Every finding on record at Avir at Azalea Heights

Based on observation, interview, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 1 of 2 medication carts (Medication/Nurse Cart for Hall C) reviewed for labeling and storage of medication. The facility did not ensure the Medication/Nurse Cart #1 (medication cart for Hall C), was secured and unable to be accessed by unauthorized personnel on 8/28/26. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion.Findings included: During an observation on 8/28/26 at 11:25 a.m. the Medication/Nurse Cart for Hall C was at the front of the hall near the nurse's station and unlocked. During an observation on 8/28/26 at 11:30 a.m. the Medication/Nurse Cart for Hall C was unlocked with an unidentified resident sitting next to the cart. During an observation on 8/28/26 at 11:31 a.m. the Treatment Nurse walked by and locked the Medication/Nurse Cart for Hall C. During an interview on 8/28/26 at 11:31 a.m. the Treatment Nurse said the cart that was unlocked was the Nurse Cart. The Treatment Nurse said the Nurse Cart was split between two different nurses and she did not know who the last nurse to access it was. The Treatment Nurse said the Medication and Nurse Carts should not be left unlocked. The Treatment Nurse said the importance of ensuring the Medication and Nurse Carts were locked was to prevent a resident getting into the medications stored on the carts. During an interview on 8/28/26 at 11:35 a.m. RN A said he was the nurse for Hall C. RN A said he was the last person who accessed the Nurse Cart for Hall C. RN A said the Nurse Cart should not have been left unlocked and he did not know why he left it unlocked. RN A said it was important to ensure the Medication and Nurse Carts were locked for resident safety. During an interview on 8/28/26 at 12:38 p.m. the Administrator said Medication and Nurse Carts should be locked at all times when unattended. The Administrator said the importance of ensuring Medication and Nurse Carts were locked was to prevent residents from accessing and taking medications not prescribed to them and to prevent medications from being stolen. Record review of the facility's Medication Storage and Labeling policy, dated 6/2023, indicated, Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: Secured (locked) locations, accessible only to designated staff.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 staff (CNA A) viewed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes while providing incontinent care to Resident #1 on 4/29/26. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building.Findings Include: During an observation on 4/29/26 at 1:16 p.m. CNA A performed incontinent care with assistance from CNA B on Resident #1. CNA A and CNA B obtained hand sanitizer from dispenser on the wall outside Resident #1's room. CNA A and CNA B knocked on the door prior to entering and closed door behind them. CNA A and CNA B used the hand sanitizer in their hand to perform hand hygiene and put on a clean pair of gloves. CNA A moved Resident #1's bed out from against the wall, removed her gloves, and did not perform hand hygiene. CNA A put on clean gloves, opened front of Resident #1's brief, used disposable wipes to wipe Resident #1's pelvic and vaginal area, removed her gloves, and did not perform hand hygiene. CNA B assisted Resident #1 in rolling onto her side. CNA A put on clean gloves, used disposable wipes to wipe Resident #1's bottom, removed the dirty brief, removed gloves, and did not perform hand hygiene. CNA A obtained a clean brief, put on clean gloves, and removed chuck pad (highly absorbent, disposable or washable underpads designed to protect beds, furniture, and wheelchairs from fluid leaks) from underneath Resident #1. CNA A removed gloves, did not perform hand hygiene, and obtained clean chuck pad. CNA A put on clean gloves, placed clean chuck pad underneath and put clean brief on Resident #1. CNA A gathered up trash, removed, gloves, exited room, performed hand hygiene, and disposed of trash. During an interview on 4/29/26 at 1:26 p.m. CNA A said hand hygiene should be performed prior and after providing care to a resident. CNA A said hand hygiene should be performed between glove changes. CNA A said she did not perform hand hygiene between glove changes because the hand sanitizer dispensers were located outside the resident rooms in the hallway. CNA A said the facility did have small bottles of hand sanitizer floating around somewhere but she was not sure where. CNA A said the importance of proper hand hygiene was to prevent the spread of germs and cross contamination. During an interview on 4/30/26 at 11:41 a.m. the DON said she expected staff to perform hand hygiene before entering a room, before putting on gloves, after taking off gloves, during care, and when exiting a room. The DON said the importance of hand hygiene was infection control. During an interview on 4/30/26 at 12:00 p.m. the Administrator said she expected hand hygiene to be performed before and after providing care, eating, and using the restroom, before putting on gloves, and after removing gloves. The Administrator said the importance of proper hand hygiene was to prevent the spread of germs. Record review of the facility's Handwashing/Hand Hygiene policy updated 1/2025 indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. Hand hygiene is indicated: a. immediately before touching a resident.c. after contact with blood, body fluids, or contaminated surfaces. d. after touching a resident. e. after touching the resident's environment.g. immediately after glove removal. immediately after glove removal.

Based on observation, interview and record review, the facility failed to provide personal privacy when providing care for 1 of 7 (Resident #1) residents reviewed for privacy. The facility did not ensure CNA A and CNA B pulled the privacy curtain while providing incontinent care on Resident #1 on 4/29/26. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.Findings included: 1. Record review of the face sheet dated 4/29/26 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Guillain-Barre Syndrome (a rare autoimmune disorder where the immune system attacks the peripheral nerves (nerves located away from the center of the body), causing rapid-onset weakness, tingling, and potential paralysis), anxiety, major depressive disorder, muscle weakness, and need for assistance with personal care. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #1 was dependent on staff for toileting. Record review of the care plan revised 1/3/26 indicated Resident #1 had a self-care deficit related to impaired physical mobility with interventions including incontinent care with one-person staff assist. During an observation on 4/29/26 at 1:16 p.m. CNA A performed incontinent care with assistance from CNA B on Resident #1. Resident #1's roommate was observed lying in bed with eyes closed. CNA A and CNA B did not pull the privacy curtain prior to starting or during incontinent care. During an interview on 4/29/26 at 1:24 p.m. CNA B said when performing incontinent care the privacy curtain should be pulled. CNA B said Resident #1 had not been provided with privacy during incontinent care. CNA B said she forgot to ensure the privacy curtain was pulled. CNA B said the importance of providing privacy during incontinent care was so no one could watch and so the resident was covered. During an interview on 4/29/26 at 1:26 pm CNA A said when performing incontinent care, the door should be shut, or the privacy curtain should be pulled. CNA A said she thought the privacy curtain had been shut during Resident #1's incontinent care. CNA A said the importance of providing privacy during incontinent care was resident rights. During an interview on 4/30/26 at 11:41 a.m. the DON said she expected staff to provide privacy to a resident when performing personal care. The DON said she expected staff to provide privacy by closing the door, pulling the privacy curtain, and closing the blinds. The DON said the importance of providing privacy during care was for the residents' dignity. During an interview on 4/30/26 at 12:00 p.m. the Administrator said she expected staff to provide privacy to the residents anytime they were providing a resident with personal care. The Administrator said she expected staff to provide privacy by closing the door, pulling the privacy curtain, and closing the blinds. The Administrator said the importance of providing privacy to the residents during care was so the residents did not feel their privacy was being invaded. Record review of the facility's Perineal (diamond-shaped region located between the thighs) Care revised 2/2018 indicated, The purpose of this procedure is to provide comfort and cleanliness to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Steps in Procedure.f. Provide privacy as appropriate, such as closing doors/curtain, drape resident. Record review of the facility's Resident Rights policy revised 2/2021 indicated, Employees shall treat all resident with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence.t. privacy and confidentiality.

Based on observation, interview and record review, the facility failed to ensure medications were prepared and administered in a manner that prevented medication errors for 1 of 2 MA medication carts (MA Cart #1) and 1 of 2 licensed nurse medication carts (LN Cart #1) observed for controlled medications storage.LVN B was observed on 12/10/2025 signing the controlled substance count sheets for the end of their shift at the beginning of their shift on LN Cart #1.MA A was observed on 12/10/2025 signing the controlled substance count sheets for the end of their shift at the beginning of their shift on MA Cart #1. These failures created the potential for medication diversion, administration of incorrect medication and compromised resident safety could place residents at risk of not receiving medications as ordered by the physician.Findings included:During an observation on 12/10/2025 at 3:22 PM, while doing observation of 2/4 med cart it was discovered that LVN A and MA B, were signing on and off at the same time of signing on at shift count, The controlled drugs on hand. During a record review on 12/10/2025 at 3:22 PM, the sign on/off sheet read, signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication count is in agreement with the quantity stated on the controlled.During an interview on 12/10/2025 at 3:25 PM, LVN A he said he always signed both coming/going slots on the Nurse on and Nurse off at the same time so he would not forget at the end of his shift, He said he knew he should not because he would be responsible if something happened to him during his shift. During an interview on 12/10/2025 at 3:30 PM, MA B she said she always signed both coming/going slots on the: Nurse on and Nurse off, at the same time so she would not forget at the end of her shift. She said she had gotten into trouble for forgetting to sign off so she did it at the same time. She knows she should not do it that way because if the count was wrong, she would be responsible if something happened to her during her shift.During an interview on 12/10/2025 at 3:35 PM, the ADON, Treatment Nurse, and DON all said each nurse and MA were to sign the Drug Administration Record Controlled Drug Count Record at the time coming on to their shift and at the time they were going off their shift. The DON said she had in serviced all nurses and MAs on the procedure and she was ultimately responsible for monitoring and making sure it was done correctly. Record review of a policy and procedure document titled Controlled Substances indicated the facility with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II -V of the comprehensive Drug Abuse Prevention and Control Act of 1976) revised November 2022.4. Nursing staff coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #45) reviewed for care plans. The facility failed to ensure Resident #45's care plan reflected her fingernail care needs and preference for eating her meals with her fingers and hands. This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs. Findings included: A review of a face sheet dated 12/10/2025 indicated Resident #45 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder (encompasses several types of dementia involving the progressive degeneration of the brain marked by communication loss, motor skill decline, and cognitive and physical impairment). A review of an annual MDS assessment dated [DATE] reflected Resident #45 had a BIMS score of 99 indicating she was not able to complete the interview. Further review of the same MDS indicated Resident #45 was non-ambulatory, incontinent, and dependent on staff for all activities of daily living. A review of the physician orders dated 12/10/2025 indicated Resident #45 had an order dated 10/18/2024 for a regular diet, regular consistency with no other specific instructions. A review of Resident #45's undated comprehensive care plan indicated an identified concern for self-care deficit that was initiated on 12/18/2024 and revised on 09/22/2025. The care plan did not address Resident #45's preference for finger foods, use of her fingers to eat and nail care needs. A review of Resident #45's nurse aides' task assignment sheet dated December 2025 did not indicate Resident #45 had any nail care needs. During an observation on 12/08/2025 at 11:05 AM, Resident #45 was observed sitting in a Geri-chair in the dining room following an activity. Resident #45 was observed to have a dried, brownish substance underneath her fingernails on both hands. An attempt to engage Resident #45 in conversation was unsuccessful. During an observation on 12/08/2025 at 12:25 PM, Resident #45 was observed sitting at a table in the dining room with an unidentified staff person sitting beside her. The staff person was observed to spoon feed Resident #45 bites of a vegetable salad while Resident #45 was observed to feed herself pieces of a hot dog and bun using her fingers. Resident #45's was noted to have a dried, brownish substance underneath her fingernails on both hands. During an observation on 12/08/2025 at 02:00 PM, Resident #45 was observed sitting in the dining room after lunch and was noted to have a dried, brownish substance underneath her fingernails on both hands. During an observation on 12/08/2025 at 04:30 PM, Resident #45 was observed sitting in the dining room at a table and a dried brownish substance was noted underneath her fingernails on both hands. During an observation on 12/09/2025 at 08:45 AM, Resident #45 was observed sitting in the dining room after breakfast and was noted to have a dried brownish substance underneath her fingernails on both hands. During an observation on 12/09/2025 at 12:30 PM, Resident #45 was observed sitting in the dining room at a table, using her fingers to feed herself a sandwich with CNA-F sitting beside her and spoon feeding her a vegetable. Resident was noted to have a dried, brownish substance underneath the fingernails on both hands. During an observation on 12/09/2025 at 02:10 PM, Resident #45 was observed sitting in the dining room with other residents, and was noted to have a dried, brownish substance underneath her fingernails on both hands. During an observation on 12/09/2025 at 04:45 PM, Resident #45 was observed sitting at a table in the dining room waiting for evening meal to be served. Her fingernails on both hands were noted to have a dried, brownish substance under them. During an observation on 12/10/2025 at 08:08 AM, Resident #45 was observed sitting upright in bed with the head of the bed elevated. Her fingernails on both hands were noted to be dirty with a dried, brown substance underneath her nails. During an interview and observation on 12/10/2025 at 08:11, the ADON opened Resident #45's hands and held them out for a closer observation of Resident #45's fingernails. All fingernails on both hands were observed to be dirty with a dried, brownish substance underneath them. The ADON said Resident #45's fingernails needed cleaning. During an interview and observation on 12/10/2025 at 09:30 AM, CNA-F was observed sitting beside Resident #45's bed and was cleaning Resident #45's fingernails. CNA-F said Resident #45 ate her meals using her fingers and hands. She said Resident #45 preferred having foods she could pick up with her fingers and eat. CNA-F said Resident #45 would allow staff to spoon feed her some things as long as Resident #45 could have something in her hands that she could feed herself. She said the dried, brownish substance was dried food. CNA-F said she should have cleaned Resident #45's fingernails after she helped her eat lunch on 12/09/2025. She said Resident #45 needed to have her fingernails and hands cleaned after every meal. CNA-F said if a resident required special instructions like nail care after meals, it should be on the nurse aides' task assignment sheet. During an interview on 12/10/2025 at 09:40 AM, CNA-G said she took care of Resident #45 on 12/08/2025. She said she did not notice Resident #45 needed nail care. An attempt to interview CNA-H, who was assigned to provide care to Resident #45 on 12/09/2025, by phone on 12/10/2025 at 10:02 AM was unsuccessful. During an interview with CNA-E on 12/10/2025 at 10:15 AM, she said she helped on the hall on 12/09/2025 where Resident #45 resided but could not recall providing any care to Resident #45. During an interview on 12/10/2025 at 02:10 PM, the DON said Resident #45's care plan and nurse aides' task assignment sheet should address Resident #45's preference for finger foods and her need for nail care after meals. She said the care plan team was responsible for ensuring the care plan addressed the specific needs of residents. She said eating with dirty fingernails could lead to illness. She said the nurses were responsible for ensuring residents received needed hygiene care. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered and dated as revised March 2018 and updated February 2025 included the following: 7. The comprehensive, person-centered care plan: .d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one of five residents (Resident # 45) reviewed for quality of life. The facility failed to ensure Resident #45 received nail care. This failure could place residents at risk for poor hygiene, dignity issues, and a decline in quality of life. Findings included: A review of a face sheet dated 12/10/2025 indicated Resident #45 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder (a disorder that encompasses several types of dementia involving the progressive degeneration of the brain marked by communication loss, motor skill decline, and cognitive and physical impairment). A review of an annual MDS assessment dated [DATE] reflected Resident #45 had a BIMS score of 99 indicating she was not able to complete the interview. Further review of the same MDS indicated Resident #45 was dependent on staff for all activities of daily living (ADLs) which included showering and personal hygiene care. A review of a comprehensive care plan dated as initiated on 12/18/2024 indicated Resident #45 had a self-care deficit for activities of daily living. The care plan included interventions to address Resident #45's need for assistance with hygiene care. Record review of a nurse aides' task assignment sheet dated 12/2025 indicated the task of assisting Resident #45 with hand hygiene as needed was assigned to the certified nurse aides. Record review of the plan of care flowsheet schedule for 12/2025 indicated Resident #45 received hand hygiene care on 12/08/2025 at 04:04 AM, 01:59 PM, and 08:44 PM. The flow sheet indicated Resident #45 received hand hygiene on 12/09/2025 01:59 PM and 08:20 PM and again on 12/10/2025 at 04:10 AM. During an observation on 12/08/2025 at 11:05 AM, Resident #45 was observed sitting in a Geri-chair in the dining room following an activity. Resident #45 was observed to have a dried, brownish substance underneath her fingernails on both hands. An attempt to engage Resident #45 in conversation was unsuccessful. During an observation on 12/08/2025 at 12:25 PM, Resident #45 was observed sitting at a table in the dining room with an unidentified staff person sitting beside her. The staff person was observed to spoon feed Resident #45 bites of a vegetable salad while Resident #45 was observed to feed herself pieces of a hot dog and bun using her fingers. Resident #45's was noted to have a dried, brownish substance underneath her fingernails on both hands. During an observation on 12/08/2025 at 02:00 PM, Resident #45 was observed sitting in the dining room after lunch and was noted to have a dried, brownish substance underneath her fingernails on both hands. During an observation on 12/08/2025 at 04:30 PM, Resident #45 was observed sitting in the dining room at a table and a dried brownish substance was noted underneath her fingernails on both hands. During an observation on 12/09/2025 at 08:45 AM, Resident #45 was observed sitting in the dining room after breakfast and was noted to have a dried brownish substance underneath her fingernails on both hands. During an observation on 12/09/2025 at 12:30 PM, Resident #45 was observed sitting in the dining room at a table, using her fingers to feed herself a sandwich with CNA-F sitting beside her and spoon feeding her a vegetable. Resident was noted to have a dried, brownish substance underneath the fingernails on both hands. During an observation on 12/09/2025 at 02:10 PM, Resident #45 was observed sitting in the dining room with other residents, and was noted to have a dried, brownish substance underneath her fingernails on both hands. During an observation on 12/09/2025 at 04:45 PM, Resident #45 was observed sitting at a table in the dining room waiting for evening meal to be served. Her fingernails on both hands were noted to have a dried, brownish substance under them. During an observation on 12/10/2025 at 08:08 AM, Resident #45 was observed sitting upright in bed with the head of the bed elevated. Her fingernails on both hands were noted to be dirty with a dried, brown substance underneath her nails. During an interview and observation on 12/10/2025 at 08:11, the ADON opened Resident #45's hands and held them out for a closer observation of Resident #45's fingernails. All fingernails on both hands were observed to be dirty with a dried, brownish substance underneath them. The ADON said Resident #45's fingernails needed cleaning. During an interview and observation on 12/10/2025 at 09:30 AM, CNA-F was observed sitting beside Resident #45's bed and was cleaning Resident #45's fingernails. CNA-F said Resident #45 ate her meals using her fingers and hands. She said Resident #45 preferred having foods she could pick up with her fingers and eat. CNA-F said Resident #45 would allow staff to spoon feed her some things as long as Resident #45 could have something in her hands that she could feed herself. She said she thought the dried, brownish substance was dried food. CNA-F said she should have cleaned Resident #45's fingernails after she helped her eat lunch on 12/09/2025. She said Resident #45 needed to have her fingernails and hands cleaned after every meal. CNA-F said if a resident required special instructions like nail care after meals, it should be on the nurse aides' task assignment sheet. During an interview on 12/10/2025 at 09:40 AM, CNA-G said she took care of Resident #45 on 12/08/2025. She said she did not notice Resident #45 needed nail care. An attempt to interview CNA-H by phone on 12/10/2025 at 09:50 AM was unsuccessful. During an interview with CNA-E on 12/10/2025 at 10:15 AM, she said she helped on the hall on 12/09/2025 where Resident #45 resided but could not recall providing any care to Resident #45. During an interview on 12/10/2025 at 02:10 PM, the DON said Resident #45's care plan and nurse aides' task assignment sheet should address Resident #45's preference for finger foods and her need for nail care after meals. She said the care plan team was responsible for ensuring the care plan addressed the specific needs of residents. She said eating with dirty fingernails could lead to illness. She said the nurses were responsible for ensuring residents received needed hygiene care. A review of the facility's policy titled Activities of Daily Living(ADL), Supporting 2001, revised March 2018, and updated February 2025 included the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with:a. hygiene .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2) reviewed for Enhanced Barrier Precautions. CNA C failed to don PPE when she provided direct care for Resident #2 who required EBP.This failure could place residents under their care at risk for the transmission of communicable diseases and infections. Findings included:Record review of a face sheet dated 12/10/2025 indicated Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included diabetes, difficulty swallowing, high blood pressure, atrial fibrillation (ineffective pumping of the upper heart chambers), chronic pain, radiculopathy of lumbar vertebrae (inflammation of a nerve root in the lower back), intervertebral disc degeneration (wear and tear of lower back that may lead to disc bulging, loss of disc space, compression and irritation of the adjacent nerve root), and osteoporosis (bone disease that develops when bone mineral density and bone mass decreases).Record review of the quarterly MDS dated [DATE] noted Resident #2 had a BIMS score of 15 which indicated she was not impaired cognitively. She required maximum assistance with most ADLs. She could feed herself. She was incontinent of bowel and bladder.Record review of Resident #2's care plan, last reviewed 10/29/2025, indicated she was at risk for infection or recurrent/chronic infection because she had a history of MDRO/ESBL/VRE of multi drug- resistant UTI requiring isolation and antibiotics. It also indicated she had a sheer wound on her right hip and was at risk for infection. EBP was not specifically indicated for her care issues.Record review of Resident #2's physician orders, active as of 12/10/2025, indicated to practice EBP as indicated, due to chronic wounds and history of MDRO every shift related to ESBL. The care plan indicated wound treatment to the right side of coccyx, sheer, clean with normal saline then apply Ansept gel and collagen powder and a drybordered gauze and to change it daily and PRN until healed. During an observation and interview on 12/08/2025 at 10:24 AM, CNA C was completing incontinent care and holding Resident #2 against her body. The CNA was wearing only gloves and no gown. She said the resident had a wound. At that time the resident said she had to urinate again so CNA affixed brief and told her to go ahead. She covered her and said she needed to go get more supplies to re-clean her and would be back. There was an EBP sign on the door and on the wall at bedside.During an observation on 12/08/2025 at 10:49 AM CNA C was observed returning to Resident #2's room to perform incontinent care. She entered the room and did not don a gown. She was wearing only gloves.During an observation on 12/08/2025 at 10:57 AM CNA C was providing incontinent care to Resident #2 and wearing only gloves. During an interview on 12/08/2025 at 11:11 AM CNA C said she was supposed to put on a gown to provide direct care to Resident #2 and she did not. She had no reason why she did not put on the gown.During an interview on 12/10/2025 at 11:00 AM the DON, said she was the infection preventionist and the one responsible for the infection control training. She said staff have been trained that the red heart placed on the door signifies a resident requiring EBP. A sign was also placed on the door and in the room indicating the resident required EBP. She said when direct care was to be used for a resident requiring EBP they had to put on a gown and gloves. She said residents requiring EBP have a device such as a catheter or feeding tube, a wound, or a history of multi-resistant organism infection.Record review of the facility's policy revised February 2025, and titled Enhanced Barrier Precautions indicated the following: .2a. Gloves and gown are applied prior to performing the high contact resident care activity.3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: .f. changing briefs or assisting with toileting.4. EBPs are indicated.for residents infected or colonized with a CDC targeted or epidemiologically important MDRO, including.g. ESBL-producing Enterobacterales; h. Vancomycin-resistant Enterococci.

