Every finding on record at Aviata at Jacksonville

Based on food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to clean one of two microwaves located in a unit nourishment room. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: Observations of the nourishment rooms were conducted during the follow-up tour on 12/10/2025 at 10:55 am. During the tour, the unit microwave in one of two nourishment rooms located on the 100-300 unit was observed to have black substances of unknown origin resembling fungal growth on the inside ceiling. Another observation was made on 12/11/2025 at 11:42 am of the same black substances on the inside ceiling of the microwave. (Photographic evidence obtained) During the follow-up tour in the kitchen, the Certified Dietary Manager (CDM) reported the facility had two nourishment rooms and Environmental Services (EVS) was responsible for cleaning the microwaves in nourishment rooms. An interview was conducted on 12/11/2025 at 8:50 am with Employee A, Dietary Aide, who reported the CDM cleans the refrigerator, but was unsure who was responsible for cleaning the nourishment room microwaves. An interview was conducted on 12/11/2025 at 9:16 am with Employee B, Manager in Training, who reported she was unsure who cleaned the microwave in nourishment rooms. An interview was conducted on 12/11/2025 at 9:30 am with [NAME] C, stated he was not sure who cleaned microwaves in the nourishment rooms. An interview was conducted on 12/11/2025 at 9:53 am with the CDM, who confirmed that [NAME]/CNA staff were responsible for cleaning the nourishment room microwave. A review of the facility's policy and procedure entitled Equipment, revised 9/2017 revealed: Policy Statement: All food service equipment will be clean, sanitary, and in proper working order. Procedures: 1 All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023) Annex 4. Equipment, Utensils, and Linens. 4-602.12. Cooking and Baking Equipment. Page 129. (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 4-602.13 Nonfood-Contact Surfaces. Nonfood-Contact Surfaces of Equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues

Based on interviews and record reviews, the facility failed to document and respond appropriately to resident grievances regarding missing clothing items for 1 out of 5 residents reviewed. (Resident #46)The findings include:During an interview on 12/9/2025 at 2:45pm, Resident #46 reported missing two pairs of pants. She said, I told [Environmental Services Account Manager] about it, but nothing ever got done.Review of the grievance log for the previous 12 months did not reveal a grievance filed by the resident.During an interview on 12/11/2025 at 10:30am, the Environmental Services Account Manager stated, I remember she [Resident #46] said something to me about a pair of pants a few months ago, but like I tell them, I check the inventory and if it's listed on the inventory, then I look for it. The ES Account Manager was asked if he initiated a grievance for all reported missing items. He stated, Not until I see if I can find it, then I let Social Services know either I found it, or I didn't. When asked how he kept track of residents' verbal reports of missing items, he replied, It's discussed in the morning meeting. He indicated that the information is on the daily report, but was unable to provide the report for review.Review of Resident #46's inventory sheet showed one pair of black sweatpants on June 13, 2025. Review of the facility Policy and Procedure entitled Personal Property-Loss or theft (N-1037, revision date 7/24/2017) revealed, Process: An employee receiving a concern regarding lost or missing item(s) from a resident or resident representative will initiate a Complaint/Grievance form or electronic equivalent.Review of the facility Policy and Procedure entitled Complaint/Grievance (Revision Date 10/24/2022) revealed, Procedure: An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form.

Based on record reviews and interviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately to the administrator and to other officials in one of one identified occurrence. (Resident #118)The findings include:Review of the grievances for dining complaints revealed a grievance filed by Resident #118 on August 25, 2025. The grievance stated, Kitchen staff told me he could make my life harder. I don't understand what I actually did. I was talking to the nurse . The documentation section of the grievance form revealed that the Certified Dietary Manager (CDM) documented, Spoke with [identified employee name] about abuse towards residents. [Identified employee name] has been issued an ECA [Employee Corrective Action]. It is documented that the complaint is resolved and that the complainant is satisfied with the resolution.During an interview on 12/11/2025 at 10:00 am, Resident #118 stated, The deal was he [identified employee name] wasn't supposed to leave the kitchen anymore. That's what I was told. Well, he's leaving the kitchen. He just sort of stands around and smirks. I'll be honest, I check out the windows for his car. If he's here, I don't eat out of the kitchen. I was just telling the guy I'd move out of the way, and that's when he came at me with, I can make your life harder than it already is. During an interview on 12/11/2025 at 10:30 am, the Executive Director (ED) stated, I'm aware of other issues with this employee, but I was not aware that this had happened. The ED added that the Social Services employee that was identified as addressing the original complaint was no longer employed at the facility. The ED confirmed that this allegation had not been reported as required.During an interview on 12/11/2025 at 10:50 am, the Certified Dietary Manager (CDM) stated, I spoke with him [identified employee] and provided him [identified employee] abuse training. When asked if the employee was to remain in the kitchen, the CDM replied, Yes, he is doing dishes and trays. He is not to leave the kitchen. The CDM denied awareness that the employee was leaving the kitchen during his scheduled work hours. When asked why the ED was not notified of the occurrence, CDM stated, I thought Social Services would tell her.Review of the facility policy entitled Abuse, Neglect, Exploitation & Misappropriation, with an annual review date of January 2025, revealed, 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 two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, are not later than 24 hours if the events that caused 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.

Based on observations, interviews, and policy and procedure review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. The findings include: Observations of the tray line on 12/10/2025 at 10:55 am revealed the Dietary Aide (Caller) calls the diet, the cook prepares and plates the food, and the Manager in Training checks tickets to ensure items match, then load the meal trays on the cart. Observations revealed meal tickets not matching the meal plated/inaccurate protein portions or meal tray placed in the cart for distribution with missed food item/apple/cranberry order/preference not provided per meal ticket; nectar shake not provided per meal ticket; bread not followed by order/preference on meal ticket; and gravy not provided per meal ticket. All items were pulled from the meal cart and corrected. An additional complaint from Resident #118 included that the resident does not eat pork, but continues to receive pork items. There was no attempted resolution for the resident's issue with food. An interview was conducted on 12/11/2025 at 8:50 am with Employee A, Dietary Aide, who explained the tray line process and who was responsible for what task. She stated, the A1/Dietary Aide was responsible for placing drinks, dessert, cold cereal, condiments on each tray and call the tickets. The A2 staff was responsible for adding hot plates, juice and milk, tray accuracy, lids, and placing trays on cart. The cook was responsible for food temperatures, food accuracy, and placing plates on top of the tray line for the A2 staff to receive. When asked, how does the kitchen determine how much food to prepare for each meal she replied, The CDM provides prep guide daily for every food item needed; it states the need for the day. When asked to explain the process for measuring protein/meat, she responded she was unsure of the cook's duty. She reported a 3-ounce (oz) protein is required for a regular diet tray; 6-oz was considered a double protein; 2 scoops of all food items were considered a double portion; 1 1/2 protein was a large portion of protein; and 4-oz was considered a large protein. When asked how often are meal substitutions provided she replied, Not very often but it does happen sometime. When it happens, the CDM will add the substitute to the bottom of the ticket and 'please accept this item'. Substitutions are tracked on the prep guide. An interview was conducted on 12/11/2025 at 9:16 am with Employee B, Manager in Training, who was asked to explain the tray line process and who was responsible for what task. She stated the lead calls tickets, places condiments, drinks, and desserts on the tray; the cook prepares the plate, and the catcher reviews tickets and plates for accuracy, then places the meal tray in the cart. When asked how the kitchen determines how much food to prepare for each meal she replied, Use of the production sheet tells how many regular, mechanical, puree, and fortified meals to prepare. When asked to explain the process for measuring protein/meat, she stated most of the food comes proportioned to 3 oz or 6 oz. She reported a 3-ounce (oz) protein was required for a regular diet tray; 2 servings of the meat/protein was considered a double protein; and double everything/plate was considered a double portion. She stated she was very new to the position and was unsure of what a 1 1/2 was considered. A large protein was considered a large meat portion. She also was not sure how often meal substitutions were provided. An interview was conducted on 12/11/2025 at 9:30 am with [NAME] C, who explained the tray line process and who was responsible for what task. He stated, the lead reads the ticket, calls the diet, adds condiments and desserts to the tray; the [NAME] responds to the ticket and plates the food, places the food/plate on top of the tray line; the catcher adds beverages, ensures plate accuracy, then places the meal tray in the cart. When asked0 how the kitchen determines how much food to prepare for each meal he replied, Follow recipe; use scale to measure protein. He noticed the scale was broken during lunch on 12/10/2025. He notified the CDM and was told another scale was ordered and should arrive on 12/11/2025. The [NAME] confirmed he used eyeballs to portion the pork roast served at lunch during the time of the survey. When asked to explain the process for measuring protein/meat he replied, Slice a few pieces of the protein, then measure on the scale. He reported a 4-oz protein was required for a regular diet tray; 4-oz x 2 was considered a double protein; 2 separate plates were considered a double portion; 1 1/2 protein is 6-oz protein; and 1 1/2 protein was considered a large protein. When asked how often are meal substitutions provided he replied, It has happened but very rare. The CDM will inform staff of menu changes, verbally and document on the production sheet. An interview was conducted on 12/11/2025 at 9:53 am with the CDM who confirmed the first person will call tickets, set up trays with condiments and drinks, the cook prepares the meal to specification of the ticket, and the last staff pull plates, ensure the plate matches the meal ticket, place lid on the plate, add supplements/thickened drinks, and place the meal tray on the cart. When asked how the kitchen determines how much food to prepare for each meal he replied, The CDM provides a production sheet daily that includes recipes. When asked to explain the process for measuring protein/meat he replied, Ounces have been visual; pieces are the actual count. I ordered a scale yesterday and should arrive today. There was no scale in the past. Most meals have been pieces opposed to weight. He reported a 3-oz protein was required for a regular diet tray; 6-oz was considered a double protein; 1 protein and 1/2 protein: 4 oz; 6 oz was considered a double portion; 1 1/2 protein is 4-oz protein; and 1 1/2/4 oz protein was considered a large protein. When asked how often are meal substitutions provided he replied, Very rare. Substitutions are tracked on the substitution and production sheets, each unit is notified, and menu boards are changed. Review of the facility's policy and procedure: Menus revised: 10/2022 revealed Policy Statement: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures.4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition for the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2020-2025 edition. Policy and Procedure Food Quality and Palatability revised: 2/2023 revealed Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are pared and served in a manner, form, and texture to meet resident's needs. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. (Copy obtained).

Based on observations, interviews, and policy and procedure review, the facility failed to ensure food served was prepared by methods that conserve nutritive value and appearance by failing to provide appetizing and appealing food in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting on their ability to heal, and possibly resulting in an overall health status decline. The findings include: During a tour of the kitchen on 12/10/2025 at 10:55 am, carrots served on the tray line were observed to be discolored with black spots making them unsuitable for consumption, leading to five bowls being pulled and discarded to ensure food safety and quality. During the facility survey, additional complaints received included: Resident #11 reported her grilled cheese sandwich was too hard to consume; Resident #64 reported receiving black broccoli, It was rotten, they took it out of the bag like that and steamed it and served it. They overcook everything. The grilled cheese was hard as a rock.; Resident #73 reported issues with overcooked food, most recently the grilled cheese and tater tots; Resident #84 reported overcooked grilled cheese, tater tots, and peas. (Photographic Evidence Obtained) On 12/10/2025 at 10:55 am, Employee A, Dietary Aide, was asked during tray line service who was responsible for ensuring food components were appealing and suitable for meal consumption. She stated all staff working on the tray line. During the same tray line service, Employee C, Cook, was asked who was responsible for ensuring food components were appealing and suitable for meal consumption. He stated the cook. He also stated he did not notice the number of carrots that were discolored right away, but began removing them from the tray line and pan. The Certified Dietary Manager (CDM) was informed that the carrots were discolored with black spots. An interview was conducted on 12/11/2025 at 9:53 am with the CDM, who confirmed that the cook was responsible for ensuring meals were prepared by methods that conserve nutritive value and appearance and for following recipes when preparing meals. He was unaware of the black spots on the carrots prior to meal service, but stated carrots identified with the dark spots were to be discarded. Review of the facility's policy and procedure: Food Quality and Palatability revised: 2/2023 revealed Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. (Copy obtained). (Copy obtained).

Based on record reviews and interviews, the facility failed to appropriately document side effects and behaviors for psychotropic medications, in accordance with the corresponding key on the Medication Administration Record for two of five residents reviewed for psychotropic medications. (Residents #15 & #72)The findings include:1. Review of Resident #15's medical record revealed a physician's order for behavior monitoring every shift for antipsychotics agents with a start date of January 24, 2022. Data entry for corresponding codes included; 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress note. Review of Resident #15's medication administration records for November 2025 revealed that NA [Not Applicable] was documented on the following dates: 11/1/2025, 11/2/2025, 11/3/2025, 11/5/2025, 11/10/2025, 11/16/2025, 11/17/2025, 11/19/2025, 11/26/2025, 11/27/2025, 11/29/2025, and 11/30/2025. Review of Resident #15's medication administration record for December 2025 revealed that NA [Not Applicable] was documented on the following dates: 12/3/2025, 12/8/2025, and 12/10/2025. 2. Review of Resident #72's medical record revealed a physician's order for behavior monitoring every shift for antipsychotics agents with a start date of July 26, 2025. Data entry for corresponding codes included; 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress note.Review of Resident #72's medication administration record for November 2025 revealed a check mark only on the following dates: November 1, 2025-November 30, 2025.Review of Resident #72's medication administration record for December 2025 revealed a check mark only on the following dates: December 1, 2025-December 10, 2025. During an interview on 12/11/2025 at 6:45pm, Staff A, Licensed Practical Nurse (LPN), stated, We monitor for behaviors on the MAR [Medication Administration Record] and if there are any behaviors, you document the number and there should be a corresponding progress note.During an interview on 12/11/2025 at 6:55pm, Staff B, Licensed Practical Nurse (LPN), stated, It gives you a code on the MAR. If there aren't any behaviors, you document a zero, if not, there is a corresponding number that matches a behavior and there should be a progress note. During an interview on 12/11/2025 at 7:20pm, the Director of Nursing (DON) stated, I expect the staff to document any behaviors in accordance with the corresponding key.

Based on observations, interviews, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and clean interior for two (Residents #208 and #3) of 30 residents in the sample. The findings include: 1. On 12/10/23 at 1:10 p.m., Resident #208's bedside unit was observed to be a treatment cart type of unit. Red splashes of a sticky liquid were observed on the outside of the unit, on the floor, and inside each drawer. (Photographic evidence obtained) The floor in front of the unit was sticky under one's shoes. The resident was asked if this was her bedside nightstand. She stated, I guess so. It looks like a medication cart or something. Two bags were observed on top of the unit, one containing clothing and one containing personal items. The resident was asked if those items belonged to her. She replied yes. On 12/11/23 at 8:40 a.m., Resident #208's bedside unit was observed to be a treatment cart type of unit. Red splashes of a sticky liquid remained on the outside of the unit, on the floor, and inside each drawer. The floor in front of the unit was sticky under one's shoes. Two bags were observed on top of the unit that contained clothing and various personal items. The resident was asked if she kept any of her belongings inside of this unit. She stated, No, how could I? It's filthy. On 12/12/23 at 9:45 a.m., Resident #208's bedside unit was observed to be a treatment cart type of unit. Red splashes of a sticky liquid remained on the outside of the unit, on the floor, and inside each drawer. (Photographic evidence obtained) The floor in front of the unit was observed to be sticky under one's shoes. The resident was asked if she felt this bedside unit was homelike. She stated, No. Look at it. I'm pretty sure it's some kind of a cart for medications or something, and it's filthy. On 12/13/23 at 8:30 a.m., Resident #208's bedside unit was observed to be a treatment cart type of unit. Red splashes of a sticky liquid remained on the outside of the unit, on the floor, and inside each drawer. The floor in front of the unit was observed to be sticky under one's shoes. 2. On 12/10/23 at 1:03 p.m., Resident #3 was observed lying in bed, awake. Her bedside unit was observed to be a treatment cart type of unit. Beige/brown debris was observed on the outside of the unit, on each of the drawers. (Photographic evidence obtained) The resident was not interviewable due to her cognitive status. On 12/11/23 at 8:35 a.m., Resident #3 was observed lying in bed, awake. Her bedside unit was observed to be a treatment cart type of unit. Beige/brown debris remained on the outside of the unit, on each of the drawers. (Photographic evidence obtained0 On 12/12/23 at 9:40 a.m., Resident #3 was observed lying in bed, awake. Her bedside unit was observed to be a treatment cart type of unit. Beige/brown debris remained on the outside of the unit, on each of the drawers. (Photographic evidence obtained) The resident's privacy curtain was open between the two resident's beds. Pink/light red splatters were observed on the bottom right portion of the curtain. (Photographic evidence obtained) On 12/13/23 at 8:25 a.m., Resident #3 was observed lying in bed, awake. Her bedside unit was observed to be a treatment cart type of unit. Beige/brown debris remained on the outside of the unit, on each of the drawers. On 12/13/23 at 8:55 a.m., in an interview with the Housekeeping Director, he was asked to describe the cleaning process for resident rooms. He stated, One of the first steps we take is for regular room cleaning. We go in and empty the waste basket and put a new liner in the basket. We disinfect anything, like pictures, dressers and the drawers on the outside, the bedside table, the bed rails, the window sills, the outside surface of the air conditioner unit, the door knobs, then into the bathrooms to clean and disinfect that area. The floor is the last thing done for mopping. He was asked how often that type of cleaning was done for each resident room. He replied daily. He was asked how often the privacy curtains were inspected and cleaned. He stated, With privacy curtains we do an inspection, if we can spot clean it, we will do that. If it requires a whole cleaning, we will take the curtain down and I will take it to the laundry for cleaning. We usually let them air dry and put up a different curtain while that's drying. We do have extra curtains. He was asked again how often the privacy curtains were inspected. He stated, That's a routine inspection for the housekeeper during QCI (Quality Control Inspection), so on a daily basis. He was asked to view the bedside units for Residents #208 and #3, and the privacy curtain for Resident #3. On 12/13/23 at 9:05 a.m., the bedside unit and privacy curtain for Resident #3 were observed with the Housekeeping Director. He was asked if he could see the pink/light red splatters on the privacy curtain. He stated yes. He was asked if the curtain should have been inspected daily. He stated yes. He was asked to observe the resident's bedside unit. He observed the unit and touched the brown/beige splatters on the front of the drawers. He stated he'd need to get a wet rag to wipe it off and see what was on the unit. He was asked if that should be inspected and cleaned daily. He stated yes. At 9:10 a.m., the bedside unit for Resident #208 was observed by the Housekeeping Director. He was asked if the red splatters observed on the bedside unit and in the bedside units drawers and on the floor around the unit were expected to have been cleaned on a daily basis. He stated yes. He was asked why these bedside units were observed in this state for the past four days. He stated they must have been overlooked. A review of a facility policy titled: Daily Patient Cleaning (Revised 9/5/2017) revealed: Every room to be cleaned is that of a resident's home - treat it as such. 2: Horizontal dusting. With a cloth and disinfectant wipe all horizontal (flat) surfaces. 3: Spot clean. With a cloth and disinfectant spray clean all vertical services. 5: Damp mop floor with germicidal solution, damp mop floor working from back corner to to door. A review of a facility policy titled: Cleaning Cubicle Curtains (Revised 9/5/2017) revealed: Examine curtains while doing QCI or at discharge. If curtain is stained, remove immediately. Have spare curtains on hand to immediately replace dirty or torn curtains.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide two (Resident #90 and Resident #84) residents who were unable to carry out activities of daily living, from a total sample of 30 residents, the necessary services to maintain personal hygiene (fingernail care). The findings include: 1. On 12/10/23 at 12:30 p.m., Resident #90 was observed in his room with elongated/jagged fingernails with brown debris under each nail on both hands. Right hand fingernails were in contact with the palm of his hand due to a hand contraction. The resident was asked if he was satisfied with the state of his fingernails. He shook his head no. He was asked if staff cleaned and trimmed his fingernails. He clicked his tongue and shook his head no. He was asked if he had asked staff to clean and trim his fingernails. He nodded yes. (Photographic evidence obtained) On 12/11/23 at 1:45 p.m., Resident #90 was observed self-propelling in a wheelchair in the hallway, headed toward his unit. He was dressed in day clothes. The fingernails on all of his fingers were elongated/jagged with brown debris under each nail, just as they ha dbeen observed on 12/10/23 at 12;30 p.m. On 12/12/23 at 9:20 a.m., Resident #90 was observed sitting on the side of his bed dressed for the day. His fingernails remained elongated and jagged with brown debris observed under each nail on both hands. A medical record review revealed diagnoses which included cerebral vascular accident (CVA - stroke), aphasia, contracture of the right shoulder, weakness, anxiety disorder, major depressive disorder, lack of coordination, and muscle weakness (generalized). A review of the quarterly Minimum Data Set (MDS) assessment, dated 10/19/23, revealed the resident had no behaviors exhibited and had not refused care during the look back period. A review of the person-centered care plan created for Resident #90 revealed the following: Focus Area (8/3/23, revised 8/24/23) Resident has an activities of daily living (ADL) self-care deficit performance related to CVA with hemiplegia, contracted right shoulder. Goal: Resident will improve current level of function in his activities of daily living (ADLs) through the review date. Interventions: Bathing/showering: check nail length and trim and clean nails on bath day an as necessary. Report any changes to the nurse. A review of the certified nursing assistants (CNAs) Tasks/Kardex (Photographic evidence obtained) revealed the following: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 12/12/23 at 9:50 a.m., in an interview with Licensed practical Nurse (LPN) A, she was asked who provided fingernail care to residents (trimming and cleaning their fingernails). She stated, Activities staff does fingernails and manicures. CNAs provide fingernail care. Nursing can do it too. Nurses provide the fingernail care if the resident is a diabetic. I'll trim and clean residents' nails as I see them, or I'll ask a CNA to do it. She was asked if there was a specific timeframe/time of day that fingernails should be trimmed and cleaned other than as needed. She stated, Well, they should be done on shower days because it's easier to trim and clean the nails when they are soft. She was asked if CNAs were trained to alert nursing staff if a resident refused nail care. She stated yes. She was asked what was done if a resident refused fingernail care. She stated, I would see if they would allow me to do it and try to attempt it. She was asked where the refusal would be documented if they also refused her attempt. She stated, It should be documented right in the nurses' notes. In an interview with Certified Nursing Assistant (CNA) D on 12/13/23 at 8:35 a.m., she was asked if she was caring for Resident #90 today. She stated yes. She was asked who trimmed and cleaned his fingernails. She stated, We do, the CNAs. She was asked when residents received fingernail trimming and cleaning. She stated, It should be on their shower days. She was asked what shift Resident #90 received his showers. She stated day shift. She was asked if Resident #90 had displayed behaviors of refusing nail care. She stated no. She was asked if she had ever trimmed and cleaned Resident #90s fingernails. She stated yes. She was asked for the last time she had performed nail care for Resident #90. She stated, I'm not sure, but he does allow me to trim and clean them. A review of the facility's policy titled Care of Nails (revised 9/1/17) revealed: Procedure: Explain the procedure to the resident and bring the following equipment to resident's bedside: Basin (optional) Towel Emery Board Orange Stick Nail Clippers May soak hand in basin half full with warm water if needed. Trim fingernails. Clean nails. A review of the facility's policy titled Bathing/Showering (revised 9/1/17) revealed: Policy: Assistance with showering and bathing will be provided at least twice a week and as needed to cleanse and refresh the resident. 48947 2. On 12/10/23 at 12:07 p.m., Resident #84 was observed with elongated fingernails on both hands with brown matter under his fingernails. He was asked when he last had his fingernails cleaned and trimmed. He stated, My nails grow fast. They just cut them about 3-4 weeks ago. He expressed his desire to have his fingernails trimmed. On 12/11/23 at 9:55 a.m., Resident #84 was observed with elongated fingernails on both hands with brown matter under his fingernails. (Photographic evidence obtained) On 12/12/23 at 9:35 a.m., Resident #84 was observed lying in bed with both hands underneath the bed covers. When he was asked whether the staff had cut or cleaned his fingernails, he pulled his hands out from under the bed covers. His fingernails remained elongated with brown matter underneath the nails. On 12/12/23 at 10:05 a.m., CNA G was interviewed and stated she had been employed by the facility for one year. CNA G stated she had taken care of or had been assigned to care for and was familiar with all of the residents on the unit where Resident #84 lived. She was asked who was tasked to provide fingernail care for these residents. She stated the CNAs provided fingernail care on shower days and as needed, and the Activities staff also provided fingernail care. She was asked what she did if a resident refused fingernail care. She stated, I respect their right to refuse or sometimes I may go back and ask again later. I also report to the nurse that the resident refused. A medical record review revealed that Resident #84 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, a need for assistance with personal care, contracture of the left knee, protein-calorie malnutrition, contracture of the left hip, epilepsy, and heart failure. A review of the Annual Minimum Data Set (MDS) assessment, dated 8/24/23, revealed that Resident #84 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. He was also documented as dependent on staff for bed mobility, transfers, toilet hygiene, personal hygiene, and indicated no refusal of care behaviors during the lookback period. A review of his patient centered care plan, dated 11/24/23, revealed: FOCUS: Resident has activities of daily living (ADL) self-care performance deficit related to mobility problem, paraplegia, arthritis. Goal: Resident will maintain current level of function in his ADLs through the review date. Intervention: BATHING/SHOWERING: Check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. A review of the resident's progress notes revealed no documentation indicating refusal of care or a preference to wear his fingernails long. .

