Every finding on record at Award Care at Beneva

Based on record review and interviews, the facility failed to ensure the care plan was updated with appropriate interventions after a significant change for 1 (Resident #1) of 3 residents reviewed for accidents/falls.The findings included:Review of the clinical record for Resident #1 revealed a progress note dated 7/8/26 which indicated the resident was complaining of pain and a discoloration was noted to the resident's right upper arm. The physician ordered an X-Ray which was obtained. Resident #1 continued to experience pain and was sent to the emergency room before the facility received the results of the X-Ray.A progress note dated 7/13/26 indicated that Resident #1 was discharged from the hospital and returned to the facility on 7/13/26. A Physician progress note dated 7/14/26 indicated Resident #1 was seen following his return from hospitalization where he had been transferred after sustaining a right humerus fracture and subsequently underwent a right humerus open reduction and internal fixation (ORIF) on 7/9/2026. The clinical record did not contain documentation that Resident #1 sustained a fall or injury resulting in the right arm fracture.Review of the care plan and the Kardex (summary of essential patient information and daily care needs for quick reference) revealed that Resident #1 required the assistance of 1 staff for personal hygiene, bed mobility, and shower/bathing.On 8/4/26 at 12:43 p.m., in an interview, the Director of Nursing (DON) said they conducted an investigation when Resident #1's fracture was identified. The investigation determined the injury likely occurred the previous night (7/7/26) when Resident #1 became combative when staff were doing perineal care. Resident #1 was in bed and had a fear of falling. Another staff member came in to assist. The resident did not report any pain at the time but did use his arms to reposition himself while staff were providing care. She said to prevent recurrence they initiated 2 staff assist with perineal care and revised the care plan to reflect 2 Staff assist with perineal care. She said the Minimum Data (MDS) Set Coordinator was the person responsible to update the care plan.On 8/4/26 at 1:39 p.m., in an interview, Registered Nurse (RN) Staff A said that on 7/8/26 during the day shift, she took care of Resident #1. RN Staff A said the Certified Nurse Assistant (CNA) notified her that Resident #1's arm looked swollen. The CNA said that the resident was pointing at his arm saying hurt. She went to assess the resident. His arm was visibly swollen, and he wouldn't let her touch it. He just kept saying hurt, hurt. RN Staff A said she immediately called the physician who issued an order for an x-ray. Resident #1 was sent out to the hospital. She said that Resident #1 did not get up every day and tells the staff when he gets up. He did not get out of bed during the day shift on 7/8/26 and nothing would have indicated that he sustained an injury. RN Staff A said that Resident #1 sat a certain way in the bed and will scoot and move himself up in the bed. Staff help him transfer from bed to his wheelchair. He self-propels the wheelchair and is typically all over. Resident #1's upper body strength was super strong. She said that Resident #1 had behaviors at time; he could get angry or didn't want to be bothered. If he did not want to move, he would put a grip on his wheels and say no, and it would not move. She said when he got like that, they just left him alone because he was strong and he could become combative. On 8/4/26 at 1:07 p.m., in an interview, Resident #1's sister said they don't really know caused the fracture, no one reported a fall or any other type of accident. She said that at the hospital, she spoke with the surgeon at length. He told her the fracture was more the type of a high impact injury like from a fall, accident, something like a car accident. The sister said that she thought he was maybe reaching for something and fell out of the wheelchair. He tried to brace himself and landed on his elbow.On 8/4/26 at 12:35 p.m., in an interview, Certified Nurse Assistant (CNA) Staff B said she had been employed at the facility for 3 weeks and has been assigned twice to Resident #1. She said he didn't allow you to help him, so she will ask for help. She said she always called someone to assist since she didn't know Resident #1 well. CNA Staff B said that the amount of assistance needed was noted in the Kardex. Review of the Kardex with CNA Staff B revealed that Resident #1 was a 1 staff assist with personal hygiene, bed mobility and shower/bathing. On 8/4/26 at 1:00 p.m., in an interview, the MDS coordinator said she was aware of Resident #1's fracture and updated his care plan. The MDS coordinator verified that the care plan and Kardex noted that Resident #1 required the assistance of 1 staff for personal hygiene, bed mobility and shower/bathing. She said that no one told her that Resident #1 level of assistance had changed to 2 person assist for personal hygiene, bed mobility and shower/bathing.On 8/4/26 at 2:15 p.m., in an interview, the DON said she reviewed Resident #1's care plan and Kardex and verified they had not been updated to reflect 2 person assist with perineal care which could result in future instances of staff not providing the appropriate support to Resident #1.

Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to prevent avoidable accidents by failing to ensure the appropriate storage of ignition devices for 6 (Residents #71,#106, #9, #26, #43, and #67) of 23 residents who smoke tobacco products and/or use oxygen.The unsafe practice of allowing residents to store ignition sources such as lighters in their rooms where oxygen is in use created a significant fire safety risk to the entire facility. A fire originating in one resident's room can rapidly spread through bedding, furnishing, producing smoke and toxic fumes that travel quickly through hallways and ventilation systems, creating a likelihood of serious injury, impairment or death of all 101 residents from thermal burns and inhalation of toxic fumes and resulted in the determination of Immediate Jeopardy.The findings included:Cross reference F835, F865, F926On 1/6/26, the facility provided a list of current residents who smoke tobacco products dated December 18, 2025. The list contained 23 smokers, including Residents #71, #106, #9, #26, #43, and #67.Review of the facility policy titled, Smoking-Supervised with an effective date of 11/30/2014 and a revision date of 02/07/2020 revealed, . Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. The Center will retain and store matches, lighters, etc. for all residents . Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement .Review of the Smoking Agreement/Notice of Policy utilized by the facility and signed by residents who smoke read, Smoking is allowed by the center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All residents who wish to smoke at the center will abide by the center's smoking policy. Resident electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial action includes but is not limited to warning, revocation of smoking privileges, police intervention, and/or discharge. This agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the terms set forth in the policy.I, the undersigned, understand that these safety rules apply to me and the safety of the other residents and violations may result in subsequent education, warnings, and other remedial actions at the discretion of the Executive Director.Resident #9:On 1/6/26 at 9:56 a.m., in an interview Resident #9 said the residents get to smoke three times a day. She said she keeps her cigarettes and lighter in her purse and stores them in her room. Resident #9 said she knew she was supposed to turn the cigarettes and lighter into the nurses' station but they turned up missing. She said about a month ago, she voiced her concerns to the Administrator who said she would address them. Resident #9 said so far the Administrator had not addressed her concerns. She just keeps her cigarettes and lighter in her purse and brings them out with her.On 1/6/26 at 1:28 p.m., Resident #9 was observed exiting her room with her purse on her lap. She entered the vending machine room that leads to the smoking area. The Director of Patient Experience was observed approaching Resident #9 and speaking with her. Resident #9 opened her purse, took out a pack of cigarettes and a lighter and handed them to the Director of Patient Experience. Review of the clinical record for Resident #9 revealed an admission date of 5/17/23. The Annual MDS assessment dated [DATE] revealed Resident #9 used tobacco products. The MDS noted the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included cerebrovascular accident (CVA), Diabetes Mellitus, seizure disorder, and depression with anxiety.Review of the care plan revealed Resident #9 was a smoker and chooses to smoke in a laying down position. The goal was for the resident not to smoke without supervision. The interventions included: The resident was educated on proper positioning while smoking. Resident #9 stated that she is more comfortable laying down.Instruct resident about the facility policy on smoking, locations, times and safety concerns; The resident requires a smoking apron while smoking; The resident requires supervision while smoking.Review of the smoking evaluations revealed the last smoking evaluation was completed on 11/23/23 and contained conflictive information. The smoking evaluation noted the resident was determined to be a safe smoker and required constant supervision while smoking.On 8/31/25 Resident #9 signed the Smoking Agreement/Notice of Policy form.Resident #71:On 1/6/26 at 1:21 p.m., Resident #71 was observed in the smoking area. The Director of Patient Experience was also observed in the smoking area. She said that all smokers signed an agreement and are not supposed to have a lighter on them. She said Resident #71 had a lighter and he would not give it to the staff.On 1/6/26 at 1:24 p.m., Resident #71 was observed in the presence of the Director of Patient Experience using a red lighter he had with him to light his cigarette. On 1/6/26 at 3:35 p.m., observation of the resident's room revealed an oxygen concentrator at the resident's bedside.Review of the clinical record for Resident #71 revealed an admission date of 5/27/25. The admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident used tobacco. The MDS noted Resident #71 scored 12 on the BIMS, indicating moderate cognitive impairment (May need help with daily tasks).On 9/2/25, Resident #71 signed the Smoking Agreement/Notice of Policy form.The last smoking evaluation was dated 9/11/25. The evaluation noted Resident #71 was a safe smoker and the supervision required while smoking was constant.The physician's orders dated 5/28/25 included Oxygen at 2 Liters (L) as needed.The care plan with a review start date of 12/10/25 noted Resident #71 was a smoker. The goal was for the resident not to smoke without supervision. The interventions included: Observe clothing and skin for signs of cigarette burns; Instruct resident about the facility policy on smoking: locations, times, safety concerns; The resident requires supervision while smoking. The care plan did not address Resident #71's known violation of the facility's smoking policy for storage of ignition devices.Resident #106:On 1/6/26 at 1:16 p.m., Resident #106 was observed entering the smoking area. She took cigarettes out of her purse. No lighter was observed with the resident. The smoking attendant approached the resident and lit the cigarette.On 1/6/26 at 3:39 p.m., observation of the resident's room revealed an oxygen concentrator at the resident's bedside.Review of the clinical record for Resident #106 revealed an admission date of 3/28/24.The admission MDS assessment dated [DATE] revealed Current Tobacco Use was listed under Other Health Conditions.On 1/20/25, Resident #106 signed the Smoking Agreement/Notice of Policy.The physician's orders dated 9/6/25 included Oxygen at 2 L as needed and Oxygen at 2 L continuously.Review of the care plan with a review start date of 10/17/25 revealed a focus for smoking. The goal was for the resident not to suffer injury from unsafe smoking practices.The clinical record lacked documentation of a smoking evaluation to identify unsafe smoking practices and determine if the resident required assistance or supervision for smoking.Resident #26:Review of the clinical record for Resident #26 revealed an admission date of 7/1/25.Review of the admission MDS assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview for Mental Status score of 15. The MDS listed Current Tobacco Use under Other Health Conditions. On 9/3/25, Resident #26 signed the Smoking Agreement/Notice of Policy form.The last smoking evaluation was dated 12/20/25. The evaluation did not address the safe storage of ignition material. The summary of the evaluation noted Resident #26 was determined to be Safe smoker.On 1/7/26 at 3:23 p.m., in an interview Resident #26 said, I smoke every day. I go out at all smoking times. I never signed a contract for smoking and I was never told about the facility's smoking policy. The resident said, Right now, I don't have my lighter or cigarettes, they took them.Resident #43:Review of the clinical record for Resident #43 revealed an admission date of 5/12/22.Review of the Annual MDS assessment dated [DATE] revealed the resident's cognition was intact with a BIMS score of 15.The MDS listed Current Tobacco Use under Other Health Conditions. Resident #43 signed the Smoking Agreement/Notice of Policy on 11/8/23.The most recent smoking evaluation was dated 9/11/25 and did not include the safe storage of ignition devices. The evaluation noted Resident #43 was a safe smoker and none was entered for Supervision needed while smoking.On 1/7/26 at 3:41 p.m., in an interview Resident #43 said he smokes every day at all scheduled times. Resident #43 said the facility went over the smoking policy in a Resident Council Meeting but he didn't sign the smoking contract. He said, I am not going to. When asked about the facility policy for storing cigarettes and lighters, Resident #43 said, I buy my cigarettes and lighters, I'm allowed to keep them. I paid for it, not them. I'm not 7 years old, I do not smoke in my room. When they take your cigarettes, they never give them back. That's my money, I paid for them, not this place. I have never smoked in my room.Resident #67:Review of the clinical record for Resident #67 revealed an admission date of 7/11/25.The admission MDS assessment dated [DATE] revealed the resident's cognition was intact with a BIMS score of 13. The MDS noted Yes for current tobacco use.The most recent smoking evaluation dated 9/11/25 documented that Resident #67 was determined to be a safe smoker and no supervision was needed while smoking.There was no documentation Resident #67 was given the facility's smoking policy and signed the Smoking Agreement/Notice of Policy.On 1/6/26 at 1:51 p.m., in an interview Smoking Attendant Staff C said it was known that several of the residents kept cigarettes and lighters in their possession. She said the Administrator has had many meetings with residents regarding keeping cigarettes and lighters. Staff C said the residents go to the store, buy cigarettes and lighters and keep them. She said some of the residents don't bring them to staff for storage. Staff C said, The next thing you know, they come to the smoking area with their own cigarettes and lighters. She said the residents would say no when she asks them to give her their cigarettes and lighters. Staff C said she can ask for the lighter, but she can't take it from them. She said she reports it to the Unit Manager. She said a lot of their residents use electric wheelchairs and go to the corner store, or visitors brings them cigarettes and lighters, how do you fix that?. She said the residents signed papers that they would turn in their lighters. She may have the residents' cigarettes/lighters in the locked smoking box, but the residents come right past her. They do not get the smoking supplies from her and start smoking. The observation of Resident #71 using a lighter he had with him to light his cigarette was shared with Staff C. She said she knew Resident #71 kept his cigarettes but did not know he had a lighter. Staff C said there had been times when 17 residents were out there smoking and she was not able to keep a close eye on that many residents.Staff C reviewed the facility provided list of smokers and said Residents #9, #106, #26, #43 and #67 were known to keep cigarettes and lighters in their possession. She said the facility administration was aware of the issue and has had many discussions about smoking rules with the smokers. Staff C said unless something was enforced, they would keep getting away with it.On 1/6/26 at 2:00 p.m., the Administrator provided the facility's smoking policy. She said residents were not supposed to have smoking materials in their possession or room. She said if the resident leaves the building, they can sign out their smoking supplies.On 1/6/25 at 3:13 p.m., in an interview the Director of Nursing (DON) said the smoking concerns have been an ongoing issue since she began employment in September 2025. She said in December 2025 they met with the residents and talked to them about smoking and turning in their lighters. They also went over the risks involved with oxygen. She said if the smoking attendants see residents with cigarettes and lighters, they should let them (Administrator and DON) know.On 1/6/26 at 3:20 p.m., in an interview the Administrator said she started employment at the facility in October 2025. They had noticed issues with residents keeping their smoking supplies. She said the residents were only allowed to have their smoking supplies if they were out of the facility on leave of absence. Otherwise, cigarettes and lighters should be turned in. The Administrator said they held special Resident Council meetings to discuss smoking.On 1/7/26 at 11:15 a.m., in an interview Unit Manager Staff T said it had been brought to his attention that residents were keeping cigarettes and lighters on them. He said they educated the residents on the smoking policy and thought that a month ago they met with the smokers and reviewed the smoking policy with them.

Based on observation, record review, residents and staff interviews, the facility administration failed to provide effective oversight and enforcement of safe smoking practices. The facility Administration became aware of the concerns of unsafe storage of ignition devices and failed to intervene to protect the health and safety of all residents, as evidenced by interviews with the Director of Nursing and the Administrator who both stated that the issues were brought to their attention in September and October of 2025 when they started working in the facility. This failure created an environment that placed all 101 residents who reside in the single-story facility at a likelihood of serious injury, impairment or death from thermal burns and inhalation of toxic fumes and resulted in the determination of Immediate Jeopardy. The findings included:Refer to F689, F865, F926Review of the Executive Director (Administrator)'s job description revealed, The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times . You will also provide leadership to all facility staff in meeting the goal of providing quality resident care . Duties and Responsibilities . Ensure a safe, clean and comfortable environment for residents, visitors and staff . Specific Requirements . Must possess the ability to develop, implement . policies, and procedures that are necessary to for providing quality care and maintaining a sound operation .On 8/19/25, the Administrator signed the job description, accepting the position and agreed to perform the functions contained in this job description in a safe manner and in accordance with the facility's established procedures. Review of the Director of Nursing (Director of Clinical Services)'s job description revealed, As the company Director of Clinical Services, you are entrusted with the responsibility of caring for our resident, families, co-workers, visitors, and all others. The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility . to ensure that the highest degree of quality care is maintained at all times . Duties and responsibilities . Maintain and guide the implementation of current policies and procedures . On 9/24/25, the Director of nursing signed the job description attesting that she had read the job description and agreed to, perform the tasks outlined in this job description in a safe manner and in accordance with the facility's established procedures. Review of the facility policy titled, Smoking-Supervised with an effective date of 11/30/2014 and a revision date of 02/07/2020 revealed, . Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. The Center will retain and store matches, lighters, etc. for all residents . All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures . Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement.On 1/6/26, review of the facility provided list of current residents who smoke tobacco products dated December 18, 2025, revealed Residents #71, #106, #9, #26, #43, and #67 were smokers.On 1/6/26 at 9:56 a.m., in an interview Resident #9 said that her cigarettes and lighter turned up missing when she turned them into the nurses' station. She said about a month ago, the Administrator said she would address her concerns, but she has not. Resident #9 said she keeps her cigarettes and lighter in her purse and stores them in her room.On 1/6/26 at 1:28 p.m., Resident #9 was observed exiting her room. She retrieved a pack of cigarettes and a lighter and handed them to the Director of Patient experience.Clinical record review revealed Resident #9 had an admission date of 5/17/23. The last smoking evaluation was completed on 11/23/23. The evaluation noted the resident was determined to be a safe smoker and required constant supervision while smoking.On 1/6/26 at 1:21 p.m., Resident #71 was observed in the designated smoking area. The Director of Patient Experience said Resident #71 had a lighter and he would not give it to the staff.On 1/6/26 at 1:24 p.m., Resident #71 was observed lighting a cigarette with a red lighter he had with him.Clinical record review revealed the Minimum Data Set (MDS) assessment dated [DATE] noted Resident #71 scored 12 on the Brief Interview for Mental Status, indicating moderate cognitive impairment.Review of the physician's orders dated 5/28/25 revealed an order for supplemental Oxygen at 2 Liters (L) as needed.The last smoking evaluation was dated 9/11/25. The evaluation noted Resident #71 was a safe smoker and the supervision required while smoking was constant.On 1/6/26 at 3:35 p.m., an oxygen concentrator was observed at the resident's bedside.On 1/6/26 at 1:16 p.m., Resident #106 was observed in the designated smoking area. The smoking attendant lit a cigarette that Resident #106 took out of her purse.Review of Resident #106's clinical record revealed an admission date of 3/28/24 and a physician's order dated 9/6/25 for Oxygen at 2 L as needed and Oxygen at 2 L continuously.On 1/6/26 at 3:39 p.m., an oxygen concentrator was observed at Resident #106's bedside.The clinical record lacked documentation of a smoking evaluation since the admission date of 3/28/24.On 1/6/26 at 1:51 p.m., in an interview Smoking Attendant Staff C said that several of the residents kept cigarettes and lighters in their possession. She said the residents refuse to give her the lighters and cigarettes when she asks and she cannot take the cigarettes and lighters from them. She reports it to the Unit Manager. The residents go to the corner store, or visitors bring them cigarettes and lighters. Staff C said there had been times when 17 residents were out there smoking and she was not able to keep a close eye on that many residents. Staff C said Residents #9, #106, #26, #43 and #67 were known to keep lighters and cigarettes in their possession. The facility Administration has had many discussions about the smoking rules with the smokers but unless something was enforced, they would keep getting away with it.On 1/6/26 at 3:13 p.m., an interview was held with the Director of Nursing (DON) to discuss her duties and responsibilities related to implementation of the facility's smoking policy to ensure the safety of all residents. The unsafe smoking observations, the incomplete clinical records related to smoking agreements and smoking evaluations were also discussed with the DON. The DON said since she started employment at the facility in September 2025, the smoking concerns have been an ongoing issue. She said the smoking attendants should report to them if they see residents with cigarettes and lighters. The DON said there has been no monitoring or auditing to ensure residents complied with the smoking policy.On 1/6/26 at 3:20 p.m., an interview was held with the Administrator to discuss the unsafe smoking practices and the administration failure to intervene to protect the health and safety of all residents, visitors and staff in the building.The Administrator said she started employment at the facility in October 2025. They had noticed issues with residents keeping their smoking supplies. She said cigarettes and lighters should be turned in. She said they held special Resident Council meetings to discuss smoking.Review of the facility provided special Resident Council Meeting minutes revealed:On August 29, 2025, the Administrator led the meeting, and the smoking policy was reviewed. The meeting minutes read, Safety concerns were highlighted, with emphasis on maintaining a healthy and secure environment for all residents. Specific instructions were stressed to turn lighters into the smoking attendant prior to leaving the designated outdoor smoking area. Residents are not allowed to keep lighters in their possession anywhere in the facility.The meeting attendees list included 10 of the current 23 smokers. Residents #106, #9, and #67 did not attend the meeting.On November 25, 2025, the Administrator and the DON attended the Resident Council meeting and reviewed the smoking policy with the residents. The meeting minutes included, Both cigarettes and lighters must be given to the smoking attendant. If leaving the facility, lighters and cigarettes may be taken on errands but given back to the smoking aid upon return . These rules need to be followed and will be enforced by the company. The list of 12 attendees did not include Residents #71, #106, and #67.On December 9, 2025, the Resident Council meeting minutes noted under old business that, Smoking policy was reviewed with residents expressly reviewing that lighters may not be kept in possession of resident and must be turned into the smoking attendant. Safety risk.The list of 12 attendees included 10 of the current smokers. Residents #71, #106, #9, #26, #43, and #67 did not attend the meeting. On 1/7/26 at 3:23 p.m., in an interview Resident #26 said he was never told about the facility's smoking policy. He said right now he didn't have his cigarettes and lighter with him because they took the cigarettes and lighter from him.On 1/7/26 at 3:41 p.m., in an interview Resident #43 said the facility went over the smoking policy in a Resident Council Meeting but he refused to sign the smoking contract. The resident said, I am not going to. Resident #43 said he buys his cigarettes and lighters, and he was allowed to keep them. He said, When they take your cigarettes, they never give them back.Clinical record review for Resident #67 revealed an admission date of 7/11/25. The admission MDS dated [DATE] documented Yes for Current Tobacco Use.There was no documentation Resident #67 was given the facility's smoking policy and signed the Smoking Agreement/Notice of Policy.On 1/7/25 at 4:25 p.m., the facility Administrator provided a blank Mock Survey (Quality Assurance) checklist that included Are there signs/smells of smoke in the room? Are there any lighters or cigarettes visible? She stated the management staff use the form to conduct Angel rounds (Proactive walk-through rounds to ensure residents safety, comfort, and well-being).When asked to review the completed Mock Survey checklists, the Administrator stated that the completed forms were discussed in morning meeting and then shredded. The Administrator had no documentation that the rounds were completed and the management staff conducting the rounds identified the unsafe storage of ignition devices in residents' rooms where oxygen is stored and used.

Based on observation, record review and interviews, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to address the known unsafe smoking practices since September 2025 for 6 (Residents #71, #106, #9, #26, #43, and #67) of 6 sampled residents who smoke tobacco products. The facility failure to develop corrective actions to ensure the safe storage of ignition devices and continuing to allow residents who use oxygen to retain/store lighters in their rooms created a significant, avoidable fire safety risk that could impact all 101 residents who reside in the single-story facility. A fire originating in one resident's room can rapidly spread, produce smoke and fumes that travel rapidly through hallways and ventilation systems, creating a likelihood of serious harm, injury or death. The failure of the QAPI program to address these concerns resulted in the determination of immediate jeopardy.The findings included:Cross reference F689, F835, F926Review of the facility's policy and procedure titled, Quality Assurance Performance Improvement Program (QAPI) with a revision date of 10/24/2022 revealed, The Center and organization has [sic] a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. The center's QAPI program is on-going comprehensive review of care and services provided to residents . Important functional areas may include but are not limited to Residents rights and responsibilities . Resident assessment . Potential Adverse Events . The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. The center will establish and utilize a systematic approach to identify underlying causes of the problems . The center will develop corrective actions based on the information gathered and review effectiveness of the actions .Review of the facility's policy and procedure titled, Smoking-Supervised with a revision date of 2/7/2020 revealed residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. The Center will retain and store matches, lighters, etc. for all residents. Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement.The facility provided list of current residents who smoke dated December 18, 2025, included Residents #71, #106, #9, #26, #43, and #67.On 1/6/26 at 9:56 a.m., in an interview Resident #9 said about a month ago, she voiced concerns to the Administrator that her cigarettes and lighter turned up missing when she turned them into the nursing station. She said so far, the Administrator had not addressed her concerns. She just keeps her cigarettes and lighter in her purse.On 1/6/26 at 1:21 p.m., in an interview, the Director of Patient Experience said Resident #71 had a lighter and he would not give it to the staff.On 1/6/26 at 1:24 p.m., Resident #71 was observed in the designated smoking area with a red lighter that he used to light a cigarette.On 1/6/26 at 1:28 p.m., Resident #9 was observed exiting her room. She retrieved a pack of cigarettes and lighters from her purse and handed them to the Director of Patient Experience who was observed speaking with the resident.On 1/6/26 at 1:51 p.m., in an interview Smoking Attendant Staff C said that Residents #9, #106, #26, #43 and #67 were known to keep lighters and cigarettes in their possession. The facility Administration has had many discussions about the smoking rules with the smokers but unless something was enforced, they would keep getting away with it.On 1/6/26 at 3:35 p.m., and 3:39 p.m., observation of Residents #71 and #106's rooms revealed an oxygen concentrator at each resident's bedside.On 1/6/26 at 3:13 p.m., an interview was held with the Director of Nursing (DON) to discuss corrective actions to address the unsafe smoking practices and review of the effectiveness of actions implemented. The DON said since she started employment at the facility in September 2025, the smoking concerns have been an ongoing issue. She said the smoking attendants should report to them if they see residents with cigarettes and lighters. The DON said there has been no monitoring or auditing to ensure residents complied with the smoking policy.On 1/6/26 at 3:20 p.m., an interview was held with the Administrator to discuss systematic approaches implemented by the facility to address the unsafe smoking practices. The Administrator stated that she started employment at the facility in October 2025. They had noticed issues related to residents keeping their smoking supplies. The Administrator said the unsafe smoking practices were discussed in a QAPI meeting on October 30, 2025, but no performance improvement plan was put in place. She said they also held special Resident Council Meetings on 8/29/25, 11/25/25, and 12/9/25, to discuss smoking.Review of the form dated October 27, 2025, provided by the Administrator showed a section for Smoking=Quarterly. The areas to be addressed included: No Evidence that residents have lighters or matches and Smokers are identified on admission and assessed quarterly for safety.No data was entered for these areas and 0 was entered in the 3 columns on the form for Smoking subtotal.On 1/8/25 at 2:00 p.m., an interview was held with the Administrator to discuss the Resident Council Meeting minutes for November 2025 which stated that both cigarettes and lighters must be given to the smoking attendant were reviewed with the Administrator.The Administrator said that it was a mistake. The facility's policy has always been that smokers were allowed to keep their cigarettes.When asked about enforcing the facility's smoking policy and procedure for the known unsafe smoking practices, such as revoking smoking privileges, the Administrator said that she had not taken that route with anyone at this time.

