24 was received. Staff education sign-in sheets were also received, and a comparison was made to ensure that all staff working in the facility at 6:30 p.m., on 10/17/24 signed that they were educated on elopement, how to manage elopement risks, etc. Several staff were identified that had worked the evening/night shift that had not signed as having received education. Also identified was a certified nursing assistant (CNA #4) who was currently working who had not signed as having received education. CNA #4 was interviewed and confirmed she had not received any education. A sample of staff across all departments to include therapy, housekeeping, laundry, nursing and dietary were interviewed to ensure that they received training and understood elopement risk, how to respond in the event of a missing resident, and how to respond if the wander guard alarm sounds, etc. On 10/18/24 at 10 a.m., the administrator was asked to come to the conference room. When shown the staff that that had not signed as being educated, the administrator provided additional sign-in sheets that the survey team had not been given. The survey team was able to identify that all staff currently working and who had worked since 6:30 pm on 10/17/24 had received training except for CNA #4. On 10/18/24 at 10:10 a.m., the facility administrator was made aware the survey team had found that a staff member had not been educated. The administrator was notified that the survey team could not verify abatement of IJ until CNA #4 was trained. On 10/18/24 at 10:20 a.m., the facility administrator provided evidence that CNA #4 had been educated. On 10/18/24 at 10:20 a.m., the survey team was able to confirm that the immediacy had been removed. Following the removal of immediate jeopardy the scope and severity was lowered to a level three, isolated, as R113 suffered pain following the elopement incident and fall. No more information was provided.

Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide care and services to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being, which resulted in psychosocial harm for five residents (Resident #7- R7, Resident #8- R8, Resident #12- R12, Resident #13- R13, and Resident #15- R15). The resident who was the known aggressor, was targeting female residents. Therefore 59 of the 98 residents residing in the facility who were female, had the potential to be affected. This deficient practice resulted in immediate jeopardy. The findings included: 1. For R7, who was self-isolating because of R10, the facility staff failed to implement interventions so that the resident could maintain the highest practicable psychosocial well-being. On 7/31/24 at 3:20 p.m., an interview was conducted with resident #7- R7. R7 told the surveyor of an incident that occurred at the vending machine involving resident #10 (R10) talking about sex and saying that my belly button is pushed out because a 250-pound lady was on top of me R7 reported that R10's comments made her very uncomfortable. R7 reported that she returned to her room, turned the lights off, and got in bed. R7 reported that someone came in and didn't say anything, then a voice [she identified as R10] said I will talk to you tomorrow. R7 reported that she has stayed away from R10 since then and said, He talks very nasty and disgusting . He always begins the conversation with I still like sex. R7 reported that she told her daughter and the daughter talked with social services. R7 went on to say, I had a sign on my door that said stop, but it is gone. R7 reported that she rarely comes of out her room, because she wants to stay away from Resident #10. R7 reported, she didn't realize how much R10's behaviors bothered her until she realized that she rarely leaves her room now. On 7/31/24, a clinical record review was conducted of R7's chart. This review included the care plan and progress notes. There was no documentation regarding the incident with R10, the implementation of a stop-sign banner, or any concerns related to R10 and R7 no longer coming out of her room. On 7/31/24 and 8/1/24, the facility's grievance log was reviewed and there was no evidence of a grievance related to R7's report of R10 entering her room uninvited. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying that he was still capable of having sex. R7 reported that she .froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted], he is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into the room in the dark. I am very uncomfortable to even pass him in the hall. Daily observations were conducted of R7's room at various times of the day throughout 7/30/24-8/2/24. Each of the observations revealed no stop-sign banner present or in use. On 8/5/24 at 4:32 p.m., during an interview with the director of nursing (DON), the DON reported that one day she was talking to R7's daughter in the hallway and the social worker asked the DON to step into the office. The DON said the social worker reported the incident where R10 went into R7's room. The DON said, I went to put the stop sign across her door and she denied that he had been back. I asked the resident and her daughter about the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered her room. The administrator said, I did hear he had come in her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked where the grievance, or investigation regarding the incident was, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations. 2. For R8, the facility staff failed to provide care and services to provide the resident with the highest practicable psychosocial well-being, which resulted in R8 no longer visiting a common area within the facility, to avoid Resident #10. On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, He is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He will say he loves me. He discusses what he likes to do to women, says he likes older women's stuff and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 3. For R12, the facility staff failed to ensure the resident was able to maintain her highest practicable psychosocial well-being and without being fearful of another resident. On 8/1/24 at 4:20 p.m., Resident #12 was observed in the common area on the 400 unit. Resident #12 was observed crying, when asked what was wrong, she reported that she and Resident #10 got into an argument last night because he is pressuring me to have sex and I'm just not that kind of woman. Resident #12 reported that she is scared and uncomfortable. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted], we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10] personal behavior, his nasty talking. I felt very uncomfortable. There are things I don't tolerate with my friends . I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I am nervous talking about it. During the interview, R12's hands were observed to be shaking. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). The DON said, I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, That with female residents, he [R10] is doing sexual things to them, and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big who-ha. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. On 8/5/24, during an interview with the DON, she was asked if she identified who the resident was that R10 had his hands between the legs of that she mentioned on 8/1/24. The DON said, Yes, I spoke to a staff member who told me it was [names redacted, R10 and R12]. The witness statement is in my office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made aware by overhearing staff talking amongst themselves about resident #10 had his hand down the pants of resident #12 while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw resident #10 have his hand down resident #12s pants resident #12 had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with resident #12 and asked her if she opposed to this behavior or it was not wanted, she replied no it was fine at this time it was determined no abuse had occurred. [SIC] The statement was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about his role in ensuring residents are safe and free from sexual harassment by R10, the administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it . It's all just a total cluster, because when she [the DON] heard that, you start an investigation by talking to staff and residents. 4. Resident #13 was not afforded care and services to maintain the highest practicable psychosocial wellbeing as she had altered usual social patterns and was avoiding common areas due to the unwanted behaviors of R10. On 8/1/24 at 10:11 a.m., an interview was conducted with Resident #13 (R13). R13 said, He [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and so I leave because of it. I don't stay anymore and my husband told me to stay away from him. 5. R15, who was subjected to witness multiple occurrences of sexual activity between Resident #9 [who was the roommate of R15] and R10, because the privacy curtain was not pulled, which affected R15's psychosocial well-being. On 7/31/24 at 2:55 p.m., an interview was conducted with resident #15 (R15). R15 reported that R9's [who was her roommate] . boyfriend put a [NAME] on her neck. R15 went on to say that R9 .has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, The curtain wasn't pulled. I don't want to see that mess. R15 indicated that these types of observations were recurrent and appeared visibly upset. On 8/1/24 at 9:16 a.m., an interview was conducted again with R15. R15 said, Mr. [R10's name redacted] gave her [R9] a [NAME]. R15 went on to talk about what she had seen between R10 and R9. He [referring to R10] puts his tongue down her [R9]'s throat. When asked if anything sexual has occurred R15 said, Yes, I saw it, he walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. R15 indicated that she had felt like she didn't matter. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, There are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, Last week [CNA #4's name redacted] saw her [R9] [which is R15's roommate] with his penis in her hand. Maybe Sunday. I went and talked to Ms. [R15's name redacted], she said she didn't want him in her room. The nurse went down and told him and told him, if he went in that room he would be removed. She [R15] said she didn't want to see what they do, that incident [where R9 had R10's penis in her hand] is why she doesn't want him in there. On 8/1/24 at 10:46 a.m., the administrator and DON were made aware of the above interviews and that R7, R8, R12, R13, and R15 were reporting being scared and changing their daily routine because of R10's behaviors. The DON said, I didn't know residents are scared of him or afraid to come out of their room. The administrator said, I'm just hearing about this. After talking with him the other week, his brother came in and I told him about it, and he said he tells him all the time he is not God's gift to women. The administrator reported that he had no documentation or credible evidence to provide the survey team with regards to the conversation he had with R10. On 8/2/24 at 8:50 a.m., the survey team identified the facility was in immediate jeopardy for failure to provide care and services to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. On 8/2/24 at 5:43 p.m., the facility submitted an IJ removal plan that was accepted. The plan of removal read as follows: F675- Quality of Life. Resident #10 was placed on 1:1 supervision. The resident will be educated on appropriate behaviors towards others including verbal abuse and unwanted/inappropriate sexual activity. Resident #7 will be reminded that resident #10 is on 1:1 supervision and will be provided reassurance that she is safe to come out of her room whenever she desires. Resident #8 will be reminded that resident #10 is on 1:1 supervision and will be provided reassurance that she can covert back to her preferred daily routine and that she can go to the library and outside safely whenever she desires. Resident #12 will be reminded that resident #10 is on 1:1 supervision. Resident #12 will be reminded to report to facility staff if/when she is scared or uncomfortable. Resident #13 2ill be reminded that resident #10 is on 1:1 supervision and will be provided reassurance that she can go to the library and common area safely whenever she desires. Resident #15 has been offered a room change. Resident #15 will be reminded resident #10 is on 1:1 supervision and to call for staff assistance should she ever need the privacy curtain pulled. Residents #7, #8, #12, #13 and #15 will receive daily social services/designee visits to ensure their psychosocial needs are being met and that they feel safe and are able to enjoy their resident centered activities of their choice and timing. Residents #7, #8, #12, #13 and #15 will be evaluated by Psychiatric NP for any psychosocial harm that may have occurred. Care plans for residents # 7, #8, #12, #13 and #15 will be updated to address psychosocial needs and protection from verbal/mental abuse. All facility staff will be educated on the abuse policy to include providing immediate protection to any resident that reports any allegation of abuse to include psychosocial harm and capacity to consent. Allegation of compliance 8/3/24 at 11:50 p.m. On 8/5/24, the survey team made multiple observations of Resident #10 to verify that one to one supervision was being provided. The survey team reviewed the log of one-to-one supervision to ensure that the supervision had been continuous since initiated. The survey team reviewed and verified that resident #7, #8, #12, and #13 had been educated that resident #10 was on one-to-one supervision and they were safe to resume normal daily routines. The survey team confirmed that resident #15 had been offered a room change and knew to call staff if the privacy curtain needed to be pulled. The survey team confirmed that residents #7, #8, #12, #13, and #15 had received daily social services visits which were documented within the clinical records. The survey team reviewed the progress notes from the psychiatric nurse practitioner to confirm residents #7, #8, #12, #13 and #15, had been seen. The survey team reviewed the sign in sheets from the staff education and used a sample of staff on the as worked schedule for 8/5/24, to confirm they had been trained. The survey team then conducted interviews with a sample of employees, across all departments, to ensure they had received abuse training, were aware of sexual harassment as being considered abuse, and if residents have questionable cognitive impairment, they need to be assessed to determine capacity to consent to sexual relations. The IJ was removed/abated on 8/5/24 at 4:30 p.m. and the scope and severity was lowered to a level three, pattern.

Based on resident interviews, facility staff interviews, clinical record review and facility documentation review, the facility staff failed to investigate allegations of abuse and sexual harassment by Resident #10 (R10) who was targeting female residents, and to take measures to protect residents and prevent further potential abuse, which had the potential to affect 59 residents that were female out of 98 residents residing in the facility. This failure resulted in immediate jeopardy being identified and resulted in psychosocial harm for six residents. The findings included: 1. For Resident #9 (R9), the facility staff failed to take measures to protect the resident from further potential abuse and conduct an investigation to determine if R9 had the capacity to consent to sexual activity. On 7/31/24 at 2:50 p.m., an interview was conducted with Resident #9 (R9). When asked if any residents had been bothering her or making her feel uncomfortable, R9 said, Oh no, they would have a bloody nose and two black eyes. R9 was noted to be very frail and not able to move her left extremities freely. On 7/31/24 at 2:55 p.m., an interview was conducted with R9's roommate, Resident #15 (R15). R15 stated that R9 had not been telling the truth earlier during the interview with the surveyor and said that R9's .boyfriend put a [NAME] on her neck. R15 went on to say that R9 has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, The curtain wasn't pulled. I don't want to see that mess. On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported that she has seen R10 at the doorway of R9's room. CNA #11 reported R9 did have a [NAME] on her neck the end of June or early July. When asked if she was aware of any instances where R10 and R9 were having any sexual activity, CNA #11 said, I was here the day it happened, but I didn't' see it, I heard about it. CNA #11 went on to say, [R9] said [activity director's name redacted] married them. She will ask if I got the mustang she bought me, her mind isn't exactly right. On 7/31/24 at 2:58 p.m., an interview was conducted with CNA #6. CNA #6 said, I heard about her touching his penis about a month or month and a half ago, but I haven't seen it. I heard about the [NAME]. I've seen them holding hands. CNA #6 was asked if anyone in management was aware and she said, someone made them aware, and I don't know how they handled it. We had some Inservice about we no longer have to separate residents who want to have sex. She [R9] is aware but has some confusion. She is a little off, she talks about having to go pick up her baby and stuff. On 7/31/24 at 3 p.m., an interview was conducted with LPN #3, the unit manager where R9 and R10 reside. When asked about R9's cognitive skills, LPN #3 said, with everyday stuff she seems ok, she can request food, drink, pain meds, etc. But she does have delusions, she owns jets, corvettes, etc. When asked if she was aware of any sexual activity between R9 and R10, LPN #3 said, There has been quite a bit of hearsay about that. I don't know if anyone saw it. He [R10] can be verbally inappropriate. He does like the ladies, but I've never caught him being inappropriate. When asked if she had any knowledge of R9 having a [NAME], LPN #3 said, yes, they spoke to the daughter [R9's daughter] and she made it very clear she wanted him to be able to visit her mom. She said she knew her Mom had a [NAME], and it didn't bother her. LPN #3 went on to talk about how R9 reports she married R10 and when she sees other women walk by, R9 will accuse R10 of sleeping with them. When asked if administration was aware of the [NAME] and the allegation of R9 having R10's penis in her hand, LPN #3 said, Administration is aware, they said they had an incident at [sister facility's name redacted] and that people who are capable of having relations its ok and we may think it is inappropriate. LPN #3 went on to talk about R9's delusions and how R9 says she has brought the staff cars, is sending them on elaborate vacations, etc. LPN #3 said, I've looked, and she doesn't have any diagnosis for the delusions, but she has always had them, I don't know if they haven't spent enough time with her to notice or what, but something is off [cognitively]. On 7/31/24 at 4:49 p.m., an interview was conducted with Resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 said, She [referring to R9] thought we were married. She was going to fly me to a retreat. We are friends and we get involved and live out her fantasies. [Facility administrator's name redacted] had talked to me. R10 was asked about sexual activity and confirmed he had put a [NAME] on R9's neck. When asked if anything more had occurred, R10 said, She's bipolar and she's not going to tell you, and neither am I. They can't prove it. R10 was asked about the other women within the facility, and he called R12 by name and said, She's bipolar too. We enjoy spending time together. R10 stated, The first time I got in trouble was about an aide. On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10 and R9. CNA #12 reported, He [referring to R10] is a socializer. He rolls around all over the place all day. I've seen him stop at [R9's name redacted] room, stop and wave but I've never seen him in there. When asked about R9 having a [NAME], CNA #12 said, I saw the [NAME], but I didn't know he did it. When asked about any sexual activity, CNA #12 said, I heard about the penis incident weeks ago, but I don't know who saw it . One day she [R9] was crying, she said she wanted to marry him and was upset . He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:05 a.m., R9 was visited in her room by the surveyor again. R9 had a rose in a cup by the bedside and when asked about it, R9 said, my boyfriend gave it to me. When asked who was her boyfriend, R9 said R10's name. R9 went on to say, We are supposed to get married today. Did you know I am a Princess of Allett, a country off Spain? My Mom and Dad are Queen and King When asked about a [NAME], R9 said, Yes and admitted that R10 had given her a [NAME]. When asked if they had done anything sexual, R9 said, No, that's for marriage, and we are getting married today. On 8/1/24 at 9:16 a.m., an interview was conducted again with R15. R15 said, Mr. [R10's name redacted] gave her [R9] a [NAME]. R15 went on to talk about what she had seen between R10 and R9. He [referring to R10] puts his tongue down her [R9]'s throat. When asked if anything sexual has occurred R15 said, Yes, I saw it, he walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. R15 indicated that she had felt like she didn't matter. During the above interview with LPN #1, she was asked about R9's cognitive ability. LPN #1 said, she says she has had 3 babies, and we stole them, she has an airplane, I don't believe she is mentally capable, but they [management] say she has a BIMS [brief interview for mental status] of 15. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants fondling her . He has been caught jacking off . On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. On 8/1/24, a clinical record review was conducted of R9's chart. There was no documentation within the record of any interactions between R9 and R10. There was no documentation of the [NAME], nor of R10 being at the bedside masturbating. R9's most recent brief interview for mental status (BIMS) assessment was conducted on 6/14/24 and scored R9 as 12 of 15, which noted moderately impaired cognitive skills for daily decision making. R9 had last been seen by the physician on 5/13/24, and there was no mention to R9's cognitive ability other than noting awake, alert . Neurologic: Cranial Nerves Grossly Intact. There was no indication of any concerns other than with R9's skin. There was no evidence of any investigation or assessment of R9's ability to consent to sexual contact documented within the clinical record. On 8/1/24 at approximately 1:30 p.m., an interview was conducted with the medical nurse practitioner (NP)/Other staff #3. When asked about R10's behaviors and interactions with R9, and the fact that R9 had a [NAME] on her neck, the NP said, It got brought to my attention Tuesday morning [7/30/24]. I talked to [R9's name redacted] and she said she is widowed for 7 years. She has always had delusions; she doesn't have a psychiatric diagnosis to go with that. Her daughter allows her to make decisions. When asked if she had assessed R9's ability to consent for sexual activity, the NP said, They are able to give consent even when in memory care units. So just because she has delusions doesn't mean she can't consent. The NP went on to say she had talked to the director of nursing (DON) and she has talked to the daughter, and she is aware. When asked if she was aware of any other interactions involving R9 and R10, the NP said, I am not aware of any other issues or concerns. The NP went on to say she would have the psychiatric nurse practitioner see R9 with regards to the delusions because she (the NP) wasn't comfortable diagnosing that. On 8/1/24 at 2:09 p.m., a telephone interview was conducted with the psychiatric nurse practitioner (Psych NP)/ Other staff #4. The Psych NP said she was not aware of any relationship between R9 and R10. The Psych NP said that she sees R10, that he was last seen 6/20/24, and that she made no notes with regards to any sexual tendencies or behaviors and was not aware of any concerns. When asked if she had seen R9 or assessed for the ability to consent to sexual activity, the Psych NP said, No, I wasn't aware of any of this and wouldn't really know how to go about doing that. On 8/1/24 at 4:33 p.m., a telephone interview was conducted with R9's daughter, who was listed as emergency contact. The daughter was asked about her knowledge of R9 and R10's relationship. The daughter said, I know they say they are boyfriend and girlfriend, and he visits her. My Mom is not right in the head, she thinks they are getting married. When asked if she was aware her mother had a [NAME] on her neck, she said, I was aware of that and I was kind of shocked by that. When asked if she had any knowledge of them kissing or having anything more intimate occurring, the daughter said, No, I told them they had to behave, you can't do that. As far as having any other pleasure, that's not appropriate. I don't know how they could do that with Mom's condition anyway. Mom's not right in her head, I don't know if she has Alzheimer's or dementia or what. I've talked to [LPN #3, the unit manager's name redacted] but the doctor never said anything. It kind of gets old, she is talking about helicopters, new vehicles, money, all the time. It's a fantasy. On 8/1/24, the facility administrator provided the survey team with the only two investigations that had been conducted in the past three months. Neither of which involved R9 or R10. On the afternoon of 8/2/24, the director of nursing provided the survey team with a Witness Statement. The statement read, Me and [name of medical records coordinator redacted] spoke with resident [R9's name redacted] regarding concerns of a bruise on right side of neck. [R9's name redated] stated it was a [NAME] from [R10's name redacted] and they had gotten married over the weekend. She was asked if she wanted this and if it feels good, it feels good, stated by [R9's name redacted]. She was smiling and in no distress noted. Asked if [R10's name redacted] did anything to you that you did not want him to do to you, her reply was No, don't worry about him, I can handle him. The statement was signed by the Director of Nursing and medical records coordinator and dated 6/24/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about R9 having a [NAME], the administrator stated, I heard about it about an hour before we met on Thursday. When asked if he was aware that reports had been made that R10 was at R9's bedside pleasuring himself, the administrator said, I was told the day it happened, the roommate was in there. When asked if he, the administrator, had done anything to investigate or report this incident to regulatory agencies such as the state survey agency, adult protective services, ombudsman, or police, the administrator said, I know an investigation was done by the nursing department. When asked where the credible evidence was, the administrator said, As far as I know, they just looked at her BIMS. No evidence was provided that the allegation was reported. 2. For R7, the facility staff failed to take measures to protect the resident and investigate an allegation of abuse, which resulted in the resident changing her daily routine to avoid the perpetrator (R10) and caused R7 to self-isolate. On 7/31/24 at 3:20 p.m., an interview was conducted with resident #7- R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking about sex and saying that my belly button is pushed out because a 250-pound lady was on top of me ., that made her very uncomfortable. R7 reported she returned to her room, turned the lights off and got in bed. R7 reported someone came in and didn't say anything, then a voice said I will talk to you tomorrow. R7 reported it was R10 and she has stayed away from him since then as R10 talks very nasty and disgusting, he always begins the conversation with I still like sex. R7 reported she told her daughter and the daughter talked with social services. R7 went on to say, I had a sign on my door that said stop, but it is gone. R7 reported that she rarely comes of out her room, because she wants to stay away from Resident #10. R7 reported, she didn't realize how much R10's behaviors bothered her until she realized she rarely leaves her room now. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying he was still capable of having sex. R7 reported she froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted], he is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into the room in the dark. I am very uncomfortable to even pass him in the hall. On 7/31/24 and 8/1/24, attempts were made by the surveyor to reach R7's daughter but were not successful. On 7/31/24, a clinical record review was conducted of R7's chart. This review included the care plan and progress notes. There was no documentation regarding the incident with R10, the implementation of a stop-sign banner, or any concerns related to R10 and R7 no longer coming out of her room. On 7/31/24 and 8/1/24, the facility's grievance log was reviewed and there was no evidence of a grievance related to R7's report of R10 entering her room uninvited. Daily observations were conducted of R7's room at various times of the day throughout 7/30/24-8/2/24. Each of the observations revealed a stop-sign banner was not in place at the doorway. On 8/5/24 at approximately 1:30 p.m., an observation of R7's room revealed the stop sign mesh banner to be in place at the doorway. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON reported that one day she was talking to R7's daughter in the hallway and the social worker asked the DON to step into the office. The DON said the social worker reported the incident where R10 went into R7's room. The DON said, I went to put the stop sign across her door and she denied that he had been back. I asked the resident and her daughter about the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered the room. The administrator said, I did hear he had come in her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked if any information regarding the incident/allegation was available, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations, which would include reporting incidents to regulatory and protective agencies. No further information was provided with regards to R7. 3. For R8, the facility staff failed to investigate and take measures to protect the resident following an allegation of abuse. On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, he is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He will say he loves me. He discusses what he likes to do to women, says he likes older women's stuff and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 4. For R12, the facility staff failed to investigate allegations of inappropriate behavior by R10, to ensure R12 was free from continued abuse, which resulted in psychosocial harm. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted] we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10] personal behavior. His nasty talking, I felt very uncomfortable. There are things I don't tolerate with my friends. [R13's name redacted] felt very uncomfortable. I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I am nervous talking about it. During the interview, R12's hands were noted to be shaking. On 8/1/24 at 4:20 p.m., R12 was observed in the common area room on the unit crying. On 8/1/24 at approximately 4:25 p.m., Resident #12 was interviewed and said that Resident #10 was pressuring me to have sex. We [referring to her and resident #10] argued last night. I am scared. I don't want to have sex and he is wanting to have sex. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said Yes. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON was asked if she identified who the resident was that R10 had his hands between the legs of that she mentioned on 8/1/24. The DON said, Yes, I spoke to a staff member who told me it was [R10 and R12 names redacted]. The witness statement was in my office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made ware by overhearing staff talking amongst themselves about resident #10 had his hand down the pants of resident #12 while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw resident #10 have his hand down resident #12's pants resident #12 had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with resident #12 and asked her if she opposed to this behavior or it was not wanted, she replied no it was fine at this time it was determined no abuse had occurred. This statement was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it. 5. For Resident #13 (R13) who was subjected to sexual harassment which caused her to avoid common areas within the facility to prevent encountering R10, the facility staff failed to conduct an investigation. On 8/1/24 at 10:11 a.m., an interview was conducted with resident #13- R13. R13 said, he [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and so I leave because of it. I don't stay anymore and my husband told me to stay away from him. 6. For Resident #15 (R15), was subjected Resident #15, who was the roommate of Resident #9, reported she had witnessed multiple occurrences of sexual activity between Resident #9 and #10 because the privacy curtain was not pulled. Resident #15 said that she didn't desire to see such activity and was not comfortable around Resident #10. Review of the facility's communication book, used to communicate resident changes had an entry dated 7/17/24, that noted Resident #10's name and read, concern: increased sexuality, which at the time of survey had yet to be addressed. Resident #10 was observed throughout the duration of the survey to self-propel his wheelchair. He was observed at the doorway of female resident's rooms, visiting with and interacting with female residents on each of the nursing units, which puts all residents at risk for continued abuse and sexual harassment. Throughout the survey multiple interviews were conducted with facility staff. Interviews included: On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10. CNA #12 said, He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, There are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, The ladies in room [room number redacted] they don't like him; they say they get a bad feeling from him. LPN #1 identified Resident #13 (R13) and said, She is friends with him, but I've never seen anything inappropriate. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants .fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. He thinks he can do it to all the ladies. He's been doing it to the residents on the down low and we didn't know it. He told me, in the hall in front of the women, 'Old ladies are good in bed. Elderly ladies have the best p#$$y.' I don't understand these people. We are telling the nurses, and no one acknowledges us. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. When asked if this was the case for all allegations, that they must be put in writing, the DON said Yes. During the above interview with the facility administrator and DON, they were asked if they had any evidence to provide the survey team regarding investigations that had been conducted. They both replied, No. Following surveyor inquiries, the facility staff reported that the allegations of abuse and that an investigation had been initiated. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation was conducted. The policy read in part, . 5. Investigation: The abuse Coordinator or his/her designee shall investigate all reprots or allegations of abuse, neglect, misappropriation and exploitation. A Social Services representative may be offered in the role of resident advocate during any questioning of or interivewing of residents .6. Protection: . The resident will be evaluated for any signs of injury, including a physical exam and/or psychosocial assessment, as appropriate. Increased supervision of the alleged victim and residents. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Protection from retaliation. Provide the resident with emotional support and counseling during and after the investigation, if needed . On 8/2/24 at 8:50 a.m., the survey team identified that the facility was in immediate jeopardy (IJ) regarding failure to protect residents from abuse and failure to investigate allegations of abuse. On 8/2/24 at 4:45 p.m., the facility submitted an approved plan of removal for IJ. The plan read as follows: F610-Investigate and Protection Resident #10 placed on 1:1 on 8/1/24. Resident will be seen by MD/NP to address increased sexual behaviors. Resident #15 has been offered to move to another room. All residents with a BIMS of 9 and above will be interviewed about potential abuse to identify any other residents with psychosocial harm. Facility Reportable Incident that was submitted 8/1/24 has been updated to represent #7, #8, #12, and #13 for alleged abuse and re-submitted on 8/2/24. Residents #7, #8, #12, and #13 will be reminded that it is safe to come out of their room and how to report to staff if they experience or witness any type of abuse. All facility staff will be educated on recognizing all types of abuse and assuring resident is immediately protected upon recognition/allegation followed by reporting appropriately all allegations of abuse. Residents will be reminded what constitutes abuse and how/who to report any allegations or suspicions. The DON will be educated by the RDCS [regional director of clinical services] on abuse recognition, protection, investigating, and reporting. Allegation of compliance 8/3/2024 at 11:59pm. On 8/5/24, the survey team conducted the following activity to verify IJ removal: On 8/5/24, the survey team made multiple observations of Resident #10 to ensure that one to one supervision was in place. The survey team reviewed the log of staff who had provided one-to-one since the initiation of the one-to-one supervision began on 8/4/24. Resident #15 being offered a room change was verified through documentation review and interview with the resident. The surveyor used a resident census report and ensured that each resident with a BIMS of 9 and above were interviewed regarding abuse. The remaining residents had a skin check. There were 14 residents identified that the facility had not interviewed or performed a skin check. The submitted FRI was reviewed to ensure all agencies were notified as required. The local police notification was verified. Resident #7, #8, #12, and #13's documentation of being educated that they can resume normal activity was verified. On 8/5/24 at 1:04 p.m., the survey team identified that IJ had not been removed/abated because R9's capacity to consent was only addressed by one provider. The facility was also informed that the resident interview or skin checks had not been performed for all residents. There were also no staff or responsible party interviews available for review. On the afternoon of 8/5/24, the facility administration made the survey team aware that the residents identified without having been interviewed or having had a skin check conducted were all new admissions and had not been assessed for a BIMS score and therefore were missed. The facility conducted interviews accordingly, which were verified by the survey team. The survey team conducted staff interviews with a sample of staff from all departments to confirm that they were educated on the abuse policy, aware that sexual harassment is considered abuse, that their role is to protect the residents, and to report any allegations of abuse. The education of the DON on abuse was also verified. IJ was abated on 8/5/24 at 4:30 p.m. The scope and severity of the remaining noncompliance was lowered to a level three, pattern.