Based on observations, interviews, record review, and facility policy review, the facility failed to implement interventions, including monitoring placement and function of wander-alarm devices, consistent with a resident's needs, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident for one (Resident #93) of 30 residents sampled. Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning. The findings include: On 12/10/23 at 12:45 p.m., in an interview with Resident #93's spouse, he stated, They put that bracelet thing on her ankle and the door locks when I take her outside. He stated his wife did not wander or walk around, that she used a wheelchair. He further stated staff did not tell him why she had the device on her ankle. Resident #93 presented as pleasantly confused when interviewed. She was unable to answer simple questions accurately. A Wanderguard device was observed on her right ankle. On 12/11/23 at 8:30 a.m., Resident #93 was observed lying in bed, awake. A Wanderguard device was observed on her right ankle. She was asked if she minded having the Wanderguard device on her ankle. She was pleasantly confused and answered, smiling and laughing, Oh, I meant to give that back to them haha. On 12/12/23 at 9:40 a.m., Resident #93 was observed in a Fall Focus program, in her wheelchair and dressed for the day. She was well groomed. She was one of five residents and one staff member, Certified Nursing Assistant (CNA) B, who was asked asked if Resident #93 wore a Wanderguard device and if so, what the reason was for the device. CNA B stated, Yes, she used to wander all the time when she was first here, back in June. She was always looking to get outside. CNA B was asked if the resident was still exit seeking. She stated, Not so much now. She's calmer but she can still get around in her wheelchair, so the possibility is there. She's confused so we can't explain to her in a way she would understand and remember why she can't leave the building. On 12/12/23 at 9:50 a.m., during an interview with Licensed Practical Nurse (LPN) A, she was asked if she was caring for Resident #93 today. She confirmed that she was. She was asked if the resident wore a Wanderguard device, and if so, why. She replied, When she first came here, that was back in June of this year, all she wanted to do was leave. She wanted to go find her husband. She's very confused. She would try all the doors to go look for him. She doesn't seem to do that so much anymore, but she can self propel in her wheelchair. LPN A was asked if the resident had the Wanderguard device since admission. She stated, Yes, I think she was identified as exit seeking right from admission. On 12/12/23 at 1:37 p.m., in a follow-up interview with LPN A, she was asked where she documented the resident's Wanderguard placement and function. She stated, In the eMAR (Electronic Medication Administration Record). She was asked to show where she documented that. She pulled up Resident #93's eMAR on her medication cart computer, but was unable to find anywhere in the resident's record where this was documented. She stated, This is where it's supposed to be. I don't know. It's not here, but I do check it each shift. On 12/12/23 at 1:50 p.m., in an interview with Registered Nurse (RN) H, she was asked why a focus area for Elopement/Wandering was added to Resident #93's care plan on 9/22/23. She stated, She was trying to leave. She was wandering down the hallway in her wheelchair looking for an exit to leave. The staff on the 400 hall witnessed her exit-seeking behavior and I witnessed her looking for an exit. She was asked if the resident had an elopement risk assessment completed at that time. She stated, Yes, she did. The nurses will do the elopement risk assessment in the computer. She was asked if she could provide a copy of that elopement risk assessment. She stated, Yes, I will find it for you. On 12/12/23 at 3:40 p.m., RN H stated she was unable to provide any elopement risk assessments completed after 6/9/23, the resident's admission assessment. She was asked to describe the resident's wandering and/or elopement risk behaviors that she witnessed. She stated, There were no behaviors of exit seeking prior to that day. She was wheeling up to the doors saying I gotta get out of here. RN H was asked if the resident ever eloped from the building. She replied no. She was asked if the resident had an order to place a Wanderguard device. She stated, Yes she did, and we added her to the elopement risk sheet and the elopement risk books. The nurse placed the Wanderguard on her. I remember she had some edema on her ankles. She was asked where the Wanderguard device monitoring documentation was located. She stated, It should be in the care plan. The signing off would be on the nursing documentation. She was asked if there was any documentation of the Wanderguard device being signed off as monitored for placement and function each shift or day. She left to retrieve information and upon return stated there was no documentation to show the Wanderguard device was being signed off as having been checked for placement and/or functionality each shift or day. A medical record review for Resident #93 revealed diagnoses which included unspecified dementia; attention and concentration disorder, and anxiety disorder. A review of the active physician's orders for Resident #93 revealed no order for Wanderguard use, placement or monitoring. A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from September 1, 2023 through December 12, 2023, revealed no orders related to a Wanderguard device for checking placement or function of the device. Further review of the medical record revealed no behavior log for wandering or attempted diversional activities. A review of the person centered Care Plan revealed: Focus Area (9/22/23) Resident is an elopement risk/wanderer related to dementia, cognitive loss, impaired safety awareness, has episodes of wandering at times. Goal: Residents safety will be maintained through the review date. Resident will not leave the facility unattended through the review date. Interventions: Electronic monitoring (Wanderguard) device as ordered; identify pattern of wandering; is wandering purposeful, aimless, or escapist? Is resident looking for something? Monitor location frequently. Document wandering behavior and attempted diversional activities in behavior log. A review of the Admission Elopement Risk Evaluation for Resident #93, dated 6/6/23, revealed the resident was not at risk for elopement. An second Elopement Risk Evaluation, documented in medical record on 6/9/23, revealed a score of 0.0, indicating no elopement risk. No Elopement Risk Evaluations were found during a medical record review as having been completed after 6/9/23. A review of an Elopement Book at the facility's reception desk revealed that Resident #93's information and photograph were included. A review of the facility's policy titled Elopement/Wandering Risk Guideline (revised 8/1/20) revealed: Overview: To evaluate and identify patients/residents that are at risk for elopement and develop individualized interventions. Process: Patients/residents to be evaluated on admission, re-admission, seven days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If utilizing a wander monitoring system device, check placement of the device every shift and functionality daily.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, received that care as ordered and consistent with professional standards of practice, for one (Resident #35) of a total sample of 30 residents. The findings include: On 12/10/23 at 2:21 p.m., Resident #35 was observed lying in bed receiving oxygen via a nasal cannula. Her oxygen concentrator, located at bedside, was set at a flow rate of 3L/min. (3 liters of oxygen per minute) (Photographic evidence obtained) On 12/11/23 at 9:33 a.m., a second observation was made of Resident #35 lying in bed receiving oxygen via a nasal cannula. Her oxygen concentrator was set with a flow rate of 3L/min. (Photographic evidence obtained) On 12/13/23 at 9:47 a.m., a third observation was made of Resident #35 lying in bed wearing a nasal cannula with her oxygen concentrator flow rate set at 3L/min. (Photographic evidence obtained) A review of the medical record revealed no active physician's orders for oxygen therapy. Further review of the active physician's orders revealed: ProAir HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 MCG (micrograms)/ACT, 2 puffs inhale orally every 12 hours as needed for Chronic Obstructive Pulmonary Disease (COPD). The order was dated 11/30/23. Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT, 1 puff inhale orally in the morning for COPD, dated 12/1/2023, Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3ml (milligrams per milliliter) 0.083%, 1 dose inhale orally via nebulizer every 6 hours for SOB (shortness of breath), wheezing for 5 days, dated 12/11/23, and Medrol 2 tabs therapy pack 4 mg po every morning and at bedtime for SOB, wheezing for 1 day then give 1 tab PO BID (by mouth twice daily) for SOB, wheezing for 2 days then give 2 tabs PO at bedtime for SOB, wheezing for 1 day then give 1 tab PO in the morning for SOB, wheezing for 5 days then give 1 tab PO at bedtime for SOB, wheezing for 3 days, dated 12/11/23 to 12/25/23. Respiratory Oxygen 2L/min (2 liters per minute) via nasal cannula PRN (as needed) for shortness of breath was discontinued on 10/7/23. Further review of the record revealed an admitted [DATE] with an initial admitted [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), shortness of breath; repeated falls; other lack of coordination; difficulty in walking, not elsewhere classified; major depressive disorder, recurrent, unspecified; anxiety disorder, unspecified; schizoaffective disorder, depressive type; unspecified lack of coordination; depression, unspecified; bipolar II disorder; opioid dependence, uncomplicated; other bipolar disorder; heart failure, unspecified; anemia, unspecified, and Cerebral Ischemia. A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2023 revealed nothing about oxygen therapy. All other medications were documented as having been provided as ordered by the physician. (Copy obtained) A review of Resident #35's Care Plan, revised 7/7/23, revealed a focus area for oxygen therapy related to ineffective gas exchange/COPD. Interventions included oxygen settings as ordered. A review of Resident #35's hospital Patient Transfer form, dated 11/30/23 (her date of admission to the nursing home), revealed oxygen at 3L/min continuous via nasal cannula. On 12/13/23 at 11:47 a.m., Licensed Practical Nurse (LPN) E confirmed that Resident #35 was receiving oxygen and the oxygen order was not in the Electronic Medical Record (EMR). She stated the admitting nurse or any nurse could add the order. When asked who provided ongoing monitoring of the resident's oxygen therapy, she replied, the nurse. She stated the nurse was also responsible for assuring that the resident was receiving the correct oxygen flow rate per the order. Correct oxygen settings were identified by checking the 3008 form (Hospital transfer form) on admission, and thereafter checking orders in the EMR. Night shift nursing staff were responsible for changing the resident's oxygen tubing. Correct settings were communicated from one staff person to another through verbal communication. On 12/13/23 at 11:57 p.m., the Director of Nursing (DON) was asked how correct oxygen settings were communicated from one staff person to another. She replied, by checking the order in the computer. A review of the facility's policy and procedure titled Oxygen Therapy (revised: 08/28/2017) revealed: Procedure: Review physician's order . monitor respiratory rate and heart rate . document initiation of therapy in the resident's chart. .

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medication error rates were not 5% or greater. Two errors were identified out of 32 opportunities for error, resulting in a medication error rate of 6.25% and affecting two (Residents #64 and #33) of five residents observed during medication administration, from a total of 30 residents in the sample. The findings include: On 12/11/23 at 11:36 a.m., Licensed Practical Nurse (LPN) I was observed checking Resident #64's blood glucose level. The resident was observed eating lunch and had already consumed more than 50% of the meal at the time of the blood glucose testing. LPN I then proceeded to administer Aspart Sliding Scale insulin to Resident #64 according to his blood glucose level. At this time the resident had consumed all of his lunch meal. An interview was conducted with Licensed Practical Nurse (LPN) I on 12/11/23 at 11:48 a.m. She was asked to review the orders for blood glucose monitoring and Aspart insulin administration. She pulled the order up on her medication cart computer and stated, Glucometer checks before meals and at bedtime. Administer Aspart Insulin U-100/ml (milliliter) per sliding scale before meals and at bedtime. She was asked why she had checked the resident's blood glucose level while he was eating, and why she had administered his insulin after he had completed his meal. She stated, I saw the trays come up and I told him to wait for me, but he didn't. On 12/13/23 at 9:17 a.m., LPN F prepared medications to administer to Resident #33. After the nurse prepared the medications, she picked up the cup that held the medications and a pre-dosed syringe of Trulicity (Type II diabetes medication), which was observed to be Trulicity 0.75/0.5ml. She locked her medication cart and proceeded to enter the resident's room. She was stopped and asked if she was going to administer the medications she had prepared. She responded yes. She was asked to check the dosage of the Trulicity she was going to administer against the physician's order. LPN F checked the medication order and compared the dosage of the Trulicity that she had prepared to the dosage that was currently ordered on the Electronic Medical Administration Record (EMAR). LPN F then stated, Oh no, I'm not going to give this, it's not the right dose. A medical record review for Resident #64 revealed an active physician's order which stated: Glucometer checks before meals and at bedtime, Administer Aspart Insulin U-100/ml per sliding scale before meals and at bedtime. A medical record review for Resident #33 revealed an order which stated: Trulicity- subcutaneous, Inject 1.5mg/0.5ml weekly. A review the facility's policy titled Medication-Oral Administration of (revision date 08/15/2019) revealed: Procedure: Review MAR or EMAR; should there be any uncertainties, verify the MAR or EMAR with the Physician's Order Sheet (POS) and seek clarification as indicated. Compare the medication unit/dose label against the MAR or EMAR prior to supporting the resident to accept and ingest the medication.

Based on observations, interviews, and facility policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections, by inappropriately storing and disposing of used sharps. The findings include: On 12/11/23 at 11:36 a.m., Licensed Practical Nurse (LPN) I was observed checking Resident #64's blood glucose level. When she was finished, she placed the used lancet in her jacket pocket and not in the sharps container. After administering Aspart sliding scale insulin to Resident #64, she disposed of the lancet and the KwikPen insulin needle, wrapped in her used gloves, into the trash can in the resident's room. An interview was conducted with LPN I on 12/11/23 at 11:48 a.m. She was asked to explain the procedure for disposal of sharps. She stated, Sharps material is disposed of in the sharps container, but this (referring to a new KwikPen insulin needle that she retrieved from the medication cart) is not a sharps. LPN I confirmed that the lancet she disposed of in the trash can should have been disposed of in the sharps container. A review of the facility's policy titled Insulin Administration-Injection Pens (revision date 10/10/2017) revealed: Procedure: Assemble the equipment, including disposable safety needle. Check eMAR for order three times, remove and discard the needle per manufacturer's instruction in an approved sharps container. A review of the facility's policy titled Insulin Administration (revision date 11/04/2020) revealed: Obtain physician's order, utilizing the medication card, medication sheet or electronic equivalent, check the label of medication three times. Do not recap the needle; engage safety sheath per manufacturer's instruction, dispose of needle and syringe in sharps container. A review of the facility's policy titled Sharps Disposal (revised January 2012) revealed: Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure it provided an effective discharge planning process that evaluated and identified changes requiring modifications and updates as needed for 1 (Resident #1) of 4 residents reviewed for discharge. Failure to effectively communicate discharge concerns and assess individual needs can potential put residents at risk for an unsafe discharge. The findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] from an acute hospital and was discharged home alone on 10/5/23. Resident #1's primary diagnosis was metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood, such as from an illness). Additional diagnoses included hypertension, hyperlipidemia, depression, altered mental status, cognitive communication deficit, and non-Alzheimer's dementia. Resident #1 participated in the MDS assessment, and no discharge planning was occurring. Review of the quarterly minimum data set (MDS) assessment dated [DATE] noted Resident #1 had a brief interview for mental status (BIMS) score of 14 out of 15 points, indicating she was cognitively intact and capable of making daily decisions. Resident #1 was care planned on 4/20/23 for short term care, with a goal of returning home per resident's wishes. The goal was revised on 6/12/23 and last reviewed 7/27/23 to remain in the facility for long term care. The resident was also care planned as being at risk for elopement (leaving facility without authorization), activities of daily living skills deficits, fall risk, multiple medical diagnoses and conditions and impaired cognitive function/dementia. Review of nursing progress notes found no indication the facility was actively preparing Resident #1 for a discharge home. One note dated 8/19/23 indicated Resident #1 was continually asking if she could leave. Resident #1's Medical Nurse Practitioner (NP) wrote a progress note on 10/3/23 reporting resident wanted to go home. Resident was saying her (family member and representative) was keeping her there (in the facility). When the NP went into the resident's room, she was on the phone getting her driver's license renewed and then calling her insurance company to determine status. Resident #1 reported she owned her home, was routinely gardening and very active prior to admission. The NP attempted to speak with the Social Worker, but she was not available in person. Instead, she noted she reached out via email regarding the situation. Psychiatry was consulted for a capacity evaluation. Resident #1 was noted to be alert and oriented x4 (to person, place, time, and situation). The plan was to reach out to the Director of Nursing (DON) and Medical Director (MD) to discuss this. (Photographic evidence was obtained) The Psychiatric NP saw Resident #1 on 10/3/23 for a psychiatric evaluation. The report said the Medical NP had asked she be seen and was very concerned about the resident wanting to go home. [Resident #1] often states she will become problematic and anxious if she can't go home. When seen today, [Resident #1] was conversing with staff, laughing, cutting up and having a great day. The Psychiatric NP assessed Resident #1 as disjointed at times and with difficulty with recall. She had poor memory, insight, and judgement. Diagnoses were major depressive disorder, recurrent, and anxiety due to her medical condition. Recommendations were to continue current medications, encourage activities, orient as needed, and acknowledge the resident's feelings. There was no mention of whether Resident #1 had the capacity to discharge and live on her own. (Photographic evidence was obtained) Resident #1's PCP saw her on 10/4/23 and noted the patient was looking forward to going home. He mentions she has underlying dementia and had transitioned to long term care. Diagnoses included hypertension, hyperlipidemia, chronic kidney disease and unspecified dementia without behavioral disturbance. The PCP noted he discussed this with the Executive Director, and that [Resident #1] will need a psych eval for competency to make her own decision. (Photographic evidence was obtained) Further review of Resident #1's record found no assessment was completed of her competency or capacity to live independently. There was no evidence the interdisciplinary team (ID Team) discussed Resident #1's capacity to discharge home. Per a nursing progress note dated 10/5/23, Resident #1 discharged at 1300 (1:00 pm) that day. Her medications were sent with her. She was alert and walked out of the facility alone for transport. A Functional Status Evaluation for discharge date d 10/5/23 noted Resident #1 was independent with eating, oral care, toileting hygiene, bathing, dressing upper and lower body, putting on her shoes, bed mobility, sitting, sit to stand, and transfers. Resident #1 could walk 150 feet independently. A Discharge Plan/Instruction document dated 10/5/23 reported Resident #1 discharged after reaching the optimum level of stay. She discharged home alone and was transported by car. The physician's order for Resident #1's discharge with home health services was dated 10/5/23 and ordered by her PCP. The order was taken off by Licensed Practical Nurse (LPN)/Unit Manager (UM) A and electronically signed on 10/6/23 by the Medical Director. (Photographic evidence obtained) A telephone interview was conducted with Resident #1's PCP on 10/9/23 at 1:33 pm. He said he was shocked when he heard Resident #1 was allowed to go home. Resident #1's sister called him a few days ago and told him. He recalled seeing Resident #1 (on 10/4/23) but said he did not order the discharge; she needed a psych evaluation first, due to underlying dementia. The PCP explained Resident #1 was elderly, and he was not ready to let her go home. The PCP was told that her physician's order to discharge on 10/5/23 was ordered by him. He said he did not order her discharge; he did not know who did. The PCP said he just spoke with the ED and told her he was shocked over the discharge. The ED had no explanation and said she didn't know what happened, as she was out for a wedding. She knew nothing. Resident #1's Psychiatric NP was interviewed via telephone on 10/9/23 at 1:35 pm. She confirmed she saw Resident #1 last week and that the Medical NP had expressed concern about her potential to discharge. However, nobody reported to her that a discharge was scheduled. Resident #1's cognitive status was the biggest barrier to her living independently. She has told the facility this in the past and has documented that Resident #1 was not appropriate for discharge home with no caregiver. The Psychiatric NP was asked if anyone contacted her to assess Resident #1's capacity, per the PCP's recommendation on 10/4/23. She stated, No. She further stated, This resident lacks capacity to reside on her own. The Social Services Director (SSD) was interviewed on 10/9/23 at 2:08 pm. She stated she only recently started working in the facility, but then went on leave for a week and a half. She returned on the day of Resident #1's discharge (10/5/23). During the morning meeting that day, she learned the Medical NP had been in to see the resident. Being as independent as she was, and having a BIMS of 14, they felt she was ready to discharge home. However, the SSD had not been involved in Resident #1's discharge planning since she was on leave. Her assumption was that Resident #1 had already been deemed safe to go home. On 10/9/23 at 2:20 pm, the Unit Manager (UM) was asked about Resident #1's discharge order. She replied on the day of discharge, Resident #1's PCP was in the building. He walked past her (the UM's) office and asked her, Why is she (Resident #1) here? She can discharge, get her out of here! The UM insisted the Medical NP also said Resident #1 was okay to discharge. The UM did not know Resident #1 well enough to question the discharge, as she only worked in the facility for 3 weeks. She admits to taking off the physician's order to discharge under the PCP's verbal directive. She confirmed it was the Medical Director, not the PCP, who reviewed the order, set up home health, and signed off on the order. The UM was told Resident #1's PCP had recommended a psych evaluation the day before discharge to determine capacity prior to going home, but it was never completed. The UM said she did not know if the Psychiatric NP had reviewed his note/recommendation that a capacity evaluation was needed. The Medical Director (MD) was interviewed on 10/9/23 at 2:30 pm. He said he did not know Resident #1 well; she was [PCP's] patient. The MD confirmed signing Resident #1's discharge order on 10/6/23. As he recalled, staff could not get hold of the PCP that day to do so, so he signed. He would assume everything would be in place for discharge. When advised of the PCP's recommendation for a psych evaluation prior to discharge, the MD said he had no awareness of any follow-up evaluation. He had no explanation why Resident #1 was not evaluated for capacity and asked, What can I do to fix this? The MD said, moving forward, he would consider a different approach. The DON was interviewed on 10/9/23 at 3:15 pm. She explained Resident #1 did not come in for long term care. Later, Resident #1's representative asked the facility to keep her and not let her go home. The DON explained Resident #1 has BIMS 14 and always wanted to go home. They say sometimes she can be confused, but she never saw that. The Tuesday before discharge (103/23), the DON received a message from the Medical NP saying she wanted to talk about Resident #1. The NP told her Resident #1 wants to go home and needs to be discharged . The NP recommended she be discharged , as she has a BIMS of 14; she felt she should be allowed to go home. The NP was concerned, so we made sure everything was checked before she went home (electricity on, etc .). Everybody else said they had talked to the PCP, and he was ok with discharge. When asked who everybody else was, she said she could not recall. The DON continued, saying Resident #1's representative called Saturday and was upset because she didn't want Resident #1 at home. Resident #1's neighbors had concerns about her ability to live alone without someone to watch her. This surveyor advised the DON of the PCP and NP's documented concerns and recommendations, and of the contradicting interviews related to this resident's discharge. The DON replied by insisting that the Medical NP felt Resident #1 shouldn't be here. The ED was interviewed on 10/9/23 at 3:34 pm. She explained Resident #1 asked multiple times why she couldn't go home and didn't understand how her representative obtained that authority to keep her in the facility. The ED was not aware there were discrepancies or concerns about Resident #1 going home among ID Team members. The ED explained she was on leave when the discharge happened. When advised of the contradicting record reviews and interviews, and failure to obtain a capacity determination prior to discharge, the ED acknowledged the concern and the contradictory information. The ED expressed awareness that without a cohesive ID Team determination, it was not possible to verify Resident #1 was safe to discharge. On 10/9/23 at 3:48 pm, the DON requested the Medical NP who saw Resident #1 on 10/3/23 be called. She insisted the Medical NP told her Resident #1 should go home! The Medical NP said Resident #1 shouldn't be here. The Medical NP will tell you, call her. A telephone interview was conducted with the Medical NP at this time (she was on speakerphone and the DON and ED were both in the room). The NP said she spoke with the Psychiatric NP, and they both agreed Resident #1 did not have capacity to live on her own and should not be discharged . (The DON's head abruptly dropped to the desk and she rested her forehead on her folded forearms). The NP didn't know Resident #1 had been allowed to discharge; the Psychiatric NP said Resident #1 wasn't competent. The Medical NP explained it was her impression everyone (in the facility) said Resident #1 couldn't discharge without 24-hour care. She even talked to the DON about this resident's need for 24-hour care. No official evaluation was done for capacity, but I can tell you now, I do not feel she was competent. The Medical NP did admit this was her first time seeing Resident #1, as she was covering for another practitioner that day. She said the Psychiatric NP told her Resident #1 gets confused, although seems alert and oriented. When asked if she or the Psychiatric NP documented their determination that Resident #1 was unsafe for discharge, she said, That is why I asked the Psych NP. She looked through the record and confirmed no capacity evaluation was completed prior to discharge. A review of the facility's policy titled Interdisciplinary Discharge Planning (Document SS-195 effective 11/30/13) revealed the following: Policy: Discharge Planning begins on the day of admission. The process involves the resident and family, Care Management/Social Services, and those members of the clinical team involved in the resident's care. Procedure: 1. A discharge goal and estimated length of stay will be established upon admission and reviewed/revised at the resident's first and subsequent team conference(s). The goal is based upon clinical findings, available community and family resources, and resident and family goals. 2. Discharge plans are adjusted, as appropriate, at subsequent team conferences . 6. If the Interdisciplinary Team determines the resident is at risk regarding discharge, Social Services is to notify a local agency for at risk persons in the community. (Copy obtained) A review of SS-197 Attachment A - Social Services -- Discharge Planning Checklist (Eff. 01/10) revealed the following: -Discharge plan and home care services confirmed by team. -Discharge planning conference held and/or offered to resident/family. (Copy obtained)

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to store all drugs in locked compartments for one (Resident #4) of four sampled residents. Specifically, an expired Albuterol inhaler, not ordered by the physician, was found on the resident's bedside tray table. Failure to ensure safe and secure storage of all resident medications, can result in resident access to medications that are not their own among other potential concerns. The findings include: On [DATE] at 11:30 a.m., Licensed Practical Nurse (LPN) A was observed checking Resident #4's blood glucose level. An Albuterol inhaler was observed on the resident's bedside tray table. It was not labeled and the nurse did not remove it from the resident's room. On [DATE] at 11:35 a.m., Resident #4 was asked if she used this inhaler. She stated, Yes, I use it if I get short of breath. She was asked if she let staff know when she used the inhaler. She stated, No, should I be telling them? The inhaler was noted to have an expiration date of [DATE]. She stated she last used the inhaler yesterday (,d+[DATE]). When she was asked if she was aware that the inhaler had expired in [DATE], she replied, No, I can't read that small writing. (Photographic evidence obtained) On [DATE] at 11:40 a.m., LPN A was asked if she was aware that Resident #4 had an Albuterol inhaler in her room on her bedside table. She stated, I didn't notice it. She was asked if Resident #4 had an order for an Albuterol Inhaler. She stated, Let me check and then stated, No, not an Albuterol inhaler, but an Albuterol nebulizer. She was asked if medications should be left in residents' rooms. She replied, No, they should be locked in the med cart unless they have an order to keep them in their room. She was asked if this resident had an order to keep medications in her room. She stated no. She was asked if she had checked the expiration date on the inhaler. She stated no, and then checked and stated, Oh, this expired in January of 23. On [DATE] at 11:50 a.m., in an interview with Registered Nurse (RN) B, she was asked if residents were permitted to have inhalers in their rooms. She stated, If they have an order and a self-administration evaluation. She was asked if she was familiar with Resident #4. She stated yes. She was asked if this resident had an order to keep any medications in her room. She stated, I had a long discussion about her inhaler with her the other day. She was asking for a long-acting inhaler but her doctor didn't want to order that. She was asked if the resident had the Albuterol inhaler in her room when she spoke with her. She stated yes. She was asked if she left the inhaler in the room when they were done speaking. She replied yes. She was asked again if the resident had an order to keep medications in her room and self-administer. RN B stated, No, I don't see an order for that and I don't see that she is care planned for that. She was asked what the expiration date on the Albuterol inhaler was. She looked at the inhaler and stated [DATE]. A medical record review for Resident #4 revealed diagnoses including type 2 diabetes, COPD (Chronic Obstructive Pulmonary Disease), dyspnea, CKD (Chronic Kidney Disease), heart failure (unspecified), and anemia. The resident's medical record contained no physician's order for an Albuterol inhaler. The record review revealed an order written on [DATE] for the following: Albuterol Sulfate Inhalation Nebulizer Solution (2.5mg/3ml) 0.83%: 3 ml: inhale orally via nebulizer every 6 hours as needed for SOB (shortness of breath). A review of the eMAR (electronic medication administration record) revealed that this medication had not been signed out as having been administered since it was first ordered on [DATE]. A review of the facility's policy titled Self-Administration of Medication at Bedside (revised [DATE]) revealed: The resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medications and to keep accurate documentation of these actions. Procedure: The eMAR must identify that meds are self-administered and the medication nurse will need to follow-up with resident as to documentation and storage of medication during each med pass. If kept at bedside, the medication must be kept in a locked drawer.