Based on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's supervised smoking policy to ensure safe smoking practices for 6 (#71, #106, #9, #26, #43, and #67) of 6 sampled smokers and prohibit the storage of ignition devices around oxygen use for 2 (Residents #71 and #106) of 2 sampled residents reviewed for safe smoking.The facility failure to enforce the smoking policy that clearly addressed the safe storage of ignition devices by allowing residents who use oxygen, or share rooms with residents who use oxygen, to keep lighters/ignition devices unsecured in their rooms created an avoidable fire safety risk, placing all 101 residents who reside in the single story facility at a likelihood serious harm, injury or death from thermal burns and inhalation of toxic fumes. These concerns resulted in the determination of immediate jeopardy. A fire originating in one resident's room can rapidly spread, produce smoke and fumes that travel very quickly through hallways and ventilation systems.The findings included:Cross reference F689, F835, F865Review of the facility's policy and procedure titled, Smoking-Supervised, with a revision date of 02/07/2020 revealed, Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the Center will include the appropriate information in the care plan . The Center will retain and store matches, lighters, etc. for all residents . All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement . Electronic cigarettes are permitted, but only in facility designated smoking areas. The same rules that apply to regular tobacco cigarettes also apply to electronic smoking materials. Electronic cigarettes and materials, including the liquids, will be retained and stored by nursing staff .Review of the Smoking Agreement/Notice of Policy revealed, Smoking is allowed by the center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All resident [sic] who wish to smoke at the center will abide by the center's smoking policy. Residents electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial action includes but is not limited to warning, revocation of smoking privileges, police intervention, and/or discharge. This agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the terms set forth in the policy.Each smoker signed the agreement noting, I, the undersigned, understand that these safety rules apply to me and the safety of the other residents and violations may result in subsequent education, warnings, and other remedial actions at the discretion of the Executive Director.Review of the facility provided list of 23 current residents who smoke tobacco products dated December 18, 2025, revealed Residents #71, #106, #9, #26, #43, and #67 were smokers.Resident #9:Review of the clinical record for Resident #9 revealed an admission date of 5/17/23. The Annual MDS assessment dated [DATE] revealed Resident #9 used tobacco products. The MDS noted the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included cerebrovascular accident (CVA), Diabetes Mellitus, seizure disorder, and depression with anxiety.The last smoking evaluation was completed on 11/23/23.The smoking evaluation noted the resident was determined to be a safe smoker and required constant supervision while smoking.On 8/31/25 Resident #9 signed the Smoking Agreement/Notice of Policy form.Review of the care plan revealed Resident #9 was a smoker and chooses to smoke in a laying down position. The goal was for the resident not to smoke without supervision. The interventions included, The resident was educated on proper positioning while smoking. Resident #9 stated that she is more comfortable laying down. Instruct resident about the facility policy on smoking, locations, times and safety concerns, The resident requires a smoking apron while smoking. The resident requires supervision while smoking.On 1/6/26 at 9:56 a.m., in an interview Resident #9 said the residents get to smoke three times a day. She said she keeps her cigarettes and lighter in her purse and stores them in her room. Resident #9 said she knew she was supposed to turn the cigarettes and lighter into the nurses' station but they turned up missing. She said about a month ago, she voiced her concerns to the Administrator who said she would address them. Resident #9 said so far the Administrator had not addressed her concerns. She said she just keeps her cigarettes and lighter in her purse and brings them out with her.On 1/6/26 at 1:28 p.m., Resident #9 was observed exiting her room with her purse on her lap. She entered the vending machine room that leads to the smoking area. The Director of Patient Experience was observed approaching Resident #9 and speaking with her. Resident #9 opened her purse, took out a pack of cigarettes and a lighter and handed them to the Director of Patient Experience. Resident #71:On 1/6/26, review of the clinical record for Resident #71 revealed an admission date of 5/27/25. The admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident used tobacco. The MDS noted Resident #71 scored 12 on the BIMS, indicating moderate cognitive impairment (May need help with daily tasks).On 9/2/25, Resident #71 signed the Smoking Agreement/Notice of Policy form.The last smoking evaluation was dated 9/11/25. The evaluation noted Resident #71 was a safe smoker and the supervision required while smoking was constant.The physician's orders dated 5/28/25 included Oxygen at 2 Liters (L) as needed.The care plan with a review start date of 12/10/25 noted Resident #71 was a smoker. The goal was for the resident not to smoke without supervision. The interventions included, The resident requires supervision while smoking.On 1/6/26 at 1:21 p.m., in an interview, the Director of Patient Experience said Resident #71 had a lighter and he would not give it to the staff.On 1/6/26 at 1:24 p.m., Resident #71 was observed lighting a cigarette with a red lighter he had with him. The Director of Patient Experience verified the observation of Resident #71 lighting a cigarette with a lighter he had with him.On 1/6/26 at 3:35 p.m., an oxygen concentrator at Resident #71's bedside.Resident #106:Review of the clinical record for Resident #106 revealed an admission date of 3/28/24. The admission MDS assessment dated [DATE] included Current Tobacco Use under Other Health Conditions.The physician's orders dated 9/6/25 included Oxygen at 2 L as needed and Oxygen at 2 L continuously.Review of the care plan with a review start date of 10/17/25 revealed a focus for smoking. The goal was for the resident not to suffer injury from unsafe smoking practices.The clinical record lacked documentation of a smoking evaluation to identify unsafe smoking practices and determine if Resident #106 required assistance or supervision for smoking.Resident #26:Review of the clinical record for Resident #26 revealed an admission date of 7/1/25.Review of the admission MDS assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview for Mental Status score of 15. The MDS listed current tobacco use under Other Health Conditions. On 9/3/25, Resident #26 signed the Smoking Agreement/Notice of Policy form.The last smoking evaluation was dated 12/20/25. The evaluation did not include the safe storage of ignition material. The summary of the evaluation noted Resident #26 was determined to be Safe smoker.On 1/7/26 at 3:23 p.m., in an interview Resident #26 said, I smoke every day. I go out at all smoking times. I never signed a contract for smoking and I was never told about the facility's smoking policy. The resident said, Right now, I don't have my lighter or cigarettes, they took them.Resident #43:Review of the clinical record for Resident #43 revealed an admission date of 5/12/22.Resident #43 signed the Smoking Agreement/Notice of Policy on 11/8/23.Review of the Annual MDS assessment dated [DATE] revealed the resident's cognition was intact with a BIMS score of 15.The MDS listed current tobacco use under Other Health Conditions. The most recent smoking evaluation was dated 9/11/25 and did not include the safe storage of ignition devices. The evaluation noted Resident #43 was a safe smoker and none was entered for Supervision needed while smoking.On 1/7/26 at 3:41 p.m., in an interview Resident #43 said he smokes every day at all scheduled times. Resident #43 said the facility went over the smoking policy in a Resident Council Meeting but he didn't sign the smoking contract. He said, I am not going to. When asked about the facility policy for storing cigarettes and lighters, Resident #43 said, I buy my cigarettes and lighters, I'm allowed to keep them. I paid for it, not them. I'm not 7 years old, I do not smoke in my room. When they take your cigarettes, they never give them back. That's my money, I paid for them, not this place. I have never smoked in my room.Resident #67:Review of the clinical record for Resident #67 revealed an admission date of 7/11/25.The admission MDS assessment dated [DATE] revealed the resident's cognition was intact with a BIMS score of 13. The MDS noted Yes for current tobacco use.The most recent smoking evaluation dated 9/11/25 documented that Resident #67 was determined to be a safe smoker and no supervision was needed while smoking. The smoking evaluation did not include the safe storage of ignition material.On 1/6/26 at 1:51 p.m., in an interview, Smoking Attendant Staff C said it was known that several of the residents kept cigarettes and lighters in their possession. She said the Administrator has had many meetings with residents regarding keeping cigarettes and lighters. Staff C said the residents go to the store, buy cigarettes and lighters and keep them. She said some of the residents don't bring them to staff for storage. Staff C said, The next thing you know, they come to the smoking area with their own cigarettes and lighters. She said the residents would say no when she asks them to give her their cigarettes and lighters. Staff C said she can ask for it, but she can't take it from them. She said she reports it to the Unit Manager. She said a lot of their residents use electric wheelchairs and go to the corner store, or visitors brings them cigarettes and lighters, how do you fix that?. She said the residents signed papers that they would turn in their lighters. She said she may have the residents' cigarettes/lighters in the locked smoking box, but they come right past her and start smoking. They do not get the smoking supplies from her. The observation of Resident #71 using a lighter he had with him to light his cigarette was shared with Staff C. She said she knew Resident #71 kept his cigarettes but did not know he had a lighter. Staff C said there had been times when 17 residents were out there smoking and she was not able to keep a close eye on that many residents.Staff C reviewed the facility provided list of smokers and said Residents #9, #106, #26, #43 and #67 were known to keep cigarettes and lighters in their possession. She said the facility administration was aware of the issue and has had many discussions with the smokers about smoking rules. Staff C said unless something was enforced, they would keep getting away with it.On 1/6/26 at 3:20 p.m., an interview was held with the Administrator to discuss operationalizing the facility's Smoking-Supervised policy to ensure the safety of all residents, staff and visitors.The Administrator said she started employment at the facility in October 2025. They had noticed issues with residents keeping their smoking supplies. She said they held special resident council meetings with the smokers on 8/29/25, 11/25/25, and 12/9/25, to discuss smoking.Review of the facility provided Resident Council Meeting minutes revealed:On 8/29/25, the Administrator led the meeting and the smoking policy was reviewed.The meeting attendees list included 10 of the current 23 smokers. Residents #106, #9, and #67 did not attend the meeting.On 11/25/25, the Administrator and DON attended the Resident Council Meeting and reviewed the smoking policy with the smokers.The meeting attendees list of 12 residents did not included Residents #71, #106, and #67.On 12/9/25, the Resident Council Meeting minutes noted under old business that the smoking policy was reviewed with residents, expressly reviewing that lighters may not be kept in possession of residents and must be turned into the smoking attendant.The list of 12 attendees included 10 of the current smokers. #71, #106, #9, #26, #43, and #67 did not attend the meeting. Review of the Executive Director (Administrator)'s job description signed on 8/19/25 revealed, duties and responsibilities included to ensure a safe, clean and comfortable environment for residents, visitors and staff. Specific Requirements listed in the job description included, Must possess the ability to develop, implement . policies, and procedures that are necessary to for providing quality care and maintaining a sound operation .On 1/7/26 at 11:07 a.m., in an interview Licensed Practical Nurse (LPN) Staff R said the nurses do not complete smoking assessments. She said the Unit Managers do the assessments to see if a resident needs to be supervised. LPN Staff R said she did not know how often the smoking assessments were done and had never supervised smoking. She said around November or December she found a lighter in a resident's room and gave it to the Smoking Aid.On 1/7/26 at 11:15 a.m., in an interview LPN Staff F said she had never completed a smoking assessment. She said she would have to ask the DON or Assistant Director of Nursing (ADON) when and how often smoking assessments were done. She said she was not sure who was responsible for completing smoking assessments but thought it was the DON, Administrator, or the Unit Manager. LPN Staff F said it was not brought to her attention that residents were keeping smoking materials.On 1/7/26 at 11:15 a.m., in an interview Unit Manager, LPN Staff T said smoking assessments are completed at admission and quarterly. LPN Staff T said, We check to see if they are safe and if not, then we put the apron on them or change them to an e-cigarette. Staff T said the smoking assessments are completed by the admission nurses and management staff. He said, If they are not completed, it is usually because we have some difficult residents here that are noncompliant. When asked how he supervised smoking, Staff T said, I just make sure the residents are safe, that there is a physician order for them to smoke. If not, I get one. LPN Staff T said it was brought to his attention that residents were keeping cigarettes and lighters with them and said, I think we just had a meeting a month ago and the smoking policy was reviewed with them.On 1/7/26 at 11:47 a.m., in an interview LPN Staff I said residents were not allowed to have cigarettes and/or lighters. She said the Smoking Aide monitored the residents who smoke at all times. If they have any concerns, they are required to inform the nurse to ensure the resident remains safe when smoking. She said the smoking evaluation is normally completed by the nurse on duty or the Unit Manager. The admitting nurse completes the initial smoking evaluation, then it is done quarterly or as needed.On 1/7/25 at 11:54 a.m., an interview was held with the DON to discuss her duties and responsibilities related to implementation of the facility's smoking policy to ensure the safety of all residents. She said she started employment at the facility in September 2025. She said nursing is supposed to complete the smoking assessments on the day they are due. She said she did not know how the smoking assessments were tracked in the past and said, We probably have not been tracking it. She said she has not done any training with the nurses on completing the smoking assessments. The DON said they were going to develop a better process for the completion of the smoking assessments.Review of the Director of Nursing job description signed on 9/24/25 revealed duties and responsibilities included to maintain and guide the implementation of current policies and procedures.On 1/7/25 at 4:25 p.m., the facility Administrator provided a blank Mock Survey (Quality Assurance) checklist that included Are there signs/smells of smoke in the room? Are there any lighters or cigarettes visible?. She stated the management staff use the form to conduct Angel rounds (Proactive walk-through rounds to ensure residents safety, comfort, and well-being). The Administrator had no documentation that the rounds were completed and the management staff conducting the rounds identified the unsafe storage of ignition devices in residents' rooms where oxygen is stored and used.The Administrator stated that the completed forms are discussed in morning meeting and then shredded.

Based on observation, record review and interviews, the facility failed to follow physician orders for enteral feeding supplies for 1 of 3 residents sampled, (Resident #41).The findings included: On 1/5/26 at 10:26 a.m., during a tour of the facility observed a peg tube syringe and 2 water pitchers with dark liquid, a carton of Nutren (brand name liquid nutritional formula), 1 carton of whole milk and 1 carton of 1% low fat milk on Resident #41's overbed table. Observed on bedside table was a basin containing pudding, sardines, 2 large cartons of chicken broth and canned sausages. (photographic evidence obtained).On 1/5/26 at 1:47 p.m., during a tour of the facility observed a feeding tube syringe, 1 water with straw containing clear liquid; 1 water pitcher with dark liquid, and 3 plastic cups with light brown liquid on Resident #41's overbed table. Observed on bedside table was a basin containing pudding, sardines, 2 large cartons of chicken broth and canned sausages. (photographic evidence obtained)Review of the clinical record documented Resident #41 was originally admitted to the facility 2/13/25 with diagnosis malignant neoplasm of tongue, dysphagia, oropharyngeal phase, major depressive disorder, severe protein-calorie malnutrition, and chronic obstructive pulmonary disease.Review of Quarterly Minimum Data Set (MDS) with an assessment date of 10/8/25 documented Resident #41 was dependent on staff for oral hygiene; eating was not attempted due to medical condition. The MDS noted resident was independent with bed mobility and transfer. The MDS documented that Resident #41 had a BIMS (Brief Interview for Mental Status) with a score of 12 indicating his cognitive status was moderately impaired.Review of physician orders dated 10/5/25 documented Diet - Nothing by mouth (NPO). Enteral Feed (providing nutrition into abdominal wall access )Ordered 6 times daily for nutrition support; Nutren 2.0 250 milliliters at 6am, 10am, 1pm, 4pm, 8pm and 11pm via peg tube (Percutaneous endoscopic gastrostomy tube is a flexible feeding tube inserted through the abdominal wall directly into the stomach to provide long-term nutritional support, fluids and/or medications). Enteral Feed Order 6 times daily for nutrition support: enteral flush total 600 milliliters water via peg tube via peg; flush with 50 milliliters water before and after feedings via peg tube.Review of physician order dated 10/25/25 documented remove peg equipment from bedside every shift for dysphagia/peg tube feeding.Review of physician orders dated 10/29/25 documented for staff to date opened foods that patient has purchased and remove from room when out of date every shift for dysphagia/peg tube feed re: resident has a history of self-feeding.Review of Care Plan dated 2/14/25 documented the resident requires tube feeding related to dysphagia and cancer. Nothing by mouth. Interventions include remove peg tube feeding equipment from bedside as ordered; the resident is dependent with tube feeding and water flushes.Review of Care Plan dated 4/25/25 documented that the resident does not cooperate with care related to ordering food/liquid from outside and putting it in his peg tube. Staff removing feeding equipment from bedside, all food items dated when opened when observed in in room opened. Interventions included date open food in room that resident purchased and remove when out of date; educate resident/resident's representative/caregivers of the possible outcome(s) of not complying with treatment or care.Review of Care Plan dated 9/8/25 documented the resident has impaired cognitive function/or impaired thought processes related to diagnosis dementia, cancer of the tongue, mood disorder and depression. Interventions included communicate with the resident/resident's representative/caregivers regarding resident capabilities and needs.Review of facility notes for care conference conducted on 10/30/25 which included Resident #41 spouse documented Resident is NPO (nothing by mouth), has G-tube (gastric tube for providing liquid nutrition) for all nutrition / hydration. Observed by staff pouring liqs down feeding tube. Explained to wife that this process is unsafe and is at risk for infection / aspiration as he is also taking po (by mouth) items. On 1/5/26 at 1:52 p.m., in an interview Registered Nurse (RN) Staff Q, said when she went past Resident #41's room she saw him administering something into his feeding tube. RN, Staff Q, said Resident #41 said it was a mixture of feeding formula and coffee. She said she signed for administering the feeding at 1:00 p.m. even though she did not administer it. Staff Q, RN said she saw the cups on the overbed table and documented he consumed 100%. Staff Q, RN said it is really hard to tell what Resident #41 is consuming. She confirmed he should not have any tube feeding supplies in his room. She said he came up to the nurse's station and asked for a new syringe. Staff Q, RN said staff should not be providing the resident with feeding tube supplies and should be removing them from his room.On 1/7/26 at 12:41 p.m., a feeding tube syringe was observed on Resident #41's bed. Observed on bedside table was a basin containing pudding, sardines, 2 large cartons of chicken broth and canned sausages. (photographic evidence obtained)On 1/7/26 at 12:55 p.m., in an interview Licensed Practical Nurse (LPN), Staff F said resident #41's diet is Nothing by Mouth (NPO) but he put liquids in his feeding tube himself. She said he is not supposed to have a syringe in his room. She said she is not sure where he got it from. LPN, Staff F said Resident #41 does not have an order to give himself formula. She said he does give himself formula. LPN, Staff F said none of the food in his room should be there because he is NPO. She said he could aspirate if he had any of that food.On 1/7/26 at 1:14 p.m., in an interview LPN Unit Manager, Staff T and the Director of Nursing (DON) said Resident #41 orders food and supplies from outside. LPN, Staff T Unit Manager, said staff does remove the feeding tube supplies and food but obviously something was missed. The DON said staff were in-serviced but there is no documentation to show the education. The DON said there are room rounds and she will check to see if staff documented. The DON said the staff should be removing food from the resident's room. The DON said it does not look like there is anything documented to show the resident was educated about the risks of consuming food or fluids. The DON said the resident did not have a Self-Administer Assessment for tube feedings. The DON said staff never watched the resident to make sure the resident was properly administering his own feedings. The DON confirmed the resident does not have a physician order to administer his own feedings.On 1/9/26 at 10:29 a.m., a feeding tube syringe and 2 water pitchers with dark liquid were observed on Resident #41s overbed table. (photographic evidence obtained)On 1/9/26 at 10:50 a.m. in an interview the Licensed Speech Therapist said Resident #41 is at risk for aspiration that could lead to pneumonia or respiratory issues. She said the staff should be removing any food and tube feeding supplies and document every time he is non-compliant.Enteral Feeding N-405 Policies and Procedures effective date 11/30/2014, revision dated 11/12/2018 documented nurses administer enteral feeding when volume control is indicated and as ordered by physician.

Based on observation, review of facility policy and staff interviews, the facility failed to provide a clean and sanitary environment for 3 residents, (Resident #82, #41 and #59) of 7 residents sampled.The findings included: Review of Facility Policy 5-Step Room Cleaning revised date 10/25/16 documented Purpose: To teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a healthcare facility. 4) Dust Mop: the entire floor must be dust mopped - especially behind dressers and beds. 5) The most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily.On 1/5/26 at 10:05 a.m., during a tour of the facility, 2 floor mats observed for Resident #82 covered with an unclean black substance. (photographic evidence obtained).On 1/5/26 at 10:26 a.m., during a tour of the facility, 2 floor mats for Resident #41were observed covered with an unclean black substance and a soiled water pitcher on overbed table. (photographic evidence obtained).On 1/5/26 at 10:54 a.m., during a tour of the facility, observed 1 floor mat and floor for Resident #59 covered with brown, sticky substance. (photographic evidence obtained).On 1/8/26 at 12:28 p.m., in an interview Staff S, Licensed Practical Nurse (LPN), Unit Manager and Staff T, LPN Unit Manager said they do not know when floor mats are cleaned or replaced. Staff T, LPN Unit Manager said cleaning is the responsibility of housekeeping. Staff T, LPN, Unit Manager said if nursing sees any soiled mats, they stand them up and use sanitizer wipes to clean them. Accompanied Staff T, LPN, Unit Manager, to Resident #82's room and he said the floor mats need to be replaced. Staff T, LPN, Unit Manager, said he was not sure about the last time this room was cleaned.On 1/8/26 at 12:30 p.m., in an interview the Floor Technician said housekeeping is supposed to move the floor mats and clean the floor mats and floor every day. Accompanied Floor Technician to Resident #82's room and he said the floor mats are not acceptable.On 1/8/26 at 1:00 p.m., in an interview the Housekeeping Manager said the floor mats should be cleaned every day when housekeeping goes in the room. She said housekeeping should move the floor mats, stand them up to be able to sweep and clean the floor. The Housekeeping Manager said the floor mats for Resident #82 should have been cleaned all week and it appears they were not.

Based on observation, review of facility policy, record review and resident and staff interview, the facility failed to ensure 1, (Resident #89), of 1 resident with a pressure ulcer received treatments, including turning and repositioning using a wedge pillow, as part of pressure ulcer prevention and management.The findings included:Review of the facility policy and procedures Clinical Guideline Skin and Wound effective 4/1/2017 documented To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Develop individualized goals and interventions and document on the care plan and the CNA Kardex.(Certified Nursing Assistant (CNA) Kardex is clinical documentation to show CNAs resident specific treatment plan.)Review of the clinical record revealed Resident #89 originally admitted on [DATE] with diagnoses including type 2 diabetes mellitus, ASHD (atherosclerotic heart disease), dysphagia, need for assistance with ADL's (Activities of Daily Living) and cardiac pacemaker. admission MDS (Minimum Data Set) dated 2/14/25 section M documented the resident was not at risk for pressure ulcers and did not have any pressure ulcers upon admission. BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. Quarterly MDS dated [DATE] section M identified a pressure ulcer, present on admission stage 4. (severe full thickness wound with high infection risk) BIMS score of 15. The MDS noted the resident was dependent on staff for toileting, personal hygiene and bed mobility. Resident #89 was discharged on 12/17/25 and readmitted on [DATE]. readmission diagnosis included stage 4 pressure ulcer of the left buttocks, osteomyelitis, need for assistance with personal care.Review of the care plan initiated 10/7/25, identified the resident had a stage 4 pressure wound on the left ischium. The interventions instructed staff to reposition/off load torso as ordered/tolerated. Review of the Certified Nursing Assistant (CNA) Kardex documented reposition/off load torso as ordered/tolerated, must use foam wedge, turn every 2 hours and no lying on the left side.Clinical record review for Resident #89's spouse (Resident #90) documented on the Quarterly MDS dated [DATE] a BIMS score of 15 cognitively intact.On 1/5/2026 at 10:39 a.m., during an observation and interview Resident #89 said he had a wound on the left buttocks. Resident #89 said the staff do not come and turn him every 2 hours like they are supposed to. He was observed positioned on his back with a wedge positioning cushion under the left side of his upper back. A sign was noted above the resident's bed instructing staff to turn the resident every 2 hours.On 1/5/2026 at 1:18 p.m., during an observation Resident #89 was observed in bed positioned on his back. He said the staff had not come in to turn him. His wife (Resident #90), who is also his roommate, confirmed staff had not been in to turn her husband every 2 hours as required. There was a wedge positioning device under the resident's left upper back. On 1/5/2026 at 4:01 p.m., Resident #89 was observed in his bed lying on his back. He had a wedge positioning device that was placed on the left side of the resident's upper back. On 1/6/2026 at 8:49 a.m., Resident #89 was observed in bed lying on his back. The wedge positioning device was on the resident's right side of the upper back. On 1/6/26 at 3:23 p.m., in an interview the Director of Rehabilitation said if a wedge positioning device is used to decrease pressure on the buttocks area it's placement would vary on where the wound was located. She explained that the wedge should not be under the wound because it would cause pressure. The Director of Rehabilitation said the device should be placed at the lower back/hip area. She said the ideal position would be for the resident to be on their side. If on the left side, then the right leg would cross over the left to keep the resident positioned properly.On 1/6/26 at 4:32 p.m., Resident #89 was observed in bed on his back. The wedge positioning device was observed on the wheelchair next to the bed. His wife (Resident #90) said they will position him one more time then and put on his back to sleep for the night. She said he spends the entire night on his back; no one comes in to turn him. On 1/7/26 at 9:45 a.m., in an interview CNA Staff N said residents are turned every 2 hours. She said she was not assigned to Resident #89 today but cared for him in the past. She said the resident was dependent for care, except feeding himself. On 1/7/26 at 10:00 a.m., in an interview CNA Staff H said he was assigned to Resident #89 today. He said he did not know about repositioning /turning and was not able to answer any questions regarding the resident's care needs. On 1/7/26 at 4:00 p.m., Resident #89's spouse (Resident #90) was very upset. She said no one has turned her husband since 11:00 a.m. She said she had put the call light on and asked CNA Staff H three times to change her husband due to incontinence and pull him up in the bed, but the CNA did not understand her request. She said she had approached Unit Manager Staff T and the Administrator for assistance but received none. Resident #89 was observed scooted down in bed on his back and his head was resting on the side rail. He was upset and said, CNA Staff H did not come back in here to do anything. I'm tired of this, he doesn't speak the language, and he can't do anything you ask for. Resident #89's wife said, I have been at the desk complaining and no one has done anything.On 1/7/26 at 4:05 p.m., observed Resident #89's call bell activated from the hall. Several staff members were observed walking past the room, not answering the call light. Transportation CNA Staff M entered the room to assist the resident and asked the resident who his CNA was for the evening shift. Resident #89 told her CNA Staff L was in here and that he had told him he needed to be turned and changed but he does not understand. Another CNA was in the hall and called Staff L to come and assist the resident as he was assigned to Resident #89 on the evening shift. CNA Staff L entered the room and said, I do not understand. CNA Staff M told CNA Staff L the resident needed to be turned and pulled up in bed. He replied, I don't know. CNA Staff M showed him how to assist her to pull the resident up in the bed and turn him using the wedge positioning device. CNA Staff M explained to CNA Staff L he needed to turn Resident #89 every 2 hours, but CNA Staff L exited the room without speaking to the resident.On 1/7/26 at 4:30 p.m., in an interview the Administrator said, I looked and I can't find any education on the use of the position wedge. I had the Director of Rehabilitation look as well and we have nothing.

Based on observation, record review and staff and resident interview, the facility failed to administer intravenous (IV) medication as ordered for 1, (Resident #90), of 1 resident sampled with a urinary tract infection (UTI). The failure to administer antibiotics as ordered can lead to treatment failure, prolonged illness and the development of dangerous antibiotic-resistant bacteria.The findings included: Review of the clinical record revealed Resident #90 was [AGE] years old and had an admission date of 5/2/25. Diagnoses included recurrent UTI, urinary incontinence, incomplete bladder emptying, chronic renal impairment and chronic kidney disease. admission MDS (Minimum Data Set) dated 5/8/25 documented a BIMS (Brief Interview for Mental Status) score of 15 indicating resident is cognitively intact. The Quarterly MDS dated [DATE] BIMS 15,Review of the physician orders revealed an order dated 12/27/25 for Daptomycin Intravenous Solution Reconstituted 500 milligrams. (Antibiotic to treat urinary tract infections). Use 300 milliliters intravenously one time a day for UTI for 15 days.Review of the physician progress noted dated 12/27/25 documented: Review for management of a urinary tract infection requiring intravenous antibiotic therapy. The resident was seen for follow-up on a urinary tract infection for which she was recently started on intravenous Daptomycin (300 milliliters daily for 15 days). The IV was placed in the left arm on 12/26/25. Today, she is complaining of pain and bleeding at the IV insertion site, prompting notification of the IV team for troubleshooting. She is an [AGE] year-old female with multiple comorbidities including chronic kidney disease stage 3B. She has required as needed acetaminophen for pain and ondansetron for nausea over the past several days, likely related to the infection or antibiotic side effects. She has a follow-up appointment with Infectious Disease scheduled for 1/2/2026. The primary focus of today's visit is to manage the complications of her IV antibiotic therapy, monitor the underlying UTI, and coordinate care for her multiple chronic conditions in this acute setting.On 1/5/2026 at 2:55 p.m., during an observation, Resident #90 was noted with a Peripherally Inserted Central Catheter (PICC) line in her left upper arm, she said she was receiving IV antibiotics for a kidney infection. Resident #90 said she got the infection while at the facility.On 1/7/2026 at 4:00 p.m., Resident #90 who was very upset said she did not receive her 2:00 p.m., dose of the IV antibiotic. She said, I told the nurse I need my medication; I went to the nurse's desk and told them. Resident #90 was tearful and said, I just want my medication, so I can be done with this.On 1/7/26 at 4:05 p.m., Licensed Practical Nurse (LPN) Staff F arrived in Resident #90's room. The resident said, I did not get my antibiotic today, you said you would do it at 2:00 p.m. LPN Staff F said, I can't give it to you because I only have one of the medications. I don't have the one that goes with it. Resident #90 began to cry and said, Why did you not come and tell me then so I would not get upset? LPN Staff F told Resident #90 she was busy and going all day and had not had a break. The resident said If you had just come and told me I would not be so upset. Resident #90 asked why she did not have the medication and LPN Staff F responded I don't know. I don't know why it's not here.Review of the progress notes revealed LPN Staff F documented on 1/7/25, medication not at facility. Medication ordered by writer.Review of the clinical records failed to show any documentation of physician notification regarding the missed antibiotic dose on 1/7/25.On 1/8/2026 at 3:23 p.m., in an interview the Assistant Director of Nursing (ADON) said she was not aware Resident #90 did not receive her schedule antibiotic on 1/7/26. The ADON said, I would imagine the pharmacy did not send it. I will check with the DON.On 1/8/2026 at 3:28 p.m., in an interview the Director of Nursing (DON) said Resident #90 did not receive her IV medication because it was not delivered from pharmacy. The DON confirmed there was no documentation that the Physician was notified of the missed antibiotic dose.