Based on interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status of 1 of 5 residents (Resident #5) reviewed for accuracy of assessments. The facility failed to ensure 1 admission MDS assessment dated [DATE] and 2 quarterly MDS assessments dated 04/02/25 and 07/03/25 were accurately coded to reflect Resident #5's diagnoses of schizophrenia (a chronic brain disorder causing distorted reality), seizures, and TBI (an injury to the brain caused by an external force leading to functional, physical, cognitive, emotional, or behavioral problems). This failure could place residents at risk for not receiving needed care and services to maintain the highest level of well-being.Findings included: A review of a face sheet dated 12/10/2025 indicated Resident # 5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included TBI, seizures, recurrent depressive disorder, and mood (affective) disorder (any of a group of conditions of mental and behavior disorders and include major depression disorder and bipolar disorder). A review of hospital records dated 03/07/2025 and sent to the facility on [DATE] reflected a list of Resident #5's medical diagnoses which included diagnoses of major depressive disorder, history of traumatic brain injury, and seizure disorder. A review of Resident #5's undated care plan indicated a focus/concern initiated on 03/11/2025 (day of admission) for antipsychotic medication related to Resident #5 having mood disturbances related to diagnoses of depression and schizophrenia. The same care plan also indicated a focus/concern initiated on 03/11/2025 for Resident #5 having difficulty expressing needs and the potential to misunderstand others due to cognitive communication deficits related to his history of traumatic brain injury. A review of an admission MDS dated [DATE] reflected Resident #5 had a BIMS score of 14 indicating his cognition was intact. The same MDS indicated Resident #5 was non-ambulatory, continent, and able to self-transfer. Further review of the admission MDS dated [DATE] reflected Section I: Active Diagnoses was not correctly coded to include Resident #5's medical diagnoses of TBI, seizures, and schizophrenia. A review of a quarterly MDS dated [DATE] reflected Section I: Active Diagnoses was not correctly coded to include Resident #5's medical diagnoses of TBI and schizophrenia. A review of a quarterly MDS 07/03/2025 reflected Section I: Active Diagnoses was not correctly coded to include Resident #5's medical diagnosis of TBI. During an interview with the MDS Coordinator on 12/10/2025 at 10:20 AM, she said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said it was her responsibility to correctly code the MDS. When asked about the coding of Resident #5's diagnoses on the MDS's, the MDS Coordinator said it was her mistake, and she was not sure how she missed coding them. During an interview with the DON on 10/12/2025 at 03:15 PM, she said she expected the MDS assessments to be coded correctly. She said it was a team effort to ensure the MDS's were coded correctly. A review of the October 2024 RAI 3.0 Manual: Section I: Active Diagnoses included the following: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided accurate Preadmission Screening and Resident Review (PASARR) Screenings for 1 of 5 residents (Resident #5) reviewed for PASARR. The facility failed to ensure Resident #5 had an accurate PASARR Level 1 Screening which indicated a diagnosis of mental illness and refer Resident #5 to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASARR Evaluation), individualized care, and specialized services to meet their needs.Findings included: A review of a face sheet dated 12/10/2025 indicated Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder and mood (affective) disorder (any of a group of conditions of mental and behavior disorders such as major depression disorder and bipolar disorder). A review of an admission MDS dated [DATE] reflected Resident #5 had a BIMS score of 14 indicating his cognition was intact. Further review of the same MDS indicated Resident #5 was non-ambulatory, continent, and able to self-transfer. A record review of Resident #5's PASRR Level 1 Screening completed by the referring entity on 03/11/2025 indicated in section C0100 there was no evidence of this individual having mental illness. A review of hospital records dated 03/07/2025 and sent to the facility on [DATE], the day before Resident #5's discharge and admission to the facility, reflected a list of Resident #5's medical diagnoses which included a diagnosis of major depressive disorder. A record review of the care plan with a date initiated on 03/11/2025 indicated Resident #5 was at risk for complications of antipsychotic medication therapy related to Resident #5 having mood disturbances related to diagnoses of depression and schizophrenia. A record review of a MAR dated 03/11/2025 - 03/31/2025 indicated Resident #5 had orders for and received the psychotropic medications of sertraline and bupropion to treat a depressive disorder and quetiapine to treat an unspecified mood (affective) disorder. Record review of the Comprehensive (admission) MDS assessment dated [DATE] reflected in Section I: Active Diagnoses that Resident #5 had diagnoses of depression and mood disorder. During an interview on 12/10/2025 at 10:25 AM, the MDS Coordinator said she was responsible for ensuring the accuracy of the PASRR Level I screenings. She said she missed seeing that Resident #5's PASRR Level I was incorrect.She said Resident #5 did not receive a Level II PASRR screening due to the incorrect Level I PASRR. She said she coded the admission MDS assessment for depression and mood disorder but did not catch that the PASRR Level 1 screening was incorrect. She said the facility did not ensure an accurate Level I PASRR was completed which led to a Level II PASRR screening not being completed. During an interview with the SW on 12/10/2025 at 10:40 AM, she said she was responsible for notifying the LA of an incorrect PASRR. She said she was not aware that Resident #5's Level I PASRR was incorrect. During an interview on 12/10/2025 at 02:05 PM, the DON said the facility should have caught the error on Resident #5's PASRR Level I. She said it was important to have correct PASRR Level screenings to ensure residents were referred for PASRR Level II evaluations. The DON said incorrect PASRR screenings could result in a resident not receiving needed services. She said the facility used the RAI Version 3.0 Manual as the policy for completing PASRR tasks. A review of the October 2024 RAI 3.0 Manual: Chapter 3: Section A 1500 indicated the following: All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for a possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan within 48 hours of admission and provide the resident and or the resident representative with a summary of the baseline care plan for 1 of 5 residents reviewed for the base line care plans. (Resident # 93) The facility did not complete a baseline care plan within 48 hours of admission and provide a written summary of the baseline care plan to Resident # 93 or their responsible party. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Findings included:A review of Resident # 93's face sheet and physician's orders for December 8, 2025, indicated the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including displaced fracture of base of neck of right femur, seizures, hypertension, and Gasto-esophageal reflux disease. A review of the electronic record on 12/08/2025 for Resident #93 indicated no documentation of a baseline care plan or a written summary was performed and provided to the resident or her responsible party. During an observation and interview on 12/8/2025 at 9:30A.M., Resident # 93 was in his room. He was clean, well-groomed, and in bed with the bed in a low position, water and call light within reach. No signs of abuse, neglect, or environmental hazards were observed. The resident stated he was recently admitted for rehabilitation following a fall at home and hoped to return soon. During an interview on 12/08/2025 at 11:05 AM, ADON said the baseline care plan for Resident #93 was not in the clinical record and could not be located in the electronic clinical record. She said a baseline care plan for Resident #93, who was admitted on [DATE] and was due by 12/06/2025, should have been initiated by a RN or the DON with the interdisciplinary team adding to it. She explained that the baseline care plan is then reviewed with the resident and/or the responsible party, signed and filed in the electronic clinical record. During an interview on 12/10/2025 at 11:10 AM, the DON said the baseline care plan was not present in the clinical record for Resident #93. She said it was not done. She said the baseline care plan should have been initiated when Resident #93 admitted to the facility on [DATE] and completed on 12/06/2025. She said the RN in charge, usually the DON, should initiate the baseline care plan and the interdisciplinary team add to it and then it is presented to the resident and/or their responsible party and reviewed together. She said then the resident or the party responsible would sign they had received and reviewed the baseline care plan, and it would be indicated in the clinical record. Record review of the facility policy Care Plans - Baseline revised March 2022 indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.4. The resident and/or representative are provided a written summary of the baseline care plan.5. Provision of the summary.is documented in the medical record.

Based on interview and record review, the facility failed to complete a required discharge summary for one of five residents reviewed for discharge (Resident #6). The facility failed to meet the requirement by not providing a completed discharge summary to the receiving healthcare facility for Resident #6. This failure could place residents at risk for not having continuity of care. Record review of Resident #6's undated face sheet indicated Resident #6 was admitted on [DATE] and discharged to another nursing home on [DATE]. Record review of Resident #6's medical record accessed on 12/10/2025 did not reveal a discharge summary. During an interview on 12/10/2025 at 1:30 PM, the ADON stated she did not know the facility's policy on discharge summaries. The ADON stated that she was told the SW and DON complete the discharge summary. The ADON stated with a completed discharge summary, the resident and receiving facility were aware of items including the correct medications and instructions for taking the medications and doctor's orders. During an interview on 12/10/2025 at 1:40 PM the SW revealed that she did not know the facility's policy on discharge summaries. She stated she had not been told if it was her responsibility. She stated she did not know who was responsible for completing the residents' discharge summaries. The SW stated that when a residents' discharge summary was not completed, it placed them at risk for missed appointments. During an interview and record review on 12/10/2025 at 1:50 PM, the DON provided an incomplete document entitled Discharge Summary - Planning/Instructions/Recapitulation. Record review of this document indicated it was incomplete in Resident #6's communication, physical functioning and structural problems, nutritional status, and discharge planning and missing Resident #6's customary routine, cognitive patterns, vision, mood and behavior patterns, psychosocial well-being, continence, dental status, and documentation of participation in assessment. The DON verbally confirmed that this was the document used as a discharge summary and recognized that it was not complete. During an interview on 12/10/2025 at 1:59 PM, the ADM stated nursing staff were responsible for discharge summaries. The ADM stated she was unaware of the facility's policy on discharge summaries. The ADM stated if they're supposed to have it, they're supposed to have it. Record review of the facility's policy dated October 2022 entitled Transfer or Discharge, Facility-Initiated indicated the following: Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Information Conveyed to Receiving Provider g. All other information necessary to meet the resident's needs, including but not limited to. (6) a copy of the resident's discharge summary.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1)The facility failed to prevent Resident #1 from sustaining a fall from the bed on 08/28/2025 which resulted in a fractured right femur. The noncompliance was identified as PNC (past noncompliance). The IJ began on 08/28/2025 and ended on 09/02/2025. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of potential accidents, injuries, harm, or death.Findings included:Record review of Resident #1's face sheet on 09/29/2025 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including: anoxic brain damage (a medical emergency that occurs when the brain does not get enough oxygen, even when blood flow is adequate), convulsions, aphasia (disorder that affects how you communicate), nonpsychotic mental disorder (a mental health condition that does not involve psychosis and includes anxiety disorders, depression and personality disorders), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disease), and high blood pressure.Record review of a quarterly MDS dated [DATE] indicated Resident #1 had no speech, sometimes understood others and was sometimes understood, she had a BIMS score of 00 indicating severe cognitive impairment. She required total assistance with ADLs and could not feed herself. She was incontinent of bladder and bowel. She was dependent with mobility and walking unassisted. She had one fall with major injury since the prior MDS assessment. She received a mechanically altered diet. She had a surgical wound.Record review of care plans for Resident #1 indicated she had a care plan initiated on 10/18/2023 and revised on 05/02/2024 which indicated she was at risk for falls due to debility, weakness, and cognitive impairment. Goals included: The resident will be free from falls and/or will not experience significant injuries associated with falls through next review date. Care plan interventions included: bed at appropriate height when unattended and a bolster on mattress for safe boundaries to minimize risk for rolling out of bed.Review of Resident #1's Progress Notes in the electronic record indicated the following:Progress note dated 8/28/2025 at 2:55 PM indicated resident noted lying on her right side on the floor by her bed, laceration noted to face just under left eyebrow, purple bruise noted to right knee, decreased length and internal rotation noted to right lower extremity, resident shows signs and symptoms of pain when she attempts to move, all other extremities have normal ROM, EMS notified and in route, DON, Administrator, NP and family notified, attempted to make resident as comfortable as possible on floor without excessive movement, will continue to observe. Progress note dated 8/28/2025 at 3:08 PM indicated EMS in facility to transfer resident, resident in route to ER, attempted to call report in to hospital, nurse at ER stated she will receive report from EMS.Progress notes dated 8/31/2025 at 6:22 PM indicated Resident came from hospital after right hip surgery. resident currently stable, alert, and without acute distress. Dressing to surgical wound dry and intact. v/s BP 103/56, temp. 99.3 oxygen saturation 100% on room air heart rate 109. Will continue routine care and monitoring.During an observation on 09/29/2025 at 8:20 AM Resident #1 was at the nurses' station in her specialized wheelchair with the back tilted backwards. She was alert to her surroundings and looking about. She was clean and dressed appropriately for the day.During an observation on 09/29/2025 at 2:20 PM Resident #1 was in her bed. The head of the bed was elevated 45 degrees and she was lying on her left side. She opened her eyes when the room was entered but laid her head back down and closed her eyes. The bed was in the low position and bolsters were present on the bed on both sides of the resident. The bolsters were short in length and covered the middle length of the mattress.During an interview on 09/29/2025 at 2:25 PM CNA U was in Resident #1's room and said she had worked at the facility about a year. She said Resident #1 was to have bolsters on her bed when she was in the bed because she moved around a lot and could fall out of bed.During an interview on 09/29/2025 at 3:15 PM, ADON A said she was next door to Resident #1's room on the afternoon of 08/28/2025 and heard a loud bump or thud sound; She said LVN Q was making his start of shift rounds and called to her to come to Resident #1's room. She said the resident was on the floor. She said a wedge cushion was in front of the closet at the foot of the roommate's bed. She said the bed was also left in the higher position where it would normally be during a mechanical lift transfer. She said she did not see any bolsters or wedge cushions on the bed or around the resident. She said the resident required the bolsters because she wiggled and moved about in the bed and had very poor control over her body. During an observation on 09/30/2025 at 9:25 AM Resident #1 was sitting in her specialized wheelchair at the bedside. LVN E was taking the resident's blood pressure prior to administering medications. Resident #1 was calm and alert and did not exhibit any fear. Bolsters were present on both sides of her bed.During an interview on 09/30/2025 at 9:45 AM the DON said CNA B said she had placed a black wedge positioning device under the sheet on Resident#1's bed on 08/28/2025 when she returned her to bed between 1:00 PM-1:30 PM prior to leaving her shift. She said the resident was asleep in bed when she left at 2:00 PM. She said LVN Q told her he did not see the wedge when Resident #1 was found on the floor. She said CNA B demonstrated how she placed the black wedge on the bed. She said CNA B told her the bolsters were not on the bed when she came on shift at 6:00 AM and the black wedge was being used. She said the CNA B said she did not know why the bolsters were not being used as in the past, but she used the wedge like she had seen that morning. The DON said CNA B was suspended immediately pending the results of the investigation. She said the bolsters were found in front of the closet in the resident's room. She said all direct care staff had access to the Kardex through computers on the hall, in the break room and at the nurses' station. She said the Kardex designated care needs and procedures to be done for each individual resident in the facility. She said it was a plan of care and contained everything a staff member may need to know to properly care for a resident including positioning/safety devices. She said she had verified with CNA B she knew how to use the Kardex and she indicated she did. She said the facility immediately began developing an action plan regarding the fall with major injury.During an interview on 09/30/2025 at 4:00 PM LVN Q said he was making his beginning of shift rounds on 08/28/2025 and found Resident #1 on the floor by her bed. He said he could not recall for sure if there was a black positioning wedge present on or around her bed. He said he received assistance from ADON A who happened to be next door. He said the resident had small cuts on her left eyebrow and her right leg was turned inward, and she expressed pain when being repositioned. LVN Q said he along with all staff received in-services on fall prevention and safety, abuse and neglect, resident rights and use of the Kardex. He said he made rounds at least 2-3 times per shift and always at the beginning and end of shift. Record review of a printed form of the Kardex for Resident #1 dated 08/28/2025 indicated under Safety bolster on mattress to for safe boundaries to minimize risk for rolling out of bed and under Monitors bed at appropriate height when left unattended.A review of the facility investigation report indicated the incident occurred on 08/28/2025 at 2:55 PM and was reported to the state agency on 08/28/2025 at 6:16 PM. Resident #1 was found lying on the floor beside her bed. She had a laceration to her left eyebrow and under her left eye. Her right leg was turned inward and she expressed pain and discomfort upon movement. She was immediately sent to the ER and she was diagnosed with a fracture to her right femur. The resident was supposed to have bolsters on the mattress to minimize risk of rolling out of bed. The CNA had used a black wedge instead of the bolsters when the resident was returned to bed prior to her leaving her shift at 2:00 PM. The CNA was immediately suspended during the investigation. Record review of a handwritten statement dated 08/28/2025 CNA B stated she had put Resident #1 to bed after lunch and placed a pad under her.Record review of a handwritten statement dated 08/28/2025 at 7:45 PM by an unknown interviewer indicated CNA B got Resident #1 out of bed for breakfast and she stayed up through lunch. She was put back to bed after lunch, and she inserted a black pad underneath the sheet. The CNA stated the resident was asleep in bed when she left the facility at 2:00 PM.Record review of a handwritten statement dated 08/28/2025 at 9:00 PM by the DON indicated CNA B was interviewed at the facility regarding her activities with Resident #1 on 08/28/2025. The CNA said the resident did not have any special devices in bed with her. When asked about the bolsters she said she used the small one which was the same one on the bed that morning. She said the resident usually had long ones but someone must have taken them off the bed and replaced them with the small one. The DON had the CNA demonstrate how she placed the black wedge on the bed in the room. She asked the CNA about the long bolsters she was referring to and the CNA indicated 2 bolsters half the length of the mattress in front of the closet. When asked why she did not use the bolsters she replied she did not know why and shrugged her shoulders. She said she just put back what had been there that morning. She said she usually used the bolsters but did not because they had been taken off the bed. The CNA was then told she was suspended pending the rest of the investigation.During multiple interviews on 09/30/2025 with nurses, CNAs, and MAs from two shifts (6AM-2PM and 2PM-10PM) (RN D, LVN E, CNA/MA F, CNA G, CNA H, CNA J, CNA/MA K, CNA L, LVN M, CNA N, CNA P, CNA R, CNA/MA S, CNA/MA T, CNA U, CNA V, CNA W, CNA/MA X, CNA Y) from 9:25 AM-11:38 AM and 4:00 PM 4:35 PM indicated they were trained on Fall Prevention and Safety, Abuse and Neglect, Resident Rights, and use of the Kardex. They could explain what information was contained in the Kardex and knew how to access the Kardex for any information regarding residents' care. They were aware Resident #1's need for bolsters when she was in bed and for the bed to be in a low position.The Administrator was informed of PNC IJ on 09/30/2025 at 2:40 PM.The facility completed the following to correct the noncompliance prior to state surveyor entrance:CNA B was immediately suspended pending investigation and terminated 09/02/2025 due to disregard for resident safety.Record review of documentation of training of all staff conducted beginning 08/28/2025 after the fall and completed 09/01/2025 on Fall Prevention and Safety, Abuse and Neglect, Resident Rights, and use of the Kardex.Record review of documentation indicated the MDS Coordinator completed 100% care plan and Kardex audit to validate accuracy of level of care needed with ADLs and transfers was completed 08/28/2025.Record review of documentation of Safe Surveys done on random residents and staff completed 08/29/2025. Residents indicated they felt safe in the facility and had no incidents of mistreatment by staff.Record review of documentation of Monitoring Response indicated: 1) weekly rounds to validate interventions related to fall prevention are in place 1-7 days for 2 months; 2) conduct random skills validation regarding Kardex use 3-7 days a week for 2 months. 3) additional education based on needs observed during this process; 4) all findings to be reported to QAIP during monthly meeting until 100% compliance was met.The noncompliance was identified as PNC. The IJ began on 08/28/2025 and ended on 09/02/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation. The paper towel dispensers at the hand wash sink and employee restroom had no paper towels. The bulk flour bin had a large scoop stored inside the product on 09/16/24 and 09/17/24. The utensil drawer was soiled with food debris and dried liquid. A 25 lb. bag of brown sugar and 2-16 oz. bags of potato chips were opened and not re-sealed. The 3 compartment sink was not sanitizing and was being used. The 3 compartment sink and dish machine logs had been pre-filled with results for the entire day (09/16/24) when the noon and evening meals had not occurred. The results indicated temperatures and sanitizing conditions. The large ice machine in the dining area contained copious amounts of black debris on the ice chute. In the 2 door stainless steel reach in cooler 1-46 oz. nectar thick orange juice had been opened and not labeled with the open date. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations, interviews and record reviews on 09/16/24 of the kitchen the following was noted: *at 9:10 AM there were no paper towels in the dispenser at the hand washing sink by the dish room. *at 9:18 AM in the employee restroom there were no paper towels in the dispenser. *at 9:21 AM the bulk flour bin contained a scoop in the flour. *at 9:26 AM the utensil drawer under the prep table by the French door oven had dried food debris in the bottom of the drawer and the edge of the drawer had dried liquid where food crumbs had stuck to it. The DM said the drawer was cleaned weekly and then said 2 to 3 times. *at 9:30 AM in the dry pantry one light brown sugar 25 lb bag was opened and not re-sealed, *at 9:32 AM 2-16 oz. potato chip bags were opened and the tops were rolled down and not secured or placed in a re-sealable bag, *at 9:42 AM [NAME] A was washing pans and placing them in the rinse water sink and then into the sanitizing sink. The DM checked the sanitizing sink with a quarternary test strip and the test strip indicated the solution was not sanitizing. [NAME] A said she had just made up the 3 sinks but did not test the sink for sanitizing solution. She said she did not take the temperatures because she knows the temperature by the feel of it on her hands. The DM said they are supposed to check the sanitizer when they make a fresh sink. He asked [NAME] A when they put on the new bottle of sanitizer and she said on Saturday. The DM said the sanitizing solution should test between 200 and 400 ppm. He said the kitchen staff were to check the sanitizer when they wash the dishes for each meal and log it on the Test Strip Log for the Three Compartment Sink. Review of the log at 9:54 AM on 09/16/2024 indicated the whole day (3 meal times) had already been filled in. It indicated the sanitizer was reading 200 ppm and the temperatures of the wash and rinse water were 150 degrees. A review of the Dish Machine & Sanitizing Log on 09/16/2024 at that same time indicated the log had been filled out for the lunch and evening meals. The DM was asked about the log being pre-filled and he got a liquid paper dispenser in order to cover the entries. A copy was made before it was changed. The DM said he would call the vendor to recalibrate the dispenser. *at 10:00 AM in the large ice machine in the dining area the ice chute was wiped with a paper towel and returned with copious amounts of black debris. The Maintenance Supervisor said the machine was cleaned one month ago by the vendor. He said the vendor said the black debris was from the local water supply. He said there was a filter on the incoming water line into the machine. He said the vendor deep cleaned the machine every 3 months and he cleaned the coils, emptied the bin and cleaned it, cleaned the fins, and put in a new filter. He said the filter usually just had a bit of silt or [NAME] material. He showed his receipt on his phone from the vendor where the machine had been deep cleaned on 08/27/2024. He said he cleaned the machine on 09/02/2024. He said the kitchen staff were supposed to clean the chute, door and entry front of the machine at least weekly if not more often. There was no documentation provided by the dietary manager as to the kitchen cleaning the front of the ice machine. The small ice machine adjacent to the large machine was clean and received water through the same water line as the large machine. There was no debris on the chute. During an observation of the kitchen on 09/17/24 at 11:27 AM the bulk flour bin had a large scoop stored in the flour. At 11:28 AM the 2 door stainless steel reach in cooler had 1-46 oz. nectar thick orange juice that had been opened and not labeled with the open date. The package indicated Once opened may be kept up to 7 days under refrigeration. Record review of a Dietary Service policy, revised date of January 2023, indicated the following: .The community ensures that the nutritive value of food is not compromised and destroyed by the following: prolonged food storage and exposure to light and air . .The community procures food from sources approved or considered satisfactory by federal, state, or local authorities and stores, prepares, distributes, and serves food under sanitary conditions.Sanitary conditions are defined as the proper storage, preparation, distribution, and serving of food to prevent food borne illness. .Water temperatures .Manual: Compartment sink (wash, rinse, sanitize): Sanitizing solution used according to manufacturer's instructions. Record review of the General Kitchen Sanitation policy, undated, indicated the following: . 5. After cleaning and until use, store and handle all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects and other contaminants .11. Check retrooms regularly throughout the shift, and be sure they are stocked with soap, toilet paper and paper towels 12. Make sure hand-washing facilities are easily accessible and supplied with soap and paper towels. Record review of the Manual Cleaning and Sanitizing of Utensil and Portable Equipment policy, undated, indicated the following: .6. In the first sink, immerse the equipment or utensils in a hot, clean detergent solution at a temperature of no less than 120 degrees F. 7. Rinse in the second sink using clear, clean water between 120 degrees F and 140 degrees F to remove all traces of food, debris and detergent. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: . b. Immerse for t least 60 seconds in a clean sanitizing solution containing: . iii. Any other chemical sanitizing agent which has demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75 degrees F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer's label directions. 9. Test and record the parts per million concentration of the solution.