Based on observations, interview, record review, and facility policy review, the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food service safety by failing to 1) Maintain milk at proper temperature during tray line service, 2) Dispose of undated food items, and 3) Ensure nourishment room refrigerator is at appropriate temperature. The findings include: 1. An observation of the kitchen was made during lunch service on 9/1/2022 at 12:00 pm. Milk was on the tray line area with no ice on them. The Certified Dietary Manager (CDM) was asked to test the temperature of the milk cartons. The first carton opened was 50 F. The second milk carton opened was at 49 F. After seeing the temperatures, the CDM proceeded to add ice to the plastic box the milk cartons were in. (Photographic evidence obtained) 2. On 9/2/2022 at 11:18 am, an observation was made of the nourishment room in the 400-hall. Seven sandwiches were sitting on a tray on top of the microwave. Only one out of seven sandwiches had the date on it. In the refrigerator, one foam plate of food was covered with another foam plate without a date or room number listed. (Photographic evidence obtained) 3. A review of the August 2022 refrigerator temperature log for the 400-hall nourishment room revealed the following days above 41 F: 44 F on August 1st, 44 F on August 15th, and 43 F on August 19th, 2022. (Photographic evidence obtained) A review of the September 2022 temperature log for same refrigerator revealed a recorded temperature of 42 F on September 2nd, 2022. (Photographic evidence obtained) The temperature log form listed a range of 35 to 45 F, as the appropriate temperature the refrigerator should stay within, which does not follow facility policy. (Photographic evidence obtained) A review of facility's Food Storage: Cold Food policy revised 9/2017 read: All time/temperature control for safety foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA food code. (Photographic evidence obtained) The facility policy titled Food: Safe Handling for Foods from Visitors dated 9/2017 read: 5. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and have temperature monitored daily for refrigeration < 41 F and freezer <10 F. (Photographic evidence obtained)

Based on observations, interviews, record review and facility policy and procedure review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, and provide maintenance services as necessary in five resident rooms (102, 500, 501, 512 and 511) affecting six (Residents #4, #59, #19, # 49, #151, and #92) out of a total of 41 residents in the sample. Specifically, there were concerns with sticky floors in bathrooms, dead roaches, debris on floors and under resident's beds, enteral feeding product splattered on feeding pumps, IV poles, walls, mattresses, bed frames and floors, and Air Conditioning (AC)/Heating units filters were not clean. A clean-living environment is necessary to reduce the spread of infection and promotes the highest well-being of residents. The findings include: On 02/14/2022 at 10:32 AM, Resident #4's and #59's room (#102) was observed. Enteral food product was splattered on the feeding pump, IV pole, walls, mattress, bed frame and floor. A brown biological substance was smeared on the wall near the closet over garbage can. Plastic tubing caps were on the floor. A metal screw, a dead roach, dust, and debris were on the floor under the bed. Pieces of bread were on the floor next to the garbage can. (Photographic evidence obtained) During an interview with Resident #59 on 02/15/2022 at 7:15 AM, she stated that the housekeeping staff only clean the room every other day. They mop the dirt into the corners and that's why there is a buildup of dried dirt and debris in the corners of the bathroom. The floor of the bathroom is sticky too. She stated that there are live roaches in her room at night and she if very afraid of roaches. She stated her roommate, Resident #4, cannot talk so she tries to watch out for her. The buildup of dirt and debris and the sticky floor in the bathroom were observed. (Photographic evidence obtained) On 02/15/2022 at 10:35 AM, Resident #4 was observed lying in bed, covered with a sheet and a blanket. The enteral food product had not been cleaned up. The dried on brown biological substance smeared on the wall near closet over garbage can had not been wiped off. Plastic tubing caps were on the floor. A metal screw, a dead roach, dust, and debris were under the bed. (Photographic evidence obtained) On 02/16/2022 at 9:02 AM, Resident #4 was observed lying in bed, covered with a sheet and a blanket. The enteral food product had not been cleaned up yet. The dried on brown biological substance smeared on the wall had not been wiped off. Plastic tubing caps were on the floor. A metal screw, the dead roach, dust, and debris were under the bed. (Photographic evidence obtained) During an interview with Employee A, Unit Manager on 02/16/2022 at 12:10 PM, she stated, she is very new to her position and does not know Resident #4 well. She was asked to come to the resident's room and see that it had not been cleaned appropriately. She was shown the debris on the floor and the walls, the food product on the wall, pump, pole, and floor. While in the residents' restroom, she stated that the floor in the bathroom was sticky. She agreed that it appeared the dirt and debris had been mopped into the corners. She stated that she was not sure who was responsible for cleaning up the food product, but she would let housekeeping know that they needed to come clean her room. During an interview with the Corporate Environmental Services Director on 02/17/2022 at 11:56 AM, he stated they were still cleaning Resident #4's and #59's room. He acknowledged the room needed a deep cleaning. During an interview with the Vice President of Clinical Services (VP) and the Director of Nursing (DON) on 02/17/2022 at 02:55 PM, the VP stated that any staff can clean the IV pole and pump for g-tube feedings. He stated, Our policy is if you see it, you should clean it. He informed that department heads round in the resident rooms every morning. He stated Clearly, there is room for growth, and acknowledged that room 102 was not being cleaned each day. On 02/14/2022 at 11:14 AM and again on 1:45 PM, the toilet seat and rim in Room 500 (Resident #19's room) were observed with dry debris. (Photographic evidence obtained) On 02/14/2022 at 11:26 AM, the air conditioning/heating wall unit filters in Room 501 (Resident #49's room) were observed with thickened dust and debris. (Photographic evidence obtained) On 02/14/2022 at 12:09 PM, the air conditioning/heating wall unit filters in Room 512 (Resident #151's room) were observed with thickened dust and debris. (Photographic evidence obtained) On 02/14/2022 at 12:45 PM, Room 511's (Resident #92's room) floor and over-the-bed table were both covered with dried liquid splatter. On 02/15/2022 at 9:07 AM, Room 500 was observed. The resident's toilet rim and seat were observed with dark dry debris. The floor in the resident's room was observed unclean and was sticky to the feet when ambulating from the residents' position to bathroom and around resident's bed. (Photographic evidence obtained) On 02/15/2022 at 9:23 AM, Room 512 was observed. The air conditioning/heating wall unit filters were thickened with dust and debris. (Photographic evidence obtained) On 02/15/2022 at 10:51 AM, Room 511 was observed. Enteral feeding liquid was observed splattered on the over-the-bed table, and on the floor. On 02/16/2022 at 12:35 PM, Room 511 was observed. The enteral feeding liquid was still observed on the floor and table. The maintenance manager was interviewed on 02/16/2022 at 1:40 PM. He stated that all facility hallways were being cleaned and disinfected according to facility practices. The communal shower room on the 100-200 hallway was observed on 02/16/2022 at 1:50 PM. Broken tiles were observed sitting on one of the corners of the shower area. (Photographic evidence obtained) On 02/16/2022 at 2:39 PM, Room 501 was observed. Resident's bathroom paper holder was unclean and dusty, with debris. A dirty phone charging cable was plugged into the bathroom outlet. (Photographic evidence obtained) On 02/17/2022 at 8:40 AM, the communal shower room on the 100-200 hallway was observed. The broken tiles were observed in the same position as previously seen on 02/16/2022. The communal shower was observed in continuous use throughout 02/17/2022. On 02/17/2022 at 9:25 AM, Room 501 was observed. The resident's bathroom was still unclean, and with debris. The phone charger was still plugged into a bathroom outlet that was unclean. Two certified nursing assistants (CNAs) were interviewed on 02/17/2022 at 1:58 PM. They said that all staff contribute to clean the surfaces in the residents' rooms as needed, when they see it unclean or messed-up. Both staff members verbalized that if something is spilled onto the floor, we clean it ourselves, unless it doesn't come out easy, then we call housekeeping. It was also verbalized that by one of the staff members it is everyone's responsibility to clean up after themselves, but housekeeping does the harder cleaning. The environmental services staff (EVS) was interviewed on 02/17/2022 at 2:12 PM. They stated that it was their responsibility to clean each resident room daily. This task was divided between 3 EVS staff members throughout the facility. Specifically, the staff member stated that her role included dusting furniture items, cleaning all floors and bathroom including toilet and sink, contact areas such as the bed including bed rails and call bell, and bedside table. When asked about the deep cleaning of each room, the EVS staff member verbalized that this task, which included the AC/Heating unit vents, was performed by maintenance and it was usually done once a week. A review of the facility's policy and procedure entitled, Interim Recommendations for Routine & Terminal COVID-19 Isolation Room/Unit Cleaning and Kitchen Floor Wet Mop Procedures dated 02/18/2021 read: [Contracted Environmental Services Group] and its subsidiaries promotes the health and safety of all employees, as well as that of the clients and residents we serve. Purpose: To assist in preventing the spread of COVID-19 (Coronavirus-2109) from isolation rooms units to non-infected areas/persons. Cleaning: When you clean a surface you remove all visible debris. Clean Walls: Using an EPA (United States Environmental Protection Agency) approved solution, wipe down vertical surfaces. (Copy obtained)

Based on observations, interviews and record reviews, the facility failed to ensure physician's orders for oxygen were in place prior to administering oxygen for two (Residents #301 and #453) of eight residents receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. A review of Resident #301's clinical record revealed she was admitted to the facility on [DATE] with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/14/22 at 11:03 AM, Resident #301 was observed in her room receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 Liters per minute (L/Min). The oxygen tubing was not properly connected to the concentrator and the resident was not receiving oxygen. Resident #301 denied having any difficulty with breathing. There were no signs of respiratory distress observed. (Photographic evidence obtained) The Minimum Data Set (MDS) assessment for Resident #301 was being completed by the facility and was unavailable for review. A review of the baseline care plan for Resident #301 did not indicate any oxygen use. A review of current physician's orders for Resident #301 revealed no oxygen order. On 02/15/22 at 1:05 PM, Resident #301 was observed in her room receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 L/min. During an interview with Employee U, Licensed Practical Nurse (LPN) on 02/17/22 at 10:54 AM, she confirmed that the concentrator for Resident #301 was not connected correctly, and the resident was not getting any oxygen. She stated the oxygen concentrator was set at 2.5 L/min. She was then asked to confirm Resident #301's oxygen orders. After reviewing the resident's orders, she stated, Resident #301 did not have any oxygen orders. She then notified the unit manager. (Copy obtained) During an interview with Employee B, LPN/Unit Manager on 02/17/22 at 11:00 AM, she confirmed that Resident #301 had no orders for oxygen. She added that the resident was admitted with 3 L/min oxygen, however, the orders were not entered into point click care (PCC - facility electronic medical record). She then went to the resident's room and adjusted the oxygen setting to 3 L/min. and added the oxygen orders to the medication administration record. 2. On 02/14/22 at 11:28 AM, Resident #453 was observed resting on bed receiving oxygen therapy via nasal cannula. When she was asked what her oxygen concentrator was supposed to be set, she responded, I'm unsure at what level I'm supposed to be on. The oxygen concentrator was set at 3.5 L/min. A review of Resident #453's clinical record revealed she was admitted to the facility on [DATE]. Further record review for Resident #453 revealed no physician orders for oxygen. On 02/15/22 at 01:32 PM, Resident 453 was observed sleeping in bed wearing nasal cannula. The oxygen concentrator was set at 3 L/min. On 02/16/22 at 11:17 AM, Resident 453 was observed in her room wearing her nasal cannula. The oxygen concentrator was set a 3 L/min. (Photographic evidence obtained) Skilled note dated 02/12/22 was entered at 14:26 read, Respiratory status is clear no SOB noted. Lung sounds are clear no cough noted. Oxygen is used via nasal cannula 2.5 litres/minute (l/min). On 02/17/22 at 9:28 AM, an interview was conducted with Resident #453's assigned nurse, Employee O, LPN. When she was asked to confirm Resident #453's current oxygen orders, she stated, I think she is on two liters (O2 flow), let me check. I believe it's two liters. After looking in PCC and hard chart, Employee O, LPN stated, I do not see any orders for O2. She explained that the nurses gets the orders of what the resident needs from the medication administrative record (MAR).

Based on observations, interviews, record review and facility policy and procedure review, the facility failed to ensure nutritional supplements kept in 2 of 2 nourishment refrigerators were stored in accordance with professional standards for food service saftey and failed to ensure equipment in the nourishment rooms were clean and free of debris. The findings include: During an observation of the two-nourishment rooms in the facility on [DATE] at 12:21 PM revealed the following: Each refrigerator had a container of Med Pass which were expired (expiration dates of [DATE] and [DATE]). A review of the Medpass shake instructions revealed, use within 4 days of opening. (Photographic evidence obtained) The freezer in the nourishment room on hall 200 contained a dried brownish stain in it. (Photographic evidence obtained) Microwaves in the nourishment rooms were not clean. One microwave had dried reddish stain in it and the other had a dried whitish stain in it. (Photographic evidence obtained) On [DATE] at 10:14 AM, a second observation of nourishment room on hall 200 revealed the same results as the observation on [DATE]. Refrigerator had a container of Med Pass which was expired (expiration date of [DATE]). The freezer in the nourishment room on hall 200 contained a dried brownish stain in it. (Photographic evidence obtained) One microwave had dried reddish stain in it. (Photographic evidence obtained) An interview was conducted with Employee M, Certified Nursing Assistant (CNA) on [DATE] at 10:30 AM. Employee M stated that the CNAs pass snacks and drinks from nourishment room. An interview conducted with Employee N, Licensed Practical Nurse (LPN) on [DATE] at 10:24 am. Employee N, LPN stated that the nurses check refrigerator temperatures and housekeeping cleans the microwave and refrigerator. The CNAs try to keep the counters clean, and the dietary staff checks the refrigerator for expired items. An interview was conducted with Director of Nursing (DON) on [DATE] at 2:45 PM. The DON stated that CNAs, unit manager, and dietary staff keep nourishment rooms clean. She stated that CNAs clean inside the refrigerator. During an interview with the Certified Dietary Manager (CDM) on [DATE] at 3:25 PM, he confirmed the dietary staff was responsible for cleaning the refrigerators and bringing snacks to nourishment room. A review of the facility's policy for Safe Handling for Foods from Visitors, dated ,d+[DATE], stated #5. Refrigerators/freezers for storage of foods brought in by visitors will be properly maintained and have temperature monitored daily. Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more than seven days and cleaned weekly.

Based on observations, clinical record review and interviews, the facility failed to provide reasonable accommodation of individual needs by ensuring one (Resident #92) of 41 residents in the sample, from a total of 102 residents had access to his call light at all times. The findings include: A review of Resident #92's clinical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Minimum Data Set (MDS) assessment completed on 01/24/2022, documented his Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. He required extensive 2 person assist with bed mobility and transfer. The resident had impairment of his right side and was wheelchair bound. On 02/14/2022 at 12:45 PM, Resident #92 was observed in bed watching television. The call button was not within reach. Resident stated, he was unaware he had a call button. The resident's hand use was notedly impaired. (Photographic evidence) On 02/15/2022 at 10:55 AM, Resident #92 was observed in bed watching television. The resident's call button was within reach. The resident tested his call button to demonstrate he was able to use it with his left hand. On 02/16/2022 at 12:35 PM, Resident #92 was observed in bed watching television. The resident's call button was observed on the floor by the bed and not within reach. (Photographic evidence) On 02/17/2022 at 1:00 PM, Resident #92 was observed in bed watching television. The call button was not within reach of the resident. (Photographic evidence) A review of Resident #92's care plan, dated 04/23/2021, revealed a focus area for communication problem related to the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to keep the call light within reach, adequate low glare light, to have the resident bed in the lowest position, and to avoid isolation. An interview was conducted with Employee S, Certified Nursing Assistant (CNA) on 02/17/2022 at 1:15 PM. She stated, she checked the placement of Resident #92's call buttons before lunch today and frequently throughout her shift, for each resident. The CNA observed the call button for Resident #92, out of reach. She stated that it was each staff members responsibility to notify maintenance if a call light was missing a clip to hold it in place. The CNA stated that the resident never presses his button anyway. An interview was conducted with Employee T, Occupational Therapy Assistant (OTA) on 02/17/2022 at 1:20 PM, who was familiar with Resident #92. The OTA stated that she was familiar with the type of call button for the resident, and that his level of hand dexterity was appropriate for the type of call button he had been provided. She stated each call light should have a clip, and she recommended it be clipped to his person. The Director of Nursing (DON) was interviewed on 02/17/2022 at 2:45 PM. The DON was unaware of any call light policy at the facility. The DON stated that department heads make rounds to check each room daily in the morning, and again at 2:30 PM. The facility did not keep records of the rounds. The DON stated that it was the responsibility of all staff to ensure the call button lights remained reachable, and that there was frequent training on call lights, but not necessarily as to the proper placement. She confirmed that call light buttons should always be accessible to residents. The DON was unaware as to the call button status or placement for Resident #92. .

Based on interviews and record reviews, the facility failed to ensure the resident's right to make choices about aspects of his or her life by failing to make appointments for health care services for one (Resident #51) of three residents reviewed for medical appointments, out of a total of 41 residents in the sample. The findings include A clinical record review for Resident #51 revealed he was admitted to the facility on [DATE]. On 02/14/2022 at 2:11 PM, an interview was conducted with Resident #51. He reported, he had been waiting to see an orthopedic surgeon and a dermatologist. A review of the resident's Quarterly Minimum Data Set (MDS) assessment completed on 01/04/2022, documented his Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. Further record review for Resident #51 revealed a physician referral made on 12/15/2021 to see an orthopedic doctor. A dermatology consult referral was made and signed on 12/15/2021. A second referral form for a dermatology consult was signed off by prescribing physician on 01/20/2022. Appointments for these referrals could not be found. On 02/17/2022 at 11:04 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN)/Unit Manager. She reported, she had just started a month ago and was not aware of Resident #51 needing appointments. She also stated, she had made a couple of appointments for other residents but only because they were left on her desk. She reported there is no scheduling nurse currently. On 02/17/2022 at 2:45 PM, an interview was conducted with the Director of Nursing (DON). She reported that the unit clerk makes the appointments, but we do not have one at this time. She reported the unit manager is currently doing the scheduling. On 02/17/2022 at 3:41 PM, a second interview was conducted with the DON. She was asked if Resident #51 has any upcoming appointments. She stated No, none that I've found.

Based on observation, resident interview, clinical record review, staff interview and facility policy and procedure review, the facility neglected to provide vascular consultant services to one resident (#1) out of three sampled residents for pressure wound care that were necessary to avoid physical harm. Resident #1's wound care physician recommended a consult by a vascular specialist after a diagnostic test revealed an arterial occlusion in the right lower leg of the resident. The wound care physician was treating a pressure wound on the lateral right ankle that was not healing and became infected. The facility failed to arrange for the consult and carry out the order of the primary care physician to refer the resident to a vascular specialist. Resident #1's wound continued to deteriorate, and she developed three new wounds on the right lower extremity. The wound care physician initiated an emergency transfer to the hospital where the resident's right leg was amputated above the knee due to gangrene infection in the existing wound. Neglecting to arrange for the vascular consult delayed the ability of the interdisciplinary team to be informed and make critical clinical decisions that may have been instrumental in avoiding the resident's need for an amputation. The findings include: Resident #1 was observed on 10/14/2020 at 11:20 am lying in her bed with her eyes closed. The room was dark, and the privacy curtain was pulled. Resident #1 did not respond when her name was called out. No distress was noted. Upon approach she woke up and granted permission for entry into her room. When asked if she remembered the events leading up to the day when she was transferred to the hospital in April 2020 where her right leg was amputated, she remembered that there was a wound on her ankle, and it got infected. She did not remember much else. She could not remember the doctors telling her much about it. The resident's right leg appeared to have been amputated above the knee joint. She stated that she has no pain in the right leg. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed as having [DIAGNOSES REDACTED]. She has impairment in both lower extremities and uses a wheelchair for mobility. Review of the care plan dated 5/22/2020, revealed the resident was readmitted to the facility on [DATE] with a right above the knee amputation. Risk for skin impairment and pressure ulcers. At risk for complications/discomforts related to amputation (Copy obtained). The prior care plan indicated wound care to the right lower extremity prior to this admission. Resolved. Review of the wound care physician's progress notes for Resident #1 dated 03/11/2020 revealed: Patient present with wound on her right lateral ankle. At the request of provider (Primary Care Physician) a thorough wound care assessment and evaluation was performed today. She has an unstageable (due to necrosis) of the right lateral ankle for at least 1 days duration. There is no exudate. The wound (Site 1) Unstageable (due to necrosis) of the right, lateral ankle, measured L 2.0 cm (centimeters) x W 2.0cm x D not measurable cm. Surface area 4.00cm (squared). Thick adherent black necrotic tissue (eschar) 100%. Etiology: pressure. Examination of left lower extremities: No [MEDICAL CONDITION]. Foot hot. Recommend intravenous (IV) antibiotics to address peri wound [MEDICAL CONDITION] and right foot x-ray to assess for osteo[DIAGNOSES REDACTED] (OM). Off-load wound. Facility does not allow bedside debridement. I will discuss with facility and primary care physician to send patient to outpatient clinic for procedure. This patient's care was discussed with another health care provider nursing staff member during this visit (Copy obtained). Review of the Doppler Report dated 03/11/2020 revealed: Results: Right Lower Extremity Arterial Duplex Ultrasound: Clinical history: nonhealing wounds. Waveforms are monophasic continuous throughout the extremity with tardus parvus visualized in the mid- and distal superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries with velocities of 235, 90, 29, 60, 23, 24, and 15 cm/sec. Conclusion: Moderate to high degree stenosis throughout the extremity based upon tardus parvus waveforms throughout. Recommend angiographic correlation if treatment is considered. On the form was a handwritten note that read: Consult with (Vascular Consultant) signed by the wound care physician and dated 03/12/2020 (Copy obtained). Review of the physician's order dated 3/12/2020 revealed: Infectious Disease (ID) consult for wound [MEDICAL CONDITION]. Cardiology evaluation for [MEDICAL CONDITION] (Vascular Consultant). Review of the wound care physician's progress note for Resident #1 dated 03/18/2020 revealed: This patient has multiple wounds. At the request of provider (Primary Care Physician) a thorough wound care assessment and evaluation was performed today. She has an unstageable deep tissue injury of the right lateral foot for at least 1 days duration. Site 1: Unstageable (due to necrosis) of the right, lateral ankle, measured L 3 cm x 4 cm x not measurable cm. Surface area: 12.00 cm squared. Thick adherent black necrotic tissue (eschar) 100%. Wound progress: deteriorated. Site 2: Unstageable deep tissue injury of right lateral foot. Etiology: pressure. Wound size 1.5cm x 1.5cm x measurable cm. Surface area : 2.25 cm squared. Exudate: none. Site 3: Unstageable deep tissue injury of right heel. Etiology: pressure. Wound size: 3.5cm x 5.0 cm x measurable cm. Surface area: 17.50 cm squared. Exudate: none. Site 4: Unstageable deep tissue injury of right proximal dorsal foot. Etiology: pressure. Wound size: 8.0 cm x 4.0 cm x measurable cm. Surface area 32.00 cm squared. Exudate: none. Recommendation: Off load wound; float heels in bed; EZ boots to be worn in bed and chair to off-load wound. Additional wound detail: patient on IV [MEDICATION NAME] per infectious disease - vascular also following-pending angiogram. This patient's care was discussed with another health care provider nursing staff member during this visit (Copy obtained). Review of the physician's orders for Resident #1 revealed an order dated 3/24/2020 that read: Refer to vascular specialist RLE (right lower extremity). The indication/[DIAGNOSES REDACTED]. Review of the wound care physician's progress note for Resident #1 dated 03/25/2020 revealed: This patient has multiple wounds. Patient present with wound on her right lateral ankle. At the request of provider (Primary Care Physician) a thorough wound care assessment and evaluation was performed today. She has an unstageable (due to necrosis) of the right lateral ankle for at least 13 days duration. There is moderate purulent exudate. The patient appears to have associated pain evidenced by grimacing. The wound (Site 1) Unstageable (due to necrosis) of the right, lateral ankle, measured 5.0 cm x 6.0 cm x not measurable cm. Surface area: 30.00 cm squared. Peri wound radius [DIAGNOSES REDACTED], Exudate: Moderate purulent. Thick black necrotic tissue (eschar) 100%. Wound progress: deteriorated. Site 2: Unstageable deep tissue injury of the right, lateral foot. Etiology: pressure. Wound size 1.8 cm x 2.4 cm x not measurable cm. Surface area: 4.32 cm squared. Exudate: none. Blister: fluid filled. Wound progression: deteriorated. Site 3: Site 3: Unstageable deep tissue injury of right heel. Etiology: pressure. Wound size: 5.0 cm. x 6.0 cm x not measurable cm. Surface area: 30.00 cm squared. Exudate none. Wound progression: deteriorated. Site 4: Pressure wound of right proximal dorsal foot. Etiology: pressure. Wound size: 13.0 cm x 6.0 cm x not measurable cm. Surface area: 78.00 cm squared. Exudate: light serous. Wound progression: deteriorated. Additional wound detail: patient on IV [MEDICATION NAME] and followed by the infectious disease and vascular-pending Computed Tomography angiogram (CTA) of the right lower extremity (Copy obtained). Review of the wound care physician's progress note for Resident #1 dated 04/01/2020 revealed: This patient has multiple wounds. She has an arterial wound of the right proximal, dorsal ankle for at least 14 days duration. There is moderate serosanguinous exudate. The patient appears to have associated pain evidenced by grimacing. The wound (Site 1) Stage 4 pressure wound of the right, lateral ankle. Wound size L 9cm x W 6 cm x not measurable cm. Surface area: 54.0 cm squared. Exudate: Heavy serosanguinous. Thick adherent black necrotic tissue 100%. Site 2: Unstageable DTI of the right, lateral foot. Wound size L 2.5 cm x W 2.5 cm x not measurable. Surface area: 6.25 cm squared. Exudate: None. Blister: fluid filled. Wound progression: deteriorated. Site 3: Unstageable DTI of the right heel. Wound size: L 5.5 cm x W 5.0 cm x not measurable cm. Surface area: 27.50 cm squared. Exudate: none. Wound progression: improved. Site 4: Arterial wound of the right proximal, dorsal ankle. Etiology: arterial. Duration > 14 days. Wound size: L 8.0cm x W 6.0 cm x 1 cm. Surface area: 48. 0 cm squared. Exudate: Moderate serosanguinous. Thick adherent black necrotic tissue 90%. Granulation tissue: 10%. This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of the biofilm. Wound progress: improved. This patient's care was discussed with another health care provider nursing staff member during this visit (Copy obtained). Review of the wound care physician's progress note for Resident #1 dated 04/08/2020 revealed: This patient has multiple wounds. She has a Stage 4 pressure wound of the right, lateral ankle for at least 25 days duration. There is moderate serous exudate. The patient appears to have associated pain evidenced by grimacing. The wound (Site 1) Stage 4 pressure wound of the right, lateral ankle. Wound size L 10.5 cm x W 6.5 cm x not measurable cm. Surface area: 68.25 cm squared. Thick adherent black necrotic tissue 90%. Granulation tissue 5%. Other viable tissue 5% (tendon). Wound progression: deteriorated. Additional wound detail: Patient needs to go to the hospital today for vascular intervention ASAP-back on IV vanc per ID. Site 2: Unstageable DTI of the right, lateral foot. Wound size L 5.0 cm x W 4.0 cm x not measurable. Surface area: 20 cm squared. Exudate: None. Blister: fluid filled. Wound progression: deteriorated. Site 3: Unstageable DTI of the right heel. Wound size: L 5.5 cm x W 5.0 cm x not measurable cm. Surface area: 27.50 cm squared. Exudate: none. Wound progression: no change. Site 4: Arterial wound of the right proximal, dorsal ankle. Etiology: arterial. Duration > 14 days. Wound size: L 9.0cm x W 7.0 cm x 1 cm. Surface area: 63. 0 cm squared. Exudate: light serosanguinous. Thick adherent black necrotic tissue 80%. Granulation tissue: 10%. Other viable tissue (tendon) 10%. This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of the biofilm. Wound progress: deteriorated. Debridement not indicated secondary to severe [MEDICAL CONDITION] (Copy obtained). Review of the physician's orders for Resident #1 revealed an order dated 4/08/2020 that read: Send to (hospital) for further evaluation with treatment due to wound deterioration. The order was taken verbally and given by the wound care physician (Copy obtained). Review of the cardiology consult progress notes revealed: 03/18/2020 Resident #1 consulted due to recent findings of moderate to high stenosis throughout right lower extremity due to wounds not healing. Recommend vascular specialist (Copy obtained). 03/20/2020 Patient seen today. Blood pressure is elevated likely due to pain form wound. Recommend vascular specialist (Copy obtained). 03/24/2020 Patient seen and examined today. Care discussed with wound care nurse at bedside. Wound care nurse reports that wound is not healing and has reported to PCP of wound status and treatment moving forward. Discussed that patient is to be seen by vascular specialist. Recommend vascular specialist (Copy obtained). Review of primary care physician progress notes [REDACTED].>03/09/2020 Wound care nurse reports drainage and redness to ankle wound and treatment in place. Advise to culture wound. Patient reports pain to touch at wound site. Skin: Right lateral ankle wound and purulent drainage and [DIAGNOSES REDACTED] surrounding wound. Right ankle wound [MEDICAL CONDITION] - new. Acute. Wound culture. Consult wound care MD, continue dressing changes per wound care, start [MEDICATION NAME] x 10 days (Copy obtained). 03/12/2020 Labs: wound culture - light growth of staphylococcus. Doppler: arterial stenosis. Right ankle wound [MEDICAL CONDITION] - on [MEDICATION NAME]. Consult ID since wound care reports possible need for IV antibiotics. Wound-multifactorial possible DTI vs PAD (Peripheral artery disease). Wound care to follow. PAD - severe. Cardiology to evaluate for possible intervention (Copy obtained). 03/17/2020 Wound culture came back [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). Cardiology has evaluated patient for [MEDICAL CONDITIONS]. Right ankle wound [MEDICAL CONDITION] -[MEDICAL CONDITION]. ID is following. On vanco with pharmacy and ID managing dosing. Isolation (Copy obtained). 03/19/2020 Patient seen for DTI on right heel. Right leg is more contracted and causes increase in discomfort. Patient continues to receive IV antibiotics with Vanco trough being low. Dose of medications to be adjusted by ID and pharmacy. Right lateral malleolus wound with discharge. Right heel DTI (Copy obtained). 03/24/2020 Patient continues with IV antibiotics. Pain management to assess. Right lateral malleolus wound with discharge. Right heel DTI. Patient continues to receive IV antibiotics with Vanco. ID is following (Copy obtained). 03/26/2020 Drainage from wound persists with wound care reporting that dressing changes were adjusted. It was also reported that wound care MD asked for ID re-evaluation since he believes that wound remains infected despite no leukocytosis, fever and patient being on antibiotics. Conflicted information obtained from wound care nurse. Right lateral malleolus wound with discharge. Right heel DTI. Discussed wound care with wound care nurse and asked to intensify wound care and drainage control. Discussed DTI and use of heel protectors (Copy obtained). 03/30/2020 Patient is afebrile. Wound care continues. Right lateral malleolus wound with discharge. Right heel DTI. Right ankle wound [MEDICAL CONDITION] -[MEDICAL CONDITION]. ID is following. Vanco completed 03/27/2020. DTI - needs position changes. Wound care follows (Copy obtained). 04/02/2020 Seen and examined. Patient has had fever of 102 yesterday. Work up was performed and it appears that patient has developed UTI (urinary tract infection). Right lateral malleolus wound with discharge. Right heel DTI. Right ankle wound [MEDICAL CONDITION] -[MEDICAL CONDITION]. Antibiotics for 4 weeks. Records reviewed including medications. Care coordinated with RN (registered nurse) (Copy obtained). 04/06/2020 Patient is afebrile. Arterial: Patient has decreased pedal pulses bilaterally. No [MEDICAL CONDITION] in extremities. Right lower extremity contracture. Right lateral malleolar wound. Right heel DTI. UTI -acute. Continue [MEDICATION NAME] until 04/08/2020. Leukocytosis -mile. Acute. [DIAGNOSES REDACTED] predominance. Likely due to wound infection and UTI. PAD - Vascular work up pending (Copy obtained). 04/07/2020 Patient is afebrile. Right lower extremity contracture. Right lateral malleolar wound. Right heel DTI. Right ankle wound [MEDICAL CONDITION]. UTI - acute. Continue [MEDICATION NAME] until 04/08/2020. Leukocytosis - resolved. Right ankle wound will need aggressive wound care by wound care team. PAD - Cardiology is following. Vascular work up pending (Copies obtained). During an interview with the Director of Nursing (DON) and the Regional Nurse Consultant on 10/15/2020 at 12:35 pm, the DON confirmed the physician's orders for a vascular consult had not been carried out. The DON stated that the physician who is contracted for vascular consults is elderly and due to the COVID-19 pandemic he stopped making in-person assessments of the residents. The last time he came to the facility was in March 2020. Since then, they have not had a vascular specialist to refer to. He was of the understanding that the primary care physician could assess the residents for vascular problems. During a telephone interview with Resident #1's primary care physician (PCP) on 10/15/2020 at 1:28 pm he stated, I am considered her PCP/Nursing Home doctor. When she developed the wound, we consulted cardio, wound care doctor, and Infectious Disease (ID). I don't remember discussing it with the cardiologist, but usually the cardiologist will take the resident to their office to do a procedure. He stated that he is not a vascular specialist and that Resident #1 should have been referred out to a vascular surgeon after the Doppler results came back that there was an occlusion in the lower leg. The facility should have acted on the physician's order right away on 3/24/2020. He was not sure why the order was not written until 3/24/2020 when the Doppler had been done on 3/11/2020. He did not remember writing it and thought maybe his Advanced [MEDICATION NAME] Registered Nurse (APRN) wrote it. He stated the occlusion meant that there was not as much blood flowing into the limb to aid in the healing process for the pressure ulcer. The wound was infected, and they were administering Resident #1 a very powerful antibiotic, [MEDICATION NAME], but it was not enough because of the lack of blood supply to the area. He further stated, I would never disagree with a consultant's recommendation. When cardio recommends, I always agree with him. He confirmed that wound care recommended a vascular specialist. I'm not a specialist. If they asked me if she needs vascular consult I always agree. They are also doctors so they can write orders and the facility can carry out the orders. If doctor (Vascular Consultant) was not coming in to the facility, they could send her to another vascular specialist. I would not argue with that. During a telephone interview with the facility's current wound care physician on 10/15/2020 at 4:25 pm he stated, If it was me, I would call the PCP myself to expedite the order. If it wasn't an emergency, it might take weeks. If it was an emergency, they should send her out right away. If it was an old occlusion it might slow healing but if it was an emergency, they should have sent her immediately. During a telephone interview on 10/15/2020 at 4:49pm with Resident #1's wound care physician at the time of the amputation, he confirmed he was providing wound care to Resident #1 prior to the amputation and for a while after the amputation. He stated that he had been made aware of the occlusion in the right lower extremity and that the blood flow to the wound he was treating was compromised. He remembered that he had written an order for [REDACTED]. He remembered that he continued to note in his progress notes when he saw her that he wanted a vascular consult. He stated that when a consult is requested, the expectation is that it would be carried out within a week or two if it was not an emergency. For Resident #1, he expected it be done the following day. He could see that her pressure ulcer wounds were getting much worse and nothing was being done so he decided to send her to the hospital on [DATE] because something had to be done and the wounds were getting worse. He stated he was not a vascular surgeon, but he felt the occlusion and contracture contributed to the worsening of the wounds. Blood flow was impeding the healing process. He explained that the wound needed more blood with nutrients and the antibiotic she was receiving to heal the wound. The wound was deteriorating, and she developed three new wounds on the right foot before he finally sent her out to the hospital on [DATE]. He stated he could not say for sure that the delay in sending her to the hospital is what caused her to have her leg amputated, but the occlusion in her leg did compromise the amount of circulation in that leg and impeded wound healing. He confirmed the wound was infected and the resident was being treated with [MEDICATION NAME] and [MEDICATION NAME] intravenously. He stated, There was a delay in getting the vascular consult done. He did not know why. He stated, Things were really going downhill, so yes, I sent her out. I thought it was an emergency at that point. Review of the facility policy and procedure entitled Clinical Guideline Skin & Wound WC-100 effective 4/01/2017 revealed: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Process: Develop individualized goals and interventions Monitor residents' response to treatment and modify treatment as indicated. Evaluate the effectiveness of interventions, and progress towards goals during the care management meeting and as needed. Review of the facility policy and procedure entitled Abuse, Neglect, Exploitation & Misappropriation, N-1265, effective 11/30/2014 and revised on 11/28/2017 read: Neglect is the failure of the center, 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. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that cased by improper or excessive action. Reference: Acute arterial occlusion is synonymous with acute limb ischemia and is considered a vascular emergency. Acute limb ischemia is defined as a sudden loss of limb perfusion for up to 2 weeks after the initiating event. Acute arterial occlusion can occur in any peripheral artery of the upper and lower extremities. [DATE]. Acute Arterial Occlusion - StatPearls - NCBI Bookshelf.www.ncbi.nlm.nih.gov > books > NBK4418