Based on resident interviews, facility staff interviews, clinical record review and facility documentation review, the facility staff failed to report allegations of abuse and sexual harassment by resident #10 (R10), affecting five residents and resulted in psychosocial harm for all five (resident #9, Resident #7, Resident #8, Resident #12 and Resident #13). This failure resulted in immediate jeopardy being identified. The findings included: 1. For resident #9 (R9), the facility staff failed to report the sexual behavior endured by R10, when R9's ability to consent had not been assessed. Failure to report to other regulatory and protective services did not afford R9 the opportunity to have other agencies which can provide protective services and conduct an investigation. On 7/31/24 at 2:50 p.m., an interview was conducted with Resident #9 (R9). R9 was asked about if any residents had bothered her and she said, oh no, they would have a bloody nose and 2 black eyes. On 7/31/24 at 2:52 p.m., an interview was conducted with R9's roommate, resident #15 (R15). R15 reported that R9 was not telling the truth during the interview with the surveyor and said R9's boyfriend put a [NAME] on her neck. R15 went on to say that R9 has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, the curtain wasn't pulled, and I don't want to see that mess. On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported that she has seen R10 at the doorway of R9's room. CNA #11 reported R9 did have a [NAME] on her neck the end of June or early July. When asked if she was aware of any instances where R10 and R9 were having any sexual activity, CNA #11 said, I was here the day it happened, but I didn't' see it, I heard about it. CNA #11 went on to say, R9 said [activity director's name redacted] married them. She will ask if I got the mustang she bought me, her mind isn't exactly right. On 7/31/24 at 2:58 p.m., an interview was conducted with CNA #6. CNA #6 said, I heard about her touching his penis about a month or month and a half ago, but I haven't seen it. I heard about the [NAME]. I've seen them holding hands. CNA #6 was asked if anyone in management was aware and she said, someone made them aware, and I don't know how they handled it. We had some Inservice about we no longer have to separate residents who want to have sex. She [R9] is aware but has some confusion. She is a little off, she talks about having to go pick up her baby and stuff. On 7/31/24 at 3 p.m., an interview was conducted with LPN #3, the unit manager where R9 and R10 reside. When asked about R9's cognitive skills, LPN #3 said, with everyday stuff she seems ok, she can request food, drink, pain meds, etc. But she does have delusions, she owns jets, corvettes, etc. When asked if she was aware of any sexual activity between R9 and R10, LPN #3 said, There has been quite a bit of hearsay about that. I don't know if anyone saw it. He [R10] can be verbally inappropriate. He does like the ladies, but I've never caught him being inappropriate. When asked if she had any knowledge of R9 having a [NAME], LPN #3 said, yes, they spoke to the daughter [R9's daughter] and she made it very clear she wanted him to be able to visit her mom. She said she knew her Mom had a [NAME], and it didn't bother her. LPN #3 went on to talk about how R9 reports she married R10 and when she sees other women walk by, R9 will accuse R10 of sleeping with them. When asked if administration was aware of the [NAME] and the allegation of R9 having R10's penis in her hand, LPN #3 said, Administration is aware, they said they had an incident at [sister facility's name redacted] and that people who are capable of having relations its ok and we may think it is inappropriate. LPN #3 went on to talk about R9's delusions and how R9 says she has brought the staff cars, is sending them on elaborate vacations, etc. LPN #3 said, I've looked, and she doesn't have any diagnosis for the delusions, but she has always had them, I don't know if they haven't spent enough time with her to notice or what, but something is off [cognitively]. On 7/31/24 at 4:49 p.m., an interview was conducted with resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 said, [referring to R9] she thought we were married. She was going to fly me to a retreat. We are friends and we get involved and live out her fantasies. [facility administrator's name redacted] had talked to me. R10 was asked about sexual activity and confirmed he had put a [NAME] on R9's neck. When asked if anything more had occurred, R10 said, she's bipolar and she's not going to tell you, and neither am I. They can't prove it. R10 was asked about the other women within the facility, and he called R12 by name and said, she is bipolar too, we enjoy spending time together. R10 reported that the first time I got in trouble was about an aide. On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10 and R9. CNA #12 reported, he [referring to R10] is a socializer, he rolls around all over the place all day. I've seen him stop at [R9's name redacted] room, stop and wave but I've never seen him in there. When asked about R9 having a [NAME], CNA #12 said, I saw the [NAME], but I didn't know he did it. When asked about any sexual activity, CNA #12 said, I heard about the penis incident weeks ago, but I don't know who saw it . One day she [R9] was crying, she said she wanted to marry him and was upset . He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:05 a.m., R9 was visited in her room by the surveyor again. R9 had a rose in a cup by the bedside and when asked about it, R9 said, my boyfriend gave it to me. When asked who her boyfriend was R9 said R10's name. R9 went on to say, we are supposed to get married today. Did you know I am a princess of Allett, a country off Spain? My Mom and Dad are Queen and King When asked about a [NAME], R9 said, yes and admitted that R10 had given her a [NAME]. When asked if they had done anything sexual, R9 said, no, that's for marriage, and we are getting married today. On 8/1/24 at 9:16 a.m., an interview was conducted again with R9's roommate, R15. R15 said, Mr. [R10's name redacted] gave her a [NAME]. R15 went on to talk about R10 is putting his tongue down her [R9]'s throat. When asked if anything sexual has occurred R15 said, yes, I saw it, he walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, Last week [CNA #4's name redacted] saw her [R9] with his penis in her hand. Maybe Sunday. I went and talked to Ms. [R15's name redacted], she said she didn't want him in her room. The nurse went down and told him and told him, if he went in that room he would be removed. She [R15] said she didn't want to see what they do, that incident [where R9 had R10's penis in her hand] is why she doesn't want him in there. During the above interview with LPN #1, she was asked about R9's cognitive ability. LPN #1 said, she says she has had 3 babies, and we stole them, she has an airplane, I don't believe she is mentally capable, but they [management] say she has a BIMS [brief interview for mental status] of 15. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. On 8/1/24, a clinical record review was conducted of R9's chart. There was no documentation within the record of any interactions between R9 and R10. There was no documentation of the [NAME], nor of R10 being at the bedside masturbating. R9's most recent brief interview for mental status (BIMS) assessment was conducted on 6/14/24. R9 scored 12 of 15, which noted moderately impaired cognitive skills. R9 had last been seen by the physician on 5/13/24, and there was no mention to R9's cognitive ability other than noting awake, alert . Neurologic: Cranial Nerves Grossly Intact. There was no indication of any concerns other than with R9's skin. On 8/1/24 at approximately 1:30 p.m., an interview was conducted with the medical nurse practitioner (NP)/Other staff #3. When asked about R10's behaviors and interactions with R9, and the fact that R9 had a [NAME] on her neck. The NP said, it got brought to my attention Tuesday morning. I talked to [R9's name redacted] and she said she is widowed for 7 years. She has always had delusions; she doesn't have a psychiatric diagnosis to go with that. Her daughter allows her to make decisions. When asked if she has assessed R9's ability to consent for sexual activity had been assessed, the NP said, They are able to give consent even when in memory care units, so just because she has delusions doesn't mean she can't consent. The NP went on to say she had talked to the director of nursing (DON) and she has talked to the daughter, and she is aware. When asked if she was aware of any other interactions involving R9 and R10, she said, I am not aware of any other issues or concerns. The NP went on to say she would have the psychiatric nurse practitioner see R9 with regards to the delusions because she (the NP) wasn't comfortable diagnosing that. On 8/1/24 at 2:09 p.m., a telephone interview was conducted with the psychiatric nurse practitioner (Psych NP)/ Other staff #4. The Psych NP said she was not aware of any relationship between R9 and R10. The Psych NP said she sees R10, and he was last seen 6/20/24, and she made no notes with regards to any sexual tendencies or behaviors and was not aware of any concerns. When asked if she had seen R9 or assessed for the ability to consent to romantic activity, the Psych NP said, No, I wasn't aware of any of this and wouldn't really know how to go about doing that. On 8/1/24 at 4:33 p.m., a telephone interview was conducted with R9's daughter, who was listed as emergency contact. The daughter was asked about her knowledge of R9 and R10's relationship. The daughter said, I know they say they are boyfriend and girlfriend, and he visits her. My Mom is not right in the head, she thinks they are getting married. When asked if she was aware her mother had a [NAME] on her neck, she said, I was aware of that and I was kind of shocked by that. When asked if she had any knowledge of them kissing or having anything more intimate occurring, the daughter said, No, I told them they had to behave, you can't do that. As far as having any other pleasure that's not appropriate. I don't know how they could do that with Mom's condition anyway. Mom's not right in her head, I don't know if she has Alzheimer's or dementia or what. I've talked to [LPN #3, the unit manager's name redacted] but the doctor never said anything. It kind of gets old, she is talking about helicopters, new vehicles, money, all the time, it's a fantasy. On 8/1/24, the facility administrator provided the survey team with the only two investigations that had been conducted in the past three months. Neither of which involved R9 or R10. On the afternoon of 8/2/24, the director of nursing provided the survey team with a Witness Statement. The statement read, me and [name of medical records coordinator redacted] spoke with resident [R9's name redacted] regarding concerns of a bruise on right side of neck. [R9's name redated] stated it was a [NAME] from [R10's name redacted] and they had gotten married over the weekend. She was asked if she wanted this and if it feels good, it feels good, stated by [R9's name redacted]. She was smiling and in no distress noted. Asked if [R10's name redacted] did anything to you that you did not want him to do to you, her reply was no, don't worry about him, I can handle him. The statement was signed by the Director of Nursing and medical records coordinator and dated 6/24/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about R9 having a [NAME], the administrator stated, I heard about it about an hour before we met on Thursday. When asked if he was aware that reports had been made that R10 was at R9's bedside pleasuring himself, the administrator said, I was told the day it happened, the roommate was in there. When asked if he, the administrator, had done anything to investigate or report this incident to regulatory agencies such as the state survey agency, adult protective services, ombudsman, or police, he said, I know an investigation was done by the nursing department. When asked where the credible evidence was, he said, as far as I know they just looked at her BIMS. No evidence was provided that the allegation was reported. 2. For R7, the facility staff failed to report an allegation of verbal abuse and sexual harassment, which resulted in the resident changing her daily routine to avoid the perpetrator (R10) and caused R7 to self-isolate. On 7/31/24 at 3:20 p.m., an interview was conducted with resident #7- R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking about sex and saying that my belly button is pushed out because a 250-pound lady was on top of me ., that made her very uncomfortable. R7 reported she returned to her room, turned the lights off and got in bed. R7 reported someone came in and didn't say anything, then a voice said I will talk to you tomorrow. R7 reported it was R10 and she has stayed away from him since then as R10 talks very nasty and disgusting, he always begins the conversation with I still like sex. R7 reported she told her daughter and the daughter talked with social services. R7 went on to say, I had a sign on my door that said stop, but it is gone. R7 reported that she rarely comes of out her room, because she wants to stay away from Resident #10. R7 reported, she didn't realize how much R10's behaviors bothered her until she realized she rarely leaves her room now. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying he was still capable of having sex. R7 reported she froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted], he is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into the room in the dark. I am very uncomfortable to even pass him in the hall. On 7/31/24 and 8/1/24, attempts were made by the surveyor to reach R7's daughter but were not successful. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON reported that one day she was talking to R7's daughter in the hallway and the social worker asked the DON to step into the office. The DON said the social worker reported the incident where R10 went into R7's room. The DON said, I went to put the stop sign across her door and she denied that he had been back. I asked the resident and her daughter about the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered the room. The administrator said, I did hear he had come in her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked if any information regarding the incident/allegation was available, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations, which would include reporting incidents to regulatory and protective agencies. No further information was provided with regards to R7. 3. For R8, the facility staff failed to report an allegation of abuse and sexual harassment, which caused R8 psychosocial harm, R8 changed her daily routine to avoid the perpetrator, who was resident #10 (R10). On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, he is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He will say he loves me. He discusses what he likes to do to women, says he likes older women's stuff and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 4. For R12, the facility staff failed to report allegations of inappropriate behavior by R10, to ensure R12 was free from abuse and sexual harassment, which resulted in psychosocial harm. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted] we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10] personal behavior. His nasty talking, I felt very uncomfortable. There are things I don't tolerate with my friends. [R13's name redacted] felt very uncomfortable. I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I am nervous talking about it. During the interview, R12's hands were noted to be shaking. On 8/1/24 at 4:20 p.m., resident #12 was observed in the common area room on the unit crying. On 8/1/24 at approximately 4:25 p.m., Resident #12 was interviewed and said that Resident #10 was pressuring me to have sex. We [referring to her and resident #10] argued last night. I am scared. I don't want to have sex and he is wanting to have sex. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said yes. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON was asked if she identified who the resident was that R10 had his hands between the legs of that she mentioned on 8/1/24. The DON said yes, she spoke to a staff member who told her it was R10 and R12 and that a witness statement was in her office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made ware by overhearing staff talking amongst themselves about resident #10 had his hand down the pants of resident #12 while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw resident #10 have his hand down resident #12s pants resident #12 had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with resident #12 and asked her if she opposed to this behavior or it was not wanted, she replied no it was fine at this time it was determined no abuse had occurred. The note was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it. 5. For Resident #13 (R13) who was subjected to sexual harassment which caused her to avoid common areas within the facility to prevent encountering R10, the facility staff failed to report such allegations to adult protective services and the state survey agency. On 8/1/24 at 10:11 a.m., an interview was conducted with resident #13- R13. R13 said, he [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and I leave because of it. I don't stay and my husband told me to stay away from him. Review of the facility's communication book, used to communicate resident changes had an entry dated 7/17/24, that noted Resident #10's name and read, concern: increased sexuality, which at the time of survey had yet to be addressed. Resident #10 was observed throughout the duration of the survey to self-propel his wheelchair. He was observed at the doorway of female resident's rooms, visiting with and interacting with female residents on each of the nursing units, which puts all residents at risk for continued abuse and sexual harassment. Throughout the survey multiple interviews were conducted with facility staff. Interviews included: On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10. CNA #12 said, He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, there are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, the ladies in room [room number redacted] they don't like him; they say they get a bad feeling from him. LPN #1 identified resident #13 (R13) and said, she is friends with him, but I've never seen anything inappropriate. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. He thinks he can do it to all the ladies. He's been doing it to the residents on the down low and we didn't know it. He told me, in the hall in front of the women, old ladies are good in bed, elderly ladies have the best p#$$y. I don't understand these people. We are telling the nurses, and no one acknowledges us. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said yes. During the above interview with the facility administrator and DON, they were asked if any of the allegations had been reported. They replied no. Following surveyor intervention the facility staff reported the allegations of abuse to the local police, adult protective services and state survey agency. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation was conducted. The policy read in part, . 7. Reporting/Response. Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property , to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of nursing is the designated abuse coordinator. Once an allegation of abuse if reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred . On 8/2/24 at 8:50 a.m., the survey team identified the facility was in immediate jeopardy (IJ) regarding reporting allegations of abuse. On 8/2/24 at 4 p.m., the facility submitted an approved plan of removal for IJ. The plan read as follows: F609-Reporting Facility staff completed an FRI and submitted it to the Virginia Department of Health, Adult Protective Services and Ombudsman. Local police were notified (case number 20240002626). Residents with a BIMS of 9 or above were interviewed about potential abuse. Facility Reportable Incident that was submitted yesterday has been updated on 8/2/2024 to represent #7, #8, #12 and #13 for allegation of abuse. Resident #10 will remain on 1:1 until he has been evaluated by psychiatric services for abuse towards others and seen to address increased sexual behaviors. Resident #9 will be assessed by two physicians/practitioners for her ability to consent to sexual activity. Social worker is no longer employed by the center. All facility staff will be educated in reporting all allegations of abuse. Residents with BIM score of 9 or greater will be educated in reporting abuse and who to report to. Allegation of compliance 8/3/2024 at 11:59pm On 8/5/24, the survey team returned to verify that the plan for IJ removal had been implemented and the immediacy had been removed. The FRI submitted by the facility was reviewed to ensure all agencies were notified as required. The local police notification was verified. On 8/5/24, the survey team made multiple observations of Resident #10 to ensure that one to one supervision was in place. The survey team observed the log of staff who had provided one to one, since the initiation of one to one began on 8/4/24. Using the resident census report, the surveyor attempted to verify that each resident with a BIMS of 9 and above were interviewed regarding abuse, while the remaining residents had a skin check. It was found that there were 14 residents identified that the facility had not either interviewed or conducted a skin check on. Resident #9 was assessed by the nurse practitioner (NP) and mental health nurse practitioner. The medical NP noted R9 has capacity to consent. The mental health practitioner note did not indicate the resident did or did not have capacity to consent to sexual activity. On 8/5/24 at 1:04 p.m., the survey team identified that the IJ had not been removed because R9's capacity to consent was noted indicated by a second provider, the facility had not either conducted interviews or skin checks of all residents, and that there was no evidence of staff or responsible party interviews available for review. On the afternoon of 8/5/24, the facility administration made the survey team aware that the residents identified without having been interviewed or having had a skin check conducted were new admissions, had not been assessed for a BIMS score, and therefore were missed. The facility conducted interviews accordingly and provided evidence as noted. The survey team conducted staff interviews with a sample of staff from all departments to confirm they were educated on the abuse policy, aware that sexual harassment is considered abuse, and that their role is to protect the residents and report any allegations of abuse. On 8/5/24 at 4:30 p.m., the facility administration provided the survey team with an amended note from the psychiatric nurse practitioner that stated Resident #9 had the capacity to consent to sexual activity. IJ was abated on 8/5/24 at 4:30 p.m. The scope and severity of the remaining noncompliance was lowered to a level three, pattern.