Based on record review and interview, the facility failed to ensure residents who were offered an opportunity to consent or decline vaccines, received the vaccines consented for, unless medically contraindicated for 1 (Resident # 5) of 5 residents reviewed for vaccines. The findings included: On 1/7/25, a record review of Resident #5's chart revealed an informed consent for pneumococcal vaccine dated 11/30/25 on which Resident #5 indicated he consented to receiving the pneumococcal vaccine. Further review of Resident #5's chart failed to reveal documentation that he had received the vaccine.On 1/8/26 at 10:22 a.m., in a meeting with the Director of Nursing (DON) and the Infection Control Preventionist (ICP), Resident #5's pneumococcal vaccine was discussed. The DON reviewed the electronic chart and said she was unable to find documentation in computerized file that it had been given. The ICP checked Resident #5's hard paper chart and was unable to find documentation the vaccine had been given. Neither the DON nor ICP could offer an explanation why the consented for vaccine hadn't been given. The DON said, it had been missed. The DON said they did not have a facility policy for administering the pneumococcal vaccine.

Based on record review, residents and staff interviews, the facility failed to ensure 2 (Residents #900 and #800) of 3 dependent residents reviewed were treated with dignity by failing to respond timely to residents' call lights and failing to provide incontinent care to meet the residents' needs. The findings included:On 10/13/25, review of the facility's grievance log revealed residents' grievances for delays in responding to the call lights on 9/1/25, 9/4/25, 9/5/25, 9/16/25 and 9/24/25.On 9/24/25 a complaint/grievance form report documented, Delayed call light on overnight 11-7.On 10/13/25 at 10:42 a.m., in an interview Resident #900 said staff often do not answer the call light after 5:30 p.m. to 6:00 p.m. When they do, they turn it off, say they'll be back, but they don't. There has been time he had to sit in a soiled incontinent brief for 1 to 2 hours. Staff come in with an attitude when they have to provide care and say they were busy. The resident said staff get mad at him when he keeps pressing the call light to request assistance. They tell him, You are not the only one. He said he has fallen trying to take himself to the bathroom. Resident #900 said it was frustrating, upsetting and inhumane to sit in a soiled brief.Review of the clinical record revealed Resident #900 had an admission date of 9/9/25. Diagnoses included weakness, hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) affecting the right side.Review of the admission Minimum Data Set (MDS) with an assessment reference date of 9/15/25 revealed Resident #900 was dependent for toileting, dressing and bathing and was always incontinent of bowel and bladder. The MDS noted the resident scored 13 on the Brief Interview for Mental Status, indicating of intact cognitive skills for daily decision.Review of the Certified Nursing Assistant (CNA) documentation for September 2025 through October 13, 2025, failed to reveal documentation of bladder and bowel incontinence care on 10/1/25 (morning shift), on 9/22/25, 9/30/25, 10/2/25, 10/7/25 (evening shift), on 9/26/25, and 9/30/25 (night shift). On 10/13/25 at 12:00 p.m., in an interview Resident #800 said staff take more than 45 minutes to answer her call light. She said, When I am wet, I get a feeling of irritation when they don't come and change me. When they do show up, they tell me We are behind. They just don't get to me to get me up or change me. Sometimes they just don't care.Review of the clinical record for Resident #800 revealed an Annual MDS with an assessment reference date of 8/1/25. The MDS noted Resident #800 scored 15 on the BIMS, indicating intact cognition. The resident was dependent on staff for incontinent care, personal hygiene and bathing.Review of the Care Plan with a revision date of 9/25/24 revealed Resident #800 had an activities of daily living (ADL) self-care performance deficit related to decreased mobility, chronic pain, lymphedema (swelling of arms or legs), and lower extremities weakness. The goal with a revision date of 5/8/25 noted the resident would receive appropriate staff support with ADL's/mobility. The care plan noted the resident was incontinent of bowel and bladder.Review of the CNA documentation for September 2025 through October 13, 2025, failed to reveal documentation of incontinent care on 9/20/25 (day shift), 9/1/25, 9/8/25, 9/18/25, 9/30/25 (evening shift), 9/6/25, 9/30/25, 10/9/25 (night shift).On 9/11/25, 9/12/25, 9/20/25, and 9/29/25, N/A was entered for the evening shift.On 9/10/25, N/A was entered for the night shift. On 10/13/25 at 3:17 p.m., in an interview related to answering call lights, CNA Staff G said I don't know what the expected time is to answer a call light. If I'm in a room or if I go on break, I can't see if the light is on. I really don't know.On 10/14/25 at 9:19 a.m., an interview was held with the Administrator related to the failure of staff to respond timely to residents' call lights and the failure to provide incontinent care to meet the needs of the residents. The Administrator said the facility had no policy on call light response time or incontinent care. All staff can answer the call lights. If they are not able to assist the resident, they are to leave the call light on and find someone who can assist help. The Administrator said they held a Quality Assurance and Performance Improvement meeting on 9/18/25 to address call light response time. She said they were also auditing call light response. The expectation was to answer the call lights within 5 minutes.Review of the Ad Hoc (unplanned) Quality Assurance and Performance Improvement Meeting dated 9/18/25 revealed there had been an increase in Resident grievances related to call light response time within the past 2 weeks. During staff rounds call lights were not always within reach. Call lights should be answered as timely as possible preferably within 5 minutes.Review of the call light audits revealed on 9/23/25 from 1:00 p.m. to 2:30 p.m., the call light response was not within 10 minutes for 6 of 10 rooms. The observer conducting the audit documented the CNA was there, but no one answered in time. She wrote, I told CNA that they need to answer light faster. I told nurses when they hear the light if CNA not around for them to answer lights.On 9/26/25 the observer answered: No for Call light answered timely and call lights are within reach upon rounds for one room. The observer documented, . Action was taken for one room audited. CNA was told that her light was on for 10 min [minutes] and that was to [sic] long. She understood and did apologize.The Administrator did not provide audits conducted on the evening shift or the night shift.

Based on record review, resident and staff interviews, the facility failed to provide assistance with showers as outlined in the resident's care plan and according to residents' preferences for 2 (Residents #900 and #800) of 3 dependent residents reviewed.The findings included:Review of the clinical record revealed Resident #900 had an admission date of 9/9/25. Diagnoses included weakness, hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) affecting the right side.Review of the admission Minimum Data Set (MDS) with an assessment reference date of 9/15/25 revealed Resident #900 was dependent for toileting, dressing and bathing and was always incontinent of bowel and bladder. The MDS noted the resident scored 13 on the Brief Interview for Mental Status, indicating of intact cognitive skills for daily decision.On 10/13/25 at 10:42 a.m., in an interview Resident #900 said he doesn't get his scheduled showers on Wednesdays and Sundays. He has gone days, even weeks without a shower. When he asks for a shower, staff tell him they'll be back to shower him but they don't.The resident pointed to a sign on the wall that documented his showers were scheduled on Wednesday and Sunday during the 7:00 a.m. to 3:00 p.m., shift.Review of the Certified Nursing Assistant (CNA) documentation for September and October 2025 revealed Resident #900 was scheduled for showers on Thursday and Sunday during the 7:00 a.m. to 3:00 p.m., shift.On 9/11/25, 9/18/25, 9/25/25 and 9/28/25 on scheduled shower days, a bed bath was documented.On 9/16/25, 9/23/25 and 9/30/25 there was no documentation of care.On 10/5/25 and 10/9/25 on scheduled shower days, N/A (not applicable) was entered for shower.Review of the clinical record for Resident #800 revealed an Annual MDS with an assessment reference date of 8/1/25. The MDS noted Resident #800 scored 15 on the BIMS, indicating intact cognition. The resident was dependent on staff for incontinent care, personal hygiene and bathing.Review of the Care Plan with a revision date of 9/25/24 revealed Resident #800 had an activities of daily living (ADL) self-care performance deficit related to decreased mobility, chronic pain, lymphedema (swelling of arms or legs), and lower extremities weakness. The goal with a revision date of 5/8/25 noted the resident would receive appropriate staff support with ADL's (Activities of Daily Living).On 10/13/25 at 12:00 p.m., in an interview Resident #800 said she likes to shower and get her hair washed but has not received a shower in several weeks.Review of the CNA documentation for September 2025 and October 2025, revealed Resident #800's shower days were Mondays and Thursdays on the 7:00 a.m. to 3:00 p.m. shift.On 9/1/25, 9/4/25, 9/11/25, 9/15/25 and 10/9/25 the documentation showed Resident #800 received a bed bath.On 9/29/25, N/A was documented.On 10/14/25 at 12:04 p.m., in an interview the Administrator said the facility had no policy on ADL care or bathing. The staff are expected to follow the shower schedule.On 10/14/25 at approximately 12:35 p.m., in an interview CNA Staff F said There is shower list at the desk, and you follow it. The residents will let you if they want a shower.

Based on observation, record review, staff interview and review of facility policy and procedure the facility failed to implement corrective actions to achieve and maintain compliance in previously cited deficiencies.The findings included: Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) dated 11/30/14 (revised 10/24/22) documented The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement that focuses on indicators of the outcomes of care and quality of life.The center's QAPI program is on-going comprehensive review of care and services provided to residents.The program is a coordinated effort among departments and services within the organization that involves Leadership working with input from Center staff, families and residents.The Center will collect and monitor data from different departments reflecting its performance.The Center will utilize performance indicator to how much does it cost you monthly and when you're making monthly and compare the two that's how realistic budget established goals comma identify opportunities for improvement comma and evaluate progress towards goals.During a recertification and follow-up survey conducted on 1/5/26 through 1/9/26 the facility failed to maintain ongoing compliance by failing to ensure 1 of 3 dependent residents reviewed were treated with dignity by failing to respond timely to residents' call lights and failing to provide incontinent care to meet the residents' needs and showers.Review of the facility Plan of Correction specified by 11/20/25 the Director of Nursing (DON) will have completed quality review of current resident's plan of care charting to ensure showers and incontinent care are documented.The facility conducted 9 audits from 12/1/25 through 12/22/25 indicating all Certified Nursing Assistant (CNA) ADL (Activities of Daily Living) documentation was completed with showers and incontinent care completed and documented. On 1/6/26 at 8:58 a.m., Resident #800 said I put the call light on and usually they change me sometimes they tell me I have to wait and I don't like to wait when I'm wet. A sign indicating her shower days were Monday and Thursday on the 7-3 shift was on the wall above the bed. Resident #800 said showers are not always given, I don't refuse them. When they come in and say they are going to give me a shower I just let them do it. Sometimes it takes a long time for them to come in to help when I use the call light, maybe 15 to 30 minutes, sometimes it's an hour.Review of the CNA documentation revealed # 800 did not receive scheduled showers on 11/6/25 and 11/27/25. She received a bed bath on 12/4/25, and 12/29/25.By 11/20/25 the Social Service Director will complete weekly visits to ensure Resident #800 is not affected by the deficiency.On 1/9/26 at 10:00 a.m., in an interview with the Social Service Director, she said she documented all her visits in a progress note but was unable to provide the notes. She said, I did one audit with the resident on 12/29/25. The rest were in bypassing.On 1/5/2026 at 10:39 a.m., Resident #89 said he is not being turned, and no one answers his call light. He said on the evening shift they do not come for 15 minutes to an hour, and they will turn the light off and leave without providing care.The facility also failed to implement a system to ensure 2 of 3 dependent residents received scheduled showers.The facility conducted 9 audits from 12/1/25 through 12/22/25 indicating all CNA ADL documentation was completed and showers were documented.Review of the CNA documentation for November 2025 revealed Resident #800 was scheduled for showers on Monday and Thursday on the 7-3 shift. On 11/6/25 and 11/27/25 she received a bed bath. Review of the December 2025 CNA documentation revealed on 12/4/25, and 12/29/25 she received a bed bath.A review of the Certified Nursing Assistant (CNA) documentation for November to December 2005 revealed a bed bath was provided to Resident #800 in place of the scheduled evening showers on Wednesday and Saturday on 11/22/25, 12/3/25, 12/10/25, and 12/13/25. There was no documentation of a shower on 12/27/25 and 12/31/25.On 1/5/2026 at 10:39 a.m., during an observation and interview Resident #89 was noted to have long fingernails extending 1/2 inch past the tip of the fingers with a brown substance under the nail beds. He said he does not like them that long because they cut into his left hand due to a contracture. He was able to open his fingers slightly to show this writer his pinky finger had started to cause irritation to the palm of his hand. He said he does not have a splint, and no one ever puts anything in his hand to prevent the pressure. He was unshaven with 3 days of facial hair growth. Resident #89 said he had a wound on the left buttocks he acquired while at the facility and had to have 2 surgeries to close the wound after an infection to the bone.On 1/7/26 at 10:00 a.m., in an interview CNA Staff H said he was assigned to Resident #89 today. He said he did not know about shaving, doing nail care or repositioning /turning and was not able to answer any questions regarding the resident's care needs. On 1/7/26 at 10:50 a.m., this writer showed Unit Manager Licensed Practical Nurse Staff T and Resident Liaison Staff B the condition of Resident #89's fingernails and facial hair growth. Unit Manager Staff T said he did not know when the CNAs were supposed to shave or cut fingernails. I think it is whenever the resident asks them to.

Based on record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to report an allegation of physical abuse to the Agency for Health Care Administration within the specified timeframe for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of the facility provided Abuse, Neglect, Exploitation & Misappropriation Policies and Procedures with an effective date of 11/30/2014 and a revision date of 11/16/2022 revealed, Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse . to a resident, is obligated to report such information immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . to the Administrator and to other officials in accordance with State law . Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .Review of the clinical record revealed Resident #1 had an admission date of 7/9/25 with diagnoses including Parkinson's Disease with dyskinesia (involuntary, uncontrolled muscle movements), and anxiety.Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 9/30/25 revealed Resident #1 scored a 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition.Review of the Care Plan initiated on 10/1/25 for Alteration in Usual Functional Performance in Mobility/Transfer revealed Resident #1 required supervision or touching assist with 1 staff for bed to chair transfer and toilet transfers.On 10/13/25 at 10:55 a.m., in an interview Resident #1 said that the Certified Nursing Assistant (CNA) who was assigned to her the night of 10/5/25 hurt her arm while assisting her to the bathroom. She reported the incident to CNA Staff H on 10/6/25.On 10/13/25 at 12:16 p.m., in an interview the Assistant Director of Nursing (ADON) said on 10/6/25, Licensed Practical Nurse (LPN) Staff I reported to her that Resident #1 alleged during the night of 10/5/25 the CNA who was assigned to her hurt her arm while assisting her to the bathroom. The ADON said she reported the allegation to the Administrator on 10/6/25 at approximately 9:00 a.m., during morning meeting.On 10/13/25 at 12:31 p.m., in an interview LPN Staff I said on 10/6/25 she was doing rounds when CNA Staff H reported to her that Resident #1 said during the night shift of 10/5/25, CNA Staff J hurt her arm while assisting her to the bathroom. LPN Staff I said she immediately reported the allegation to the Director of Nursing (DON) on 10/6/25 at approximately 8:30 a.m. Review of the facility provided investigation revealed the resident informed the ADON that during the night shift, the CNA came into the room to answer the light. The Resident informed the CNA that she needed assistance with toileting. The CNA grabbed the resident by the right hand and pulled her up. The resident stated that the CNA pulled her arm hard and it hurts from the wrist to the shoulder.The investigation noted the incident occurred on 10/5/25 at 8:00 p.m., and staff became aware of the incident on 10/6/25 at 12:00 p.m. The incident investigation noted the Administrator was notified of the incident on 10/6/25 at 2:07 p.m.Review of the incident reporting history revealed that the allegation of abuse was not reported to the Agency for Health Care Administration within 2 hours after the allegation was made as required. The report was submitted to the Agency for Health Care Administration on 10/7/25 at 1:07 p.m.On 10/14/25 at 12:59 p.m., in an interview the Administrator said the allegation of physical abuse should have been reported to the Agency for Health Care Administration within 2 hours and it was not.

Based on observation, review of facility's policy and procedure and staff interview, the facility failed to ensure medications were kept locked in 1 (300 hall) of 4 medications carts observed when not in use and under direct supervision. The findings included: Review of the facility policy 1.0 Medication Dispensing System (no effective date) documented Medication carts are always to be locked when out of sight or unattended.On 10/13/25 at 10:23 a.m., during a tour of the facility the 300-hall medication cart was observed unlocked, and unattended and unsecured for approximately 4 minutes. Residents and staff were observed passing by the unlocked medication cart.On 10/13/25 at 10:27 a.m., Licensed Practical Nurse Staff A was observed coming around the corner. She said she went to gather supplies for a resident and verified she left the medication cart unlocked and unattended for several minutes.

Based on record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to protect residents' rights to be free from neglect by failing to follow physician medication orders for 2 (Resident #875 and #775) of 4 residents reviewed. The facility failed to perform and document weekly skin evaluations for 1 (Resident #99) of 3 sampled residents at risk for pressure ulcer to ensure timely identification and treatment of skin alterations. The findings included: Review of the facility policy N-1265 Abuse, Neglect, Exploitation and Misappropriation, documented It is inherent in the nature and dignity of each resident at the center that he or she be afforded basic human rights including the right to be free from abuse, and neglect, mistreatment. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, and mistreatment.The facility defines neglect as the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: Failure to take precautionary measures to protect the health and safety of the resident. Intentional lack of attention to physical needs. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed. 1. Review of the clinical record revealed Resident #875 was an alert and oriented [AGE] year old female admitted to the facility on [DATE] at 4:30 p.m. Diagnoses included convulsions, neuropathy, peripheral vascular disease, type 2 diabetes mellitus, hypertension, discitis and osteomyelitis to lumbar spine.Review of Resident #875's physician orders revealed an order to administer Carbamazepine 200 milligrams, 3 tablets at bedtime for seizures.Review of the Medication Administration Record (MAR) lacked documentation the medication was administered on 6/12/25.Review of the facility's provided investigation for neglect revealed documentation that Resident #875 was admitted to the facility on [DATE] around 4:00 p.m. On 6/13/25 it was discovered that the assigned nurse, Licensed practical nurse (LPN) Staff D failed to activate the medication orders that were in the computer system. The failure to activate the medication orders resulted in the pharmacy not being aware of the new admission and the medication orders that needed to be filled and delivered. The nurses on the following shift were able to obtain some of the resident's medications from the facility emergency medication supply. Carbamazepine 200 milligrams give 3 tablets at bedtime for seizures was not available and was not administered on 6/12/25.Review of the Employee Corrective Action Form dated 6/17/25 for LPN Staff D documented On 6/12/25 employee did not activate the medication orders for a new admission. Employee did not obtain signatures for consent forms that are necessary to be able to treat patient. Employee failed to complete the nursing admissions assessments and due to the employee's negligence, the patient did not receive her medications timely. The employee was terminated.The facility did not substantiate the allegation of neglect.On 6/16/25, 3 days after admission, Resident #875 requested to be discharged . On 8/11/25 at 3:25 p.m., in a telephone interview, Resident #875 said, I did not get all of my medications when I arrived there. I did not get my Carbamazepine. I take 3 tablets at bedtime for seizures. I was tearful and afraid. It is so important that I get that. I don't know why they did not have my medicine when I got there. I was only there 3 days, and I was ready to leave day 1. I was upset, I was crying. I did throw a fit because I needed my seizure medication. I had just come from a long hospital stay and I did not want to go back. The facility never told me why they did not have my medication.On 8/12/25 at 8:25 a.m., in an interview the Regional Nurse Consultant (RNC) said Resident #875 did not get the Carbamazepine on 6/12/25 because the nurse did not complete the admission. She said, We did education and the nurse (LPN Staff D) was terminated. On 8/13/2025 at 2:10 p.m., in an interview the Director of Clinical Services (DCS) was asked about the facility's process for ordering medications to ensure new admissions received their ordered medications in a timely manner. The DCS said it should be done within 24 hours. When asked about the timeframe requirement for a nurse to complete the medication orders, he said, It depends on what it is going on throughout the day and how many medications the resident is on. When asked how the pharmacy receives the orders for medications, he said Once they are in the electronic system they are activated immediately. As soon as you put in the orders, it's activated and in. Pharmacy gets the notification at that time. When asked to clarify activation, he said, When orders are put in the system, they go into a queue. It shows up as red. The nurse reviews and verifies the orders then hits activate the order which goes to pharmacy. The DCS demonstrated the process of entering, queuing, and activating the orders in the system. The DCS said if the medications are put in by 5:00 p.m., they should be in by midnight. After 5:00 p.m., they pull medications from the facility's emergency medication system. If the medication is not available in the emergency medication system, they notify the physician. He said sometimes they can call it in as stat (immediately) but it still may take a few hours. The DCS said the medications for Resident #875 were entered into the system on 6/12/25 at 10:09 p.m., but they were not activated until 6/13/25 at 6:21 a.m. The Pharmacy can't view or send the medications until the nurse activates them. 2. On 8/11/25 at 9:55 a.m., Resident #775 was observed lying on her left side in bed in her room. The resident's left eye was observed with mild redness and swelling. In an interview, Resident #775 the pain to her eye was better and she could see out of it. The resident said she was now receiving her eye drops. On 8/11/25 at 11:38 a.m., in an interview related to Resident #775's swelling and pain to the left eye, Licensed Practical Nurse (LPN) Staff E said Resident #775 had eye surgery. The physician's ordered eye drops were not administered as ordered before or after the surgery. She said she failed to enter the orders in the system. She said after the surgery, I remember we were busy, and I did not put the orders in. I told the oncoming nurse and she did not do it. LPN Staff E said, We were monitoring her eye. Thank god we got it cleared and she did not lose her vision. On 8/11/25 at 12:22 p.m., in an interview the Registered Nurse Consultant (RNC) said LPN Staff E was a brand-new nurse. She could not figure out where the paperwork for the pre and post-surgical information and orders was.On 8/11/25 at 1:26 p.m., in an interview the DCS said, The first I found out about the whole thing was when the surgeon called and said her left eye was infected.Review of the clinical record for Resident #775 revealed and admission date of 6/23/22. Diagnoses included cerebral ischemia, major depressive disorder, paranoid schizophrenia and muscle wasting.Review of the Brief Interview for Mental Status dated 5/21/25 documented Resident #775 had a score of 12, indicating moderate cognitive impairment.Review of the facility provided incident investigation related to the facility's neglect to administer physician's ordered necessary eye drops before and after eye surgery revealed:On 7/1/25, Resident #775 went out of the facility to the eye doctor. The resident returned with pre-surgical eye drops for cataract surgery. LPN Staff E failed to put the orders into the electronic facility record system. On 7/14/25 the resident had cataract surgery on her left eye and returned to the facility with post-surgical instructions including the eye drops. LPN Staff E was the nurse assigned to the resident post-surgery and failed to place the physician orders into the system. Resident #775 received no pre-surgical or post-surgical care to the left eye. On 7/23/25 the resident had a follow-up appointment with the eye doctor who immediately sent the resident to a retina specialist for an eye infection. On 7/23/25 the eye doctor contacted the facility and spoke with the DCS informing him that the operative eye was inflamed and showed signs of infection. The DCS investigated the matter and discovered the eye drops ordered by the physician had not been transcribed and were not administered. The facility's investigation documented Resident #775 had pain and inflammation in the left eye.On 7/23/25 the facility completed their investigation and verified the allegation of neglect.Review of the physician's ordered eye drops schedule revealed:Week 1: Starting day of surgery:Moxifloxacin (antibiotic) every hour while awake until bedtimeKetorolac (non-steroidal anti-inflammatory) 3 times daily.Prednisolone (steroid) 4 times daily. Week 2:Prednisolone 3 times daily.Ketorolac 3 times daily.Week 3:Ketorolac 3 times daily.Prednisolone 2 times daily.Week 4:Ketorolac 3 times dailyPrednisolone 1 time daily.Review of the post cataract surgery instructions revealed to, Take it easy for one week. Avoid lifting heavy objects or anything more than 10 lbs. Avoid bending over with your head below the level of your waist. Avoid any exercise or sexual activities. Strenuous types of activities can cause elevated pressure in the eye, which might cause problems during the first week after the surgery. No dirt or water in your eye for one week. The only substance that should get in your operated eye are the prescribed eye drops, or eyewash included in your post-op kit.Review of the surgical physician progress note dated 7/23/25 revealed Resident #775 had, Severe inflammation vs (versus) endophthalmitis (infection) left eye. The physician referred Resident #775 to the retina specialist for follow up/potential injection for lack of response to treatment and ordered: Prednisolone 1% one drop every hour.Moxifloxacin 0.3% one drop 4 times a day.Review of the Retina specialist progress note dated 7/25/25 revealed to continue Moxifloxacin 4 times a day and decrease Prednisolone from every 1 hour to every 2 hours while awake.On 8/13/25 at 11:16 a.m., in a telephone interview the ophthalmic surgeon's Surgical Technician said on 7/23/25 when the resident was seen for her follow up they became aware she did not receive any pre-op- or post op eye drops. The surgical technician said, The outcome could have been blindness, she could have gone blind, not just have an eye infection.On 8/13/25 at 1:15 p.m., in a telephone interview the ophthalmic surgeon said, I gave very clear written and verbal instruction for both pre-op and post op for cataract surgery. They did not administer any eye drops to her. When I saw her at the post-op follow up on 7/23/25 her eye looked terrible. It was inflamed, red. I immediately sent her to the retina specialist, I was that concerned. The patient could have gone blind, that is the outcome that could have occurred. I have been doing cataract surgery since 2016 and generally 1/50,000 will lose the vision in the operative eye. In my career, I have had 2 and she would have been number 3. It is that serious that they receive the eye drops. We did everything. We sent the scripts electronically to the pharmacy. The eye drops should have started the morning of her surgery. The surgery was at 2:00 p.m., so they had all day to start the drops. The instructions were clear and easy to follow. It was important not to get the left eye wet, not to lift anything, not to rub the eye and to administer the eye drops as ordered.3. Review of the facility policy WC-100, Clinical Guideline Skin and Wound with an effective date of 4/1/17 revealed, to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of or prevention of pressure injury. On admission or readmission, the resident skin will be evaluated for base line skin condition and documented in the resident record. Licensed nurse to document presence of skin impairment or new skin impairment when observed and weekly until resolved. Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. Licensed nurse to report changes in skin integrity to the physician or practitioner and resident or responsible party and documents in the medical record.On 8/11/25 at 10:12 a.m., Resident #99 was observed lying in bed on her left side. In an interview the resident said the nurse had just finished changing the dressings on her wounds. The resident said she was in pain from the wound care and had requested a pain pill. Resident #99 said she requires help to turn in bed.Review of the facility provided weekly wound reports for pressure injury revealed documentation on 2/21/25 Resident #99 had a facility acquired pressure ulcer to the sacrum that measured 3.5 centimeters (cm) in length by 3.5 cm in width.Review of the Wound Care Physician (WCP) progress note dated 2/27/25 revealed Resident #99 had an unstageable pressure ulcer to the sacrum measuring 3.5 centimeters (cm) length by 3.5 cm width. The WCP ordered to cleanse with normal saline, apply Santyl (debridement ointment) and cover with a dry dressing daily.Review of the facility provided incident investigation for Resident #99's facility acquired pressure ulcer revealed on 2/21/25 a nurse reported an open area over Resident #99's sacrum. The Director of Clinical Services (DCS) assessed the wound and it was deemed unstageable. The incident investigation documented the 2 Certified Nursing Assistants (CNAs) who took care of Resident #99 on 2/15/25 said the resident had redness over the area and on 2/17/25 the area opened a little. Tissue injury may have been present under the skin but was not noted until it opened. The investigation noted on 9/19/24 the wound care physician identified a deep tissue injury to Resident #99's sacral area that healed. At some point between 12/17/24 and 2/21/25 the deep tissue injury re-developed and later became a pressure ulcer. The resident has several co-morbidities and healing of any wound is compromised by her diagnoses of peripheral vascular disease, Raynaud's disease and CREST syndrome (autoimmune disease that causes the skin and connective tissues to harden and tighten).The facility's investigation noted that Resident #99 returned to the facility on [DATE]. The hospital form 3008 noted that the resident had no wound over the sacrum. There was no record of a facility admission skin assessment or subsequent skin assessments. These should have been done weekly per facility policy.The summary of relevant resident record review noted that review of the Treatment Administration Record revealed two nurses documented that they performed skin assessments when in fact they were not done.The facility verified the allegation of neglect and documented, The two nurses involved did not perform the weekly skin assessment and is dereliction of duty. Furthermore, they documented on the Treatment Administration Record that the skin assessment were done but they did not do them. There is no record of skin assessments.On 8/11/25, Review of the clinical record for Resident #99 revealed an admission date of 7/26/24. Diagnoses included peripheral vascular disease, protein calorie malnutrition, left below knee amputation, major depressive disorder and current cigarette smoker.Review of Minimum Data Set (MDS) assessments revealed on 12/17/24 Resident #99 had an unplanned discharge to an acute care hospital. Resident #99 returned to the facility on [DATE].Review of the Quarterly MDS assessment with a target date of 12/29/24 revealed Resident #99's cognitive skills for decision making were intact with a Brief Interview for Mental Status score of 15. The MDS noted the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcer. Resident #99 was always incontinent of bladder or bowel.Review of the Treatment Administration Record (TAR) for January 2025 and February 2025 revealed Licensed Practical Nurse (LPN) Staff B documented she completed the weekly skin sweeps on 1/6/25, 1/12/25, 1/19/25, 1/28/25, 2/2/25 and 2/16/25.LPN Staff A documented she completed the weekly skin sweeps on 2/9/25 and 2/23/25.On 8/12/25 at 12:00 p.m., in an interview LPN Staff A confirmed on 2/2/25 and 2/16/25 she signed the Treatment Administration Record (TAR) verifying she completed the weekly skin evaluation but she did not do them. LPN Staff A said she could not remember why she did not do the skin evaluation on 2/2/25 and 2/16/25. She said she must have been busy.