Based on observation, resident interviews, staff interviews, and record review, the facility's abuse policies failed to prohibit sexual abuse of 1 resident (Residents #1), out of 5 residents reviewed for abuse. The facility had knowledge that Resident #1, who was severely cognitively impaired, exhibited sexualized behaviors toward Resident #2. The facility did not report these behaviors to Resident #1's psychiatric provider, or protect the resident from Resident #2, who was at a much higher level of cognitive function. The facility also had knowledge that an employee reported an allegation of sexual abuse involving residents #1 and #2 on February 9, 2015, but failed to investigate the allegation of abuse and ensure that Resident #1 was protected from the alleged perpetrator from 02/09/2015 to 02/13/2015. After the staff member's allegation, the alleged abuser continued to reside in the same location within the facility and to have unencumbered access to Resident #1 from 02/09/2015 through 2/13/2015 at approximately 1:00 pm, when both residents were put on one-to-one supervision. This resulted in Immediate Jeopardy beginning on 2/09/2015. The facility's failure to prevent and investigate physical abuse, protect the victim, and monitor the alleged abuser, placed residents in the facility who were cognitively impaired at risk for serious injury, harm, or impairment. Immediate Jeopardy was ongoing on exit on 2/17/15. Substandard quality of care was identified at F-224 (S/S J). Cross reference to F-225 (S/S J), F-226 (S/S J), and F-323 (S/S J). The findings include: A complaint survey was conducted at the facility on 02/12/2015 at 9:10 am. The anonymous complaint alleged facility failure to prevent and investigate an incident of resident to resident sexual abuse. A review of the medical record for Resident #1 revealed a nursing note, dated 02/09/2015 at 1:40 pm, that read, "Writer observed resident giving oral sex to another resident (Resident #2). Writer immediately stopped both residents and separated them. Proper supervisor as well as Social Services was notified. Social Services will notify families of incident. Resident (#1) is alert with dementia. Resident (#1) has to be redirected at times. Wanders throughout the facility. Resident (#1) has WanderGuard? (a signaling device that alarms when the resident exits the property) in place. Resident tolerated meds (medications) well today. No SOB (shortness of breath) noted. Denies pain. Resident will be monitored closely." The note was signed by Employee A, Licensed Practical Nurse (LPN). In a telephone interview on 2/12/2015 at 4:28pm with Employee A, she stated that on 2/09/2015, at approximately 1:20 pm, as she was walking down the hall and passed by Resident #1's room, she glanced into the room and saw a man with his pants down, standing next to the bed nearest to the window. She stated she knew that was Resident #1's bed, and she became alarmed. Employee A stated that she went into the room and saw Resident #1 lying in her bed on her left side, facing Resident #2. Resident #1 was supporting herself on her elbow, and had her hand on Resident #2's penis in her mouth. Employee A stated in the interview, "I saw it happening. I physically saw it. I know what I saw." She stated she immediately told the residents to stop, and for Resident #2 to leave the room. She stated she went to the nurses' station and immediately reported the incident to the Unit Manager (UM). She stated that the UM told her to report the incident to the Director of Nurses (DON) right away. Employee A stated that she then spoke with the Social Services Director (SSD) about the incident, and they both reported it to the DON. Employee A stated that the DON treated her like she was lying about what she saw, and told her and the SSD that nothing could be done about the incident, because the residents were consenting adults. Employee A stated that she told the DON that Resident #1 was not able to consent because she had advanced senile dementia, and she was not as high functioning mentally as Resident #2. She stated that she told the DON that she was afraid that Resident #2 may have and would continue to take advantage of Resident #1. She stated that the facility should not allow this to happen even if it appeared that Resident #1 was not harmed. In an interview on 2/13/15 at 1:30pm with the SSD, she said that she told the DON that she had interviewed both residents, and that both were denying the allegation. The SSD said that Employee A then told the DON again that she saw the incident, and she was sure of what she saw. The DON asked if anyone else saw it, and Employee A told her she didn't think so. The SSD stated that the DON then said that both residents were consenting adults. The SSD stated at the time of the interview that she did not believe Resident #1 was a consenting adult. In an interview with Employee D, CNA, on 2/13/15 at 3:05pm she stated that on 02/09/2015, she was right there at Resident #1's room at the time that Employee A said she saw Residents #1 and #2 involved in oral sex in Resident #1's room. Employee D stated that she saw Resident #2 with his hands on his pants. She couldn't see what he was doing. His pants were up. Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurses' station, and overheard Employee A tell the UM that the two residents were having sex. In an interview with Employee B, LPN, on 02/13/2015 at approximately 2:48 pm, she stated that she has worked at the facility since March, 2014, and she is assigned regularly to Resident #2. She stated that she was caring for Resident #2 on 2/9/15, when Employee A told her at approximately 1:30 pm that she just witnessed the two residents having oral sex in Resident #1's room. Employee B stated that earlier that same day (02/09/2015), she saw Resident #1 sitting on Resident #2's bed. She said that Resident #2 was fully dressed and he was lying on his bed. Resident #1 was seated on the bed at the foot of the bed. Employee B stated that she saw Resident #1 rubbing Resident #2's pants leg near his ankle. Employee B said that she told Resident #1 to come out of the room. Employee B was asked if she reported this observation to anyone, and she stated she had not. She added, "Everybody knows how they are, them two. Sometimes she is seen rubbing his back." She stated, "It's common knowledge that she will come up to him and touch him." In an interview on 2/13/15 at 4:35pm with the UM, she stated that on 2/9/15 at an unknown time, Employee A reported observing two residents having oral sex. The UM said that she instructed Employee A to report the incident to the DON. The UM said that when Employee A returned to the floor, Employee A said that the DON told her that both residents were alert and oriented, and nothing needed to be done. The UM told Employee A to document everything in the resident's record. The UM stated that she was not instructed by the DON to do anything more about this incident. When asked, the UM stated that she didn't think Resident #1 was capable of making decisions regarding sex. She stated that Resident #1 was confused, and that was probably why the incident happened. She stated that Employee B did not report to her on 2/9/15 that Resident #1 had been in Resident #2's room earlier in the day. She stated that she did not call the abuse hotline about the incident because she thought the DON would do it. She stated that she did not know if Resident #1's physician had been notified of the incident. She reviewed Resident #1's record and stated that the resident had not been examined since the incident. Record review revealed that Resident #1 resided in room [ROOM NUMBER]W. She was [AGE] years old and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record also showed a [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 50mg twice a day for [MEDICAL CONDITION] disorder, [MEDICATION NAME] 50mg daily for depression, and [MEDICATION NAME] XR 28mg daily for dementia. The resident's daughter signed the resident's consents for treatment. Review of the Minimum Data Set (MDS), dated [DATE], revealed in Section C, Cognitive, that Resident #1 had a Brief Interview for Mental Status (BIMS, to determine the individual's attention, orientation and ability to register and recall new information) with a score of 5 (severe impairment) out of a possible 15. She was assessed as not being oriented to year, month, or day, and could recall two out of three items after being cued. She continuously had difficulty focusing her attention, and had disorganized thinking with no fluctuation. Section D, Mood, revealed that Resident #1 had trouble concentrating on things, such as watching television or reading a newspaper. She had behavior of restlessness or moving around more than usual during half or more of the days of the assessment period. Record review for Resident #2 revealed that he was [AGE] years old, and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record noted a short term memory problem, alert to person and place, independent in cognitive decision making, makes self understood, and no confusion. Issues assessed at his 1/20/15 neurology appointment included [MEDICAL CONDITION] ([MEDICAL CONDITION] caused by a blow to the head) and erectile dysfunction. Review of Resident #2's safety care plan, original date 4/1/14 and latest revision date 12/31/14, revealed problems of removes his WanderGuard? and continues to go outside unattended, and refuses smoking policy. There were no interventions listed for these behaviors. Also listed (no date) as a problem on the care plan was the statement, "Resident has had sex acts performed on him by female resident." The intervention listed stated, "Attempt to redirect if found in sex act with another resident, provide privacy if both residents in agreement." Review of the facility map revealed that Resident #2's room, #300A, was located at the beginning of the 300 hallway next to the nursing station. Resident #1's room, 204W, was on the next hallway that began at the nursing station, about 4 doors down the 300 hallway. In an interview on 02/12/2015 at 5:08 pm with the DON, when asked how she determined that Resident #1 was a consenting adult, she stated that Employee A and the SSD told her that the resident was sometimes confused, but she was alert and oriented. The DON added that the resident was able to carry on a conversation, and sometimes converts to Spanish. The DON said that when she interviewed Employee A, she asked her if both residents were alert and oriented, and Employee A told her they were. She stated that the SSD then left the room to interview both residents involved, the nurse went back to the floor, and "that was the end of it." The DON stated that she was not aware of any incident between the two residents earlier in the day. She stated that law enforcement had not been informed of the incident. In an interview on 2/13/2015 at 1:30 pm with the SSD, she stated that she thought the incident happened between 1:00 pm and 2:00 pm on 2/9/15. She stated she received a frantic phone call from the UM on the long term care unit, asking her to come to the unit. She stated that when she got to the unit the UM told her that Employee A had reported that she saw Resident #1 and Resident #2 having oral sex. The SSD said she went directly to Resident #2's room and interviewed him. She said she asked him about "an incident that just happened" and he told her, "I did not do that. You believe everything everybody else tells you." The SSD's progress note dated 2/9/15 at 2:35pm stated that Resident #2 "became upset about this writer not believing him." The SSD asked Resident #2 if he was in another resident's room, and he stated he wasn't. The SSD said that Resident #2 started to become agitated with her, so she thanked him and went to Resident #1's room. The SSD stated that she found Resident #1 sleeping on her bed. The SSD tapped the resident on the shoulder and woke her up. The SSD asked the resident about the incident that just happened. Resident #1 denied that a man was in her room, or that the incident occurred. In an interview on 2/12/2015 at 12:25 pm with the SSD, she stated that she called the families of Residents #1 and #2 after the incident on 2/09/2015. She stated she left a message for Resident #1's daughter, but she had not heard from her yet. She stated that she had not tried to contact the secondary family member that was listed in Resident #1's record (the resident's son). She stated she was not told to do any investigation into this incident. She stated that the DON would be the one to investigate, since she was the Abuse Coordinator. The SSD said she has had no further involvement in this case. In an interview on 2/12/2015 at 2:35pm with the Administrator and the DON, the DON stated after the reading Employee A's nursing note about the incident dated 2/09/2015, "I went down and interviewed both residents and they denied it ever happened." She was asked, "Was there any investigation into this?" She stated, "Why would there be? They are both alert and oriented consenting adults." When informed by this surveyor that Resident #1 was cognitively impaired with a BIMS score of 5 out of a possible 15, the DON made no reply. The DON was asked if anything was done to protect the residents in the facility since the incident, such as moving one of the residents to a different location, or changing the supervision of the residents; She stated, "No." She stated she did not investigate the allegation because she was informed that both residents were consenting adults. When the administrator read the nurse's note about the incident, he stated, "I didn't know anything about this." An interview with Employee A on 02/16/2015 at 10:02 am revealed that when asked if she was told by her supervisors to call the State abuse reporting hotline, or notify the residents' doctors, she stated, "No, I was told by the DON that nothing else needed to be done. I asked if I needed to fill out any forms or write a statement, and I was told that 'nothing more can be done', so I went back to the floor." Interview on 2/12/15 at approximately 3:10 pm with the Administrator revealed that he was very disappointed that the incident had not been brought to his attention. He stated he had already instructed the DON to begin an investigation. He stated, "I asked (the DON), what were you thinking? Why didn't you report this?" He stated he would have reported and investigated this incident if he had known. Review of the Federal Report for abuse dated 2/12/15, the incident was reported to the Florida abuse registry on 2/12/15 at 5:52pm. Resident #2 was observed on 02/12/2015 at 11:15 am ambulating, without use of an assistive device, off of the long term care unit. He returned a few minutes later and got a wheelchair and pushed it off the unit toward the dining room. He was observed at approximately 11:35 am seated in his wheelchair, backing it up in front of the nurses' station. The resident did not interact with staff or other residents during the observations. He was not being supervised. Residents #1 and #2 were both observed in the main dining room from approximately 2:20 pm until 2:50 pm on 02/12/2015. Both residents were observed to be dancing to music being played by a male entertainer hired by the facility to provide music for the residents. Facility staff was present in the dining room and the hallway outside the dining room. Residents #1 and #2 were not on one-to-one supervision, and had access to each other. Both came and went from the dining room without supervision. An interview with Resident #2 on 2/12/2015 at approximately 4:05 pm revealed that he spoke English with a very thick accent, and he was alert and oriented to person, place, time, and circumstance. He was pleasant and appeared well groomed and appropriately dressed. He stated he was not interested in Resident #1 because she was too old for him. When asked if he would be interested in younger women, he said, "Yes, but he was in this place, a hospital." He stated that he could not have erections since his accident, so there was no way he could have been with Resident #1. He stated, "It doesn't work down there." He pointed toward his crotch. He was asked if he was in Resident #1's room on Monday, and if the nurse came in and told him to leave. He stated, "I go down and around her room but I don't go in." He said that the nurse who made the allegation "talks too much," while at the same time, he made duck quacking gestures with his hands. He repeatedly stated he had problems having erections since his accident, and the incident could not have happened. An interview on 02/13/2015 at 2:35 pm with the psychiatric Advanced Registered Nurse Practitioner (ARNP) revealed that the facility called her on 2/12/15 to consult on Resident #2 regarding the 2/9/15 incident. She stated that Resident #2 denied anything regarding the allegation. The ARNP stated that she sees Resident #1 on a regular basis, and she (the ARNP) doesn't think Resident #1 could consent to having sex. Review of the ARNP's progress note for Resident #1 dated 2/16/15 revealed that the resident had slow thought processes, poor insight/judgment, was well oriented to person only, had impaired memory and delusions. The ARNP documented that the sexual incident was reported to her on 2/13/15. When the ARNP interviewed Resident #1 on 2/16/15, she denied knowing anything about the incident. The note stated that staff reported Resident #1 has been seen on other occasions acting inappropriately in a sexual manner. The ARNP documented that she had not "seen or had other reports before now." Review of the ARNP's progress note for Resident #2 revealed that he was examined on 2/13/15. His behavior and thought processes were normal, insight/judgment were adequate, he was oriented to person, place, and time, his memory was intact, and his mood was normal. In an interview with Resident #3 on 2/16/15 at 3:01pm, when asked whether she had seen any residents behave in a sexually inappropriate manner, she said that Resident #1 "walks around and likes to mess with men." She said that Resident #1 "twists in front of everybody and sits on their laps." She said that staff try to get her up and away, but she doesn't know any better." During an interview with Employee C, Certified Nursing Assistant (CNA), on 02/13/2015 at approximately 2:58 pm, she stated that she worked full time on the 7a-3p shift, and she was familiar with Resident #1. Employee C stated that at times Resident #1 is confused, and she has to re-direct her. She stated that Resident #1 is social in the dining room, and she gravitates to Resident #2. Employee C said that resident #1 is "touchy" with Resident #2. She stated, "She dances in the dining room, and when he's around she acts like she wants to do more with him." She stated she took care of Resident #2 when he was first admitted on the short term rehabilitation unit, and she described him as "flirty." She stated she saw Resident #2 taking Resident #1 out the back hallway one day toward the smoking area. She stopped Resident #1 from going with him. She stated that Resident #2 knows the code for the back door. She explained that the alarm for Resident 1's WanderGuard? only goes off at the front door. She stated she thinks that Resident #1 wears a WanderGuard?. When asked, Employee C stated that she didn't think Resident #1 could consent to sex. Employee C stated that Residents #1 and #2 were not on one-to-one supervision this morning (2/13/15). She stated, "They did not put them on one-to-one until after I got back from lunch." She thought it was around 12:30pm. She stated that there were two CNAs assigned to be one-to-one with the two residents now. Regarding re-training for abuse, Employee C stated that she was not in-serviced, but at around 2:30pm today she was asked to sign a one page paper showing that she had received education on abuse today. During an interview on 2/13/15 at 3:05pm with Employee D, CNA, she stated that she worked the 7a-3pm shift on the 200 hall, and she was usually assigned to Resident #1. She stated, "She's sweet. She's a little promiscuous. She likes to shake her bootie a lot. Every now and then, I catch her kissing somebody." She stated that she has seen Resident #1 gravitate toward Resident #2. She stated that Resident #1 "loves men." Employee D stated that Resident #1 liked another resident in the past, but the man's wife got upset with the attention Resident #1 was paying to her husband. The staff made sure that Resident #1 didn't go near that resident anymore. Employee D stated that Resident #1 usually goes into Resident #2's room. She stated that when she sees her go in the room, she goes to get her. Employee D stated that when Resident #2 first got moved to the long term care unit, he was flirtatious with her and would try to kiss her hands. She corrected him and she hasn't had a problem with him since. She was asked if she thought Resident #1 was able to consent to sex with Resident #2, and she stated that she didn't think so. When asked about re-training for abuse, Employee D stated that the Assistant Director of Nursing (ADON) gave her education on abuse today. There were 5 staff members in the group. The ADON explained about sexual abuse, and to separate the residents if found having sex. She stated the ADON had her sign a form today saying she'd been educated about abuse. Review of the care plan for Resident #1 dated 1/13/2015 revealed that the resident was not care planned for any of the sexualized behaviors observed by staff. A hand written note, dated 02/10/2015, on the resident's Behavior care plan indicated the resident makes sexual gestures, is exit seeking, rummages, and is physically inappropriate (performs sex acts on male resident). In the Approaches and Interventions column of the plan, a hand written update, dated 2/10/2015, read, "Attempt to redirect if found performing sex act, but provide privacy if residents are both in agreement." During an interview with Employee E, CNA, on 02/13/2015 at approximately 3:10 pm, she stated that she had worked at the facility for 2.5 years and she has been assigned to Resident #2. She stated that Resident #2 was pleasant and very independent. She said that he keeps to himself, Skypes (live audio and visual communication via internet connection) with his sister on the computer, asks for the things he needs, and goes out to smoke and chat with other smoking residents. She was asked if she knew Resident #1, and she stated that she did, adding that Resident #1, "Walks the hallways and goes into every room; She's like a butterfly. She doesn't understand that she shouldn't be in other peoples' rooms. Her mind set is like she's fifty. She touches people on the shoulders. Some residents complain about it. She touches males and females. She's very easy to like." She stated she didn't think that Resident #1 could give consent to have sex. Employee E stated that Resident #1 had a WanderGuard? alarm on, and when she goes out the doors someone goes out and gets her. She stated she got abuse training today from the ADON around 2:15 pm - 2:30 pm. She stated she was told to read a piece of paper with information on abuse, and asked to sign it. She said that the training took approximately 5 minutes. During an interview on 02/13/15 at 5:00 pm with the MDS Coordinator, she stated that she attended morning meetings on 2/10/15 - 2/12/15, and there was no discussion at the meetings about the incident involving Resident #1 and Resident #2. She stated that the DON informed her on 2/13/15 that there had been a sexual incident between the two residents, and she was to update the care plan. She said the DON told her exactly what to write on the care plans. In an interview conducted on 2/13/15 at 5:22pm with the DON she reviewed Resident #1's medical record and stated that there was no documentation of an assessment of Resident #1 after the incident, or that her physician was notified. She was asked if both should have been done, and she stated that they should have been. The DON confirmed that she had not conducted interviews of all facility staff involved in the incident. She stated that she completed an incident report on 2/12/15 regarding the incident, and sent it to the facility's corporate office. She could not produce a copy of the report for review. The administrator stated that he had not reviewed the incident report prior to it being sent through the mail to the corporate office. The DON told the surveyor, "I should have investigated, and I take responsibility for that." A phone interview with Resident #1's physician was conducted on 2/17/15 at 11:40 am. He stated he was not sure what date he was notified about the incident that occurred between Resident #1 and Resident #2 on 02/09/2015. He stated that the earliest date he could recall being told about it was on 2/11/15. He stated he was asked on 2/13/15 to examine Resident #1. He stated that staff should have notified him on 02/09/2015 about the incident. Review of the physician progress notes [REDACTED]. In an interview with Employee F, CNA, on 2/13/15 at 4:00pm she stated that she thought she got education about abuse today, but she wasn't sure. She said it lasted a couple of minutes. She said she signed her name, but she wasn't sure what it was because she was walking with a resident. She stated she really didn't have time to read it. Review of the Resident Abuse policy and procedure, dated 11/30/2014, revealed that the policy defined sexual abuse as including sexual harassment, sexual coercion, sexual assault or allowing a resident to be sexually abused by another, and inciting any of the above. The policy stated, "Furthermore, the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors, or volunteers." The "Employee Obligation" section read, "All employees have a duty to respect the rights of all residents, to treat them with dignity, and to prevent others from violating their rights. Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the Clinical Nurse in charge, Director of Clinical Services, and the Executive Director." The policy did not mention the individual obligation of all staff who witness abuse to report to state authorities. The "Identification of Abuse" section stated that the Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator and an abuse investigation will be conducted. In the absence of the Executive Director, the Director of Clinical Services will serve as Abuse Coordinator." The "Preliminary Investigation" section stated that immediately upon report of an incident to the individual in charge, the suspect shall be segregated from the resident. The policy did not address protecting all residents from the alleged abuser. The policy stated that the Clinical Nurse in charge or the Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. The policy did not specify when this should be done. The policy stated that an incident report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion. The "Procedure for Reporting Abuse" section read, "All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, and the Executive Director. Once reported to one of the three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation." The policy then stated that the abuse coordinator is responsible for reporting to appropriate officials in accordance with Federal and State Regulations. The policy did not mention the obligation of all staff who witness abuse to report to state authorities. The "Investigations" section read, "The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s), and all possible witnesses, including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared." The "Discipline" section read, "The Abuse Coordinator of The Company will refer any or all incidents and reports of resident abuse to the appropriate state agencies." There was no mention in the facility's abuse policy of notification of law enforcement. The facility's handout titled "Freedom From Abuse Notice To Employees," used by the facilty in re-training of staff commencing on 2/13/15, described the following reporting structure for staff in the event of suspected or observed abuse: Executive Director, Vice President of Human Resources, Medical Director, Director Of Clinical Services, Ombudsman, and all other officials required by law. This document did not mention sexual abuse, and did not include notification of law enforcement or the abuse coordinator. .