Based on observations, interviews, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were completed and accurately documented for 1 of 4 residents (Resident #281) reviewed for medical records accuracy. The facility failed to ensure an order for enteral feedings (liquid nutrition delivered via a tube inserted into the body) from the hospital was documented in Resident #281 s physician's orders at the facility. The facility failed to document the administration of liquid nutrition for 4 consecutive days after Resident #281 was admitted to the facility. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of Resident #281's face sheet and physician's orders dated 09/17/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included, dysphagia (difficulty swallowing), gastrostomy tube (a tube inserted through the abdominal wall, into the stomach for the purpose of delivering liquid nutrition), cardiac arrest, respiratory failure, and hypertension. Record review of the physician's orders dated 09/13/2024 indicated there was no order for Resident #281 to receive any enteral nutrition. Record Review of Resident #281's MAR for September 2024, indicated there was no documentation he received Jevity 1.2 @ 70 ml/hour with 60 ml water flushes every 4 hours on 9/13/2024, 9/14/2024, 9/15/2024, 9/16/2024, and 9/17/2024. Record review of Resident #281's Hospital Discharge Records indicated an order for him to receive Jevity 1.2 at 70ml/hour with a water flush of 30ml/hour via the gastrostomy tube. During an observation on 09/16/2024 at 10:20 a.m., Resident #281 was non-interview able and was observed to be lying in bed with his eyes closed with the head of the bed elevated approximately 30 degrees. A container of Jevity 1.2 (liquid nutrition) was noted to be hanging from a metal pole and infusing via a tube leading to the resident's stomach at a rate of 70ml/hour. Resident #281 was again observed to be receiving the same liquid nutrition on 09/16/2024 at 3:30 p.m., on 09/17/2024 at 9: 30 a.m., and on 09/18/2024 at 10:00 a.m . During an interview on 09/18/2024 at 1:30 p.m., the MDS RN said a physician order for Jevity 1.2 @ 70 ml/hr. with 60 ml water flush every 4 hours, was entered into electronic health records, and on the MAR but it was entered late at 3:30 p.m., as a start date for 09/17/2024 . During an interview on 09/18/2024 at 2:30 p.m., the Director of Clinical Operations Nurse said, LVN B received report at the change of shift from the day shift agency nurse and completed the New Admission form. She said LVN B failed to enter Resident #281's physician order for external feedings into his EHR. She said all of Resident #281's other admission orders were entered into his EHR accurately . During an interview on 09/18/2024 at 4:30 p.m., LVN B said he had worked for the facility for [AGE] years, he stated on 09/13/2024, he received, and accepted report at the change of shift from the day shift agency nurse, she had received a verbal order from the hospital for the external feeding. LVN B stated, the agency nurse had completed the setup and the external feeding (Jevity 1.2 @ 70 ml/hour.), it was already hanging. LVN B stated he proceeded with the admission assessment and failed to enter Resident #281's external feeding order into his EHR. LVN B said all other orders were entered into the electronic health records accurately . During an interview on 09/18/2024 at 5:30p.m., the DON, said the two facility's ADON's were responsible for checking and reviewing all new admissions, re-admissions, check lists, and physician orders to ensure orders were put in accurately. She said the ADON's were responsible for ensuring Medication administration orders were entered into the EHR for the correct patient, correct time, correct route, correct dose, correct medication, and the correct documentation accurately . Reviewed the facility Professional Standard of Care Policy dated implemented 02/2017 and revised on 01/2024 stated, . Nurses should conduct assessments or evaluations and document within the medical record in the following instance: 1) admission, re-admission, and as clinically indicated. 2) at the time of an incident or change in conditions. 3) when exceptions are identified. 4) as otherwise directed.

Based on observation, interview and record review, the facility failed to provide the necessary services to maintain acceptable grooming and personal hygiene for 2 of 3 residents reviewed for ADLs (Resident's #1 and Resident #2). The facility failed to ensure Resident #1's received a bath until 5 days after his admission. The facility failed to ensure Resident #2 received a bath/shower for 4 weeks. This failure could place dependent residents at risk for poor personal hygiene, skin infections and decreased quality of life. Findings included: Record review of the face sheet dated 4/22/24 for Resident #1 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease, high blood pressure, restlessness and agitation, anxiety disorder, heart disease, neuropathy (Weakness, numbness, and pain from nerve damage), visual hallucinations, major depressive disorder, agoraphobia (Fear of places and situations that might cause panic, helplessness, or embarrassment), and orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down). Record review of the MDS for Resident #1 dated 4/6/24 indicated he usually made himself understood and usually understood others. The MDS indicated Resident #1 had short-term and long-term memory problems. The MDS indicated he had severely impaired cognitive skills for decision machining. The MDS indicated he had no behavior of rejecting care. The MDS indicated he was dependent on staff for eating, oral hygiene, toileting, showers/bathing, dressing (both the upper and lower body), putting on footwear, and personal hygiene. The MDS indicated he was always incontinent of bowel and bladder. Record review of the care plan dated 4/2/24 indicated Resident #1 was at risk for self-care deficit. The care plan interventions included 2-person assistance with bed mobility, hygiene, transfers, and toileting. During an interview on 4/25/24 at 10:39 a.m., Resident #1's family member said she visited Resident #1 every day while he was in the facility. Resident #1's family member said he remained in the same clothes for the first 4 days he was in the facility (4/1/24 to 4/4/24) and did not think he had received a shower. Record review of Resident #1's ADL documentation did not indicate he had received a shower or bath from 4/1/24 to 4/5/24. 2. Record review of the face sheet for Resident #2 dated 4/26/24 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including paraplegia (Paralysis that affects all or part of the trunk, legs, and pelvic organs), COPD (group of lung diseases that block airflow and make it difficult to breathe), artificial openings of the urinary tract status, colostomy (an opening in the large intestine, or the surgical procedure that creates one. The opening is formed by drawing the healthy end of the colon through an incision in the anterior abdominal wall and suturing it into place), and depression. Record review of the MDS dated [DATE] for Resident #2, indicated he made himself understood and understood others. The MDS indicated he had no cognitive impairment (BIMS of 15). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #2 required substantial/maximal assistance with toileting. The MDS indicated he was dependent on staff for shower/bathing. During an observation and interview on 4/26/24 at 12:40 p.m., revealed Resident #2 laid in his bed. His hair appeared greasy. Resident #2 had a faint smell of body odor. Resident #2 said he had not received a shower or bed bath in 4 weeks. Resident #2 said he had not asked any staff about not receiving a bath or shower but knew he was supposed to receive them. Resident #2 said he felt staff had not provided him a shower because doing so was a bit of process. Resident #2 explained he had to be lifted from the bed with a mechanical lift and lowered onto a shower bed. Resident #2 said he felt staff just didn't want to go through the process of providing him a shower. During an interview and observation on 4/29/24 at 9:35 a.m., Resident #2 laid in his bed. His hair appeared greasy. Resident #2 had a faint smell of body odor. Resident #2 said he had not received a shower or bed bath since 4/26/24. Resident #2 said his gown was changed but he was not given a shower. Resident #2 said he asked for a washcloth to wash his face and arm pits but was not provided one. Resident #2 said he did not know the name of the CNA he asked for a washcloth. Record review of the ADL documentation for Resident #2 from 4/13/24 to 4/29/24 indicated he received a bath/shower on the following dates: *4/27/24- documented by CNA L *4/25/24- documented by CNA M *4/20/24- documented by CNA N *4/18/24- documented by CNA O *4/16/24- documented by CNA P During an interview on 4/29/24 at 1:26 p.m., CNA M said she did not give a bath or shower to Resident #2 on 4/25/24. CNA M said she was not even assigned to him on that day. CNA M said she gave her sign in information to agency staff so they could document and that was why the documentation reflected she had documented Resident #2 had received a bath on that day (4/25/24). CNA M said she could not remember the agency staff members name. CNA M said she had given her sign in information to multiple agency staff. During an interview on 4/29/24 at 2:37 p.m., CNA L said she had provided Resident #2 a bed bath when she worked on 4/27/24. CNA L said Resident #2 received a bed bath on 4/27/24 because he refused to a shower. An interview with CNA N regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. An interview with CNA O regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. An interview with CNA P regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. During an interview on 4/29/24 at 2:15 p.m., CNA L said it was important residents received scheduled bathing/showers in order to maintain hygiene and identify any skin changes. CNA L said the administration of showers/baths were documented in EMR record. During an interview on 4/29/24 at 2:17 p.m., LVN F said it was important for residents to receive showers/baths to ensure good hygiene and make the resident feel better. During an interview on 4/29/24 at 2:37 p.m., the DON said she expected CNAs to provide residents with showers/baths. The DON said it was important for residents to receive their showers/baths to promote hygiene. Record review of the facility policy and procedure titled Activities Daily Living revised January 2023 stated .each resident's abilities to perform activities of daily living will not diminish .Activities of daily living include: personal hygiene . The facility policy and procedure did not specifically address ensuring dependent resident received showering/bathing.

Based on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate monitoring) for 1 (Resident # 1) of 4 residents whose medications were reviewed for pharmacy services. The facility failed to ensure Resident #1 was consistently and adequately monitored for adverse side effects of Lorazepam (medication used to treat anxiety, lorazepam belongs to a class of drugs known as benzodiazepines which act on the brain and nerves [central nervous system] to produce a calming effect). This failure could place residents at risk of possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of the face sheet dated 4/22/24 for Resident #1 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease, high blood pressure, restlessness and agitation, anxiety disorder, heart disease, neuropathy (Weakness, numbness, and pain from nerve damage), visual hallucinations, major depressive disorder, agoraphobia (Fear of places and situations that might cause panic, helplessness, or embarrassment), and orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down). Record review of the MDS for Resident #1 dated 4/6/24 indicated he usually made himself understood and usually understood others. The MDS indicated Resident #1 had short-term and long-term memory problems. The MDS indicated he had severely impaired cognitive skills for decision machining. The MDS indicated he had no behavior of rejecting care. The MDS indicated he had no indicators of psychosis and displayed no physical or verbal behaviors towards others or himself. The MDS indicated he was dependent on staff for ADLS. Record review of the care plan dated 4/2/24 indicated Resident #1 required the use of anti-anxiety medication, the care plan interventions included administer medications per MD orders, monitor/document/report to the MD any adverse reactions to anti-anxiety therapy (drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, disorientation, depression, dizziness, lightheadedness, impaired thinking, and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision) or unexpected side effects (mania, hostility, rage, aggressive or impulsive behavior, hallucinations). Record review of Resident #1's physician order dated 4/1/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth at bedtime for anxiety hold for sedation. This order was discontinued on 4/10/24. Record review of Resident #1's physician order dated 4/2/24 indicated Resident #1 was to be monitored for the following Antianxiety Side Effects Monitoring: sedation/drowsiness, increased falls/dizziness, hypotension, anxiety/agitation, blurred vision, sweating/rashes, weakness, headache, dystonia, urinary retention/hesitancy, anticholinergic symptoms, cardiac abnormalities, hangover effect. The order indicated any other side effects noted should be documented in a progress note. This order was discontinued on 4/10/24. Record review of Resident #1's physician order dated 4/10/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth three times a day for anxiety hold for sedation. This order was discontinued on 4/14/24. Record review of Resident #1's physician order dated 4/14/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth two times a day for anxiety hold for sedation. This order was discontinued on 4/18/24. Record review of Resident #1's physician order dated 4/18/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth at bedtime for anxiety hold for sedation. This order was discontinued on 4/23/24. Record review of Resident #1's MAR for April 2024 indicated he had been administered his Lorazepam as ordered by the physician from 4/1/24 to 4/18/24. Record review of the MAR indicated Resident #1 was monitored for the following Antianxiety Side Effects Monitoring: sedation/drowsiness, increased falls/dizziness, hypotension, anxiety/agitation, blurred vision, sweating/rashes, weakness, headache, dystonia, urinary retention/hesitancy, anticholinergic symptoms, cardiac abnormalities, hangover effect, from 4/2/24 to 4/10/24. The MAR did not indicate Resident #1 was monitored for the antianxiety side effects from 4/11/24 to 4/19/24. Record review of Resident #1's nurse's notes dated 4/11/24-4/13/24 found the following documentation related to antianxiety side effects monitoring: *4/11/24 at 3:00 a.m., no adverse effects of lorazepam *4/12/24 at 1:39 a.m., no adverse effects of lorazepam *4/13/24 - no notes related to antianxiety side effects monitoring were documented Record review of Resident #1's nursing note dated 4/14/24 at 1:34 p.m., stated .resident responding to verbal and physical stimuli very slowly. Resident family requesting that Ativan (brand name for lorazepam) be put on hold until resident is more alert. Notified MD .received new order . Record review of Resident #1's nurse's notes dated 4/15/24-4/17/24 found the following documentation related to antianxiety side effects monitoring: *4/15/24 - no notes related to antianxiety side effects monitoring were documented *4/16/24- no sedation noted *4/17/24- no notes related to antianxiety side effects monitoring were documented Record review of Resident #1's nursing progress note dated 4/18/24 at 1:34 p.m., indicated an order for all psychotropic medications to be put on hold had been obtained due to lethargy. During an interview on 4/24/24 at 12:14 p.m., LVN J said she took care of Resident #1 regularly. LVN J said she took care of Resident #1 on 4/13/24. LVN J said there were a lot of changes with Resident #1's lorazepam. LVN J said nurses should assess residents on antianxiety medications at least once a shift and document on the MAR. LVN J said there was a place to document antianxiety side effects monitoring on the MAR. LVN J said it would be especially important to assess/document for antianxiety side effects monitoring for residents having changes in dosage like Resident #1. LVN J said if for some reason the antianxiety side effects monitoring was not on the MAR the nurse should document the antianxiety side effects monitoring on a nursing progress note. LVN J said she had not realized she had not documented antianxiety side effects monitoring for Resident #1 on 4/13/24. LVN J said she did document when Resident #1 was found over sedated and notified the MD on 4/14/24. LVN J said Resident #1 was not over sedated on 4/13/24 or she would have documented and notified the MD at that time. During an interview on 4/24/24 at 1:26 p.m., LVN K said she took care of Resident #1 on 4/17/24. LVN K said there was a place to document antianxiety side effects monitoring on the MAR. LVN K said it would be especially important to assess/document for antianxiety side effects monitoring for residents having changes in dosage like Resident #1. LVN K said if for some reason the antianxiety side effects monitoring was not on the MAR, she would document the antianxiety side effects monitoring on a nursing progress note. LVN K said she had not realized she had not documented antianxiety side effects monitoring for Resident #1 on 4/17/24. During an interview on 4/24/24 at 1:30 p.m., ADON I said he had spoken to the MD and received the order for the increase of Resident #1's lorazepam on 4/10/24. ADON I said he had dc'd the old order for the lorazepam but did not realize the side effect monitoring was dc'd at the time. ADON I said it was important to monitor residents on antianxiety medications especially after an increase in dosage to ensure they were not overly sedated or experiencing any adverse effects. ADON I said he wasn't sure if he had to enter the monitoring as a separate order or if it was coupled with lorazepam order. During an interview on 4/24/24 at 3:30 p.m., the DON said she expected nurses to monitor and document for adverse effects/side effects of antianxiety medications at least once a shift. The DON said she did not understand how the antianxiety side effect monitoring was removed from Resident #1's MAR. The DON said antianxiety side effect monitoring should have remained on the MAR the entire time Resident #1 was on the antianxiety medication. The DON said it was especially important for antianxiety side effect monitoring to be performed with the increase in dosage Resident #1 was ordered. The DON said there had not been a specific system in place to ensure nurses were monitoring/documenting for psychotropic adverse/side effects prior to 4/19/24. The DON said she was know monitoring resident's receiving psychotropic medications weekly to ensure they received appropriate monitoring. A facility policy and procedure regarding the monitoring residents on psychotropic medications was requested but not received.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 2 residents reviewed for accident hazards (Resident #3). The facility failed to ensure Resident #3 had no history of elopement before accepting her as resident (the facility did not have a secure unit nor a wander guard system and thus would not accept residents with a history of elopement). The facility did not accurately assess Resident #3's physical ability to leave the facility upon her admission on 4/24/24. This failure could place residents with recent at risk for inadequate supervision elopement and significant injury. Findings included: Record review of the face sheet for Resident #3 dated 4/26/24 indicated she was [AGE] years old, admitted to the facility on [DATE] with diagnoses including Dementia, high blood pressure, atherosclerosis (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), osteoporosis (A condition in which bones become weak and brittle) and high cholesterol. Record review of the baseline care plan for Resident #3 dated 4/24/24 indicated Resident #3 had a diagnosis of Dementia and would be provided care and safety checks throughout each shift. The care plan was updated on 4/25/24 and indicated Resident #3 was exit seeking and at risk for elopement and/or wandering with unsafe boundaries. The care plan indicated Resident #3 had a history of actual attempts to leave the facility unattended. The care plan interventions included 1 on 1 observation (1 staff member with the Resident at all times) until she could be transferred to a memory care unit. Record review of the nursing note dated 4/25/24 at 11:30 a.m. for Resident #3 indicated the nurse heard the D hall alarm go off the nurse responded to the alarm and saw Resident #3 walking across the parking lot. The nursing note indicated the nurse followed Resident #3 and asked her to come back to the facility but Resident #3 continued heading down the sidewalk when another employee joined her and was able to catch up to Resident #3. The note indicated the facility staff were able to convince Resident #3 to come back to the facility and call her family. The nursing note indicated upon return to the facility Resident #3 was placed on 1 to 1 observation. During an interview on 4/26/24 at 1:00 p.m., RN A said Resident #3's elopement incident occurred early in the morning on 4/25/24 at approximately 7:45 a.m. RN A said she was at the nursing station when the D hall alarm went off. RN A said she went to the D hall exit door and looked outside and saw Resident #3. RN A said Resident #3 was approximately 20 feet from the exit door walking briskly and started across the parking lot. RN A said she just couldn't keep up with her and said she could not run to get her. RN A said she continued to follow Resident #3 across the parking lot when human resources staff E pulled into the parking lot. RN A said Resident #3 crossed the side street and started onto the sidewalk (across the side street from the facility). RN A said human resources staff E ran and got Resident #3 by the hand. RN A said human resources staff E stood talking with Resident #3 until she (RN A) could reach her (Resident #3). RN A said Resident #3 was then taken back into the facility. RN A said she immediately notified the DON who instructed her to ensure Resident #3 was placed on 1 to 1 observation. RN A said 1 to 1 observation meant a staff member was to stay with Resident #3 at all times and have no other assignment. RN A said she knew nothing of Resident #3's elopement history. During an interview on 4/26/24 at 1:10 p.m., human resources staff E said as she arrived to the facility at approximately 7:45 a.m. on 4/25/24, she saw Resident #3 walking across the parking lot. Human resources staff E said she was not sure at first that Resident #3 was a resident and thought perhaps she was just someone out walking, cutting across the parking lot. Human resources staff E explained Resident #3 was walking at a brisk pace and did not seem confused or lost. Human resources staff said as she pulled into her parking spot Resident #3 had crossed the side street and started onto the sidewalk. Human resources staff E said she saw RN A walking across the parking lot and asked her if the lady walking was a resident. Human resources staff E said RN A yelled Yes, and so she ran up to Resident #3 held her hand and started talking to her. Human resources staff E said RN A caught up to them and they took her (Resident #3) back into the facility. During an observation and interview on 4/26/24 at 1:40 p.m., Resident #3 said she just left the facility because she needed to call her family. Resident #3 sat smoking a cigarette in the smoking area with staff beside her. Resident #3 was asked again about leaving the facility and she said, Oh I don't know about that. During an interview on 4/26/24 at 2:09 p.m. Resident #3's family member #2 said she spoke with the admissions coordinator last Friday (4/19/24) and sent over all the necessary paperwork to have her admitted . Family member #2 said Resident #3 was admitted to facility in the afternoon on 4/25/24 but could not say exactly what time. Family member #2 said the facility contacted her on 4/26/24 and told her Resident #3 had eloped from the facility. Family member #2 said they were keeping someone with Resident #3 at all times and would do so until they could find a facility with a secure unit for her. During an interview on 4/26/24 at 2:13 p.m., Resident #3's family member said Resident #3 was admitted into the facility on [DATE] sometime after 1:30 p.m. in the late afternoon. Resident #3's family member said he had been contacted and told Resident #3 had eloped from the facility and that the facility was seeking out a home that could provide a secured unit for Resident #3. The family member said he understood the need for a secured unit and had no problem with the transfer but was a little frustrated because the whole reason the family sought long-term care was because Resident #3 had wandered off from her apartment and was found by the police. The family member said they (the family) was upfront with the facility and had told them of the event. Record review of Resident #3's admission paperwork found no documentation of elopement history or the incident described by Resident #3's family member in which she left her apartment and was found by police. During an interview on 4/26/24 at 3:20 p.m., admissions coordinator B said she had talked to the Resident #3's family member #2 last Friday (4/19/24) regarding an admission for Resident #3. Admissions coordinator B said when she spoke with family member #2, she told her the family was seeking admission into long term care because she (Resident #3) had reached a point she would call family members constantly and the care she needed was just too much for them. Admissions coordinator B said family member #2 said she/he worked during the day and could not