Based on observation, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to ensure staff consistently performed weekly skin evaluations for 1 (Resident #99) of 3 residents reviewed for early identification and treatment of pressure ulcers. The findings included:Review of the facility provided weekly wound reports for pressure injury revealed documentation on 2/21/25 Resident #99 had a facility acquired pressure ulcer to the sacrum that measured 3.5 centimeters (cm) in length by 3.5 cm in width.On 8/7/25 the weekly wound report noted Resident #99 had a facility acquired stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) on the sacrum measuring 2 cm x's 1.8 cm with 0.8 cm depth. A left hip facility acquired stage 4 pressure ulcer identified on 5/22/25 measured 2.5 cm x's 2.5 cm with 1.5 cm depth.Review of the facility provided incident investigation for Resident #99's facility acquired pressure ulcer revealed on 2/21/25 a nurse reported an open area over Resident #99's sacrum. The Director of Clinical Services (DCS) assessed the wound, and it was deemed unstageable. The incident investigation documented the 2 Certified Nursing Assistants (CNAs) who took care of Resident #99 on 2/15/25 said the resident had redness over the area and on 2/17/25 the area opened a little. Tissue injury may have been present under the skin but was not noted until it opened. The investigation noted on 9/19/24 the wound care physician identified a deep tissue injury to Resident #99's sacral area that healed. At some point between 12/17/24 and 2/21/25 the deep tissue injury re-developed and later became a pressure ulcer. The resident has several co-morbidities and healing of any wound is compromised by her diagnoses of peripheral vascular disease, Raynaud's disease and CREST syndrome (autoimmune disease that causes the skin and connective tissues to harden and tighten).The facility's investigation noted that Resident #99 returned to the facility on [DATE]. The hospital form 3008 noted that the resident had no wound over the sacrum. There was no record of a facility admission skin assessment or subsequent skin assessments. These should have been done weekly per facility policy.The summary of relevant resident record review noted that review of the Treatment Administration Record revealed two nurses documented that they performed skin assessments when in fact they were not done.The facility verified the allegation of neglect and documented, The two nurses involved did not perform the weekly skin assessment and is dereliction of duty. Furthermore, they documented on the Treatment Administration Record that the skin assessment was done but they did not do them. There is no record of skin assessments.On 8/11/25, Review of the clinical record for Resident #99 revealed an admission date of 7/26/24. Diagnoses included peripheral vascular disease, protein calorie malnutrition, left below knee amputation, major depressive disorder and current cigarette smoker.Review of Minimum Data Set (MDS) assessments revealed on 12/17/24 Resident #99 had an unplanned discharge to an acute care hospital. Resident #99 returned to the facility on [DATE].Review of the Quarterly MDS assessment with a target date of 12/29/24 revealed Resident #99's cognitive skills for decision making were intact with a Brief Interview for Mental Status score of 15. The MDS noted the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcer. Resident #99 was always incontinent of bladder or bowel.Review of the Treatment Administration Record (TAR) for January 2025 and February 2025 revealed Licensed Practical Nurse (LPN) Staff B documented she completed the weekly skin sweeps on 1/6/25, 1/12/25, 1/19/25, 1/28/25, 2/2/25 and 2/16/25.LPN Staff A documented she completed the weekly skin sweeps on 2/9/25 and 2/23/25.Review of the Wound Care Physician (WCP) progress note dated 2/27/25 revealed Resident #99 had an unstageable pressure ulcer to the sacrum (Pressure ulcer's tissues are obscured such that the depth of soft tissue damage cannot be observed) measuring 3.5 centimeters (cm) length by 3.5 cm width. The WCP ordered to cleanse with normal saline, apply Santyl (ointment to remove dead tissue) and cover with a dry dressing daily.On 8/11/25 at 10:12 a.m., Resident #99 was observed lying in bed on her left side. In an interview the resident said the nurse had just finished changing the dressings on her wounds. The resident said she was in pain from the wound care and had requested a pain pill. The resident rated her pain a 9 out of 10 (severe pain). Resident #99 said she requires help to turn in bed.On 8/11/25 at 10:23 a.m., in an interview with Registered Nurse (RN) Staff H said she was doing the wound care today. She said she was not the wound care nurse but when there was an extra person on the assignment, someone does the wound care. The RN Staff H said Resident #99 had 3 wounds. The sacrum and the left hip were treated with Moist Dakins solution (broad spectrum antiseptic) and dry sterile dressing daily and as needed. The Left hip was infected, and the resident was receiving the antibiotic Bactrim. RN Staff H said the resident was not able to turn completely in bed, she requires 2 people to assist her.On 8/12/25 at 9:10 a.m., observation of wound care with Resident #99, with her consent. Unit Manager LPN Staff F provided wound care and CNA Director of Patient Services Staff G assisted with positioning the resident. The left hip wound was yellow with slough (dead tissue), and tan drainage, a moderate amount. The Sacral wound was approximately the size of a deck of cards, black with an open area at 6:00 O'clock. The treatment was Dakins soaked gauze and dry dressing for all the wounds. The Unit Manager said the wound care is completed daily but she often does not let the wound care physician look at the wounds and she refuses treatments at times. The Unit Manager said the resident likes to sit outside and smoke most of the day.On 8/12/25 at 10:16 a.m., in a telephone interview with the Wound Care Physician he said the resident refused care and is non-compliant. We recommended a low air loss mattress, and she refused it. She is non-compliant and a smoker. There is a low chance for the sacral wound to heal. I visit once a week it is on and off with her. She does not always allow me to see her, and she is alert and oriented. She is very stubborn, and she refused the air mattress and said it was too hard. She does not comply with turning and repositioning. The left hip is showing signs of infection, and she is on antibiotics for that.On 8/12/25 at 12:00 p.m., in an interview LPN Staff A confirmed on 2/2/25 and 2/16/25 she signed the Treatment Administration Record (TAR) verifying she completed the weekly skin evaluation but she did not do them. LPN Staff A said she could not remember why she did not do the skin evaluation on 2/2/25 and 2/16/25. She said she must have been busy.

Based on review of facility's policies and procedures, review of the Resident council meeting minutes, and staff interviews, the facility failed to respond to grievances and recommendation voiced by the Resident Council for 5 (May, June, July, September, and October 2023) of 7 months of council minutes reviewed. The findings included: A review of facility policy titled, Resident Council Meeting dated 11/1/21 specified, Residents will be provided the opportunity to meet at least monthly in an organized group setting to discuss current issues/topics of their choice. These topics may include events, activities, resident rights, care, and service and concerns. In addition, a review of old business, problem resolution, and development of action plans may be discussed . Procedure: 4. Record minutes on the Resident Council Minutes form and copy to the Executive Director for review. 5. Utilize the Resident Council Minutes (section Department Overview/Develop Action Plan) for any issues requiring a follow up response. Resident Council will review this section at each meeting to determine if concern was resolved, not resolved, or partially resolved. Unresolved or partially resolved concerns are brought forward to the next set of minutes for Resident Council Review. A review of Facility policy titled, Complaint/Grievance revision date 10/24/22 specified, The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution . Procedure: 3. The grievance officer/designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. A review of a Resident Council Minutes form dated 5/1/2023 revealed 10 residents attended the meeting. The residents voiced concerns related to call light response on 3-11 and 11-7 shifts, and laundry issue related to returning items in a timely manner. There was no documentation that the facility addressed the concerns voiced by the resident council group. Review of a Resident Council Minutes form dated 6/5/23 revealed 14 residents attended the meeting and voiced concerns related to food, provide residents with alternative menu when requested. The form documented the issue was partially resolved. Missing laundry, return all items within 2-3 days - not resolved. Review of a Resident Council Meeting form dated 7/3/23 revealed 14 residents attended the meeting. The concerns included missing laundry. The residents would like laundry back in two to three days. This marked as partially resolved. Concerns related to dietary, providing residents with requested alternatives when requested was marked as not resolved. No Resident Council Meeting was held for the month of August 2023. Review of Resident Council Minutes form dated 9/11/23 revealed 9 residents attended the meeting and the following concerns were not resolved: Food and dietary, don't always get our selection. Confused residents going in and out of other rooms, residents want them to be kept out. Concerns for missing clothes. Review of Resident Council Minutes form dated 10/9/23 revealed 13 residents attended the meeting and the following concerns were not resolved: Food half cooked, meals cold when served, do not follow special orders that residents request, cereal served without milk, dietary staff do not give resident cream/sugar/salt and pepper when requested. Items that are posted on the menu are not what they receive. Housekeeping/Laundry, getting back clothes in a timely manner to resident and making sure every item is labeled with resident name. On 10/10/23 at 10:30 a.m., a meeting was held with nine Resident Council members, including Resident #5, #6, #12, #23, #33, #43, #64, #67, and #72. The meeting minutes of the last six months were discussed. The residents all said the issues brought up in resident council in the past six months had not been resolved, the issues continued. The residents stated the food and dietary issues, and the missing cloths from the laundry were a continuing problem that were either partially resolved or not resolved. On 10/11/23 at 3:15 p.m., the Activity Director said she started employment at the facility a couple of weeks ago and held her first Resident Council Meeting this month. She said she gives the minutes to the Administrator for her review. The Administrator distributes the concerns to the appropriate staff member to address. On 10/12/23 at 1:12 p.m., the Administrator said the Activities Director brings the meeting minutes to her. She directs the concerns to the appropriate department and gives them a certain amount of time to look into the concerns and resolve them. The resolutions should be brought back to the resident council to see if they have seen any improvement.

Based on record review and staff interview the facility failed to ensure a comfortable environment for 1 (Resident #59) of 2 residents sampled for missing property in that they failed to exercise reasonable to minimize the loss of personal property. The findings included: Review of the facility's document titled Personal Property Loss or Theft, dated 11/30/14 read, The center has processes to minimize the risk of loss or theft of residence personal property. At admission resident's belongings will be identified and recorded . An employee receiving a concern regarding lost or missing items from a resident or resident representative will initiate a Complaint /Grievance form or electronic equivalent .The center will track frequency and patterns of lost items and will initiate with the Executive Director contact with the Police Department where deemed appropriate . On 10/9/23 at 8:30 a.m., Resident #59 said her clothes are always missing. She reports it to the Housekeeping Supervisor all the time. A review of the facility's complaint, and grievance report revealed Resident #59 filed a complaint related to missing property on 3/4/23, 9/11/23 and 10/1/23. Review of the Nursing Progress Note dated 8/27/23 documented CNA (Certified Nursing Assistant) notified this writer the Resident stated she is missing 2 packages of cigarettes. On 10/10/23 at 8:21 a.m., Resident #59 said Resident #40 wanders around the facility and takes other people's things. She said, Yesterday she had my clothes on. On 10/10/23 at 8:25 a.m., Certified Nursing Assistant (CNA) Staff E said the day before, she observed Resident #40 wearing Resident #59's shirt and pants. Staff E said, It happens all the time. I don't know what laundry is doing. They are always delivering the wrong clothes to other residents' rooms. I try to look for things if my residents said they are missing something, I will go and check for myself. On 10/10/23 at 8:30 a.m., Resident #59 said Resident #40 goes into other residents' rooms. She said, It does not matter if you have your door closed, it doesn't stop her. She said the facility placed a lock on the drawers of the nightstand to keep Resident #40 out. She said, I have told the Director of Nursing, the Administrator and the nurse but nothing is done about her, she wanders all day long. On 10/10/23 at 1:38 p.m., Resident #59 was observed at the nursing station. Resident #59 was telling CNA Staff E Resident #40 was wearing her clothes again. CNA Staff E verified Resident #40 was wearing Resident #59's clothes. On 10/10/23 at 3:58 p.m., Unit Manager Staff D said he was not aware Resident #59 had reported missing items. Staff D said Resident #40 wanders and goes into other residents' rooms and takes things. Staff D said, We try to redirect Resident #40, she is confused with dementia, and there is nothing we can really do. On 10/12/23 at 8:30 a.m., the Director of Nursing (DON) said Resident #59 tells stories about missing items. She said she was not aware CNA Staff E had observed Resident #40 wearing Resident #59's clothes. On 10/12/23 at 12:44 p.m., further review of the Grievance Log failed to show facility representatives initiated a Complaint/Grievance to address Resident #59's concerns related to the missing clothing.

Based on observation, review of facility policies and procedures, record review, staff and resident interviews, the facility failed to demonstrate effective coordination to ensure 3 (Resident #37, #96 and #399) of 3 resident's reviewed received appropriate medical care and treatment. The findings included: The facility policy and procedures for Self-Administration of Medication at Bedside dated 11/30/14 noted, the resident may request to keep medications at bedside for self-administration in accordance with resident rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medications and to keep accurate documentation of these actions. Procedure: Verify physicians order in the residence chart for self-administration of specific medications under consideration. Complete a self-administration of medication evaluation. Complete the care plan for approved self-administrated drugs The MAR (medication administration record) must identify meds that are self-administered, and the medication nurse will need to follow up with the resident as to documentation and storage of medication during each med pass. If it is kept at bedside the medication must be kept in a locked drawer. 1. Review of the clinical record revealed Resident #399 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD), chronic kidney disease, atrial fibrillation, and anxiety. On 10/9/23 at 10:47 a.m., Resident #399 said he was not receiving all of his medications and the nurse tells him it is because they are not able to reach the physician. He said he came from the assisted living facility (ALF) side of the facility to the hospital and was admitted to the skilled nursing facility. Resident #399 said he was not receiving the medications he needed to treat his COPD. Resident #399 had a nebulizer (a device that turns liquid medicine into a mist which is inhaled) on the nightstand next to his bed. Resident #399 said the nebulizer here works but no one takes care of it, and they were not giving him the medication he needed. The resident said, I have told every nurse who walks in this room, I need my nebulizer, I have COPD and asthma. I can't breathe right. I keep getting the same answer, the doctor has to order it. The resident said, How hard is it to call the man and get an order? I'm ready to check myself out of here and walk next door to the ALF and have my medication. Further review of the clinical record revealed there was no order for a nebulizer or medication for the nebulizer. On 10/10/23 at 9:09 a.m., Resident #399 said he still had not received the nebulizer treatment. He said he asked someone to go the ALF where he resides and bring the medication to him. He was self-administering the nebulizer treatment but only had one vial left. The resident said he used it four times a day. Resident #399 said he will have to have someone go to the ALF and get him more medication. He said I had a friend go there last week to my apartment and bring me the medication. I have reported it to the nurse every day and they tell me I can't get it because they have not reached the physician yet. I have been here for days, and you're telling me no one has looked at my record? Resident #399 showed a vial of nebulizer medication to the surveyor, placed the liquid medication into the nebulizer cup and turned the machine on. On 10/10/23 at 4:17 p.m., the Unit Manager Staff D said he knew Resident #399 had a nebulizer in his room but was not receiving any medication. The Unit Manager checked the residents electronic record and said he did not have an order for the nebulizer. He said Resident #399 had his previous roommate go to the ALF and get his backpack, I guess he had it in there. He has not received any medication in the nebulizer. The observation of Resident #399 self-administering a nebulizer treatment was shared with Staff D. Staff D said Resident #399 really did not require skilled nursing and would probably return to his room in the ALF tonight or tomorrow anyway. Staff D said he would let the physician know Resident #399 was requesting nebulizer medication. On 10/11/23 at 9:15 a.m., Resident #399 said he had COPD, allergies, was coughing and needed his nebulizer treatment. He said the physician ordered the medication last night, but he still has not received it. On 10/11/23 at 9:21 a.m., Unit Manager Staff D verified the physician ordered the medication last night and it arrived from the pharmacy. Staff D said he would make sure the resident gets the medication. On 10/11/23 at 1:10 p.m., a review of the MAR showed a physician order for Ipratropium-Albuterol solution 0.5-2.5 (3) mg/3ml via nebulizer every 6 hours as needed for shortness of breath. On 10/11/23 at 4:46 p.m., the Director of Nursing (DON) said she was unaware Resident #399 had a nebulizer and was self-administering the respiratory treatment in his room. The DON said the physician ordered the medication the day before. 25618 2. On 10/10/23 at 9:45 a.m., during an interview with Resident #96, she said she was admitted to the facility on [DATE] after having hip surgery. She said when she was admitted to the facility, she had a wound vac to the surgical site which was stapled together. The wound-vac stopped working and the wound care nurse discontinued the wound-vac the next day and left the staples intact at the surgical site. After several days she said she asked the wound care nurse when he would remove the staples from the surgical site, and he told her the surgical site was red and the staples could not be removed at that time. Resident #96 said she kept asking the wound care nurse and the floor nurses when the staples would be removed, when was her follow-up appointment with the surgeon and when would her primary care physician (PCP) be coming to the facility to see her. She said the nursing staff told her they did not know when the staples would be removed, and they did not know when her follow-up appointment would be with the surgeon. She further said when she asked the wound care nurse last week when her follow-up appointment was with the surgeon, he told her she was responsible for calling the surgeon and making the follow-up appointment with the surgeon. She said she did not think the surgeon's office, the facility, and her PCP were communicating with each other to address the removal of the staples to the surgical wound site. A review of Resident #96's medical record revealed she was admitted to the facility on [DATE] after a joint replacement surgery to the left hip. A physician's order dated 9/21/23 stated to remove the left hip wound vac on 9/27/23 and call the surgeon's Nurse Practitioner (NP) to arrange for a follow-up visit with the surgeon. A review of a Weekly Skin Integrity Review form dated 10/1/23 stated the left thigh (rear) surgical site was red with drainage. The Weekly Skin Integrity Review form dated 10/5/23 stated the left trochanter post-surgical site measures 17 x 0.1 x 0.1 centimeters (cm) with 100% epithelial tissue. The Weekly Skin Integrity Review form dated 10/8/23 noted staples to the left hip but did not identify the number of staples in the incision. The Admission/Readmission Data Collection form dated 9/21/23 stated Resident #96 had a left trochanter wound vac. A Surgical & Wound Care progress note dated 10/5/23 noted the wound care physician was asked to see Resident #96 for his opinion on how to manage the patient's wounds. The wound care physician wrote the left hip surgical site wound had erythema (redness) and edema (swelling). He recommended Doxycycline (antibiotic) 100 milligrams (mg) twice a day for 10 days; cleanse the wound with 0.125% Dakins Solution, apply betadine, and change the dressing every day and as needed. Further review of the wound care physician's progress note revealed no documentation of the staples to the left hip surgical site. A review of a nursing progress note dated 9/21/23 stated Resident #96's left hip wound vac was in place, clean, dry, and intact. A nursing progress note dated 10/5/23 stated the nurse attempted to call the surgeon's Nurse Practitioner (NP) for a follow-up appointment for when the wound vac was originally scheduled to be discontinued. The wound care nurse was made aware of the attempt to contact the surgeon's NP. The progress notes further stated Resident #96 was seen by the wound care physician at the bedside and Resident #96 was started on ABT (antibiotic therapy) prophylactically for the left hip surgical site. A review of the nursing progress notes dated 10/6/23, 10/7/23, and 10/8/23 stated the nurse called the surgeon's NP for a follow-up appointment when the wound vac was scheduled to come off, and that Resident #96 was being seen by the Wound Care Physician. A review of the Notification of Change in Condition policy and procedure #N-105 effective 11/30/14 and last revised 12/16/20, stated The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there was a change in the status or condition .The nurse to notify the attending physician and Resident Representative when there is a (n) .a need to alter treatment significantly, new treatment, discontinuation of a current treatment due to but not limited to adverse consequences, acute condition, and exacerbation of chronic condition. On 10/12/23 at 11:21 a.m., in an interview with the Wound Care Physician, he reviewed his 10/5/23 progress note. He confirmed he was asked by the wound care nurse to evaluate Resident #96's left hip surgical site for his opinion on how to manage Resident #96's surgical wound. He confirmed he wrote the left hip, surgical site wound had erythema and edema, and he recommended Doxycycline 100 mg twice a day for 10 days and a treatment for the surgical site. The wound care physician said he did not believe Resident #96 had staples to the surgical site at the time of his assessment because he did not document the staples in his progress note. On 10/12/23 at 11:35 a.m., in a second interview with the Wound Care Physician said he was informed by the Wound Care Nurse, that Resident #96's left hip surgical wound staples were removed yesterday (10/11/23) by the surgeon. He said he was asked by the Wound Care Nurse to look at Resident #96's surgical site but did not know if the facility and/or the Wound Care Nurse had informed Resident #96's PCP and/or the surgeon the facility had requested his evaluation and treatment of Resident #96's surgical site. On 10/12/23 at 1:17 p.m., in an interview with the Wound Care Nurse, he confirmed Resident #96 was admitted to the facility on [DATE] with a wound vac to the left hip surgical site with staples. He said the wound vac stopped working on 9/22/23 so he discontinued the wound vac and tried to call the surgeon's NP several times but was unable to reach them.? He confirmed he asked the Wound Care Physician to evaluate Resident #96's surgical wound for possible treatment orders. He said he was unable to find documentation he and/or another facility staff had informed Resident #96's surgeon and/or Resident #96's PCP the wound vac had stopped working on 9/22/23 and the facility had asked the Wound Care physician on 10/5/23 to conduct an evaluation of Resident #96's surgical wound site. On 10/12/23 at 2:07 p.m., in an interview with the Director of Nursing (DON), she said the facility's policy stated the nurse was required to inform a resident's primary care physician for any change in resident status. She confirmed Resident #96 was admitted on [DATE] with a left hip surgical site with staples and a wound vac. She said Resident #96 had an order which stated when the wound vac was discontinued to call the surgeon to arrange for a follow-up visit. The DON said after reviewing all of Resident #96's medical records, the wound vac stopped working on 9/22/23 and there was no documentation the facility staff called the surgeon and/or Resident #96's PCP to inform them the wound vac had stopped working. She said she noted the nursing staff had called and left a message for the surgeon's NP on 10/5/23 which was 14 days after the wound vac had stopped working. She further said they had no documentation Resident #96's surgeon was informed the Wound Care physician was asked to evaluate the surgical site and an ABT was ordered for Resident #96's surgical wound. She said the facility staff did not follow their Notification of Change policy as required when they did not notify the surgeon and/or Resident #96's PCP on 9/22/23 when the wound vac was discontinued because it was not working and when they asked the Wound Care physician to evaluate and treat Resident #96's surgical wound care site due to the surgical wound site had erythema and edema for which the wound care physician prescribed a new treatment order and ABT for 10 days. 41905 3. Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses including aftercare following joint replacement surgery and presence of right artificial hip joint. Review of the Order Summary Report revealed an antibiotic order for Ceftriaxone Sodium Intravenous (IV) solution 2 grams, use intravenously from 9/26/23 until 11/1/23. Review of the Medication Administration Records (MARs) for September and October 2023 revealed the antibiotic was being administered through the IV each day at 1:00 p.m. starting on 9/26/23. On 10/10/23 at 11:52 a.m., observed Resident #37 in bed, left arm exposed. IV dressing to left inner arm had a hand-written date of 9/23/23. There was a brown substance under the transparent dressing where the catheter entered the resident's arm. Resident #37 said the IV dressing had not been changed since the hospital put it in. Photographic evidence obtained. Review of the MARs for September 2023 did not include orders to change the IV dressing. Review of the Order Summary Report revealed orders for IV catheter dressing change on 10/9/23: Change Dressing on admission or 24 hours after insertion and weekly there after and prn (as needed). Review of the MARs for October 2023 revealed the IV dressing change was completed on 10/10/23. On 10/11/23 at 10:15 a.m., observed Resident #37 in bed. The IV dressing had not been changed as the October MAR indicated, and the date was still 9/23/23. The brown substance was still under the transparent dressing and the dressing was peeling away from the skin in one corner. The Director of Nursing (DON) was in the room at the time and said the IV dressing was outdated and should have been changed. On 10/12/23 at 10:28 a.m., Registered Nurse Staff D said he was the certified Infection Preventionist for the facility. He said Resident #37 has a mid-line IV catheter, but he was not aware the dressing was outdated. He said the nurse should have checked with the doctor and included the IV dressing changes when the resident returned on 9/25/23. He said the midline IV needs to be changed when resident is admitted or within 24 hours and then each week or seven days thereafter.