Based on observation, resident and staff interviews, and record review, the facility failed to report and investigate the sexual abuse of one resident who was cognitively impaired (Resident #1), out of 5 residents reviewed for allegations of abuse or neglect. The facility had knowledge that an employee reported witnessing a sexual act between Resident #1 and Resident #2 on February 9, 2015, but failed to investigate the allegation of abuse or report it to the Administrator. In addition, the facility failed to ensure that Resident #1 was protected from the alleged perpetrator (Resident #2) after the sexual act was observed. Resident #2 continued to reside in the same location within the facility and to have unencumbered access to Resident #1 and all other residents in the facility from 02/09/2015 through 2/13/2015 at approximately 1:00 pm, when both Residents #1 and #2 were put on one to one supervision. The facility also failed to identify and act upon sexualized behaviors exhibited by Resident #1 that placed her at risk for abuse. This resulted in Immediate Jeopardy beginning on 2/09/2015. The facility's failure to prevent and investigate an incident of sexual abuse, and protect residents from the alleged abuser, placed cognitively impaired residents in the facility at risk for serious injury, harm, or impairment. Immediate Jeopardy was ongoing on exit on 2/17/15. Substandard quality of care was identified at F-225 (S/S J). Cross reference F-224 (S/S J), F-226 (S/S J), and F-323 (S/S J). The findings include: A review of the medical record for Resident #1 revealed a nursing note, dated 02/09/2015 at 1:40 pm, that read, "Writer observed resident giving oral sex to another resident (Resident #2). Writer immediately stopped both residents and separated them. Proper supervisor as well as Social Services was notified. Social Services will notify families of incident. Resident (#1) is alert with dementia. Resident (#1) has to be redirected at times. Wanders throughout the facility. Resident (#1) has WanderGuard? (a signaling device that alarms when the resident exits the property) in place. Resident tolerated meds (medications) well today. No SOB (shortness of breath) noted. Denies pain. Resident will be monitored closely." The note was signed by Employee A, Licensed Practical Nurse (LPN). In a telephone interview on 2/12/2015 at 4:28pm with Employee A, she stated that on 2/09/2015, at approximately 1:20 pm, as she was walking down the hall and passed by Resident #1's room, she glanced into the room and saw a man with his pants down, standing next to the bed nearest to the window. She stated she knew that was Resident #1's bed, and she became alarmed. Employee A stated that she went into the room and saw Resident #1 lying in her bed on her left side, facing Resident #2. Resident #1 was supporting herself on her elbow, and had her hand on Resident #2's penis in her mouth. Employee A stated in the interview, "I saw it happening. I physically saw it. I know what I saw." She stated she immediately told the residents to stop, and for Resident #2 to leave the room. She stated she went to the nurses' station and immediately reported the incident to the Unit Manager (UM). She stated that the UM told her to report the incident to the Director of Nurses (DON) right away. Employee A stated that she then spoke with the Social Services Director (SSD) about the incident, and they both reported it to the DON. Employee A stated that the DON treated her like she was lying about what she saw, and told her and the SSD that nothing could be done about the incident, because the residents were consenting adults. Employee A stated that she told the DON that Resident #1 was not able to consent because she had advanced senile dementia, and she was not as high functioning mentally as Resident #2. She stated that she told the DON that she was afraid that Resident #2 may have and would continue to take advantage of Resident #1. She stated that the facility should not allow this to happen even if it appeared that Resident #1 was not harmed. In an interview on 2/13/15 at 1:30pm with the SSD, she said that she told the DON that she had interviewed both residents, and that both were denying the allegation. The SSD said that Employee A then told the DON again that she saw the incident, and she was sure of what she saw. The DON asked if anyone else saw it, and Employee A told her she didn't think so. The SSD stated that the DON then said that both residents were consenting adults. The SSD stated at the time of the interview that she did not believe Resident #1 was a consenting adult. In an interview with Employee D, CNA, on 2/13/15 at 3:05pm she stated that on 02/09/2015, she was right there at Resident #1's room at the time that Employee A said she saw Residents #1 and #2 involved in oral sex in Resident #1's room. Employee D stated that she saw Resident #2 with his hands on his pants. She couldn't see what he was doing. His pants were up. Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurses' station, and overheard Employee A tell the UM that the two residents were having sex. In an interview with Employee B, LPN, on 02/13/2015 at approximately 2:48 pm, she stated that she has worked at the facility since March, 2014, and she is assigned regularly to Resident #2. She stated that she was caring for Resident #2 on 2/9/15, when Employee A told her at approximately 1:30 pm that she just witnessed the two residents having oral sex in Resident #1's room. Employee B stated that earlier that same day (02/09/2015), she saw Resident #1 sitting on Resident #2's bed. She said that Resident #2 was fully dressed and he was lying on his bed. Resident #1 was seated on the bed at the foot of the bed. Employee B stated that she saw Resident #1 rubbing Resident #2's pants leg near his ankle. Employee B said that she told Resident #1 to come out of the room. Employee B was asked if she reported this observation to anyone, and she stated she had not. She added, "Everybody knows how they are, them two. Sometimes she is seen rubbing his back." She stated, "It's common knowledge that she will come up to him and touch him." In an interview on 2/13/15 at 4:35pm with the UM, she stated that on 2/9/15 at an unknown time, Employee A reported observing two residents having oral sex. The UM said that she instructed Employee A to report the incident to the DON. The UM said that when Employee A returned to the floor, Employee A said that the DON told her that both residents were alert and oriented, and nothing needed to be done. The UM told Employee A to document everything in the resident's record. The UM stated that she was not instructed by the DON to do anything more about this incident. When asked, the UM stated that she didn't think Resident #1 was capable of making decisions regarding sex. She stated that Resident #1 was confused, and that was probably why the incident happened. She stated that Employee B did not report to her on 2/9/15 that Resident #1 had been in Resident #2's room earlier in the day. She stated that she did not call the abuse hotline about the incident because she thought the DON would do it. She stated that she did not know if Resident #1's physician had been notified of the incident. She reviewed Resident #1's record and stated that the resident had not been examined since the incident. Record review revealed that Resident #1 resided in room [ROOM NUMBER]W. She was [AGE] years old and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record also showed a [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 50mg twice a day for [MEDICAL CONDITION] disorder, [MEDICATION NAME] 50mg daily for depression, and [MEDICATION NAME] XR 28mg daily for dementia. The resident's daughter signed the resident's consents for treatment. Review of the Minimum Data Set (MDS), dated [DATE], revealed in Section C, Cognitive, that Resident #1 had a Brief Interview for Mental Status (BIMS, to determine the individual's attention, orientation and ability to register and recall new information) with a score of 5 (severe impairment) out of a possible 15. She was assessed as not being oriented to year, month, or day, and could recall two out of three items after being cued. She continuously had difficulty focusing her attention, and had disorganized thinking with no fluctuation. Section D, Mood, revealed that Resident #1 had trouble concentrating on things, such as watching television or reading a newspaper. She had behavior of restlessness or moving around more than usual during half or more of the days of the assessment period. Record review for Resident #2 revealed that he was [AGE] years old, and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record noted a short term memory problem, alert to person and place, independent in cognitive decision making, makes self understood, and no confusion. Issues assessed at his 1/20/15 neurology appointment included [MEDICAL CONDITION] ([MEDICAL CONDITION] caused by a blow to the head) and erectile dysfunction. Review of Resident #2's safety care plan, original date 4/1/14 and latest revision date 12/31/14, revealed problems of removes his WanderGuard? and continues to go outside unattended, and refuses smoking policy. There were no interventions listed for these behaviors. Also listed (no date) as a problem on the care plan was the statement, " Resident has had sex acts performed on him by female resident. " The intervention listed stated, " Attempt to redirect if found in sex act with another resident, provide privacy if both residents in agreement. " Review of the facility map revealed that Resident #2's room, #300A, was located at the beginning of the 300 hallway next to the nursing station. Resident #1's room, 204W, was on the next hallway that began at the nursing station, about 4 doors down the 300 hallway. In an interview on 02/12/2015 at 5:08 pm with the DON, when asked how she determined that Resident #1 was a consenting adult, she stated that Employee A and the SSD told her that the resident was sometimes confused, but she was alert and oriented. The DON added that the resident was able to carry on a conversation, and sometimes converts to Spanish. The DON said that when she interviewed Employee A, she asked her if both residents were alert and oriented, and Employee A told her they were. She stated that the SSD then left the room to interview both residents involved, the nurse went back to the floor, and "that was the end of it." The DON stated that she was not aware of any incident between the two residents earlier in the day. She stated that law enforcement had not been informed of the incident. In an interview on 2/13/2015 at 1:30 pm with the SSD, she stated that she thought the incident happened between 1:00 pm and 2:00 pm on 2/9/15. She stated she received a frantic phone call from the UM on the long term care unit, asking her to come to the unit. She stated that when she got to the unit the UM told her that Employee A had reported that she saw Resident #1 and Resident #2 having oral sex. The SSD said she went directly to Resident #2's room and interviewed him. She said she asked him about " an incident that just happened " and he told her, "I did not do that. You believe everything everybody else tells you." The SSD's progress note dated 2/9/15 at 2:35pm stated that Resident #2 " became upset about this writer not believing him. " The SSD asked Resident #2 if he was in another resident's room, and he stated he wasn't. The SSD said that Resident #2 started to become agitated with her, so she thanked him and went to Resident #1's room. The SSD stated that she found Resident #1 sleeping on her bed. The SSD tapped the resident on the shoulder and woke her up. The SSD asked the resident about the incident that just happened. In an interview on 2/12/2015 at 12:25 pm with the SSD, she stated she was not told to do any investigation into this incident. She stated that the DON would be the one to investigate, since she was the Abuse Coordinator. The SSD said she has had no further involvement in this case. In an interview on 2/12/2015 at 2:35pm with the Administrator and the DON, the DON stated after the reading Employee A's nursing note about the incident dated 2/09/2015, "I went down and interviewed both residents and they denied it ever happened." She was asked, "Was there any investigation into this?" She stated, "Why would there be? They are both alert and oriented consenting adults." When informed by this surveyor that Resident #1 was cognitively impaired with a BIMS score of 5 out of a possible 15, the DON made no reply. The DON was asked if anything was done to protect the residents in the facility since the incident, such as moving one of the residents to a different location, or changing the supervision of the residents; She stated, "No." She stated she did not investigate the allegation because she was informed that both residents were consenting adults. When the administrator read the nurse's note about the incident, he stated, "I didn't know anything about this." An interview with Employee A on 02/16/2015 at 10:02 am revealed that when asked if she was told by her supervisors to call the State abuse reporting hotline, or notify the residents' doctors, she stated, "No, I was told by the DON that nothing else needed to be done. I asked if I needed to fill out any forms or write a statement, and I was told that 'nothing more can be done,' so I went back to the floor." Interview on 2/12/15 at approximately 3:10 pm with the Administrator revealed that he was very disappointed that the incident had not been brought to his attention. He stated he had already instructed the DON to begin an investigation. He stated, "I asked (the DON), what were you thinking? Why didn't you report this?" He stated he would have reported and investigated this incident if he had known. Review of the Federal Report for abuse dated 2/12/15, the incident was reported to the Florida abuse registry on 2/12/15 at 5:52pm. Resident #2 was observed on 02/12/2015 at 11:15 am ambulating, without use of an assistive device, off of the long term care unit. He returned a few minutes later and got a wheelchair and pushed it off the unit toward the dining room. He was observed at approximately 11:35 am seated in his wheelchair, backing it up in front of the nurses' station. The resident did not interact with staff or other residents during the observations. He was not being supervised. Residents #1 and #2 were both observed in the main dining room from approximately 2:20 pm until 2:50 pm on 02/12/2015. Both residents were observed to be dancing to music being played by a male entertainer hired by the facility to provide music for the residents. Facility staff was present in the dining room and the hallway outside the dining room. Residents #1 and #2 were not on one to one supervision, and had access to each other. Both came and went from the dining room without supervision. An interview with Resident #2 on 2/12/2015 at approximately 4:05 pm revealed that he spoke English with a very thick accent, and he was alert and oriented to person, place, time, and circumstance. He was pleasant and appeared well groomed and appropriately dressed. He stated he was not interested in Resident #1 because she was too old for him. When asked if he would be interested in younger women, he said, "Yes, but he was in this place, a hospital." He stated that he could not have erections since his accident, so there was no way he could have been with Resident #1. He stated, "It doesn't work down there." He pointed toward his crotch. He was asked if he was in Resident #1's room on Monday, and if the nurse came in and told him to leave. He stated, "I go down and around her room but I don't go in." He said that the nurse who made the allegation "talks too much," while at the same time, he made duck quacking gestures with his hands. He repeatedly stated he had problems having erections since his accident, and the incident could not have happened. An interview on 02/13/2015 at 2:35 pm with the psychiatric Advanced Registered Nurse Practitioner (ARNP) revealed that the facility called her on 2/12/15 to consult on Resident #2 regarding the 2/9/15 incident. She stated that Resident #2 denied anything regarding the allegation. The ARNP stated that she sees Resident #1 on a regular basis, and she (the ARNP) doesn't think Resident #1 could consent to having sex. Review of the ARNP's progress note for Resident #1 dated 2/16/15 revealed that the resident had slow thought processes, poor insight/judgment, was well oriented to person only, had impaired memory and delusions. The ARNP documented that the sexual incident was reported to her on 2/13/15. When the ARNP interviewed Resident #1 on 2/16/15, she denied knowing anything about the incident. The note stated that staff reported Resident #1 has been seen on other occasions acting inappropriately in a sexual manner. The ARNP documented that she had not "seen or had other reports before now." Review of the ARNP's progress note for Resident #2 revealed that he was examined on 2/13/15. His behavior and thought processes were normal, insight/judgment were adequate, he was oriented to person, place, and time, his memory was intact, and his mood was normal. In an interview with Resident #3 on 2/16/15 at 3:01pm, when asked whether she had seen any residents behave in a sexually inappropriate manner, she said that Resident #1 "walks around and likes to mess with men." She said that Resident #1 "twists in front of everybody and sits on their laps." She said that staff try to get her up and away, but she doesn't know any better." During an interview with Employee C, Certified Nursing Assistant (CNA), on 02/13/2015 at approximately 2:58 pm, she stated that she worked full time on the 7a-3p shift, and she was familiar with Resident #1. Employee C stated that at times Resident #1 is confused, and she has to re-direct her. She stated that Resident #1 is social in the dining room, and she gravitates to Resident #2. Employee C said that resident #1 is "touchy" with Resident #2. She stated, "She dances in the dining room, and when he's around she acts like she wants to do more with him." She stated she took care of Resident #2 when he was first admitted on the short term rehabilitation unit, and she described him as "flirty." She stated she saw Resident #2 taking Resident #1 out the back hallway one day toward the smoking area. She stopped Resident #1 from going with him. She stated that Resident #2 knows the code for the back door. She explained that the alarm for Resident 1's WanderGuard? only goes off at the front door. She stated she thinks that Resident #1 wears a WanderGuard?. When asked, Employee C stated that she didn't think Resident #1 could consent to sex. Employee C stated that Residents #1 and #2 were not on one-to-one supervision this morning (2/13/15). She stated, "They did not put them on one-to-one until after I got back from lunch." She thought it was around 12:30pm. She stated that there were two CNAs assigned to be one-to-one with the two residents now. Regarding re-training for abuse, Employee C stated that she was not in-serviced, but at around 2:30pm today she was asked to sign a one page paper showing that she had received education on abuse today. During an interview on 2/13/15 at 3:05pm with Employee D, CNA, she stated that she worked the 7a-3pm shift on the 200 hall, and she was usually assigned to Resident #1. She stated, "She's sweet. She's a little promiscuous. She likes to shake her bootie a lot. Every now and then, I catch her kissing somebody." She stated that she has seen Resident #1 gravitate toward Resident #2. She stated that Resident #1 "loves men." Employee D stated that Resident #1 liked another resident in the past, but the man's wife got upset with the attention Resident #1 was paying to her husband. The staff made sure that Resident #1 didn't go near that resident anymore. Employee D stated that Resident #1 usually goes into Resident #2's room. She stated that when she sees her go in the room, she goes to get her. Employee D stated that when Resident #2 first got moved to the long term care unit, he was flirtatious with her and would try to kiss her hands. She corrected him and she hasn't had a problem with him since. She was asked if she thought Resident #1 was able to consent to sex with Resident #2, and she stated that she didn't think so. When asked about re-training for abuse, Employee D stated that the Assistant Director of Nursing (ADON) gave her education on abuse today. There were 5 staff members in the group. The ADON explained about sexual abuse, and to separate the residents if found having sex. She stated the ADON had her sign a form today saying she'd been educated about abuse. Review of the care plan for Resident #1 dated 1/13/2015 revealed that the resident was not care planned for any of the sexualized behaviors observed by staff. A hand written note, dated 02/10/2015, on the resident's Behavior care plan indicated the resident makes sexual gestures, is exit seeking, rummages, and is physically inappropriate (performs sex acts on male resident). In the Approaches and Interventions column of the plan, a hand written update, dated 2/10/2015, read, "Attempt to redirect if found performing sex act, but provide privacy if residents are both in agreement." During an interview with Employee E, CNA, on 02/13/2015 at approximately 3:10 pm, she stated that she had worked at the facility for 2.5 years and she has been assigned to Resident #2. She stated that Resident #2 was pleasant and very independent. She said that he keeps to himself, Skypes (live audio and visual communication via internet connection) with his sister on the computer, asks for the things he needs, and goes out to smoke and chat with other smoking residents. She was asked if she knew Resident #1, and she stated that she did, adding that Resident #1, "Walks the hallways and goes into every room; She's like a butterfly. She doesn't understand that she shouldn't be in other peoples' rooms. Her mind set is like she's fifty. She touches people on the shoulders. Some residents complain about it. She touches males and females. She's very easy to like." She stated she didn't think that Resident #1 could give consent to have sex. Employee E stated that Resident #1 had a WanderGuard? alarm on, and when she goes out the doors someone goes out and gets her. She stated she got abuse training today from the ADON around 2:15 pm - 2:30 pm. She stated she was told to read a piece of paper with information on abuse, and asked to sign it. She said that the training took approximately 5 minutes. During an interview on 02/13/15 at 5:00 pm with the MDS Coordinator, she stated that she attended morning meetings on 2/10/15 - 2/12/15, and there was no discussion at the meetings about the incident involving Resident #1 and Resident #2. She stated that the DON informed her on 2/13/15 that there had been a sexual incident between the two residents, and she was to update the care plan. She said the DON told her exactly what to write on the care plans. In an interview conducted on 2/13/15 at 5:22pm with the DON she reviewed Resident #1's medical record and stated that there was no documentation of an assessment of Resident #1 after the incident, or that her physician was notified. She was asked if both should have been done, and she stated that they should have been. The DON confirmed that she had not conducted interviews of all facility staff involved in the incident. She stated that she completed an incident report on 2/12/15 regarding the incident, and sent it to the facility's corporate office. She could not produce a copy of the report for review. The administrator stated that he had not reviewed the incident report prior to it being sent through the mail to the corporate office. The DON told the surveyor, "I should have investigated, and I take responsibility for that." In an interview with Employee F, CNA, on 2/13/15 at 4:00pm she stated that she thought she got education about abuse today, but she wasn't sure. She said it lasted a couple of minutes. She said she signed her name, but she wasn't sure what it was because she was walking with a resident. She stated she really didn't have time to read it. Review of the Resident Abuse policy and procedure, dated 11/30/2014, revealed that the policy defined sexual abuse as including sexual harassment, sexual coercion, sexual assault or allowing a resident to be sexually abused by another, and inciting any of the above. The policy stated, "Furthermore, the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors, or volunteers." The "Employee Obligation" section read, "All employees have a duty to respect the rights of all residents, to treat them with dignity, and to prevent others from violating their rights. Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the Clinical Nurse in charge, Director of Clinical Services, and the Executive Director." The policy did not mention the individual obligation of all staff who witness abuse to report to state authorities. The "Identification of Abuse" section stated that the Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator and an abuse investigation will be conducted. In the absence of the Executive Director, the Director of Clinical Services will serve as Abuse Coordinator." The "Preliminary Investigation" section stated that immediately upon report of an incident to the individual in charge, the suspect shall be segregated from the resident. The policy did not address protecting all residents from the alleged abuser. The policy stated that the Clinical Nurse in charge or the Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. The policy did not specify when this should be done. The policy stated that an incident report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion. The "Procedure for Reporting Abuse" section read, "All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, and the Executive Director. Once reported to one of the three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation." The policy then stated that the abuse coordinator is responsible for reporting to appropriate officials in accordance with Federal and State Regulations. The policy did not mention the obligation of all staff who witness abuse to report to state authorities. The "Investigations" section read, "The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s), and all possible witnesses, including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared." The "Discipline" section read, "The Abuse Coordinator of The Company will refer any or all incidents and reports of resident abuse to the appropriate state agencies." There was no mention in the facility's abuse policy of notification of law enforcement. The facility's handout titled "Freedom From Abuse Notice To Employees," used by the facilty in re-training of staff commencing on 2/13/15, described the following reporting structure for staff in the event of suspected or observed abuse: Executive Director, Vice President of Human Resources, Medical Director, Director Of Clinical Services, Ombudsman, and all other officials required by law. This document did not include notification of law enforcement or the abuse coordinator. Also, this document did not mention sexual abuse. .