check on Resident #3 as often was needed and could not take her calls as often as she would call. Admissions coordinator B said the family seemed to be in a rush to get her admitted and had all the necessary paperwork to them on Friday (4/29/24). Admissions coordinator B said the facility used a centralized admission process. She explained that once all the necessary paperwork was gathered it was sent to the company's central office for review. Admissions coordinator B said sometimes the central office will send back notes or conditions after reviewing the paperwork. Admissions coordinator B said for example a nurse may have to go out and evaluate the potential resident. Admissions coordinator B said this was not the case for Resident #3 as the central office had cleared her for admission. Admissions coordinator B said family member #2 said nothing to her about Resident #3 having eloped from her independent living apartment and being found by the police. Admissions coordinator B said the facility did not take Residents with a history of elopement. During an interview on 4/26/24 at 3:32 p.m., the DON said she knew nothing of Resident #3's history of elopement and there was nothing in the records received regarding a history of elopement. The DON said the facility simply would not have accepted Resident #3, had they known about the elopement history. The DON said the facility did not have a wander guard system nor a secured unit and therefore did not accept residents with an elopement history. The DON said the facility had secured placement for Resident #3 in a facility with a secured unit, but the facility could not take her until Monday (4/29/24). The DON said Resident #3 would remain on 1 on 1 observation until she was transferred to the facility with the secured unit. During an interview on 4/29/24 at 10:40a.m., Resident #1's family member said the family had decided Resident #3 needed to be placed in long term care because she had left her apartment and was found by the police on 4/18/24. The family member said Resident #3 lived independently in her apartment until that incident. The family member said the facility had been contacted regarding possible admission and all the required paperwork was sent 4/19/24. The family member said admissions coordinator B, business office manager C and social worker D all were aware of Resident #3's history of eloping from her apartment and being found by the police on 4/18/24. During an interview on 4/29/24 at 10:50 a.m., admissions coordinator B said she had spoken with family member #2 and it was never relayed to her that Resident #3 had eloped form her apartment. Admissions coordinator B said the facility just would not have taken her and had just denied someone placement last week because they had a history of elopement. During an interview on 4/29/24 at 10:55 a.m., business office manager C said the family had not told her anything about Resident #3's elopement history. Business office manager C said she had only discussed financial aspects and payor sources with the family as that was what her job entailed. During an interview on 4/29/24 at 11:04 a.m., social worker D said the family had not said anything to her about Resident #3 having a history of elopement. Social worker D said she helped the family complete a DNR and completed PASRR paperwork and the family never mentioned Resident #3 had left her apartment and was found by police. Record review of the admission assessment dated [DATE] at 4:08 p.m. section L Exit seeking tool, indicated Resident #3 did not have the physical ability to leave the building on her own. This section of the admission assessment had no further assessment questions answered as the tool stated . (1) Is the resident physically able to leave the building on their own? If no, disregard remaining questions. This assessment was completed by LVN F. During an interview on 4/29/24 at 1:30 p.m., ADON G said she could not say why LVN F would have marked no on the admission assessment, as Resident #3 had the physical ability to leave the building but said she did not feel this assessment would have prevented Resident #3 from eloping the facility. ADON G said the remaining questions on the exit seeking tool if the question, Is the resident physically able to leave the building on their own? was marked yes asked about wandering, wandering history, exit seeking, exit seeking history, and the display of behaviors related to wandering and exit seeking. ADON G said at the time the assessment had been completed Resident #3 had been in the facility a few hours and Resident #3 had not displayed any of those behaviors. The ADON said she knew nothing of Resident #3's elopement history. ADON G said the facility does not accept resident with exit seeking behavior. During an interview on 4/29/24 at 1:35 p.m., the DON said Resident #3 had been transferred to a facility with a secured unit. The DON said she had always taken the question on the admission assessment under section L Exit seeking tool to mean would the resident leave the building on their own. The DON said after re-reading the question she understood the question to ask whether or not a resident had the physical ability to leave the building. The DON said she did not feel the assessment would have prevented Resident #3's elopement from the building. She said the remaining questions on the exit seeking tool if the question, Is the resident physically able to leave the building on their own? was marked yes asked about wandering, wandering history, exit seeking, exit seeking history, and the display of behaviors related to wandering and exit seeking. The DON said at the time the assessment had been completed Resident #3 had been in the facility a few hours and Resident #3 had not displayed any of those behaviors. The DON said she knew nothing of Resident #3's elopement history. The DON said had she have known Resident #3 had a history of elopement the facility would have not accepted her. During an interview on 4/29/24 at 2:17 p.m., LVN F said she marked no on the admission assessment under section L Exit seeking tool because she understood the question to mean would the resident leave the building on their own. LVN F said Resident #3 had been in the facility a few hours but had not displayed any exit seeking behaviors and was content in her room when she cared for her. Record review of the facility policy and procedure revised January 2023, titled Elopement Response & Exit Seeking Management stated, .A. Elopement Response: Unable to locate resident (1) If a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside premises B. Response following the location of the resident: (1) Once located and safety confirmed, conduct an assessment. (2) Place resident on enhanced monitoring, consider 1:1 for a specified time as needed to ensure the safety of resident or consider placement in secured unit for continued monitoring and safety. The facility policy and procedure did not detail the facility would not accept Resident's with a history of elopement. During an interview on 4/29/24 at 2:20 p.m., the corporate RN said the facility did not have a policy and procedure that specifically addressed the accurate completion of admission assessments or regarding the centralized admission process. Record review of the facility policy and procedure revised January 2023, titled Professional Standards of Care, stated, .Nurses should conduct assessments or evaluations and document nurses' notes in the following instances: 1) routine charting for residents should reflect the recipient's ability as assessed upon admission, re-admission and as clinically indicated; and 2) at the time of accidents, incidents or change in condition. All exceptions to stable, baseline or usual status should be recorded as exceptions and included in the clinical record .

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #1) residents reviewed for quality of care. 1. The facility failed to monitor Resident #1's condition following elevated blood sugar readings. 2. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110) 3. The facility's Diabetic Management policy failed to address high blood sugars. 4. The facility failed to include blood sugar parameters for physician notification in Resident #1's physician orders. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m., the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in diabetic residents suffering injury, hospitalization , or death related elevated blood sugars Findings include: Record review of a face sheet dated 10/6/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility om 3/3/04 with diagnoses including diabetes, dementia, major depressive disorder, and hypertension (elevated blood pressure). Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 09 and was moderately cognitively impaired. Record review of the care plan last updated 8/31/23 indicated Resident #1 had diabetes and was at risk for complications associated with diabetes such as frequent infections, diabetic wounds, vision impairment, and hyper\hypo-glycemia. Interventions included administer medications as recommended by the doctor, monitor labs as indicated, and promptly report abnormal labs results and significant clinical findings to the doctor. Record review of the physician orders dated 10/4/23 indicated Resident #1 had an order for Humalog (a fast-acting insulin to treat diabetes) 100u/ml inject 14 unit subcutaneously before meals related to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23. Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m. Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings. Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she had, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar. I checked the resident's blood sugar and the reading was HI [blood sugar reading greater than 600] . Call placed to [the physician] and received voicemail that instructed me to text and wait for response. Awaiting response. Record review of the nursing progress dated 9/25/23 at 4:20 a.m. written by RN A indicated Spoke with [the NP]. Order received to recheck blood glucose [on Resident #1]. Blood glucose rechecked and still reads HI. 4:40 a.m. called [the NP] and new order received. 4:50 a.m. [Resident #1] was given 10units of Humalog Insulin. Record review of the nursing progress note dated 9/25/23 at 5:50 a.m. written by RN A indicated Recheck of [Resident #1's] blood glucose revealed glucometer still reading HI. Call placed to [the NP] and was instructed to send resident to hospital. EMS called and resident transferred to [hospital]. Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946. Record review of the hospital discharge summary dated 10/2/23 indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack). During an interview on 10/4/23 at 1:45 p.m. RN B said the facility did not have standing orders to add blood sugar parameters of when to notify the physician for blood sugar readings if too high or too low. RN B said some residents did have individualized parameters in place for when to notify the physician regarding their blood sugars. RN B said blood sugar parameters of when to notify the physician were normally if the blood glucose level was less than 60 or greater than 400. RN B said if she had a resident who had a blood sugar of 400, 500, or 600 she would notify the physician. RN B said physician notification and new orders should have been documented. During an interview on 10/4/23 at 1:49 p.m. The NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received to blood sugar results she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater. During an interview on 10/5/23 at 12:38 p.m. RN A said she was employed at the facility since March 2023. RN A said on 9/25/23 at approximately 4:00 a.m., the nurse who worked the 2:00 p.m.-10:00 p.m. shift on 9/24/23 called and informed her she had forgot to tell her Resident #1's blood sugar was high. RN A said she immediately went to take Resident #1's blood sugar and it only read high. RN A said she called the physician and when he did not answer she waited approximately 30 minutes and then called the on-call for the administration. RN A she spoke RN B who was on-call for administrative call and was told to call the NP. RN A she called the NP and was told to administer 10u of Humalog and recheck in 1 hour RN A said Resident #1 was not very responsive when she administered the Humalog. After re-checking the blood sugar and it was still HI, she reported to NP, and called 911. She said Resident #1 was semi-conscious when she left for the hospital. RN A said she was unsure whether the facility had standing parameters of when to notify a physician regarding blood sugars. RN A said the physician or NP should have been notified if the glucometer read HI when checking a blood sugar. RN A said a glucometer reading of HI was usually over 600. RN A said she would probably notify the physician of a blood sugar reading of 400 or 500. During an interview on 10/6/23 at 2:59 p.m. LVN C worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital. During an interview on 10/6/23 at 3:17 p.m. the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. Record review of the undated EvenCare G2 Blood Glucose Monitoring System's Healthcare Professional Operator's Manual indicated a reading of HI meant the patient's blood glucose was greater than 600. Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders . The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m. The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included: Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident #1 was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident readmitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23. Date of completion: 10/4/23 The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. Date completed: 10/4/2023. The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medical record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/2023. Date to be completion: 10/4/2023. Risk Response: All residents who are diabetic may potentially be affected by the deficient practice. Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date to be completed: 10/5/2023. Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin. Date completed: 10/4/2023. The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date completed: 10/4/2023. Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date completed: 10/4/2023. 10:00PM Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date completed: 10/4/2023. Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As, and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. Date completed: 10/5/2023 All staff will be in-serviced on Abuse, Neglect and Exploitation, Prevention, Identification, Protecting and Reporting. This is for educational purposes for our employees. Date Commenced: 10/4/2023 Date to be completion: 10/5/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response for the plan of correction. The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia. Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters. Record review of Resident #1's physician orders for insulin indicated she had insulin orders starting 10/4/23 which included diabetic parameters to notify the physician for blood sugar readings of less than 60 or greater than 400. Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure. Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification. Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for resident rights. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110) This failure resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m. the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could result in diabetic residents suffering injury, hospitalization , or death related elevated blood sugars. Findings Include: 1. Record review of a face sheet dated 10/6/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility om 3/3/04 with diagnoses including diabetes, dementia, major depressive disorder, and hypertension (elevated blood pressure). Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 09 and was moderately cognitively impaired. Record review of Resident #1's care plan last updated 8/31/23 indicated Resident #1 had diabetes and was at risk for complications associated with diabetes such as frequent infections, diabetic wounds, vision impairment, and hyper\hypo-glycemia. Interventions included administer medications as recommended by the doctor, monitor labs as indicated, and promptly report abnormal labs results and significant clinical findings to the doctor. Record review of the physician orders dated 10/4/23 indicated Resident #1 had an order for Humalog (a fast-acting insulin to treat diabetes) 100u/ml inject 14 unit subcutaneously before meals related to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23. Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m. Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings. Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar. Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI (blood sugar reading greater than 600) and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946. Record review of the hospital discharge summary dated 10/2/23 indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack). During an interview on 10/4/23 at 1:49 p.m., the NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.- 6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received the blood sugar results, she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later, the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater. During an interview on 10/6/23 at 2:59 p.m., LVN C said she worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital. During an interview on 10/6/23 at 3:17 p.m., the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders . The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m. The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included: Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident readmitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23 Date of completion: 10/4/23 The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. Date completed: 10/4/2023 The Director of Nursing Services/Assistant Director of Nursing conducted and education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23 Date to be completion: 10/4/2023 Risk Response: All residents who are diabetic may potentially be affected by the deficient practice. Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date of Completion: 10/5/2023 Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin. Date completed: 10/4/2023 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 10/4/23 Date to be completion: 10/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. We are using the education on abuse, neglect, and exploitation as an opportunity for our team members. Date completed: 10/4/2023 10:00PM Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date completed 10/4/2023. Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. Date of completed: 10/5/2023. All staff will be in-serviced on Abuse, Neglect and Exploitation- Prevention, Identification, Protecting and Reporting. This is used for educational purposes. Date Commenced: 10/4/2023 Date to be completion: 10/5/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia. Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters. Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure. Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification. Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 9 (Resident #4, Resident #5, and Resident #6) residents reviewed for ADLs . 1.The facility failed to provide assistance with facial hair removal for Resident #4 and Resident #5. 2. The facility failed to ensure Resident #5's fingernails were trimmed. 3. The facility failed to provide scheduled showers to Resident #6 This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings Include: 1. Record review of the face sheet dated 10/6/23 indicated Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, COPD, hemiparesis and hemiplegia following a cerebral infarction (paralysis and weakness of one side following a stroke), and hypertension (elevated blood pressure). Record review of the MDS assessment dated [DATE] indicated Resident #4 was understood by other and usually understood others. The MDS indicated Resident #4 had a BIMS score of 04 and was severely cognitively impaired. The MDS indicated Resident #4 required extensive assistance with dressing and toileting. The MDS indicated Resident #4 required total dependence for bathing. Record review of the care plan dated 8/24/23 indicated Resident #4 had a self-care deficit related to poor physical functioning. The care plan indicated interventions included bathing, dressing and grooming, and hygiene assistance times 1 person assist. During an observation and interview on 10/5/23 at 1:23 p.m. Resident #4 had thick white/grey chin hair approximately 0.5cm in length. Resident #4 said she would love to have assistance with removing her chin hair. Resident #4 said some of the staff would assist with chin hair removal and others would not. Resident #4 said she did receive her scheduled showers when she wanted them. 2. Record review of the face sheet dated 10/6/23 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following a cerebral infarction (paralysis and weakness of one side following a stroke), contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joint) of the right wrist, contracture of the right hand, and weakness. Record review of the MDS dated [DATE] indicated Resident #5 was usually understood by others and usually understood others. The MDS indicated Resident #5 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #5 required extensive assistance with dressing, toileting, and personal hygiene. The MDS indicated Resident #4 Record review of the care plan dated 8/6/23 indicated Resident #5 had a self-care deficit related to poor physical functioning. The care plan indicated interventions included bathing, dressing and grooming, and hygiene assistance times 1 person assist. During an observation and interview on 10/5/23 at 1:29 p.m. Resident #5 had chin hair approximately 0.5cm in length. Resident #5 said she would like her chin hair removed. Resident #5 had a contracture to her right hand and fingernails to her right hand approximately 1-2cm in length above the tip of her finger. Resident #5 said she wanted staff to cut her fingernails short. 3. Record review of the face sheet dated 10/6/23 indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, schizoaffective disorder-bipolar type (a mental illness that can affect your thoughts, mood, and behavior), and mood disorder. Record review of the MDS dated [DATE] indicated Resident #6 was understood by others and understood others. The MDS indicated Resident #6 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #6 required supervision with dressing and toileting. The MDS indicated Resident #6 required limited assistance with personal hygiene. The MDS indicated Resident #6 required supervision with bathing. Record review of the care plan dated 9/27/23 indicated Resident #6 had a self-care or mobility deficit related to immobility or weakness. Record review of the Documentation Survey Report dated September 2023 indicated Resident #6 was scheduled for showers on Mondays, Wednesdays, and Fridays. The Documentation Survey report indicated Resident #6 did not receive a shower on 9/1/23, 9/8/23, 9/15/23, 9/18/23, 9/22/23, and 9/25/23. The Documentation Survey Report indicated Resident #6 received showers on 9/4/23, 9/6/23, 9/11/23, 9/20/23, 9/27/23, and 9/29/23. The Documentation Survey Report indicated Resident #6 refused her shower on 9/13/23. During an interview on 10/5/23 at 1:33 p.m. Resident #6 said she did not receive her scheduled showers. Resident #6 said the CNAs complained because she had long hair and it took too long to shampoo. Resident #6 said she received a shower on 10/04/23 and prior to that it had been approximately a week since she had received a shower. Resident #6 said the staff did not think about the fact the residents wanted to be clean and go to bed clean like the staff had the option to do when they got home from work. During an interview on 10/6/23 at 10:05 a.m. LVN G said CNAs were responsible for providing residents their scheduled showers. LVN G said the importance of ensuring residents received their scheduled showers was to prevent skin breakdown, urinary tract infections, and fungal rashes. During an interview on 10/6/23 at 10:35 a.m. LVN J said the CNAs were responsible for resident showers. LVN J said facial hair removal for women should have been done daily or as needed. LVN J said resident's nails should be cared for by facility policy or on shower days. LVN J said the importance of facial hair removal, nail care, and showers was dignity, hygiene, fungal infection and rash prevention, and skin integrity. During an interview on 10/6/23 at 3:17 p.m. the DON said CNAs were responsible for showers, facial hair removal, and nail care. The DON said she had issues with agency staff not providing showers to the residents. The DON said she had received grievance regarding residents not receiving their showers. The DON said the importance for providing scheduled showers, facial hair removal, and nail care was for the residents' overall well-being and to make them feel good. During an interview on 10/6/23 at 3:35 p.m. the Administrator said the only thing about showers he really was comfortable saying was resident showers should be scheduled and provided according to the resident's preference. Record review of the facility's Activities of Daily Living policy dated February 2017 indicated, Each resident's abilities to perform activities of daily living will no diminish unless the individual's clinical condition demonstrates that diminution was unavoidable. Activities of daily living include: personal hygiene . Record review of the facility's Certified Nurse Aide Standards of Clinical Practice policy dated 3/12/19 indicated, .The CNA assists the resident in activities of daily living such as feeding, drinking, turning and positioning, ambulating, bathing, grooming, toileting, dressing, and socialization .