Based on record review, staff interviews, review of the facility's abuse and neglect policy and procedure, the facility failed to protect vulnerable residents' rights to be free from abuse for 1 (Resident #1) of 3 sampled residents. On 7/18/22, Resident #1 was observed with his mouth on Resident #2's penis. Resident #1 had severe cognitive impairment and could not consent to sexual activities. The facility failed to protect resident #1 from further potential abuse by allowing Resident #1 and Resident #2 to continue to share a room without adequate supervision after the incident. Sexual abuse can cause feelings of shame, terror, and guilt. Due to the trauma and negative emotions linked to sexual abuse, survivors are at risk for mental health conditions. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The failure to protect residents' rights to be free from sexual abuse, and the failure to intervene appropriately to prevent further potential sexual abuse resulted in noncompliance at the Immediate Jeopardy level starting on 7/18/22. The Administrator was notified of the Immediate Jeopardy on 12/2/22 at 5:37 p.m. and provided the Immediate Jeopardy templates. After surveyor verification of the removal of immediacy on 7/19/22 and achievement of compliance on 9/20/22 the determination of past noncompliance was made. The findings included: Cross reference F610 The facility's policy and procedure for abuse, neglect, exploitation and misappropriation with a revision date of 11/28/2017 noted, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse . Sexual abuse is non-consensual sexual contact of any type with a resident.Generally, sexual contact is non-consentual if the resident either: appears to want the contact to occur, but lacks the cognitive ability to consent; or does not want the contact to occur. Review of the Resident Census records revealed on 7/18/22 Resident #1 and Resident #2 were roommates. Resident #1 was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease. Review of the clinical record revealed a certificate of incapacity signed and dated by the physician on 3/17/20, indicating the resident was unable to make health care decisions for himself or provide informed consent to medical treatment. The physician noted there was no reasonable probability that the resident will recover competency to make health care decisions. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 4 on the Brief Interview for Mental Status, indicative of severe cognitive impairment. Review of the progress notes revealed a late entry dated 7/19/22 which noted Resident #1, was observed with his mouth on another male resident's penis (Resident #2). Residents were immediately separated . Review of the clinical record for Resident #2 revealed an admitted [DATE] with diagnoses including psychosis, and schizophrenia. The Quarterly MDS dated [DATE] noted Resident #2 scored 14 on the BIMS, indicating intact cognition. Review of the progress notes revealed a late entry dated 7/19/22 which noted Resident #2, was observed with his penis in another male resident's mouth (Resident #1). Residents were immediately separated . On 7/18/22 Licensed Practical Nurse (LPN) Agency Nurse A wrote on a witness statement she put Resident #1 back to bed around 12:00 a.m. after he sat in the hallway following the incident. Supportive staff checked on the resident every two hours and she checked on the resident every hour throughout the entire shift. On 7/19/22 Certified Nursing Assistant (CNA) Staff B wrote on a witness statement at about 9:00 p.m., he saw Resident #1 in bed with Resident #2 with his mouth on Resident #2's penis. He immediately got the nurse. They separated the residents. Resident #2 got dressed and went to sit in the common area. Resident #2 was in and out of facility throughout the night for smoke breaks. Resident #1 sat in the twilight room until about midnight when he went to his bed for the night. The nurse and him (CNA Staff B) took turns checking on the residents every hour. At 7:00 a.m., the supervisor separated the residents and moved Resident #1 to another room. On 7/19/22 the Administrator documented she interviewed Resident #2 who gave a verbal statement and stated he asked Resident #1 for oral sex. Resident #2 stated he believed the act to be consensual. He stated he just wanted sex. The psychiatric Advanced Practice Registered Nurse (APRN) progress note dated 7/19/22 noted Resident #1 was seen due to incident reported by facility staff. Staff reported on 7/18/22 Resident #1 and his roommate were found involved in sexual act. Resident #1 was found giving fell atio (oral stimulation of a man's penis) to his roommate. After the incident Resident became more depressed, withdrawn and tearful. Resident #1 has been incapacitated on 3/17/20. Resident #1 did not want to talk about the incident and continued to report, I don't know, I don't know. He denies suicidal ideation but continues to report he feels embarrassed about the incident and kept stating he did not want to talk about this. Upon assessment, patient does present with emotional distress from incident, but more so because he is embarrassed and does not want others knowing about his sexual preferences. The practitioner wrote, . As per collected information and interview, it appears the patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying depression and anxiety disorder. The symptoms are occurring daily and causing mod (moderate)/severe distress. The practitioner documented she decided to discontinue Cymbalta (antidepressant) and start Zoloft (antidepressant) 50 milligrams twice a day, keep the resident on one-to-one supervision. On 7/19/22 the Psychiatric APRN documented in a progress note, Patient (Resident #2) seen today due to incident reported by facility staff. Staff reports on 7/18 that patient was involved in incident of inappropriate behavior with roommate. Patient is currently on 1:1(one-to-one supervision). Patient is alert and oriented to person, place, time and situation and able to make his needs known. He is able to make his own decisions. He reports his roommate was the one who initiated the oral sex. He denies having had asked the roommate for sexual favor but states he was also embarrassed about incident. The patient does not present with emotional distress and appears stable. Patient to remain on 1:1 at this time for safety. On 11/30/22 at 12:05 p.m., the administrator said the sex act occurred on 7/18/22 during the 3:00 p.m. to 11:00 p.m. shift, and she found out about the incident on 7/19/22 at 7:30 a.m. She said staff did not tell her about the incident until the next day. The Administrator said they failed to separate the residents immediately, the LPN did not separate them. Residents #1 and #2 were roommates at the time and, that was the error in that the nurse did not separate them. On 11/30/22 at 1:43 p.m., the administrator said after the incident, Resident #2 stayed in the original room and Resident #1 moved to a private room close to the nurse's station. Both residents were placed on one-on-one supervision 24 hours a day, seven days a week. A CNA was assigned to each resident, each shift. They stayed on one-on-one supervision until they were discharged . On 11/30/22 at 1:51 p.m., CNA Staff B said he was at the facility on 7/18/22 working 7:00 p.m., to 7:00 a.m. shift the day of the sex incident and walked in on it. CNA Staff B said he closed the door and right away told Agency Nurse, LPN A about it. He and the nurse went back in the room and by that time, Residents #1 and #2 had stopped the act. He said that night, all nurses were from agencies. He did not know the protocol, so he told the nurse. He said Agency LPN A reported the incident the next morning to another nurse who told her what she should have done but did not. CNA Staff B said he thought the Administrator was aware of Resident #1's sexual preferences, so he did not feel the need to tell anyone. On 11/30/22 at 3:45 p.m., the Social Service Director (SSD) said Resident #2 had been at the facility for five years. She said Resident #2 was not incapacitated and never spoke about Resident #1. She said Resident #1 could hold a conversation; he had unspecified dementia. The SSD said Resident #1 was incapacitated and could not consent to oral sex. The SSD said Resident #2 could act willfully. On 11/30/22 at 5:15 p.m., the Assistant Director of Nursing said she's been the risk manager at the facility since April 2022. She said Resident #1 was confused and had an incapacity statement. She was not aware of any behavior prior to the incident. She said she interviewed Resident #2 who told her he asked Resident #1 for a blow job and Resident #1 did it. Resident #2 said the act would not matter if it occurred in prison. Review of the Nursing Home Federal Reporting website revealed on 7/25/22 at 2:52 p.m. the facility submitted a Federal Day 5 report to the Agency for Health Care Administration substantiating the allegation of abuse. The report noted, Residents visualized in a sexual act. Facility failed to immediately separate residents and place on 1:1. Abuse coordinator and Administrator were not notified, and facility failed to report in timely manner. The determination of past noncompliance was made after verification of immediate actions implemented by the facility according to the Immediate Jeopardy removal plan which included: As of 7/19/22, Resident #2 was placed on one-to-one observation and remains on one-to-one observation. As of 7/19/22, Resident #1 was placed on one-to-one observation and remained on one-to-one observation. As of 7/19/22 Resident #1 and Resident #2 were evaluated by a Registered Nurse and experienced no negative outcome. As of 7/19/22 skin assessment was completed on resident #1 and Resident #2 and experienced not negative outcome. As of 7/19/22 Resident #1 and Resident #2 were evaluated by psychological services and will continue to be monitored by psychological services. As of 7/19/22 Resident #1 and Resident #2's attending physician was contacted with new order for STD (Sexually Transmitted Diseases) panel. As of 7/20/22 Residents with a BIMS of 10 or greater interviews were conducted to ensure no other allegations of abuse were not reported and investigated. As of 7/19/22 residents with a BIMS of 9 or less skin evaluations were completed by a licensed nurse to ensue no other allegations of abuse were not reported and investigated. As of 7/20 through 7/22/22 psychological services evaluated residents identified with behaviors. As of 7/20/22 current residents identified that encountered resident were evaluated by a Registered Nurse and experienced no negative outcome. Beginning on 7/20 and 7/22/22, staff interviews will be conducted to identify residents' behaviors, such as; do they kick, bite, scream, resist care, yells out, crying, spitting, disrobing, paces, wandering, sexually inappropriate or who lies? If behaviors, what do you do to get them cared for or to prevent further reoccurrence of the behavior? Licensed Nurses received education beginning on 7/20/22 on reporting of resident behaviors, managing and monitoring resident behaviors. Licensed Nurses received education beginning on 7/20/22 on change in condition and monitoring for sexually transmitted diseases. As of 7/20/22, resident behaviors will be documented using the behavior monitoring sheets by the Licensed Nurses and will be reviewed by the clinical team during the morning clinical meeting. Resident behaviors will be monitored and managed through the care plan process with activities and psychosocial support. Whole house education beginning on 7/20/22 on the abuse policy to include preventing abuse, identification and protection, investigating and reporting inappropriate resident behaviors to the nurse. A post test was given to ensure competency of the information as presented in the in-service. Any staff member that did not receive education related to the above mentioned will be sent a certified letter as of 7/22/22 indicating they may not return to work until the education is received. Newly hired staff will receive education in orientation. Agency licensed nurses and certified nursing assistants will be educated prior to starting shift on floor. On 12/2/22 interviewed licensed nurses on duty, including one agency Licensed Practical nurse, three staff Licensed Practical Nurse, and three Certified Nursing Assistants. All nurses and Certified Nursing Assistants interviewed verified receipt of education on abuse, neglect, and exploitation. All were able to verbalize process to follow for any allegation of abuse. Verified documentation of staff education. Content included what constitutes abuse. Description of physical, sexual, psychological abuse, involuntary seclusion. Misappropriation (financial). Signs of abuse and neglect. Definition of neglect, exploitation. Preventing abuse, and reporting abuse. Hand out given to all staff included phone numbers of the Executive Director, Director of Nursing and Assistant Director of Nursing.

Based on record review, review of facility's policies and procedures, and staff interview the facility failed to take immediate appropriate actions to prevent further potential abuse following observation of resident-to-resident sexual abuse for 1 (Resident #1) of 3 residents reviewed for abuse investigation. On 7/18/22, Resident #1 was observed with his mouth on Resident #2's penis. Resident #1 had severe cognitive impairment and could not consent to sexual activities. The facility staff failed to immediately report the observation of sexual abuse and failed to protect Resident #1 from further potential abuse by allowing Resident #2 unsupervised access to Resident #1 after the observed sexual abuse. Sexual abuse can cause feelings of shame, terror, and guilt. Due to the trauma and negative emotions linked to sexual abuse, survivors are at risk for mental health conditions. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The facility failure to take appropriate measures and provide ongoing protection to Resident #1 to prevent further potential sexual abuse by Resident #2 resulted in noncompliance at the Immediate Jeopardy level starting on 7/18/22. On 12/2/22 at 5:37 p.m., the Administrator was notified of the Immediate Jeopardy and provided the Immediate Jeopardy templates. After surveyor verification of the removal of immediacy on 7/19/22 and achievement of compliance on 9/20/22 the determination of past noncompliance was made. The findings included: Cross reference to F600 The facility's policy and procedure for abuse, neglect, exploitation and misappropriation with a revision date of 11/28/2017 noted, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse. Sexual abuse is non-consensual sexual contact of any type with a resident.Generally, sexual contact is non-consentual if the resident either: appears to want the contact to occur, but lacks the cognitive ability to consent; or does not want the contact to occur. All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse. to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.to the Administrator and to other officials in accordance with State law.Protection. Increased supervision of the victim. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Review of the clinical record for Resident #2 revealed an admitted [DATE] with diagnoses including psychosis, and schizophrenia. The Quarterly MDS dated [DATE] noted Resident #2 scored 14 on the BIMS, indicating intact cognition. Review of the progress notes revealed a late entry dated 7/19/22 which noted Resident #2, was observed with his penis in another male resident's mouth (Resident #1). Residents were immediately separated . Review of the clinical record for Resident #1 revealed a readmitted [DATE] with diagnoses including Alzheimer's disease. The clinical record revealed a certificate of incapacity signed and dated by the physician on 3/17/20, indicating the resident was unable to make health care decisions for himself or provide informed consent to medical treatment. The physician noted there was no reasonable probability that the resident will recover competency to make health care decisions. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 4 on the Brief Interview for Mental Status, indicative of severe cognitive impairment. Review of the progress notes revealed a late entry dated 7/19/22 which noted Resident #1, was observed with his mouth on another male resident's penis (Resident #2). Residents were immediately separated . On 7/19/22 Certified Nursing Assistant (CNA) Staff B wrote on a witness statement at about 9:00 p.m., he saw Resident #1 in bed with Resident #2 with his mouth on Resident #2's penis. He immediately got the nurse. They separated the residents. Resident #2 got dressed and went to sit in the common area. Resident #2 was in and out of facility throughout the night for smoke breaks. Resident #1 sat in the twilight room until about midnight when he went to his bed for the night. The nurse and him took turns checking on the residents every hour. At 7:00 a.m., the supervisor separated the residents and moved Resident #1 to another room. On 7/19/22 Licensed Practical Nurse (LPN) Agency Nurse A wrote in a witness statement she was told by Certified Nursing Assistant (CNA) Staff B he witnessed both patients (Resident #1 and Resident #2) in (room number) involved in sexual (oral) intercourse when passing ice. On 7/18/22 LPN Agency nurse A wrote on a witness statement she put Resident #1 back to bed around 12:00 a.m. after he sat in the hallway following the incident. Supportive staff checked on the resident every two hours and she checked on the resident every hour throughout the entire shift. On 7/19/22 the Administrator documented she interviewed Resident #2 who gave a verbal statement and stated he asked Resident #1 for oral sex. Resident #2 stated he believed the act to be consensual. He stated he just wanted sex. Review of the Nursing Home Federal Reporting website revealed on 7/25/22 at 2:52 p.m. the facility submitted a Federal Day 5 report to the Agency for Health Care Administration substantiating the allegation of abuse. The report noted, Residents visualized in a sexual act. Facility failed to immediately separate residents and place on 1:1. Abuse coordinator and Administrator were not notified, and facility failed to report in timely manner. Agency nurse who failed to report abuse put on do not return list . On 11/30/22 at 12:05 p.m., the administrator said the sex act occurred on 7/18/22 during the 3:00 p.m. to 11:00 p.m. shift, and she found out about the incident on 7/19/22 at 7:30 a.m. She said staff did not tell her about the incident until the next day. The Administrator said they failed to separate the residents immediately, the LPN did not separate them. Residents #1 and #2 were roommates at the time and, that was the error in that the nurse did not separate them. On 11/30/22 at 1:51 p.m., CNA Staff B said he was at the facility on 7/18/22 working 7:00 p.m., to 7:00 a.m. shift the day of the sex incident and walked in on it. CNA Staff B said he closed the door and right away told Agency Nurse, LPN A about it. He and the nurse went back in the room and by that time, Residents #1 and #2 had stopped the act. He said that night, all nurses were from agencies. He did not know the protocol, so he told the nurse. CNA Staff B said LPN Agency Nurse A did not ask him for the Administrator's phone number, but he did not have it anyway. He said Agency LPN A reported the incident the next morning to another nurse who told her what she should have done but did not. On 11/30/22 at 5:15 p.m., the Assistant Director of Nursing said she's been the risk manager at the facility since April 2022. She said Resident #1 was confused and had an incapacity statement. She said she interviewed Resident #2 who told her he asked Resident #1 for a blow job and Resident #1 did it. Resident #2 said the act would not matter if it occurred in prison. The determination of past noncompliance was made after verification of immediate actions implemented by the facility according to the Immediate Jeopardy removal plan which included: As of 7/19/22, Resident #2 was placed on one-to-one observation and remains on one-to-one observation. As of 7/19/22, Resident #1 was placed on one-to-one observation and remained on one-to-one observation. As of 7/19/22 Resident #1 and Resident #2 were evaluated by a Registered Nurse and experienced no negative outcome. As of 7/19/22 skin assessment was completed on resident #1 and Resident #2 and experienced not negative outcome. As of 7/19/22 Resident #1 and Resident #2 were evaluated by psychological services and will continue to be monitored by psychological services. As of 7/19/22 Resident #1 and Resident #2's attending physician was contacted with new order for STD (Sexually Transmitted Diseases) panel. As of 7/20/22 Residents with a BIMS of 10 or greater interviews were conducted to ensure no other allegations of abuse were not reported and investigated. As of 7/19/22 residents with a BIMS of 9 or less skin evaluations were completed by a licensed nurse to ensue no other allegations of abuse were not reported and investigated. As of 7/20 through 7/22/22 psychological services evaluated residents identified with behaviors. As of 7/20/22 current residents identified that encountered resident were evaluated by a Registered Nurse and experienced no negative outcome. Beginning on 7/20 and 7/22/22, staff interviews will be conducted to identify residents' behaviors, such as do they kick, bite, scream, resist care, yells out, crying, spitting, disrobing, paces, wandering, sexually inappropriate or who lies? If behaviors, what do you do to get them cared for or to prevent further reoccurrence of the behavior? Licensed Nurses received education beginning on 7/20/22 on reporting of resident behaviors, managing and monitoring resident behaviors. Licensed Nurses received education beginning on 7/20/22 on change in condition and monitoring for sexually transmitted diseases. As of 7/20/22, resident behaviors will be documented using the behavior monitoring sheets by the Licensed Nurses and will be reviewed by the clinical team during the morning clinical meeting. Resident behaviors will be monitored and managed through the care plan process with activities and psychosocial support. Whole house education beginning on 7/20/22 on the abuse policy to include preventing abuse, identification and protection, investigating and reporting inappropriate resident behaviors to the nurse. A posttest was given to ensure competency of the information as presented in the in-service. Any staff member that did not receive education related to the above mentioned will be sent a certified letter as of 7/22/22 indicating they may not return to work until the education is received. Newly hired staff will receive education in orientation. Agency licensed nurses and certified nursing assistants will be educated prior to starting shift on floor. On 12/2/22 interviewed licensed nurses on duty, including one agency Licensed Practical nurse, three staff Licensed Practical Nurse, and three Certified Nursing Assistants. All nurses and Certified Nursing Assistants interviewed verified receipt of education on abuse, neglect, and exploitation. All were able to verbalize process to follow for any allegation of abuse. Verified documentation of staff education. Content included what constitutes abuse. Description of physical, sexual, psychological abuse, involuntary seclusion. Misappropriation (financial). Signs of abuse and neglect. Definition of neglect, exploitation. Preventing abuse, and reporting abuse. Hand out given to all staff included phone numbers of the Executive Director, Director of Nursing and Assistant Director of Nursing.

Based on record review, staff interviews, review of the facility's abuse and neglect policy and procedure, the facility failed to protect vulnerable residents' rights to be free from abuse. The facility neglected to implement adequate interventions for 1 (Resident #900) of 3 sampled residents with known wandering behaviors that had a likelihood of physical and/or sexual abuse. On 5/16/21 Resident #900, who was cognitively impaired was found in Resident #800's room with her head on his lap. Resident #800's penis was exposed and erected. Resident #900 was not able to consent to sexual activity. Sexual abuse can cause feelings of shame, terror, and guilt. Due to the trauma and negative emotions linked to sexual abuse, survivors are at risk for mental health conditions. Survivors of sexual abuse may develop depression, anxiety, post-traumatic stress, personality disruptions, attachment issues and addiction. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The facility's neglect to protect residents' rights to be free from sexual abuse resulted in noncompliance at the Immediate Jeopardy level starting on 5/16/21. The Administrator was notified of the Immediate Jeopardy on 6/4/21 at 10:00 a.m. and provided the IJ templates. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 6/4/21 at 6:00 p.m. and the scope and severity were reduced to a D . The findings included: Cross Reference to F607, F610, and F835. The facility policy N-1265, Abuse, Neglect, Exploitation and Misappropriation (revised 11/28/17) specified It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment and exploitation. Abuse is the willful infliction of injury. with resulting physical harm, pain, or mental anguish . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable though [sic] the use of technology . Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breast or perineal area. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity. Forced observation of masturbation and/or pornography; and Taking sexually explicit photographs and/or audio/video of recordings of a resident(s) and maintaining and/or distributing them (i.e., posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident . Resident #900 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) admission assessment with a reference date of 4/13/21 noted Resident #900 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The Elopement Risk Evaluation completed on 4/29/21 documented Resident #900 had cognitive impairment and wandered oblivious to safety needs, indicating the resident was at risk for elopement. Review of the progress notes revealed on 4/11/21, 4/23/21 the Licensed nurse noted Resident #900's behavioral problems are wandering. The care plan initiated on 4/30/21 noted Resident #900 was an Elopement risk/wanderer r/t [related to] Dementia, disoriented to place, impaired safety awareness. The goal was for the resident will not leave the facility unattended. The interventions/tasks included Distract resident from wandering by offering 1:1 as needed . The care plan did not include specific interventions to address Resident #900's wandering and safety due to impaired safety awareness. The nursing progress note dated 5/15/21 at 11:31 a.m., documented Resident #900 was oriented to person . Propels self in wheelchair about the facility, goes toward doors and in patient's room. Wanderguard in place and functioning. Review of the Nursing Home Federal Reporting to the Florida State Survey Agency dated 5/16/21 submitted by the facility noted on 5/16/21 at approximately 10:15 a.m., Certified Nursing Assistant (CNA) Staff B stated she was walking past Resident #800's room and saw Resident #900 bent over Resident #800's legs. Her head was on his lap. When she pulled Resident #900's wheelchair away, she saw Resident #800 pushing his penis back in his pajamas. She took Resident #900 out of the room and reported the incident to the nurse right away. On 5/16/21 CNA Staff B wrote a statement that read She [Resident #900] was bent over his [Resident #800] legs. Her hands were in her lap. Her face was in his lap. When I pulled away her w.c [wheelchair] I saw him [Resident #800] pushing his penis back in his P.J.S [pajamas]. He said Darn it. You got me caught. She [Resident #900] didn't say anything. She just smiled. She did not have a mask on. Neither did he. On 5/17/21 at 4:30 p.m., Psychiatric Advanced Practice Registered Nurse (APRN) Staff P documented she assessed Resident #900 via telepsych (visit conducted via video chat), Pt [patient] information obtained from Nursing, pt and pt record. Nursing reports pt found performing oral sex on another resident. Assessment and Plan for today's visit: Pt was alert, severely demented, calm, smiling . Upon assessment via telepsych, pt unable to recall incident with other resident. Pt does not appear to have any emotional distress . Please Start [MEDICATION(S)] (Anticonvulsant that can be prescribed as a mood stabilizer) 300 milligrams BID [Twice a day] for Dementia with behaviors. Continue 1:1 Q 15 minute [every 15 minutes] checks for 24 hrs [hours] then discontinue. Will monitor. On 6/2/21 at 5:45 p.m., the Registered Nurse Consultant provided a Psychiatric progress note signed and dated 5/17/21 at 4:30 p.m. The note listed Psychiatric APRN Staff P as the provider but was electronically signed by Psychiatric APRN Staff Q. The note read Pt was seen via telepsych due to her sudden wandering behavior. Per staff reports she was found in another Patient's room, the male patient was fully dressed, and pt had her head in his lap. Not [sic] inappropriate behavior was noted on the behalf of the male patient. Pt was seen in her bed; she was calm and cooperative she was unable to remember the incident of 5/16/21. She was incoherent, due to her advanced dementia, however, due to her impulsive behaviors she will be started on [MEDICATION(S)] 300 mg BID. She will remain on 1 to 1[one-to-one] for the night and take her off on 5/18/21 in the AM . The clinical record lacked documentation Resident #900 was placed on one to one supervision to prevent further wandering into other residents' rooms with a likelihood of resident-to-resident abuse, including sexually inappropriate behaviors. On 5/19/21 the Licensed Nurse documented Monitor for behaviors, reminders not to touch other people. Had to redirect often. On 5/20/21 at 1:22 p.m., Licensed Practical Nurse Staff C documented Resident . up in w/c [wheelchair] self-propelled left day room and entered male resident room and was in bed, male resident (Resident #885) stated they were only talking, no sexual behaviors noted, male resident stated he tried to put call on but was mashing bed control, both residents fully dressed. On 5/20/21 Psychiatric APRN Staff P documented seeing Resident #900 for a follow up visit. She wrote Patient last seen on 05/17/21 via Telepsych. Correction: For pt note on 5/17/21, Pt was not witnessed performing actual oral sex on another male resident. Staff reports pt was seen with her head laying [sic] on other resident's lap only. Staff cannot say they witnessed oral sex being performed between pt and other resident, only that it may or may not have occurred. Earlier today, nursing reports staff member witnessed pt stroking the arm of another male resident telling him how beautiful he was. Pt was also just found laying [sic] beside another male resident in his room and in his bed. However, nursing reports other resident reported nothing happened as they were just talking. Nursing has placed pt on 1:1 . Pt unable to remember and does not recall prior incidents. Pt continues to have hypersexual inappropriate behaviors toward male residents since last med [medication] change. Therefore, I decided to start [MEDICATION(S)] 20 mg (milligrams) PO (orally) QD (daily) for Dx (diagnosis) Depression as it will help decrease sexual inappropriate behaviors. On 6/1/21 at 3:15 p.m., in a telephone interview CNA Staff B said on 5/16/21 at 10:15 a.m., she walked past the room and noticed Resident #900 and Resident #800 had their wheelchairs facing each other. Resident #900 had her head in his lap. Resident #800's penis was out of his boxers, and he had an erection. Her head was down there. I saw his penis out and that is what made me turn around. I thought Did I just see what I think I saw? I walked into the room, and I pulled [Resident #900] from him. She was in her wheelchair. I pulled [Resident #900] from him [Resident #800] in her wheelchair and [Resident #800] said Damn it, you got me caught. I told the risk manager he said that. [Resident #800] looked scared like he knew he was in trouble because he got caught. CNA Staff B said his penis was hard and he was trying to get it back in his pants. He told me he was scared because he thought he was in trouble because he got caught. On 6/1/21 at 3:00 p.m., in an interview the Risk Manager said Resident #900 did not show sexually inappropriate behavior prior to 5/16/21. She said Resident #900 would wander in her wheelchair at times but never showed any behaviors. She would pat or rub a male resident's arm or knee and they redirected her. She said she interviewed staff and Resident #800 who said Resident #900 came into his room. She said she assumed Resident #800 penis just fell out of his pajamas when Resident #900 put her head in his lap. She said she could not confirm Resident #800 was the initiator of the incident. She said, I assumed it was [Resident #900] because she would rub male residents on their arms. She said she did not place Resident #800 on one-to-one supervision because she assumed Resident #900 was the aggressor. She said I think like I said she [Resident #900] wandered into his [Resident #800]'s room and put her head in his lap. He got an erection, and his penis just came out of his pants because he had an erection. She said she never asked Resident #800 if he had removed his penis out of his pants. On 6/1/21 at 4:41 p.m., the Risk Manager said she could not find documentation in Resident #900's chart indicating she was touching other male residents on the arm. She said, we just knew she was and would redirect her. She said based on that behavior she assumed she (Resident #900) was the aggressor. She said she interviewed other male residents on the same hall to see if Resident #900 came into their rooms but did not document it anywhere. She said she also spoke with Resident #800, and he seemed upset by it and was depressed over his wife. He said Resident #900 came into his room and he never touched her. On 6/2/21 at 8:15 a.m., in an interview LPN Staff D, said Resident #900 had only been in the current room for about a week. She said, they told me when she was on the other side that she likes to get into bed with other men, but I really don't know much about her. On 6/2/21 at 8:30 a.m., in an interview LPN Staff G said Resident #900 was alert, confused and needed assistance with activities of daily living. She likes to wander and has one-to-one sitter and I know they found her in bed with other men, but I have not seen any behaviors. She has only been on Station 1 for about a week. On 6/2/21 at 8:45 a.m., in an interview LPN Staff C said Resident #900 liked to wander and heard she had an incident where they found her in another man's bed, but she only knew of the incident when she found her in Resident #885's bed on 5/20/21. She said Resident #900 does not know where she is or what she is doing. She wanders and that is why we put the wander guard on her so she could not leave the facility. On 6/2/21 at 8:50 a.m., in an interview CNA Staff E said Resident #900 liked to wander, she is confused and wandered but she never saw her do anything or touching anyone. She said she heard about her being in bed with a man when she was on the other Station. CNA Staff E said Resident #900 was on one-to-one supervision because the nurse said she liked to get into men's beds. On 6/2/21 at 10:02 a.m., in an interview LPN Staff H said on 5/16/21 said the CNA came out of the room and said that they were facing each other, and her head was down in his lap and came up quickly when she knocked and entered the room. She called the supervisor, and he took over. She said she did see Resident #900 wandering the halls before the incident but never saw her touching other men. She went into other residents' rooms, and they would get her out. On 6/2/21 at 1:40 p.m., in a telephone interview Psych APRN Staff P said she saw Resident #900 on 5/14/21 but it was for a decreased appetite and not anything else. She is severely demented. She saw her again on 5/17/21 by telehealth. They told her they found Resident #900 with head on someone's lap but there was no sexual act. She said Resident #900 is not able to give consent to anything, she has dementia. She thought it was odd that she initiated anything with her dementia. She assumed Resident #900 initiated what happened because they said she was stroking another man on his arm in the facility. She said she thought maybe Resident #900 thought Resident #800 was her husband or old boyfriend and she was just laying her head in his lap. She said no one told her Resident #800's penis was out. She did not know anything about his penis being out and did not interview the CNA. She said the Director of Nursing (DON) was the one who told her what happened. At first, they said it was oral sex but then they said there was no sexual act, just Resident #900 head was on his lap and nothing about his penis. The APRN said Resident #800 was alert and oriented to person and place and was capable of knowing what was going on. She said Resident #800 never mentioned his penis was out when she spoke to him. She added it was possible Resident #800 knew what was going on. The psychiatric APRN said she was at the facility on 5/20/21 when Resident #900 climbed into bed with Resident #885. Resident #885 told her (Resident #900) you can't climb in my bed. He said he kept pushing the call light until the staff came and removed her. She said Resident #900 needed continued one-to-one supervision. She never told them to take her off the one-to-one supervision, they were supposed to keep her on. On 6/2/21 at 2:00 p.m., in an interview Resident #885 said Resident #900 came into my room in a wheelchair, and I told her she could not be here, but she wheeled herself up to the bed and climbed in my bed. Nothing happened, we just talked. I hit the call-light and no one came for the longest time. Resident #885 said it was about 30 minutes before anyone came into the room. They tried to tell me I was pushing the bed button and not the call light. He said the incident made him feel creepy. He said he saw Resident #900 wandering in her wheelchair in the facility a couple of times before it happened but not since. He never saw Resident #900 do anything sexual with anyone else, she just goes her way. Resident #885 said the facility did not do anything and did not know what the facility could have done after, they talked to me and that was about it. They just asked me what happened, they didn't do anything else, that was it. On 6/2/21 at 4:25 p.m., the LPN Weekend Supervisor said Resident #900 wanders throughout the whole facility. He said he did not put any intervention in place to address the wandering as he thought it was good exercise for her. He said on the day of the incident he walked past Resident #900 and #800 in the hallway as he was heading to another unit. He got called a few minutes later and informed of the incident in Resident #800's room. On 6/2/21 at 5:00 p.m., in a telephone interview Psychiatric APRN Staff Q said she gave the order to discontinue the one-to-one supervision on 5/18/21 because Resident #900 was started on [MEDICATION(S)], and she thought it would decrease the sexually inappropriate behavior. She said Resident #900 has a history of being intrusive and aggressive, hence the reason she thought she was the aggressor. She said Mr. [Resident #800] has no history of doing anything wrong, but her [Resident #900] she was intrusive and aggressive. On 6/3/21 at 9:20 a.m., in an interview at his place of residence at the Assisted Living Facility (ALF), Resident #800 said he remembered the incident with the female resident on 5/16/21 but said he did not want to talk about it. He said, it's in the past and it is best if it stays there. He said no one at the facility spoke with him about the incident and said he could not remember if he exposed his penis and did not think about things like that anymore. He said, I want to forget about it. On 6/3/21 at 12:00 p.m., in an interview the Director of Nursing (DON) said she thought Resident #900's wandering was addressed. She said, if she was wandering, I imagine they would redirect her, that is what we normally do. On 6/3/21 at 12:00 p.m., the Administrator who was participating in the interview said, We did follow our process, psych involvement, physician involvement and medication changes. 6/3/21 at 2:35 p. m., in an interview the Social Service Director said it was brought to her attention Resident #900 had wandered into a male resident's room on 5/16/21. They found her in gentleman's room her head was in his lap, no other details. She said they came up with the one-to-one supervision but no other interventions. She spoke with Resident #900's daughter about possible secured placement because she wandered. She said, If a wanderguard is not sufficient and they are going to other resident rooms, I call and let them know they need to find alternate placement. The Social Service Director said Resident #900 rolled around in her wheelchair and was pleasant. She said she was told on 5/20/21 Resident #900 was in a male resident's bed. She made sure she and the other resident were ok by going by and checking on them. She said she would talk to them and see if they were doing well. Resident #800 said he was fine, nothing happened, and Resident #885 said he was fine. She said, I did not put anything into place for the wandering or after the incidents, I just made sure the psychosocial needs were met by notifying psych. The facility failed to have documentation of appropriate supervision and individualized care plan to address Resident #900's wandering behaviors which created a likelihood Resident #900 could be sexually assaulted and suffer serious physical harm from going into other residents' rooms. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team included the following: As of 5/26/2021, resident (#800) was discharged from the facility to an Assisted Living Facility (ALF). As of 5/20/21, resident (#900) was placed on one-to-one observation and remains on one-to-one observation. As of 6/4/2021, resident #900 was evaluated by a Registered Nurse and experienced no negative outcome. As of 6/3/2021, skin assessment was completed on resident (#900) and experienced no negative outcome. As of 5/16/2021, resident #900 was evaluated by psychological services and will continue to be monitored by psychological services. As of 5/20/2021, resident's #900 attending physician was contacted with no new orders. As of 6/2/2021, residents with a BIMS of 10 or greater interviews were conducted to ensure no other allegations of abuse were not reported and investigated. As of 6/3/2021, residents with a BIMS of 9 or less skin evaluations were completed by a licensed nurse to ensure no other allegations of abuse were not reported and investigated. As of 6/4/2021, psychological services evaluated residents identified with behaviors. As of 6/4/2021, current residents identified that encountered resident (#900) were evaluated by a Registered Nurse and experienced no negative outcome. Beginning on 6/3/2021, staff interviews will be conducted to identify residents with behaviors, such as; do they kick, bite, scream, resist care, yells out, crying, spitting, disrobing, paces, wandering, sexually inappropriate or who lies. If behaviors, what do you do to get them cared for or to prevent further reoccurrence of the behavior. Licensed Nurses received education beginning on 6/3/2021 on reporting of resident behaviors, managing and monitoring resident behaviors. Licensed Nurses received education beginning on 6/4/2021 on change in condition and monitoring for sexually transmitted diseases. As of 6/3/2021, resident behaviors will be documented using the behavior monitoring sheets by the Licensed Nurses and will be reviewed by the clinical team during the morning clinical meeting. Resident behaviors will be monitored and managed through the care plan process with activities and psychosocial support. The interdisciplinary team, licensed nurses, certified nursing assistants, receptionist, dietary staff, and therapy staff received education beginning on 6/2/2021 on the abuse policy to include preventing abuse, identification, and protection, investigating, and reporting and reporting inappropriate resident behaviors to the nurse. A post-test was given to ensure competency of the information as presented in the in-service. Any staff member that did not receive education related to the above mentioned will be sent a certified letter as of 6/4/2021 indicating they may not return to work until the education is received. Newly hired staff will receive education in orientation.