Based on resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure five residents were free from abuse (Resident #9- R9, Resident #7- R7, Resident #8- R8, Resident #12- R12, and Resident #13-R13), which resulted in psychosocial harm, and had the potential to affect the 59 female residents residing in the facility, as the perpetrator was targeting female residents. This resulted in immediate jeopardy. The facility staff also failed to ensure two residents (Resident #20 and Resident #21), in a survey sample of 28, were free from neglect. The findings included: 1. For R9, who was known to have delusions, the facility staff failed to protect the resident from sexual abuse by ensuring the resident had been assessed to determine the capacity to consent to sexual relations. On 7/31/24 at 2:50 p.m., an interview was conducted with Resident #9 (R9). When asked if any residents had been bothering her or making her feel uncomfortable, R9 said, Oh no, they would have a bloody nose and two black eyes. R9 was noted to be very frail and not able to move her left extremities freely. On 7/31/24 at 2:55 p.m., an interview was conducted with R9's roommate, Resident #15 (R15). R15 stated that R9 had not been telling the truth earlier during the interview with the surveyor and said that R9's .boyfriend put a [NAME] on her neck. R15 went on to say that R9 has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, The curtain wasn't pulled, and I don't want to see that mess. R15 indicated that she had seen multiple incidents of sexual activity between R10 & R9. On 7/31/24 at 4:49 p.m., an interview was conducted with Resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 said, [referring to R9] She thought we were married. She sais she was going to fly me to a retreat. We are friends and we get involved and live out her fantasies . [facility administrator's name redacted] had talked to me. When asked about sexual activity, R10 confirmed he had put a [NAME] on R9's neck. When asked if anything more had occurred, R10 said, She's bipolar and she's not going to tell you, and neither am I. They can't prove it. R10 was asked about the other women within the facility, and he called R12 by name and said, She's bipolar too. We enjoy spending time together. Indicating that there was no problems with his interactions with the female residents, R10 stated,The first time I got in trouble was about an aide. On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported that she has seen R10 at the doorway of R9's room. CNA #11 reported that R9 did have a [NAME] on her neck about the end of June or early July. When asked if there were any other instances that indicated R10 and R9 were having any sexual activity, CNA #11 said, I was here the day it happened, but I didn't' see it, I heard about it. CNA #11 went on to say, [R9] said that [activity director's name redacted] had married them. [R9] would ask if I got the mustang she bought me, her mind isn't exactly right. On 7/31/24 at 2:58 p.m., an interview was conducted with CNA #6. CNA #6 said, I heard about her touching his penis about a month or month and a half ago, but I haven't seen it. I heard about the [NAME]. I've seen them holding hands. CNA #6 was asked if anyone in management was aware and she said, Someone made them aware, and I don't know how they handled it. We had some Inservice that we no longer have to separate residents who want to have sex . [R9] is aware but has some confusion . [R9] is a little off, she talks about having to go pick up her baby and stuff. On 7/31/24 at 3 p.m., an interview was conducted with LPN #3, the unit manager where R9 and R10 reside. When asked about R9's cognitive skills, LPN #3 said, With everyday stuff she seems ok, she can request food, drink, pain meds, etc. but she does have delusions, she owns jets, corvettes, etc. When asked if she was aware of any sexual activity between R9 and R10, LPN #3 said, There has been quite a bit of hearsay about that. I don't know if anyone saw it. [R10] can be verbally inappropriate. He does like the ladies, but I've never caught him being inappropriate. When asked if she had any knowledge of R9 having a [NAME], LPN #3 said, Yes, they spoke to the daughter [R9's daughter] and that she had made it very clear she wanted him to be able to visit her mom. She said she knew her Mom had a [NAME], and it didn't bother her. LPN #3 went on to talk about how R9 reports that she married R10 and that when she sees other women walk by, R9 will accuse R10 of sleeping with them. When asked if administration was aware of the [NAME] and the allegation of R9 having R10's penis in her hand, LPN #3 said, Administration is aware, they said they had an incident at [sister facility's name redacted] and that for people who are capable of having relations, its ok and we may think it is inappropriate. LPN #3 went on to talk about R9's delusions and how R9 says that she has brought the staff cars, is sending them on elaborate vacations, etc. LPN #3 said, I've looked, and she doesn't have any diagnosis for the delusions, but she has always had them. I don't know if they haven't spent enough time with her to notice or what, but something is off [cognitively]. On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10 and R9 interactions. CNA #12 reported, [R10] is a socializer, he rolls around all over the place, all day. I've seen him stop at [R9's name redacted] room, stop and wave, but I've never seen him in there. When asked about R9 having a [NAME], CNA #12 said, I saw the [NAME], but I didn't know he did it. When asked about any sexual activity, CNA #12 said, I heard about the penis incident weeks ago, but I don't know who saw it . One day [R9] was crying, she said she wanted to marry him, and was upset . [R10] used to stop at [another resident's name redacted]'s door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:05 a.m., R9 was visited in her room by the surveyor again. R9 had a rose in a cup by the bedside and when asked about it, R9 said, My boyfriend gave it to me. When asked who her boyfriend was, R9 said R10's name. R9 went on to say, We are supposed to get married today. Did you know I am a princess of Allett, a country off Spain? My Mom and Dad are Queen and King When asked about having a [NAME], R9 said, Yes and admitted that R10 had given her a [NAME]. When asked if they had had sex, R9 said, No, that's for marriage, and we are getting married today. On 8/1/24 at 9:16 a.m., an interview was conducted again with R9's roommate, R15. R15 said, Mr. [R10's name redacted] gave her a [NAME]. R15 went on to talk about R10 is putting his tongue down [R9]'s throat. When asked if anything sexual has occurred, R15 said, Yes, I saw it. He walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, Last week [CNA #4's name redacted] saw [R9] with his penis in her hand. Maybe Sunday, I went and talked to Ms. [R15's name redacted], who said that she didn't want him in her room. The nurse went down and told him, if he went in that room he would be removed. She [R15] said she didn't want to see what they do, that incident [where R9 had R10's penis in her hand] is why she doesn't want him in there. During the above interview with LPN #1, she was asked about R9's cognitive ability. LPN #1 said, [R9] says she has had 3 babies, and we stole them, that she has an airplane . I don't believe she is mentally capable, but they [management] say she has a BIMS [brief interview for mental status] of 15. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 stated that she has seen R10 .with his hands down [R9's] pants, fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out, jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. On 8/1/24, a clinical record review was conducted of R9's chart. There was no documentation within the record of any interactions between R9 and R10. There was no documentation of the [NAME], nor of R10 being at the bedside masturbating. R9's most recent brief interview for mental status (BIMS) assessment was conducted on 6/14/24, which scored R9 as 12 of 15, indicating moderately impaired cognitive skills. On 8/1/24 at approximately 1:30 p.m., an interview was conducted with the medical nurse practitioner (NP)/Other staff #3. When asked about R10's sexual behaviors, the interactions with R9, and the fact that R9 had sustained a [NAME] on her neck, the NP said, It got brought to my attention Tuesday morning. I talked to [R9's name redacted] and she said she is widowed for 7 years. She has always had delusions; she doesn't have a psychiatric diagnosis to go with that. Her daughter allows her to make decisions. When asked if she had assessed R9's ability to consent for sexual activity, the NP said, They are able to give consent even when in memory care units, so just because she has delusions doesn't mean she can't consent. The NP went on to say that she had talked to the director of nursing (DON) and she has talked to the daughter, and she is aware. When asked if she was aware of any other interactions involving R9 and R10, the NP said, I am not aware of any other issues or concerns. The NP added that she would have the psychiatric nurse practitioner see R9 with regards to the delusions because she (the NP) wasn't comfortable diagnosing that. On 8/1/24 at 2:09 p.m., a telephone interview was conducted with the psychiatric nurse practitioner (Psych NP)/ Other staff #4. The Psych NP said that she was not aware of any relationship between R9 and R10. The Psych NP said that she sees R10, that he was last seen 6/20/24, that she had made no notes with regards to any sexual tendencies or behaviors, and was not aware of any concerns. When asked if R9 had been seen or assessed for the ability to consent to sexual activity, the Psych NP said, No, I wasn't aware of any of this and wouldn't really know how to go about doing that. On 8/1/24 at 4:33 p.m., a telephone interview was conducted with R9's daughter, who was listed as emergency contact. The daughter was asked about her knowledge of R9 and R10's relationship. The daughter said, I know they say they are boyfriend and girlfriend, and he visits her. My Mom is not right in the head, she thinks they are getting married. When asked if she was aware her mother had a [NAME] on her neck, she said, I was aware of that and I was kind of shocked by that. When asked if she had any knowledge of them kissing or having anything more intimate occurring, the daughter said, No, I told them they had to behave, you can't do that. As far as having any other pleasure, that's not appropriate. I don't know how they could do that with Mom's condition anyway. Mom's not right in her head, I don't know if she has Alzheimer's or dementia or what. I've talked to [LPN #3, the unit manager's name redacted] but the doctor never said anything. It kind of gets old, she is talking about helicopters, new vehicles, money, all the time. It's a fantasy. On the afternoon of 8/2/24, the director of nursing provided the survey team with a Witness Statement, which read, me and [name of medical records coordinator redacted] spoke with resident [R9's name redacted] regarding concerns of a bruise on right side of neck. [R9's name redacted] stated it was a [NAME] from [R10's name redacted] and they had gotten married over the weekend. She was asked if she wanted this and if it feels good, it feels good, stated by [R9's name redacted]. She was smiling and in no distress noted. Asked if [R10's name redacted] did anything to you that you did not want him to do to you, her reply was No, don't worry about him, I can handle him. The statement, dated 6/24/24, was signed by the Director of Nursing and medical records coordinator. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about R9 having a [NAME], the administrator stated, I heard about it about an hour before we met on Thursday. When asked if he was aware that reports had been made that R10 was at R9's bedside pleasuring himself, the administrator said, I was told the day it happened, the roommate was in there. When asked if he, the administrator, had done anything to investigate this incident, he said, I know it was done by the nursing department. When asked for the credible evidence, the administrator said, As far as I know, they just looked at her BIMS. 2. For R7, the facility staff failed to ensure the resident was free from verbal abuse and sexual harassment, which resulted in the resident altering daily social patterns to avoid the perpetrator (R10) and caused R7 to self-isolate. On 7/31/24 at 3:20 p.m., an interview was conducted with R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking to her about having sex and that R10 had said, My belly button is pushed out because a 250-pound lady was on top of me R7 stated that it had made R7 feel very uncomfortable. R7 reported having returned to her room, turned the lights off, and got into bed. R7 said, Someone came in and didn't say anything. Then a voice said 'I will talk to you tomorrow' and left. R7 reported that it had been R10 and that R7 had tried to stay away from him since then. He [R10] talks very nasty and disgusting. He always begins the conversation with I still like sex. R7 stated that she had told her daughter, who had talked with social services. R7 went on to say, I had a sign on my door that said stop, but it's gone. R7 stated rarely coming of out their room now, because I want to stay away from [R10]. R7 then stated having not realized how much R10's behaviors bothered her until saying that she rarely leaves her room. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying he was still capable of having sex. R7 reported that she .froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared, and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted] . He is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into my room in the dark. I am very uncomfortable to even pass him in the hall. On 7/31/24 and 8/1/24, attempts were made by the surveyor to reach R7's daughter but were not successful. On 8/5/24 at 4:32 p.m., during a telephone interview, the director of nursing (DON) reported that one day she was talking to R7's daughter in the hallway, when the social worker asked the DON to step into the office. The DON stated that the social worker had reported the incident when R10 had gone into R7's room. The DON said, I went to put the stop sign across her door and [R7]denied that he had been back. I asked the resident and her daughter about using the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered the room. The administrator said, I did hear he had come into her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked if any information regarding the incident was available, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations. No further information was provided with regards to R7. 3. For R8, the facility staff failed to ensure the resident was free from abuse and sexual harassment, which caused R8 to change her daily routine to avoid the perpetrator, who was resident #10 (R10). On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, He is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He would say he loves me. He discusses what he likes to do to women, says he likes older women's stuff, and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 4. For R12, the facility staff failed to respond to reports of inappropriate behavior by R10 and failed to ensure R12 was free from abuse and sexual harassment, which resulted in psychosocial harm. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted] we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10's] personal behavior. His nasty talking, I felt very uncomfortable. There are things I don't tolerate with my friends. [R13's name redacted] felt very uncomfortable. I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing, and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I'm nervous just talking about it. During the interview, R12's hands were observed to be shaking. On 8/1/24 at 4:20 p.m., Resident #12 was observed in the common area room on the unit crying. On 8/1/24 at approximately 4:25 p.m., Resident #12 was interviewed. When asked about the crying, R12 said that R10 .was pressuring me to have sex. We [referring to her and R10] argued last night. I am scared. I don't want to have sex and he is wanting to have sex. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she had heard, the DON said, That with female residents, doing sexual things to them and making sexual comments. It was consensual. Yesterday he was touching a lady, it was a big whohaa. He had his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. When asked if this was the case for all allegations, that they must be put in writing, the DON said, Yes. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON was asked if she identified who the resident was that [R10] had his hands between the legs of that she mentioned on 8/1/24. The DON said, Yes, I spoke to a staff member who told me it was [R12]. The witness statement is in my office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made ware by overhearing staff talking amongst themselves about [R10] had his hand down the pants of [R12] while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw [R10] have his hand down [R12s] pants, [R12} had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with [R12] and asked her if she opposed to this behavior or it was not wanted, she replied No. It was fine. At this time, it was determined no abuse had occurred. This statement was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it. 5. Resident #13 (R13) was subjected to sexual harassment which caused her to avoid common areas within the facility to prevent encounters with R10. On 8/1/24 at 10:11 a.m., an interview was conducted with R13, who said, He [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and so I leave because of it. I don't stay anymore and my husband told me to stay away from him. Staff interviews were conducted which included the following: On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10. CNA #12 said, He [R10] used to stop at [another resident's name redacted]'s door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, There are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, [Resident #15's name redacted] says he and [Resident #9's name redacted] kiss. The ladies in room [room number redacted] don't like him; they say they get a bad feeling from him. LPN #1 identified R13 and said, She is friends with him, but I've never seen anything inappropriate. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down [R9's] pants fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. He thinks he can do it to all the ladies. He's been doing it to the residents on the down low and we didn't know it. He told me, in the hall in front of the women, old ladies are good in bed, elderly ladies have the best p#$$y. This lady [R9], her mind is not right, she is going to buy me a car, owns this place, the nurses say the daughter can say its ok. I don't understand these people. We are telling the nurses, and no one acknowledges us. They say her daughter knows. [The unit manger's name redacted] knows. One time he had his hand in her diaper, and he was kissing her, just last week. I've seen him in the back hall near laundry and he was talking stuff to them [the staff], he goes to unit 2. [Resident #26's name redacted] says to close her door from that pervert just a few days ago. [R13's name redacted] tells me she doesn't like him, he's a pervert. Please help us, help these residents, it's not right what he is doing, they know and won't do nothing. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said yes. During the above interview, the administrator stated, yesterday I went into the library to read and [R10's name redacted] was in there and everything was kosher. The administrator went on to say that R10 had written a note to one of the students that he wanted to meet them after graduation, and she felt uncomfortable. I brought him in the office and in general showed him the note and explained that when people are uncomfortable, they can call the cops and if they feel threatened, they can go further. He said he won't ever do it again. He is as 2 faced as they come. He knew he had done wrong, he listened to what I said, it may have lasted 5 minutes. It was about 2-3 weeks ago. I haven't heard anything else about it. The administrator went on to say, our old social worker wanted me to give him a 30-day discharge, because they were thinking it was about to be a pattern and wanted me to react, but I've never put people out in all my years. The administrator was asked if he knew R9 had a [NAME] on her neck. The administrator said, I heard about it this morning. I didn't know she had a [NAME]. The DON went on to say, I called my regional DON, and she said no, you cannot, 1st let's do a medication review. I let [medical nurse practitioner's name redacted] and [psychiatric nurse practitioner's name redacted] know for a medication review, because I know some antidepressants can help curb sexual tendances. When asked about R9 having a [NAME], the DON said, I interviewed [R9's name redacted], her BIMS is 13-15 so I dropped it, it was consensual, she was very excited about it. Her daughter is aware and approves. It was a bruise of unknown origin and the nurse put a note in the chart and me and [name of medical records coordinator redacted] went and talked to the resident. According to the facility document of the communication book for the medical providers, an entry was made on 7/17/24, that noted R10's name and read, increased sexuality. On 8/1/24 at 10:46 a.m., the administrator and DON were made aware of the above interviews and that R7, R8, R12, R13, and R15 reporting being scared and changing their daily routine because of R10's behaviors. The DON said, I didn't know residents are scared of him or afraid to come out of their room. The administrator said, I'm just hearing about this. After talking with him the other week, his brother came in and I told him about it, and he said he tells him all the time he is not God's gift to women. The administrator reported he had no documentation or credible evidence to provide the survey team with regards to the conversation he had with R10. The facility administrator was asked to provide the survey team with the minutes from their morning meetings and the 24-hour report for the past 3 months. On the afternoon of 8/1/24, the administrator reported to the survey team that he had not keep the notes from the daily department managers meeting and only had the notes available for the current week. The 24-hour reports were reviewed with no mention of R10's behaviors or interactions with any residents. The administrator explained that he conducts the morning meeting each day and grievances, the 24-hour report and anything going on within the facility is discussed. On 8/1/24 in the afternoon, LPN #3 who was the unit manager, assisted the surveyor with locating the communication book used to communicate issues to the providers. The medical nurse practitioner had the medical communication book. LPN #3 provided the surveyor with a copy of the psychiatric communication form where on 7/17/24, she made an entry at the direction of the director of nursing and it read, [R10's name redacted] increased sexuality. LPN #3 said she put the same entry in the book for the medical provider. The surveyor reviewed the medical provider's communication book, but the previous pages had been removed and were not available. On 8/2/24 at 8:45 a.m., the facility staff had failed to provide the survey team with any evidence that the resident's reports and allegations of misconduct by R10 had been investigated, reported or acted upon. On 8/2/24 at 8:50 a.m., the survey team identified the facility was in immediate jeopardy (IJ) in Abuse. On 8/2/24 at 2:34 p.m., the facility's medical director/physician (MD) met with the survey team. The MD expressed frustration over the survey's team identification of immediate jeopardy and stated, This is bonkers. There has to be a standard that applies at one and every facility . If the standard is an old man that makes inappropriate comments would be an IJ, then every facility you go into would have IJ. For anyone to walk in and throw around IJ's at will, for something that can't be fixed . He [referring to R10] has knowingly made inappropriate comments to my assistant. She's blonde and 30 and he makes comments about her looks and dress. It's common and there is not a lot to do about it. It is not criminal. As a facility everyone wants people to have a good experience . if he is not threatening, it's not a crime. He is an inappropriate dirty old man who makes some residents not want to be around him. It won't get him kicked out, it isn't going to get a TDO [temporary detaining order] . We can't impose our own jail or lock him up . When the survey team explained that R10 was doing more than just commenting on how someone looks and making comments about how they dress, the MD responded, I don't suspect him . it would surprise me if he has aggression . I don't call putting hands between someone's legs aggressive. On 8/2/24 at 4:22 p.m., the facility administration provided the survey team with an accepted removal plan. The facility's plan to remove IJ read as follows: Resident #10 was put on one-to-one supervision on 8/1/2024 at approximately 2:30pm. Facility staff completed a FRI and submitted it to the Virginia Department of Health, Adult Protective Services, and Ombudsman. Local police were notified of resident-to-resident allegation (report number 2024-0002626). Residents with a BIMS of 9 or above were interviewed about potential abuse, instances of abuse and reporting a [TRUNCATED]

Based on resident interviews, staff interviews, and facility documentation review, the facility staff failed to administer the facility in a manner that enables residents to attain or maintain their highest practicable psychosocial well-being and be free from sexual harassment and abuse by a male resident who was targeting female residents, which had the potential to affect the 59 female residents residing on 2 of 2 nursing units, and caused psychosocial harm to residents. The findings included: The facility administrator, who had knowlege of or should have been aware, failed to respond and implement interventions in response to several instances where a male resident (resident #10- R10), was displaying inappropriate sexual behaviors and sexually harassing multiple female residents and staff, to stop the abuse and harassment, which resulted in psychosocial harm for four residents. On 7/30/24, during a survey entrance conference, the facility administrator identified himself as the interim administrator and reported he had been at the facility for a few months. On 7/31/24, the survey team was made aware of an allegation of multiple residents being sexually abused and several residents were identified as having been affected. The survey team began interviewing residents. On 7/31/24 at 3:20 p.m., an interview was conducted with resident #7- R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking about sex and saying that my belly button is pushed out because a 250-pound lady was on top of me ., that made her very uncomfortable. R7 reported she returned to her room, turned the lights off and got in bed. R7 reported someone came in and didn't say anything, then a voice said I will talk to you tomorrow. R7 reported it was R10 and she has stayed away from him since then as R10 talks very nasty and disgusting, he always begins the conversation with I still like sex. R7 reported she told her daughter and the daughter talked with social services. R7 went on to say, I had a sign on my door that said stop, but it is gone. R7 reported that she rarely comes of out her room, because she wants to stay away from Resident #10. R7 reported, she didn't realize how much R10's behaviors bothered her until she realized she rarely leaves her room now. On 7/31/24 at 2:50 p.m., an interview was conducted with Resident #9 (R9). R9 was asked about if any residents had bothered her and she said, oh no, they would have a bloody nose and 2 black eyes. On 7/31/24 at 2:55 p.m., an interview was conducted with R9's roommate, resident #15 (R15). R15 reported that R9 was not telling the truth during the interview with the surveyor and said R9's boyfriend put a [NAME] on her neck. R15 went on to say that R9 has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, the curtain wasn't pulled, and I don't want to see that mess. On 7/31/24 at 4:49 p.m., an interview was conducted with resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 said, [referring to R9] she thought we were married. She was going to fly me to a retreat. We are friends and we get involved and live out her fantasies. [facility administrator's name redacted] had talked to me. R10 was asked about sexual activity and confirmed he had put a [NAME] on R9's neck. When asked if anything more had occurred, R10 said, she's bipolar and she's not going to tell you, and neither am I. They can't prove it. R10 was asked about the other women within the facility, and he called R12 by name and said, she is bipolar too, we enjoy spending time together. R10 reported that the first time I got in trouble was about an aide. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying he was still capable of having sex. R7 reported she froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted], he is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into the room in the dark. I am very uncomfortable to even pass him in the hall. On 8/1/24 at 9:05 a.m., R9 was visited in her room by the surveyor again. R9 had a rose in a cup by the bedside and when asked about it, R9 said, my boyfriend gave it to me. When asked who her boyfriend was R9 said R10's name. R9 went on to say, we are supposed to get married today. Did you know I am a princess of Allett, a country off Spain? My Mom and Dad are Queen and King When asked about a [NAME], R9 said, yes and admitted that R10 had given her a [NAME]. When asked if they had done anything sexual, R9 said, no, that's for marriage, and we are getting married today. On 8/1/24 at 9:16 a.m., an interview was conducted again with R9's roommate, R15. R15 said, Mr. [R10's name redacted] gave her a [NAME]. R15 went on to talk about R10 is putting his tongue down her [R9]'s throat. When asked if anything sexual has occurred R15 said, yes, I saw it, he walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. On 8/1/24 at 9:30 a.m., an interview was conducted with resident #14- R14. R14 said, I know who [resident #10's name redacted] is, and he has tried to have every lady here. [Resident #12's name redacted] and R10 hang out all day long together. He feeds her certain things. He tells [R12's name redacted] he loves her . On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted] we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10] personal behavior. His nasty talking, I felt very uncomfortable. There are things I don't tolerate with my friends. [R13's name redacted] felt very uncomfortable. I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I am nervous talking about it. During the interview, R12's hands were noted to be shaking. On 8/1/24 at 10:11 a.m., an interview was conducted with resident #13- R13. R13 said, he [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and I leave because of it. I don't stay and my husband told me to stay away from him. On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, he is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He will say he loves me. He discusses what he likes to do to women, says he likes older women's stuff and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. On 8/1/24 at 4:20 p.m., resident #12 was observed in the common area room on the unit crying. Resident #7 reported to the surveyor that Resident #10 was pressuring her to have sex. On 8/1/24 at approximately 4:25 p.m., Resident #12 was interviewed and said, we [referring to her and resident #10] argued last night. I am scared. I don't want to have sex and he is wanting to have sex. Facility staff were interviewed, and those interviews are as follows: On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported that she has seen R10 at the doorway of R9's room. CNA #11 reported R9 did have a [NAME] on her neck the end of June or early July. When asked if she was aware of any instances where R10 and R9 were having any sexual activity, CNA #11 said, I was here the day it happened, but I didn't' see it, I heard about it. CNA #11 went on to say, R9 said [activity director's name redacted] married them. She will ask if I got the mustang she bought me, her mind isn't exactly right. On 7/31/24 at 2:58 p.m., an interview was conducted with CNA #6. CNA #6 said, I heard about her touching his penis about a month or month and a half ago, but I haven't seen it. I heard about the [NAME]. I've seen them holding hands. CNA #6 was asked if anyone in management was aware and she said, someone made them aware, and I don't know how they handled it. We had some Inservice about we no longer have to separate residents who want to have sex. She [R9] is aware but has some confusion. She is a little off, she talks about having to go pick up her baby and stuff. On 7/31/24 at 3 p.m., an interview was conducted with LPN #3, the unit manager where R9 and R10 reside. When asked about R9's cognitive skills, LPN #3 said, with everyday stuff she seems ok, she can request food, drink, pain meds, etc. But she does have delusions, she owns jets, corvettes, etc. When asked if she was aware of any sexual activity between R9 and R10, LPN #3 said, There has been quite a bit of hearsay about that. I don't know if anyone saw it. He [R10] can be verbally inappropriate. He does like the ladies, but I've never caught him being inappropriate. When asked if she had any knowledge of R9 having a [NAME], LPN #3 said, yes, they spoke to the daughter [R9's daughter] and she made it very clear she wanted him to be able to visit her mom. She said she knew her Mom had a [NAME], and it didn't bother her. LPN #3 went on to talk about how R9 reports she married R10 and when she sees other women walk by, R9 will accuse R10 of sleeping with them. When asked if administration was aware of the [NAME] and the allegation of R9 having R10's penis in her hand, LPN #3 said, Administration is aware, they said they had an incident at [sister facility's name redacted] and that people who are capable of having relations its ok and we may think it is inappropriate. LPN #3 went on to talk about R9's delusions and how R9 says she has brought the staff cars, is sending them on elaborate vacations, etc. LPN #3 said, I've looked, and she doesn't have any diagnosis for the delusions, but she has always had them, I don't know if they haven't spent enough time with her to notice or what, but something is off [cognitively]. On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10 and R9. CNA #12 reported, he [referring to R10] is a socializer, he rolls around all over the place all day. I've seen him stop at [R9's name redacted] room, stop and wave but I've never seen him in there. When asked about R9 having a [NAME], CNA #12 said, I saw the [NAME], but I didn't know he did it. When asked about any sexual activity, CNA #12 said, I heard about the penis incident weeks ago, but I don't know who saw it . One day she [R9] was crying, she said she wanted to marry him and was upset . He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, there are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, [Resident #15's name redacted] says he and [Resident #9's name redacted] kiss and the ladies in room [room number redacted] they don't like him, they say they get a bad feeling from him. LPN #1 identified resident #13 (R13) and said, she is friends with him, but I've never seen anything inappropriate. Last week [CNA #4's name redacted] saw her [R9] with his penis in her hand. Maybe Sunday. I went and talked to Ms. [R15's name redacted], she said she didn't want him in her room. The nurse went down and told him and told him, if he went in that room he would be removed. She [R15] said she didn't want to see what they do, that incident [where R9 had R10's penis in her hand] is why she doesn't want him in there. During the above interview with LPN #1, she was asked about R9's cognitive ability. LPN #1 said, she says she has had 3 babies, and we stole them, she has an airplane, I don't believe she is mentally capable, but they [management] say she has a BIMS [brief interview for mental status] of 15. He [R10] said this morning he has a lady over on the 400 unit, that he likes but her daughter doesn't like him. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. He thinks he can do it to all the ladies. He's been doing it to the residents on the down low and we didn't know it. He told me, in the hall in front of the women, old ladies are good in bed, elderly ladies have the best p#$$y. This lady [R9], her mind is not right, she is going to buy me a car, owns this place, the nurses say the daughter can say its ok. I don't understand these people. We are telling the nurses, and no one acknowledges us. They say her daughter knows. [The unit manger's name redacted] knows. One time he had his hand in her diaper, and he was kissing her, just last week. I've seen him in the back hall near laundry and he was talking stuff to them [the staff], he goes to unit 2. [Resident #26's name redacted] says to close her door from that pervert just a few days ago. [R13's name redacted] tells me she doesn't like him, he's a pervert. Please help us, help these residents, it's not right what he is doing, they know and won't do nothing. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said yes. During the above interview, the administrator stated, yesterday I went into the library to read and [R10's name redacted] was in there and everything was kosher. The administrator went on to say that R10 had written a note to one of the students that he wanted to meet them after graduation, and she felt uncomfortable. I brought him in the office and in general showed him the note and explained that when people are uncomfortable, they can call the cops and if they feel threatened, they can go further. He said he won't ever do it again. He is as 2 faced as they come. He knew he had done wrong, he listened to what I said, it may have lasted 5 minutes. It was about 2-3 weeks ago. I haven't heard anything else about it. The administrator went on to say, our old social worker wanted me to give him a 30-day discharge, because they were thinking it was about to be a pattern and wanted me to react, but I've never put people out in all my years. The administrator was asked if he knew R9 had a [NAME] on her neck. The administrator said, I heard about it this morning. I didn't know she had a [NAME]. The DON went on to say, I called my regional DON, and she said no, you cannot, 1st let's do a medication review. I let [medical nurse practitioner's name redacted] and [psychiatric nurse practitioner's name redacted] know for a medication review, because I know some antidepressants can help curb sexual tendances. When asked about R9 having a [NAME], the DON said, I interviewed [R9's name redacted], her BIMS is 13-15 so I dropped it, it was consensual, she was very excited about it. Her daughter is aware and approves. It was a bruise of unknown origin and the nurse put a note in the chart and me and [name of medical records coordinator redacted]. On 8/1/24 at 10:46 a.m., the administrator and DON were made aware of the above interviews and that R7, R8, R12, R13, and R15 reporting being scared and changing their daily routine because of R10's behaviors. The DON said, I didn't know residents are scared of him or afraid to come out of their room. The administrator said, I'm just hearing about this. After talking with him the other week, his brother came in and I told him about it, and he said he tells him all the time he is not God's gift to women. The administrator reported he had no documentation or credible evidence to provide the survey team with regards to the conversation he had with R10. The facility administrator was asked to provide the survey team with the minutes from their morning meetings and the 24-hour report for the past 3 months. On the afternoon of 8/1/24, the administrator reported to the survey team that he had not keep the notes from the daily department managers meeting and only had the notes available for the current week. The 24-hour reports were reviewed with no mention of R10's above noted behaviors or interactions with any residents. The administrator explained that he conducts the morning meeting each day and grievances, the 24-hour report and anything going on within the facility is discussed. On 8/1/24 in the afternoon, LPN #3 who was the unit manager, assisted the surveyor with locating the communication book used to communicate issues to the providers. The medical nurse practitioner had the medical communication book. LPN #3 provided the surveyor with a copy of the psychiatric communication form where on 7/17/24, she made an entry at the direction of the director of nursing and it read, [R10's name redacted] increased sexuality. LPN #3 said she put the same entry in the book for the medical provider. The surveyor reviewed the medical provider's communication book, but the previous pages had been removed and were not available. On 8/2/24 at 8:45 a.m., the facility staff had failed to provide the survey team with any evidence that the resident's reports and allegations of misconduct by R10 had been investigated, reported or acted upon. The survey team identified the facility was in immediate jeopardy in the areas of Abuse and Quality of Life on 8/2/24 at 8:50 a.m. On the afternoon of 8/2/24, the director of nursing provided the survey team with a Witness Statement. The statement read, myself and [name of medical records coordinator redacted] spoke with resident [R9's name redacted] regarding concerns of a bruise on right side of neck. [R9's name redated] stated it was a [NAME] from [R10's name redacted] and they had gotten married over the weekend. She was asked if she wanted this and if it feels good, it feels good, stated by [R9's name redacted]. She was smiling and in no distress noted. Asked if [R10's name redacted] did anything to you that you did not want him to do to you, her reply was no, don't worry about him, I can handle him. The statement was signed by the Director of Nursing and medical records coordinator and dated 6/24/24. According to a clinical record review, R9's most recent brief interview for mental status (BIMS) assessment conducted prior to the incident was dated 6/14/24, and R9 scored a 12, which noted moderately impaired cognitive skills. There was no evidence of any further assessment(s) being conducted. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON reported that one day she was talking to R7's daughter in the hallway and the social worker asked the DON to step into the office. The DON said the social worker reported the incident where R10 went into R7's room. The DON said, I went to put the stop sign across her door and she denied that he had been back. I asked the resident and her daughter about the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. During the above interview with the DON she was asked if she identified who the resident was that R10 had his hands between the legs of that she mentioned on 8/1/24. The DON said yes, she spoke to a staff member who told her it was R10 and R12 and that a witness statement was in her office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made ware by overhearing staff talking amongst themselves about resident #10 had his hand down the pants of resident #12 while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw resident #10 have his hand down resident #12s pants resident #12 had her legs spread open, while he had his hand in her pants. She didn't' do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with resident #12 and asked her if she opposed to this behavior or it was not wanted, she replied no it was fine at this time it was determined no abuse had occurred. The note was signed by the DON and dated 8/1/24. On 8/6/24 at approximately 8:45 a.m., the regional vice president of operations confirmed that the facility administrator is the abuse coordinator for the facility. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered the room. The administrator said, I did hear he had come in her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked where the grievance, or investigation regarding the incident was, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations. During the above interview with the facility's administrator, the administrator confirmed he is the abuse coordinator for the facility. When asked what that involves, the administrator said, I immediately get things going to make sure the incident is reported and sent in, start the investigation, but the director of nursing usually does the investigation. I read all of the statements and make sure all the dots line up. The administrator was asked to explain his role in the morning meeting. The administrator said, I lead the meetings. We discuss the agenda, and all grievances are reviewed. The administrator again confirmed he was aware that Resident #10 had entered Resident #7's room during the night. When asked about R9 having a [NAME], the administrator stated, I heard about it about an hour before we met on Thursday. When asked if he was aware that reports had been made that R10 was at R9's bedside pleasuring himself, the administrator said, I was told the day it happened, the roommate was in there. When asked if he, the administrator, had done anything to investigate this incident, he said, I know it was done by the nursing department. When asked where the credible evidence was, he said, as far as I know they just looked at her BIMS. When asked what he, the administrator, as the abuse coordinator does when an allegation is made of abuse or inappropriate behaviors he said, I see what's happening and if someone needs to be pulled out of the situation, then make sure to report within 2 hours When asked about his role in ensuring residents are safe and free from sexual harassment by R10, the administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it. The administrator went on to discuss that abuse allegations do not have to be made in writing to be acted upon and went on to say, Its all just a total cluster, because when she [the DON] heard that you start an investigation by talking to staff and residents. During the above interview on 8/6/24 at 9:06 a.m., with the facility administrator, when asked, as the abuse coordinator should you have known what was going on in your building? The administrator said, I depended on the DON to follow through on it all as we discussed it. When asked if he had a role in it, since he was the abuse coordinator, the administrator said, I've had oversight, and they would talk to me about it. I would ask a lot of questions. On 8/6/24 at 9:30 a.m., the facility's corporate staff and consultant were made aware of the above findings. They said, we deserve everything we get in this 2567 [survey report], rightfully so. We will fix it and we will suspend both of them [the administrator and DON]. A review of the facility provided document that was the job description of the Executive Director 1 (Administrator), was conducted. The document read in part, . The primary purpose of the Executive Director is to direct the day-to-day functioning of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times . You will also provide leadership to all facility staff in meeting the goal of providing quality resident care . The facility policy titled, Abuse, Neglect, Exploitation & Misappropriation, was reviewed. The facility read in part, . Once an allegation of abuse if reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a responsible suspicion of crime has occurred . The Abuse Coordinator will endeavor to protect the rights of resident and employees . No additional information was provided.