Based on observation, resident and staff interviews, and record review, the facility failed to develop and implement policies to report and investigate sexual abuse of one resident who was cognitively impaired (Resident #1), out of 5 residents reviewed for allegations of abuse or neglect. The facility had knowledge that an employee reported witnessing a sexual act between Resident #1 and Resident #2 on February 9, 2015, but failed to investigate the allegation of abuse or report it to the Administrator. In addition, the facility failed to ensure that Resident #1 was protected from the alleged perpetrator (Resident #2) after the sexual act was observed. Resident #2 continued to reside in the same location within the facility and to have unencumbered access to Resident #1 and all other residents in the facility from 02/09/2015 through 2/13/2015 at approximately 1:00 pm, when both Residents #1 and #2 were put on one to one supervision. The facility also failed to identify and act upon sexualized behaviors exhibited by Resident #1 that placed her at risk for abuse. This resulted in Immediate Jeopardy beginning on 2/09/2015. The facility's failure to prevent and investigate an incident of sexual abuse, and protect residents from the alleged abuser, placed cognitively impaired residents in the facility at risk for serious injury, harm, or impairment. Immediate Jeopardy was ongoing on exit on 2/17/15. Substandard quality of care was identified at F-226 (S/S J). Cross reference F-224 (S/S J), F-225 (S/S J), and F-323 (S/S J). The findings include: A review of the medical record for Resident #1 revealed a nursing note, dated 02/09/2015 at 1:40 pm, that read, "Writer observed resident giving oral sex to another resident (Resident #2). Writer immediately stopped both residents and separated them. Proper supervisor as well as Social Services was notified. Social Services will notify families of incident. Resident (#1) is alert with dementia. Resident (#1) has to be redirected at times. Wanders throughout the facility. Resident (#1) has WanderGuard? (a signaling device that alarms when the resident exits the property) in place. Resident tolerated meds (medications) well today. No SOB (shortness of breath) noted. Denies pain. Resident will be monitored closely." The note was signed by Employee A, Licensed Practical Nurse (LPN). In a telephone interview on 2/12/2015 at 4:28pm with Employee A, she stated that on 2/09/2015, at approximately 1:20 pm, as she was walking down the hall and passed by Resident #1's room, she glanced into the room and saw a man with his pants down, standing next to the bed nearest to the window. She stated she knew that was Resident #1's bed, and she became alarmed. Employee A stated that she went into the room and saw Resident #1 lying in her bed on her left side, facing Resident #2. Resident #1 was supporting herself on her elbow, and had her hand on Resident #2's penis in her mouth. Employee A stated in the interview, "I saw it happening. I physically saw it. I know what I saw." She stated she immediately told the residents to stop, and for Resident #2 to leave the room. She stated she went to the nurses' station and immediately reported the incident to the Unit Manager (UM). She stated that the UM told her to report the incident to the Director of Nurses (DON) right away. Employee A stated that she then spoke with the Social Services Director (SSD) about the incident, and they both reported it to the DON. Employee A stated that the DON treated her like she was lying about what she saw, and told her and the SSD that nothing could be done about the incident, because the residents were consenting adults. Employee A stated that she told the DON that Resident #1 was not able to consent because she had advanced senile dementia, and she was not as high functioning mentally as Resident #2. She stated that she told the DON that she was afraid that Resident #2 may have and would continue to take advantage of Resident #1. She stated that the facility should not allow this to happen even if it appeared that Resident #1 was not harmed. In an interview on 2/13/15 at 1:30pm with the SSD, she said that she told the DON that she had interviewed both residents, and that both were denying the allegation. The SSD said that Employee A then told the DON again that she saw the incident, and she was sure of what she saw. The DON asked if anyone else saw it, and Employee A told her she didn't think so. The SSD stated that the DON then said that both residents were consenting adults. The SSD stated at the time of the interview that she did not believe Resident #1 was a consenting adult. In an interview with Employee D, CNA, on 2/13/15 at 3:05pm she stated that on 02/09/2015, she was right there at Resident #1's room at the time that Employee A said she saw Residents #1 and #2 involved in oral sex in Resident #1's room. Employee D stated that she saw Resident #2 with his hands on his pants. She couldn't see what he was doing. His pants were up. Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurse's station, and overheard Employee A tell the UM that the two residents were having sex. In an interview with Employee B, LPN, on 02/13/2015 at approximately 2:48 pm, she stated that she has worked at the facility since March, 2014, and she is assigned regularly to Resident #2. She stated that she was caring for Resident #2 on 2/9/15, when Employee A told her at approximately 1:30 pm that she just witnessed the two residents having oral sex in Resident #1's room. Employee B stated that earlier that same day (02/09/2015), she saw Resident #1 sitting on Resident #2's bed. She said that Resident #2 was fully dressed and he was lying on his bed. Resident #1 was seated on the bed at the foot of the bed. Employee B stated that she saw Resident #1 rubbing Resident #2's pants leg near his ankle. Employee B said that she told Resident #1 to come out of the room. Employee B was asked if she reported this observation to anyone, and she stated she had not. She added, "Everybody knows how they are, them two. Sometimes she is seen rubbing his back." She stated, "It's common knowledge that she will come up to him and touch him." In an interview on 2/13/15 at 4:35pm with the UM, she stated that on 2/9/15 at an unknown time, Employee A reported observing two residents having oral sex. The UM said that she instructed Employee A to report the incident to the DON. The UM said that when Employee A returned to the floor, Employee A said that the DON told her that both residents were alert and oriented, and nothing needed to be done. The UM told Employee A to document everything in the resident's record. The UM stated that she was not instructed by the DON to do anything more about this incident. When asked, the UM stated that she didn't think Resident #1 was capable of making decisions regarding sex. She stated that Resident #1 was confused, and that was probably why the incident happened. She stated that Employee B did not report to her on 2/9/15 that Resident #1 had been in Resident #2's room earlier in the day. She stated that she did not call the abuse hotline about the incident because she thought the DON would do it. She stated that she did not know if Resident #1's physician had been notified of the incident. She reviewed Resident #1's record and stated that the resident had not been examined since the incident. Record review revealed that Resident #1 resided in room [ROOM NUMBER]W. She was [AGE] years old and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record also showed a [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 50mg twice a day for [MEDICAL CONDITION] disorder, [MEDICATION NAME] 50mg daily for depression, and [MEDICATION NAME] XR 28mg daily for dementia. The resident's daughter signed the resident's consents for treatment. Review of the Minimum Data Set (MDS), dated [DATE], revealed in Section C, Cognitive, that Resident #1 had a Brief Interview for Mental Status (BIMS, to determine the individual's attention, orientation and ability to register and recall new information) with a score of 5 (severe impairment) out of a possible 15. She was assessed as not being oriented to year, month, or day, and could recall two out of three items after being cued. She continuously had difficulty focusing her attention, and had disorganized thinking with no fluctuation. Section D, Mood, revealed that Resident #1 had trouble concentrating on things, such as watching television or reading a newspaper. She had behavior of restlessness or moving around more than usual during half or more of the days of the assessment period. Record review for Resident #2 revealed that he was [AGE] years old, and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record noted a short term memory problem, alert to person and place, independent in cognitive decision making, makes self understood, and no confusion. Issues assessed at his 1/20/15 neurology appointment included [MEDICAL CONDITION] ([MEDICAL CONDITION] caused by a blow to the head) and erectile dysfunction. Review of Resident #2's safety care plan, original date 4/1/14 and latest revision date 12/31/14, revealed problems of removes his WanderGuard? and continues to go outside unattended, and refuses smoking policy. There were no interventions listed for these behaviors. Also listed (no date) as a problem on the care plan was the statement, "Resident has had sex acts performed on him by female resident." The intervention listed stated, "attempt to redirect if found in sex act with another resident, provide privacy if both residents in agreement." Review of the facility map revealed that Resident #2's room, #300A, was located at the beginning of the 300 hallway next to the nursing station. Resident #1's room, 204W, was on the next hallway that began at the nursing station, about 4 doors down the 300 hallway. In an interview on 02/12/2015 at 5:08 pm with the DON, she denied saying that nothing could be done about the incident that occurred between Residents #1 and #2. When asked how she determined that Resident #1 was a consenting adult, she stated that Employee A and the SSD told her that the resident was sometimes confused, but she was alert and oriented. The DON added that the resident was able to carry on a conversation, and sometimes converts to Spanish. The DON said that when she interviewed Employee A, she asked her if both residents were alert and oriented, and Employee A told her they were. She stated that the SSD then left the room to interview both residents involved, the nurse went back to the floor, and "that was the end of it." The DON stated that she was not aware of any incident between the two residents earlier in the day. She stated that law enforcement had not been informed of the incident. In an interview on 2/13/2015 at 1:30 pm with the SSD, she stated that she thought the incident happened between 1:00 pm and 2:00 pm on 2/9/15. She stated she received a frantic phone call from the UM on the long term care unit, asking her to come to the unit. She stated that when she got to the unit the UM told her that Employee A had reported that she saw Resident #1 and Resident #2 having oral sex. The SSD said she went directly to Resident #2's room and interviewed him. She said she asked him about "an incident that just happened" and he told her, "I did not do that. You believe everything everybody else tells you." The SSD's progress note dated 2/9/15 at 2:35pm stated that Resident #2 "became upset about this writer not believing him." The SSD asked Resident #2 if he was in another resident's room, and he stated he wasn't. The SSD said that Resident #2 started to become agitated with her, so she thanked him and went to Resident #1's room. The SSD stated that she found Resident #1 sleeping on her bed. The SSD tapped the resident on the shoulder and woke her up. The SSD asked the resident about the incident that just happened. Resident #1 stated that there was not a man in her room, and the incident did not occur. In an interview on 2/12/2015 at 12:25 pm with the SSD, she stated that she was not told to do any investigation into this incident. She stated that the DON would be the one to investigate, since she was the Abuse Coordinator. The SSD said she has had no further involvement in this case. In an interview on 2/12/2015 at 2:35pm with the Administrator and the DON, the DON stated after the reading Employee A's nursing note about the incident dated 2/09/2015, "I went down and interviewed both residents and they denied it ever happened." She was asked, "Was there any investigation into this?" She stated, "Why would there be? They are both alert and oriented consenting adults." When informed by this surveyor that Resident #1 was cognitively impaired with a BIMS score of 5 out of a possible 15, the DON made no reply. The DON was asked if anything was done to protect the residents in the facility since the incident, such as moving one of the residents to a different location, or changing the supervision of the residents; She stated, "No." She stated she did not investigate the allegation because she was informed that both residents were consenting adults. When the administrator read the nurse's note about the incident, he stated, "I didn't know anything about this." An interview with Employee A on 02/16/2015 at 10:02 am revealed that when asked if she was told by her supervisors to call the State abuse reporting hotline, or notify the residents' doctors, she stated, "No, I was told by the DON that nothing else needed to be done. I asked if I needed to fill out any forms or write a statement, and I was told that 'nothing more can be done', so I went back to the floor." Interview on 2/12/15 at approximately 3:10 pm with the Administrator revealed that he was very disappointed that the incident had not been brought to his attention. He stated he had already instructed the DON to begin an investigation. He stated, "I asked (the DON), what were you thinking? Why didn't you report this?" He stated he would have reported and investigated this incident if he had known. Review of the Federal Report for abuse dated 2/12/15, the incident was reported to the Florida abuse registry on 2/12/15 at 5:52pm. Resident #2 was observed on 02/12/2015 at 11:15 am ambulating, without use of an assistive device, off of the long term care unit. He returned a few minutes later and got a wheelchair and pushed it off the unit toward the dining room. He was observed at approximately 11:35 am seated in his wheelchair, backing it up in front of the nurses' station. The resident did not interact with staff or other residents during the observations. He was not being supervised. Residents #1 and #2 were both observed in the main dining room from approximately 2:20 pm until 2:50 pm on 02/12/2015. Both residents were observed to be dancing to music being played by a male entertainer hired by the facility to provide music for the residents. Facility staff was present in the dining room and the hallway outside the dining room. Residents #1 and #2 were not on one to one supervision, and had access to each other. Both came and went from the dining room without supervision. An interview with Resident #2 on 2/12/2015 at approximately 4:05 pm revealed that he spoke English with a very thick accent, and he was alert and oriented to person, place, time, and circumstance. He was pleasant and appeared well groomed and appropriately dressed. He stated he was not interested in Resident #1 because she was too old for him. When asked if he would be interested in younger women, he said, "Yes, but he was in this place, a hospital." He stated that he could not have erections since his accident, so there was no way he could have been with Resident #1. He stated, "It doesn't work down there." He pointed toward his crotch. He was asked if he was in Resident #1's room on Monday, and if the nurse came in and told him to leave. He stated, "I go down and around her room but I don't go in." He said that the nurse who made the allegation "talks too much," while at the same time, he made duck quacking gestures with his hands. He repeatedly stated he had problems having erections since his accident, and the incident could not have happened. An interview on 02/13/2015 at 2:35 pm with the psychiatric Advanced Registered Nurse Practitioner (ARNP) revealed that the facility called her on 2/12/15 to consult on Resident #2 regarding the 2/9/15 incident. She stated that Resident #2 denied anything regarding the allegation. The ARNP stated that she sees Resident #1 on a regular basis, and she (the ARNP) doesn't think Resident #1 could consent to having sex. Review of the ARNP's progress note for Resident #1 dated 2/16/15 revealed that the resident had slow thought processes, poor insight/judgment, was well oriented to person only, had impaired memory and delusions. The ARNP documented that the sexual incident was reported to her on 2/13/15. When the ARNP interviewed Resident #1 on 2/16/15, she denied knowing anything about the incident. The note stated that staff reported Resident #1 has been seen on other occasions acting inappropriately in a sexual manner. The ARNP documented that she had not "seen or had other reports before now." Review of the ARNP's progress note for Resident #2 revealed that he was examined on 2/13/15. His behavior and thought processes were normal, insight/judgment were adequate, he was oriented to person, place, and time, his memory was intact, and his mood was normal. In an interview with Resident #3 on 2/16/15 at 3:01pm, when asked whether she had seen any residents behave in a sexually inappropriate manner, she said that Resident #1 "walks around and likes to mess with men." She said that Resident #1 "twists in front of everybody and sits on their laps." She said that staff try to get her up and away, but she doesn't know any better." During an interview with Employee C, Certified Nursing Assistant (CNA), on 02/13/2015 at approximately 2:58 pm, she stated that she worked full time on the 7a-3p shift, and she was familiar with Resident #1. Employee C stated that at times Resident #1 is confused, and she has to re-direct her. She stated that Resident #1 is social in the dining room, and she gravitates to Resident #2. Employee C said that resident #1 is "touchy" with Resident #2. She stated, "She dances in the dining room, and when he's around she acts like she wants to do more with him." She stated she took care of Resident #2 when he was first admitted on the short term rehabilitation unit, and she described him as "flirty." She stated she saw Resident #2 taking Resident #1 out the back hallway one day toward the smoking area. She stopped Resident #1 from going with him. She stated that Resident #2 knows the code for the back door. She explained that the alarm for Resident 1's WanderGuard? only goes off at the front door. She stated she thinks that Resident #1 wears a WanderGuard?. When asked, Employee C stated that she didn't think Resident #1 could consent to sex. Employee C stated that Residents #1 and #2 were not on one-to-one supervision this morning (2/13/15). She stated, "They did not put them on one-to-one until after I got back from lunch." She thought it was around 12:30pm. She stated that there were two CNAs assigned to be one-to-one with the two residents now. Regarding re-training for abuse, Employee C stated that she was not in-serviced, but at around 2:30pm today she was asked to sign a one page paper showing that she had received education on abuse today. During an interview on 2/13/15 at 3:05pm with Employee D, CNA, she stated that she worked the 7a-3pm shift on the 200 hall, and she was usually assigned to Resident #1. She stated, "She's sweet. She's a little promiscuous. She likes to shake her bootie a lot. Every now and then, I catch her kissing somebody." She stated that she has seen Resident #1 gravitate toward Resident #2. She stated that Resident #1 "loves men." Employee D stated that Resident #1 liked another resident in the past, but the man's wife got upset with the attention Resident #1 was paying to her husband. The staff made sure that Resident #1 didn't go near that resident anymore. Employee D stated that Resident #1 usually goes into Resident #2's room. She stated that when she sees her go in the room, she goes to get her. Employee D stated that when Resident #2 first got moved to the long term care unit, he was flirtatious with her and would try to kiss her hands. She corrected him and she hasn't had a problem with him since. She was asked if she thought Resident #1 was able to consent to sex with Resident #2, and she stated that she didn't think so. When asked about re-training for abuse, Employee D stated that the Assistant Director of Nursing (ADON) gave her education on abuse today. There were 5 staff members in the group. The ADON explained about sexual abuse, and to separate the residents if found having sex. She stated the ADON had her sign a form today saying she'd been educated about abuse. Review of the care plan for Resident #1 dated 1/13/2015 revealed that the resident was not care planned for any of the sexualized behaviors observed by staff. A hand written note, dated 02/10/2015, on the resident's Behavior care plan indicated the resident makes sexual gestures, is exit seeking, rummages, and is physically inappropriate (performs sex acts on male resident). In the Approaches and Interventions column of the plan, a hand written update, dated 2/10/2015, read, "Attempt to redirect if found performing sex act, but provide privacy if residents are both in agreement." During an interview with Employee E, CNA, on 02/13/2015 at approximately 3:10 pm, she stated that she had worked at the facility for 2.5 years and she has been assigned to Resident #2. She stated that Resident #2 was pleasant and very independent. She said that he keeps to himself, Skypes (live audio and visual communication via internet connection) with his sister on the computer, asks for the things he needs, and goes out to smoke and chat with other smoking residents. She was asked if she knew Resident #1, and she stated that she did, adding that Resident #1, "Walks the hallways and goes into every room; She's like a butterfly. She doesn't understand that she shouldn't be in other peoples' rooms. Her mind set is like she's fifty. She touches people on the shoulders. Some residents complain about it. She touches males and females. She's very easy to like." She stated she didn't think that Resident #1 could give consent to have sex. Employee E stated that Resident #1 had a WanderGuard? alarm on, and when she goes out the doors someone goes out and gets her. She stated she got abuse training today from the ADON around 2:15 pm - 2:30 pm. She stated she was told to read a piece of paper with information on abuse, and asked to sign it. She said that the training took approximately 5 minutes. During an interview on 02/13/15 at 5:00 pm with the MDS Coordinator, she stated that she attended morning meetings on 2/10/15 - 2/12/15, and there was no discussion at the meetings about the incident involving Resident #1 and Resident #2. She stated that the DON informed her on 2/13/15 that there had been a sexual incident between the two residents, and she was to update the care plan. She said the DON told her exactly what to write on the care plans. In an interview conducted on 2/13/15 at 5:22pm with the DON she reviewed Resident #1's medical record and stated that there was no documentation of an assessment of Resident #1 after the incident, or that her physician was notified. She was asked if both should have been done, and she stated that they should have been. The DON confirmed that she had not conducted interviews of all facility staff involved in the incident. She stated that she completed an incident report on 2/12/15 regarding the incident, and sent it to the facility's corporate office. She could not produce a copy of the report for review. The administrator stated that he had not reviewed the incident report prior to it being sent through the mail to the corporate office. The DON told the surveyor, "I should have investigated, and I take responsibility for that." In an interview with Employee F, CNA, on 2/13/15 at 4:00pm she stated that she thought she got education about abuse today, but she wasn't sure. She said it lasted a couple of minutes. She said she signed her name, but she wasn't sure what it was because she was walking with a resident. She stated she really didn't have time to read it. Review of the Resident Abuse policy and procedure, dated 11/30/2014, revealed that the policy defined sexual abuse as including sexual harassment, sexual coercion, sexual assault or allowing a resident to be sexually abused by another, and inciting any of the above. The policy stated, "Furthermore, the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors, or volunteers." The "Employee Obligation" section read, "All employees have a duty to respect the rights of all residents, to treat them with dignity, and to prevent others from violating their rights. Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the Clinical Nurse in charge, Director of Clinical Services, and the Executive Director." The policy did not mention the individual obligation of all staff who witness abuse to report to state authorities. The "Identification of Abuse" section stated that the Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator and an abuse investigation will be conducted. In the absence of the Executive Director, the Director of Clinical Services will serve as Abuse Coordinator." The "Preliminary Investigation" section stated that immediately upon report of an incident to the individual in charge, the suspect shall be segregated from the resident. The policy did not address protecting all residents from the alleged abuser. The policy stated that the Clinical Nurse in charge or the Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. The policy did not specify when this should be done. The policy stated that an incident report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion. The "Procedure for Reporting Abuse" section read, "All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, and the Executive Director. Once reported to one of the three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation." The policy then stated that the abuse coordinator is responsible for reporting to appropriate officials in accordance with Federal and State Regulations. The policy did not mention the obligation of all staff who witness abuse to report to state authorities. The "Investigations" section read, "The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s), and all possible witnesses, including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared." The "Discipline" section read, "The Abuse Coordinator of The Company will refer any or all incidents and reports of resident abuse to the appropriate state agencies." There was no mention in the facility's abuse policy of notification of law enforcement. The facility's handout titled "Freedom From Abuse Notice To Employees," used by the facilty in re-training of staff commencing on 2/13/15, described the following reporting structure for staff in the event of suspected or observed abuse: Executive Director, Vice President of Human Resources, Medical Director, Director Of Clinical Services, Ombudsman, and all other officials required by law. This document did not mention sexual abuse, and did not include notification of law enforcement or the abuse coordinator. .

Based on observation, resident and staff interviews, and record review, the facility failed to provide supervision to prevent abuse for a resident who exhibited sexualized behaviors (Resident #1), out of 5 residents reviewed for abuse or neglect. The facility had knowledge that Resident #1, who was severely cognitively impaired, exhibited sexualized behaviors toward Resident #2. The facility did not report these behaviors to Resident #1's psychiatric provider, or protect the resident from Resident #2, who was at a much higher level of cognitive function. The facility also had knowledge that an employee reported an allegation of sexual abuse involving Residents #1 and #2 on February 9, 2015, but failed to investigate the allegation of abuse and ensure that Resident #1 was protected from the alleged perpetrator from 02/09/2015 through 02/13/2015. After the staff member's allegation, the alleged abuser continued to reside in the same location within the facility and to have unencumbered access to Resident #1 from 02/09/2015 through 2/13/2015 at approximately 1:00 pm, when both residents were put on one-to-one supervision. This resulted in Immediate Jeopardy beginning on 2/09/2015. The facility's failure to to provide supervision of a resident who exhibited sexualized behaviors, and failure to monitor the alleged abuser, placed cognitively impaired residents in the facility at risk for serious injury, harm, or impairment. Immediate Jeopardy was ongoing on exit on 2/17/15. Substandard quality of care was identified at F-323 (S/S J). Cross reference F-224 (S/S J), F-225 (S/S J), and F-226 (S/S J). The findings include: A review of the medical record for Resident #1 revealed a nursing note, dated 02/09/2015 at 1:40 pm, that read, "Writer observed resident giving oral sex to another resident (Resident #2). Writer immediately stopped both residents and separated them. Proper supervisor as well as Social Services was notified. Social Services will notify families of incident. Resident (#1) is alert with dementia. Resident (#1) has to be redirected at times. Wanders throughout the facility. Resident (#1) has WanderGuard? (a signaling device that alarms when the resident exits the property) in place. Resident tolerated meds (medications) well today. No SOB (shortness of breath) noted. Denies pain. Resident will be monitored closely." The note was signed by Employee A, Licensed Practical Nurse (LPN). In a telephone interview on 2/12/2015 at 4:28pm with Employee A, she stated that on 2/09/2015, at approximately 1:20 pm, as she was walking down the hall and passed by Resident #1's room, she glanced into the room and saw a man with his pants down, standing next to the bed nearest to the window. She stated she knew that was Resident #1's bed, and she became alarmed. Employee A stated that she went into the room and saw Resident #1 lying in her bed on her left side, facing Resident #2. Resident #1 was supporting herself on her elbow, and had her hand on Resident #2's penis in her mouth. Employee A stated in the interview, "I saw it happening. I physically saw it. I know what I saw." She stated she immediately told the residents to stop, and for Resident #2 to leave the room. She stated she went to the nurses' station and immediately reported the incident to the Unit Manager (UM). She stated that the UM told her to report the incident to the Director of Nurses (DON) right away. Employee A stated that she then spoke with the Social Services Director (SSD) about the incident, and they both reported it to the DON. Employee A stated that the DON treated her like she was lying about what she saw, and told her and the SSD that nothing could be done about the incident, because the residents were consenting adults. Employee A stated that she told the DON that Resident #1 was not able to consent because she had advanced senile dementia, and she was not as high functioning mentally as Resident #2. She stated that she told the DON that she was afraid that Resident #2 may have and would continue to take advantage of Resident #1. She stated that the facility should not allow this to happen even if it appeared that Resident #1 was not harmed. In an interview on 2/13/15 at 1:30pm with the SSD, she said that she told the DON that she had interviewed both residents, and that both were denying the allegation. The SSD said that Employee A then told the DON again that she saw the incident, and she was sure of what she saw. The DON asked if anyone else saw it, and Employee A told her she didn't think so. The SSD stated that the DON then said that both residents were consenting adults. The SSD stated at the time of the interview that she did not believe Resident #1 was a consenting adult. In an interview with Employee D, CNA, on 2/13/15 at 3:05pm she stated that on 02/09/2015, she was right there at Resident #1's room at the time that Employee A said she saw Residents #1 and #2 involved in oral sex in Resident #1's room. Employee D stated that she saw Resident #2 with his hands on his pants. She couldn't see what he was doing. His pants were up. Resident #1 was fully dressed and facing Resident #2. She stated that she followed Employee A to the nurse's station, and overheard Employee A tell the UM that the two residents were having sex. In an interview with Employee B, LPN, on 02/13/2015 at approximately 2:48 pm, she stated that she has worked at the facility since March, 2014, and she is assigned regularly to Resident #2. She stated that she was caring for Resident #2 on 2/9/15, when Employee A told her at approximately 1:30 pm that she just witnessed the two residents having oral sex in Resident #1's room. Employee B stated that earlier that same day (02/09/2015), she saw Resident #1 sitting on Resident #2's bed. She said that Resident #2 was fully dressed and he was lying on his bed. Resident #1 was seated on the bed at the foot of the bed. Employee B stated that she saw Resident #1 rubbing Resident #2's pants leg near his ankle. Employee B said that she told Resident #1 to come out of the room. Employee B was asked if she reported this observation to anyone, and she stated she had not. She added, "Everybody knows how they are, them two. Sometimes she is seen rubbing his back." She stated, "It's common knowledge that she will come up to him and touch him." In an interview on 2/13/15 at 4:35pm with the UM, she stated that on 2/9/15 at an unknown time, Employee A reported observing two residents having oral sex. The UM said that she instructed Employee A to report the incident to the DON. The UM said that when Employee A returned to the floor, Employee A said that the DON told her that both residents were alert and oriented, and nothing needed to be done. The UM told Employee A to document everything in the resident's record. The UM stated that she was not instructed by the DON to do anything more about this incident. When asked, the UM stated that she didn't think Resident #1 was capable of making decisions regarding sex. She stated that Resident #1 was confused, and that was probably why the incident happened. She stated that Employee B did not report to her on 2/9/15 that Resident #1 had been in Resident #2's room earlier in the day. She stated that she did not call the abuse hotline about the incident because she thought the DON would do it. She stated that she did not know if Resident #1's physician had been notified of the incident. She reviewed Resident #1's record and stated that the resident had not been examined since the incident. Record review revealed that Resident #1 resided in room #204W. She was [AGE] years old and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record also showed a [DIAGNOSES REDACTED]. The resident was prescribed Seroquel 50mg twice a day for bipolar disorder, Zoloft 50mg daily for depression, and Namenda XR 28mg daily for dementia. The resident's daughter signed the resident's consents for treatment. Review of the Minimum Data Set (MDS), dated [DATE], revealed in Section C, Cognitive, that Resident #1 had a Brief Interview for Mental Status (BIMS, to determine the individual's attention, orientation and ability to register and recall new information) with a score of 5 (severe impairment) out of a possible 15. She was assessed as not being oriented to year, month, or day, and could recall two out of three items after being cued. She continuously had difficulty focusing her attention, and had disorganized thinking with no fluctuation. Section D, Mood, revealed that Resident #1 had trouble concentrating on things, such as watching television or reading a newspaper. She had behavior of restlessness or moving around more than usual during half or more of the days of the assessment period. Record review for Resident #2 revealed that he was [AGE] years old, and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record noted a short term memory problem, alert to person and place, independent in cognitive decision making, makes self understood, and no confusion. Issues assessed at his 1/20/15 neurology appointment included traumatic brain injury (brain dysfunction caused by a blow to the head) and erectile dysfunction. Review of Resident #2's safety care plan, original date 4/1/14 and latest revision date 12/31/14, revealed problems of removes his WanderGuard? and continues to go outside unattended, and refuses smoking policy. There were no interventions listed for these behaviors. Also listed (no date) as a problem on the care plan was the statement, "Resident has had sex acts performed on him by female resident." The intervention listed stated, "Attempt to redirect if found in sex act with another resident, provide privacy if both residents in agreement." Review of the facility map revealed that Resident #2's room, #300A, was located at the beginning of the 300 hallway next to the nursing station. Resident #1's room, 204W, was on the next hallway that began at the nursing station, about 4 doors down the 300 hallway. In an interview on 02/12/2015 at 5:08 pm with the DON, when asked how she determined that Resident #1 was a consenting adult, she stated that Employee A and the SSD told her that the resident was sometimes confused, but she was alert and oriented. The DON added that the resident was able to carry on a conversation, and sometimes converts to Spanish. The DON said that when she interviewed Employee A, she asked her if both residents were alert and oriented, and Employee A told her they were. She stated that the SSD then left the room to interview both residents involved, the nurse went back to the floor, and "that was the end of it." The DON stated that she was not aware of any incident between the two residents earlier in the day. She stated that law enforcement had not been informed of the incident. In an interview on 2/13/2015 at 1:30 pm with the SSD, she stated that she thought the incident happened between 1:00 pm and 2:00 pm on 2/9/15. She stated she received a frantic phone call from the UM on the long term care unit, asking her to come to the unit. She stated that when she got to the unit the UM told her that Employee A had reported that she saw Resident #1 and Resident #2 having oral sex. The SSD said she went directly to Resident #2's room and interviewed him. She said she asked him about "an incident that just happened" and he told her, "I did not do that. You believe everything everybody else tells you." The SSD's progress note dated 2/9/15 at 2:35pm stated that Resident #2 "became upset about this writer not believing him." The SSD asked Resident #2 if he was in another resident's room, and he stated he wasn't. The SSD said that Resident #2 started to become agitated with her, so she thanked him and went to Resident #1's room. The SSD stated that she found Resident #1 sleeping on her bed. The SSD tapped the resident on the shoulder and woke her up. The SSD asked the resident about the incident that just happened. resident #1 denied that there was a man in her room, or that the incident occurred. In an interview on 2/12/2015 at 2:35pm with the Administrator and the DON, the DON stated after the reading Employee A's nursing note about the incident dated 2/09/2015, "I went down and interviewed both residents and they denied it ever happened." She was asked, "Was there any investigation into this?" She stated, "Why would there be? They are both alert and oriented consenting adults." When informed by this surveyor that Resident #1 was cognitively impaired with a BIMS score of 5 out of a possible 15, the DON made no reply. The DON was asked if anything was done to protect the residents in the facility since the incident, such as moving one of the residents to a different location, or changing the supervision of the residents; She stated, "No." She stated she did not investigate the allegation because she was informed that both residents were consenting adults. When the administrator read the nurse's note about the incident, he stated, "I didn't know anything about this." Interview on 2/12/15 at approximately 3:10 pm with the Administrator revealed that he was very disappointed that the incident had not been brought to his attention. He stated he had already instructed the DON to begin an investigation. He stated, "I asked (the DON), what were you thinking? Why didn't you report this?" He stated he would have reported and investigated this incident if he had known. Resident #2 was observed on 02/12/2015 at 11:15 am ambulating, without use of an assistive device, off of the long term care unit. He returned a few minutes later and got a wheelchair and pushed it off the unit toward the dining room. He was observed at approximately 11:35 am seated in his wheelchair, backing it up in front of the nurses' station. The resident did not interact with staff or other residents during the observations. He was not being supervised. Residents #1 and #2 were both observed in the main dining room from approximately 2:20 pm until 2:50 pm on 02/12/2015. Both residents were observed to be dancing to music being played by a male entertainer hired by the facility to provide music for the residents. Facility staff was present in the dining room and the hallway outside the dining room. Residents #1 and #2 were not on one-to-one supervision, and had access to each other. Both came and went from the dining room without supervision. An interview with Resident #2 on 2/12/2015 at approximately 4:05 pm revealed that he spoke English with a very thick accent, and he was alert and oriented to person, place, time, and circumstance. He was pleasant and appeared well groomed and appropriately dressed. He stated he was not interested in Resident #1 because she was too old for him. When asked if he would be interested in younger women, he said, "Yes, but he was in this place, a hospital." He stated that he could not have erections since his accident, so there was no way he could have been with Resident #1. He stated, "It doesn't work down there." He pointed toward his crotch. He was asked if he was in Resident #1's room on Monday, and if the nurse came in and told him to leave. He stated, "I go down and around her room but I don't go in." He said that the nurse who made the allegation "talks too much," while at the same time, he made duck quacking gestures with his hands. He repeatedly stated he had problems having erections since his accident, and the incident could not have happened. An interview on 02/13/2015 at 2:35 pm with the psychiatric Advanced Registered Nurse Practitioner (ARNP) revealed that the facility called her on 2/12/15 to consult on Resident #2 regarding the 2/9/15 incident. She stated that Resident #2 denied anything regarding the allegation. The ARNP stated that she sees Resident #1 on a regular basis, and she (the ARNP) doesn't think Resident #1 could consent to having sex. Review of the ARNP's progress note for Resident #1 dated 2/16/15 revealed that the resident had slow thought processes, poor insight/judgment, was well oriented to person only, had impaired memory and delusions. The ARNP documented that the sexual incident was reported to her on 2/13/15. When the ARNP interviewed Resident #1 on 2/16/15, she denied knowing anything about the incident. The note stated that staff reported Resident #1 has been seen on other occasions acting inappropriately in a sexual manner. The ARNP documented that she had not "seen or had other reports before now." Review of the ARNP's progress note for Resident #2 revealed that he was examined on 2/13/15. His behavior and thought processes were normal, insight/judgment were adequate, he was oriented to person, place, and time, his memory was intact, and his mood was normal. In an interview with Resident #3 on 2/16/15 at 3:01pm, when asked whether she had seen any residents behave in a sexually inappropriate manner, she said that Resident #1 "walks around and likes to mess with men." She said that Resident #1 "twists in front of everybody and sits on their laps." She said that staff try to get her up and away, but she doesn't know any better." During an interview with Employee C, Certified Nursing Assistant (CNA), on 02/13/2015 at approximately 2:58 pm, she stated that she worked full time on the 7a-3p shift, and she was familiar with Resident #1. Employee C stated that at times Resident #1 is confused, and she has to re-direct her. She stated that Resident #1 is social in the dining room, and she gravitates to Resident #2. Employee C said that resident #1 is "touchy" with Resident #2. She stated, "She dances in the dining room, and when he's around she acts like she wants to do more with him." She stated she took care of Resident #2 when he was first admitted on the short term rehabilitation unit, and she described him as "flirty." She stated she saw Resident #2 taking Resident #1 out the back hallway one day toward the smoking area. She stopped Resident #1 from going with him. She stated that Resident #2 knows the code for the back door. She explained that the alarm for Resident 1's WanderGuard? only goes off at the front door. She stated she thinks that Resident #1 wears a WanderGuard?. When asked, Employee C stated that she didn't think Resident #1 could consent to sex. Employee C stated that Residents #1 and #2 were not on one-to-one supervision this morning (2/13/15). She stated, "They did not put them on one-to-one until after I got back from lunch." She thought it was around 12:30pm. She stated that there were two CNAs assigned to be one-to-one with the two residents now. Regarding re-training for abuse, Employee C stated that she was not in-serviced, but at around 2:30pm today she was asked to sign a one page paper showing that she had received education on abuse today. During an interview on 2/13/15 at 3:05pm with Employee D, CNA, she stated that she worked the 7a-3pm shift on the 200 hall, and she was usually assigned to Resident #1. She stated, "She's sweet. She's a little promiscuous. She likes to shake her bootie a lot. Every now and then, I catch her kissing somebody." She stated that she has seen Resident #1 gravitate toward Resident #2. She stated that Resident #1 "loves men." Employee D stated that Resident #1 liked another resident in the past, but the man's wife got upset with the attention Resident #1 was paying to her husband. The staff made sure that Resident #1 didn't go near that resident anymore. Employee D stated that Resident #1 usually goes into Resident #2's room. She stated that when she sees her go in the room, she goes to get her. Employee D stated that when Resident #2 first got moved to the long term care unit, he was flirtatious with her and would try to kiss her hands. She corrected him and she hasn't had a problem with him since. She was asked if she thought Resident #1 was able to consent to sex with Resident #2, and she stated that she didn't think so. Review of the care plan for Resident #1 dated 1/13/2015 revealed that the resident was not care planned for any of the sexualized behaviors observed by staff. A hand written note, dated 02/10/2015, on the resident's Behavior care plan indicated the resident makes sexual gestures, is exit seeking, rummages, and is physically inappropriate (performs sex acts on male resident). In the Approaches and Interventions column of the plan, a hand written update, dated 2/10/2015, read, "Attempt to redirect if found performing sex act, but provide privacy if residents are both in agreement." During an interview with Employee E, CNA, on 02/13/2015 at approximately 3:10 pm, she stated that she had worked at the facility for 2.5 years and she has been assigned to Resident #2. She stated that Resident #2 was pleasant and very independent. She said that he keeps to himself, Skypes (live audio and visual communication via internet connection) with his sister on the computer, asks for the things he needs, and goes out to smoke and chat with other smoking residents. She was asked if she knew Resident #1, and she stated that she did, adding that Resident #1, "Walks the hallways and goes into every room; She's like a butterfly. She doesn't understand that she shouldn't be in other peoples' rooms. Her mind set is like she's fifty. She touches people on the shoulders. Some residents complain about it. She touches males and females. She's very easy to like." She stated she didn't think that Resident #1 could give consent to have sex. Employee E stated that Resident #1 had a WanderGuard? alarm on, and when she goes out the doors someone goes out and gets her. She stated she got abuse training today from the ADON around 2:15 pm - 2:30 pm. She stated she was told to read a piece of paper with information on abuse, and asked to sign it. She said that the training took approximately 5 minutes. During an interview on 02/13/15 at 5:00 pm with the MDS Coordinator, she stated that she attended morning meetings on 2/10/15 - 2/12/15, and there was no discussion at the meetings about the incident involving Resident #1 and Resident #2. She stated that the DON informed her on 2/13/15 that there had been a sexual incident between the two residents, and she was to update the care plan. She said the DON told her exactly what to write on the care plans. In an interview conducted on 2/13/15 at 5:22pm with the DON she reviewed Resident #1's medical record and stated that there was no documentation of an assessment of Resident #1 after the incident, or that her physician was notified. She was asked if both should have been done, and she stated that they should have been. The DON confirmed that she had not conducted interviews of all facility staff involved in the incident. She stated that she completed an incident report on 2/12/15 regarding the incident, and sent it to the facility's corporate office. She could not produce a copy of the report for review. The administrator stated that he had not reviewed the incident report prior to it being sent through the mail to the corporate office. The DON told the surveyor, "I should have investigated, and I take responsibility for that."