Based on record review, and interviews the facility failed to operationalize their abuse policy and procedure by failure to implement adequate interventions to prevent incidents of resident-to- resident sexual abuse for 1 (Resident #900) of 3 sampled residents. Resident #900 was cognitively impaired with a documented behavior of wandering into other residents' rooms. The facility failed to implement systemic actions to protect Resident #900 from wandering into other residents' rooms which created a likelihood Resident #900 could be physically or sexually assaulted and suffer serious psychosocial and physical harm. On 5/16/21, staff observed Resident #900, who was cognitively impaired in male Resident #800's room, with her head on the lap of Resident #800. Resident #800 was alert, oriented and cognitively intact. Resident #800's penis was exposed and erected. Resident #900 was unable to consent to sexual activity. On 5/20/21 Resident #900 wandered unsupervised into male Resident #885's room and climbed into bed with him. The facility's failure to implement their policy and procedure and prevent resident-to-resident incidents of sexual abuse resulted in non- compliance at the Immediate Jeopardy starting on 5/16/21. The Administrator was notified of the Immediate Jeopardy on 6/4/21 at 10:00 a.m. and provided the IJ templates. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 6/4/21 at 6:00 p.m. and the scope and severity were reduced to a D . The findings included: Cross Reference to F600, F610, and F835 The facility policy N-1265, Abuse, Neglect, Exploitation and Misappropriation (revised 11/28/17) specified It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment and exploitation. Abuse is the willful infliction resulting in physical harm, pain, or mental anguish . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable though [sic] the use of technology . Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breast or perineal area. This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident . The policy documented Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the allegation. The Policy also specified: Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse. 1. The abuse coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. 2. The resident will be evaluated for any signs of injury, including a physical exam or psychosocial assessment, if needed. 3. Increased supervision of the alleged victim and residents. 4. Upon completion of the investigation, a detailed report shall be prepared. Resident #900 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) admission assessment with a reference date of 4/13/21 noted Resident #900 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Review of the progress notes revealed on 4/11/21, 4/23/21 the Licensed nurse noted Resident #900's behavioral problems are wandering. The care plan initiated on 4/30/21 noted Resident #900 was an Elopement risk/wanderer r/t [related to] Dementia, disoriented to place, impaired safety awareness. The goal was for the resident will not leave the facility unattended. The interventions/tasks included Distract resident from wandering by offering 1:1 as needed . The care plan did not include specific interventions to address Resident #900's wandering and safety due to impaired safety awareness. The Elopement Risk Evaluation completed on 4/29/21 documented Resident #900 had cognitive impairment and wandered oblivious to safety needs. The nursing progress note on 5/15/21 at 11:31 a.m., documented oriented to self . Propels self in w/c about the facility, goes toward doors and in patient's room, wander guard in place and functioning . Review of the Nursing Home Federal Reporting to the Florida State Survey Agency, dated 5/16/21 submitted by the facility noted on 5/16/21 at approximately 10:15 a.m., Certified Nursing Assistant (CNA) Staff B stated she was walking past Resident #800's room and saw Resident #900 bent over Resident #800's legs. Her head was on his lap. When she pulled Resident #900's wheelchair away, she saw Resident #800 pushing his penis back in his pajamas. She took Resident #900 out of the room and reported the incident to the nurse right away. On 5/16/21 CNA Staff B wrote a statement that read She [Resident #900] was bent over his [Resident #800] legs. Her hands were in her lap. Her face was in his lap. When I pulled away her w.c [wheelchair] I saw him [Resident #800] pushing his penis back in his P.J.S [pajamas]. He said Darn it. You got me caught. She [Resident #900] did not say anything. She just smiled. She did not have a mask on. Neither did he. On 6/1/21 at 3:15 p.m., in a telephone interview CNA Staff B said on 5/16/21 at 10:15 a.m., she walked past the room and noticed Resident #900 and Resident #800 had their wheelchairs facing each other. Resident #900 had her head in his lap. Resident #800's penis was out of his boxers, and he had an erection. Her head was down there. I saw his penis out and that is what made me turn around. I thought Did I just see what I think I saw? I walked into the room, and I pulled Resident #900 from him. She was in her wheelchair. I pulled [Resident #900] from him in her wheelchair and [Resident #800] said Damn it, you got me caught. I told the risk manager he said that. Resident #800 looked scared like he knew he was in trouble because he got caught. She said his penis was hard and he was trying to get it back in his pants. The CNA said, He told me he was scared because he thought he was in trouble because he got caught. On 5/17/21 Psychiatric Advanced Practice Registered Nurse (APRN) Staff P documented Pt [patient] information obtained from Nursing, pt and pt record. Nursing reports pt found performing oral sex on another resident. Assessment and Plan for today's visit: Pt was alert, severely demented, calm, smiling . Upon assessment via telepsych, pt unable to recall incident with other resident. Pt does not appear to have any emotional distress . Please Start [MEDICATION(S)] (Anticonvulsant that can be prescribed as a mood stabilizer) 300 milligrams BID [Twice a day] for Dementia with behaviors. Continue 1:1 Q 15 minute [every 15 minutes] checks for 24 hrs [hours] then discontinue. Will monitor. On 5/20/21 Psychiatric APRN Staff P documented seeing Resident #900 for a follow up visit. She wrote Patient last seen on 05/17/21 via Telepsych. Correction: For pt note on 5/17/21, Pt was not witnessed performing actual oral sex on another male resident. Staff reports pt was seen with her head laying [sic] on other resident's lap only. Staff cannot say they witnessed oral sex being performed between pt and other resident, only that it may or may not have occurred. Earlier today, Nursing reports staff member witnessed pt stroking the arm of another male resident telling him how beautiful he was. Pt was also just found laying [sic] beside another male resident in his room and in his bed. However, nursing reports other resident reported nothing happened as they were just talking. Nursing has placed pt on 1:1 . Pt unable to remember and does not recall prior incidents. Pt continues to have hypersexual inappropriate behaviors toward male residents since last med [medication] change. Therefore, I decided to start [MEDICATION(S)] 20 mg (milligrams) PO (orally) QD (daily) for Dx (diagnosis) Depression as it will help decrease sexual inappropriate behaviors. On 6/1/21 at 3:00 p.m., in an interview the Risk Manager said Resident #900 did not show sexually inappropriate behavior prior to 5/16/21. She said Resident #900 would wander in her wheelchair at times but never showed any behaviors. She would pat or rub a male resident's arm or knee and they redirected her. She said she interviewed staff and Resident #800 who said Resident #900 came into his room. She said she assumed Resident #800 penis just fell out of his pajamas when Resident #900 put her head in his lap. She said she could not confirm (Resident #800) was the initiator of the incident. She said, I assumed it was [name] Resident #900 because she would rub male residents on their arms. She said she did not place Resident #800 on one-to-one because she assumed Resident #900 was the aggressor. She said I think like I said she (Resident #900) wandered into his (Resident #800)'s room and put her head in his lap. He got an erection, and his penis just came out of his pants because he had an erection. She said she never asked Resident #800 if he had removed his penis out of his pants. On 6/1/21 at 4:41 p.m., the Risk Manager said she could not find documentation in Resident #900's chart indicating she was touching other male residents on the arm. She said, we just knew she was and would redirect her. She said based on that behavior she assumed she was the aggressor. She said she interviewed other male residents on the same hall to see if Resident #900 came into their rooms but did not document it anywhere. She said she also spoke with Resident #800, and he seemed upset by it and was depressed over his wife. He said Resident #900 came into his room and he never touched her. On 5/20/21 at 1:22 p.m., Licensed Practical Nurse (LPN) Staff C documented Resident . up in w/c [wheelchair] self-propelled left day room and entered male resident room and was in bed male resident (Resident #885) stated they were only talking, no sexual behaviors noted, male resident stated he tried to put call on but was mashing bed control, both residents fully dressed. On 6/2/21 at 2:00 p.m., in an interview Resident #885 said Resident #900 came into my room in a wheelchair, and I told her she could not be here, but she wheeled herself up to the bed and climbed in my bed. Nothing happened, we just talked. I hit the call-light and no one came for the longest time. Resident #885 said it was about 30 minutes before anyone came into the room. They tried to tell me I was pushing the bed button and not the call light. Resident #885 said the incident made him feel creepy. On 6/2/21 at 4:25 p.m., the LPN Weekend Supervisor said Resident #900 wanders throughout the whole facility. He said he did not put any intervention in place to address the wandering as he thought it was good exercise for her. On 6/2/21 at 1:40 p.m., in a telephone interview Psych APRN Staff P said she was at the facility on 5/20/21 when Resident #900 climbed into bed with Resident #885. Resident #885 said he told her [Resident #900] you can't climb in my bed. He said he kept pushing the call light until the staff came and removed her. She said Resident #900 needed continued one-to-one supervision. She never told them to take her off the one-to-one supervision, they were supposed to keep her on. On 6/2/21 at 3:00 p.m., interview the Risk Manager said I really don't think anything happened between Resident #900 and #800. I think Resident #900 went into his room and laid her head on his lap and he got an erection, and his penis came out of his pants. The Risk Manager confirmed there were no interventions initiated for Resident #800 because I don't think he did anything. I don't think anything happened. The Risk Manager confirmed she could not be certain that Resident #800 did not initiate the incident or confirm exactly what did or did not occur. The Risk Manager said I don't think anything happened; Resident #800 was a quiet man who kept to himself. Resident #900 was the one who wandered and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Risk Manager said we found out the first incident on 5/16/21, we reported it, we had professionals involved (psych) and we followed the recommendations, and it did not work. We put in place redirection, that is what we did there are wanderers and we redirected them. On 6/2/21 at 5:00 p.m., in a telephone interview Psych APRN Staff Q said she gave the order to discontinue the one-to-one supervision on 5/18/21 because Resident #900 was started on [MEDICATION(S)], and she thought it would decrease the sexually inappropriate behavior. She said Resident #900 has a history of being intrusive and aggressive, hence the reason she thought she was the aggressor. She said Mr [name] Resident #800 has no history of doing anything wrong, but her she was intrusive and aggressive. On 6/3/21 at 2:44 p.m., in an interview the Risk Manager said no one physically assessed Resident #900, #800 and #855 after the incidents. The Risk Manager said she had no documentation of interviews with residents or staff. She said no physician visits were made; the physician was notified but did not actually see the residents. She said, I did interviews but like I told you already, I have nothing documented. On 6/3/21 at 1:12 p.m., during a phone interview with Resident #900's family member said, when my mother was admitted to the skilled facility, I told them she was wandering and bored and looking for something to do. I asked them to give her something to do, involve her in something. They told me they had plenty of staff there and would be able to handle her wandering and activities. I told them day one she gets bored, wanders, and needs something to do, activities or someone to talk to. They assured me they had plenty of staff to provide supervision. On 6/4/21 at 6:00 p.m., in an interview the Risk Manager said the investigation she completed for 5/16/21 and 5/20/21 is summarized in the Nursing Home Federal 5-day report (to the State Survey Agency). The Risk Manager said, everything is in the 5-day report, that was the investigation, I have no other documentation. Review of the 5-day Nursing Home Federal reporting updated on 5/21/21 noted A complete and thorough investigation was conducted to include medical review, care plan review and staff interviews . Resident [Resident #900] has inappropriate sexual behaviors towards another resident . On 5/16/21 at approximately 10:15 am CNA [Staff B] states, I was walking past [room number] and saw [Resident #900] in a wheelchair in front of [Resident #800] in his wheelchair. Resident [#900] was bent over [ Resident #800]' legs. Her head was on his lap. When I pulled her wheelchair away, I saw him [Resident #800] pushing his penis back in his pajamas . 5/20/21. [Resident #900] self-propelled left day room and entered male resident's room [Resident #885] and was in his bed . Male resident [Resident #885] stated he tried to put call light on but was mashing bed control . Both residents fully dressed. [Resident #900] seen by psychiatric ARNP. She writes .Pt [Patient] continues to have hypersexual inappropriate behaviors toward male residents. As per collected information and interview, patient continues to be unstable. Patient [Resident #900] has hyper-sexual symptoms and inappropriate behaviors toward male residents. The frequency of symptoms is daily. therefore I decided to start [MEDICATION(S)] (antidepressant) 20 milligrams . as it will help decrease sexually inappropriate behaviors.based on the results of this investigation abuse cannot be substantiated. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team included the following: As of 5/16/2021, an allegation of sexual abuse was completed and reported for sexual abuse for resident (#900), Department of Children and Families (DCF) called, and Law Enforcement notified. As of 5/20/21, resident (#900) was placed on one-to-one observation and remains on one-to-one observation. As of 6/4/2021, resident (#900) was evaluated by a Registered Nurse and experienced no negative outcome. As of 06/03/2021, a skin evaluation was completed by a licensed nurse on resident (#900) and experienced no negative outcome. As of 5/20/2021, resident (#900) attending physician was contacted with no new orders. As of 5/16/2021, resident (#900) was evaluated by psychological services and will continue to be monitored by psychological services. As of 6/2/2021, resident with a BIMS of 10 or greater interviews were conducted to ensure no other allegations of abuse were not reported and investigated. As of 6/3/2021, residents with a BIMS of 9 or less interviews skin evaluations were conducted to ensure no other allegations of abuse were not reported and investigated. Beginning on 6/4/2021, psychological services began to evaluate residents identified with behaviors. As of 6/4/2021, current residents identified that encountered resident (#900) were evaluated by a Registered Nurse and experienced no negative outcome. As of 6/3/2021, Resident behaviors will be documented using the behavior monitoring sheets by the Licensed Nurses and will be reviewed by the clinical team during the morning clinical meeting. Resident behaviors will be monitored and managed through the care plan process with activities and psychosocial support. The Interdisciplinary team, licensed nurses, certified nursing assistants, receptionist, dietary staff, and therapy staff received education beginning on 6/2/2021 on the abuse policy to include preventing abuse, identification and protection, investigating and reporting and reporting inappropriate resident behaviors to the nurse. A post-test was given to ensure competency of the information as presented in the in-service. Any staff member that did not receive education related to the above mentioned will be sent a certified letter as of 6/4/2021 indicating they may not return to work until the education is received. Newly hired staff will receive education in orientation. As of 6/4/2021, the Executive Director and Director of Clinical Services received education by the Corporate Risk Manager on abuse policy and procedure to prevent abuse and neglect, and to protect residents from further abuse, identification, protection, completing a thorough investigating, to include obtaining witness statements from staff and other residents and reporting.