Based on medication pass observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to ensure professional standards of nursing practice were followed at the facility for 1 (one) of 25 residents in the survey sample, Resident #10. Immediate Jeopardy (IJ) was identified in the area of Comprehensive Person-Centered Care Planning on [DATE] at 1:55 p.m. The facility removed the immediacy on [DATE] at 8:55 p.m. After removal of the immediacy the Scope and Severity was lowered to a Level III, isolated. Immediate Jeopardy: Concerns were voiced to the State Agency (SA) supervisory team regarding the system wide issue of agency nurses not receiving orientation when coming to work at the facility. This issue created a deficient practice related to medication administration, including actual harm to residents in the survey sample, medications not given on time, wrong medications administered and critical medications not available. The SA supervisory staff directed the survey team to speak with facility administration to obtain their policies and procedures regarding how agency nurses were oriented to the facility and educated on facility policies and procedures for pain management, diabetic management, and medication management. On [DATE] at 12:40 p.m., a meeting was held with the facility administrative staff, including the administrator, the administrator who would be in charge after [DATE], the director of nursing, the regional director of clinical services, the HR director, and the medical director. The administrative team was asked how agency nurses who came to work at the facility were oriented to facility policies and procedures and what the process was. The process was explained as follows: -Background information received from the agency (License, resume, CPR , background check) - Information put into the system - DON informed that information is in the system - Agency nurse comes to work -Upon arrival the agency nurse receives report from staff nurse and is shown where meds are, medication cart, doctor's book The administrative team was asked if there was any type of competency checklist done by the facility prior to the agency nurses starting work. Also requested were policies and procedures regarding pain management, medication administration, diabetic management and facility orientation policies. On [DATE] at 1:50 p.m., the administrator informed the team leader that a corporate policy regarding the orientation of agency staff had been obtained and included a competency checklist that was to be completed by the facility prior to the agency nurse beginning work. She stated they had not been aware of the policy or the checklist and that it had not been done for any of the agency nurses currently working at the facility. After consultation with the SA supervisor, IJ was called on [DATE] at 1:55 p.m. for the system wide failure of the facility to orient and educate agency nurses on facility practice for the administration of medications, pain management and diabetic management. On [DATE] at approximately 2:00 p.m., the survey team again met with the facility staff. They were informed that IJ had been identified as of 1:55 p.m. due to the facility failure to provide orientation to agency staff per facility policy. Directive was given to develop a plan for the removal of IJ. A plan for removal of IJ was presented on [DATE] at 3:05 p.m. The plan included the 5 points but did not include how the agency staff would be trained or how the facility would deem the agency nurses competent in the training received. On [DATE] at 5:00 p.m., the second plan of correction was presented and accepted. The facility staff presented completed competencies and training information to the survey team with IJ lifted on [DATE] at 8:55 p.m. For Resident #10, the facility staff medicated Resident #10 with the wrong dose of [MEDICATION NAME] which resulted in altered mental status, decreased oxygen saturations, and aspiration pneumonitis which resulted in an overnight stay at the hospital for opioid overdose. Facility staff treated a blood sugar of 25 without notifying the physician and receiving orders to treat. Findings included: Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Resident #10 was assessed as moderately impaired in her cognitive status with a total cognitive score of 10 out of 15. Resident #10's clinical record was reviewed on [DATE] at 2:15 p.m. and again on [DATE] at 11:00 a.m. Included in Resident #10's most recent POS (physician order [REDACTED].[MEDICATION NAME] ER 60 MG (milligrams) Tablet ER (extended release) For [MEDICATION NAME] 1 (one) Tab by Mouth Every 12 Hours for Pain . and an order dated [DATE] that stated: .[MEDICATION NAME] 15 MG Tablet For [MEDICATION NAME] Take 1 (one) Tab by Mouth every 4 (four) Hours As Needed for Pain . ***NOTE: [MEDICATION NAME] sulfate extended-release tablets are an opioid agonist product indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. WARNING: ADDICTION, ABUSE, and MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; .: Life-Threatening Respiratory Depression: Serious, life-threatening, or fatal respiratory depression may occur with use of [MEDICATION NAME] sulfate extended-release tablets. Monitor for respiratory depression, especially during initiation of [MEDICATION NAME] sulfate extended-release tablets or following a dose increase. OVERDOSAGE: Clinical Presentation: Acute overdosage with [MEDICATION NAME] is manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and, in some cases, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and death Medication Guide: Important information about [MEDICATION NAME] sulfate ER tablets: Get emergency help right away if you take too much [MEDICATION NAME] sulfate ER tablets (overdose). When you first start taking [MEDICATION NAME] sulfate ER tablets, when your dose is changed, or if you take too much (overdose), serious or life-threatening breathing problems that can lead to death may occur. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=19c7d9cc-6ce,[DATE]c5c-8c3f-c24fd 04 (END OF NOTE***) An Interdisciplinary Progress Note dated [DATE] Late Entry included the following: On Sunday ,[DATE], I took report from (Name) RN, (registered nurse) after I was moved from Unit 4, at aprox 1130 and I noticed around 1pm, (Name) Resident #10 falling asleep reading newspaper. I checked her oxygen level was 88% her O2 was placed on and her oxygen came up to normal levels, after being toileted she requested to go to bed. A little after that around 3 pm her daughter called because she had tried to call her on her cell phone and she did not answer. I reported the change of condition to her daughter, she stated 'well she doesn't sound right so I will see you in a little bit.' About an hour later she arrived and she spoke with me. I read her the vital signs which I obtained. I reported her temp was elevated and respirations low, and we both agreed that she appeared the same way she had the last time she had a UTI (urinary tract infection), including facial grimacing and she should be sent out to be checked. I read her the last lab result for U/A (urinalysis) C&S (culture and sensitivity) and it was negative for [MEDICATION NAME]. I spoke with (Name) transport and they informed me they had no availability until 9:30 p-10 pm. At that time I called (Name) and obtained claim # for transport at aprox 6:50 pm. (Name) Resident #10's daughter had told me that her 'mother had not felt right since she had taken that extra pain pill.' I went to check the MAR (medication administration sheet) and saw the medication error. I also asked (Name) another RN to do a respiratory assessment. At aprox 1915 (7:15 p.m.) the crew was still not here so I called the (unintelligible word) my ride # for (Name) ambulance service. At aprox ,[DATE] (7:,[DATE]:45 p.m.) the crew arrived to transport (Name) Resident #10. (Name) Physician, nursing supervisor, (Name) Hospital ER (emergency room ) aware of all health issues of said pt. (patient). A second Interdisciplinary Progress Note dated [DATE] 1945 (7:45 p.m.) included the following documentation: Nurse on front hall asked this nurse to assess lung fields of resident d/t (due to) medication error causing respiratory depression. This nurse auscultated all lung fields noting clear lung sounds w/respirations slow and shallow. Low respiratory count of ,[DATE] breaths per minute w/ periods of apnea .This nurse advised the nurse working front hall to admit resident to ER at (Name) hospital for further evaluation d/t decreased respiratory and the medication given causing the respiratory issues. History and Physical from the emergency room dated [DATE], seen by MD (physician) 21:14 (9:14 p.m.). .Chief Complaint: Altered Mental State; History of Present Illness: .She was sent from (Name) nursing home with concern for accidental overdose. Patient reportedly received 60mg (milligrams) long-acting [MEDICATION NAME] at 9AM and 11AM today. She became less responsive throughout the day and was eventually sent to the ED for evaluation. Patient is unable to provide and history and at best grimaces to pain .Differential Diagnosis: [REDACTED].ED Course/Procedures: Patient is a [AGE] year old female who presents from nursing facility with concern for accidental narcotic overdose. She is somnolent on arrival and, at best, grimaces to sternal rub . Primary Diagnosis: [REDACTED]. Hospitalist H&P dated [DATE] 0312 (3:12 a.m.) HPI: presented to the ED from her nursing facility after she was found to be progressively somnolent. Briefly, the patient appears to have been in her usual state of health until earlier in the day when she inadvertently received twice the dose of her long-acting [MEDICATION NAME] which she takes for her chronic pain. It appears that she received 60 mg at 9 AM and a second dose of 60 in lieu of a as needed dose of her immediate release [MEDICATION NAME] at 11 AM. She was then noted to become increasingly somnolent and less responsive and so was sent to the emergency room .Assessment and Plan: (1)[MEDICAL CONDITION]: The patient presented with fever and leukocytosis of 17,000 in the setting of some mild [MEDICAL CONDITION] and what appears to be right lower lobe infiltrate meeting criteria [MEDICAL CONDITION]. At this time I still suspect that her source is [MEDICAL CONDITION] and further have clinical suspicion that the patient may have aspirated following and inadvertent [MEDICATION NAME] overdose resulting in an aspiration pneumonitis .(2) Aspiration pneumonitis: The patient has apparent right lower lobe airspace disease which in the setting of her presentation I believe represents a chemical aspiration pneumonitis .(4) Acute [MEDICAL CONDITION]: The patient was reportedly increasingly somnolent at the nursing facility however upon evaluation she is awake, alert and oriented x3 and so I believe that her acute [MEDICAL CONDITION] was due to an inadvertent [MEDICATION NAME] overdose which is now resolved . Nursing Facility H&P dated [DATE] 1611 (4:11 p.m.), signed by the physician. Assessment/Plan: (1) Toxic [MEDICAL CONDITION] (2) Aspiration pneumonitis .Discussion: I saw the patient today to readmitted to our facility after a hospitalization for urinary tract infection, aspiration pneumonitis, and unintentional opioid overdose. The day prior to admission, the patient received 120 mg of extended release [MEDICATION NAME], which was an extra dose, instead of her 15 mg breakthrough dose. This resulted in lethargy and some respiratory depression, and she was sent to the emergency department. There, she was found have aspiration pneumonitis . A Medication Error Report dated [DATE] 1105 AM included, Medication as ordered: prn [MEDICATION NAME] 15mg po (orally) Description of error .PRN Order for [MEDICATION NAME] 15mg; took 60mg tablet instead .Outcome to resident and care provided: Resident had a change to respiratory/alertness status. Sent to hospital and admitted for [MEDICAL CONDITION] .Type of Error: Wrong dose; Reason for Error: Misread error . Signed by RN that administered wrong medication and dose of [MEDICATION NAME]. This RN was working a mandated overtime of four hours the morning of [DATE] from 7:00 a.m. to 11:00 a.m. This RN had worked their scheduled shift the night before starting on [DATE] at 7:00 p.m. until [DATE] at 7:00 a.m. The Administrator was asked for a copy of any investigation regarding the above incident. The investigation was received by this surveyor. The Administrator stated, She was given the wrong dose of her [MEDICATION NAME] and when the error was realized we sent her to the emergency room . Included in the investigation was the policy, Adverse Drug Reactions & Medication Discrepancy; Effective Date: [DATE]; Policy: Medication discrepancies and adverse drug reactions are documented and reported. Medication discrepancy refers to: a) Failure to administer, b) Administered at the wrong time, c) Administered wrong amount of medication, d) Administered to wrong resident, e) Administered through wrong route, f) Administered the wrong Medication. Adverse reaction refers to an unintended/undesirable effect that occurs as a result of giving a medication . Fundamentals of Nursing 6th Edition on page 841 states concerning medication administration, Standards are those actions that ensure safe nursing practice. To ensure safe medication administration the nurse should be aware of a nursing standard called the six rights of medication administration. All medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. (1) During review of Resident #10's medical record on [DATE] at approximately 10:00 a.m. the following documentation was located in the clinical record. Interdisciplinary Progress Note dated [DATE] 0500 (5:00 a.m.) I checked the resident's BS (blood sugar) and it was 25. I gave the resident a glucose tab (tablet) and pudding but she couldn't chew the tab. I then gave her the [MEDICATION NAME] shot to raise her BS. The final number was 85. I called her RP (responsible party) and will notify the MD (physician). Fundamentals of Nursing 6th Edition on page 419 states concerning notification of the physician with a change in condition, The physician is responsible for directing medical treatment .one of the most litigated issues is whether the nurse kept the physician informed of the client's condition. To inform a physician properly, nurses must perform a competent nursing assessment of the client to determine the signs and symptoms that are significant in relation to the attending physician's tasks of [DIAGNOSES REDACTED].If a verbal order is necessary .it should be written and signed by the physician as soon as possible, usually within 24 hours . (2) LPN #2 (licensed practical nurse) (Facility nurse) was interviewed on [DATE] at 10:55 a.m. LPN #2 stated, There are no standing orders for diabetes. I asked that when I got here. LPN #3 (Agency nurse) was interviewed on [DATE] at 11:10 a.m. LPN #3 stated, Received in report of low blood sugar this morning. (Name) PA (physician assistant) knows. I rechecked; it was 127. I don't know if the on-call doctor was notified. PA was interviewed on [DATE] at 11:15 a.m. PA stated, I was notified this morning at 9:08 when I came in. I don't know if the on-call doctor was notified or not. I am going to find out who was on-call last night and ask them myself. I will let you know. She also didn't get her bedtime snack last night. On [DATE] at approximately 1:00 p.m. the PA entered the conference room and handed this surveyor the following note: [DATE] Noon To Whom It May Concern: In regard to (Name) Resident #10, I was notified at 0908 (9:08 a.m.) that her accuchek (blood sugar) was 25. Nursing gave her a glucose tab and pudding. She then was administered a [MEDICATION NAME] injection. I inquired about any input from the on call doctor but no one knew. I called over office (sic) and there was no call made to the on call physician to direct these orders. This incident occurred about 5:30 a.m. today. An accuchek at time of exam was 136 . The Administrator and DON (director of nursing) were notified of the above findings during a meeting with the survey team on [DATE] at approximately 5:45 p.m. No further information was received by the survey team prior to the exit conference on [DATE]. (1) and (2) Potter, Patricia A. and Perry, Anne G. Fundamentals of Nursing. St. Louis: Mosby, 2005. This is a complaint deficiency.