Based on observation, staff interview, clinical and facility records review the facility failed to thoroughly investigate and report an injury of unknown origin, and an allegation of mistreatment for 1 (Resident #103) of 4 sampled residents. It was discovered that Resident #103 had bruise of unknown origin on her genitalia. The facility failed to conduct a thorough investigation, including a medical examination to determine if there was trauma or sexual assault. The staff who identifed this burise failed to immediately notify the Clinical Nurse in charge, or Director, Director of Clinical Services or Executive Director according to the facility policy. The Interim Director of Nursing/Abuse Coordinator did not perform or document a thorough nursing assessment and discuss these findings with the physician until almost 3 days after the bruise was discovered. Due to the location and nature of the bruise, the facility failure to report and investigate timely for potential physical or sexual assaulty could delay medical/psychological treatment for [REDACTED]. These findings resulted in Immediate jeopardy and is ongoing for failure to thoroughly investigate an injury of unknown origin, and placed all residents residing in the facility at risk for abuse. The findings include: 1. An observation of Resident #103 on 08/09/12 at 2:20 PM revealed the resident sleeping and her daughter was at the bedside. Per the daughter, she recently found bruising on her mother's vagina. She revealed the Unit Manager informed her that the bruising was a result of the incontinence brief her mother was wearing. A clinical record review for Resident #103 revealed she was admitted to the facility on [DATE] with a readmission date of [DATE]. The admission [DIAGNOSES REDACTED]. A review of the Admission Data Collection Form dated 01/30/12 revealed the resident had a language barrier, and staff was unable to orient the resident because she spoke Arabic. A review of the Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/09/12, Section B, revealed the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Review of the Quarterly MDS Assessment with an ARD of 04/27/12 revealed Resident #103 had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. A review of the physician's orders [REDACTED]. A review of the Nurses Note dated 07/27/12 for Resident #103 (untimed) revealed the resident's daughter brought to the nurse's attention a bruise on her mother's peri- area. The note also revealed that the resident complained of pain to the right abdomen when coughing or pressing the right lower quadrant of her abdomen. A Nurses Note dated 07/28/12 (untimed) for Resident #103 revealed the nurse continued to observe bruising to the outer aspect of the labia majora. Review of the Physician/Nurse Practitioner/Physician Assistant Communication and Progress Note for New Symptoms, Signs and other changes in condition (SBAR) forms dated 07/28/12, 07/29/12 and 07/30/12 revealed evidence that the daughter had reported on 07/27/12 the bruise on the resident genitalia. The instructions on the form indicated that the form should be completed before contacting the physician. Review of the form revealed that "S" was the Situation, "B" was the Background, "A" was the Assessment or Appearance, and "R" was the Request. The section on the forms to document the date, time and name of the doctor, nurse practitioner or physician's assistant was blank. On 08/09/12 at 2:52 PM an interview with the GNR Unit Manager (UM), Nursing Home Administrator/Risk Manager (NHA/RM), and Interim Director of Nursing/Abuse Coordinator (IDON/AC) revealed the GNR UM and IDON/AC examined the resident on 07/30/12. The Interim IDON revealed she completed the physical assessment of the bruise on Resident #103's vagina on 07/30/12 after the morning meeting. The IDON indicated the resident had a linear bruise consistent with the rubber of an incontinence brief. She revealed she discussed the findings with the physician. She revealed she did not believe the resident was assessed by the physician, but an order was obtained to monitor the area. On 08/10/12 at 11:15 AM a telephone interview with Nurse #60 revealed on 07/27/11 on the 3-11pm shift Resident #103's daughter approached her while she was at the medication cart and requested something for pain for her mother. She revealed she went down to evaluate the resident as the daughter had mentioned that she had observed a bruise to her mother's vagina. The nurse revealed the she observed the resident's vaginal area and determined there was a bruise to the labia minora (lip of the vagina) that was bluish-purplish in color, and about 1 1/2 to 2 inches long. The nurse revealed that she did not know what happened to the resident including what caused the bruise or when the resident sustained [REDACTED]. The nurse revealed that she called the physician and did not receive a call back. She revealed she reported off to the oncoming nurse so that when the physician did called back they would know the reason for the call. The nurse stated that she documented in the chart and also completed a bruise report and documented the incident on the 24 hour report. She revealed she did not inform management about the bruise to the resident's vagina, because there was no management available. A review of the Comprehensive 24- Hour Report (Quality Assurance) dated 07/27/12 revealed there was documentation Resident #103's family had concerns regarding a bruise on the resident and a report form was filled out. There was no documentation an attempt had been made to notify the physician. On 08/10/12 at 12:58 PM a telephone interview with the Advanced Registered Nurse Practitioner (ARNP) revealed that he was familiar with Resident #103, but had not physically evaluated the resident in about two months. He was advised there was a telephone order indicating the nurse spoke to him about a vaginal bruise to the resident's vagina on 07/29/12. He revealed that he did not remember receiving a phone call from the facility regarding an incident with the resident having vaginal bruising. He revealed that was not a typical phone call he would receive and something like that would stand out to him. On 08/10/12 at 1:14 PM a telephone interview with certified nursing assistant (CNA) #61 revealed she was the aide caring for the resident when the daughter noted the bruise to her mother's vagina. She revealed she did not know how the bruise occurred or when it occurred and she referred the resident's daughter to the nurse. She also revealed she observed the bruise on the resident's vagina. An interview with NHA/RM on 08/10/12 at 1:25 PM revealed the incident occurred before he was employed at the facility. He revealed he became aware of the incident when he went through the incident reports. He revealed he trusted the Director of Nursing's decision about notifying the physician. He also revealed the protocol for investigation of bruising would depend on the situation and that he was not always notified; it depended on the type of bruising. If the issue had the making of an adverse incident then he would be notified. He revealed the incident reports are reviewed at the morning meetings and if there was potential abuse he would be notified and it would be investigated. Per the NHA/RM the IDON was convinced it was the brief that was applied inappropriately and that was what caused the bruising. There were no statements that indicated abuse. He also revealed that he would have expected something like vaginal bruising to be reported to the IDON at the time it was found. An interview with Physician #1 on 08/10/12 at 2:06 PM revealed he was not notified that Resident #103 had vaginal bruising. He revealed his ARNP was notified on 07/29/12. He revealed that he had not examined the resident until today. His examination revealed the resident had minimal [DIAGNOSES REDACTED] (redness) on the right groin, no excoriation or drainage. There was no evidence of trauma. He indicated the [DIAGNOSES REDACTED] appeared to be due to a brief. He revealed the resident had severe dementia, was in the facility for end of life care because of a [DIAGNOSES REDACTED] and was totally dependent on staff for care. An interview with Resident #103's Attending Physician and the Director of Medical Services on 08/11/12 at 9:10 AM revealed he was not made aware that Resident #103 had vaginal bruising on 07/27/12. Review of the Resident Abuse Policy and Procedure dated 01/07, revised 01/10 revealed the following: The Policy section included, but was not limited to the following: It is in the nature and dignity of each resident at Consulate Health Care that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Procedure section included, but was not limited to the following: VI. Identification All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Clinical Director of Services. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services will serve as Abuse Coordinator. VII. Procedure for Reporting Abuse A. All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, or the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation. VIII. The Abuse Coordinator of Consulate Health Care will endeavor to protect the rights of residents and employees. The administrator recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened. Thus, while the Administration reserves the right to suspend pending an investigation, such suspension is not be deemed as an assessment of guilt. IX. Investigation of Abuse. A. The Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. A Social Service representative shall be present in the role of resident advocate during any questioning of or interviewing of residents. B. Investigations will be accomplished in the following manner. 1. Preliminary investigation: c. The Clinical Nurse in charge or Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. d. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report should be filed as soon as possible in order to provide the most accurate information in a timely fashion. 2. Investigation a. The Abuse/Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. b. Any suspect (s), once he/she has (have) been identified will be suspended pending the investigation. 3. Review of Report: a. Once completed, the investigation's report shall be reviewed by the Director of Clinical Services, the Abuse Coordinator, and one other Administrative staff member. 4. Discipline: c. The Abuse Coordinator of Consulate Healthcare will refer any or all incidents and reports of abuse to the appropriate state agencies. .

Based on observation, staff interview, clinical and facility records review the facility failed to thoroughly investigate and report an injury of unknown origin, and an allegation of mistreatment for 1 (Resident #103) of 4 sampled residents. It was discovered that Resident #103 had bruise of unknown origin on her genitalia. The facility failed to conduct a thorough investigation, including a medical examination to determine if there was trauma or sexual assault. The staff who identifed this burise failed to immediately notify the Clinical Nurse in charge, or Director, Director of Clinical Services or Executive Director according to the facility policy. The Interim Director of Nursing/Abuse Coordinator did not perform or document a thorough nursing assessment and discuss these findings with the physician until almost 3 days after the bruise was discovered. Due to the location and nature of the bruise, the facility failure to report and investigate timely for potential physical or sexual assaulty could delay medical/psychological treatment for [REDACTED]. These findings resulted in Immediate jeopardy and is ongoing for failure to thoroughly investigate an injury of unknown origin, and placed all residents residing in the facility at risk for abuse. On August 29, 2012 the facility was found to have taken action and initiated the investigative and reporting requirements for Resident #103. Facility wide training and education was provided to all current staff and residents regarding identification, reporting, and investigating allegations of abuse, neglect or injuries of unknown origin, and monitoring was ongoing. The IJ at F225 was removed as of 08/15/12. However, F225 remained out of compliance at S/S F. The findings include: 1. An observation of Resident #103 on 08/09/12 at 2:20 PM revealed the resident sleeping and her daughter was at the bedside. Per the daughter, she recently found bruising on her mother's vagina. She revealed the Unit Manager informed her that the bruising was a result of the incontinence brief her mother was wearing. A clinical record review for Resident #103 revealed she was admitted to the facility on [DATE] with a readmission date of [DATE]. The admission [DIAGNOSES REDACTED]. A review of the Admission Data Collection Form dated 01/30/12 revealed the resident had a language barrier, and staff was unable to orient the resident because she spoke Arabic. A review of the Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/09/12, Section B, revealed the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Review of the Quarterly MDS Assessment with an ARD of 04/27/12 revealed Resident #103 had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. A review of the physician's orders [REDACTED]. A review of the Nurses Note dated 07/27/12 for Resident #103 (untimed) revealed the resident's daughter brought to the nurse's attention a bruise on her mother's peri- area. The note also revealed that the resident complained of pain to the right abdomen when coughing or pressing the right lower quadrant of her abdomen. A Nurses Note dated 07/28/12 (untimed) for Resident #103 revealed the nurse continued to observe bruising to the outer aspect of the labia majora. Review of the Physician/Nurse Practitioner/Physician Assistant Communication and Progress Note for New Symptoms, Signs and other changes in condition (SBAR) forms dated 07/28/12, 07/29/12 and 07/30/12 revealed evidence that the daughter had reported on 07/27/12 the bruise on the resident genitalia. The instructions on the form indicated that the form should be completed before contacting the physician. Review of the form revealed that "S" was the Situation, "B" was the Background, "A" was the Assessment or Appearance, and "R" was the Request. The section on the forms to document the date, time and name of the doctor, nurse practitioner or physician's assistant was blank. On 08/09/12 at 2:52 PM an interview with the GNR Unit Manager (UM), Nursing Home Administrator/Risk Manager (NHA/RM), and Interim Director of Nursing/Abuse Coordinator (IDON/AC) revealed the GNR UM and IDON/AC examined the resident on 07/30/12. The Interim IDON revealed she completed the physical assessment of the bruise on Resident #103's vagina on 07/30/12 after the morning meeting. The IDON indicated the resident had a linear bruise consistent with the rubber of an incontinence brief. She revealed she discussed the findings with the physician. She revealed she did not believe the resident was assessed by the physician, but an order was obtained to monitor the area. On 08/10/12 at 11:15 AM a telephone interview with Nurse #60 revealed on 07/27/11 on the 3-11pm shift Resident #103's daughter approached her while she was at the medication cart and requested something for pain for her mother. She revealed she went down to evaluate the resident as the daughter had mentioned that she had observed a bruise to her mother's vagina. The nurse revealed the she observed the resident's vaginal area and determined there was a bruise to the labia minora (lip of the vagina) that was bluish-purplish in color, and about 1 1/2 to 2 inches long. The nurse revealed that she did not know what happened to the resident including what caused the bruise or when the resident sustained [REDACTED]. The nurse revealed that she called the physician and did not receive a call back. She revealed she reported off to the oncoming nurse so that when the physician did called back they would know the reason for the call. The nurse stated that she documented in the chart and also completed a bruise report and documented the incident on the 24 hour report. She revealed she did not inform management about the bruise to the resident's vagina, because there was no management available. A review of the Comprehensive 24- Hour Report (Quality Assurance) dated 07/27/12 revealed there was documentation Resident #103's family had concerns regarding a bruise on the resident and a report form was filled out. There was no documentation an attempt had been made to notify the physician. On 08/10/12 at 12:58 PM a telephone interview with the Advanced Registered Nurse Practitioner (ARNP) revealed that he was familiar with Resident #103, but had not physically evaluated the resident in about two months. He was advised there was a telephone order indicating the nurse spoke to him about a vaginal bruise to the resident's vagina on 07/29/12. He revealed that he did not remember receiving a phone call from the facility regarding an incident with the resident having vaginal bruising. He revealed that was not a typical phone call he would receive and something like that would stand out to him. On 08/10/12 at 1:14 PM a telephone interview with certified nursing assistant (CNA) #61 revealed she was the aide caring for the resident when the daughter noted the bruise to her mother's vagina. She revealed she did not know how the bruise occurred or when it occurred and she referred the resident's daughter to the nurse. She also revealed she observed the bruise on the resident's vagina. An interview with NHA/RM on 08/10/12 at 1:25 PM revealed the incident occurred before he was employed at the facility. He revealed he became aware of the incident when he went through the incident reports. He revealed he trusted the Director of Nursing's decision about notifying the physician. He also revealed the protocol for investigation of bruising would depend on the situation and that he was not always notified; it depended on the type of bruising. If the issue had the making of an adverse incident then he would be notified. He revealed the incident reports are reviewed at the morning meetings and if there was potential abuse he would be notified and it would be investigated. Per the NHA/RM the IDON was convinced it was the brief that was applied inappropriately and that was what caused the bruising. There were no statements that indicated abuse. He also revealed that he would have expected something like vaginal bruising to be reported to the IDON at the time it was found. An interview with Physician #1 on 08/10/12 at 2:06 PM revealed he was not notified that Resident #103 had vaginal bruising. He revealed his ARNP was notified on 07/29/12. He revealed that he had not examined the resident until today. His examination revealed the resident had minimal [DIAGNOSES REDACTED] (redness) on the right groin, no excoriation or drainage. There was no evidence of trauma. He indicated the [DIAGNOSES REDACTED] appeared to be due to a brief. He revealed the resident had severe dementia, was in the facility for end of life care because of a [DIAGNOSES REDACTED] and was totally dependent on staff for care. An interview with Resident #103's Attending Physician and the Director of Medical Services on 08/11/12 at 9:10 AM revealed he was not made aware that Resident #103 had vaginal bruising on 07/27/12. Review of the Resident Abuse Policy and Procedure dated 01/07, revised 01/10 revealed the following: The Policy section included, but was not limited to the following: It is in the nature and dignity of each resident at Consulate Health Care that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Procedure section included, but was not limited to the following: VI. Identification All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Clinical Director of Services. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services will serve as Abuse Coordinator. VII. Procedure for Reporting Abuse A. All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, or the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation. VIII. The Abuse Coordinator of Consulate Health Care will endeavor to protect the rights of residents and employees. The administrator recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened. Thus, while the Administration reserves the right to suspend pending an investigation, such suspension is not be deemed as an assessment of guilt. IX. Investigation of Abuse. A. The Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. A Social Service representative shall be present in the role of resident advocate during any questioning of or interviewing of residents. B. Investigations will be accomplished in the following manner. 1. Preliminary investigation: c. The Clinical Nurse in charge or Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. d. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report should be filed as soon as possible in order to provide the most accurate information in a timely fashion. 2. Investigation a. The Abuse/Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. b. Any suspect (s), once he/she has (have) been identified will be suspended pending the investigation. 3. Review of Report: a. Once completed, the investigation's report shall be reviewed by the Director of Clinical Services, the Abuse Coordinator, and one other Administrative staff member. 4. Discipline: c. The Abuse Coordinator of Consulate Healthcare will refer any or all incidents and reports of abuse to the appropriate state agencies. .

Based on observation, family and staff interviews, and clinical and facility records review the facility failed to implement their written policies and procedures related to resident abuse for 1 (Resident #103) of 4 sampled residents. It was discovered that resident #103 had a bruise of unknown origin on her genitalia. The facility failed to implement their Abuse Prohibition policies and procedures for reporting this discovery to immediately notify the Clinical Nurse in charge, or Director, Director of Clinical Services or Executive Director according to the facility policy. The facility failed to implement their Abuse Prohibition policies and procedures to conduct a thorough investigation including the Interim Director of Nursing/Abuse Coordinator performing or documenting a thorough nursing assessment promptly and requesting a medical examination to determine if there was trauma or sexual assault. The failure for the facility to implement their Abuse Prohibition policies and procedure for reporting and investigation for a potential physical or sexual assault could delay medical/psychological treatment for [REDACTED]. These findings resulted in Immediate jeopardy (IJ) is ongoing for failure of the facility to implement their policy and procedure related to resident abuse as this failure places all residents residing in the facility at risk for abuse. The findings include: 1. An observation of Resident #103 on 08/09/12 at 2:20 PM revealed the resident sleeping and her daughter was at the bedside. Per the daughter, she recently found bruising on her mother's vagina. She revealed the Unit Manager informed her that the bruising was a result of the incontinence brief her mother was wearing. A clinical record review for Resident #103 revealed she was admitted to the facility on [DATE] with a readmission date of [DATE]. The admission [DIAGNOSES REDACTED]. A review of the Admission Data Collection Form dated 01/30/12 revealed the resident had a language barrier, and staff was unable to orient the resident because she spoke Arabic. A review of the Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/09/12, Section B, revealed the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Review of the Quarterly MDS Assessment with an ARD of 04/27/12 revealed Resident #103 had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. A review of the physician's orders [REDACTED]. A review of the Nurses Note dated 07/27/12 for Resident #103 (untimed) revealed the resident's daughter brought to the nurse's attention a bruise on her mother's peri- area. The note also revealed that the resident complained of pain to the right abdomen when coughing or pressing the right lower quadrant of her abdomen. A Nurses Note dated 07/28/12 (untimed) for Resident #103 revealed the nurse continued to observe bruising to the outer aspect of the labia majora. Review of the Physician/Nurse Practitioner/Physician Assistant Communication and Progress Note for New Symptoms, Signs and other changes in condition (SBAR) forms dated 07/28/12, 07/29/12 and 07/30/12 revealed evidence that the daughter had reported on 07/27/12 the bruise on the resident genitalia. The instructions on the form indicated that the form should be completed before contacting the physician. Review of the form revealed that "S" was the Situation, "B" was the Background, "A" was the Assessment or Appearance, and "R" was the Request. The section on the forms to document the date, time and name of the doctor, nurse practitioner or physician's assistant was blank. On 08/09/12 at 2:52 PM an interview with the GNR Unit Manager (UM), Nursing Home Administrator/Risk Manager (NHA/RM), and Interim Director of Nursing/Abuse Coordinator (IDON/AC) revealed the GNR UM and IDON/AC examined the resident on 07/30/12. The Interim IDON revealed she completed the physical assessment of the bruise on Resident #103's vagina on 07/30/12 after the morning meeting. The IDON indicated the resident had a linear bruise consistent with the rubber of an incontinence brief. She revealed she discussed the findings with the physician. She revealed she did not believe the resident was assessed by the physician, but an order was obtained to monitor the area. On 08/10/12 at 11:15 AM a telephone interview with Nurse #60 revealed on 07/27/11 on the 3-11pm shift Resident #103's daughter approached her while she was at the medication cart and requested something for pain for her mother. She revealed she went down to evaluate the resident as the daughter had mentioned that she had observed a bruise to her mother's vagina. The nurse revealed the she observed the resident's vaginal area and determined there was a bruise to the labia minora (lip of the vagina) that was bluish-purplish in color, and about 1 1/2 to 2 inches long. The nurse revealed that she did not know what happened to the resident including what caused the bruise or when the resident sustained [REDACTED]. The nurse revealed that she called the physician and did not receive a call back. She revealed she reported off to the oncoming nurse so that when the physician did called back they would know the reason for the call. The nurse stated that she documented in the chart and also completed a bruise report and documented the incident on the 24 hour report. She revealed she did not inform management about the bruise to the resident's vagina, because there was no management available. A review of the Comprehensive 24- Hour Report (Quality Assurance) dated 07/27/12 revealed there was documentation Resident #103's family had concerns regarding a bruise on the resident and a report form was filled out. There was no documentation an attempt had been made to notify the physician. On 08/10/12 at 12:58 PM a telephone interview with the Advanced Registered Nurse Practitioner (ARNP) revealed that he was familiar with Resident #103, but had not physically evaluated the resident in about two months. He was advised there was a telephone order indicating the nurse spoke to him about a vaginal bruise to the resident's vagina on 07/29/12. He revealed that he did not remember receiving a phone call from the facility regarding an incident with the resident having vaginal bruising. He revealed that was not a typical phone call he would receive and something like that would stand out to him. On 08/10/12 at 1:14 PM a telephone interview with certified nursing assistant (CNA) #61 revealed she was the aide caring for the resident when the daughter noted the bruise to her mother's vagina. She revealed she did not know how the bruise occurred or when it occurred and she referred the resident's daughter to the nurse. She also revealed she observed the bruise on the resident's vagina. An interview with NHA/RM on 08/10/12 at 1:25 PM revealed the incident occurred before he was employed at the facility. He revealed he became aware of the incident when he went through the incident reports. He revealed he trusted the DON's decision about notifying the physician. He also revealed the protocol for investigation of bruising would depend on the situation and that he was not always notified; it depended on the type of bruising. If the issue had the making of an adverse incident then he would be notified. He revealed the incident reports are reviewed at the morning meetings and if there was potential abuse he would be notified and it would be investigated. Per the NHA/RM the IDON was convinced it was the brief that was applied inappropriately and that was what caused the bruising. There were no statements that indicated abuse. He also revealed that he would have expected something like vaginal bruising to be reported to the IDON at the time it was found. An interview with Physician #1 on 08/10/12 at 2:06 PM revealed he was not notified that Resident #103 had vaginal bruising. He revealed his ARNP was notified on 07/29/12. He revealed that he had not examined the resident until today. His examination revealed the resident had minimal [DIAGNOSES REDACTED] (redness) on the right groin, no excoriation or drainage. There was no evidence of trauma. He indicated the [DIAGNOSES REDACTED] appeared to be due to a brief. He revealed the resident had severe dementia, was in the facility for end of life care because of a [DIAGNOSES REDACTED] and was totally dependent on staff for care. An interview with Resident #103's Attending Physician and the Director of Medical Services on 08/11/12 at 9:10 AM revealed he was not made aware that Resident #103 had vaginal bruising on 07/27/12. Review of the Resident Abuse Policy and Procedure dated 01/07, revised 01/10 revealed the following: The Policy section included, but was not limited to the following: It is in the nature and dignity of each resident at Consulate Health Care that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Procedure section included, but was not limited to the following: VI. Identification All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Clinical Director of Services. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services will serve as Abuse Coordinator. VII. Procedure for Reporting Abuse A. All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, or the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation. VIII. The Abuse Coordinator of Consulate Health Care will endeavor to protect the rights of residents and employees. The administrator recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened. Thus, while the Administration reserves the right to suspend pending an investigation, such suspension is not be deemed as an assessment of guilt. IX. Investigation of Abuse. A. The Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. A Social Service representative shall be present in the role of resident advocate during any questioning of or interviewing of residents. B. Investigations will be accomplished in the following manner. 1. Preliminary investigation: c. The Clinical Nurse in charge or Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. d. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report should be filed as soon as possible in order to provide the most accurate information in a timely fashion. 2. Investigation a. The Abuse/Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. b. Any suspect (s), once he/she has (have) been identified will be suspended pending the investigation. 3. Review of Report: a. Once completed, the investigation's report shall be reviewed by the Director of Clinical Services, the Abuse Coordinator, and one other Administrative staff member. 4. Discipline: c. The Abuse Coordinator of Consulate Healthcare will refer any or all incidents and reports of abuse to the appropriate state agencies. .