Based on record review, resident and staff interview, the facility failed to have evidence of thorough investigation of resident-to-resident sexual abuse for 1 (Resident #900) of 3 sampled residents. Resident #900 was cognitively impaired with poor safety awareness and a known behavior of wandering throughout the facility and into other residents' rooms. On [DATE], staff observed Resident #900 with her head on the lap of Resident #800 who is alert, oriented and cognitively intact. Resident #800's penis was exposed and erected. Resident #900 was unable to consent to sexual activity. The facility failed to implement systemic action to protect Resident #900 and other vulnerable residents and prevent further incidents of resident-to-resident negative interactions including potential sexual abuse. On [DATE] Resident #900 wandered unsupervised into male Resident #885's room and climbed into bed with him. The facility's failure to address Resident #900's at risk behaviors, the failure to thoroughly investigate inappropriate resident-to-resident interaction and protect Resident #900 created a likelihood Resident #900 could be sexually assaulted and suffer serious psychosocial and physical harm. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. These failures resulted in noncompliance at the Immediate Jeopardy level starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:00 a.m. and provided the IJ templates. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on [DATE] at 6:00 p.m. and the scope and severity were reduced to a D . The findings included: Cross Reference to F600, F607, and F835 The facility policy N-1265, Abuse, Neglect, Exploitation and Misappropriation (revised [DATE]) specified It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment and exploitation. Abuse is the willful infliction resulting in physical harm, pain, or mental anguish . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable though [sic] the use of technology . Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breast or perineal area. This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident . Furthermore, the Administrator of the Company recognizes that resident abuse can be committed by other residents. Sexual abuse is non-consensual sexual contact of any type with a resident. Generally, sexual contact is non-consensual if the resident either: Appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur . Prevention: Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk of vulnerable for abuse, for indication of changes in behavior, changes in condition or other non-verbal indication of abuse. All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services . The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation, and exploitation . The resident will be evaluated for any signs of injury, including a physical exam or psychosocial assessment, if needed. Increased supervision of the alleged victim and residents. Room or staffing changes, if necessary, to protect the resident(s) form [sic] the alleged perpetrator . Preliminary investigation: Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation . of the allegation . The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. Upon completion of the investigation, a detailed report shall be prepared . Resident #900 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) admission assessment with a reference date of [DATE] noted Resident #900 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The Elopement Risk Evaluation completed on [DATE] documented Resident #900 had cognitive impairment and wandered oblivious to safety needs, indicating the resident was at risk for elopement. Review of the progress notes revealed on [DATE], [DATE] the Licensed nurse noted Resident #900's behavioral problems are wandering. The care plan initiated on [DATE] noted Resident #900 was an Elopement risk/wanderer r/t [related to] Dementia, disoriented to place, impaired safety awareness. The goal was for the resident will not leave the facility unattended. The interventions/tasks included Distract resident from wandering by offering 1:1 as needed . the resident was fitted with a wanderguard (Device that triggers alarms and can lock monitored doors to prevent the resident from leaving unattended). The care plan did not include specific interventions to address Resident #900's wandering and safety due to impaired safety awareness. The nursing progress note dated [DATE] at 11:31 a.m., documented Resident #900 was oriented to person . Propels self in wheelchair about the facility, goes toward doors and in patient's room. Wanderguard in place and functioning . On [DATE] at 8:15 a.m., in an interview LPN Staff D, said Resident #900 had only been in the current room for about a week. She said, they told me when she was on the other side that she likes to get into bed with other men, but I really don't know much about her. On [DATE] at 8:30 a.m., in an interview LPN Staff G said Resident #900 was alert, confused and needed assistance with activities of daily living. She likes to wander and has one-to-one sitter and I know they found her in bed with other men, but I have not seen any behaviors. She has only been on Station 1 for about a week. On [DATE] at 8:45 a.m., in an interview LPN Staff C said Resident #900 liked to wander and heard she had an incident where they found her in another man's bed, but she only knew of the incident when she found her in Resident #885's bed on [DATE]. She said Resident #900 does not know where she is or what she is doing. She wanders and that is why we put the wanderguard on her so she could not leave the facility. On [DATE] at 8:50 a.m., in an interview CNA Staff E said Resident #900 liked to wander, she is confused and wandered but she never saw her do anything or touching anyone. She said she heard about her being in bed with a man when she was on the other Station. CNA Staff E said Resident #900 was on one-to-one supervision because the nurse said she liked to get into men's beds. On [DATE] at 10:02 a.m., in an interview LPN Staff H said on [DATE] said the CNA came out of the room and said that they were facing each other, and her head was down in his lap and came up quickly when she knocked and entered the room. She called the supervisor, and he took over. She said she did see Resident #900 wandering the halls before the incident but never saw her touching other men. She went into other residents' rooms, and they would get her out. Review of the Nursing Home Federal Reporting to the Florida State Survey Agency, dated [DATE] submitted by the facility noted on [DATE] at approximately 10:15 a.m., Certified Nursing Assistant (CNA) Staff B stated she was walking past Resident #800's room and saw Resident #900 bent over Resident #800's legs. Her head was on his lap. When she pulled Resident #900's wheelchair away, she saw Resident #800 pushing his penis back in his pajamas. She took Resident #900 out of the room and reported the incident to the nurse right away. On [DATE] CNA Staff B wrote a statement that read She [Resident #900] was bent over his [Resident #800] legs. Her hands were in her lap. Her face was in his lap. When I pulled away her w.c [wheelchair] I saw him [Resident #800] pushing his penis back in his P.J.S [pajamas]. He said Darn it. You got me caught. She [Resident #900] did not say anything. She just smiled. She did not have a mask on. Neither did he. On [DATE] at 3:15 p.m., in a telephone interview CNA Staff B said on [DATE] at 10:15 a.m., she walked past the room and noticed Resident #900 and Resident #800 had their wheelchairs facing each other. Resident #900 had her head in his lap. Resident #800's penis was out of his boxers, and he had an erection. Her head was down there. I saw his penis out and that is what made me turn around. I thought Did I just see what I think I saw? I walked into the room, and I pulled Resident #900 from him. She was in her wheelchair. I pulled [Resident #900] from him in her wheelchair and [Resident #800] said Damn it, you got me caught. I told the risk manager he said that. Resident #800 looked scared like he knew he was in trouble because he got caught. She said his penis was hard and he was trying to get it back in his pants. He told me he was scared because he thought he was in trouble because he got caught. On [DATE] the facility initiated a care plan with a focus that read Resident #900 has inappropriate sexual behaviors towards another resident. The goal was not specific to stop and prevent the sexually inappropriate behavior but noted the resident will have fewer episodes of inappropriate behaviors by review date. The interventions as of [DATE] included administer medications as ordered. Observe/document for side effects and effectiveness; If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; Praise any indication of the resident's progress/improvement in behavior. The care plan did not include adequate supervision for Resident #900 with a known history of wandering into other residents' rooms and inappropriate sexual behaviors placing the resident at risk for negative resident-to-resident interaction, including verbal, sexual and physical abuse. On [DATE] Psychiatric Advanced Practice Registered Nurse (APRN) Staff P assessed Resident #900 via a telepsych visit and documented Pt [patient] information obtained from Nursing, pt and pt record. Nursing reports pt found performing oral sex on another resident. Assessment and Plan for today's visit: Pt was alert, severely demented, calm, smiling . Upon assessment via telepsych, pt unable to recall incident with other resident. Pt does not appear to have any emotional distress . Please Start [MEDICATION(S)] (Anticonvulsant that can be prescribed as a mood stabilizer) 300 milligrams BID [Twice a day] for Dementia with behaviors . Continue 1:1 Q 15 minute [every 15 minutes] checks for 24 hrs [hours] then discontinue. Will monitor. On [DATE] Psychiatric APRN Staff P documented she assessed Resident #800 and wrote Pt good historian . Pt A&O [Alert and oriented] . Writer asked pt about incident between him and another female resident that recently occurred. Pt reports the female resident came into his room and layed [sic] her head on his lap, but nothing happened. Pt talked about his deceased wife and that he has no interest in other women. Pt says nothing happened and he has moved on and put it behind him. Pt appears stable with no emotional distress from recent incident. He is not on psych medications. No changes are recommended at this time. Would like to monitor . Review of Resident #800's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day MDS assessment dated [DATE] noted Resident #12 had a BIMs score of 12, indicating intact cognition. On [DATE] the facility initiated a care plan noting Resident #800 has inappropriate sexual behaviors towards another resident. The interventions included Anticipate and meet the resident's needs; Educate the resident/resident representative on successful coping and interaction strategies; If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. The care plan did not include increased supervision during the investigation to prevent further inappropriate resident-to-resident sexual abuse towards other vulnerable residents. On [DATE] at 1:22 p.m., Licensed Practical Nurse Staff C documented Resident . up in w/c [wheelchair] self-propelled left day room and entered male resident room and was in bed male resident (Resident #885) stated they were only talking, no sexual behaviors noted, male resident stated he tried to put call on but was mashing bed control, both residents fully dressed. On [DATE] at 3:00 p.m., in an interview the Risk Manager said on [DATE] at 1:00 p.m., Resident #900 was found in another male resident's bed (Resident #885). The Risk Manager said, we were looking for her and we found them both fully clothed in Resident #885's bed. The Risk Manager said nothing had occurred and Resident #885 was trying to push the call light to get her out. The Risk Manager said Resident #900 was in there 3 to 4 minutes and we were getting a one-to-one sitter for her. The Risk Manager said, Resident #900's daughter had said her mother had always been a touchy-feely person. On [DATE] at 2:00 p.m., in an interview Resident #885 said Resident #900 came into my room in a wheelchair, and I told her she could not be here, but she wheeled herself up to the bed and climbed in my bed. Nothing happened, we just talked. I hit the call-light and no one came for the longest time. Resident #885 said it was about 30 minutes before anyone came into the room. They tried to tell me I was pushing the bed button and not the call light. He said the incident made him feel creepy. On [DATE] the psychiatric APRN documented seeing Resident #900 for a follow up visit. She wrote Patient last seen on [DATE] via Telepsych. Correction: For pt note on [DATE], Pt was not witnessed performing actual oral sex on another male resident. Staff reports pt was seen with her head laying on other resident's lap only. Staff cannot say they witnessed oral sex being performed between pt and other resident, only that it may or may not have occurred. Earlier today, Nursing reports staff member witnessed pt stroking the arm of another male resident telling him how beautiful he was. Pt was also just found laying [sic] beside another male resident in his room and in his bed. However, nursing reports other resident reported nothing happened as they were just talking. Nursing has placed pt on 1:1 . Pt unable to remember and does not recall prior incidents. Pt continues to have hypersexual inappropriate behaviors toward male residents since last med [medication] change. Therefore, I decided to start [MEDICATION(S)] 20 mg (milligrams) PO (orally) QD (daily) for Dx (diagnosis) Depression as it will help decrease sexual inappropriate behaviors. On [DATE] the care plan noted the facility placed Resident #900 on one-to-one observation at this time. On [DATE] at 3:00 p.m., in an interview the Risk Manager said Resident #900 did not show sexually inappropriate behavior prior to [DATE]. She said Resident #900 would wander in her wheelchair at times but never showed any behaviors. She would pat or rub a male resident's arm or knee and they redirected her. She said she interviewed staff and Resident #800 who said Resident #900 came into his room. She said she assumed Resident #800 penis just fell out of his pajamas when Resident #900 put her head in his lap. She said she could not confirm Resident #800 was the initiator of the incident. She said, I assumed it was [name] Resident #900 because she would rub male residents on their arms. She said she did not place Resident #800 on one-to-one because she assumed Resident #900 was the aggressor. She said I think like I said she (Resident #900) wandered into his (Resident #800)'s room and put her head in his lap. He got an erection, and his penis just came out of his pants because he had an erection. She said she never asked Resident #800 if he had removed his penis out of his pants. On [DATE] at 4:41 p.m., the Risk Manager said she could not find documentation in Resident #900's chart indicating she was touching other male residents on the arm. She said, we just knew she was and would redirect her. She said based on that behavior she assumed she was the aggressor. She said she interviewed other male residents on the same hall to see if Resident #900 came into their rooms but did not document it anywhere. She said she also spoke with Resident #800, and he seemed upset by it and was depressed over his wife. He said Resident #900 came into his room and he never touched her. On [DATE] at 1:12 p.m., in a telephone interview Resident #900's daughter said the facility was aware from day one her mother wandered. They assured her they had enough staff to monitor and keep her engaged in activities. She told them her mother wanders because she gets bored and wants something to do. She said the facility notified her on [DATE] of the incident but told her both residents were demented. She was not so concerned then because she did not think either one knew what was going on. The DON did inform her Resident #800's penis was out. She said the DON told her they put her mother on a medication to decrease her libido. The medication would take approximately 3 days to take effect. She questioned that because she thought it would take a few weeks or months, but they told her no they should know in 3 days, and she should be ok. She said they would place her on one-to-one supervision and after 3 days on the medication she should be ok. She said she was notified of the second incident on [DATE] but they made it sound like it was no big deal. All they told her is that she needed to get her mother out of the facility. They left it up to her to find alternate placement. On [DATE] at 2:44 p.m., the Risk Manager said after the allegation of sexual abuse involving Resident #800 and #900 on [DATE] and the incident of [DATE] the facility did not complete a physical assessment of Resident #800, #900 and #885. The Risk Manager said she did not have documentation other residents or staff members were interviewed. She said the facility notified the physicians, but the physicians did not actually see the residents. She said, I did interviews, but like I told you already, I have nothing documented. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team included the following: As of [DATE], resident (#800) was discharged from the facility to an ALF. As of [DATE], resident (#900) was placed on one-to-one observation and remains on one-to-one observation. As of [DATE], resident #900 was evaluated by a Registered Nurse and experienced no negative outcome. As of [DATE], skin assessment was completed on resident (#900) and experienced no negative outcome. As of [DATE], resident #900 was evaluated by psychological services and will continue to be monitored by psychological services. As of [DATE], resident's #900 attending physician was contacted with no new orders. As of [DATE], residents with a BIMS of 10 or greater interviews were conducted to ensure no other allegations of abuse were not reported and investigated. As of [DATE], residents with a BIMS of 9 or less skin evaluations were completed by a licensed nurse to ensure no other allegations of abuse were not reported and investigated. As of [DATE], psychological services evaluated residents identified with behaviors. As of [DATE], current residents identified that encountered resident (#900) were evaluated by a Registered Nurse and experienced no negative outcome. Beginning on [DATE], staff interviews will be conducted to identify residents with behaviors, such as; do they kick, bite, scream, resist care, yells out, crying, spitting, disrobing, paces, wandering, sexually inappropriate or who lies. If behaviors, what do you do to get them cared for or to prevent further reoccurrence of the behavior. Licensed Nurses received education beginning on [DATE] on reporting of resident behaviors, managing and monitoring resident behaviors. Licensed Nurses received education beginning on [DATE] on change in condition and monitoring for sexually transmitted diseases. As of [DATE], resident behaviors will be documented using the behavior monitoring sheets by the Licensed Nurses and will be reviewed by the clinical team during the morning clinical meeting. Resident behaviors will be monitored and managed through the care plan process with activities and psychosocial support. As of [DATE], the Executive Director and Director of Clinical Services received education by the Corporate Risk Manager on abuse policy and procedure to prevent abuse and neglect, and to protect residents from further abuse, identification, protection, completing a thorough investigating, to include obtaining witness statements from staff and other residents and reporting. The interdisciplinary team, licensed nurses, certified nursing assistants, receptionist, dietary staff, and therapy staff received education beginning on [DATE] on the abuse policy to include preventing abuse, identification, protection and investigating and reporting and reporting inappropriate resident behaviors to the nurse. A post-test was given to ensure competency of the information as presented in the in-service. Any staff member that did not receive education related to the above mentioned will be sent a certified letter as of [DATE] indicating they may not return to work until the education is received. Newly hired staff will receive education in orientation.

Based on record review, resident, resident representative and staff interviews, the facility administration failed to utilize resources effectively and provide necessary services and adequate supervision to ensure the protection of vulnerable residents from sexual abuse. These failures resulted on Resident #900, who was cognitively impaired wandering in Resident #800's room on 5/16/21. Resident #900 was found with her head on the lap of Resident #800 who is alert and oriented. Resident #800's penis was exposed and erected. Resident #900 was unable to consent to sexual activity. The facility administration failed to conduct a thorough investigation, recognize sexual abuse, and implement adequate supervision to prevent the likelihood of further occurrence of resident-to- resident abuse. On 5/20/21 Resident #900 wandered unsupervised into male Resident #885's room and climbed into bed with him. The isolated noncompliance resulted in Immediate Jeopardy that started on 5/16/21. On 6/4/21 at 10:00 a.m., the facility Administrator was notified of the determination of Immediate Jeopardy and provided the IJ template. The Immediate Jeopardy was removed on 6/4/21 at 6:00 p.m., after verification of the IJ removal plan. The Immediate Jeopardy scope and severity was reduced to D. The facility administration failed to ensure that staff had the competencies to meet the behavioral health needs of Resident #900's to assure her safety and maintain the highest practicable physical, mental and psychosocial well-being. The facility administration failed to ensure accurate accounting and management of resident trust funds The findings included: Refer to F568, F600, F607, F610, and F741 The job description signed by the Administrator on 12/23/18 listed duties and responsibilities that included to Ensure a safe, clean and comfortable environment for residents . Maintain a file for and monitor incident reports . Adhere to facility policies and procedures and participate in facility quality improvement and safety programs. The job description signed by the Director of Nursing on 12/20/21 noted the job function included to Assume the primary role in ensuring the delivery of high quality, efficient nursing care. Supervises Nurse Practitioner. The duties and responsibilities included Maintain and guide the implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines. Ensure compliance with resident rights policies and work to resolve resident grievances . The facility policy N-1265, Abuse, Neglect, Exploitation and Misappropriation (revised 11/28/17) specified It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment and exploitation. Abuse is the willful infliction resulting in physical harm, pain, or mental anguish . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable though [sic] the use of technology . Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breast or perineal area. This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident . Furthermore, the Administrator of the Company recognizes that resident abuse can be committed by other residents. Sexual abuse is non-consensual sexual contact of any type with a resident . Generally, sexual contact is non-consensual if the resident either: Appears to wan the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur . Prevention: Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk of vulnerable for abuse, for indication of changes in behavior, changes in condition or other non-verbal indication of abuse. All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services . The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation, and exploitation . The resident will be evaluated for any signs of injury, including a physical exam or psychosocial assessment, if needed. Increased supervision of the alleged victim and residents. Room or staffing changes, if necessary, to protect the resident(s) form [sic] the alleged perpetrator . Preliminary investigation: Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation . of the allegation . The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. Upon completion of the investigation, a detailed report shall be prepared . Resident #900 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) admission assessment with a reference date of 4/13/21 noted Resident #900 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The care plan initiated on 4/30/21 noted Resident #900 was an Elopement risk/wanderer r/t [related to] Dementia, disoriented to place, impaired safety awareness. The goal was for the resident will not leave the facility unattended. The interventions/tasks included Distract resident from wandering by offering 1:1 as needed . The care plan did not include specific interventions to address Resident #900's wandering and safety due to impaired safety awareness. The nursing progress note dated 5/15/21 at 11:31 a.m., documented Resident #900 was oriented to person . Propels self in wheelchair about the facility, goes toward doors and in patient's room. Wanderguard in place and functioning . Review of the Nursing Home Federal Reporting to the Florida State Survey Agency, dated 5/16/21 submitted by the facility noted on 5/16/21 at approximately 10:15 a.m., Certified Nursing Assistant (CNA) Staff B stated she was walking past Resident #800's room and saw Resident #900 bent over Resident #800's legs. Her head was on his lap. When she pulled Resident #900's wheelchair away, she saw Resident #800 pushing his penis back in his pajamas. She took Resident #900 out of the room and reported the incident to the nurse right away. On 6/1/21 at 3:15 p.m., in a telephone interview CNA Staff B said on 5/16/21 at 10:15 a.m., she walked past the room and noticed Resident #900 and Resident #800 had their wheelchairs facing each other. Resident #900 had her head in his lap. Resident #800's penis was out of his boxers, and he had an erection. Her head was down there. I saw his penis out and that is what made me turn around. I thought Did I just see what I think I saw? I walked into the room, and I pulled Resident #900 from him. She was in her wheelchair. I pulled [Resident #900] from him in her wheelchair and [Resident #800] said Damn it, you got me caught. I told the risk manager he said that. Resident #800 looked scared like he knew he was in trouble because he got caught. She said his penis was hard and he was trying to get it back in his pants. He told me he was scared because he thought he was in trouble because he got caught. On 5/17/21 the facility initiated a care plan with a focus that read Resident #900 has inappropriate sexual behaviors towards another resident. The goal was not specific to stop and prevent the sexually inappropriate behavior but noted the resident will have fewer episodes of inappropriate behaviors by review date. The interventions as of 5/17/21 included administer medications as ordered. Observe/document for side effects and effectiveness; If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; Praise any indication of the resident's progress/improvement in behavior. The care plan did not include adequate supervision for Resident #900 with a known history of wandering into other residents' rooms and inappropriate sexual behaviors placing the resident at risk for negative resident-to-resident interaction, including verbal, sexual and physical abuse. On 5/20/21 Resident #900 wandered unsupervised into male resident #885's room and climbed into bed with him. On 6/2/21 at 2:00 p.m., in an interview Resident #885 said Resident #900 came into my room in a wheelchair, and I told her she could not be here, but she wheeled herself up to the bed and climbed in my bed. Nothing happened, we just talked. I hit the call-light and no one came for the longest time. Resident #885 said it was about 30 minutes before anyone came into the room. They tried to tell me I was pushing the bed button and not the call light. He said the incident made him feel creepy. On 6/2/21 at 4:25 p.m., the Licensed Practical Nurse (LPN) Weekend Supervisor said Resident #900 wanders throughout the whole facility. He said he did not put any intervention in place to address the wandering as he thought it was good exercise for her. On 6/2/21 at 3:42 p.m., in an interview the Administrator of the Assisted Living Facility (ALF) attached to the skilled nursing facility, where Resident #900 lived prior to this facility, said Resident #900 would often pat the maintenance man on the rear end and she crawled into other residents' beds, and we would get her out. On 6/1/21 at 3:00 p.m., in an interview the Risk Manager said on 5/20/21 at 1:00 p.m., Resident #900 was found in another male resident's bed (Resident #885). The Risk Manager said, we were looking for her and we found them both fully clothed in Resident #885's bed. The Risk Manager said nothing had occurred and Resident #885 was trying to push the call light to get her out. The Risk Manager said Resident #900 was in there 3 to 4 minutes and we were getting a one-to- one sitter for her. The Risk Manager said, Resident #900's daughter had said her mother had always been a touchy-feely person. On 6/1/21 at 3:00 p.m., in an interview the Risk Manager said Resident #900 did not show sexually inappropriate behavior prior to 5/16/21. She said Resident #900 would wander in her wheelchair at times but never showed any behaviors. She would pat or rub a male resident's arm or knee and they redirected her. She said she interviewed staff and Resident #800 who said Resident #900 came into his room. She said she assumed Resident #800 penis just fell out of his pajamas when Resident #900 put her head in his lap. She said she could not confirm (Resident #800) was the initiator of the incident. She said, I assumed it was [name] Resident #900 because she would rub male residents on their arms. On 6/3/21 at 12:00 p.m., an interview was conducted with the Administrator, the Director of Nursing, and the Risk Manager. The DON said she thought Resident #900's wandering was addressed. She said, if she was wandering, I imagine they would redirect her, that is what we normally do. The Administrator said, We did follow our process, psych involvement, physician involvement and medication changes. The Administrator said Resident #900 had the wander guard on. She did not leave the building and the redirection worked because she was removed from the room. He said the wanderguard lets you know if she gets near a door, but it doesn't work to let you know when she goes into a resident's room. He said the Executive Director at the Assisted Living Facility said Resident #900 did not have any preference. She would get into bed with females and males when at the ALF. She had no idea what she was doing. The Risk Manager said, we followed Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/3/21 at 1:12 p.m., in a telephone interview Resident #900's daughter said the facility was aware from day one her mother wandered. They assured her they had enough staff to monitor and keep her engaged in activities. She told them her mother wanders because she gets bored and wants something to do. She said the facility notified her on 5/16/21 of the incident but told her both residents were demented. She was not so concerned then because she did not think either one knew what was going on. The DON did inform her Resident #800's penis was out. She said the DON told her they put her mother on a medication to decrease her libido. The medication would take approximately 3 days to take effect. She questioned that because she thought it would take a few weeks or months, but they told her no they should know in 3 days, and she should be ok. She said they would place her on one-to-one supervision and after 3 days on the medication she should be ok. She said she was notified of the second incident on 5/20/21 but they made it sound like it was no big deal. All they told her is that she needed to get her mother out of the facility. They left it up to her to find alternate placement. On 6/3/21 at 2:35 p. m., in an interview the Social Service Director said it was brought to her attention Resident #900 had wandered into a male resident's room on 5/16/21. They found her in gentleman's room her head was in his lap, no other details. She said the came up with the one-to-one supervision but no other interventions. She spoke with Resident #900' daughter about possible secured placement because she wandered. She said, If a wanderguard is not sufficient and they are going to other resident rooms, I call and let them know they need to find alternate placement. The Social Service Director said Resident #900 rolled around in her wheelchair and was pleasant. She said she was told on 5/20/21 Resident #900 was in a male resident's bed. She made sure she and the other resident were ok by going by and checking on them. She said she would talk to them and see if they were doing well. Resident #800 said he was fine, nothing happened, and Resident #885 said he was fine. She said, I did not put anything into place for the wandering or after the incidents, I just made sure the psychosocial needs were met by notifying psych. 2. On 6/3/21 at 3:35 p.m., in an interview the Activity Director said the facility did not have a specific program for wandering residents with dementia, we redirect them or take them outside. We take them to their room and turn on the television. We offer 20-30 pieces puzzles. We try to keep them occupied. She said Resident #900 used to come and sit for Bingo. She wanders about, we take her outside for fresh air and music. She likes to wander about the facility. She said I was not aware of her behaviors until after it happened on 5/16/21 when she had inappropriate behavior and had her head in his [Resident #800]'s lap. She said since she has one-to-one sitter, we really are not involved with her because the sitter takes care of that. She said no one ever spoke to me about interventions for her wandering, we just redirect her. Review of the activity participation for Resident #900 failed to reveal documentation the resident participated in group activities, one to one activities or self-directed activities on 5/16/21, or 5/20/21. 3. The facility's Policy and Procedure Resident Trust Fund - Resident Fund Withdrawal Tickets Effective Date 11/30/2014, Document Name BO-408, Revised 10/1/19: All disbursements made from resident trust funds must be documented with a properly signed withdrawal ticket. A pre-numbered withdrawal ticket is prepared when a withdrawal is made from the resident trust fund petty cash box or from the resident trust fund checkbook. Signatures are required for all withdrawals. If the resident is unable to sign the withdrawal ticket two witnessing signatures must be obtained. Signatures of witnesses must be legible to identify the correct name of the witness. Witnesses cannot be the person receipting the money or the check request. All receipts and documentation relating to the withdrawal must be stapled to the withdrawal sheet. This should include receipts and supporting documentation. On 6/3/21 at 3:00 p.m., in an interview the Regional Director of Business Office Services said in February 2021 she conducted a first audit which included dates from February 2020 through January 2021. She discovered withdrawal receipts from resident trust accounts without the required signature documentation proving the residents received the money. She said there were receipts that totaled $245.00 for Resident #2, #3, #4, #5, #6, and #7 but the withdrawal receipt was not signed by the residents making it impossible to verify the resident received the money. She said the residents were either incapacitated, not reliable, or no longer resided at the facility. The Regional Director of Business Office Services said during the first audit she also discovered there was $1600.00 in withdrawals made from the trust funds of Residents #8, #9, #885, and #11 for spend down without documentation verifying resident #8, #9, #11 and #885 authorized the withdrawals. On 6/3/21 at 3:00 p.m., the Regional Director of Business Office Services said on 4/16/21 she conducted a second audit from 2/11/21 through 4/19/21 and discovered $1000.00 was withdrawn from the trust accounts of Resident's #12, #13, #14, #15, and #9 for spend down. There was no documentation the residents authorized the withdrawals. Record review of the Withdrawal Transaction Report with Posting Date 4/9/21 showed a withdrawal amount for $1000.00 each for Residents #12, #13, #14, #15, and #9. She said at the conclusion of the two audits, she could not confirm there was not misappropriation of resident funds at the facility. She said she had a meeting with the Administrator after the first audit in February 2021 to discuss the findings and recommended termination of the Assistant Business Office Manager (ABOM). The Business Office Services Regional Director said after the second audit in April 2021 she recommended termination of the Business Office Manager (BOM). She said she is unaware of an investigation, a report to police, or report filed with the Agency for Health Care Administration (AHCA) regarding the matter. On 6/4/21 at 4:51 p.m., the Risk Manager confirmed she was assigned the tasks of investigating adverse events at the facility and filing reportable events with The Agency for Health Care Administration (AHCA). She said she was aware there was a problem with the receipts, but did not think it involved missing funds, so she did not investigate or file a report with AHCA. On 6/4/21 at 5:03 p.m., the Administrator said during the meeting with the Regional Business Office Manager he was made aware of ongoing performance issues with the ABOM. He said it was never presented to him there were resident funds missing, just issues with missing receipts and missing signatures on the receipts. He said if he thought there was misappropriation of funds or theft, he would have had the matter investigated and a report filed with the Agency for Healthcare Administration (AHCA). On 6/4/21 at 5:16 p.m., the Regional Director of Business Office Services said the administrator was aware of the withdrawal of money from the residents' trust funds without proper authorization. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team included the following: Licensed Nurses received education beginning on 6/3/2021 on reporting of resident behaviors, managing and monitoring resident behaviors. Licensed Nurses received education beginning on 6/4/2021 on change in condition and monitoring for sexually transmitted diseases. As of 6/3/2021, resident behaviors will be documented using the behavior monitoring sheets by the Licensed Nurses and will be reviewed by the clinical team during the morning clinical meeting. Resident behaviors will be monitored and managed through the care plan process with activities and psychosocial support. The interdisciplinary team, licensed nurses, certified nursing assistants, receptionist, dietary staff, and therapy staff received education beginning on 6/2/2021 on the abuse policy to include preventing abuse, identification, and protection, investigating, and reporting and reporting inappropriate resident behaviors to the nurse. A post-test was given to ensure competency of the information as presented in the in-service. As of 6/4/2021, the Executive Director and Director of Clinical Services received education by the Corporate Risk Manager on abuse policy and procedure to prevent abuse and neglect, and to protect residents from further abuse, identification, protection, completing a thorough investigating, to include obtaining witness statements from staff and other residents and reporting. As of 6/4/2021, the Executive Director received education by the Regional Vice President of Operations on protecting residents' health and safety and to protect residents from abuse and neglect with focus on facility oversight as it relates to the regulation. An ADHOC Quality Improvement Performance Committee meeting was held on 6/3/2021 to discuss the deficient practice related to abuse and to review the results of facility wide quality reviews completed. The following team members attended: Executive Director, Director of Clinical Services, Social Services Director, Staffing Coordinator, Risk Manager, Admissions Director, and the Regional Director of Clinical Services. The ADHOC QAPI Committee approved the recommendations. The Executive Director and the Director of Clinical services will ensure the Quality Assurance/Performance Improvement Committee will meet weekly until the committee determines substantial compliance has been met and recommends moving to monthly monitoring by the Regional Director of Clinical Services and the Regional Vice President of Operations when completing their systems review.

Based on record review, family and staff interviews, the facility failed to provide adequate assistance with transfer for 1 ((Resident #163) of 7 sampled residents. The facility failed to assist a resident with a potential for hazards in safe mobilization, which resulted in an accident for Resident #163 requiring surgery. The findings included: Resident #163 fell at the facility twice on 6/22/17 and was admitted to the hospital. The resident was readmitted to the facility on [DATE]. Review of the Recertification/Monthly Summary showed on 6/18/17 Resident #163 was to perform sit-stand-pivot transfers with a left knee brace for support. The document showed the amount of assistance the therapist was to use was minimum/moderate. Review of the MDS-Rehab Level of Assistance Crosswalk showed Minimum Assist: Patient completes 75% of the task. Caregiver is providing 25% physical support for the patient to complete the task. Moderate Assist: Patient completes 50% of the task. Caregiver is providing 50% physical support for the patient to complete the task. Review of the documentation by Physical Therapy Assistant (PTA) Staff FF on 6/22/17 read, Patient refused to preform proper weight shifting while performing stand and pivot transfer using hemi walker today during therapy and stated, I am going to do this my way. Patient had a loss of balance when performing stand and pivot transfer and was lowered to the floor using a gait belt-Patient reported unspecified pain in the left hip after being lowered to the floor. On 7/6/17 at 1:50 p.m., PTA Staff FF said 6/22/17 was the first time he had worked with Resident #163. He said he had not reviewed the care plan or the therapy notes before providing care to the resident. He said he had observed PTA Staff Z providing care to the resident prior to 6/22/17. He said the Resident #163 wanted to do things her own way during the procedure and he was allowing her to do so and providing cues as she was transferring. PTA Staff FF said he was using a gait belt and the resident had a hemi walker. The PTA stated he was providing contact guard assistance to the resident during the transfer. PTA Staff FF said the resident lost her balance and became dead weight and fell forward and away from him. He said he went down with her and he had used all his strength to prevent her from falling. The resident landed on floor on her buttocks on the left hip area. The PTA said he could not say if the resident had declined since his observation of Staff Z transferring the resident and prior to when he had transferred the resident on 6/22/17. On 7/6/17 at 2:54 p.m. the Director of Physical Therapy said before providing care to a resident for the first time it would be protocol for the PTA to review the Plan of Care and the Therapist notes and familiarize himself with the resident. On 7/6/17 at 3:54 p.m., Occupational Therapy Assistant (OTA) Staff AA said she had witnessed the fall that had occurred on 6/22/17 with Resident #163. OTA Staff AA said PTA Staff FF was standing next to the resident and she was transferring, but Staff FF did not have a wide stance while he was transferring the resident. The OTA said Staff FF was standing by the resident. She said she had observed other therapists transferring the resident. The OTA said other staff would really get up in there when they were assisting the resident to transfer. The OTA said Resident #163 fell had and solidly hit the ground. The OTA said the resident screamed when she hit the ground. On 7/7/17 at 11:25 a.m., Resident #163's son said his mother had spoken with him by phone on the afternoon of 6/22/17 and told him she had fallen during therapy and a staff member had fallen on top of her. She said she was having pain and felt she had broken her leg. The resident's son said a staff member had called him on 6/23/17 and told him the resident had not fractured her leg when she fell in therapy. He was told the resident had fractured her leg when she was found on the floor the evening of 6/22/17. Review of the hospital record shows Resident #163 was admitted to the hospital with [REDACTED]. The hospital physician documented on 6/23/17, (Patient) was trying to get up from a chair from which she fell landing on her L (left) buttocks and the therapist fell on her. On 7/6/17 at 3:01 p.m., the DON said PTA Staff FF had not reported to her during her investigation that he had not reviewed the plan of care prior to providing care to Resident #163 on 6/22/17. Review of the investigation of the DON showed witness statements from PTA Staff FF, a time line of events on 6/22/17 (before she was admitted to the hospital), and a witness statement from the certified nursing assistant who had found the resident sitting on the floor in her room at 10:10 p.m. on 6/22/17. The DON said PTA Staff FF had not reported to her there were any witnesses to the fall that had occurred in therapy. The DON said she was not aware this was the first time Staff FF had attempted to transfer Resident #163. On 7/6/17 at 3:30 p.m. PTA Staff Z said she had never instructed or had Staff FF observe her while transferring Resident #163. The PTA said Resident #163 was minimal/moderate assist with transferring. Staff Z said this would mean the therapist would pull the resident up with a gait belt when transferring. On 7/7/17 at 2:11 p.m. the Advanced Nurse Practitioner (ARNP) said on 6/22/17 she had been called with the x-ray report and was told the x-ray was negative. She was never told the X-ray beam had suboptimal penetration. She was told the resident had another fall. She was never told the resident had fallen twice on 6/22/17. The ARNP said Resident #163 had told her she had told the therapist she wanted to stop on 6/22/17. The ARNP said the therapist had continued to push Resident #163 after she told him she did not want to continue. The ARNP said she did not feel Resident #163 would have sustained a compound fracture from rolling out of a bed in the low position. She said a compound fracture would occur from pressure or force being placed on the leg when the leg and foot was planted on the ground.