Based on resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to provide care and services for the highest practicable well being for 10 of 25 residents in the survey sample resulting in SQC (substandard quality of care), Residents #10, #12, #13, #21, #11, #18, #6, #4, #5 and #15. This resulted in harm to Resident #10, #21, #11, and #18. 1a) Facility staff failed to monitor and record Resident #10's oxygen saturations every shift as ordered by the physician. 1b) Facility staff failed to administer long acting [MEDICATION NAME] per physician order [REDACTED]. 2. Facility staff failed to monitor and record Resident #12's oxygen saturations every shift per physician order. 3. Facility staff failed to monitor and record Resident #13's oxygen saturation every shift per physician order. 4. Resident #21 was not provided pain medications for the treatment of [REDACTED]. 5. The facility staff failed to assess non-pressure areas on the foot of Resident #11 and obtain physician ordered wound clinic treatment for [REDACTED]. Physician orders [REDACTED]. Resident #11 was not seen at the wound clinic until 04/04/2017. Review of facility documentation included Weekly Skin Integrity forms and per instruction on those forms, If any skin condition present, proceed to skin condition record for each site identified. On 03/01/2017 the Weekly Skin Integrity Form documented bilateral boggy heels and a blackened area on the left fifth metatarsal. The Non-Pressure Skin Condition Record was reviewed. Measurements of the area on the left fifth metatarsal was measured at .4 cm by .4 cm. on 02/24/2017, 03/02/2017, 03/10/2017 and 03/17/2017. The facility failed to measure the areas after 03/17/2017. Weekly Skin Integrity Reviews on 03/08/2017 and 03/22/2017 documented skin intact and treatment in place. There was no further mention of the bilateral boggy heels. When Resident #11 was seen at the wound clinic, 40 days after the initial order was placed, wounds were described as follow: Left dorsal fifth toe, .6 am X .9 Cm X .1 cm, full thickness non-healing wound with 76-100 % slough; Right lateral heel, 1.9 X .4 X .2, non-healing wound with undermining, 76-100% eschar covered, 1-25 % slough. 6. The facility staff failed to follow physician's orders [REDACTED].# 18, and also failed to assess and monitor for [MEDICAL CONDITION], leading to the resident being admitted to the hospital which resulted in harm. 7. The facility staff failed to administer Vitamin D per physician's orders [REDACTED].# 6. 8. For Resident # 4, the facility staff failed to attempt the use of non-pharmacological interventions to address pain control. 9a. For Resident # 5, the facility staff failed to assess the level of pain, and the location of the pain prior to the use of pain medication. 9b. For Resident # 5, the facility staff failed to attempt the use of non-pharmacological interventions to address pain control. 9c. For Resident # 5, the facility staff failed to follow physician orders [REDACTED]. 10. For Resident # 15, the facility staff failed follow physician orders [REDACTED]. Findings included: 1a) Facility staff failed to monitor and record Resident #10's oxygen saturations every shift as ordered by the physician. Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/10/2017. Resident #10 was assessed as moderately impaired in her cognitive status with a total cognitive score of 10 out of 15. Resident #10's clinical record was reviewed on 05/02/2017 at 2:15 p.m. The most recent POS (physician order [REDACTED]. Review of TARS (treatment administration sheets) included the following documentation: March 2017 7A-7P no O2 (oxygen) Sats were recorded on 3/19, 3/20, 3/21, 3/24. 7P-7A no O2 Sats were recorded 3/03, 3/11, 3/22, 3/23, 3/25. The DON (director of nursing) was interviewed on 05/03/17 at approximately 5:45 p.m. regarding blanks on the TARS. The DON stated, If there are no sats recorded then we have to assume they were not done. 1b) Facility staff failed to administer long acting [MEDICATION NAME] per physician order [REDACTED]. Included in Resident #10's POS was an order dated 04/03/17 that stated: .[MEDICATION NAME] ER 60 MG (milligrams) Tablet ER (extended release) For [MEDICATION NAME] 1 (one) Tab by Mouth Every 12 Hours for Pain . and an order dated 04/04/17 that stated: .[MEDICATION NAME] 15 MG Tablet For [MEDICATION NAME] Take 1 (one) Tab by Mouth every 4 (four) Hours As Needed for Pain . Review of the MARS (medication administration sheets) for Resident #10 included documentation that Resident #10 did not receive a dose of [MEDICATION NAME] 60mgER on [DATE] at 8:00 a.m. or 8:00 p.m. and also did not receive a dose on 05/01/17 at 8:00 a.m. The first dose the resident received since 04/29/17 at 8:00 p.m. was on 05/01/17 at approximately 10:00 p.m. Resident #10 was administered [MEDICATION NAME] 15 MG by mouth on 04/29/17 at 7:40 p.m., 04/30/17 at 2:10 a.m. and 9:00 p.m. She received no other prn (as needed) doses according to documentation on the MAR. Resident #10 also received [MEDICATION NAME] 25 MG on 04/30/17 at 1:00 p.m. for anxiety. Resident #10's daughter was interviewed on 05/03/17 at 1:35 p.m. per her request. During this conversation Resident #10's daughter stated, .On Friday 4/28 a hard script was needed for Mom's [MEDICATION NAME] 60 MG every 12 hours. She missed a dose on Saturday, 4/29 at 8:00 p.m., Sunday, 4/30 at 8:00 a.m., 8:00 p.m., and a dose on Monday, 05/01 at 8:00 a.m. (Name) the PA (physician assistant) gave the nurse a prescription at 10:30 a.m. on Monday, 05/01. The medicine came from the pharmacy at 10:30 p.m. Monday night. Her Monday bedtime dose was late. I spoke with the Sunday nurse working 7A-7P and she would not call the doctor. Nurse stated, 'Another doctor will not write a prescription for [MEDICATION NAME].' I, myself called the on-call doctor Sunday evening around 10:00 p.m. The on-call doctor was going to call the nurse at the facility to make sure Mom's [MEDICATION NAME] would be delivered on Monday. The nurse working didn't know who the Administrator on-call was for the weekend. They gave Mom her prn [MEDICATION NAME] over the weekend every four hours when she would take it. Mom called me Sunday evening, crying and stated: I can't take this pain much longer.' LPN #1 (licensed practical nurse) was interviewed on 05/03/17 at approximately 2:00 p.m. regarding the missed [MEDICATION NAME] ER doses. LPN #1 stated, A hard script was needed on Friday and not obtained. She (Resident #10) ran out of [MEDICATION NAME] over the weekend. The Medical Director confirmed Resident #10 went into withdrawal from not having her long acting [MEDICATION NAME] over the weekend during a conversation with this surveyor on 05/03/17 at approximately 3:00 p.m. Resident #10 was interviewed on 05/08/17 at 10:30 a.m. Resident #10 stated, I ran out of my long acting [MEDICATION NAME] that weekend. My legs hurt so bad, they had constant pain, then turned to constant tingling up into my thighs. It was miserable. I didn't a take a lot of the other [MEDICATION NAME] because it didn't help. The Administrator and DON (director of nursing) were informed of the above during a meeting with the survey team on 05/03/17 at 5:45 p.m. The DON stated, The hard script should have been obtained on Friday and the medicine ordered from the pharmacy and received at the facility before (Name) Resident #10 ran out of medicine. I don't know how that happened. This is a complaint deficiency. 2. Facility staff failed to monitor and record Resident #12's oxygen saturations every shift per physician order. Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/01/17. Resident #12 was assessed as moderately impaired in her cognitive skills with a total cognitive score of 12 out of 15. Resident #12's clinical record was reviewed on 05/04/17 at 7:45 a.m. The most recent POS (physician order [REDACTED]. Review of Resident #12's TARS revealed the following dates without O2 Sats documented: January 2017: 7A-7P: 1/5, 1/6, 1/10, 1/15, 1/16, 1/17, 1/20, 1/21, 1/22, 1/23, 1/24, 1/27, 1/31. February 2017: 7A-7P: 2/17, 2/19, 2/22, 2/23, 2/24, 2/25, 2/28; 7P-7A: 2/17, 2/25, 2/28. March 2017: 7A-7P: 3/3, 3/11, 3/15, 3/19, 3/20, 3/21, 3/23, 3/24, 3/25; 7P-7A: 3/3, 3/11, 3/21, 3/23, 3/25. The DON (director of nursing) was interviewed on 05/03/17 at approximately 5:45 p.m. regarding blanks on the TARS. The DON stated, If there are no sats recorded then we have to assume they were not done. This is a complaint deficiency. 3. Facility staff failed to monitor and record Resident #13's oxygen saturation every shift per physician order. Resident #13 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/29 17. Resident #13 was assessed as severely impaired in her short and long term memory and daily decision making skills. Resident #13's clinical record was reviewed on 05/04/17 at 9:40 a.m. The most recent POS dated 04/01/17 through 05/31/17 included an order: .07/20/15: O2 Sat Every Shift, 06/07/16: O2 at 2L/Min via Nasal Cannula continuous every shift for shortness of breath . Review of Resident #13's TARS revealed the following dates without O2 Sats documented: January 2017: 7A-7P: 1/2, 1/5, 1/6, 1/10, 1/15, 1/16, 1/17, 1/20, 1/21, 1/22, 1/23, 1/24, 1/31; 7P-7A: 1/20. February 2017: 7A-7P: 2/19, 2/22, 2/23; 7P-7A: 2/25, 2/28. March 2017: 7A-7P: 3/1, 3/15, 3/20, 3/21, 3/24; 7P-7A: 3/3, 3/7, 3/11, 3/22, 3/23, 3/25. The DON (director of nursing) was interviewed on 05/03/17 at approximately 5:45 p.m. regarding blanks on the TARS. The DON stated, If there are no sats recorded then we have to assume they were not done. No further information was received by the survey team prior to the exit conference on 05/09/2017. This is a complaint deficiency. 4. Resident #21 was not provided pain medications for the treatment of [REDACTED]. Resident #21's [MEDICATION NAME] 125 mcg (micrograms) patch was discontinued abruptly and the resident was not provided any other medications for the relief of breakthrough pain. Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/17 was a quarterly assessment. The resident was assessed as being a fifteen (15) for cognitive skills; able to make needs known and independent in decision-making skills. On 5/4/17 at approximately 1:00 p.m., An APS (adult protective services) report filed in the State agency's office was reviewed regarding multiple allegations of the resident not being provided care and services while in the nursing facility. During the review of the APS report, Resident #21's clinical record was reviewed and it was documented that the resident frequently complained of pain after a [MEDICATION NAME] was discontinued due to an allegation of drug diversion related to the resident's spouse. On 5/4/17 at approximately 1:40 p.m., the Medical Director was interviewed regarding the above allegation. The medical director stated that he was aware of the above and that he would have done differently. The medical director further stated that he did not want to be responsible if she (the resident) overdosed; she was not my patient. The medical director was made aware that Resident #21 was on [MEDICATION NAME] for a while and that it was discontinued shortly after the allegation of a drug diversion concerning the Resident's husband. The Medical Director stated that he was aware of something like that but he could not speak to the situation. The Medical Director was also made aware that the resident was not offered any other alternatives for the treatment of [REDACTED]. On 5/8/17 at approximately 11:30 a.m., Resident #21's clinical record was reviewed to include the following nursing notes: 11/26/16 1800 (6:00 p.m.) Res (resident) was told that husband isn't allowed on grounds until investigation is over for the missing [MEDICATION NAME] . 11/30/16 1050 (Physician named) in to see resident. N/O (new order) to d/c [MEDICATION NAME]es. Orders for [MEDICATION NAME] 4 mg po (by mouth) q (every) 6 hours N/V (nausea and vomiting) & [MEDICATION NAME] 25mg IM (intramuscular) q 6 prn (as needed/necessary) for N/V x (times) 2 weeks. Resident has been notified. Resident was upset about having to remove patches. 100 mcg & 25 mcg /hr (hour). patches wasted . 12/2/16 7p-11p Multiple c/o's (complaints) RT (related to) [MEDICATION NAME] DC'd. c/o meds not working for pain. Has had 650 mg Tyl (tylenol), 0.5 mg [MEDICATION NAME] is now requesting [MEDICATION NAME] for pain but is aware too early want tyl again but it is too early pt (patient) short and curt c (with) staff. Hostile attitude .(sic). 12/4/16 late entry from 12/3/16 7A-7P. Resident frequently c/o generalized pain during shift. Resident would ask for pain medication early and when this nurse would tell pt it was too soon, pt would say that this nurse didn't give pt (patient) certain time. Pt stated that at one point to Give me whatever you can give. 12/14/16 0300 Has been verbally hostile c (with) nsg (nursing) staff . 12/18/16 0600 Sent word by CNA (certified nursing assistant) Give me anything, I don't care what it is just give me something. .has nothing left for pain that she hasn't already taken . 12/26/16 1700 (5:00 p.m.) Pt refused to turn & rotate stating I can't roll because my shoulders hurt to bad. This nurse repeatedly said that not rotating can cause sores but loudly said I told you I'm not rolling on my shoulders because I'm in pain & the doc (doctor) won't give me or care about my pain. On 5/8/17 at approximately 12:45 p.m. during an interview with Resident #21, the resident stated that she was not provided pain medications due to an alleged drug diversion that was investigated and unfounded, concerning her husband. Resident #21 stated that the doctor took me off of 125 mcg of [MEDICATION NAME] without tapering me off of it and I was unable to get out of bed or turn because of the pain. On 5/8/17 at approximately 5:49 p.m., the administrative staff was made aware of the above findings. The facility staff involved in the above findings were not available for interview. Two of the employees were called multiple times on 5/8/17 at 3:20 p.m. and again at 5:24 p.m., but did not answer. The remainder of the staff involved were no longer employed at the facility. On 5/9/17 at approximately 9:20 a.m. A Witness Statement for Resident #21 was reviewed to include the following: 1/27/17 (CNA-certified nursing assistant) named On 1/10/17 .Around 10:30 I saw the shower aide go into her room and offer her a shower (CNA shower aide named) she stated that (Resident named) declined her shower .she stated that she did not want it yet because she was in a lot of pain .I offered one more time before I left at 3:00 p.m. that day and (Resident named) stated that she would take care of it later and was still in pain. On 5/9/17 at approximately 1:34 p.m., the administrative staff were made aware of the above findings. 5. The facility staff failed to assess non-pressure areas on the foot of Resident #11 and obtain physician ordered wound clinic treatment for [REDACTED]. Physician orders [REDACTED]. Resident #11 was not seen at the wound clinic until 04/04/2017. Review of facility documentation included Weekly Skin Integrity forms and per instruction on those forms, If any skin condition present, proceed to skin condition record for each site identified. On 03/01/2017 the Weekly Skin Integrity Form documented bilateral boggy heels and a blackened area on the left fifth metatarsal. The Non-Pressure Skin Condition Record was reviewed. Measurements of the area on the left fifth metatarsal was measured at 0.4 cm by 0.4 cm. on 02/24/2017, 03/02/2017, 03/10/2017 and 03/17/2017. The facility failed to measure the areas after 03/17/2017. Weekly Skin Integrity Reviews on 03/08/2017 and 03/22/2017 documented skin intact and treatment in place. There was no further mention of the bilateral boggy heels. When Resident #11 was seen at the wound clinic, 40 days after the initial order was placed, wounds were described as follow: Left dorsal fifth toe, 0.6 am X 0.9 Cm X 0.1 cm, full thickness non-healing wound with 76-100 % slough; Right lateral heel, 1.9 X 0.4 X 0.2, non-healing wound with undermining, 76-100% eschar covered, 1-25 % slough. Resident #11 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data sheet) was a significant change assessment with an ARD (assessment reference date) of 05/05/2017. Resident #11 was assessed as having a problem with both long and short term memory and being severely impaired with daily decision making skills. The clinical record was reviewed beginning on 05/03/2017. Observed in the physician order [REDACTED]. and 3-27-17 1312 (1:12 p.m.) Wound care clinic Appointment STAT Indication-Dx (diagnosis) [MEDICAL CONDITION] of feet/toes. The unit manager, LPN (licensed practical nurse) was interviewed at 10:00 a.m., on 05/03/2017 regarding Resident #11's appointment at the wound clinic. She was asked when Resident #11 was first seen at the wound clinic. She stated, April 4th. She was asked why there was a delay in the length of time the initial order was written and the actual appointment. She stated that she had been at the facility for one month and had not been there at the time of the initial order. She stated she did not know why the appointment had not been made. She directed this surveyor to the staff member who made transportation arrangements and appointments, OS (other staff) #9. OS #9 was interviewed at approximately 10:15 a.m. on 05/03/2017. She was asked what her role in making appointments for residents was at the facility. She stated that when she received a request from the staff she made appointments for residents and arranged for their transportation to the appointment. She was asked if she knew why Resident #11's appointment for the wound clinic had not been made when originally ordered on [DATE]. After looking through her information she informed this surveyor that she had not gotten any information regarding an appointment at the wound clinic for Resident #11 until 03/27/2017 at which time an appointment was scheduled for 04/04/2017 and transportation was arranged. Review of facility documentation included Weekly Skin Integrity forms and per instruction on those forms, If any skin condition present, proceed to skin condition record for each site identified. On 03/01/2017 the Weekly Skin Integrity Form documented bilateral boggy heels and a blackened area on the left fifth metatarsal. The Non-Pressure Skin Condition Record was reviewed. Measurements of the area on the left fifth metatarsal was measured at 0.4 cm by0 .4 cm. on 02/24/2017, 03/02/2017, 03/10/2017 and 03/17/2017. The facility failed to measure the areas after 03/17/2017. Weekly Skin Integrity Reviews on 03/08/2017 and 03/22/2017 documented skin intact and treatment in place. There was no further mention of the bilateral boggy heels. A physician progress notes [REDACTED].Apparently the [MEDICAL TREATMENT] staff noticed her toes that were [DIAGNOSES REDACTED]tous and the left fifth toe apparently was draining some purulent material Inspection of the feet reveals a [DIAGNOSES REDACTED]tous left fifth toe with some purulent material adjacent. There is some mild [DIAGNOSES REDACTED] over the distal portion of the foot and the heel. Similar findings are noted on the right foot .The area is mildly tender with palpation Impression [MEDICAL CONDITION] of both feet .I will immediately place her on Keflex 500 mg 4 times daily X (times) 7 days. I will have the nursing staff contact the wound clinic and have them see her tomorrow . The TAR (treatment administration records) were reviewed. On the TAR for February an order to Clean right heel with DWC (wound cleanser) and apply [MEDICATION NAME] and heel cup for protection was added on 02/22/2017 and marked as completed on 2/22/2017 and 02/24/2017. All other days were blank. an order for [REDACTED]. Cleaning of the heel as described was marked as completed on 7 of 31 days and the foam boot either placed or refused by the resident on 25 of 31 days. LPN #1 was asked about the holes on the TAR for February and March. She stated, I don't know if the treatments were done or not. LPN #1 was asked who would be doing the dressing change for Resident #11 scheduled for that day (05/03/2017). She stated that she would be doing it. This surveyor asked to be present when the dressing change was completed. LPN #1 agreed to the request. Wound clinic notes from 04/04/2017, 40 days after the initial order was placed, were reviewed. Wounds were described as follow: Left dorsal fifth toe, 0.6 am X0 .9 Cm X 0.1 cm, full thickness non-healing wound with 76-100 % slough; Right lateral heel, 1.9 X 0.4 X 0.2, non-healing wound with undermining, 76-100% eschar covered, 1-25 % slough. Further documentation included: This is a chronically ill patient with [MEDICAL CONDITION], Coronary disease, [MEDICAL CONDITION]/[MEDICAL TREATMENT] and history of Wegener's vasculitis who comes into the wound clinic another time with more wounds on her feet and legs. She has been treated off and on since 8/2015. She says some of her wounds are due to her scuffing her feet on her wheelchair at her (name) nursing home .she essentially does not ambulate, she sits in a wheelchair and sleeps in a recliner .weak muscles and painful to touch foot .Wound #5 Left dorsal fifth toe is a full thickness non-healing wound and has received a status of Not Healed. Initial wound encounter measurements are 0.6 cm length X 0.9 cm width X 0.1 cm depth, with an area of 0.424 sq cm and a volume of 0.042 cubic cm .there is a scant amount of sero-sanguineous drainage noted which has no odor .Wound bed is 76-100% slough .The periwound skin exhibited: [DIAGNOSES REDACTED]. Wound #6 Right, Lateral Heel is an eschar covered Non-healing wound and has received a status of Not Healed. Initial wound encounter measurements are 1.9 cm length X 0.4 cm width X 0.2 cm depth, with an area of 0.597 sq cm and a volume of 0.119 cubic cm .undermining has been noted at 12:00 and ends at 12:00 with a maximum distance of 0.5 cm. There was no drainage noted .Wound bed is 76-100% eschar and 1-25% slough, 1-25% granulation .She has multiple wounds on both feet as she injures herself on something in her environment .[MEDICAL CONDITIONS] in a chronically ill patient who is injuring her skin .She appears to have a chronic vasculitis based on the appearance of her extremities. Notes from the wound clinic visit on 04/18/2017 contained the following: On the vascular study of 4/11/2017 her legs bilaterally have monophasic wave forms and there is distal bilateral critical ischemia. Both of her tibial arteries are occluded on the right and the posterior tibial artery on the left is occluded .Wound #5 Left dorsal Fifth Toe no change in the wound progression .Wound #6 Right lateral heel .2 cm in length X 1 cm in width X .2 cm depth .the wound is deteriorating Her wounds are the same or slowly getting worse. Is apparent that her inflow from the vascular study is very poor and wounds are unlikely to heal given the critical ischemia severe [MEDICAL CONDITION] related to her vasculitis and other health issues I think it is likely we will not be able to heal her wound of the feet and she is likely to come to amputation. On 05/03/2017 at approximately 1:25 p.m., a family member for Resident #11 came to the conference room to speak with this surveyor. She identified herself as the POA (power of attorney) for Resident #11. She stated, I wanted to speak with you about my sister's care .the quality and quantity of staffing has really gone down here .I want to show you some pictures. She showed this surveyor pictures she had taken of Resident #11's feet on 02/24/2017 and 03/27/2017. She stated, Her wounds have gotten worse and worse, they haven't been taking care of them and treating them like they should .she has a history of problems that have sent her to the wound clinic in the past, they should have been more on top of this . On 05/03/2017 the medical director (who took the position on 04/01/2017) was interviewed regarding Resident #11. He was asked about the delay in obtaining the wound clinic appointment in regard to the outcome of Resident #11 and the lack of skin assessments and wound measurements at the facility. He stated, that due to Resident #11's medical problems and history the wounds would have not healed regardless of the time frame, but had she gone to the wound clinic when originally ordered it could have changed the quality of the end of her life. He stated that had Resident #11 gone to the wound clinic when ordered she would have had Dry Gangrene as opposed to Wet Gangrene which he stated, That may sound strange but the dry is preferable to the wet .also had she gone to the wound clinic sooner we may have been able to get her on Hospice sooner which would have increased the quality of her end of life. At approximately 5:00 p.m., on 05/03/2017, LPN #1 came to the conference room to tell this surveyor that she was ready to do the dressing change for Resident #11. This surveyor told her she would be there in just a minute. This surveyor arrived on the unit at 5:10 p.m., LPN # 1 and this surveyor started down the hall to Resident #11's room. LPN #4 was coming up the hall. LPN #1 stated, Where are you going? to LPN #4. She stated, I've already done the dressing change. LPN #1 stated, She (pointing to this surveyor) wanted to see it. LPN #4 stated, Well it's already done. This surveyor asked LPN #4 if she was caring for Resident #11 for the evening. She stated, No, I work on the other side (referring to the other units on the opposite side of the building) This surveyor asked, Why did you come over here to do the dressing change? LPN #1 stated, She is more familiar with the dressing change than I am. LPN #4 stated, I can do it again if you want me to, it's only scheduled every other day .she's not doing very well and she is in pain. This surveyor stated, No, I don't want to put the resident through that, but if the dressing needs to be changed again I want to see the wounds. LPN #1 verbalized her understanding. During a meeting with the administrator, the DON (director of nursing) and the regional nurse consultant at 5:45 p.m., on 05/03/2017 the above information was discussed and concerns were voiced regarding the possibility of harm to resident #11 due to the delay in obtaining the wound clinic appointment, the lack of assessments for the non-pressure wounds and the lack of documentation regarding treatment to the areas. They were also informed that the wounds had not been seen by this surveyor due to the dressing being changed before the surveyor got to the unit. The DON was asked if due to Resident #11's history of [MEDICAL CONDITION] would she expect the nursing staff to be all the more diligent in assessing her feet and extremities. The DON stated, Yes. On 05/04/2017, LPN #1 was again asked to get this surveyor if the dressings were changed on Resident #11's feet. The dressings did not need to be changed. On 05/08/2017 when the survey team returned to the facility the DON was asked if this surveyor could see the wounds on Resident #11's feet. The DON stated, (Name of Resident #11) passed away over the weekend. No further information was obtained prior to the exit conference on 05/09/2017. This is a complaint deficiency. 6. The facility staff failed to follow physician's orders [REDACTED].# 18, and also failed to assess and monitor for [MEDICAL CONDITION], leading to the resident being admitted to the hospital which resulted in harm. Resident # 18 was a closed record review and was admitted to the facility 3/20/17 with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) dated 3/27/17 had Resident # 18 assessed with [REDACTED]. The clinical record was reviewed 5/4/17 beginning at 10:00 a.m. The POS (physician order [REDACTED]. A review of nurses' notes dated 3/21/17 through 3/28/17 revealed the following: 3/23/17 (no time documented) : Rsd straight cath. No void 7a-7p. Clot noted to come out end of cath. Urine began flowing very slowly rsd said he had no pain. Abd.(abdomen) not very distended . 3/24/17 7:00 a.(TRUNCATED)