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent injury for 1 of 10 residents reviewed for accidents. (Resident #1) The facility did not ensure 2 staff provided ADL care for Resident #1. The resident required 2 staff for all ADL care and was identified as a high fall risk. CNA F turned the resident onto her side during care and the resident fell out of the bed. Resident #1 complained of left hip pain and was the x-ray indicated she had a broken left hip. She was admitted to the hospital with [REDACTED]. This failure could place 12 residents who required 2 staff for ADLs at risk for injury, discomfort, and decreased quality of care. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 made herself understood and understood others and was moderately impaired cognition. She required total assistance of 2 staff for all ADLs, including transfers and bed mobility. She was incontinent to bowel and bladder. A care plan dated 8/24/17 indicated Resident #1 required extensive assistance of 2 staff for bed mobility. A care plan dated 11/14/17 and updated 2/6/18 indicated Resident #1 was a fall risk and the interventions included two staff members to be present when providing ADL care. A fall risk assessment dated [DATE] indicated Resident #1 was a high risk for falls. A change of condition form dated 2/6/18 indicated at 10:19 a.m., CNA F provided Resident #1 incontinent care in bed. CNA F turned Resident #1 onto her left side, the left mattress bolster gave way, and the resident slid to the floor. No injuries were documented. A witness statement written by CNA F dated 2/6/18 indicated she was turning Resident #1 to clean her and the protection cushion gave way and Resident #1 started to fall, but she caught her as much as she could to soften the fall to the floor. She said she did not see Resident #1 hit anything, but complained her behind hurt. She said she notified LVN D and assisted Resident #1 back into the bed. During an interview on 2/7/18 at 2:51 p.m., CNA F said she provided incontinent care to Resident #1 on 2/6/18. She said the resident slid out of the bed over the protection cushion when she turned her over and she could not prevent her fall onto the floor. She said she usually provided incontinent care to dependent residents by herself and only obtained another staff to assist her when she transferred a dependent resident out of bed. She said Resident #1 was dead weight and she (CNA F) probably should have used another staff to assist her with care. A nursing note dated 2/6/18 at 10:42 a.m. by LVN D indicated Resident #1 was lying on her left side on the floor. She and CNA F assisted the resident back to bed and an assessment revealed no open areas or bruising. Resident #1 complained of left hip pain. LVN D notified the NP, obtained an order for [REDACTED].#1 with pain medication. During an interview on 2/7/18 at 1:38 p.m., LVN D said CNA F notified her Resident #1 slid out of the bed over the bolster onto the floor. She said CNA F provided incontinent care by herself and was supposed to get another staff to assist her. She said she assessed the resident, assisted her back to bed with CNA F, made notifications and obtained an order for [REDACTED]. A nursing note dated 2/6/18 at 2:25 p.m. by the DON indicated Resident #1's x-ray report revealed suspicion of femoral neck fracture, recommended for clinical correlation. Resident #1's daughter requested she be transferred to the hospital for evaluation. A nursing note dated 2/6/18 at 2:36 p.m. by LVN I indicated Resident #1 was transferred to the hospital by ambulance. A nursing note dated 2/6/18 at 9:40 p.m. by LVN I indicated an emergency room nurse notified her confirmation that Resident #1 had a non-displaced left hip femoral neck fracture and would be admitted . During an interview on 2/7/18 at 1:30 p.m., CNA E said she cared for Resident #1 multiple times. She said Resident #1 was dependent and always required 2 staff to provide incontinent care. During an interview on 2/7/18 at 1:45 p.m., Resident #1's daughter said she was notified of her fall. The daughter felt she did not receive the proper assistance to prevent her fall and injury. She said her mother was in the hospital with a left femur fracture and would need to wear a brace for one month and receive blood thinner injections. During an interview on 2/7/18 at 2:30 p.m., the SW said Resident #1's most recent care plan meeting was 11/15/17. She said the care plan indicated Resident #1 was dependent and always required 2 person assist that included incontinent care in her bed. During an interview on 2/7/18 at 2:40 p.m., CNA G said Resident #1 was totally dependent and staff was always supposed to use 2 staff to provide care. She said staff sometimes used only one staff to provide care to dependent residents if there was no one else available, but the charge nurses told her and other CNAs not to use one staff after Resident #1 fell . She said the level of assist required for each resident was available in the kiosk on each hall. During an interview on 2/7/18 at 3:08 p.m., LVN H said Resident #1 required 2 staff assistance, but not so much in bed. She said the updated care plan level of assistance required for each resident was in the kiosk for all staff access. During an interview on 2/7/18 at 3:45 p.m., the DON said she had initiated in-service to all staff regarding fall protocol and all dependent staff required 2 staff to assist with bed mobility and incontinent care after the incident. An undated Fall and Post-Fall Management policy indicted each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for resident as well as staff safety. Goals included identify residents at risk for falls during ADL execution by resident individually or with staff assistance. The CMS 672 dated 2/7/18 indicated 12 residents were totally dependent.

Based on observation, interview, and record review the facility failed to ensure all allegations of abuse and neglect were immediately reported to the administrator, failed to have evidence that all alleged violations were thoroughly investigated, and failed to prevent further potential abuse or neglect while an investigation was in progress for 5 of 6 residents reviewed for neglect. (Residents #s 1, 2, 3, 4, and 5) The facility did not immediately report an incident involving Resident #1 sexually assaulting Resident #2 to the administrator and did not conduct a thorough investigation of the incident. The facility did not report the incident to the state agency and did not protect Resident #2 and other female residents from possible assault. The facility did not immediately report an incident involving Resident #3 allegedly inappropriately touching Resident #4 to the administrator, did not thoroughly investigate the incident, and did not protect Resident #4 or other residents from further sexual assault. The facility did not thoroughly investigate an incident involving Resident #3 inappropriately touching Resident #5 and did not protect Resident #5 or other residents from sexual assault. An Immediate Jeopardy situation was identified on 10/5/17. The Immediate Jeopardy was removed on 10/6/17; however, the facility remained out of compliance at a pattern of actual harm, due to the facility's need to complete in-service training, revise their secure unit policy, and evaluate the effectiveness of the corrective systems. This failure could place the census of 69 residents at risk for abuse/neglect and possible harm. Findings included: 1. Residents #1 and #2 A consolidated physician order [REDACTED].#2 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was severely cognitively impaired. She required extensive assist of two people with bed mobility and transfers. A care plan updated 10/3/17 indicated Resident #2 had communication problem related to [MEDICAL CONDITION] (unable to talk). The staff anticipated all of her needs. The resident was at risk for abuse as she could not communicate her needs. Some of the interventions were to observe who was going into her room, particularly males and observe for physical indicators of discomfort or distress. Resident #2 had problems of impaired cognitive function/dementia or impaired thought processes related to neurological symptoms ([MEDICAL CONDITION]). All decision making for the resident was anticipated and completed by staff. All of Resident #2's ADLs were anticipated and provided by staff using total assistance of one to two members. A consolidated physician order [REDACTED].#1 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 8/30/17 indicated Resident #1 with behavior problems related to anxiety. Some of the interventions were to observe for aggressive behavior, and intervene as necessary to protect the rights and safety of others. Resident #1 had long and short term memory problems. He needed verbal cues, redirection, and supervision. A care plan dated 8/22/17 indicated Resident #1 had a diagnoiss of Alzheimer's with a history of wondering throughout the facility without purpose. A physician note dated 8/31/17 indicated Resident #1 was a long-term care resident he was recently transferred to the facility from another facility due to anger and physical abuse issues with staff. An MDS dated [DATE] indicated Resident #1's BIM's score was 9, indicating moderate cognitive impaired. He ambulated with a walker and required one limited assistance with transfers and walking. He required extensive assist with dressing and supervision with eating. The MDS did not indicated any mood or behavior issues. Nursing notes for Resident #1 indicated: *9/27/17 at 1:50 a.m., the resident's wandering at night had increased and safety is now a major concern due to leaving walker. The resident stated, you might as well kill me before making me a punk. *9/30/17 at 1:53 p.m., the resident was noted standing over another resident with his hand in her brief. He was removed from the room and moved to another hall. An incident report dated 9/30/17 indicated CNA D was called to Resident #2's room and Resident #1 was standing over her with his hand in her brief. The CNA asked the resident what he was doing and he said, I am working her out. Resident #1 was removed from the room and the nurse was notified. Resident #1 was moved to another hall and he was scheduled to see a psychologist and the pharmacy was to evaluate his medications. A care plan dated 10/2/17 indicated Resident #1 had a tendency to be sexually inappropriate. Some of the interventions were to monitor and document inappropriate sexual behaviors a monitor the behaviors. During an interview on 10/4/17 at 2:07 p.m., Housekeeper F (with interpreter) said she was walking down the hall on 9/30/17 and saw Resident #1 in Resident #2's room. She said she stopped and looked around the corner of the door because she was shocked at what she saw. Housekeeper F said Resident #1 was standing over Resident 2's bed rubbing her breast. She said Resident #2 had clothes on the top portion of her body; however, her brief was removed and Resident #1 had his hand in her vaginal area rubbing in and out (she made hand motions of back and forth). The housekeeper said she got CNA D's attention and he came to the room and removed Resident #1. During an interview on 10/4/17 at 1:44 p.m., CNA D said he witnessed a sexual assault on 9/30/17. He said a housekeeper asked him to come and look while she was standing outside of Resident #2's room. He said Resident #2 was in her bed and Resident #1 had removed Resident #2's brief and was inserting his fingers into her vagina. CNA D said Resident #1 said he was working her out, referring to Resident #2. CNA D said he saw Resident #2's fingers in Resident #2's vagina. He said Resident #2 had a bowel movement and Resident #1 had bowel movement on his hands and under his nails. CNA D said he escorted Resident #1 out of the room. He said Resident #2 could not communicate, she could only lie there in bed. CNA D said he wrote a statement about the incident that occurred on 9/30/17. He said Resident #1 was not on any kind of special monitoring. He said they did not have time to watch Resident #1 because they had to provide care to the other residents on that hall. CNA D said they had several residents who required two person transfers and the two aides on the hall were in the rooms. He said if one aid was providing a shower, the other aide was answering call lights. He said there was no way they could monitor Resident #1's movements. During an interview on 10/4/17 at 1:53 p.m., LVN E said she was called to Resident #2's room and informed by CNA D Resident #1 had his hand in Resident #2's brief. LVN E said the housekeeper indicated she saw something going on and called CNA D to come quick. LVN E said she assessed Resident #2 and did not see any trauma, bruising, redness, or tears. She said Resident #2 was not able to voice any concerns. She said Resident #2 was not able to verbalize, she could only make noises. LVN E said she was not aware of Resident #1 having any prior behaviors and was not on any special precautions. She said Resident #1 had dementia and was moved to another hall the same day of the incident. During an interview on 10/4/16 at 1:20 p.m., CNA A said LVN C said to keep Resident #1 off Hall A after the incident on 9/30/17 because the housekeeper caught Resident #1 with 4 fingers inside of Resident #2's vagina. CNA A said when Resident #1 was asked what he was doing, he said he was working her out. She said Resident #1 was moved to another hall. During an interview on 10/4/17 at 3:04 p.m., CNA H said Resident #1 wandered the halls looking in rooms. CNA H said she heard CNA D informed LVN E Resident #1 sexually assaulted Resident #2. CNA H said the housekeeper told her she saw Resident #1 with 4 fingers going in out of Resident #2s vaginal area. She said she worked hall A and no one had informed her if Resident #1 was on any special precautions. CNA H said they had to provide care to other residents on the hall that were two person assist and could not watch Resident #1's whereabouts. During an interview on 10/4/17 at 3:37 p.m., the ADON said Resident #1 was moved off the A hall after the incident with Resident #2. She said Resident #2's level of supervision was increased. The ADON said there was nothing in writing, but staff were told verbally to watch Resident #1 closely and know where he was at all times. She said Resident #1 was to be redirected if they saw him headed to the A hall. The ADON said there was no way to know how frequently he was being monitored, but everyone was to be on the lookout for him. She said Resident #1 may have thought he was changing Resident #2 because she looks like a baby. She did not think any other residents were interviewed to see if he had gone in their rooms. During an interview on 10/5/17 at 10:30 a.m., Resident #1 said he did something stupid. He said he may have touched somebody, but he did not remember it. He said he has had sex at least once since he was admitted to the facility. He also said there was a bunch of the women in the facility that want to be naked with him, but he had to tell them no. During an interview on 10/4/17 at 8:13 p.m., Resident #2's mom said the facility notified her of an incident where a demented male resident had touched her daughter inappropriately. She said about a year ago some other man with dementia had touched he daughter on the breast. During an interview on 10/4/17 at 3:41 p.m., the social worker said she was told Monday (10/2/17) Resident #1 had his hand in Resident #2's brief. She said Resident #1 had dementia and was a wanderer. She said sometimes Resident #1 was more confused than at others and his behaviors were worse in the afternoon. The social worker said Resident #1 could not remember the incident with Resident #2. She said Resident #2 could not communicate, but she could show distress. Nursing notes for Resident #1 included: *10/2/17 at 2:52 a.m., Resident continued to try and go down the A hall and was frequently redirected *10/2/17 at 1:56 p.m., resident was trying to go to the other hallway, but was easily redirected. The notes indicated to continue to closely monitor Resident #1. *10/4/17 at 4:39 a.m., resident began wandering around midnight, he had to be redirected from hall A. The note indicated he went into the dining area and used coffee machine to fill several cups of coffee and then dumped them in the sink. He was redirected and returned to his room about 4 a.m. and went to bed. Will continue to monitor. A social services noted dated 10/4/17 at 4:26 p.m. indicated on 9/30/17 Resident #1 was found in a female resident's room with his hand in her brief. The social worker spoke to Resident #1 and he did not recall the incident. Staff immediately moved him to another room. The DON and the social worker decided to make a referral to the psychologist to have him evaluated today 10/4/17. During a continuous observation on 10/5/17 at 10:52 a.m. to 11 a.m., Resident #1 was seen coming out of his room and ambulating down the hallway. There were no staff in sight and no nurses at the nursing station. At 11:00 a.m. there were still no staff on the hallway and Resident #1 went into the dining room. During an interview on 10/5/17 at 1:20 p.m., the administrator said Resident #1 was found in Resident #2's room trying to insert his hand in Resident #2's brief. The administrator said Resident #1 was stopped before anything happened. She said Resident #1 had behaviors of wandering and the staff were keeping a constant eye on him. The administrator said Resident #1 was not on one to one monitoring, but they (staff) were paying more attention to him now. She said they were aware of Resident #1's movements, but there was no documentation of the monitoring and no one assigned to him specifically. She said she would have reported the incident to the state, but his BIMs score was a 4 and he was totally confused. During an interview on 10/5/17 at 1:32 p.m., the DON said there was no particular staff assigned to Resident #1 and there was no documentation on his monitoring. The DON said they moved Resident #1 to another hall following the incident involving Resident #2. She said they did not think it was abuse because Resident #1's BIMs score was low and he was confused. The DON said there was no intent and she did not conduct an investigation. She said they were only trying to protect Resident #2. 2. Residents #3 and #4 Consolidated physician orders [REDACTED].#3 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #3 had a BIMs score of 11 indicating moderate cognitive impairment. There were no indications of any mood or behavior issues. He required limited assistance with transfer and mobility. He did not walk, but used a wheelchair for mobility. A care plan dated 8/16/17 indicated Resident #3 had the potential to demonstrate verbal and physical behaviors related to mood disorder. The care plan indicated he was arguing with his roommate and threw a pillow at him and therefore was moved from his room to another room. Consolidated physician orders [REDACTED].#4 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS date 9/13/17 indicated Resident #4 had a BIMS score of 15, with no indication of cognitive impairment. There were no indications of any mood or behavior issues. Resident #4 required no assistance with transfers with limited assist with dressing and supervision with hygiene. An incident report dated 8/16/17 at 5:57 a.m. indicated Resident #3 was heard yelling at his roommate Resident #4. Resident #4 was sitting in the hallway taking things off the linen cart, as if he was taking out his frustrations. It was obvious the two roommates were in a heated argument. Resident #3 said Resident #4 turned on the light and it made him angry so he turned on his television. The nurse and aides tried talking to the residents and finally thought they were calmed down. Residents #3 and #4 got into it again and Resident #4 moved a chair out into the hall and sat down. Once again things got quiet for a minute and then Resident #3 threw a pillow at Resident #4. The residents were separated. Resident #3 agreed to move to another room. A nursing note dated 8/16/17 for Resident #4 indicated at 6:22 a.m., Resident #3 and #4 got into argument in their room and things got a little escalated. They were yelling and throwing pillows back and forth. There was a second incident, they started at each other we thought it best to separate the two residents. Resident #3 agreed to move to another room until the day shift could come and straighten things out. A nursing note at 2:09 p.m. indicated staff reported to the nurse Resident #4 barricaded himself in his room by putting furniture against the door. When they tried to enter and he told staff that he did not want to go out to bingo, it was reported to the social worker. A social worker note dated 8/16/17 indicated at 3:12 p.m. she went down and tried to go into Resident #4's room, but the door was barricaded and he refused to open it. After several attempts, Resident #4 finally allowed her to come into the room. Resident #4 said he did not want his roommate Resident #3 back in his room. The social worker note indicated Resident #4 did not say what happened, he just said he did not want Resident #3 back in the room. A nursing note dated 8/16/17 at 10:22 p.m. indicated Resident #4 agreed to allow staff in his room to remove Resident # 3's items from the room. Resident #4 removed the chairs and dresser from behind the door. During an interview on 10/4/17 at 3:04 p.m., CNA H said about a month ago Resident #4 told one of the nurses Resident #3 tried to get in bed on top of him. CNA H said all of the administrative staff were aware because they all talked about the incident. She said after the incident Resident #4 would barricade himself in room with his dresser behind the door and not let anyone in. She said the administrative staff knew about the incident and talked about it and said that Resident #3 had a [MEDICAL CONDITION]. CNA H said she had not seen Resident #3 be sexually inappropriate with anyone. A social services note dated 9/11/17 indicated Resident #4 had no difficulty focusing his attention when observed and no disorganized thinking noted. There was no altered level of consciousness observed and no evident of acute change in mental status from the baseline. Resident #4 did not have any potential indicators of [MEDICAL CONDITION]. A Quarterly activity note dated 9/16/17 indicated Resident #4's activity attendance since the last review has dropped. The group activity and events participation have dropped due to issues with another resident, but were starting to pick them back up slowly. The resident's favorite activity was bingo, music, food, beverages, movies and social hour. A care plan updated on 10/1/17 indicated Resident #3 initiated verbal aggression toward another resident after the resident asked him to stop following her and accused of him of glaring at her inappropriately. Some of the interventions included: to observe behaviors and attempt interventions. The care plan indicated Resident #3 had been accused on more than one occasion of being sexually inappropriate with other residents. One of the interventions was to monitor and document inappropriate sexual behaviors with an initiation date of 10/2/17. During an interview on 10/4/17 at 12:25 p.m., Resident #4 said his former roommate Resident #3 was mean to him and would keep him up at night bothering him. He would not explain what bothering him consisted of and refused to answer any more questions. During an interview on 10/4/17 at 2:35 p.m., LVN I said Resident #4 stayed to himself and was a pleasant man. She said Resident #3 was Resident #4's last roommate at one time. LVN I said Resident #3 and #4 got into an argument because Resident #3 made sexual advances towards Resident #4. She said she did not know if Resident #3 actually touched him or not. She said since the altercation, Resident #4 was very withdrawn and would barricade the door to his room and not let anyone in. She said Resident #4 moved the furniture around in his room and put the dresser in front to of the doorway. LVN I said recently, Resident #4 started coming out of his room and interacting a little more, but he would not stay long. During an interview on 10/4/16 at 1:09 p.m., CNA A said Resident #4 reported to the ADON and social worker he was asleep and Resident #3 was trying to mess with his bottom. She said the two residents got into an argument. CNA A said she did not think it was reported. CNA A said Resident #4 used to always come out of his room and participate in activities, but since the incident with Resident #3, Resident #4 just sat in his room. She said Resident #4 was not the same person. She said now if they went into Resident #4's room, he would get up out of bed quickly. During an interview on 10/4/17 at 3:37 p.m., the ADON said they did not know why the incident with Resident #3 and Resident #4 occurred; however, they heard a staff member say it was sexual. She said the same day of the incident Resident #3 moved and the next day Resident #4 barricaded the door. She said Resident #4 said he was not letting anyone in and said he had never exhibited that type of behavior. During an interview on 10/4/17 at 3:38 p.m., Resident # 3 said he was roommates with Resident #4 and the facility moved him. Resident #3 said he had no idea why he was moved. During an interview on 10/4/17 at 2:50 p.m., CNA G said she had a good relationship with Resident #4. She said she did not know what occurred when Resident #3 was his roommate, but it really upset him. She said after the incident Resident#4 was at the nursing station and was frightened (visibly shaking) and wanted to know why Resident #3 was still in the facility. She said Resident #4 weighed about 135 pounds and Resident #3 was about 6 feet tall and weighed about 250. During an interview on 10/4/17 at 3:41 p.m., the social worker said when the incident occurred with Residents #3 and #4, Resident #4 would not say what happened. The social worker said Resident #4 would only say Resident #3 kept him up at night. During an interview on 10/4/17 at 2:31 p.m., the DON said Resident #3 and Resident #4 were roommates and had a verbal altercation; however, neither one said what was the problem. She said one of the residents threw a pillow at the other. The DON said Resident #4 did not want Resident #3 on that hall. She said Resident #4 was a longtime resident and never had any problems before or after this incident with Resident #3. The DON said after the incident Resident #4 would barricade himself in his room. She said Resident #3 is a young man with a [MEDICAL CONDITION] and may be gay. The DON said she was not aware of any sexual inappropriate behaviors that may have occurred involving Resident #3. She said she did not speak to either resident about the incident. She did not ask Resident #4 why he barricaded himself in the room. During an interview on 10/6/17 at 9:59 a.m., the administrator said she was not aware of what occurred between Resident #3 and Resident #4. She said from what she knew, Resident #4 was upset because Resident #3 turned his television up loud and he could not sleep. 