Based on observation, record review and staff interview, 8 (#5, #11, #14, #17 #23, # 26, #27 #29) of 32 sampled employees failed to maintain an infection control program to protect all residents from the potential for widespread health care associated infection failing to; (1) Use personal protective equipment for a patient with "resistant" Clostridium Difficile infection (C-Diff) a diarrheal infection; (2) Use dedicated medical equipment or clean shared medical equipment after use with a resident with a [DIAGNOSES REDACTED] infection. (3) Place residents with [DIAGNOSES REDACTED] infection in a private room or cohort with similar infection. (4) Use proper hand hygiene during wound care to prevent cross contamination. (5) Dispose of a contaminated gown appropriately and (6) Post signage for contact isolation in a location obvious to staff and visitors. These finding resulted in Immediate Jeopardy, because the practices potentially place residents at risk for acquiring serious multi-drug resistant infections such as pseudomembranous colitis (inflammation of the colon due to infection), toxic megacolon (extreme dilation of the colon), perforations of the colon, and sepsis, and death. The findings include: 1. Record review of the medical record for Resident #40 revealed laboratory specimens collected two times on 7/17/12 were positive for[DIAGNOSES REDACTED] (Clostridium Difficile is a spore-forming, Gram positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B and is a common cause of antibiotic- associated diarrhea.). Review of the physician's progress notes revealed the resident had "resistant"[DIAGNOSES REDACTED]. On 8/8/12 at 10:10 am, a Certified Nursing Assistant (CNA #14) was observed standing next to the bed of Resident #40, without wearing Personal Protection Equipment (PPE). Resident #40 was on contact isolation for[DIAGNOSES REDACTED]. Interview with CNA #14 on 8/8/12 at 10:12 am for Resident # 40, revealed that she did not have to wear PPE (gown, or gloves) because she was not at the bedside of the resident who was diagnosed with [REDACTED]. CNA #14 stated that Resident #40 was not on isolation and the room-mate (Resident #271) of Resident #40 was on contact isolation for[DIAGNOSES REDACTED]. She stated that she floated and did not know the residents. CNA #14 stated that she was watching the room-mate (#271) of Resident #40 to ensure that he did not get up and injure himself. CNA #14 revealed that she did not realize that Resident #40 was on contact isolation for[DIAGNOSES REDACTED]. Review of the medical record for Resident #271 (room-mate) revealed he was admitted to the facility on [DATE] with pneumonia. There was no evidence in the medical record that Resident #271 had[DIAGNOSES REDACTED], but he was sharing the same room with Resident #40 who had resistant[DIAGNOSES REDACTED]. 2. On 8/8/2012 at 3:45 PM, CNA #23 was observed as she wore Personal Protective Equipment (PPE) consisting of gown, mask and gloves in front of. Interview with CNA #23 at the time of the observation revealed that she was aware of the room as an isolation room with a[DIAGNOSES REDACTED] infection. CNA #23 was observed as she took the blood pressure cuff and thermometer into the contaminated room. At 3:50 PM CNA #23 was observed; CNA #23 left the room and used antiseptic hand rub to clean her hands, rather than using soap and water to wash her hands. CNA did not clean the shared blood pressure cuff or thermometer. CNA #23 walked into other rooms in the hallway using the same shared blood pressure cuff and thermometer from room to room. Interview with the Interim Director of Nursing (IDON)/Infection Control Nurse on 8/9/12 at 3:58 PM revealed that she thought there were 2 to 3 cases of[DIAGNOSES REDACTED] in the building and it was a "guesstimate". The IDON stated that they tracked infections by completing an epidemiology worksheet considering predisposing factors to determine if infections were community or facility acquired. She stated that staff development was conducting audits and observations of hand-washing. Observation of Resident #40 on 8/10/12 at 8:00 AM revealed that he was lying in bed. CNA # 27 picked up the resident's breakfast tray from the food cart. CNA #27 entered the resident's room and placed the breakfast tray on the bedside table. CNA #27 leaned over the resident's bed rails touching the bed rails to set the resident up to eat. CNA #27 did not don any PPE before entering the room, such as a yellow gown from the utility cart outside the door or place a pair of gloves on. CNA #27 came out of the room, picked up a pair of gloves and placed the gloves on both hands without washing her hands with soap and water. CNA # 27 returned to the resident's bedside to assist him to sit up and to set up food items on the tray for him to use. CNA #27 was informed about the[DIAGNOSES REDACTED] infection by the surveyor and informed that she needed to wash her hands with soap and water since the antiseptic foam was not effective against[DIAGNOSES REDACTED]. Interview with CNA #27 on 8/10/12 at 8:05 am revealed that she was supposed to put on PPE, such as gloves and gowns before entering Resident #40's room. She stated that she touched the bedside table and bed rail when she spoke with Resident # 40. CNA #27 was asked if Resident #40 used the bathroom. She stated that Resident #271, room-mate of Resident # 40 used the bathroom. CNA #27 stated that Resident #271 did not have a[DIAGNOSES REDACTED] infection. CNA #27 stated that at times she took Resident # 40 to the bathroom. CNA #27 stated that both residents shared the same toilet. There was no bedside commode observed in the resident's room from 8/6/12-8/10/12 for Resident # 40 to use. CNA #27 stated that she was going to tell the truth. Observation of Resident # 40 with Staff Nurse #17 on 8/10/12 at 9:58 AM revealed the resident was sitting in his wheelchair in the hallway near to his room. Staff Nurse #17 demonstrated the resident's alarm system attached to his wheelchair. Staff Nurse # 17 lifted up the resident's right arm to demonstrate the alarm system equipment with a medication cup with pills in her bare hand. Staff Nurse #17 returned the cup to the medication cart and approached the resident again to demonstrate the alarm system attached to the rear of the wheelchair. Staff Nurse #17 entered the resident's room to demonstrate the bed alarm without PPE. She was observed making contact with the resident's bed linens, bed side rail, mattress and the alarm sensor equipment. Staff Nurse #17 called out to CNA #27 who was standing down the hallway on 8/10/12 at 10:11 AM and asked her to come down to the room. Staff Nurse #17 asked the CNA to demonstrate the bed alarm in the room. CNA #27 entered the room of Resident # 40 and was observed touching the side rail. CNA # 27 left the room and started to use antiseptic foam to clean her hands. She was reminded to use soap and water for effective hand washing. Review of the policy and procedure for contact precautions revealed contact precautions will be used for residents with known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident care activities that required touching the resident's dry skin or indirect contact with environmental surfaces or resident care items in the resident's environment. 3. On 08/08/12 at 10:30 AM, wound care observation was completed for Resident # 20. Nurse # 5 was performing the dressing change. Prior to beginning the treatment, Nurse #5 reviewed the resident's treatment orders. After review, Nurse # 5 went to the room and washed her hands. Nurse #5 came out of the room and went to the side of her medication cart. Nurse #5 reached into the trash receptacle to locate a trash bag to discard the soiled dressing. There were no extra trash bags available. Nurse #5 stated she would use the bedside trash can. Nurse #5 returned to the resident's room and washed her hands. Nurse #5 re-checked the treatment orders. Nurse #5 created an aluminum foil barrier on top of the wound treatment cart. Nurse #5 removed some clean gloves from a box of gloves, and placed the gloves back in the box. The nurse scratched the back of her head and removed clean gloves from the box of clean gloves and placed the gloves on top of the treatment cart without the barrier. Nurse #5 was informed that she had just scratched her head and needed to perform hand hygiene. Nurse #5 used hand antiseptic rub to clean her hands. Nurse #5 removed the contaminated gloves from the top of the treatment cart and discarded them. Nurse #5 placed clean gloves on the aluminum foil barrier. Nurse #5 obtained 2 plastic medication cups from the top drawer of the treatment cart and placed them on the clean field. Nurse #5 placed the clean field on top of the resident's bedside table. Nurse #5 did not gather the bandages for dressing. Nurse #5 stated, "I don't know what I am doing." Nurse #5 returned to the treatment cart and gathered 4 X 4 ' s and a roll of kerlix and took them into the room, and placed them on top of the clean field. The kerlix (gauze) obtained from the treatment cart was open. Nurse #5 kept stating, "I don't know what I'm doing." The unit manager was notified that Nurse #5 was overwhelmed and confused. Nurse #11 came to the resident's room to perform the dressing change. Nurse #11 went into a resident's room across the hall from the resident, and washed her hands. Nurse #11 returned to the treatment cart. Nurse #11 created an aluminum foil barrier to gather her supplies. Nurse #11 placed the peroxide solution to cleanse the wound and the ointment to apply to the wound, into medication cups. Nurse #11 obtained dry 4 X 4s and Kerlix. Nurse #11 entered the resident's room and realized the resident was sitting in her wheelchair. Nurse #11 assisted the resident to pull down her pants to expose the wound. Nurse #11 removed the resident's shoes and touched the bottom of the shoes and assisted the resident to the bed. Nurse #11 went out to the treatment cart without performing hand hygiene and obtained a box of gloves by the top of the glove box with her finger inserted in the opening. Nurse #11 was informed her that she had touched the bottom of the resident's shoes and had not performed hand hygiene and had contaminated the box of gloves. Nurse #11 disposed of the box of gloves, washed her hands and obtained another box of gloves. When Nurse #11 went to remove the old dressing from the resident's leg, Nurse #5 reached into her pocket and obtained a pair of scissors and placed them on the bedside table for Nurse #11 to use to remove the resident's dressing. Nurse #5 was asked what the scissors had been used for and where the scissors had come from. Nurse #11 informed Nurse #5 that the scissors needed to be sterilized (Sterilization requires heat or chemical agents). Nurse #5 took the scissors to the resident's bathroom and washed them with soap and water in the sink and obtained alcohol pads off the medication cart to wipe the scissors. Nurse #5 was asked how she disinfected the scissors for residents with[DIAGNOSES REDACTED] and Methicillin Restraint Staphylococcus Aureus (MRSA). She revealed she would use a pair of disposable scissors. Nurse #5 left the room to obtain a pair of disposable scissors. Nurse #5 returned with a suture removal kit because there were no disposable scissors in the building. Nurse #11 utilized the scissors in the suture removal kit to remove the dressing from the resident's leg. On 08/10/12 at 10:10 AM, morning care was observed for Resident #103. The resident was on contact isolation for MRSA infection at the gastrostomy site ([DEVICE]). The [DEVICE] was covered with a dry dressing. The certified nursing assistant (CNA) # 26 performing the care revealed she had already cleaned the resident's torso and was about to begin perineal care. CNA #26 cleansed the resident's perineal area with soap and water. CNA #26 dried the area with a towel. CNA #26 removed the glove from her right hand and disposed of it in the red biohazards bag taped to the resident's bedrail and her left hand remained gloved. CNA #26 reached under her isolation gown and reached in her right pocket with her non-gloved hand and removed a packet of barrier cream. CNA #26 squeezed some of the cream into her gloved hand. CNA #26 placed the open packet of cream back into her pocket and obtained a clean glove and donned it on her right hand. CNA #26 applied the cream to the resident's perineal-area. CNA #26 positioned Resident #103 on her left side so that the resident's back could be observed. CNA #26 walked over to the left side of the bed and cleansed Resident #103's buttocks. CNA #26 removed her right glove with her left hand and reached into her pocket with non-gloved hand and obtained the packet of barrier cream that she had placed in her pocket. CNA #26 applied the cream to the resident's buttocks. These findings were discussed with the CNA. A review of the Hand washing Technique Policy and Procedure dated 01/07 revealed all personnel would wash their hands to remove dirt, organic material, and transient microorganisms to prevent the spread of infections. Hands must be washed: ? After contact with blood/body fluids ? In between resident contacts ? Before clean procedure ? After contact with contaminated items or surfaces ? After the removal of gloves 4. On 8/7/2012 at 3:27 PM, CNA #29 was observed on the 400 hallway when she dropped a clean gown that she had just retrieved from a covered clean linen cart on the floor. CNA # 29 picked up the contaminated gown and returned the gown back on the covered clean linen cart. Interview with CNA #29 on 8/7/12 at 3:29 PM revealed the CNA admitted she dropped the gown on the floor and placed it back on the cart. CNA #29 stated that the normal process was to put items on the floor into a bag and place in the dirty utility room. Interview with the Environmental Service Director on 8/7/12 at 3:30 PM, revealed that contaminated or dropped items on the floor should be placed in a bag and taken to the dirty utility room. He stated it should never be returned to the clean linen cart. The Environmental Service Director removed the cart from the hallway. 5. On 8/7/2012 at 9:20 AM, surveyor observed a cart containing PPE supplies by the door of Resident #184. The isolation sign on the top of the cart that informs visitors and staff to stop before entering the room was obscured by a box of gloves. An unidentified nurse who was in the hallway at the time was what resident the PPE cart belonged to and what kind of infection the resident had. Staff responded that the resident had[DIAGNOSES REDACTED] and that surveyor should wear gloves before going into the room. The sign was not posted on the door and if visitors so visitors could walk straight into the room without taking any precautions. Observation of the PPE cart for Resident #40 on 8/8/12 at 10:15 AM revealed there was no posted sign to see the nurse before entering for Resident #40. The sign was found taped to the top of the white plastic utility cart that contained gowns and masks. A box of gloves was located on top of the sign, preventing anyone from seeing it. Interview with the Interim Director of Nursing/Infection Control Nurse on 8/9/12 at 3:58 PM revealed that when residents were on isolation there should be a signage sign on the door for staff/visitors to stop. Review of the policy and procedure for identification of residents on isolation precautions with an effective date of 1/07, revealed isolation precautions requires the use of a stop sign to assist the healthcare worker and others in identifying the need for special precautions. .

Based on observation, staff and family interviews, clinical record and policy and procedure review the facility failed to implement safety measures for 1 (Resident #103) of 8 sampled residents. Resident #103 was in her room sitting alone in her wheelchair and the seatbelt was not in place and she fell to the foor. The resident was sent to the hospital emergency room where they determined the fall caused a fracture of her nose. The findings include: On 08/07/12 at 3:10 PM an observation of Resident #103 revealed the resident had a yellowish-green bruise to the left side of her face. The resident was alert, but was not able to communicate. On 08/09/12 at 2:20 PM an interview with the Resident #103's daughter revealed that on 07/09/12 her sister found the resident on the floor at the facility. She revealed she did not believe the wheelchair brakes were on at the time her mother fell , because her mother did not have the strength to move the chair. Review of Resident #103's clinical record revealed she was admitted to the facility on [DATE] with a readmission date of [DATE]. The resident's admission [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) of 02/09/12, Section B, revealed the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Activities such as walking in the room or corridor did not occur. Balance during walking, turning around and moving from seated to standing position did not occur. The resident's assessment revealed she had not had a fall 6 months prior to admission, and no falls since admission. Review of the Quarterly MDS Assessment with an ARD of 04/27/12 revealed Resident #103 the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Activities such as walking in the room or corridor did not occur. Balance during walking, turning around and moving from seated to standing position did not occur. The assessment revealed the resident had not had a fall 6 months prior to admission, and no falls since admission. Section P of the assessment revealed the resident had a trunk restraint used daily when up out of bed in chair. A review of the physician's orders [REDACTED]. There was a clarification order dated 05/04/12 to apply a seatbelt to the wheelchair while the resident was out of bed due to senile dementia and muscle weakness. The order included the release of the lap buddy every 2 hours and during supervised activities, and to check every 30 minutes. A review of the restraint assessment dated [DATE] revealed Resident #103 had senile dementia and muscle weakness. Medications included Seroquel 12.5mg at bedtime. The history of falls and injuries were 02/23/12 at 8:20 AM, and 04/01/12 at 7:25 AM. The current restraint used was a seatbelt to the wheelchair while out of bed. The least restrictive measure used in the past included a sensor pad alarm to the bed and chair, and placing the resident in an area of high visibility while awake. The resident's mobility status was recorded as ambulation with staff assistance; the resident was totally dependent on staff. The assessment revealed the resident was able to sit up in a wheelchair with good body alignment, and the recommendation was a seatbelt while out of bed in the wheelchair. The recommendations for the restraint use included release every two hours for toileting and activities of daily living, check every 30 minutes and remove during supervised activities. A review of the care plans revealed Resident #103 had a care plan dated 02/14/12 for fall prevention. The problem listed was that Resident #103 was at risk for falls related to her cognitive status, history of falls, and hemiparesis (weakness on one side of the body). The goal was the resident would have no falls within the next 90 days and the number of falls would decrease in the next 90 days. The care plan did not include the 5/04/12 clarification order to use a seatbelt while the resident was up in the wheelchair while out of bed due to senile dementia and muscle weakness, release every 2 hours during supervised activities and check every 30 minutes. Continued review of the clinical record revealed another care plan titled the Interdisciplinary Resident Care Plan dated 04/06/12. This care plan revealed the resident was identified as requiring a restraint as evidenced by use of a lap buddy while she was up in the wheelchair as related to dementia, poor safety awareness and a history of falls. The goal was the resident would be free from injury related fall thru the next review date. The approaches included restraints as ordered, reassess the resident quarterly and as needed, check every 30 minutes and release and reposition every two hours and as needed, monitor for unsafe actions and intervene as needed, monitor for decline in function and intervene as needed. An interview with the MDS Coordinators, Nurse # 15 and Nurse #13, on 08/09/12 at 12:36 PM confirmed Resident #103's fall care plan dated 02/14/12 had not been updated to reflect the clarification order written on 05/04/12. Review of the Weekly Nursing Progress Form dated 07/05/12 revealed Resident #103 did not have restraints, and indicated the resident's plan of care was appropriate for the resident. A review of the Treatment Records for May through July 2012 included the order written on 05/04/12 for the seatbelt on the wheelchair while out of bed due to senile dementia, muscle weakness and release every two hours during supervised activities and every 30 minutes revealed no documentation the seatbelt had been implemented. The July 2012 treatment record revealed the order was discontinued on 07/10/12. The Nurse's Note dated 07/09/12 at 11:00 PM revealed at 4:25 PM the nurse was called to Resident #103's room. Upon entering the room the nurse observed the resident lying on the floor near her dresser. The nurse immediately assessed the resident from head to toe. Range of motion to upper and lower extremities was performed. The nurse observed swelling to the resident's left eye lid and nose. There was also bruising to both areas. The nurse and the certified nursing assistant transferred the resident to bed without difficulty. The nurse contacted the physician and received an order to send the resident to the hospital for evaluation. Neurological checks were started. Per the nurse's note the resident returned to the facility at 09:30 PM that evening with a [DIAGNOSES REDACTED]. On 08/08/12 at 4:26 PM the Acting Regional Director of Clinical Services and the Nursing Home Administrator confirmed there was no documentation that Resident #103 was being monitored for safety or that the safety belt was in place at the time of the 07/09/12 fall or that there was an order to discontinue the resident's safety belt. On 08/08/12 at 5:17 PM a telephone interview with the Licensed Practical Nurse (LPN #7) revealed she was just beginning her shift when Resident #103's daughter arrived at the facility. Per LPN #7 the daughter informed the staff that her mother was on the floor. LPN #7 revealed the resident was climbing out the bed and that was why the Certified Nursing Assistant (CNA) put the resident in the wheelchair. LPN #7 confirmed no restraints were in place at the time of the resident's fall. On 08/08/12 at 5:32 PM review of the 15-Day Adverse Report dated 07/25/12 indicated the fall and subsequent nose fracture for Resident #103 was a non-adverse event. Review of the report revealed the outcome of the event was a fracture or dislocation of bones or joints. The circumstances of the event were Resident #103 had gotten out of bed and had her wheelchair brakes applied and call light within reach. She was found ten minutes later on the floor and had not indicated through call light or other means that she wanted to go back to bed. The analysis and corrective action included Resident #103 had no recent falls and had been transferred safely with the protocols the facility was using and so the staff had not been able to predict that this would happen. Resident #103 was sent to the hospital for evaluation and treatment and returned shortly with a fractured nose and some bruising to the face. The corrective action included the initiation of a safety belt for her safety in addition to the other protocols in place. Continued review revealed another 15-Day Adverse Report dated 08/01/12. This report revealed the date of the incident was 07/09/12 at 4:25 PM. After a complete investigation, the risk manger determined that the incident did qualify as an adverse incident. Circumstances of the event revealed that on 07/09/12 Resident #103 were provided care by her assigned CNA. She was immediately placed in her wheelchair. Shortly after the CNA exited the room, Resident #103 was noted lying on the floor. She was noted with bruising to the face and nose. Her attending physician was notified and orders were received to send patient to the emergency room for further evaluation. Resident #103 was transferred back to the center with a [DIAGNOSES REDACTED].#103, she was noted to have orders for a safety belt. Prior to the fall, Resident #103 did not have the safety belt in place. If the safety belt had been in place it could have possibly prevented the fall and or/injury. .

Based on observation, staff and family interviews, clinical record and policy and procedure review the facility failed to implement safety measures for 1 (Resident #103) of 8 sampled residents. Immediate Jeopardy exists at the facility for failure to implement safety measures that resulted in injury to Resident #103. Resident #103 was in her room sitting alone in her wheelchair and the seatbelt was not in place and she fell to the foor. The resident was sent to the hospital emergency room where they determined the fall caused a fracture of her nose. On August 29, 2012 the facility was found to have implemented safety devices ordered by the physician for residents at risk for injury or accidents, and monitoring was ongoing. The IJ at F323 was removed as of 08/15/12. However, F323 remained out of compliance at S/S D. The findings include: On 08/07/12 at 3:10 PM an observation of Resident #103 revealed the resident had a yellowish-green bruise to the left side of her face. The resident was alert, but was not able to communicate. On 08/09/12 at 2:20 PM an interview with the Resident #103's daughter revealed that on 07/09/12 her sister found the resident on the floor at the facility. She revealed she did not believe the wheelchair brakes were on at the time her mother fell , because her mother did not have the strength to move the chair. Review of Resident #103's clinical record revealed she was admitted to the facility on [DATE] with a readmission date of [DATE]. The resident's admission [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) of 02/09/12, Section B, revealed the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Activities such as walking in the room or corridor did not occur. Balance during walking, turning around and moving from seated to standing position did not occur. The resident's assessment revealed she had not had a fall 6 months prior to admission, and no falls since admission. Review of the Quarterly MDS Assessment with an ARD of 04/27/12 revealed Resident #103 the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Activities such as walking in the room or corridor did not occur. Balance during walking, turning around and moving from seated to standing position did not occur. The assessment revealed the resident had not had a fall 6 months prior to admission, and no falls since admission. Section P of the assessment revealed the resident had a trunk restraint used daily when up out of bed in chair. A review of the physician's orders [REDACTED]. There was a clarification order dated 05/04/12 to apply a seatbelt to the wheelchair while the resident was out of bed due to senile dementia and muscle weakness. The order included the release of the lap buddy every 2 hours and during supervised activities, and to check every 30 minutes. A review of the restraint assessment dated [DATE] revealed Resident #103 had senile dementia and muscle weakness. Medications included Seroquel 12.5mg at bedtime. The history of falls and injuries were 02/23/12 at 8:20 AM, and 04/01/12 at 7:25 AM. The current restraint used was a seatbelt to the wheelchair while out of bed. The least restrictive measure used in the past included a sensor pad alarm to the bed and chair, and placing the resident in an area of high visibility while awake. The resident's mobility status was recorded as ambulation with staff assistance; the resident was totally dependent on staff. The assessment revealed the resident was able to sit up in a wheelchair with good body alignment, and the recommendation was a seatbelt while out of bed in the wheelchair. The recommendations for the restraint use included release every two hours for toileting and activities of daily living, check every 30 minutes and remove during supervised activities. A review of the care plans revealed Resident #103 had a care plan dated 02/14/12 for fall prevention. The problem listed was that Resident #103 was at risk for falls related to her cognitive status, history of falls, and hemiparesis (weakness on one side of the body). The goal was the resident would have no falls within the next 90 days and the number of falls would decrease in the next 90 days. The care plan did not include the 5/04/12 clarification order to use a seatbelt while the resident was up in the wheelchair while out of bed due to senile dementia and muscle weakness, release every 2 hours during supervised activities and check every 30 minutes. Continued review of the clinical record revealed another care plan titled the Interdisciplinary Resident Care Plan dated 04/06/12. This care plan revealed the resident was identified as requiring a restraint as evidenced by use of a lap buddy while she was up in the wheelchair as related to dementia, poor safety awareness and a history of falls. The goal was the resident would be free from injury related fall thru the next review date. The approaches included restraints as ordered, reassess the resident quarterly and as needed, check every 30 minutes and release and reposition every two hours and as needed, monitor for unsafe actions and intervene as needed, monitor for decline in function and intervene as needed. An interview with the MDS Coordinators, Nurse # 15 and Nurse #13, on 08/09/12 at 12:36 PM confirmed Resident #103's fall care plan dated 02/14/12 had not been updated to reflect the clarification order written on 05/04/12. Review of the Weekly Nursing Progress Form dated 07/05/12 revealed Resident #103 did not have restraints, and indicated the resident's plan of care was appropriate for the resident. A review of the Treatment Records for May through July 2012 included the order written on 05/04/12 for the seatbelt on the wheelchair while out of bed due to senile dementia, muscle weakness and release every two hours during supervised activities and every 30 minutes revealed no documentation the seatbelt had been implemented. The July 2012 treatment record revealed the order was discontinued on 07/10/12. The Nurse's Note dated 07/09/12 at 11:00 PM revealed at 4:25 PM the nurse was called to Resident #103's room. Upon entering the room the nurse observed the resident lying on the floor near her dresser. The nurse immediately assessed the resident from head to toe. Range of motion to upper and lower extremities was performed. The nurse observed swelling to the resident's left eye lid and nose. There was also bruising to both areas. The nurse and the certified nursing assistant transferred the resident to bed without difficulty. The nurse contacted the physician and received an order to send the resident to the hospital for evaluation. Neurological checks were started. Per the nurse's note the resident returned to the facility at 09:30 PM that evening with a [DIAGNOSES REDACTED]. On 08/08/12 at 4:26 PM the Acting Regional Director of Clinical Services and the Nursing Home Administrator confirmed there was no documentation that Resident #103 was being monitored for safety or that the safety belt was in place at the time of the 07/09/12 fall or that there was an order to discontinue the resident's safety belt. On 08/08/12 at 5:17 PM a telephone interview with the Licensed Practical Nurse (LPN #7) revealed she was just beginning her shift when Resident #103's daughter arrived at the facility. Per LPN #7 the daughter informed the staff that her mother was on the floor. LPN #7 revealed the resident was climbing out the bed and that was why the Certified Nursing Assistant (CNA) put the resident in the wheelchair. LPN #7 confirmed no restraints were in place at the time of the resident's fall. On 08/08/12 at 5:32 PM review of the 15-Day Adverse Report dated 07/25/12 indicated the fall and subsequent nose fracture for Resident #103 was a non-adverse event. Review of the report revealed the outcome of the event was a fracture or dislocation of bones or joints. The circumstances of the event were Resident #103 had gotten out of bed and had her wheelchair brakes applied and call light within reach. She was found ten minutes later on the floor and had not indicated through call light or other means that she wanted to go back to bed. The analysis and corrective action included Resident #103 had no recent falls and had been transferred safely with the protocols the facility was using and so the staff had not been able to predict that this would happen. Resident #103 was sent to the hospital for evaluation and treatment and returned shortly with a fractured nose and some bruising to the face. The corrective action included the initiation of a safety belt for her safety in addition to the other protocols in place. Continued review revealed another 15-Day Adverse Report dated 08/01/12. This report revealed the date of the incident was 07/09/12 at 4:25 PM. After a complete investigation, the risk manger determined that the incident did qualify as an adverse incident. Circumstances of the event revealed that on 07/09/12 Resident #103 were provided care by her assigned CNA. She was immediately placed in her wheelchair. Shortly after the CNA exited the room, Resident #103 was noted lying on the floor. She was noted with bruising to the face and nose. Her attending physician was notified and orders were received to send patient to the emergency room for further evaluation. Resident #103 was transferred back to the center with a [DIAGNOSES REDACTED].#103, she was noted to have orders for a safety belt. Prior to the fall, Resident #103 did not have the safety belt in place. If the safety belt had been in place it could have possibly prevented the fall and or/injury. .