Based on clinical record review, resident interview, and staff interview, the facility staff failed for three of 25 residents in the survey sample (Residents # 4, 7, and 21), to provide care and services to prevent and treat urinary tract infections, and to provide routine urinary catheter care. 1. For Resident # 4, the facility staff failed to notify the resident's attending physician of a lab result that identified the resident as having a urinary tract infection [MEDICAL CONDITION], leading to a one month delay in treatment, which lead to the resident being hospitalized and intubated, which constituted harm. 2. For Resident # 21, the facility staff failed to provide routine catheter care resulting in the resident being hospitalized , which constituted harm. 3. Facility staff did not follow physician orders [REDACTED].#7's supra-pubic catheter. Facility staff were to provide catheter care every shift and clean around the catheter with dermal wound cleanser, paint [MEDICATION NAME] around catheter every day. During an interview with Resident #7 he stated that he was providing his own catheter care and had all the supplies in his bedside table. The findings include: 1. For Resident # 4, the facility staff failed to notify the resident's attending physician of a lab result that identified the resident as having a urinary tract infection [MEDICAL CONDITION], leading to a one month delay in treatment, which lead to the resident being hospitalized and intubated, which constituted harm. Resident # 4 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), a Significant Change, with an Assessment Reference Date (ARD) of 4/21/17, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section H (Bladder and Bowel), the resident was assessed as occasionally incontinent of bowel and bladder. Review of the Interdisciplinary Progress (Nurses) Notes revealed the following entry: 3/13/17 - 3:00 p.m. .Told this nurse she thought she had a UTI (Urinary Tract Infection) d/t (due to) burning with urination .MD notified. On 3/13/17, a telephone order from the Physician's Assistant was received for the following: UA (Urinalysis), EOS, [MEDICATION NAME] 200 mg (milligrams) PO (by mouth) tid (three times a day) x (times) 2 days. NOTE: [MEDICATION NAME] is an over the counter medication used to .relieve symptoms caused by irritation of the urinary tract such as pain, burning, and the feeling of needing to urinate urgently or frequently. Ref. www.WebMD.com. Further review of the Interdisciplinary Progress (Nurses) Notes revealed the following entries: 4/9/17 - 5:00 a.m. This nurse went in to resident room to give meds, resident asleep hard to waken. Once awake resident non-verbal, made eye contact, no facial grimacing. Resident breathing deep, skin sweaty. O2 (Oxygen) sat (saturation) 89, BS (Blood Sugar) 269, VS (vital signs) 103 - 136 (pulse), 32 (respirations), 134/58 (blood pressure). On call (MD) called was advised to send to ED (Emergency Department). 911 called, resident was taken to ED at 5:30 and RP (Responsible Party) notified. 4/9/17 - 11:10 a.m. Called AH ER (hospital emergency room ) for condition update. Resident to be admitted to ICU (Intensive Care Unit) on a breathing machine. Review of the hospital Discharge Summary revealed the following: This is a [AGE] year-old female with a history of [MEDICAL CONDITION], obesity hypoventilatio[DIAGNOSES REDACTED], [MEDICAL CONDITION] disorder, diabetes, diastolic heart failure, who was brought to the emergency room with lethargy and unresponsiveness. In the emergency room had difficulty breathing. To maintain her sats, she was ventilated. She was found to have a urinary tract infection and was admitted to ICU. She dropped her blood pressure requiring pressors (a medication used to raise blood pressure). The patient was found to have 2 out of 4 blood cultures positive for strep mitis (streptococcus mitis) .She also grew E-coli and Proteus in the urine, [MEDICATION NAME] sensitive Resident # 4 was discharged back to the facility on [DATE] with [DIAGNOSES REDACTED]. A thorough review of Resident # 4's clinical record failed to reveal the results of the UA ordered on [DATE]. At approximately 1:00 p.m. on 5/8/17, at the request of the surveyor, LPN # 2 (Licensed Practical Nurse) was able to obtain a copy of the UA results via Fax from the laboratory that processed the urine sample. According to the UA report, dated 3/14/17, the results indicated Resident # 4 had a UTI. Asked if the resident's attending physician was notified of the UA results, LPN # 2 said, He was not notified. LPN # 2 was also asked about EOS. LPN # 2 explained that EOS is a protocol and stands for Enhanced Observation Order Set for suspected UTI. According to a blank copy of the EOS furnished by LPN # 2, the protocol included the following: 1) Obtain vital signs (BP, pulse, resp rate, temp, pulse ox) every 6 hours for 3 days. 2) Record fluid intake each shift for 3 days. 3) Notify medical director or provider on call if fluid intake is less than 1600 ml per day. 4) Notify the medical director or on-call provider if condition worsens or if no improvement by the next morning. 5) Contact the medical director or on-call provider with an update on the resident's condition daily. Asked if the EOS protocol was initiated for Resident # 4, LPN # 2 replied No. At approximately 2:30 p.m. on 5/3/17, an interview was conducted with Resident # 4. The resident immediately began speaking about her recent hospitalization . I was a RN (Registered Nurse) for [AGE] years, Resident # 4 said, if I tell you I'm having trouble with something, follow up. The resident went on to say she complained she had a UTI for four or five days, that she had pain and pressure when she voided. (Name of the PA) ordered [MEDICATION NAME]. It got rid of the pain and pressure, but it did not get rid of the UTI. The resident said she continued to complain. I went to the ADON (Assistant Director of Nursing) and the Unit Manager. They didn't act. Resident # 4 went on to say that, I was in the bathroom and I felt faint. I called out 'Help me, help me, I can't breathe.' That's all I remember. The next thing I know I was in the hospital. I was intubated and put on IV (intravenous) meds. The resident went on to say, When I got back, (name of PA) said, 'We thought we were going to lose you.' Continuing, Resident # 4 said, This is not the first time this (a UTI) has happened, but it's the first time I ended up in the hospital. They (staff) should know by now when I complain something is wrong, they need to follow up. A lot of the staff just don't listen, not just now, but always. The findings were discussed at a meeting at 3:00 p.m. on 5/8/17 with the Interim Administrator, Director of Nursing, Corporate Nurse Consultant, and the survey team. 2. Resident #21's catheter was not changed monthly as ordered; the resident developed a catheter induced urinary tract infection resulting in harm. Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/17 was a quarterly assessment. The resident was assessed as being a fifteen (15) for cognitive skills; able to make needs known and independent in decision-making skills. On 5/8/17 at approximately 11:30 a.m., Resident #21's clinical record was reviewed to include the following: A physician's orders [REDACTED]. The Treatment Administration Records were reviewed to include the following: Change catheter (Foley) monthly . Upon review of the November and December TARs, the Foley was documented as being last changed on 11/30/16. A care plan initiated on 4/13/16 and updated on 10/20/16 was reviewed to include the following: Focus: The resident has altered bladder elimination r/t indwelling catheter .Interventions: Cath care as ordered and prn (as needed). A hospital Discharge Summary dated 1/9/17 was reviewed to include the following: Discharge Diagnoses: [REDACTED]. Chronic Foley .History: .resident of a local nursing care facility who presented with nausea, vomiting, and urinary tract infection. She reported that her catheter has not been changed for some time. Urinalysis was consistent with UTI and she was admitted . Hospital Course: On admission, Foley was removed and replaced. She was empirically started on [MEDICATION NAME]. Her leukocytosis resolved and she rapidly improved .The plan is to empirically treat with ongoing antibiotics to finish out a 7-day course. Assessment and Plan: Problems: (1) Complicated UTI (urinary tract infection) A&P: Has chronic Foley which had not been changed since 11/16, changed in ED (emergency department) . On 5/8/17 at approximately 1:34 p.m., the administrative staff was made aware of the above findings. The facility staff involved in the above findings were not available for interview. Two of the employees were called multiple times on 5/8/17 at 3:20 p.m. and again at 5:24 p.m., but to no avail. The remainder of the staff involved were no longer employed at the facility. During the course of the survey from 5/2/17 through 5/9/17, no other information was provided regarding the Foley catheter being changed as ordered. 3. Facility staff did not follow physician orders [REDACTED].#7's supra-pubic catheter. Facility staff were to provide catheter care every shift and clean around the catheter with dermal wound cleanser, paint [MEDICATION NAME] around catheter every day. During an interview with Resident #7 he stated that he was providing his own catheter care and had all the supplies in his bedside table. Resident #7 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 03/20/2017. Resident #7 was assessed as being cognitively intact with a cognitive summary score of 15. On 05/02/2017 at approximately 3:00 p.m., Resident #7 was interviewed regarding his care at the facility. In the course of the discussion, Resident #7 was asked about his suprapubic catheter care. He stated, I do that myself .I have all the supplies here in my drawer. The clinical record was reviewed. The following orders were observed on the POS (physician order [REDACTED].Cleanse area around catheter with dermal wound cleanser, paint [MEDICATION NAME] around catheter every day. At approximately, 3:30 p.m., LPN (licensed practical nurse) #2 was interviewed. She was asked if Resident #7 was providing his own catheter care. She stated, No, we do that. LPN #2 was told that Resident #7 had his supplies in his bedside table for catheter care and had stated that he was doing it himself. The TAR (Treatment administration record) was reviewed for April. All of the entries for the catheter care and cleaning were wither circled as not done or left blank. LPN #2 was asked what the entries meant. She stated, It looks like it wasn't done. There were no entries on the back of the TAR explaining why the care had not been done. She was asked if an order was needed for Residents to provide their own care and to have items needed at their bedside table. She stated, Yes, and he should be assessed to determine if he can do it properly. The above information was discussed during a meeting with the administrator and the DON (director of nursing) on 05/03/2017. No further information was obtained prior to the exit conference on 05/09/2017.

Based on clinical record review and staff interview, the facility staff failed, for two of 25 residents in the survey sample (Residents # 4 and 10), to promptly notify the residents' attending physician of abnormal lab results, resulting in harm. 1. For Resident # 4, the facility staff failed to notify the resident's attending physician of a lab result that identified the resident as having a urinary tract infection [MEDICAL CONDITION], leading to a one month delay in treatment, which lead to the resident being hospitalized and intubated, which constituted harm. 2. For Resident # 10, the facility staff failed to notify the resident's attending physician of low blood sugar and the initiation of hypoglycemic measures. The findings include: 1. For Resident # 4, the facility staff failed to notify the resident's attending physician of a lab result that identified the resident as having a urinary tract infection [MEDICAL CONDITION], leading to a one month delay in treatment, which lead to the resident being hospitalized and intubated, which constituted harm. Resident # 4 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), a Significant Change, with an Assessment Reference Date (ARD) of 4/21/17, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Review of the Interdisciplinary Progress (Nurses) Notes revealed the following entry: 3/13/17 - 3:00 p.m. .Told this nurse she thought she had a UTI (Urinary Tract Infection) d/t (due to) burning with urination .MD notified. On 3/13/17, a telephone order from the Physician's Assistant was received for the following: UA (Urinalysis), EOS, [MEDICATION NAME] 200 mg (milligrams) PO (by mouth) tid (three times a day) x (times) 2 days. NOTE: [MEDICATION NAME] is an over the counter medication used to .relieve symptoms caused by irritation of the urinary tract such as pain, burning, and the feeling of needing to urinate urgently or frequently. Ref. www.WebMD.com. Further review of the Interdisciplinary Progress (Nurses) Notes revealed the following entries: 4/9/17 - 5:00 a.m. This nurse went in to resident room to give meds, resident asleep hard to waken. Once awake resident non-verbal, made eye contact, no facial grimacing. Resident breathing deep, skin sweaty. O2 (Oxygen) sat (saturation) 89, BS (Blood Sugar) 269, VS (vital signs) 103 - 136 (pulse), 32 (respirations), 134/58 (blood pressure). On call (MD) called was advised to send to ED (Emergency Department). 911 called, resident was taken to ED at 5:30 and RP (Responsible Party) notified. 4/9/17 - 11:10 a.m. Called AH ER (hospital emergency room ) for condition update. Resident to be admitted to ICU (Intensive Care Unit) on a breathing machine. Resident # 4's hospitalization came approximately one month after the UA lab the identified her as having a UTI. Review of the hospital Discharge Summary revealed the following: This is a [AGE] year-old female with a history of [MEDICAL CONDITION], obesity hypoventilatio[DIAGNOSES REDACTED], [MEDICAL CONDITION] disorder, diabetes, diastolic heart failure, who was brought to the emergency room with lethargy and unresponsiveness. In the emergency room had difficulty breathing. To maintain her sats, she was ventilated. She was found to have a urinary tract infection and was admitted to ICU. She dropped her blood pressure requiring pressors (a medication used to raise blood pressure). The patient was found to have 2 out of 4 blood cultures positive for strep mitis .She also grew E-coli and Proteus in the urine, [MEDICATION NAME] sensitive Resident # 4 was discharged back to the facility on [DATE] with [DIAGNOSES REDACTED]. A thorough review of Resident # 4's clinical record failed to reveal the results of the UA ordered on [DATE]. At approximately 1:00 p.m. on 5/8/17, at the request of the surveyor, LPN # 2 (Licensed Practical Nurse) was able to obtain a copy of the UA results via Fax from the laboratory that processed the urine sample. According to the UA report, Resident # 4 had a UTI. Asked if the resident's attending physician was notified of the UA results, LPN # 2 said, He was not notified. LPN # 2 was also asked about EOS. LPN # 2 explained that EOS is a protocol and stands for Enhanced Observation Order Set for suspected UTI. According to a blank copy of the EOS furnished by LPN # 2, the protocol included the following: 1) Obtain vital signs (BP, pulse, resp rate, temp, pulse ox) every 6 hours for 3 days. 2) Record fluid intake each shift for 3 days. 3) Notify medical director or provider on call if fluid intake is less than 1600 ml (milliliters) per day. 4) Notify the medical director or on-call provider if condition worsens or if no improvement by the next morning. 5) Contact the medical director or on-call provider with an update on the resident's condition daily. Asked if the EOS protocol was initiated for Resident # 4, LPN # 2 replied No. The findings were discussed at a meeting at 3:00 p.m. on 5/8/17 with the Interim Administrator, Director of Nursing, Corporate Nurse Consultant, and the survey team. 2. Facility staff failed to notify the physician of a blood sugar result of 25 for Resident #10. Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/10/2017. Resident #10 was assessed as moderately impaired in her cognitive status with a total cognitive score of 10 out of 15. During review of Resident #10's medical record on 05/03/17 at approximately 10:00 a.m. the following documentation was located in the clinical record. Interdisciplinary Progress Note dated 5/3/17 0500 (5:00 a.m.) I checked the resident's BS (blood sugar) and it was 25. I gave the resident a glucose tab (tablet) and pudding but she couldn't chew the tab. I then gave her the [MEDICATION NAME] shot to raise her BS. The final number was 85. I called her RP (responsible party) and will notify the MD (physician). LPN #2 (licensed practical nurse) was interviewed on 05/03/2017 at 10:55 a.m. LPN #2 stated, There are no standing orders for diabetes. I asked that when I got here. LPN #3 was interviewed on 05/03/2017 at 11:10 a.m. LPN #3 stated, Received in report of low blood sugar this morning. (Name) PA (physician assistant) knows. I rechecked; it was 127. I don't know if the on-call doctor was notified. PA was interviewed on 05/03/2017 at 11:15 a.m. PA stated, I was notified this morning at 9:08 when I came in. I don't know if the on-call doctor was notified or not. I am going to find out who was on-call last night and ask them myself. I will let you know. She also didn't get her bedtime snack last night. On 05/03/2017 at approximately 1:00 p.m. the PA entered the conference room and handed this surveyor the following note: 5-3-17 Noon To Whom It May Concern: In regard to (Name) Resident #10, I was notified at 0908 (9:08 a.m.) that her accuchek (blood sugar) was 25. Nursing gave her a glucose tab and pudding. She then was administered a [MEDICATION NAME] injection. I inquired about any input from the on call doctor but no one knew. I called over office (sic) and there was no call made to the on call physician to direct these orders. This incident occurred about 5:30 a.m. today. An accuchek at time of exam was 136 . The Administrator and DON (director of nursing) were notified of the above findings during a meeting with the survey team on 05/03/2017 at approximately 5:45 p.m. No further information was received by the survey team prior to the exit conference on 05/09/2017.

Based on family interview, staff interview, clinical record review and in the course of a complaint investigation, facility staff failed to ensure medications were available for administration for one of 25 residents in the survey sample, Resident #10 resulting in harm. 1a) Facility staff failed to administer long acting morphine per physician order [REDACTED]. 1b) Resident #10 had a physician order [REDACTED].#10 had not received any doses of the ordered Nystatin. The findings include: 1a) Facility staff failed to administer long acting morphine per physician order [REDACTED]. Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/10/2017. Resident #10 was assessed as moderately impaired in her cognitive status with a total cognitive score of 10 out of 15. Resident #10's clinical record was reviewed on 05/02/2017 at 2:15 p.m. The most recent POS (physician order [REDACTED].Morphine Sulfate ER 60 MG (milligrams) Tablet ER (extended release) For MS Contin Take 1 (one) Tab by Mouth Every 12 Hours for Pain . and an order dated 04/04/17 that stated: .Morphine Sulfate 15 MG Tablet For Morphine Sulfate Take 1 (one) Tab by Mouth every 4 (four) Hours As Needed for Pain . Review of the MARS (medication administration sheets) for Resident #10 included documentation that Resident #10 did not receive a dose of Morphine Sulfate 60mgER on [DATE] at 8:00 a.m. or 8:00 p.m. and also did not receive a dose on 05/01/17 at 8:00 a.m. The first dose the resident received since 04/29/17 at 8:00 p.m. was on 05/01/17 at approximately 10:00 p.m. Resident #10 was administered Morphine 15 MG by mouth on 04/29/17 at 7:40 p.m., 04/30/17 at 2:10 a.m. and 9:00 p.m. She received no other prn (as needed) doses according to documentation on the MAR. Resident #10 also received Vistaril 25 MG on 04/30/17 at 1:00 p.m. for anxiety. Resident #10's daughter was interviewed on 05/03/17 at 1:35 p.m. per her request. During this conversation Resident #10's daughter stated, .On Friday 4/28 a hard script was needed for Mom's Morphine 60 MG every 12 hours. She missed a dose on Saturday, 4/29 at 8:00 p.m., Sunday, 4/30 at 8:00 a.m., 8:00 p.m., and a dose on Monday, 05/01 at 8:00 a.m. (Name) the PA (physician assistant) gave the nurse a prescription at 10:30 a.m. on Monday, 05/01. The medicine came from the pharmacy at 10:30 p.m. Monday night. Her Monday bedtime dose was late. I spoke with the Sunday nurse working 7A-7P and she would not call the doctor. Nurse stated, 'Another doctor will not write a prescription for Morphine.' I, myself called the on-call doctor Sunday evening around 10:00 p.m. The on-call doctor was going to call the nurse at the facility to make sure Mom's Morphine would be delivered on Monday. The nurse working didn't know who the Administrator on-call was for the weekend. They gave Mom her prn Morphine over the weekend every four hours when she would take it. Mom called me Sunday evening, crying and stated: I can't take this pain much longer.' LPN #1 (licensed practical nurse) was interviewed on 05/03/17 at approximately 2:00 p.m. regarding the missed Morphine Sulfate ER doses. LPN #1 stated, A hard script was needed on Friday and not obtained. She (Resident #10) ran out of Morphine over the weekend. The Medical Director confirmed Resident #10 went into withdrawal from not having her long acting Morphine over the weekend during a conversation with this surveyor on 05/03/17 at approximately 3:00 p.m. Resident #10 was interviewed on 05/08/17 at 10:30 a.m. Resident #10 stated, I ran out of my long acting Morphine that weekend. My legs hurt so bad, they had constant pain, then turned to constant tingling up into my thighs. It was miserable. I didn't a take a lot of the other Morphine because it didn't help. The Administrator and DON (director of nursing) were informed of the above during a meeting with the survey team on 05/03/17 at 5:45 p.m. The DON stated, The hard script should have been obtained on Friday and the medicine ordered from the pharmacy and received at the facility before (Name) Resident #10 ran out of medicine. I don't know how that happened. This is a complaint deficiency. 1b) Resident #10 had a physician order [REDACTED].#10 had not received any doses of the ordered Nystatin. During review of Resident #10's clinical record on 05/03/17 at approximately 11:00 a.m., a physician telephone order was noted that stated, 5-1-17 1213 (12:13 p.m.) Nystatin Oral Suspension 100,000 units po (orally) tid (three times daily) x (times) 7 days. May swish and swallow. Indication: Thrush. During an interview with Resident #10's daughter on 05/03/17 at 1:35 p.m., the daughter mentioned her Mother had been ordered medicine for thrush a couple of days ago, but she hadn't received any. Review of the May 2017 MAR (medication administration record) revealed Resident #10 had not received any doses of the Nystatin Oral Suspension. On 05/04/17 at 8:35 a.m., LPN #1 (licensed practical nurse) was interviewed regarding Resident #10's Nystatin. LPN #1 stated, I spoke with the pharmacy and they said they called here on Tuesday asking for an order clarification, needing the amount of cc's (cubic centimeters) to dispense. They sent Nystatin last night, but sent cream not the swish and swallow. I have called the pharmacy this morning and they are sending out Nystatin swish and swallow out of the stat pharmacy. The Administrator and DON (director of nursing) were informed of the above information during a meeting with the survey team on 05/09/17 at approximately 1:35 p.m. No further information was received prior to the exit conference on 05/09/17.

Based on staff interview, clinical record review and in the course of a complaint investigation, facility staff failed to ensure one of 25 residents was free of a significant medication error resulting in harm, Resident #10. Facility staff medicated Resident #10 with the wrong dose of [MEDICATION NAME] which resulted in altered mental status, decreased oxygen saturations, and aspiration pneumonitis which resulted in an overnight stay at the hospital for opiod overdose. Findings included: Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/10/2017. Resident #10 was assessed as moderately impaired in her cognitive status with a total cognitive score of 10 out of 15. Resident #10's clinical record was reviewed on 05/02/2017 at 2:15 p.m. and again on 05/03/2017 at 11:00 a.m. Included in Resident #10's most recent POS (physician order [REDACTED].[MEDICATION NAME] ER 60 MG (milligrams) Tablet ER (extended release) For [MEDICATION NAME] 1 (one) Tab by Mouth Every 12 Hours for Pain . and an order dated 04/04/17 that stated: .[MEDICATION NAME] 15 MG Tablet For [MEDICATION NAME] Take 1 (one) Tab by Mouth every 4 (four) Hours As Needed for Pain . An Interdisciplinary Progress Note dated 4-6-17 Late Entry included the following: On Sunday 4/2, I took report from (Name) RN, (registered nurse) after I was moved from Unit 4, at aprox 1130 and I noticed around 1pm, (Name) Resident #10 falling asleep reading newspaper. I checked her oxygen level was 88% her O2 was placed on and her oxygen came up to normal levels, after being toileted she requested to go to bed. A little after that around 3 pm her daughter called because she had tried to call her on her cell phone and she did not answer. I reported the change of condition to her daughter, she stated 'well she doesn't sound right so I will see you in a little bit.' About an hour later she arrived and she spoke with me. I read her the vital signs which I obtained. I reported her temp was elevated and respirations low, and we both agreed that she appeared the same way she had the last time she had a UTI (urinary tract infection), including facial grimacing and she should be sent out to be checked. I read her the last lab result for U/A (urinalysis) C&S (culture and sensitivity) and it was negative for [MEDICATION NAME]. I spoke with (Name) transport and they informed me they had no availability until 9:30 p-10 pm. At that time I called (Name) and obtained claim # for transport at aprox 6:50 pm. (Name) Resident #10's daughter had told me that her 'mother had not felt right since she had taken that extra pain pill.' I went to check the MAR (medication administration sheet) and saw the medication error. I also asked (Name) another RN to do a respiratory assessment. At aprox 1915 (7:15 p.m.) the crew was still not here so I called the (unintelligible word) my ride # for (Name) ambulance service. At aprox 1930-1945 (7:30-7:45 p.m.) the crew arrived to transport (Name) Resident #10. (Name) Physician, nursing supervisor, (Name) Hospital ER (emergency room ) aware of all health issues of said pt. (patient). A second Interdisciplinary Progress Note dated 4/2/17 1945 (7:45 p.m.) included the following documentation: Nurse on front hall asked this nurse to assess lung fields of resident d/t (due to) medication error causing respiratory depression. This nurse auscultated all lung fields noting clear lung sounds w/respirations slow and shallow. Low respiratory count of 10-12 breaths per minute w/ periods of apnea .This nurse advised the nurse working front hall to admit resident to ER at (Name) hospital for further evaluation d/t decreased respiratory and the medication given causing the respiratory issues. History and Physical from the emergency room dated 4/2/17, seen by MD (physician) 21:14 (9:14 p.m.). .Chief Complaint: Altered Mental State; History of Present Illness: .She was sent from (Name) nursing home with concern for accidental overdose. Patient reportedly received 60mg (milligrams) long-acting [MEDICATION NAME] at 9AM and 11AM today. She became less responsive throughout the day and was eventually sent to the ED for evaluation. Patient is unable to provide and history and at best grimaces to pain .Differential Diagnosis: [REDACTED].ED Course/Procedures: Patient is a [AGE] year old female who presents from nursing facility with concern for accidental narcotic overdose. She is somnolent on arrival and, at best, grimaces to sternal rub . Primary Diagnosis: [REDACTED]. Hospitalist H&P dated 04/03/17 0312 (3:12 a.m.) HPI: presented to the ED from her nursing facility after she was found to be progressively somnolent. Briefly, the patient appears to have been in her usual state of health until earlier in the day when she inadvertently received twice the dose of her long-acting [MEDICATION NAME] which she takes for her chronic pain. It appears that she received 60 mg at 9 AM and a second dose of 60 in lieu of a as needed dose of her immediate release [MEDICATION NAME] at 11 AM. She was then noted to become increasingly somnolent and less responsive and so was sent to the emergency room .Assessment and Plan: (1)[MEDICAL CONDITION]: The patient presented with fever and leukocytosis of 17,000 in the setting of some mild [MEDICAL CONDITION] and what appears to be right lower lobe infiltrate meeting criteria [MEDICAL CONDITION]. At this time I still suspect that her source is [MEDICAL CONDITION] and further have clinical suspicion that the patient may have aspirated following and inadvertent [MEDICATION NAME] overdose resulting in an aspiration pneumonitis .(2) Aspiration pneumonitis: The patient has apparent right lower lobe airspace disease which in the setting of her presentation I believe represents a chemical aspiration pneumonitis .(4) Acute [MEDICAL CONDITION]: The patient was reportedly increasingly somnolent at the nursing facility however upon evaluation she is awake, alert and oriented x3 and so I believe that her acute [MEDICAL CONDITION] was due to an inadvertent [MEDICATION NAME] overdose which is now resolved . Nursing Facility H&P dated 4/4/17 1611 (4:11 p.m.), signed by the physician. Assessment/Plan: (1) Toxic [MEDICAL CONDITION] (2) Aspiration pneumonitis .Discussion: I saw the patient today to readmitted to our facility after a hospitalization for urinary tract infection, aspiration pneumonitis, and unintentional opiod overdose. The day prior to admission, the patient received 120 mg of extended release [MEDICATION NAME], which was an extra dose, instead of her 15 mg breakthrough dose. This resulted in lethargy and some respiratory depression, and she was sent to the emergency department. There, she was found have aspiration pneumonitis . A Medication Error Report dated 4/2/17 1105 AM included, Medication as ordered: prn [MEDICATION NAME] 15mg po (orally) Description of error .PRN Order for [MEDICATION NAME] 15mg; took 60mg tablet instead .Outcome to resident and care provided: Resident had a change to respiratory/alertness status. Sent to hospital and admitted for [MEDICAL CONDITION] .Type of Error: Wrong dose; Reason for Error: Misread error . Signed by RN that administered wrong medication and dose of [MEDICATION NAME]. The Administrator was asked for a copy of any investigation regarding the above incident. The investigation was received by this surveyor. The Administrator stated, She was given the wrong dose of her [MEDICATION NAME] and when the error was realized we sent her to the emergency room . Included in the investigation was the policy, Adverse Drug Reactions & Medication Discrepancy; Effective Date: 11/30/2014; Policy: Medication discrepancies and adverse drug reactions are documented and reported. Medication discrepancy refers to: a) Failure to administer, b) Administered at the wrong time, c) Administered wrong amount of medication, d) Administered to wrong resident, e) Administered through wrong route, f) Administered the wrong Medication. Adverse reaction refers to an unintended/undesirable effect that occurs as a result of giving a medication . Fundamentals of Nursing 6th Edition on page 841 states concerning medication administration, Standards are those actions that ensure safe nursing practice. To ensure safe medication administration the nurse should be aware of a nursing standard called the six rights of medication administration. All medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. (1) No further information was received by the survey team prior to the exit conference on 05/09/17. This is a complaint deficiency. (1) Potter, Patricia A. and Perry, Anne G. Fundamentals of Nursing. St. Louis: Mosby, 2005.