3. Residents #3 and #5 A consolidated physician order [REDACTED].#5 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #5 had a BIMs score of 15 indicating no cognitive impairment. There was no indication of any issues with mood or behaviors. He was also listed as independent with all ADLs. A care plan dated 9/30/17 indicated Resident #5 had the potential to demonstrate verbal/physical behaviors of hitting other residents. Nursing notes dated 9/30/17 at 3:04 p.m. indicated Resident #3 was wheeling himself to the dining room and came right by Resident #5. Resident #5 said he was trying to touch him on the butt and hit Resident #3 on the back of the head. There were no injuries noted. During an interview on 10/4/17 at 1:53 p.m., LVN E said on 9/30/17 Resident #5 was standing at the nursing station and said Resident #3 tapped him on the butt. LVN E said Resident #5 hit Resident #3 upside the head and told him to stop touching his butt. She said Resident #5 said Resident #3 touched him once already that day in the laundry room. An incident report dated 9/30/17 indicated Resident #5 was standing at the nursing station and Resident #3 came by him. Resident #5 hit Resident #3 on the back of the head. Resident #5 said Resident #3 was trying to touch his butt in the dining room earlier and he was tired of him. During an interview on 10/4/17 at 2:40 p.m., the DON said she had not finished her investigation. She said she had not interviewed Resident #5 related to the incident on 9/30/17. She said Resident #3 said if he touched Resident #5's butt it was an accident. During an interview on 10/4/17 at 3:28 p.m. Resident #5 said on 9/30/17 he was sitting in the dining room and Resident #3 rolled by him in his wheelchair. He said as Resident #3 was rolling by him, he started messing with his butt by rubbing the side of it. He said he told Resident #3 to stop it, the resident did, and he rolled on by in his wheelchair. Resident #5 said he did not tell any staff member about him touching him on his butt because he did not see it as an issue yet. He said later on that day, he was standing by the nursing station and Resident #3 came up behind him and grabbed his butt. He said when Resident #3 did this, he turned around and knocked the hell out him. He said he was unaware if any staff member saw Resident #3 grab his butt, but he hit him. Resident #5 said Resident #3 had not touched him since the incident. Resident #5 said he did not know what the facility did regarding the incident. He said nothing as far as he could tell and he took care of the problem himself. He said that he heard from other employees Resident #3 has touched other residents. During an interview on 10/4/17 at 3:38 p.m., Resident #3 said he did not recall touching Resident #5 on 9/30/17. He said he wheeled himself around in his wheelchair and sometimes his hand accidentally came off the wheels so he may have accidentally touched Resident #5. Resident #3 was very guarded in his conversation and had refused to speak to the surveyor during this investigation. During an interview on 10/4/16 at 1:15 p.m., CNA A said she heard Resident #5 yell and then he slapped Resident #3. She said Resident #5 said Resident #3 would not stop grabbing his butt and he had told him to stop. CNA A said Resident #5 was usually walking around the facility. During an interview on 10/4/17 at 2:35 p.m., LVN I said over the weekend Resident #3 touched Resident #5 on the butt and the Resident #5 back handed him. LVN I said she was not aware of any special precautions or monitoring for either resident. During an interview on 10/4/17 at 3:04 p.m., CNA H said there was an incident where Resident #3 went by Resident #5 and touched him on the buttock. CNA H said she was not for sure if Resident #3 touched him or not but there was no need for Resident #3 to be that close to Resident #5. She said Resident #5 told Resident #3 I need you to stop touching my ass. CNA H said Resident #5 accused Resident #3 of touching his buttocks several times and Resident #5 was visibly upset by the incident. During an interview on 10/4/17 at 3:37 p.m., the ADON said Resident #5 never bothered anyone, but he hit Resident #3. The ADON said Resident #5 said he hit Resident #3 because Resident #3 touched his butt. The ADON said she was not a part of the investigation into the incident. She said she was not aware of either resident being on monitoring. During an interview on 10/6/17 at 9:59 a.m., the administrator said with recent allegations involving Resident #3 he was going to be monitored and the next thing he did, he would be discharged . The undated facility Prevention and Reporting of Suspected Resident Abuse and Neglect policy indicated: .Prevention- Ensure that prevention techniques are implemented in the facility. Identify, correct and intervene in situations where abuse and or neglect are more likely to occur. This includes an analysis of secluded areas of the facility; sufficient staffing on each shift to meet the needs of the residents; assigned staff demonstrate knowledge of individual resident needs; sufficient and appropriate supervisory staff to identify resident with needs and behaviors which might lead to conflict or neglect. Protection: Upon identification of suspected abuse or neglect, provide for immediate safety of the resident. Means of providing protection may include, but not limited to: moving resident to another room or unit; provide one-on-one monitoring as appropriate. Investigation: investigation of all alleged violations will be done under the direction of the DON and Administrator. Reporting: the following types of incidents must be reported- Any suspicion of physical, verbal or sexual abuse. The policy defines sexual abuse as humiliation harassment, coercion, or assault. Sexual abuse is nonconsensual sexual contact of any type with a resident . On 10/5/17 at 2:20 p.m., the administrator and DON were informed that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/5/17 at 7:36 p.m., and included: On (MONTH) 30, (YEAR) a certified nursing aide was notified by a housekeeping person to come to Resident #2 room. When the Aide entered the room he witnessed Resident #1 in the process of inserting his hand into Resident #2 brief. The Aide removed Resident #1 from the room and notified the charge nurse. Charge nurse had the Aide move Resident #1 to another hall. Charge nurse performed a head to toe examine on Resident #2 and found no indication of injury. Charge nurse notified the Director of Nursing, both resident families, and the residents physician. Immediately, Resident #1 was placed on q (every) shift monitoring rounds until 10/5/2017 resident placed on 1:1 monitoring by a dedicated staff member until a plan of correction has been submitted and accepted by the state agency and alternate living arrangements can be made for him. Resident #2 will be is as close to the nurses station as we have available at this time. We have obtained permission from her mother to have her examined and the physician has written an order to send her to the emergency room tonight (10/5/2017). The alleged failure is as follows: -The facility allegedly failed to protect resident from suspected abuse and failed to implement policy related to suspected abuse. In-servicing/ education provided in response: 1. Facility policy on Abuse and Neglect Prevention and Reporting (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/5/2017 and will be completed on 10/6/2017. All employees currently on shift will pass a post-test to demonstrate competency/understanding. All other staff will be in-service before taking any assignment in the facility, regardless of department. 2. Wandering Policy (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/05/2017 and will be completed on 10/06/2017. All employees currently on shift will pass a post-test to demonstrate competency/understanding. All other staff will be in-serviced before taking any assignment in the facility, regardless of department worked. 3. Monitoring Residents (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/05/2017 and will be completed on 10/06/2017. All other staff will be in-serviced before taking any assignment, regardless of department. NOTE: all staff will be required to be in-serviced on the above topics and pass the post-test for #1 and #2 prior taking any assignment in the facility, regardless of department worked. The Medical Director/Physician was notified on 9/30/2017 at 1:09 p.m. Preventing Reoccurrence: -The facility will take reasonable steps to prevent alleged behavior for Resident #2 by seeking a roommate that has a protective personality and will be willing to alert staff or redirect anyone entering the room. -The facility will continue with 1:1 monitoring for resident (#1) until we have located alternate placement for him. The DON will assign a staff member for 1:1 each shift including alternates for breaks and lunch. The charge nurse on each shift will monitor that the staff member is in place as assign throughout each shift. The Activity Director will include additional activities for (Resident #1) in addition to those that are offered as group activities. -The facility will monitor and document Resident #3 and any other resident exhibiting inappropriate behaviors on a 72 hour protocol. Checks will occur q 30 minutes for 24 hours, q 1 hour for 24 hours, and q 2 hours for 24 (TRUNCATED)

Based on observation, interview, and record review, the facility failed develop and implement their written policies and procedures to prohibit mistreatment or neglect for 6 of 6 residents reviewed for neglect. (Residents #s 1, 2, 3, 4, 5,and 6) The facility did not implement interventions to protect Resident #2 from sexual assault by Resident #1. They did not implement interventions to ensure Resident #1 did not have access to Resident #2 or other vulnerable female residents. The facility did not protect Resident #s 4, 5, and 6 from unwanted sexual harassment and intimidation from Resident #3. An Immediate Jeopardy situation was identified on 10/5/17. The Immediate Jeopardy was removed on 10/6/17; however, the facility remained out of compliance at a pattern of actual harm, due to the facility's need to complete in-service training, revise their secure unit policy, and evaluate the effectiveness of the corrective systems. This failure could place the census of 69 residents at risk for abuse/neglect and possible harm. Findings included: The undated facility Prevention and Reporting of Suspected Resident Abuse and Neglect policy indicated: .Prevention- Ensure that prevention techniques are implemented in the facility. Identify, correct and intervene in situations where abuse and or neglect are more likely to occur. This includes an analysis of secluded areas of the facility; sufficient staffing on each shift to meet the needs of the residents; assigned staff demonstrate knowledge of individual resident needs; sufficient and appropriate supervisory staff to identify resident with needs and behaviors which might lead to conflict or neglect. Protection: Upon identification of suspected abuse or neglect, provide for immediate safety of the resident. Means of providing protection may include, but not limited to: moving resident to another room or unit; provide one-on-one monitoring as appropriate. Investigation: investigation of all alleged violations will be done under the direction of the DON and Administrator. Reporting: the following types of incidents must be reported- Any suspicion of physical, verbal or sexual abuse. The policy defines sexual abuse as humiliation harassment, coercion, or assault. Sexual abuse is nonconsensual sexual contact of any type with a resident . 1. Residents #1 and #2 A consolidated physician order [REDACTED].#2 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was severely cognitively impaired. She required extensive assist of two people with bed mobility and transfers. A care plan updated 10/3/17 indicated Resident #2 had communication problem related to [MEDICAL CONDITION] (unable to talk). The staff anticipated all of her needs. The resident was at risk for abuse as she could not communicate her needs. Some of the interventions were to observe who was going into her room, particularly males and observe for physical indicators of discomfort or distress. Resident #2 had problems of impaired cognitive function/dementia or impaired thought processes related to neurological symptoms ([MEDICAL CONDITION]). All decision making for the resident was anticipated and completed by staff. All of Resident #2's ADLs were anticipated and provided by staff using total assistance of one to two members. A consolidated physician order [REDACTED].#1 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 8/30/17 indicated Resident #1 with behavior problems related to anxiety. Some of the interventions were to observe for aggressive behavior, and intervene as necessary to protect the rights and safety of others. Resident #1 had long and short term memory problems. He needed verbal cues, redirection, and supervision. A care plan dated 8/22/17 indicated Resident #1 had a diagnoiss of Alzheimer's with a history of wondering throughout the facility without purpose. A physician note dated 8/31/17 indicated Resident #1 was a long-term care resident he was recently transferred to the facility from another facility due to anger and physical abuse issues with staff. An MDS dated [DATE] indicated Resident #1's BIMs score was 9, indicating moderate cognitive impaired. He ambulated with a walker and required one limited assistance with transfers and walking. He required extensive assist with dressing and supervision with eating. The MDS did not indicated any mood or behavior issues. Nursing notes for Resident #1 indicated: *9/27/17 at 1:50 a.m., the resident's wandering at night had increased and safety is now a major concern due to leaving walker. The resident stated, you might as well kill me before making me a punk. *9/30/17 at 1:53 p.m., the resident was noted standing over another resident with his hand in her brief. He was removed from the room and moved to another hall. An incident report dated 9/30/17 indicated CNA D was called to Resident #2's room and Resident #1 was standing over her with his hand in her brief. The CNA asked the resident what he was doing and he said, I am working her out. Resident #1 was removed from the room and the nurse was notified. Resident #1 was moved to another hall and he was scheduled to see a psychologist and the pharmacy was to evaluate his medications. A care plan dated 10/2/17 indicated Resident #1 had a tendency to be sexually inappropriate. Some of the interventions were to monitor and document inappropriate sexual behaviors and monitor the behaviors. During an interview on 10/4/17 at 2:07 p.m., Housekeeper F (with interpreter) said she was walking down the hall on 9/30/17 and saw Resident #1 in Resident #2's room. She said she stopped and looked around the corner of the door because she was shocked at what she saw. Housekeeper F said Resident #1 was standing over Resident 2's bed rubbing her breast. She said Resident #2 had clothes on the top portion of her body; however, her brief was removed and Resident #1 had his hand in her vaginal area rubbing in and out (she made hand motions of back and forth). The housekeeper said she got CNA D's attention and he came to the room and removed Resident #1. During an interview on 10/4/17 at 1:44 p.m., CNA D said he witnessed a sexual assault on 9/30/17. He said a housekeeper asked him to come and look while she was standing outside of Resident #2's room. He said Resident #2 was in her bed and Resident #1 had removed Resident #2's brief and was inserting his fingers into her vagina. CNA D said Resident #1 said he was working her out, referring to Resident #2. CNA D said he saw Resident #2's fingers in Resident #2's vagina. He said Resident #2 had a bowel movement and Resident #1 had bowel movement on his hands and under his nails. CNA D said he escorted Resident #1 out of the room. He said Resident #2 could not communicate, she could only lie there in bed. CNA D said he wrote a statement about the incident that occurred on 9/30/17. He said Resident #1 was not on any kind of special monitoring. He said they did not have time to watch Resident #1 because they had to provide care to the other residents on that hall. CNA D said they had several residents who required two person transfers and the two aides on the hall were in the rooms. He said if one aid was providing a shower, the other aide was answering call lights. He said there was no way they could monitor Resident #1's movements. During an interview on 10/4/17 at 1:53 p.m., LVN E said she was called to Resident #2's room and informed by CNA D Resident #1 his had in Resident #2's brief. LVN E said the housekeeper indicated she saw something going on and called CNA D to come quick. LVN E said she assessed Resident #2 and did not see any trauma, bruising, redness, or tears. She said Resident #2 was not able to voice any concerns. She said Resident #2 was not able to verbalize, she could only make noises. LVN E said she was not aware of Resident #1 having any prior behaviors and was not on any special precautions. She said Resident #1 had dementia and was moved to another hall the same day of the incident. During an interview on 10/4/16 at 1:20 p.m., CNA A said LVN C said to keep Resident #1 off Hall A after the incident on 9/30/17 because the housekeeper caught Resident #1 with 4 fingers inside of Resident #2's vagina. CNA A said when Resident #1 was asked what he was doing, he said he was working her out. She said Resident #1 was moved to another hall. During an interview on 10/4/17 at 3:04 p.m., CNA H said Resident #1 wandered the halls looking in rooms. CNA H said she heard CNA D informed LVN E Resident #1 sexually assaulted Resident #2. CNA H said the housekeeper told her she saw Resident #1 with 4 fingers going in out of Resident #2s vaginal area. She said she worked hall A and no one had informed her if Resident #1 was on any special precautions. CNA H said they had to provide care to other residents on the hall that were two person assist and could not watch Resident #1's whereabouts. During an interview on 10/4/17 at 3:37 p.m., the ADON said Resident #1 was moved off the A hall after the incident with Resident #2. She said Resident #2's level of supervision was increased. The ADON said there was nothing in writing, but staff were told verbally to watch Resident #1 closely and know where he was at all times. She said Resident #1 was to be redirected if they saw him headed to the A hall. The ADON said there was no way to know how frequently he was being monitored, but everyone was to be on the lookout for him. She said Resident #1 may have thought he was changing Resident #2 because she looks like a baby. She did not think any other residents were interviewed to see if he had gone in their rooms. During an interview on 10/5/17 at 10:30 a.m., Resident #1 said he did something stupid. He said he may have touched somebody, but he did not remember it. He said he has had sex at least once since he was admitted to the facility. He also said there was a bunch of the women in the facility that want to be naked with him, but he had to tell them no. During an interview on 10/4/17 at 8:13 p.m., Resident #2's mom said the facility notified her of an incident where a demented male resident had touched her daughter inappropriately. She said about a year ago some other man with dementia had touched he daughter on the breast. During an interview on 10/4/17 at 3:41 p.m., the social worker said she was told Monday (10/2/17) Resident #1 had his hand in Resident #2's brief. She said Resident #1 had dementia and was a wanderer. She said sometimes Resident #1 was more confused than at others and his behaviors were worse in the afternoon. The social worker said Resident #1 could not remember the incident with Resident #2. She said Resident #2 could not communicate, but she could show distress. Nursing notes for Resident #1 included: *10/2/17 at 2:52 a.m., Resident continued to try and go down the A hall and was frequently redirected *10/2/17 at 1:56 p.m., resident was trying to go to the other hallway, but was easily redirected. The notes indicated to continue to closely monitor Resident #1. *10/4/17 at 4:39 a.m., resident began wandering around midnight, he had to be redirected from hall A. The note indicated he went into the dining area and used coffee machine to fill several cups of coffee and then dumped them in the sink. He was redirected and returned to his room about 4 a.m. and went to bed. Will continue to monitor. A social services noted dated 10/4/17 at 4:26 p.m. indicated on 9/30/17 Resident #1 was found in a female resident's room with his hand in her brief. The social worker spoke to Resident #1 and he did not recall the incident. Staff immediately moved him to another room. The DON and the social worker decided to make a referral to the psychologist to have him evaluated today 10/4/17. During a continuous observation on 10/5/17 at 10:52 a.m. to 11 a.m., Resident #1 was seen coming out of his room and ambulating down the hallway. There were no staff in sight and no nurses at the nursing station. At 11:00 a.m. there were still no staff on the hallway and Resident #1 went into the dining room. During an interview on 10/5/17 at 1:20 p.m., the administrator said Resident #1 was found in Resident #2's room trying to insert his hand in Resident #2's brief. The administrator said Resident #1 was stopped before anything happened. She said Resident #1 had behaviors of wandering and the staff were keeping a constant eye on him. The administrator said Resident #1 was not on one to one monitoring, but they (staff) were paying more attention to him now. She said they were aware of Resident #1's movements, but there was no documentation of the monitoring and no one assigned to him specifically. She said she would have reported the incident to the state, but his BIMs score was a 4 and he was totally confused. During an interview on 10/5/17 at 1:32 p.m., the DON said there was no particular staff assigned to Resident #1 and there was no documentation on his monitoring. The DON said they moved Resident #1 to another hall following the incident involving Resident #2. She said they did not think it was abuse because Resident #1's BIMs score was low and he was confused. The DON said there was no intent and she did not conduct an investigation. She said they were only trying to protect Resident #2. 2. Residents #3 and #4 Consolidated physician orders [REDACTED].#3 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #3 had a BIMs score of 11 indicating moderate cognitive impairment. There were no indications of any mood or behavior issues. He required limited assistance with transfer and mobility. He did not walk, but used a wheelchair for mobility. A care plan dated 8/16/17 indicated Resident #3 had the potential to demonstrate verbal and physical behaviors related to mood disorder. The care plan indicated he was arguing with his roommate and threw a pillow at him and therefore was moved from his room to another room. Consolidated physician orders [REDACTED].