Based on staff interview, resident interview, clinical record review, Adult Protective Service (APS) review, and facility document review; the facility staff failed to ensure one of 25 residents was free from neglect. Resident #21 was not provided ADL (Activities of Daily Living) during her menstrual cycle. A CNA (certified nursing assistant) stuffed wipes inside the resident's vagina and between her legs during the resident's menstrual cycle resulting in psychological harm. The resident stated in an interview, I felt awful, humiliated and embarrassed ., I am so happy to be out of there I can't imagine having to go back there. The findings include: Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/17 was a quarterly assessment. The resident was assessed as being a fifteen (15) for cognitive skills; able to make needs known and independent in decision-making skills. The resident was discharged [DATE] On 5/8/17 at approximately 11:30 a.m., An APS report was reviewed regarding Resident #21 was not provided ADL care during her menstrual cycle and that the resident was found without care related to bathing and bloody wipes were found between the resident's legs. On 5/8/17 at approximately 1:34 p.m., the administrative staff was made aware of the APS report. The facility staff involved in the APS report were not available for interview. Two of the employees were called multiple times on 5/8/17 at 3:20 p.m. and again at 5:24 p.m., but there was no answer. The remainder of the staff involved were no longer employed at the facility. On 5/8/17 at approximately 12:45 p.m. during an interview with Resident #21, the resident stated that she was not provided ADL care from the facility staff during her menstrual cycle for approximately three days and that her bed was soaked with urine. Resident #21 stated that when she was finally cleaned a CNA (certified nursing assistant) found wipes stuffed inside my vagina and between my legs saturated with blood. During the interview Resident #21 stated to this Surveyor, Can I call you back I have an appointment I have to attend and I can finish telling you what happened when we talk again. This Surveyor agreed to continue the interview at a later time. On 5/9/17 at approximately 9:07 a.m. Resident #21 was interviewed regarding the above findings of not being provided ADL care during her menstrual cycle and having to lie in bed soaked with urine for three days. Resident #21 stated, I felt awful, humiliated and embarrassed when the CNA pulled the covers back and discovered blood on the sheets and between my legs Resident #21 further stated, When the CNA pulled the covers back to see the look on her face was humiliating. Resident #21 stated, It is enough to have someone change you because you can't do it yourself but to have someone leave you laying in blood is disgusting. Resident #21 then stated, The worst part of it all was I had to go to my care plan (CP) meeting and repeat this in front of my parents and my husband, it was degrading. When you are at the mercy of someone else it is just humiliating. I am so happy to be out of there I can't imagine having to go back there. On 5/9/17 at approximately 9:20 a.m., the CNA involved in the above incident was called three times but no answer. On 5/9/17 the investigation and witness statement was reviewed to include the following: Witness Statement: 1/17 LPN-Called by aides doing shower to shower room. Bloody wipes noted, advised by aides they were between Residents legs at vagina area. Resident advised they have been there since 3-11 (second shift). I wasn't changed all night (referring to her menstrual pad) . Resident also states. My gowns not been changed for 3 days. (ADON-assistant director of nursing named) made aware . 1/17/17 CNA-On Tuesday January 17th around 1300 (1:00 p.m.) (Resident named) was scheduled for a shower. As I went to her room and got her things I brought her to the shower room. As I was preparing myself, getting all my things together, I noticed something between her legs like a napkin or her brief, I asked her what was between her legs she told me oh probably the pad I was laying on, So I put gloves on and pulled her in the shower stall and spread her legs apart and pulled a wipe from just sitting between her legs, that had menstrual blood on it. She was telling me she was on her period, and was a little shocked by what she had seen. As I start the water to do perineal care I pulled two or three wipes folded together from between her legs also, about that time I just walked back from the trash the other shower aide walked in. I asked (Aide named) to get the unit manager so I can show her. (Resident named) was concerned so I try to calm her down and informed her I got the unit manager 1/26/17 CNA- .The incident where they said the wipes were left in between her legs. The other aide asked if I would her her (sic) and she placed the wipes there to clean her. I'm not sure if they were left there or not. Because I did see the girl pull them out. On 5/9/17 at approximately 1:34 p.m., the administrative staff were made aware of the above findings. A copy of the abuse policy was requested and reviewed to include the following: Policies and Procedures: Subject: Resident Abuse .Revision Date: 2/1/17 Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed .

Based on staff interview, resident interview, APS (Adult protective services) review and clinical record review, the facility staff failed to promote the dignity and respect for three of 25 residents, which resulted in harm for one of 25 resident's Residents #21. The resident stated in an interview, I felt awful, humiliated and embarrassed ., I am so happy to be out of there I can't imagine having to go back there. The remaining residents were Resident #4, and #10 and the facility staff failed to ensure a dignified dining experience in the facility. 1. Resident #21 was left lying in a bed soiled with urine and bloody wipes, from the resident's menstrual cycle, were found between the resident's legs during ADL (activities of daily living) care resulting in psychological harm. 2. The facility staff failed to promote dignity and respect for one of 25 residents in the survey sample: Resident # 4. Resident # 4 was left sitting in urine and feces for approximately two hours, and was also left undressed and uncovered by an open window. 3. Resident #10 was put to bed on one occasion in only a bra and shirt and on another occasion in only a brief. 4. The facility failed to ensure a dignified dining experience in 22 resident rooms and the Restorative Dining Room. The findings include: 1. Resident #21 was left lying in a bed soiled with urine and bloody wipes, from the resident's menstrual cycle, were found between the resident's legs during ADL (activities of daily living) care resulting in psychological harm. Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/17 was a quarterly assessment. The resident was assessed as being a fifteen (15) for cognitive skills; able to make needs known and independent in decision-making skills. The resident was discharged [DATE] On 5/8/17 at approximately 11:30 a.m., An APS report was reviewed regarding Resident #21 was not provided ADL care during her menstrual cycle and that the resident was found without care related to bathing and bloody wipes were found between the resident's legs. On 5/8/17 at approximately 1:34 p.m., the administrative staff was made aware of the APS report. The facility staff involved in the APS report were not available for interview. Two of the employees were called multiple times on 5/8/17 at 3:20 p.m. and again at 5:24 p.m., but there was no answer. The remainder of the staff involved were no longer employed at the facility. On 5/8/17 at approximately 12:45 p.m. during an interview with Resident #21, the resident stated that she was not provided ADL care from the facility staff during her menstrual cycle for approximately three days and that her bed was soaked with urine. Resident #21 stated that when she was finally cleaned a CNA (certified nursing assistant) found wipes stuffed inside my vagina and between my legs saturated with blood. During the interview Resident #21 stated to this Surveyor, Can I call you back I have an appointment I have to attend and I can finish telling you what happened when we talk again. This Surveyor agreed to continue the interview at a later time. On 5/9/17 at approximately 9:07 a.m. Resident #21 was interviewed regarding the above findings of not being provided ADL care during her menstrual cycle and having to lie in bed soaked with urine for three days. Resident #21 stated, I felt awful, humiliated and embarrassed when the CNA pulled the covers back and discovered blood on the sheets and between my legs Resident #21 further stated, When the CNA pulled the covers back to see the look on her face was humiliating. Resident #21 stated, It is enough to have someone change you because you can't do it yourself but to have someone leave you laying in blood is disgusting. Resident #21 then stated, The worst part of it all was I had to go to my care plan (CP) meeting and repeat this in front of my parents and my husband, it was degrading. When you are at the mercy of someone else it is just humiliating. I am so happy to be out of there I can't imagine having to go back there. On 5/9/17 at approximately 9:20 a.m., the CNA involved in the above incident was called three times but no answer. On 5/9/17 the investigation and witness statement was reviewed to include the following: Witness Statement: 1/17 LPN-Called by aides doing shower to shower room. Bloody wipes noted, advised by aides they were between Residents legs at vagina area. Resident advised they have been there since 3-11 (second shift). I wasn't changed all night (referring to her menstrual pad) . Resident also states. My gowns not been changed for 3 days. (ADON-assistant director of nursing named) made aware . 1/17/17 CNA-On Tuesday January 17th around 1300 (1:00 p.m.) (Resident named) was scheduled for a shower. As I went to her room and got her things I brought her to the shower room. As I was preparing myself, getting all my things together, I noticed something between her legs like a napkin or her brief, I asked her what was between her legs she told me oh probably the pad I was laying on, So I put gloves on and pulled her in the shower stall and spread her legs apart and pulled a wipe from just sitting between her legs, that had menstrual blood on it. She was telling me she was on her period, and was a little shocked by what she had seen. As I start the water to do perineal care I pulled two or three wipes folded together from between her legs also, about that time I just walked back from the trash the other shower aide walked in. I asked (Aide named) to get the unit manager so I can show her. (Resident named) was concerned so I try to calm her down and informed her I got the unit manager 1/26/17 CNA- .The incident where they said the wipes were left in between her legs. The other aide asked if I would her her (sic) and she placed the wipes there to clean her. I'm not sure if they were left there or not. Because I did see the girl pull them out. On 5/9/17 at approximately 1:34 p.m., the administrative staff were made aware of the above findings. 2. The facility staff failed to promote dignity and respect for one of 25 residents in the survey sample: Resident # 4. Resident # 4 was left sitting in urine and feces for approximately two hours, and was also left undressed and uncovered by an open window. Resident # 4 was admitted to the facility 4/7/15 with a readmission date of [DATE]. The most recent MDS (minimum data set) was a significant change in status review and had Resident # 4 assessed as being cognitively intact. On 5/9/17 at 10:30 a.m. this surveyor conducted a resident interview with Resident # 4. Resident # 4 was included in the survey sample as part of an APS (adult protective services) report. The report included Resident # 4 had called the APS worker to report she had been left sitting in urine for approximately 2 hours. Resident # 4 reported that a CNA (certified nursing assistant) had come into the room earlier, turned off the call light telling the resident she would be right back; however, she did not return, and by this time the resident had a bowel movement (BM) as well. When the APS worker arrived at the facility at 10:45 a.m., staff were just leaving the room after cleaning the resident, but had left her with no briefs on as she was having multiple BM's and staff did not want to put a brief on her. The report also documented the resident had not only been left without a brief on, but was not clothed as well; even though the privacy curtain was pulled, the resident's bed is next to a window, which had no curtains or blinds pulled. Resident # 4 was asked about the event, and she stated yes, it most certainly happened and that it had made her feel really bad. Resident # 4 went on to say I'm sitting in urine right now; I put my call bell on at 7:00 a.m. and I am still waiting to be changed. They (the CNA staff) have left this basin of soap and water and told me to wash my top half; but I can't .I need help. I am weak in my hands and cannot squeeze the wash cloth out to wash myself. The medication nurse brings my cup of pills in, sets them on the table and leaves the room. I try to take them, but I dropped the cup in between my legs and couldn't reach it. The nurse came back in the room and asked if I had taken my pills and I showed her where they were. She got them and handed me the cup and said 'Here- take your pills.' If I try to tell her I can't, and I need help, she just looks at me and tells me I'm robbing her of her joy! I spoke with the unit manager about a week or so ago about the problem of getting someone in here to change me around 7 .she said she would tell the oncoming day shift to come and change me first thing that has yet to happen. I take a fluid pill around 5:30 a.m. and by 7:00 a.m., it kicks in and I am soaked! When I put my call bell on, they come in, turn it off, tell me they will be right back, and never come back. When I tried to explain that I am uncomfortable and wet, they tell me how busy they are, they have to deliver breakfast trays, feed other residents, and tell me to just hold it! I can't do that; when that fluid pill kicks in, that's it! They came in one day and took me down to lunch without changing my brief; I felt not only uncomfortable, but felt pretty bad and embarrassed to go to the dining room wet like that! Resident # 4 also told this surveyor that morning care wasn't given in time for her to attend activities she would like to attend, most specifically her devotions. Toward the end of the interview, the medication nurse (identified as licensed practical nurse (LPN) # 7) came into the room and asked the resident if she would like her pain medicine. Resident # 4 stated she would LPN # 7 was then asked about someone helping the resident finish her bath and get dressed. LPN # 7 looked at Resident # 4 and stated Doesn't therapy come in and work with you on that? Resident # 4 stated Not anymore; I was discharged from therapy last week. And my hands are too weak to squeeze out this washcloth; I need help. LPN # 7 then left the room. This surveyor and Resident # 4 then concluded the interview, and this surveyor was behind LPN # 7 as she was walking up the hall. When LPN # 7 got to the nurses' station, she looked at a CNA and stated Can you go finish (name of resident) bath? She's done the top half; need to finish her bottom half and get her dressed. At that time, this surveyor, who had not been noticed by LPN # 7, spoke up and told the CNA that Resident # 4 had not finished the top half, and repeated what Resident # 4 had told LPN # 7. The CNA then went and helped Resident # 4. The administrator, DON (director of nursing), and regional nurse consultant were informed of the above findings 5/9/17 during a meeting with facility staff beginning at 1:30 p.m. No further information was provided prior to the exit conference. THIS IS A COMPLAINT DEFICIENCY. 3. Facility staff failed to promote dignity and respect while caring for Resident #10's ADL's (activities of daily living). Resident #10 was put to bed on one occasion in only a bra and shirt and on another occasion in only a brief. Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/10/2017. Resident #10 was assessed as moderately impaired in her cognitive status with a total cognitive score of 10 out of 15. Resident #10's daughter was interviewed on 05/03/2017 at 1:35 p.m. in regards to concerns voiced in a complaint sent to the OLC (office of licensure and certification). The daughter stated, On January 27, 2017, Mom was put to bed in only a bra and shirt. She has nightgowns here to wear. On March 03, 2017, Mom's CNA (certified nursing assistant) put her to bed in only a brief. A basin of water was left by the bedside until 1:00 a.m. when the night shift aide found it. The evening aide told me she forgot to come back and dress Mom. I don't know why the aide left in the middle of her nighttime care. Mom was drowsy during that day and at bedtime she got a prn (as needed) pain pill and she was very sleepy. It was two different aides and when I spoke to administration about it, their solution was to move the two aides to another unit instead of addressing the problem. On 05/08/2017 at 10:30 a.m., Resident #10 was interviewed and confirmed the above information. Resident #10 stated, They put me to bed around 8:00 p.m. When I get my nighttime medicine and sometimes an extra pain pill I get very sleepy. I don't know why they put me to bed like that. The night I was put to bed in only a brief the nighttime aide found me like that and dressed me for bed. No reference to either incident was included in the clinical record. The Administrator and DON (director of nursing) were informed of the above incidences and interviews during a meeting with the survey team on 05/08/2017 at approximately 1:35 p.m. No further information was received by the survey team prior to the exit conference on 05/09/2017. This is a complaint deficiency. 4. The facility failed to ensure a dignified dining experience in 22 resident rooms and the Restorative Dining Room. At approximately 8:10 a.m. on 5/3/16, observation of the Breakfast meal served in the Restorative Dining Room found six residents were seated at three tables. At each of the three tables, staff assisting the seated residents to eat had turned the plate covers upside down and had placed dining debris, including straw sleeves, empty salt and pepper packets, empty sugar packets, empty butter packets, and other items in the plate lids. Observations on Unit Three found 12 rooms with a plate lid containing dining debris on one of the beds in each of the rooms, and three rooms with plate lids containing dining debris on both beds in each room. In three rooms, plate lids with dining debris were observed on overbed tables where residents were eating. Observations on Unit Two found six rooms with a plate lid containing dining debris on one of the beds in each of the rooms, and three rooms with plate lids containing dining debris on overbed tables where residents were eating. The findings were discussed at a meeting at 3:00 p.m. on 5/8/17 with the Interim Administrator, Director of Nursing, Corporate Nurse Consultant, and the survey team.

Based on observation, resident interview, staff interview, and clinical record review facility staff failed to ensure one of 22 residents in the survey sample, Resident # 15, received a meal after the administration of insulin resulting in a severe hypoglycemic event (harm) requiring emergency treatment to raise the resident's blood sugar level. Facility staff also failed to follow physician orders for two of 22 residents: Resident # 10 and # 12, and failed to obtain accurate physician orders for two of 22: Residents # 11 and # 19. 1. Staff failed to ensure Resident # 15 ate lunch and/or a snack immediately after the administration of scheduled insulin. 2. a. Resident # 10 did not have TED (compression stockings) applied per physician order. b. Resident # 10's blood pressure and pulse was not obtained per physician order. 3. Resident # 12 did not have TED hose applied per physician order. 4. Resident # 11 did not have accurate physician orders for wound care or isolation. 5. Resident # 19's PICC line (peripherally inserted central catheter) was flushed without a physician order. Findings include: 1. Staff failed to ensure Resident #15 ate lunch and/or a snack immediately after the administration of scheduled insulin and then transported the resident out of the facility for a physician appointment. While at the physician's office the resident became unresponsive and was assessed with [REDACTED]. Resident # 15 was admitted to the facility 8/3/11 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 3/11/16 and had Resident # 15 scored as having moderate cognitive impairment with a total summary score of 11 out of 15. On 5/16/16 at 2:30 p.m. a group interview was conducted with Resident # 15 in attendance. During the interview, while discussing facility food, Resident # 15 told the surveyor conducting the group interview of an event that occurred approximately three weeks ago when he had gone to a doctor appointment without eating lunch. He stated he passed out at the doctor's office and was sent to the emergency room for low blood sugar. The resident further stated he felt the dining room was short staffed that day, and that was why he did not get lunch. The clinical record was reviewed 5/17/16 at 3:05 p.m. A physician order dated 4/10/16 documented to Increase [MEDICATION NAME] to 18 u(units) three times a day. The MAR (medication administration record) was reviewed and revealed Resident # 15 was administered 18 u at 11:30 am 4/11/16. The MAR indicated [REDACTED]. (A normal range for blood sugars is 70-100). [MEDICATION NAME]is a fast acting insulin, and once administered, a meal should be eaten within 5 to 10 minutes. A physician progress notes [REDACTED]. This occurred because his appointment was shortly after lunch, but because of a delay in the meal delivery, he received his insulin but then left for his appointment before he had lunch. We will change his mealtime insulin order so that he is administered insulin only after he has eaten. A telephone order dated 4/11/16 documented Make sure resident eats before [MEDICATION NAME] is given. Further review of the clinical record revealed a report from the nephrology clinic dated 4/11/16. The report documented Below are the relevant portions of my evaluation. Patient presented to visit today lethargic. Found to have blood sugars in the 20's. Given po(by mouth) soda and crackers, but became too lethargic to take PO. Given [MEDICATION NAME] IM(intramuscularly) and IV(intravenous) started. Patient given 1/2 amp of D50 (unit of measure to equal 50 milliliters of [MEDICATION NAME], or sugar, in water). Patient became alert and awake. Patient states he did not eat lunch. EMS called. Patient taken to ED for assessment The nursing notes were then reviewed for documentation of the event on 4/11/16. There was no entry in the nursing notes for that date; there was an entry dated 4/9/16, and the next entry was not dated until 5/11/16. An emergency room (ER) report was not located in the clinical record, and this surveyor requested a copy from medical records. A few moments later medical records staff presented this surveyor with the ER report. The ER report documented CC (chief complaint): Low blood sugar. The patient is a [AGE] year old male got some insulin at lunch (sic), but he did not get a chance to eat and was sent to a doctor's appointment. He therefore had a sugar of 24 and was altered. He got glucose. His sugar went up above 100 .he is hungry . On 5/17/16 at 4:00 p.m. LPN (licensed practical nurse) # 4 was asked about the incident with Resident # 15 on 4/11/16. LPN # 4 stated Well, I took him down to the dining room a little before 12; the dietary manager was aware he had an appointment. The trays were being served by the time transport arrived; I thought the resident had already eaten, he didn't tell me he hadn't. I just told him it was time to go and he said 'OK'. Resident # 15 was interviewed 5/18/16 at 8:00 a.m. Resident # 15 was asked about the incident of [DIAGNOSES REDACTED]. He stated The nurse (identified as LPN # 4) gave me my insulin and then took me to the dining room. She told them (dining staff) that I had an appointment and needed my tray; she told them twice. I sat there almost an hour, no lunch, and when the nurse came to get me to leave for my appointment, I told her I didn't get my lunch. She asked again for my food, but the transport was there and ready to go, so I went on to my appointment. I don't remember much after that except when my sugar dropped I was knocked out. On 5/18/16 at 8:15 a.m. the dietary manager was interviewed. The dietary manager stated he was not aware of any problem with Resident # 15's lunch on 4/11/16. He stated he was aware of the resident needing an early breakfast tray, but was not aware of the need for an early lunch tray. This surveyor asked if a resident needed an early tray how that was communicated to the dining staff. The dietary manager stated nursing was to use a dietary communication form. The dietary manager stated he did not recall if a form had been received for Resident # 15, but he would check. He further stated that at that time, there was not an issue with being short staffed; a CNA (certified nursing assistant), and a member of administration is usually in the dining room to help pass out trays. The dietary manager was asked if there had been a communication form sent for the resident; he stated he would see what he could find out. On 5/18/16 at 8:35 a.m. the administrator and DON (director of nursing) were interviewed. The DON was asked how nursing communicates to the dietary department if a resident needed an early tray. The DON stated the nurse would call or walk up to the dining room to inform staff. The DON and administrator asked if they were aware of the incident with Resident # 15 on 4/11/16, and that he had been sent to the emergency room . They were also asked if an investigation had been done. The administrator and DON stated they were not aware anything had happened with the resident, therefore an investigation had not been done. This surveyor then informed the DON there was no documentation in the resident's record about the event; There was an entry dated 4/9/16, and the next entry was dated 5/11/16. The DON stated she was not working during the time the incident occurred with Resident # 15 as she was out on medical leave, but the ADON (assistant director of nursing) had been in charge at that time. The DON further stated LPN # 4 had not been aware the resident had gone to the ER for low blood sugar until 5/17/16 when this surveyor interviewed her. The DON stated when she asked LPN # 4 why she did not document the event, the nurse stated she got busy and forgot. On 5/18/16 at 9:15 a.m. the ADON was interviewed. The ADON stated I was not aware of what happened with Resident # 15 until yesterday; had I known I would have flipped. I'm 'old school' nursing and ex military if I had known the resident hadn't had any food after being administered insulin I would have either made transport wait, or rescheduled the appointment. If someone's been given insulin, the nurse is responsible to make sure they eat. On 5/18/16 at 11:15 a.m. the DON told this surveyor LPN # 4 left the prior to the residents return to the facility and did not know what happened until yesterday. The DON further stated Nursing should document an even as soon as it happens, or as soon as possible, and should assess the resident. On 5/18/16 at approximately 1:30 p.m. upon return to the conference room, this surveyor found additional ER notes for Resident # 15 on the table. There was also a copy of a dietary communication form dated 4/10/16 which documented Needs early lunch 4/11/16 due to an appt. Leaving at 12:30 p.m. The form was signed by the unit manager. The ER notes documented Transfer Comment: Sent w/family to NH at this time: report called to (name of facility staff) LPN. At that time, this surveyor went to the DON's office to ask about the report. The DON stated The nurse the report was called to was the unit manger at that time; she's no longer here. I can't say why she did not make a note about the events of the resident that day. No further information was presented prior to the exit conference. 2. a. Resident # 10 did not have TED (compression stockings) applied per physician order. Resident # 10 was admitted to the facility 8/29/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 5/2/16. Resident # 10 was coded as having severe cognitive impairment with a total summary score of 02 out of 15. The clinical record was reviewed 5/16/16 at 1:50 p.m. The current POS (physician order summary) included an order carried forward from 1/30/14 for TED hose on in AM/off in PM. On 5/17/16 at 8:25 a.m. Resident # 10 was observed in bed with white foot socks on both feet; the TED hose were not on per order. Several random observations of Resident # 10 revealed the TED hose not on per order. On 5/17/16 at 10:40 a.m. LPN (licensed practical nurse) # 2 was asked about the resident's TED hose. LPN # 2 stated Well, they were taken off her last night; they may not be on if they had to washed and not back up to the room yet. LPN # 2 was then asked when the TED hose would be applied according to the way the order was written. LPN # 2 replied Usually we put them on when we get her up. LPN and this surveyor then went to Resident # 10's room. LPN # 2 told the resident she was going to look in her drawer for the hose, and the resident nodded her head to indicate yes. The TED hose were located in the resident's drawer, and LPN # 2 stated I'll put them on her right now. On 5/17/16 at 2:00 p.m. during a meeting with facility staff the DON (director of nursing) was informed of the above findings, and asked about the order as written. She was also asked when the TED hose should be applied. The DON stated When morning care is provided, the hose should go on; when evening care is provided, they should come off. No further information was provided prior to the exit conference. 2.b. Resident # 10's blood pressure and pulse was not obtained weekly as ordered by the physician. The clinical record was reviewed 5/16/16 at 1:50 p.m. The current POS (physician order summary) included an order carried forward from 1/30/14 for Blood pressure and pulse every week on Thursday. The record was then reviewed for documentation of the blood pressure and pulse. The MAR (medication administration record) for December 2015 through May 2016 included the order and also had all days crossed out except Thursdays, which were left open for staff to document the readings. The MAR indicated [REDACTED]. On 5/16/16 at 2:25 p.m. LPN (licensed practical nurse) # 1, who was the unit manager was asked about the documentation, and if the readings were documented anywhere else in the record or in a vital sign book. The unit manager stated I'm not sure; I just started here so let me check. At that time, LPN # 4 walked up and stated I heard your question. The only place the blood pressure and pulse would be recorded is on the MAR. The administrator, DON (director of nursing) and regional nurse consultant were informed of the above findings during a meeting with facility staff 5/18/16. The nurse consultant stated I thought there was a flow sheet behind the nurses' notes for vitals. This surveyor informed her that LPN # 4 stated the MAR indicated [REDACTED]. No further information was provided prior to the exit conference. 3. Resident #11's clinical record did not contain complete and accurate orders for wound care and did not contain orders for contact isolation. Findings were: Resident #11 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 05/03/2016. Resident #11 was assessed as having a cognitive summary score of 12, indicating moderate impairment with her cognitive status. On 05/16/2016 at approximately 3;40 p.m. Resident #11's observed her sitting up in a chair, her podus boots were in place. There was an isolation cart outside her room. One of the CNA's (Certified Nursing Assistants) in the hallway was asked why Resident #11 was on isolation and what type of isolation it was. She stated, She is on contact isolation for [MEDICAL CONDITION]. The clinical record was reviewed on 05/16/2016. There were no current orders for isolation. The most recent order regarding isolation was dated 05/04/2016: D/C (discontinue) contact isolation. Further review of the physician order sheet dated 05/01/2016-06/30/2016 and signed by the physician on 05/03/2016, contained the following order for wound care: 4/13/2016 Tx (treatment) Cleanse left lower extremity wound with dermal wound cleanser, pat dry, apply [MEDICATION NAME], cover with non-adhesive pad and [MEDICATION NAME], wrap with kerlix every day and as needed. The TAR (treatment administration record) was reviewed. The treatment listed on the TAR was Clean LLE (left lower extremity wound) with DWC (dermal wound cleanser) may shower and/or cleanse wound with mild soap and water. Iodosorb gel (or [MEDICATION NAME] if no iodosorb available) Cover dressing with dry gauze and wrap with Kling. Do not put tape directly on skin. Change dressing QOD (every other day). The entry was dated 05/04/2016. On 05/17/2016 at approximately 8:30 a.m., the DON (director of nursing) was interviewed regarding isolation and wound care orders for Resident #11. She reviewed the record and stated, The resident should be on contact isolation right now and there should be an order for [REDACTED]. The DON came to this surveyor at approximately 9:30 a.m. and stated, the orders on the physician's order sheet are incorrect, the orders from the wound clinic are the ones that are on the TAR. The nurses should have made the change on the physician's order sheet when it was reviewed. Prior to exit the DON presented this surveyor with clarification orders written regarding the wound care and the isolation. No further information was obtained prior to the exit conference on 05/18/2016. 4. Resident #12's did not have thigh high anti-embolitic (TED) hose applied per physician order on 05/17/2016. Findings were: Resident #12 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: urinary tract infections, hypertension, [MEDICAL CONDITION], hip pain, fall history, [MEDICAL CONDITION], and dementia. The most recent MDS (minimum data set) was a significant change assessment with an ARD (Assessment reference date) of 03/30/2016. Resident #12 was assessed as having a cognitive summary score of 03, indicating severe impairment with her cognitive status. The care plan was reviewed on 05/17/2016. The current POS (physician order sheet) dated 05/01/2016-06/30/2016 contained the following orders but not limited to: Clip alarm to bed/chair every shift and Patient to wear thigh high venous compression stockings (TED Hose) on every morning off at bedtime. On 05/18/2016 at approximately 10:30 a.m., Resident #12 was observed up in her wheelchair in the hallway. She was dressed for the day in long pants, a shirt and sweater. She was wearing tennis shoes. LPN (licensed practical nurse) #2 was in the hallway with Resident #12 and was pushing her towards her room. This surveyor asked LPN #2 to pull up Resident #12's pants leg so her physician ordered TED hose could be observed. She stated, She doesn't have them on .I am taking her to her room now to put them on her. LPN #2 was asked why the TED hose had not yet been applied. She stated, I don't know. LPN #2 and CNA #1 put the TED hose on Resident #12. CNA #1 was asked if she was caring for Resident #12 She stated, No and directed this surveyor to CNA #2 who was also in the resident's room assisting the roommate. CNA #2 was interviewed regarding the TED hose. She stated, I didn't know that she had them. CNA #1 was asked if she had taken care of Resident #12 before. She stated, Yes. CNA #2 was asked how she got report and how did she know what to do for her residents. She stated, We make rounds with the night shift CNAs and they give us report. CNA #1 added, Night shift probably didn't know about the TED hose because they don't put them on or take them off, so they wouldn't tell us about them. CNA #2 was asked if there was a care plan or Kardex for the CNAs to use. She stated, Yes, it's at the nurse's station. CNA #2 was asked if she had reviewed the care plan for Resident #12 prior to providing care on that day. She stated, No. The Kardex care plan was reviewed. The top of the Kardex had the following information handwritten in: Updated 12/27/2015 The Kardex did not contain information regarding the use of TED hose for Resident #12. The DON (director of nursing) and the administrator were notified of the above information on 05/17/2016 during an end of the day meeting. 5. The facility staff failed to ensure physician's orders were obtained prior to changing a dressing and flushing a midline intravenous catheter for Resident # 19. Findings include: Resident # 19 was admitted to the facility originally on 05/27/09, with the most current readmission on 05/22/15. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with short and long term memory impairment and severe impairment in daily decision making skills. The resident was additionally assessed as requiring total assistance from staff for all ADL's (activities of daily living), including eating and taking fluids. During the closed record review on 05/17/16, Resident # 19's admission/readmission assessment dated [DATE] and timed 6:05 p.m. was reviewed. The admission assessment documented that the resident had a PICC (peripherally inserted central catheter) in the left upper extremity, with no redness/swelling/drainage and that the device was 10 cm (centimeters in length). The assessment also documented that the resident was receiving IV (intravenous) fluids only through the device. Resident # 19's admission physician's orders dated 05/22/15 were then reviewed. The admission orders [REDACTED] .Midline intravenous fluid of: D5 1/2 normal saline .to run at 50 cc (cubic centimeters) per hour .no stop date . The admission physician's orders also documented, .infusion site-check every shift .Dressing to intravenous site-change every .intravenous tubing change every . These two areas on the admission orders [REDACTED]. The resident's admission care plan dated 05/22/15 was then reviewed. The care plan was a generic, fill in the blank, check off type of template, which would be marked if indicted for the resident. The care plan documented: .dehydration/fluid maintenance: encourage fluids unless otherwise specified, monitor for S/S (signs and symptoms) of dehydration, labs as ordered, hydration protocol, monitor for [MEDICAL CONDITION] .meds as ordered, pain management, comfort care . No information was included on the resident's admission care plan regarding the midline catheter or the care and maintenance thereof. Resident # 19's MAR's (medication administration records) and TAR's (treatment administration records) were then reviewed for May 2015 and June 2015. The May TAR's documented with a hand written entry, Picc line dsg (dressing) change Q (every) 7 days 7p-7a (7 pm to 7 am shift) 05/22/15 . The start date on the TAR was 05/22/15, the dressing was documented as changed on 05/22/15 (the date of admission) and on 05/28/15, seven days later. No physician's order for this dressing change could be located in the resident's clinical record. A printed POS (physician's order set) dated 06/01/15 through 07/31/15 was then reviewed. This POS was reviewed and signed by a nurse's signature and dated 05/30/15. The physician had not signed this POS. On this POS, a hand written entry documented, PICC line L (left) arm change dsg (dressing) Q (every) 7 days & (and) PRN (as needed) . No other physician's orders were on this POS regarding the midline catheter. The resident's nursing notes were then reviewed. A nursing noted dated 05/30/15 and timed 7a-7p (no actual time) documented: Alert and difficult to arouse, resident is unable to communicate her needs resident has a midline to her left upper arm, when this writer was flushing the this (sic) per order it was noted that area was leaking, area no longer intact. Also lab results called into MD (medical doctor) BUN (blood urea nitrogen) level is 3. MD stated to d/c (discontinue) fluids at this time . No physician orders could be located to flush the midline catheter. The next and last nursing note, dated 06/02/15 documented that Resident # 19 was sent to the ER (emergency department) and was not readmitted to the long term care facility. A facility policy was requested on the care and maintenance of PICC/Midline catheters on 05/18/16 at approximately 8:30 a.m. A policy was presented by the DON at 10:00 a.m. The policy, 'The nurse's infusion manual for long term care facilities' documented, .A physician/licensed independent practitioner order is required to flush a catheter .the order must include: flushing agents, strength/concentration, volume, frequency, .assessment is to include, but is not limited to, the absence or presence of: .drainage, swelling or induration, change in skin temperature .integrity of dressing .assess site for complications .notify physician .as needed .documentation in the medical record includes, but is not limited to .date and time, site assessment, length of external catheter, reason for dressing change, resident response . The DON (director of nursing) was interviewed regarding the above information in a meeting with the survey team on 05/18/16 at 11:25 a.m. The DON voiced that residents should have immediate orders for care when admitted and if not, the nurses should follow up to ensure that orders are received for care of a resident. The DON could not explain why staff would change a dressing without a physician's order, or flush an intravenous line without orders. The DON further voiced that she was not at the facility when Resident # 19 resided at the facility, but would look information regarding the above concerns. On 05/18/16 at approximately 1:30 p.m., the administrator and DON were again made aware of the above concerns in a meeting with the survey team. The facility staff were asked for assistance regarding any additional information or documentation related to the above. At 2:10 p.m., the administrator and DON voiced that no additional information or documentation was found to evidence that Resident # 19 had physician admission orders [REDACTED]. No further information or documentation was presented prior to the exit conference on 05/18/16 at 3:15 p.m.

Based on resident interview, group interview, staff interview, facility document review and clinical record review, the facility staff failed to safely transport one of 22 residents (Resident #16) resulting in a fracture (harm) of the resident's distal femur. Facility staff also failed to promptly respond to call bells as required in the plan of care for fall/injury prevention for two of 22 residents in the survey sample (Resident #9 and #14). In addition the group interview revealed slow call bell response throughout the facility. 1. Resident #16, a paraplegic, was transported in a wheelchair without leg or foot rests. During the transport the resident's right foot and leg were caught under the wheelchair resulting in a fracture of the resident's right distal femur at the knee. The resident was hospitalized for [REDACTED]. 2. An interview with a group of cognitively intact residents reported ongoing issues with slow call bell response in the facility. Residents #9 and #14 reported slow call bell response from the night shift on unit 3. The findings include: 1. Resident #16, a paraplegic, was transported in a wheelchair without leg or foot rests. During the transport the resident's right foot and leg were caught under the wheelchair resulting in a fracture of the resident's right distal femur at the knee. The resident was hospitalized for [REDACTED]. Resident #16 was admitted to the facility on [DATE] with a re-admission on 6/7/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #16 as cognitively intact and with limited range of motion of both lower extremities (hip, knee, ankle, foot). A facility reported incident form dated 6/5/15 documented Resident #16 alleged her leg was hurt during a transport by a CNA (certified nurses' aide). The investigation report dated 6/7/15 stated, During the course of the investigation and after interviewing staff and resident it has been determined while being transported via wheelchair to be weighed, resident's foot caught on the floor causing resident to yell out. CNA immediately stopped pushing the wheelchair and asked the resident what was wrong. Resident stated her foot caught on the floor causing her discomfort in her right knee .Resident later complained of pain in her right knee .Resident was sent out to the emergency room for further evaluation. X-ray demonstrated a fracture to the resident's right knee. On 5/17/16 at 3:20 p.m. Resident #16 was interviewed about her fractured femur/knee that occurred in June 2015. Resident #16 stated she was being pushed by a CNA in a standard (manual) wheelchair to be weighed on the floor scale. Resident #16 stated during the transport in the hallway her right foot hit the floor and her right foot and leg went back under the chair. Resident #16 stated the wheelchair had no leg or foot rests. Resident #16 stated she immediately felt pain in her right knee. Resident #16 stated the swelling and pain became worse the next day and she was sent to the hospital where they diagnosed a fracture at the right knee. Resident #16 stated she had to wear an immobilizer on her right leg for weeks following the fracture. Resident #16 stated she had increased pain following the fracture that was managed with medications. When asked if she had any use of her legs/feet Resident #16 stated, No. Resident #16 stated she was a paraplegic and that nurses and aides know I can't move my legs. Resident #16 stated she routinely used a motorized chair then (June 2015) and now for mobility when out of bed. Resident #16 stated she was put in the manual wheelchair in order to be weighed but she always used her motorized chair to get around the facility. Resident #16's clinical record was reviewed on 5/17/16. Nursing notes made no mention of the incident on 6/4/15, listed no date/time of injury and documented no assessment of the resident at the time of the injury. A transport form documented the resident was sent to the emergency roiagnom on [DATE] due to right leg/knee pain and swelling that started on 6/4/15. This form listed the resident had [DIAGNOSES REDACTED]. Resident #16's hospital discharge summary dated 6/7/15 documented, .presents to the hospital after a wheel chair injury resulted in a fracture to her lateral epicondyle .The patient was in her normal state of health until the day prior to admission. At that time she was being wheeled in a wheel chair and her foot pad was not placed down. After initiating movement her foot got trapped underneath the wheel chair which resulted in a fracture of her lower extremity. The patient was brought to the ED (emergency department) where her right knee was found to be swollen. Orthopedics were consulted, however, given her paraplegic status orthopedics felt that a knee immobilizer was the only intervention required and that she would need outpatient follow-up after that . In the ED she (Resident #16) was found to be hypoxic, mildly tachycardic, and febrile . was admitted to the hospitalist service for hypoxia . The hospital discharge summary documented x-ray results of Resident #16's diagnosing a distal femoral lateral condylar fracture. The resident returned to the facility on [DATE]. physician progress notes [REDACTED]. physician progress notes [REDACTED]. 6/8/15 - .She (Resident #16) was hospitalized .from June 5th through June 7th (2015) after presenting to the emergency room with a minimally displaced fracture of the lateral condyle of the distal portion of the right femur that occurred when her leg became caught underneath a wheelchair while being transported within the nursing facility . Right now, they are using the Sit-to-Stand lift while wearing the knee immobilizer and I am concerned, however, that this is going to put too much stress on the fracture fragment in her femur and cause further displacement. Instead, we will have her transferred by a Hoyer Lift pending her evaluation by orthopedics . 6/12/15 - .seen today in follow up of her diabetes, [DIAGNOSES REDACTED], restless leg syndrome, [DIAGNOSES REDACTED] as well as her recent nondisplaced fracture of the lateral condyle of the right femur . Upon speaking with the patient today, she has no other concerns besides her right leg pain. She is currently on morphine . 6/19/15 - The patient is seen at her request complaining of increased leg spasms because of having to wear the brace on her right leg after suffering a fracture of her distal femur . We will increase her Baclofen from 10 mg (milligrams) q.i.d (four times per day) to 15 mg q.i.d. for two weeks and then drop it back down at the time to 10 mg q.i.d. 6/24/15 - The patient is seen as her request because of ongoing complaint of right leg pain from her fracture. She continues to wear the brace on her leg. She is on MS Contin 60 mg q (every) 12 hours as well as morphine sulfate 15 mg q four hours p.r.n. (as needed) . I am going to try placing her on a scheduled regimen of Tylenol 650 mg t.i.d (three times per day) and we will also start her on meloxicam 7.5 mg daily for 30 days. The resident's medication administration record (MAR) documented the resident experienced pain of her right leg and knee following the fracture and was administered as needed medication for effective pain management. The resident's June 2015 MAR documented the pain medication Morphine Sulfate 15 mg was administered on 6/12/15, 6/16/15, 6/18/15, 6/24/15, 6/25/15, 6/27/15 and two doses on 6/28/15 for leg pain. A dose of Tylenol 650 mg was administered on 6/9/15 for knee pain. In addition the medication Baclofen was increased on 6/19/15 from 10 mg four times per day to 15 mg four times per day due to increased muscle spasms in her leg. The medication Meloxicam and scheduled doses of Tylenol were added on 6/24/15 for management of her right leg pain. The record documented Resident #16 was treated by an orthopedist for follow up care for the fractured right femur on 6/10/15, 7/1/15 and 7/23/15. The orthopedic consult report dated 7/23/15 stated the fracture was healing well and discontinued use of the leg brace/immobilizer on that date. The resident was prescribed and received physical therapy at the facility following the fracture. The resident's plan of care prior to the fracture on 6/4/15 listed the resident was at risk of injury due to [DIAGNOSES REDACTED], decreased mobility and use of psychoactive medications. The care plan listed the resident was totally dependent upon staff for bed mobility and required the extensive assistance of one person for transfers due to her [DIAGNOSES REDACTED]. Interventions for injury prevention included use of an electric wheelchair for transportation and use of a mechanical sit to stand lift for transfers. On 5/17/15 at 3:50 p.m. the licensed practical nurse (LPN #2) that routinely cared for Resident #16 in June 2015 was interviewed about the 6/4/15 incident. LPN #2 stated the CNA was pushing Resident #16 in a standard wheelchair to be weighed. LPN #2 stated the wheelchair did not have leg or foot rests in place and the resident's foot caught on the floor while she was pushed down the hallway and the foot went under the chair. LPN #2 stated the resident initially was ok but the next day (6/5/15) the resident had swelling and pain in her right knee and was sent to the emergency room where they diagnosed a fracture of the right knee. LPN #2 stated the wheelchair used to transport residents to the scale was different from regular wheelchairs in that it did not have leg or foot rests and it was larger than a regular wheelchair. LPN #2 stated standard leg/foot rests were not mounted onto the weight wheelchair because the weight chair brackets were larger and the regular leg/foot rests did not fit. LPN #2 stated, I don't think the standard foot rests or leg rests will fit (the weight chair). When asked if Resident #16 was able to use her legs/feet, LPN #2 stated, No. LPN #2 stated Resident #16 routinely used a motorized chair for mobility. CNA #4 that was with Resident #16 at the time of the injury on 6/4/15 was not available for interview during the current survey. The facility's investigation statement from CNA #4 dated 6/9/15 documented, On Thursday, June 4, I went to weigh (Resident #16). She was in the bathroom and her aide (CNA #3) was in the room waiting for her. When (Resident #16) was done using the bathroom, (CNA #3) and I transferred her to the weight chair using the sit to stand lift. I began to wheel her down to the scale. The weight chair does not have leg rests. I have weighed (Resident #16) many times using this chair and she always holds her feet up off the floor. As we got close to the scale, (Resident #16) grabbed her knee and yelled, 'Ouch.' I immediately stopped and saw that she had twisted her foot back under the chair. I looked at her knee and it was not swollen. I asked (Resident #16) if she wanted to go back to her room or continue to be weighed. She chose to get weighed, which I did. I then took her back to her room and (CNA #3) and I transferred her to her electric chair using the sit to stand lift. On 5/18/16 at 10:00 a.m. the director of nursing (DON) was interviewed about Resident #16's fracture of 6/4/15. The DON stated she was not working in the facility in June 2015. The DON stated nurses should have documented an assessment of the resident and a description of the incident in the clinical record at the time it happened. The DON verified Resident #16's wheelchair incident happened on 6/4/15 at 2:30 p.m. These findings were reviewed with the administrator and DON during a meeting on 5/18/16 at 1:45 p.m. 2a. An interview with a group of cognitively intact residents reported ongoing issues with slow call bell response in the facility. Residents #9 and #14 reported slow call bell response from the night shift on unit 3. A group interview was conducted on 05/16/2016 at 2:30 p.m. Nine cognitively intact residents were in attendance. During the meeting the residents were asked about call bell response. The residents stated that the call bells were not answered timely and reported wait times varying from 15 minutes to one hour. One resident stated that she had waited over an hour and had become upset and tearful regarding the extended time. The residents stated that one shift was not any better than the other. The residents were asked if they had shared their concerns with facility staff and they stated they had. Review of the resident council meeting minutes for the past three months (February, March and April 2016) all contained information under old business that Call Bells not answered in a timely manner (needs improvement). Resident #9 was admitted to the facility on [DATE] with a re-admission on 10/5/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #9 as cognitively intact. On 5/16/16 at 1:35 p.m. Resident #9 was interviewed about quality of life and care provided by facility. Resident #9 stated she has had issues in the past several months of slow or no response to call bells especially on the night shift (11:00 p.m. to 7:00 a.m.) for incontinence care. Resident #9 stated, When you ring the call bell, they (aides) don't come. Resident #9 stated at times she has waited for almost 30 minutes and stated sometimes the aides don't come at all. Resident #9 stated several days ago she had urinated in her brief several times in the night and the brief was saturated. Resident #9 stated when the nurse came to give her an insulin injection and pulled down the top edge of the brief, urine spattered up on her because the brief was so full. Resident #9 stated, This makes me feel bad about myself. Resident #9 stated she already felt bad about herself anyway and the saturated, leaking brief just made her feel worse. Resident #9 stated she rings the call bell but can't hold her urine long enough for the aides to come. Resident #9 stated almost every morning around 4:00 a.m. she has to urinate and many times the aides do not respond timely. Resident #9 stated she has been told by aides that she does not need to ring her call bell because they are going to check on her every 2 hours anyway. Resident #9 stated she has been told by an aide, You are not the only person here. Resident #9 stated most mornings she needs the bedpan between 7:00 a.m. and 8:00 a.m. before breakfast. Resident #9 stated she has been told by aides that they don't toilet residents when they are handing out trays. Resident #9 stated she has talked with the unit manager and reported the poor call bell response to the social worker but nothing has changed. The resident's plan of care (revised 4/13/16) listed the resident was at risk of injury due to psychoactive drug use, seizure disorder and incontinence. Included in interventions for injury prevention were, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 5/17/16 at 2:50 p.m. the social worker was interviewed about Resident #9's reporting of slow call bell response. The social worker stated Resident #9 told her about poor call bell response within the last several weeks. When asked what actions had been taken to address slow call bell response, the social worker stated staff members were re-educated about responding timely to call bells. The social worker presented a grievance log listing that Resident #9 reported slow call bell response time on 5/2/16. On 5/18/16 at 1:45 p.m. the administrator was interviewed about slow call bell response. The administrator stated all staff members were supposed to respond call bells. The administrator stated the expected response time for call bells was within 15 minutes. These findings were reviewed with the administrator and director of nursing during a meeting on 5/18/16 at 1:45 p.m. 2b. Resident #14's call bell was not promptly answered by the facility's staff to aide in safe transfers for toileting. Resident #14 was admitted to the facility on [DATE] with but not limited to the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/16 was a quarterly assessment. The resident was assessed as being a fifteen (15) for cognitive skills. Section G for transfers, the resident was assessed as 3/2 (extensive assist of one person ). On 5/16/16 at approximately 8:10 a.m at approximately 11:00 a.m., during a tour of the facility, Resident #14 stated to this Surveyor that staff did not answer the call bells in a timely manner. Resident #14 stated that upon ringing the call bell, the CNA's (certified nursing assistants) will either not answer at all or take between ten (10) to fifty (50) minutes to respond to the the light. Resident #14 stated, It's mainly on the night shift. I don't have any problems on the day shift. Resident #14 stated, I have had to wet myself because I could not wait until they got here to get me to the bathroom. On 5/16/16 at approximately 8:10 a.m., Resident #14 was interviewed regarding the statement made regarding unanswered call bells. Resident #14 stated, It's still not better. I had to wait last night for about thirty minutes to go to the bathroom. On 5/17/16 at approximately 10:00 a.m., the administrative staff were made aware of the above findings. 3. LPN #3 left Resident #13's prepared medications on top of the medication (med) cart unattended. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 05/05/2016. Resident #13 was assessed as cognitively intact with a total cognitive score of 14 out of 15. Medication pass and pour observation was conducted 05/17/2016 beginning at 8:10 a.m. with LPN #3 (licensed practical nurse). LPN #3 prepared Resident #13's medications for administration. She was unable to carry all of the prepared medications to the resident's room at one time. LPN #3 carried part of the meds to the room and placed on the bedside table. The remainder of the meds were left on the med cart unattended. The med cart was two rooms up from Resident #13's room and on the opposite side of the hall. She then left meds unattended in the resident's room to retrieve the rest of her meds on the med cart. LPN #3 was interviewed regarding the medication pass and pour observation at approximately 9:20 a.m. LPN #3 acknowledged she should not have left medications unattended in Resident #13's room or on the med cart. The Administrator and DON (director of nursing) were informed of the above during a meeting with the survey team on 05/17/2015 at approximately 1:30 p.m. On 05/18/16 at 10:00 a.m. the DON stated, No medication should not be in your vision. Meds should always be secure and in sight of nurse. Facility policy, General Dose Preparation and Medication Administration included, .Procedure: 2. Dose Preparation: .2.8 Facility staff should not leave medications or chemicals unattended No further information was received by the survey team prior to the exit conference on 05/18/16.