#4 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #4 had a BIMS score of 15, with no indication of cognitive impairment. There were no indications of any mood or behavior issues. Resident # 4 required no assistance with transfers with limited assist with dressing and supervision with hygiene. An incident report dated 8/16/17 at 5:57 a.m. indicated Resident #3 was heard yelling at his roommate Resident #4. Resident #4 was sitting in the hallway taking things off the linen cart, as if he was taking out his frustrations. It was obvious the two roommates were in a heated argument. Resident #3 said Resident #4 turned on the light and it made him angry so he turned on his television. The nurse and aides tried talking to the residents and finally thought they were calmed down. Residents #3 and #4 got into it again and Resident #4 moved a chair out into the hall and sat down. Once again things got quiet for a minute and then Resident #3 threw a pillow at Resident #4. The residents were separated. Resident #3 agreed to move to another room. A nursing note dated 8/16/17 for Resident #4 indicated at 6:22 a.m., Resident #3 and #4 got into argument in their room and things got a little escalated. They were yelling and throwing pillows back and forth. There was a second incident, they started at each other we thought it best to separate the two residents. Resident #3 agreed to move to another room until the day shift could come and straighten things out. A nursing note at 2:09 p.m. indicated staff reported to the nurse Resident #4 barricaded himself in his room by putting furniture against the door. When they tried to enter and he told staff that he did not want to go out to bingo, it was reported to the social worker. A social worker note dated 8/16/17 indicated at 3:12 p.m. she went down and tried to go into Resident #4's room, but the door was barricaded and he refused to open it. After several attempts, Resident #4 finally allowed her to come into the room. Resident #4 said he did not want his roommate Resident #3 back in his room. The social worker note indicated Resident #4 did not say what happened, he just said he did not want Resident #3 back in the room. A nursing note dated 8/16/17 at 10:22 p.m. indicated Resident #4 agreed to allow staff in his room to remove Resident # 3's items from the room. Resident #4 removed the chairs and dresser from behind the door. A social services note dated 9/11/17 indicated Resident #4 had no difficulty focusing his attention when observed and no disorganized thinking noted. There was no altered level of consciousness observed and no evident of acute change in mental status from the baseline. Resident #4 did not have any potential indicators of [MEDICAL CONDITION]. A Quarterly activity note dated 9/16/17 indicated Resident #4's activity attendance since the last review has dropped. The group activity and events participation have dropped due to issues with another resident, but were starting to pick them back up slowly. The resident's favorite activity was bingo, music, food, beverages, movies and social hour. A care plan updated on 10/1/17 indicated Resident #3 initiated verbal aggression toward another resident after the resident asked him to stop following her and accused of him of glaring at her inappropriately. Some of the interventions included: to observe behaviors and attempt interventions. The care plan indicated Resident #3 had been accused on more than one occasion of being sexually inappropriate with other residents. One of the interventions was to monitor and document inappropriate sexual behaviors with an initiation date of 10/2/17. During an interview on 10/4/17 at 12:25 p.m., Resident #4 said his former roommate Resident #3 was mean to him and would keep him up at night bothering him. He would not explain what was bothering him and refused to answer any more questions. During an interview on 10/4/17 at 2:35 p.m., LVN I said Resident #4 stayed to himself and was a pleasant man. She said Resident #3 was Resident #4's last roommate at one time. LVN I said Resident #3 and #4 got into an argument because Resident #3 made sexual advances towards Resident #4. She said she did not know if Resident #3 actually touched him or not. She said since the altercation, Resident #4 was very withdrawn and would barricade the door to his room and not let anyone in. She said Resident #4 moved the furniture around in his room and put the dresser in front to of the doorway. LVN I said recently, Resident #4 started coming out of his room and interacting a little more, but he would not stay long. During an interview on 10/4/17 at 3:04 p.m. CNA H said about a month ago Resident #4 told one of the nurses Resident #3 tried to get in bed on top of him. CNA H said all of the administrative staff were aware because they all talked about the incident. She said after the incident Resident #4 would barricade himself in room with his dresser behind the door and not let anyone in. She said the administrative staff knew about the incident and talked about it and said that Resident #3 had a [MEDICAL CONDITION]. CNA H said she had not seen Resident #3 be sexually inappropriate with anyone. During an interview on 10/4/17 at 3:37 p.m., the ADON said they did not know why the incident with Resident #3 and Resident #4 occurred; however, they heard a staff member say it was sexual. She said the same day of the incident Resident #3 moved and the next day Resident # 4 barricaded the door. She said Resident #4 said he was not letting anyone in and said he had never exhibited that type of behavior. During an interview on 10/4/17 at 3:38 p.m., Resident # 3 said he was roommates with Resident #4 and the facility moved him. Resident #3 said he had no idea why he was moved. During an interview on 10/4/16 at 1:09 p.m., CNA A said Resident #4 reported to the ADON and social worker he was asleep and Resident #3 was trying to mess with his bottom. She said the two residents got into an argument. CNA A said she did not think it was reported. CNA A said Resident #4 used to always come out of his room and participate in activities, but since the incident with Resident #3, Resident #4 just sat in his room. She said Resident #4 was not the same person. She said now if they went into Resident #4's room, he would get up out of bed quickly. During an interview on 10/4/17 at 2:50 p.m., CNA G said she had a good relationship with Resident #4. She said she did not know what occurred when Resident #3 was his roommate, but it really upset him. She said after the incident Resident#4 was at the nursing station and was frightened (visibly shaking) and wanted to know why Resident #3 was still in the facility. She said Resident #4 weighed about 135 pounds and Resident 3 was about 6 feet tall and weighed about 250. During an interview on 10/4/17 at 3:41 p.m., the social worker said when the incident occurred with Residents #3 and #4, Resident #4 would not say what happened. The social worker said Resident #4 would only say Resident #3 kept him up at night. During an interview on 10/4/17 at 2:31 p.m., the DON said Resident #3 and Resident #4 were roommates and had a verbal altercation; however, neither one said what was the problem. She said one of the residents threw a pillow at the other. The DON said Resident #4 did not want Resident #3 on that hall. She said Resident #4 was a longtime resident and never had any problems before or after this incident with Resident #3. The DON said after the incident Resident #4 would barricade himself in his room. She said Resident #3 is a young man with a [MEDICAL CONDITION] and may be gay. The DON said she was not aware of any sexual inappropriate behaviors that may have occurred involving Resident #3. She said she did not speak to either resident about the incident. She did not ask Resident #4 why he barricaded himself in the room. During an interview on 10/6/17 at 9:59 a.m., the administrator said she was not aware of what occurred between Resident #3 and Resident #4. She said from what she knew, Resident #4 was upset because Resident #3 turned his television up loud and he could not sleep. 3. Residents #3 and #5 A consolidated physician order [REDACTED].#5 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #5 had a BIMs score of 15 indicating no cognitive impairment. There was no indication of any issues with mood or behaviors. He was also listed as independent with all ADLs. A care plan dated 9/30/17 indicated Resident #5 had the potential to demonstrate verbal/physical behaviors of hitting other residents. Nursing notes dated 9/30/17 at 3:04 p.m. indicated Resident #3 was wheeling himself to the dining room and came right by Resident #5. Resident #5 said Resident #3 was trying to touch him on the butt and he hit Resident #3 on the back of the head. There were no injuries noted. During an interview on 10/4/17 at 1:53 p.m., LVN E said on 9/30/17 Resident #5 was standing at the nursing station and said Resident #3 tapped him on the butt. LVN E said Resident #5 hit Resident #3 upside the head and told him to stop touching his butt. She said Resident #5 said Resident #3 touched him once already that day in the laundry room. An incident report dated 9/30/17 indicated Resident #5 was standing at the nursing station and Resident #3 came by him. Resident #5 hit Resident #3 on the back of the head. Resident #5 said Resident #3 was trying to touch his butt in the dining room earlier and he was tired of him. During an interview on 10/4/17 at 2:40 p.m., the DON said she had not finished her investigation. She said she had not interviewed Resident #5 related to the incident on 9/30/17. She said Resident #3 said if he touched Resident #5's butt it was an accident. During an interview on 10/4/17 at 3:28 p.m. Resident #5 said on 9/30/17 he was sitting in the dining room and Resident #3 rolled by him in his wheelchair. He said as Resident #3 was rolling by him, he started messing with his butt by rubbing the side of his butt. He said he told Resident #3 to stop it, the resident did, and he rolled on by in his wheelchair. Resident #5 said he did not tell any staff member about him touching him on his butt because he did not see it as an issue yet. He said later on that day, he was standing by the nursing station and Resident #3 came up behind him and grabbed his butt. He said when Resident #3 did this, he turned around and knocked the hell out him. He said he was unaware if any staff member saw Resident #3 grab his ass, but he hit him. Resident #5 said Resident #3 had not touched him since the incident. Resident #5 said he did not know what the facility did regarding the incident. He said nothing as far as he could tell and he took care of the problem himself. He said he heard from other employees Resident #3 has touched other residents. During an interview on 10/4/17 at 3:38 p.m., Resident #3 said he did not recall touching Resident #5 on 9/30/17. He said he wheeled himself around in his wheelchair and sometimes his hand accidentally came off the wheels so he may have accidentally touched Resident #5. Resident #3 was very guarded in his conversation and had refused to speak to the surveyor during this investigation. During an interview on 10/4/16 at 1:15 p.m., CNA A said she heard Resident #5 yell and then he slapped Resident #3. She said Resident #5 said Resident #3 would not stop grabbing his butt and he had told him to stop. CNA A said Resident #5 was usually walking around the facility. During an interview on 10/4/17 at 2:35 p.m., LVN I said over the weekend Resident #3 touched Resident #5 on the butt and the Resident #5 back handed him. LVN I said she was not aware of any special precautions or monitoring for either resident. During an interview on 10/4/17 at 3:04 p.m., CNA H said there was an incident where Resident #3 went by Resident #5 and touched him on the buttock. CNA H said she was not for sure if Resident #3 touched him or not but there was no need for Resident #3 to be that close to Resident #5. She said Resident #5 told Resident #3 I need you to stop touching my ass. CNA H said Resident #5 accused Resident #3 of touching his buttock several times and Resident #5 was visibly upset by the incident. During an interview on 10/4/17 at 3:37 p.m., the ADON said Resident #5 never bothered anyone but he hit Resident #3. The ADON said Resident #5 said he hit Resident #3 because Resident #3 touched his butt. The ADON said she was not a part of the investigation, into the incident. She said she was not aware of either resident being on monitoring. During an interview on 10/6/17 at 9:59 a.m., the administrator said with recent allegations about Resident #3 he was going to be monitored and the next thing he did, he would be discharged . 4. Resident #3 and #6 A consolidated physician order [REDACTED].#6 was a [AGE] year old female admitted [DATE]. She had [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #6 was severely cognitively impaired and had symptoms of [MEDICAL CONDITION] related to inattention. The MDS indicated the resident's inattention was present, but came and went and changed in severity. A nursing note dated 10/1/17 at 1:15 p.m. indicated Resident #3 was passing by a female resident and glared at her. The note indicated the female resident asked Resident #3 to stop following her. Resident #3 turned around in his wheelchair and followed her to the nursing station and began to curse the female resident demanding she shut the F*** up. Resident #3 began wheeling in her direction in a threatening and intimidating manner. The staff intervened. A nursing note dated 10/1/17 at 1:15 p.m. indicated Resident #6 said Resident #3 was following her around the facility. During an interview on 10/4/17 at 2:35 p.m., LVN I said Resident #6 said Resident #3 was looking at her as if he wanted to pounce (sexual manner) on her and they got into a verbal argument a few days ago. A social services note dated 10/4/17 at 4:01 p.m. indicated Resident #3 was asked if he wanted to see a psychologist and he refused. The family member was called and Resident #3's placement in a behavior unit was discussed. During an interview on 10/6/17 at 9:59 a.m. the administrator said she was not aware of what occurred between Resident #3 and Resident #6. She said it was brought to her attention by the surveyor yesterday (10/5/17). The administrator said Resident #6 was confused on occasion. She said if she kept on getting complaints about Resident #3 and sexually inappropriate behaviors, he would be discharged . On 10/5/17 at 2:20 p.m., the administrator and DON were informed that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/5/17 at 7:36 p.m., and included: On (MONTH) 30, (YEAR) a certified nursing aide was notified by a housekeeping person to come to Resident #2 room. When the Aide entered the room he witnessed Resident #1 in the process of inserting his hand into Resident #2 brief. The Aide removed Resident #1 from the room and notified the charge nurse. Charge nurse had the Aide move Resident #1 to another hall. Charge nurse performed a head to toe examine on Resident #2 and found no indication of injury. Charge nurse notified the Director of Nursing, both resident families, and the residents physician. Immediately, Resident #1 was placed on q (every) shift monitoring rounds until 10/5/2017 resident placed on 1:1 monitoring by a dedicated staff member until a plan of correction has been submitted and accepted by the state agency and alternate living arrangements can be made for him. Resident #2 will be is as close to the nurses station as we have available at this time. We have obtained permission from her mother to have her examined and the physician has written an order to send her to the emergency room tonight (10/5/2017). The alleged failure is as follows: -The facility allegedly failed to protect resident from suspected abuse and failed to implement policy related to suspected abuse. In-servicing/ education provided in response: 1. Facility policy on Abuse and Neglect Prevention and Reporting (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/5/2017 and will be completed on 10/6/2017. All employees currently on shift will pass a post-test to demonstrate competency/understanding. All other staff will be in-service before taking any assignment in the facility, regardless of department. 2. Wandering Policy (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/05/2017 and will be completed on 10/06/2017. All employees currently on shift will pass a post-test to demonstrate competency/understanding. All other staff will be in-serviced before taking any assignment in the facility, regardless of department worked. 3. Monitoring Residents (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/05/2017 and will be

Based on observation, interview, and record review, the facility failed develop and implement their written policies and procedures to prohibit mistreatment and neglect for 5 of 6 residents reviewed for neglect. (Residents #s 1, 2, 3, 4, and 5) The facility did not immediately report an incident involving Resident #1 sexually assaulting Resident #2 to the administrator and did not conduct a thorough investigation of the incident. The facility did not report the incident to the state agency and did not protect Resident #2 and other female residents from possible assault. The facility did not immediately report an incident involving Resident #3 allegedly inappropriately touching Resident #4 to the administrator, did not thoroughly investigate the incident, and did not protect Resident #4 or other residents from further sexual assault. The facility did not thoroughly investigate an incident involving Resident #3 inappropriately touching Resident #5 and did not protect Resident #5 or other residents from sexual assault. An Immediate Jeopardy situation was identified on 10/5/17. The Immediate Jeopardy was removed on 10/6/17; however, the facility remained out of compliance at a pattern of actual harm, due to the facility's need to complete in-service training, revise their secure unit policy, and evaluate the effectiveness of the corrective systems. This failure could place the census of 69 residents at risk for abuse/neglect and possible harm. Findings included: The undated facility Prevention and Reporting of Suspected Resident Abuse and Neglect policy indicated: .Prevention- Ensure that prevention techniques are implemented in the facility. Identify, correct and intervene in situations where abuse and or neglect are more likely to occur. This includes an analysis of secluded areas of the facility; sufficient staffing on each shift to meet the needs of the residents; assigned staff demonstrate knowledge of individual resident needs; sufficient and appropriate supervisory staff to identify resident with needs and behaviors which might lead to conflict or neglect. Protection: Upon identification of suspected abuse or neglect, provide for immediate safety of the resident. Means of providing protection may include, but not limited to: moving resident to another room or unit; provide one-on-one monitoring as appropriate. Investigation: investigation of all alleged violations will be done under the direction of the DON and Administrator. Reporting: the following types of incidents must be reported- Any suspicion of physical, verbal or sexual abuse. The policy defines sexual abuse as humiliation harassment, coercion, or assault. Sexual abuse is nonconsensual sexual contact of any type with a resident . 1. Residents #1 and #2 A consolidated physician order [REDACTED].#2 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was severely cognitively impaired. She required extensive assist of two people with bed mobility and transfers. A care plan updated 10/3/17 indicated Resident #2 had communication problem related to [MEDICAL CONDITION] (unable to talk). The staff anticipated all of her needs. The resident was at risk for abuse as she could not communicate her needs. Some of the interventions were to observe who was going into her room, particularly males and observe for physical indicators of discomfort or distress. Resident #2 had problems of impaired cognitive function/dementia or impaired thought processes related to neurological symptoms ([MEDICAL CONDITION]). All decision making for the resident was anticipated and completed by staff. All of Resident #2's ADLs were anticipated and provided by staff using total assistance of one to two members. A consolidated physician order [REDACTED].#1 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 8/30/17 indicated Resident #1 with behavior problems related to anxiety. Some of the interventions were to observe for aggressive behavior, and intervene as necessary to protect the rights and safety of others. Resident #1 had long and short term memory problems. He needed verbal cues, redirection, and supervision. A care plan dated 8/22/17 indicated Resident #1 had a diagnoiss of Alzheimer's with a history of wondering throughout the facility without purpose. A physician note dated 8/31/17 indicated Resident #1 was a long-term care resident he was recently transferred to the facility from another facility due to anger and physical abuse issues with staff. An MDS dated [DATE] indicated Resident #1's BIM's score was 9, indicating moderate cognitive impaired. He ambulated with a walker and required one limited assistance with transfers and walking. He required extensive assist with dressing and supervision with eating. The MDS did not indicated any mood or behavior issues. Nursing notes for Resident #1 indicated: *9/27/17 at 1:50 a.m., the resident's wandering at night had increased and safety is now a major concern due to leaving walker. The resident stated, you might as well kill me before making me a punk. *9/30/17 at 1:53 p.m., the resident was noted standing over another resident with his hand in her brief. He was removed from the room and moved to another hall. An incident report dated 9/30/17 indicated CNA D was called to Resident #2's room and Resident #1 was standing over her with his hand in her brief. The CNA asked the resident what he was doing and he said, I am working her out. Resident #1 was removed from the room and the nurse was notified. Resident #1 was moved to another hall and he was scheduled to see a psychologist and the pharmacy was to evaluate his medications. A care plan dated 10/2/17 indicated Resident #1 had a tendency to be sexually inappropriate. Some of the interventions were to monitor and document inappropriate sexual behaviors a monitor the behaviors. During an interview on 10/4/17 at 2:07 p.m., Housekeeper F (with interpreter) said she was walking down the hall on 9/30/17 and saw Resident #1 in Resident #2's room. She said she stopped and looked around the corner of the door because she was shocked at what she saw. Housekeeper F said Resident #1 was standing over Resident 2's bed rubbing her breast. She said Resident #2 had clothes on the top portion of her body; however, her brief was removed and Resident #1 had his hand in her vaginal area rubbing in and out (she made hand motions of back and forth). The housekeeper said she got CNA D's attention and he came to the room and removed Resident #1. During an interview on 10/4/17 at 1:44 p.m., CNA D said he witnessed a sexual assault on 9/30/17. He said a housekeeper asked him to come and look while she was standing outside of Resident #2's room. He said Resident #2 was in her bed and Resident #1 had removed Resident #2's brief and was inserting his fingers into her vagina. CNA D said Resident #1 said he was working her out, referring to Resident #2. CNA D said he saw Resident #2's fingers in Resident #2's vagina. He said Resident #2 had a bowel movement and Resident #1 had bowel movement on his hands and under his nails. CNA D said he escorted Resident #1 out of the room. He said Resident #2 could not communicate, she could only lie there in bed. CNA D said he wrote a statement about the incident that occurred on 9/30/17. He said Resident #1 was not on any kind of special monitoring. He said they did not have time to watch Resident #1 because they had to provide care to the other residents on that hall. CNA D said they had several residents who required two person transfers and the two aides on the hall were in the rooms. He said if one aid was providing a shower, the other aide was answering call lights. He said there was no way they could monitor Resident #1's movements. During an interview on 10/4/17 at 1:53 p.m., LVN E said she was called to Resident #2's room and informed by CNA D Resident #1 had his hand in Resident #2's brief. LVN E said the housekeeper indicated she saw something going on and called CNA D to come quick. LVN E said she assessed Resident #2 and did not see any trauma, bruising, redness, or tears. She said Resident #2 was not able to voice any concerns. She said Resident #2 was not able to verbalize, she could only make noises. LVN E said she was not aware of Resident #1 having any prior behaviors and was not on any special precautions. She said Resident #1 had dementia and was moved to another hall the same day of the incident. During an interview on 10/4/16 at 1:20 p.m., CNA A said LVN C said to keep Resident #1 off Hall A after the incident on 9/30/17 because the housekeeper caught Resident #1 with 4 fingers inside of Resident #2's vagina. CNA A said when Resident #1 was asked what he was doing, he said he was working her out. She said Resident #1 was moved to another hall. During an interview on 10/4/17 at 3:04 p.m., CNA H said Resident #1 wandered the halls looking in rooms. CNA H said she heard CNA D informed LVN E Resident #1 sexually assaulted Resident #2. CNA H said the housekeeper told her she saw Resident #1 with 4 fingers going in out of Resident #2s vaginal area. She said she worked hall A and no one had informed her if Resident #1 was on any special precautions. CNA H said they had to provide care to other residents on the hall that were two person assist and could not watch Resident #1's whereabouts. During an interview on 10/4/17 at 3:37 p.m., the ADON said Resident #1 was moved off the A hall after the incident with Resident #2. She said Resident #2's level of supervision was increased. The ADON said there was nothing in writing, but staff were told verbally to watch Resident #1 closely and know where he was at all times. She said Resident #1 was to be redirected if they saw him headed to the A hall. The ADON said there was no way to know how frequently he was being monitored, but everyone was to be on the lookout for him. She said Resident #1 may have thought he was changing Resident #2 because she looks like a baby. She did not think any other residents were interviewed to see if he had gone in their rooms. During an interview on 10/5/17 at 10:30 a.m., Resident #1 said he did something stupid. He said he may have touched somebody, but he did not remember it. He said he has had sex at least once since he was admitted to the facility. He also said there was a bunch of the women in the facility that want to be naked with him, but he had to tell them no. During an interview on 10/4/17 at 8:13 p.m., Resident #2's mom said the facility notified her of an incident where a demented male resident had touched her daughter inappropriately. She said about a year ago some other man with dementia had touched he daughter on the breast. During an interview on 10/4/17 at 3:41 p.m., the social worker said she was told Monday (10/2/17) Resident #1 had his hand in Resident #2's brief. She said Resident #1 had dementia and was a wanderer. She said sometimes Resident #1 was more confused than at others and his behaviors were worse in the afternoon. The social worker said Resident #1 could not remember the incident with Resident #2. She said Resident #2 could not communicate, but she could show distress. Nursing notes for Resident #1 included: *10/2/17 at 2:52 a.m., Resident continued to try and go down the A hall and was frequently redirected *10/2/17 at 1:56 p.m., resident was trying to go to the other hallway, but was easily redirected. The notes indicated to continue to closely monitor Resident #1. *10/4/17 at 4:39 a.m., resident began wandering around midnight, he had to be redirected from hall A. The note indicated he went into the dining area and used coffee machine to fill several cups of coffee and then dumped them in the sink. He was redirected and returned to his room about 4 a.m. and went to bed. Will continue to monitor. A social services noted dated 10/4/17 at 4:26 p.m. indicated on 9/30/17 Resident #1 was found in a female resident's room with his hand in her brief. The social worker spoke to Resident #1 and he did not recall the incident. Staff immediately moved him to another room. The DON and the social worker decided to make a referral to the psychologist to have him evaluated today 10/4/17. During a continuous observation on 10/5/17 at 10:52 a.m. to 11 a.m., Resident #1 was seen coming out of his room and ambulating down the hallway. There were no staff in sight and no nurses at the nursing station. At 11:00 a.m. there were still no staff on the hallway and Resident #1 went into the dining room. During an interview on 10/5/17 at 1:20 p.m., the administrator said Resident #1 was found in Resident #2's room trying to insert his hand in Resident #2's brief. The administrator said Resident #1 was stopped before anything happened. She said Resident #1 had behaviors of wandering and the staff were keeping a constant eye on him. The administrator said Resident #1 was not on one to one monitoring, but they (staff) were paying more attention to him now. She said they were aware of Resident #1's movements, but there was no documentation of the monitoring and no one assigned to him specifically. She said she would have reported the incident to the state, but his BIMs score was a 4 and he was totally confused. During an interview on 10/5/17 at 1:32 p.m., the DON said there was no particular staff assigned to Resident #1 and there was no documentation on his monitoring. The DON said they moved Resident #1 to another hall following the incident involving Resident #2. She said they did not think it was abuse because Resident #1's BIMs score was low and he was confused. The DON said there was no intent and she did not conduct an investigation. She said they were only trying to protect Resident #2. 2. Residents #3 and #4 Consolidated physician orders [REDACTED].#3 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #3 had a BIMs score of 11 indicating moderate cognitive impairment. There were no indications of any mood or behavior issues. He required limited assistance with transfer and mobility. He did not walk, but used a wheelchair for mobility. A care plan dated 8/16/17 indicated Resident #3 had the potential to demonstrate verbal and physical behaviors related to mood disorder. The care plan indicated he was arguing with his roommate and threw a pillow at him and therefore was moved from his room to another room. Consolidated physician orders [REDACTED].#4 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS date 9/13/17 indicated Resident #4 had a BIMS score of 15, with no indication of cognitive impairment. There were no indications of any mood or behavior issues. Resident #4 required no assistance with transfers with limited assist with dressing and supervision with hygiene. An incident report dated 8/16/17 at 5:57 a.m. indicated Resident #3 was heard yelling at his roommate Resident #4. Resident #4 was sitting in the hallway taking things off the linen cart, as if he was taking out his frustrations. It was obvious the two roommates were in a heated argument. Resident #3 said Resident #4 turned on the light and it made him angry so he turned on his television. The nurse and aides tried talking to the residents and finally thought they were calmed down. Residents #3 and #4 got into it again and Resident #4 moved a chair out into the hall and sat down. Once again things got quiet for a minute and then Resident #3 threw a pillow at Resident #4. The residents were separated. Resident #3 agreed to move to another room. A nursing note dated 8/16/17 for Resident #4 indicated at 6:22 a.m., Resident #3 and #4 got into argument in their room and things got a little escalated. They were yelling and throwing pillows back and forth. There was a second incident, they started at each other we thought it best to separate the two residents. Resident #3 agreed to move to another room until the day shift could come and straighten things out. A nursing note at 2:09 p.m. indicated staff reported to the nurse Resident #4 barricaded himself in his room by putting furniture against the door. When they tried to enter and he told staff that he did not want to go out to bingo, it was reported to the social worker. A social worker note dated 8/16/17 indicated at 3:12 p.m. she went down and tried to go into Resident #4's room, but the door was barricaded and he refused to open it. After several attempts, Resident #4 finally allowed her to come into the room. Resident #4 said he did not want his roommate Resident #3 back in his room. The social worker note indicated Resident #4 did not say what happened, he just said he did not want Resident #3 back in the room. A nursing note dated 8/16/17 at 10:22 p.m. indicated Resident #4 agreed to allow staff in his room to remove Resident # 3's items from the room. Resident #4 removed the chairs and dresser from behind the door. During an interview on 10/4/17 at 3:04 p.m., CNA H said about a month ago Resident #4 told one of the nurses Resident #3 tried to get in bed on top of him. CNA H said all of the administrative staff were aware because they all talked about the incident. She said after the incident Resident #4 would barricade himself in room with his dresser behind the door and not let anyone in. She said the administrative staff knew about the incident and talked about it and said that Resident #3 had a [MEDICAL CONDITION]. CNA H said she had not seen Resident #3 be sexually inappropriate with anyone. A social services note dated 9/11/17 indicated Resident #4 had no difficulty focusing his attention when observed and no disorganized thinking noted. There was no altered level of consciousness observed and no evident of acute change in mental status from the baseline. Resident #4 did not have any potential indicators of [MEDICAL CONDITION]. A Quarterly activity note dated 9/16/17 indicated Resident #4's activity attendance since the last review has dropped. The group activity and events participation have dropped due to issues with another resident, but were starting to pick them back up slowly. The resident's favorite activity was bingo, music, food, beverages, movies and social hour. A care plan updated on 10/1/17 indicated Resident #3 initiated verbal aggression toward another resident after the resident asked him to stop following her and accused of him of glaring at her inappropriately. Some of the interventions included: to observe behaviors and attempt interventions. The care plan indicated Resident #3 had been accused on more than one occasion of being sexually inappropriate with other residents. One of the interventions was to monitor and document inappropriate sexual behaviors with an initiation date of 10/2/17. During an interview on 10/4/17 at 12:25 p.m., Resident #4 said his former roommate Resident #3 was mean to him and would keep him up at night bothering him. He would not explain what bothering him consisted of and refused to answer any more questions. During an interview on 10/4/17 at 2:35 p.m., LVN I said Resident #4 stayed to himself and was a pleasant man. She said Resident #3 was Resident #4's last roommate at one time. LVN I said Resident #3 and #4 got into an argument because Resident #3 made sexual advances towards Resident #4. She said she did not know if Resident #3 actually touched him or not. She said since the altercation, Resident #4 was very withdrawn and would barricade the door to his room and not let anyone in. She said Resident #4 moved the furniture around in his room and put the dresser in front to of the doorway. LVN I said recently, Resident #4 started coming out of his room and interacting a little more, but he would not stay long. During an interview on 10/4/16 at 1:09 p.m., CNA A said Resident #4 reported to the ADON and social worker he was asleep and Resident #3 was trying to mess with his bottom. She said the two residents got into an argument. CNA A said she did not think it was reported. CNA A said Resident #4 used to always come out of his room and participate in activities, but since the incident with Resident #3, Resident #4 just sat in his room. She said Resident #4 was not the same person. She said now if they went into Resident #4's room, he would get up out of bed quickly. During an interview on 10/4/17 at 3:37 p.m., the ADON said they did not know why the incident with Resident #3 and Resident #4 occurred; however, they heard a staff member say it was sexual. She said the same day of the incident Resident #3 moved and the next day Resident #4 barricaded the door. She said Resident #4 said he was not letting anyone in and said he had never exhibited that type of behavior. During an interview on 10/4/17 at 3:38 p.m., Resident # 3 said he was roommates with Resident #4 and the facility moved him. Resident #3 said he had no idea why he was moved. During an interview on 10/4/17 at 2:50 p.m., CNA G said she had a good relationship with Resident #4. She said she did not know what occurred when Resident #3 was his roommate, but it really upset him. She said after the incident Resident#4 was at the nursing station and was frightened (visibly shaking) and wanted to know why Resident #3 was still in the facility. She said Resident #4 weighed about 135 pounds and Resident #3 was about 6 feet tall and weighed about 250. During an interview on 10/4/17 at 3:41 p.m., the social worker said when the incident occurred with Residents #3 and #4, Resident #4 would not say what happened. The social worker said Resident #4 would only say Resident #3 kept him up at night. During an interview on 10/4/17 at 2:31 p.m., the DON said Resident #3 and Resident #4 were roommates and had a verbal altercation; however, neither one said what was the problem. She said one of the residents threw a pillow at the other. The DON said Resident #4 did not want Resident #3 on that hall. She said Resident #4 was a longtime resident and never had any problems before or after this incident with Resident #3. The DON said after the incident Resident #4 would barricade himself in his room. She said Resident #3 is a young man with a [MEDICAL CONDITION] and may be gay. The DON said she was not aware of any sexual inappropriate behaviors that may have occurred involving Resident #3. She said she did not speak to either resident about the incident. She did not ask Resident #4 why he barricaded himself in the room. During an interview on 10/6/17 at 9:59 a.m., the administrator said she was not aware of what occurred between Resident #3 and Resident #4. She said from what she knew, Resident #4 was upset because Resident #3 turned his television up loud and he could not sleep. 3. Residents #3 and #5 A consolidated physician order [REDACTED].#5 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #5 had a BIMs score of 15 indicating no cognitive impairment. There was no indication of any issues with mood or behaviors. He was also listed as independent with all ADLs. A care plan dated 9/30/17 indicated Resident #5 had the potential to demonstrate verbal/physical behaviors of hitting other residents. Nursing notes dated 9/30/17 at 3:04 p.m. indicated Resident #3 was wheeling himself to the dining room and came right by Resident #5. Resident #5 said he was trying to touch him on the butt and hit Resident #3 on the back of the head. There were no injuries noted. During an interview on 10/4/17 at 1:53 p.m., LVN E said on 9/30/17 Resident #5 was standing at the nursing station and said Resident #3 tapped him on the butt. LVN E said Resident #5 hit Resident #3 upside the head and told him to stop touching his butt. She said Resident #5 said Resident #3 touched him once already that day in the laundry room. An incident report dated 9/30/17 indicated Resident #5 was standing at the nursing station and Resident #3 came by him. Resident #5 hit Resident #3 on the back of the head. Resident #5 said Resident #3 was trying to touch his butt in the dining room earlier and he was tired of him. During an interview on 10/4/17 at 2:40 p.m., the DON said she had not finished her investigation. She said she had not interviewed Resident #5 related to the incident on 9/30/17. She said Resident #3 said if he touched Resident #5's butt it was an accident. During an interview on 10/4/17 at 3:28 p.m. Resident #5 said on 9/30/17 he was sitting in the dining room and Resident #3 rolled by him in his wheelchair. He said as Resident #3 was rolling by him, he started messing with his butt by rubbing the side of it. He said he told Resident #3 to stop it, the resident did, and he rolled on by in his wheelchair. Resident #5 said he did not tell any staff member about him touching him on his butt because he did not see it as an issue yet. He said later on that day, he was standing by the nursing station and Resident #3 came up behind him and grabbed his butt. He said when Resident #3 did this, he turned around and knocked the hell out him. He said he was unaware if any staff member saw Resident #3 grab his butt, but he hit him. Resident #5 said Resident #3 had not touched him since the incident. Resident #5 said he did not know what the facility did regarding the incident. He said nothing as far as he could tell and he took care of the problem himself. He said that he heard from other employees Resident #3 has touched other residents. During an interview on 10/4/17 at 3:38 p.m., Resident #3 said he did not recall touching Resident #5 on 9/30/17. He said he wheeled himself around in his wheelchair and sometimes his hand accidentally came off the wheels so he may have accidentally touched Resident #5. Resident #3 was very guarded in his conversation and had refused to speak to the surveyor during this investigation. During an interview on 10/4/16 at 1:15 p.m., CNA A said she heard Resident #5 yell and then he slapped Resident #3. She said Resident #5 said Resident #3 would not stop grabbing his butt and he had told him to stop. CNA A said Resident #5 was usually walking around the facility. During an interview on 10/4/17 at 2:35 p.m., LVN I said over the weekend Resident #3 touched Resident #5 on the butt and the Resident #5 back handed him. LVN I said she was not aware of any special precautions or monitoring for either resident. During an interview on 10/4/17 at 3:04 p.m., CNA H said there was an incident where Resident #3 went by Resident #5 and touched him on the buttock. CNA H said she was not for sure if Resident #3 touched him or not but there was no need for Resident #3 to be that close to Resident #5. She said Resident #5 told Resident #3 I need you to stop touching my ass. CNA H said Resident #5 accused Resident #3 of touching his buttocks several times and Resident #5 was visibly upset by the incident. During an interview on 10/4/17 at 3:37 p.m., the ADON said Resident #5 never bothered anyone, but he hit Resident #3. The ADON said Resident #5 said he hit Resident #3 because Resident #3 touched his butt. The ADON said she was not a part of the investigation into the incident. She said she was not aware of either resident being on monitoring. During an interview on 10/6/17 at 9:59 a.m., the administrator said with recent allegations involving Resident #3 he was going to be monitored and the next thing he did, he would be discharged . On 10/5/17 at 2:20 p.m., the administrator and DON were informed that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/5/17 at 7:36 p.m., and included: On (MONTH) 30, (YEAR) a certified nursing aide was notified by a housekeeping person to come to Resident #2 room. When the Aide entered the room he witnessed Resident #1 in the process of inserting his hand into Resident #2 brief. The Aide removed Resident #1 from the room and notified the charge nurse. Charge nurse had the Aide move Resident #1 to another hall. Charge nurse performed a head to toe examine on Resident #2 and found no indication of injury. Charge nurse notified the Director of Nursing, both resident families, and the residents physician. Immediately, Resident #1 was placed on q (every) shift monitoring rounds until 10/5/2017 resident placed on 1:1 monitoring by a dedicated staff member until a plan of correction has been submitted and accepted by the state agency and alternate living arrangements can be made for him. Resident #2 will be is as close to the nurses station as we have available at this time. We have obtained permission from her mother to have her examined and the physician has written an order to send her to the emergency room tonight (10/5/2017). The alleged failure is as follows: -The facility allegedly failed to protect resident from suspected abuse and failed to implement policy related to suspected abuse. In-servicing/ education provided in response: 1. Facility policy on Abuse and Neglect Prevention and Reporting (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/5/2017 and will be completed on 10/6/2017. All employees currently on shift will pass a post-test to demonstrate competency/understanding. All other staff will be in-service before taking any assignment in the facility, regardless of department. 2. Wandering Policy (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/05/2017 and will be completed on 10/06/2017. All employees currently on shift will pass a post-test to demonstrate competency/understanding. All other staff will be in-serviced before taking any assignment in the facility, regardless of department worked. 3. Monitoring Residents (all employees currently on shift), monitored by Administrator and Director of Nursing. In-services began on 10/05/2017 and will be completed on 10/06/2017. All other staff will be in-serviced before taking any assignment, regardless of department. NOTE: all staff will be required to be in-serviced on the above topics and pass the post-test for #1 and #2 prior taking any assignment in the facility, regardless of department worked. The Medical Director/Physician was notified on 9/30/2017 at 1:09 p.m. Preventing Reoccurrence: -The facility will take reasonable steps to prevent alleged behavior for Resident #2 by seeking a roommate that has a protective personality and will be willing to alert staff or redirect anyone entering the room. -The facility will continue with 1:1 monitoring for resident (#1) until we have located alternate placement for him. The DON will assign a staff member for 1:1 each shift including alternates for breaks and lunch. The charge nurse on each shift will monitor that the staff member is in place as assign throughout each shift. The Activity Director will include additional activities for (Resident #1) in addition to those that are offered as group activities. -The facility will monitor and document Resident #3 and any other resident exhibiting inappropriate behaviors on a 72 hour protocol. Checks will occur q 30 minutes for 24 hours, q 1 hour for 24 hours, and q 2 hours for 24 hours. Upon completion of 72 hour protocol facility will evaluate findings and release resident from monitoring if no related behaviors have occurred. (sic) O (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 4 residents reviewed for accidents. (Resident #1) The facility did not provide adequate supervision for Resident #1 who sustained a hematoma on his forehead, a skin tear to his arm, and a fractured hip. No measures were taken to prevent further accidents. This failure could place 47 residents who required one or two staff assistance with transfers at risk for injury. The findings included: 1. Physician orders [REDACTED].#1's was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The latest MDS dated [DATE] indicated Resident #1 had severe cognitive impairment and required the extensive assistance of 2 or more staff for transfer. The most recent care plan dated 8/25/16 indicated Resident #1 had cognitive impairment, and functional limitations related to contractures and paralysis. The care plan indicated Resident #1 required the extensive assistance of one staff for transfer and bed mobility. The latest fall risk assessment dated [DATE] indicated Resident #1 was at high risk for falls. An incident/accident report dated 10/8/16 indicated CNA E reported to the nurse Resident #1 had a 2 centimeter skin tear on his right arm and a hematoma on his right forehead. The incident/accident report indicated CNA E denied knowing what happened to Resident #1. The hospital records dated 10/12/16 indicated Resident #1 admitted [DATE]. Records indicated .Apparently he fell today and found to have a right intertrochanteric hip fracture . Hospital records indicated he had a right lateral forehead injury from a possible fall. The records indicated Resident #1 required surgery on 10/13/16 on his right hip because of the fracture. The hospital records indicated .He apparently feel out of bed landing on his right hip . The records indicated .A large area of encephalomalacia involving the right temporal, occipital, and frontal lobes, with [DIAGNOSES REDACTED] of the right cerebral peduncle and ex vacuo dilatation of the right lateral ventricle. There is a low density subdural fluid collection along the right cerebral convexity measuring approximately 15 mm in thickness. There is minimal acute subdural hemorrhage along the posterior right occipital lobe extending along the posterior falx. There is minimal, approximately 2 to 3 mm of right to left midline shift . During an interview 10/15/16 at 9:50 a.m., the DON said Resident #1 was found with a hematoma on his forehead and a skin tear on his left arm on 10/8/16. She said Resident #1 had no bruising. She said on 10/12/16 hospice noted Resident #1's right foot was swollen and an x-ray indicated a right hip fracture. She said Resident #1 was sent to the hospital. The DON said Resident #1 was difficult to understand because he spoke mostly Spanish. She said no staff members were suspended after finding the hematoma on Resident #1's head or the skin tear on his left arm. The DON said no investigation was conducted and did not know what caused the hematoma or skin tear on Resident #1. She said on 10/7/16 during the 2:00 p.m. to 10:00 p.m., shift Resident #1 had no injuries. The DON said her opinion was Resident #1 probably fell . She said Resident #1 was a 2 person transfer with a Hoyer lift. She said Resident #1 could not have gotten back into bed by himself. During an interview 10/15/16 at 10:28 a.m., LVN C said she worked 10/7/16 on the day shift. She said she left the facility at approximately 2:00 p.m., and Resident #1 was fine. She said she went back to work 10/9/16 and Resident #1 had a hematoma on his forehead and a skin tear on his right forearm. She said the facility was still doing neurological checks when she got to work on 10/9/16 at approximately 6:00 a.m. LVN C said she thought Resident #1 fell out of bed and someone put him back in bed. Resident #1 had a low air loss mattress with bolsters. LVN C said Resident #1 was not interviewable. During an interview 10/15/16 at 10:42 a.m., LVN D said CNA E reported to her the morning of 10/8/16 Resident #1 had a bruise on his head and a skin tear on his right arm. She said she assessed him and believed the call light caused the skin tear on his arm because it was lying right next to his arm. She did not know what caused the bruise on his head. LVN D said Resident #1 probably fell , but did not know how he got back in his bed because he was unable to get back in bed by himself. She said she called the DON, physician, and the family to notify of Resident #1's injuries. During an interview 10/15/16 at 11:08 a.m., the hospice RN F said on 10/10/16 Resident #1 had a large hematoma on his right forehead and a skin tear on his left arm. She said she discussed Resident #1's injuries with ADON B. Hospice RN F said Resident #1's nursing notes did not say what had happened to Resident #1 to cause his injuries. She said Resident #1 did not have any noted injuries on 10/7/16 when the hospice aide bathed him. Hospice RN F said she did a head to toe assessment on Resident #1 and he had no bruising, and no signs or symptoms of pain or distress. She said on 10/11/16 when the hospice aide bathed him he had no signs or symptoms of pain or distress. She said on 10/12/16 the hospice aide reported swelling in Resident #1's foot and it was warm to the touch. Hospice RN F was unable to go see Resident #1 so she sent an LVN from hospice. The hospice LVN reported Resident #1's right side (leg) was swollen from the knee down, and warm to the touch. An x-ray resulted positive for right hip fracture and Resident #1 was sent to the hospital. RN F said Resident #1 told the hospice aide I fell under the bridge. Hospice RN F said she thought Resident #1 fell out of bed and someone put him back in bed. She said there was no way that Resident #1 could put himself back in bed. She said both of Resident #1's legs were contracted, his left hand was contracted, and he was bedbound. She said she thought Resident #1 was dropped or was injured with turning/repositioning and no one reported it. During an interview 10/15/16 at 11:37 a.m., CNA G said Resident #1 was a 2 person Hoyer lift transfer. She said he could talk and he spoke English and Spanish. She said she saw the bruise on his head on 10/9/16. She said he would not be able to get himself back in the bed if he fell out. During an interview 10/15/16 at 11:42 a.m., CNA H said Resident #1 was a 2 person Hoyer lift transfer. She said if he fell out of bed he could not get back into the bed because his legs were contracted. She did not see the bruise on his head. During an interview 10/15/16 at 11:48 a.m., RA J said Resident #1 was a 2 person Hoyer lift transfer. She said he did not talk. She said she had repositioned him in bed a few times. She said he scooted in the bed. RA J said the bolsters on his bed prevented him from falling out of bed. She said she did not see the bruise on Resident #1's head until 10/12/16. During an interview 10/15/16 at 12:04 p.m., CNA K said she took care of Resident #1 on 10/7/16 on the day shift. She said he was fine with no bruising or injuries when she left at approximately 2:00 p.m. She said Resident #1 required a 2 person Hoyer lift for transfer. She said he was a small man and easy to maneuver. CNA K said Resident #1 talked, but it was hard to understand him. She said he could not get back in bed by himself if he had fallen out. During an interview 10/15/16 at 12:05 p.m., LVN L said Resident #1 was not transferred during the evening shift on 10/7/16. She said he had no problems or injuries when she left 10/7/16 at approximately 10:00 p.m. During an interview 10/15/16 at 12:22 p.m., Resident #1's niece said he told her sister women dropped him. She said she thought his injuries were an accident, but someone should have reported it. During an interview 10/15/16 at 12:34 p.m., the case manager for the hospital said Resident #1 had a stroke in 2014 which left him paralyzed. She said Resident #1 only had 10-15 percent mobility in his right arm. She said Resident #1's brother visited the facility twice a day and fed him his meals. She said his brother went to the facility 10/8/16 and noted a knot on his forehead and a black right eye. The case manager said Resident #1 told his brother women dropped me when he asked what caused his injuries. She said the nursing home told Resident #1's brother he fell out of bed. She said on 10/10/16, Resident #1's brother noticed his right leg was swollen and Resident #1 told his brother it hurt. The case manager said she did not know if Resident #1's brother reported his conversation with the resident. During an interview 10/15/16 at 1:14 p.m., Resident #1 was lying in the hospital in his hospital bed. He had a black right eye and a dark bruise on his right forehead. Resident #1 said (with his niece interpreting) he did not remember what caused his injuries. He said he did not remember if the staff was nice, he did not remember how he got the black eye, and did not remember what happened to his hip. During an interview 10/16/16 at 9:17 a.m., LVN O said she did not work 10/8/16 - 10/9/16 but came back to work 10/10/16. She said Resident #1 had an injury and neurological checks were being done. She said Resident #1's level of consciousness did not change and he denied any pain. LVN O said she did not check his hips or his legs on 10/10/16, but should have done a head to toe assessment. During an interview 10/16/16 at 10:31 a.m., the hospice CNA P said at approximately noon on 10/10/16 she gave Resident #1 a bed bath. She said he had no complaints of pain and acted his normal self. Hospice CNA P said Resident #1 had a hematoma on his right forehead and a scrape on his right elbow. She said his right hip was swollen and she reported it to the facility nurse and hospice nurse. Hospice CNA P said she did not remember the name of facility nurse she told. Hospice CNA P said Resident #1 was confused, but told her he fell under the bridge. She said she asked him to explain, but he began shouting jibberish. Hospice CNA P said if Resident #1 fell out of bed he would not be able to get himself back in the bed due to bilateral leg contractures and left arm contracture. She said she was not aware of any prior falls Resident #1 had in the past. She said Resident #1 was unable to move and he could not scoot in the bed. The CMS 672 dated 10/15/16 indicated 47 residents required one or two staff assistance with transfers.