Based on record review, family and staff interviews, and review of policies and procedures, facility staff failed to fully inform a resident or her representative about a serious medical condition for 1 (Resident #66) of 3 resident's whose death records were reviewed. This failure prevented them from making informed healthcare decisions. The resident subsequently expired in the facility. This failure places all residents in an immediate jeopardy situation. Cross refer to F309. The findings included: 1. Review of the facility's policies and procedures titled, Change in Resident Condition (effective date [DATE]) included the following: Procedure: The primary Clinical Nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs . The physician/Family/responsible Party will be notified as soon as possible include but not limited to significant change . With change of resident status, the Clinical Nurse will gather all subjective and objective assessment information. The nurse is responsible to complete an assessment of the resident's condition to include vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, the need to contact the agent/surrogate/contact person and or physician and must document the date, time, party's notified, findings and details of the notification in the nurses notes. Notification of the physician and agent/surrogate/contact person of a significant change in status shall routinely occur during the shift in which it occurs . 2. Resident #66 was admitted to the facility on [DATE] with multiple co-morbidities which included recent pelvic fracture, chronic [MEDICAL CONDITION], hypertension, non-pressure chronic ulcers to the right and left lower extremities, and history of [MEDICAL CONDITION]. Review of the admission assessment with a reference date of [DATE] showed a Brief Interview for Mental Status (BIMS) of 14, a measure of cognitive status, with 15 being the highest score. Resident #66 had advanced directives in place appointing her daughter as her Health Care Surrogate (HCS). The advanced directives showed the daughter was authorized to discuss healthcare information and give or withhold consent for treatment choices if the resident was unable. Record review showed Resident #66 was treated by the physician's assistant (PA) on [DATE], [DATE], and [DATE] for her bilateral leg ulcers. On [DATE], Resident #66 was examined by the vascular surgeon who documented Resident #66 underwent a right successful femoral by-pass. Her lower legs presented with deep ulcerations but were not infected. Her feet had good blood flow and with mild swelling and the ulcers continued to progress. On [DATE], the PA examined Resident #66 and documented resident was scheduled for a biopsy with dermatology as there was no progress with wound healing per nursing staff. The PA notes revealed the following: .nurses stated the resident is very sleepy and they often have to awaken her to give medications. She is alert, oriented, and in no distress at the time of the exam. Mood is congruent; healing is complicated on multiple levels. Believe immediate goals should be aimed at optimizing pain control as well as adequate wound care to prevent secondary infection. On [DATE], the PA spoke with the dermatologist who suspected Resident #66's ulcerations were related to an uncommon skin condition associated with a systemic disease. Review of the [DATE] wound center physician notes documented, I do not think this patient should be treated at the wound care center. Wounds are large and we have no ability to sedate her or administer the necessary medication. I think she needs a palliative care consult. Will discuss with daughter. Review of the facility record failed to reflect this discussion with Resident #66 or her daughter. Review of the daily skilled nurse's notes between [DATE] through [DATE] documented Resident #66's level of consciousness as alert and oriented to person and place. Under the skin section, the nurse's documented warm and dry. The nurse's notes failed to assess the color and turgor of Resident #66's skin. Review of the weekly skin assessments dated [DATE], [DATE], [DATE], and [DATE] showed no mention of the color of Resident #66's lower extremities. Review of PA notes dated [DATE] showed the she spoke with the daughter about her mother's mood which had been very depressed. The PA documented Resident #66 as very depressed, sleeping a lot, and difficult to arouse. The PA discussed the importance of Resident #66 following up with the dermatologist and vascular surgeon. There was no discussion about palliative care. On [DATE] at 11:00 a.m., nursing documented Resident #66 as alert and pleasant, alert and oriented x 3 (person, place, time). At 11:00 p.m., nursing documented, Lethargic, arousable, confusion. No c/o pain, negative statements, I want to die. Refused evening meal .c/o (complains of) abdominal cramps .drsgs (dressings) intact. A single blood pressure on the 3 p.m.-11 p.m. shift for [DATE] is recorded at ,[DATE]. (Very low; according to Understanding Blood Pressure Readings dated [DATE] by the American Heart Association-www.heart.org, a normal blood pressure is ,[DATE].) Documentation failed to show the nurse notified the physician or daughter of Resident #66's low blood pressure and lethargy. On [DATE] at 1:00 a.m., nurse's notes by Registered Nurse (RN) Staff N included the following: .Resident alert but listless. Unable to sit in chair. Assisted to bed. (There was no indication the physician or daughter was notified of Resident #66's listlessness.) Staff N failed to re-assess Resident #66's condition until 5:00 a.m. and documented, Has remained in bed and resting. At 11:00 a.m., Licensed Practical Nurse (LPN) Staff B documented: Resident remains in bed .Resident noted change in mental status. Alert and disoriented to place and time. Both legs noted with discoloration with [MEDICAL CONDITION] and feet and legs, cool to touch rt (right) foot and rt (right) leg more discolored than left leg and foot. There was no evidence LPN Staff B contacted an RN to assess Resident #66's change in orientation and the change in the color and temperature of Resident #66's legs. At 11:15 a.m., the LPN documented she called the daughter .concerning (Resident #66's) legs and mental status and concerning appointment canceled for today. At 11:20 a.m., the LPN documented, . (attending physician) office called concerning resident legs and change in mental status office will call back. There was no documentation the physician's office returned LPN Staff B's call. At 12:30 p.m., the LPN documented, .Resident remains in bed with eyes open resp. (respirations) unlabored. Skin w-d (warm-dry) 02 sat 98% Repos (reposition) by staff. Refused lunch. At 1:00 p.m., the LPN documented, .resident remains in bed no c/o (complaints/of) pain no distress noted. At 1:30 p.m., the LPN documented, .remains in bed, feet and legs molting, no c/o pain. At 2:20 p.m., the LPN documented, .all VS (vital signs) ceased. In an interview on [DATE] at 10:00 a.m., LPN Staff B said she remembered calling the daughter to let her know Resident #66 was having a change in condition and her legs were mottling. LPN Staff B said she told the daughter that Resident #66 was more confused and her legs were purple. LPN Staff B admitted she did not ask Resident #66 if she wanted to go to the hospital. LPN Staff B did not ask the daughter if her mother should be sent to the hospital. LPN Staff B confirmed Resident #66 was not in a terminal condition. Staff B said she couldn't remember if there was a do not treat or do not hospital order. LPN Staff B did not consult an RN to assess Resident #66's change of condition. LPN Staff B said she never called daughter again or the physician's office a second time. In an interview on [DATE] at 10:45 a.m., the daughter said her mother was being treated at the skilled nursing facility for her leg wounds and was going to rehab. She said she remembered getting a call from Staff B about mental changes. She said she thought the mental changes Staff B was talking about was in relation to her mother's depression over her legs and being in pain. She said Staff B never explained exactly what mental changes or mottling meant. The daughter said Staff B never told her that her mother was deteriorating and the severity of her mother's condition was never fully explained to her. The daughter said no one ever talked to her or her mother regarding palliative or comfort care. Their goal was that her wounds would heal and get stronger. The daughter stated, I didn't know they would even be thinking about this (palliative or comfort care). The daughter said she never got another call about her mother until after she expired. The daughter said if the severity of her mother's condition was explained to her, she would've told the facility to send her to the hospital. The daughter stated, I never told them she shouldn't go to her appointment. I relied on what they were telling me. My mother had ulcers on her legs but that was it. On [DATE] at 1:10 p.m., the PA said Resident #66 came to them because she had very bad lower extremity wounds. The PA stated, If anything, she (Resident #66) should've gone to the dermatology appointment. If she was as bad as they said she was, the (dermatologist) would have sent her to the hospital. The PA said if someone at the facility is having serious changes, there should be a process in place where the patient is assessed and determined to be sent out to the hospital. The PA said at times when they are seeing patients, they may be unavailable for a call from the facility, and stated, One would think they would call the medical director and a nursing supervisor to help make a decision regarding the patient's condition. During an interview on [DATE] at 2:45 p.m., the Director of Nurses (DON) said as soon as a change in condition is identified, the nurses should be notifying the physician, family and responsible party. She would expect her nurses to notify her to assess the situation if she is in the building and if they need any assistance with assessment or anything they might feel uncomfortable with. It would be her expectation the LPN get the RN to perform an assessment. She said the LPN could make the call to a family member regarding a resident's condition; but LPN's cannot assess (by Florida statute). During an interview on [DATE] at 9:37 a.m. with the Administrator and DON, the DON said LPN Staff B canceled Resident #66's dermatology appointment. She said throughout her course of care, Resident #66 said she wanted to die, was depressed and in pain. She said Resident #66 was not receiving palliative or end-of-life care. She said there were missing details in the chart and stated, some things we should've done differently. During an interview on [DATE] at 12:15 p.m., the Medical Director said he was not called in the absence of a return phone call by the attending physician. He said he was not made aware of the Resident #66's deteriorating condition. The Administrator was informed of the immediate jeopardy on [DATE] at 10:30 a.m. The facility amended their policies and provided education to nurses, nursing assistants, nurse managers, attending physician, and medical director. The facility's policy for change in resident condition now included the LPN will notify the RN on shift with a change in condition. In the event the attending physician does not respond in a reasonable amount of time, the medical director may be contacted. The facility now has a physician call list with alternate MD and phone number to call if unable to reach primary physician. The licensed staff employee roster was reviewed and by 10:00 p.m. on [DATE], the facility had inserviced 20 of the 29 nurses for change in condition policy, MD notification, medical director involvement, legal aspects of documentation; and identifying and reporting change in condition. The remaining staff are not allowed to work until can be reached and have been inserviced. On [DATE], all LPN staff members on duty were interviewed for knowledge from education provided. No issues were identified from these interviews. Random resident records were reviewed for MD and alternate MD phone numbers being present. The immediate jeopardy started [DATE] and was removed on [DATE] at 9:30 p.m. after the surveyors verified the corrective action with staff interviews. The scope and severity was lowered from J to D.

Based on record review, staff and family interview, and review of policies and procedures, the facility neglected to monitor and intervene during a serious medical condition for 1 (Resident #66) of 3 resident's whose death records were reviewed. Nursing staff failed to conduct a comprehensive assessment, failed to monitor signs and symptoms, and neglected to intervene when Resident #66's condition was deteriorating. As a result of this neglect, Resident #66 expired in the facility. This situation resulted in immediate jeopardy. Cross refer to F309. The findings included: 1. Review of the facility's policies and procedures titled, Change in Resident Condition (effective [DATE]) included the following: Procedure: The primary Clinical Nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs .The physician/Family/responsible Party will be notified as soon as possible include but not limited to significant change . With change of resident status, the Clinical Nurse will gather all subjective and objective assessment information. The nurse is responsible to complete an assessment of the resident's condition to include vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, the need to contact the agent/surrogate/contact person and or physician and must document the date, time, party's notified, findings and details of the notification in the nurses notes. Notification of the physician and agent/surrogate/contact person of a significant change in status shall routinely occur during the shift in which it occurs . 2. Resident #66 was admitted to the facility on [DATE] with multiple co-morbidities which included non-pressure chronic ulcers to the right and left lower extremities. Record review showed Resident #66 was treated for [REDACTED]. On [DATE], the resident was examined by the vascular surgeon and documented Resident #66 underwent a right successful femoral by-pass surgery. Her lower legs presented with deep ulcerations but were not infected. Her feet had good blood flow and with mild swelling. The PA notes of [DATE] documented Resident #66 was scheduled for a biopsy with dermatology as there was no progress with wound healing per nursing staff. The nurses stated the resident is very sleepy and they often have to awaken her to give medications. She is alert, oriented, and in no distress at the time of the exam. Mood is congruent; healing is complicated on multiple levels. Believe immediate goals should be aimed at optimizing pain control as well as adequate wound care to prevent secondary infection. The wound center notes of [DATE] included, I do not think this patient should be treated at the wound care center. Wounds are large and we have no ability to sedate her or administer the necessary medication. I think she needs a palliative care consult. Will discuss with daughter. Review of nursing progress notes between [DATE] and [DATE] as well as social service notes failed to show Resident #66 or her daughter (the resident's health care surrogate) were provided the opportunity to consider palliative care. Review of the daily skilled nurse's notes between [DATE] through [DATE] documented Resident #66's level of consciousness as alert and oriented to person and place. Under the skin section, the nurse's documented warm and dry. The nurse's notes failed to assess the color and turgor of Resident #66's skin. Review of the weekly skin assessments dated [DATE], [DATE], [DATE], and [DATE] showed no mention of the color of Resident #66's lower extremities. Review of PA notes dated [DATE] showed the she spoke with the daughter about her mother's mood which had been very depressed. The PA documented Resident #66 as very depressed, sleeping a lot, and difficult to arouse. The PA discussed the importance of Resident #66 following up with the dermatologist and vascular surgeon. There was no discussion about palliative care. On [DATE] at 11:00 a.m., nursing documented Resident #66 as alert and pleasant, alert and oriented x 3 (person, place, time). At 11:00 p.m., nursing documented, Lethargic, arousable, confusion. No c/o pain, negative statements, I want to die. Refused evening meal .c/o (complains of) abdominal cramps .drsgs (dressings) intact. A single blood pressure on the 3 p.m.-11 p.m. shift for [DATE] is recorded at ,[DATE]. (Very low; according to Understanding Blood Pressure Readings dated [DATE] by the American Heart Association-www.heart.org, a normal blood pressure is ,[DATE].) There was no documentation of any nursing response to Resident #66's low blood pressure, lethargy and abdominal cramps including RN assessment or notifying the physician or the daughter. On [DATE] at 1:00 a.m., nurse's notes by Registered Nurse (RN) Staff N included the following: .Resident alert but listless. Unable to sit in chair. Assisted to bed. (There was no indication the physician or daughter was notified of Resident #66's listlessness.) Staff N failed to re-assess Resident #66's condition until 5:00 a.m. and documented, Has remained in bed and resting. At 11:00 a.m., Licensed Practical Nurse (LPN) Staff B documented: Resident remains in bed .Resident noted change in mental status. Alert and disoriented to place and time. Both legs noted with discoloration with [MEDICAL CONDITION] and feet and legs, cool to touch rt (right) foot and rt (right) leg more discolored than left leg and foot. There was no evidence the LPN contacted an RN to assess Resident #66's change in orientation and the change in the color and temperature of Resident #66's legs. At 11:15 a.m., the LPN documented she called the daughter .concerning (Resident #66's) legs and mental status and concerning appointment canceled for today. At 11:20 a.m., the LPN documented, . (attending physician) office called concerning resident legs and change in mental status office will call back. There was no documentation the physician's office returned LPN Staff B's call. At 12:30 p.m., the LPN documented, .Resident remains in bed with eyes open resp. (respirations) unlabored. Skin w-d (warm-dry) 02 sat 98% Repos (reposition) by staff. Refused lunch. At 1:00 p.m., the LPN documented, .resident remains in bed no c/o (complaints/of) pain no distress noted. At 1:30 p.m., the LPN documented, .remains in bed, feet and legs molting, no c/o pain. At 2:20 p.m., the LPN documented, .all VS (vital signs) ceased. Resident #66's condition was not assessed by an RN. The physician was not called back a second time and Resident #66's daughter was not called with an update on her mother's clinical condition. Neither the resident nor her daughter were provided enough information to afford them the ability to tell the facility how she wanted to be treated. In an interview on [DATE] at 10:00 a.m., LPN Staff B didn't remember if she obtained vital signs when Resident #66 started to decline. She admitted she did not ask Resident #66 or her daughter if Resident #66 should go to the hospital for further evaluation and treatment. Staff B said she did not consult an RN to assist her in evaluating Resident #66. Staff B said she never called the physician's office back. On [DATE] at 1:10 p.m., the PA said Resident #66 had very bad lower extremity wounds. The PA stated, If anything, she (Resident #66) should've gone to the dermatology appointment. If she was as bad as they said she was, the (dermatologist) would have sent her to the hospital. The PA said if someone is having serious changes, there should be a process in place where the patient is assessed and determined to be sent out to the hospital. She said they may be unavailable for a call from the facility, and stated, One would think they would call the medical director and a nursing supervisor to help make a decision regarding the patient's condition. On [DATE] at 2:45 p.m., the Director of Nurses (DON) said as soon as a change in condition is identified, nurses should be notifying the physician, family and responsible party. She would expect her nurses to notify her to assess the situation if she is in the building and if they need any assistance with assessment or anything they might feel uncomfortable with. It would be her expectation the LPN get the RN to perform an assessment. She said LPN's cannot assess. During an interview on [DATE] at 9:37 a.m. with the Administrator and DON, the DON said LPN Staff B canceled Resident #66's appointment. The DON said throughout Resident #66's course of care, Resident #66 said she wanted to die, was depressed and in pain. The DON admitted Resident #66 was not offered palliative care. She stated, there were) some things we should've done differently. The DON said she was in the facility when Resident #66 expired and no one asked her to come and evaluate the resident. Resident #66's vital signs and level of consciousness were not routinely monitored. LPN Staff B neglected to consult an RN to assess Resident #66's declining condition. As a result of these failures, the facility neglected to provide Resident #66 with a comprehensive clinical assessment and implement interventions as her clinical symptoms deteriorated and she expired in the facility. The facility's policy for abuse prohibition defined neglect as the failure of the facility to provide goods and services to a resident that are necessary ro avoid physical harm, pain, mental anguish, or emtional distress. The failure to notify a resident's legal representative of a significant change in the resident's physical, mental or emotional condition that a prudent person would recognize. On [DATE] at 2:06 p.m., discussed with the Administrator, who is the abuse prohibition coordinator for the facility, how he monitors for abuse/neglect. The Administrator said education is provided to staff on hire and during monthly all staff and nursing meetings. He said they talk about and review all incidents, to include unintended death. He said in regards to a review of this area they start with the resident's code status, documentation of vital signs, and physician and family notification. The Administrator was informed of the immediate jeopardy on [DATE] at 10:30 a.m. The facility amended their policies and provided education to nurses, nursing assistants, nurse managers, attending physician, and medical director. The facility's policy for change in resident condition now included the LPN will notify the RN on shift with a change in condition. In the event the attending physician does not respond in a reasonable amount of time, the medical director may be contacted. The facility now has a physician call list with alternate MD and phone number to call if unable to reach primary physician. The licensed staff employee roster was reviewed and by 10:00 p.m. on [DATE], the facility had inserviced 20 of the 29 nurses for change in condition policy, MD notification, medical director involvement, legal aspects of documentation; and identifying and reporting change in condition. The remaining staff are not allowed to work until can be reached and have been inserviced. On [DATE], all LPN staff members on duty were interviewed for knowledge from education provided. No issues were identified from these interviews. Random resident records were reviewed for MD and alternate MD phone numbers being present. The immediate jeopardy started [DATE] and was removed on [DATE] at 9:30 p.m. after the surveyors verified the corrective action with staff interviews. The scope and severity was lowered from J to D.

Based on record review, staff interview, and review of policies and procedures, nursing staff failed to monitor and intervene during a serious medical condition for 1 (Resident #66) of 3 resident's whose death records reviewed. Nursing staff failed to follow professional standards of practice and ensure Resident #66 was comprehensively assessed for all subjective and objective signs and symptoms when Resident #66's condition was deteriorating. Nursing staff failed to ensure Resident #66 did not decline within the limits of her right to refuse treatment. As a result of these failures, Resident #66 expired in the facility. The Florida Nurse Practice Act (Florida Statute 464.003 as of [DATE]) for Registered Nurses includes: (20) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed and prevention of illness of others. The Florida Nurse Practice Act (Florida Statute 464.003) for a Licensed Practical Nurse includes: (19) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirmed, and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist . Cross refer to F154 and F223. The findings included: 1. Review of the facility's policies and procedures titled, Change in Resident Condition (effective [DATE]) included the following: Procedure: The primary Clinical Nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs .The physician/Family/responsible Party will be notified as soon as possible include but not limited to significant change .In the event of an emergency situation, 911 will be called and the Physician/Family/Responsible Party will be notified as soon as possible . With change of resident status, the Clinical Nurse will gather all subjective and objective assessment information. The nurse is responsible to complete an assessment of the resident's condition to include vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, the need to contact the agent/surrogate/contact person and or physician and must document the date, time, party's notified, findings and details of the notification in the nurses notes. Notification of the physician and agent/surrogate/contact person of a significant change in status shall routinely occur during the shift in which it occurs . 2. Review of facility records revealed Resident #66 was admitted to the facility on [DATE] with multiple co-morbidities which included non-pressure chronic ulcers to the right and left lower extremities. Resident #66 had advanced directives in place appointing her daughter as her Health Care Surrogate (HCS) in the event Resident #66 could not give an informed consent. Resident #66 was treated by the physician's assistant (PA) on [DATE], [DATE], and [DATE] for her leg ulcers. On [DATE], the vascular surgeon documented Resident #66 underwent a right successful femoral by-pass (surgery is used to treat blocked femoral artery). Her lower legs presented with deep ulcerations but were not infected. Her feet had good blood flow with mild swelling. Notes by the PA dated [DATE] showed Resident #66 was scheduled for a biopsy with dermatology as there was no progress with wound healing per nursing staff. The PA wrote, .Believe immediate goals should be aimed at optimizing pain control as well as adequate wound care to prevent secondary infection. The wound center physician notes of [DATE] documented, I do not think this patient should be treated at the wound care center. Wounds are large and we have no ability to sedate her or administer the necessary medication. I think she needs a palliative care consult. Will discuss with daughter. There was no discussion of the opportunity to consider palliative care found in nursing progress, social service, or attending physician notes. Review of the daily skilled nurse's notes between [DATE] through [DATE] documented Resident #66's level of consciousness as alert and oriented to person and place. The skin section noted warm and dry. The nurse's notes failed to assess the color and turgor of Resident #66's skin. On [DATE], Resident #66 was evaluated by the PA. Review of her notes showed the PA spoke with the daughter as her mother's mood had been very depressed, she was sleeping a lot and was difficult to arouse. The PA discussed the importance of Resident #66 following up with the dermatologist and vascular surgeon. There was no discussion about palliative care. On [DATE] at 11:00 p.m., nursing noted the resident was lethargic, arousable and confused. Nursing noted Resident #66 wanted to die and complained of abdominal cramps. A single blood pressure on the 3 p.m.-11 p.m. shift for [DATE] is recorded at ,[DATE]. (According to Understanding Blood Pressure Readings [DATE] by the American Heart Association-www.heart.org , normal blood pressure is ,[DATE].) There was no documentation of any response to Resident #66's low blood pressure, lethargy, and abdominal cramps including an RN assessment or notifying the physician or the daughter. On [DATE] at 1:00 a.m., nurse's notes by Registered Nurse (RN) Staff N, documented Resident #66 as listless and unable to sit in her chair. RN Staff N assisted Resident #66 to bed, but did not complete a clinical assessment of Resident #66 to include vital signs. On [DATE] at 11:00 a.m., Licensed Practical Nurse (LPN) Staff B noted: Resident remains in bed .Resident noted change in mental status. Alert and disoriented to place and time. Both legs noted with discoloration with [MEDICAL CONDITION] and feet and legs, cool to touch (right) foot and (right) leg more discolored than left leg and foot. There was no evidence the LPN contacted an RN to assess Resident #66's change in orientation and the change in the color and temperature of Resident #66's legs. On [DATE] at 11:15 a.m., LPN Staff B noted she called the daughter regarding her mother's legs and mental status and concerning an appointment canceled for that day. The LPN noted at 11:20 a.m., .(attending physician) office called concerning resident legs and change in mental status office will call back. The physician's office did not return Staff B's call and there was no second call placed to the physician. The LPN noted at 12:30 p.m., .Resident remains in bed with eyes open resp. (respirations) unlabored. Skin w-d (warm-dry) 02 (oxygen) sat 98% Repos (reposition) by staff. Refused lunch. The LPN noted at 1:00 p.m., Resident #66 remained in bed with no complaints of pain or distress. The LPN noted at 1:30 p.m., .remains in bed, feet and legs molting, no c/o pain. The LPN noted at 2:20 p.m., .all VS (vital signs) ceased. LPN Staff B did not consult an RN to clinically assess Resident #66's condition. The physician was not called back a second time and Resident #66's daughter was not called with an update on her mother's clinical condition. The resident nor her daughter were provided enough information to afford them the opportunity to tell the facility how she wanted to be treated. In an interview on [DATE] at 10:00 a.m., LPN Staff B confirmed she didn't obtain vital signs when Resident #66 was deteriorating. She did not ask Resident #66 or her daughter if her mother should go to the hospital for evaluation and treatment. LPN Staff B admitted she did not ask an RN to assist her in assessing Resident #66. The LPN said she did not call the physician's office back a second time. In an interview on [DATE] at 1:10 p.m., the PA said Resident #66 came to the facility because she had very bad lower extremity wounds. The PA said the resident should have gone to the dermatology appointment. If the resident was as bad as they said she was, the dermatologist would have sent her to the hospital. The PA said if someone at the facility is having serious changes, there should be a process in place where the patient is assessed and determined to be sent out to the hospital. The PA said at times when they are seeing patients, they may be unavailable for a call from the facility, and stated, One would think they would call the medical director and a nursing supervisor to help make a decision regarding the patient's condition. In an interview on [DATE] at 2:45 p.m., the Director of Nursing (DON) said as soon as a change in condition is identified, nurses should be notifying the physician, family and responsible party. She would expect her nurses to notify her to assess the situation if she is in the building and if they need any assistance with assessment or anything they might feel uncomfortable with. It would be her expectation the LPN get the RN to perform an assessment. She said LPN's cannot assess. During an interview on [DATE] at 9:37 a.m., the DON said the LPN canceled Resident #66's appointment. The DON said throughout Resident #66's course of care, Resident #66 said she wanted to die, was depressed and in pain. The DON admitted Resident #66 was not offered palliative care. She said there were missing details in the chart and stated, (there were) some things we should've done differently. The DON was in the facility when Resident #66 expired and said no one asked her to come and evaluate Resident #66. Resident #66 and her daughter were not afforded the choice of whether or not the dermatology appointment should be kept, whether she wanted to remain in the facility, or be transferred to the hospital for evaluation and treatment. An RN did not assess Resident #66's clinical symptoms and condition. Resident #66's vital signs were not monitored and her level of consciousness was not assessed as she deteriorated. As a result of these failures, she expired in the facility. The Administrator was informed of the immediate jeopardy on [DATE] at 10:30 a.m. The facility amended their policies and provided education to nurses, nursing assistants, nurse managers, attending physician, and medical director. The facility's policy for change in resident condition now included the LPN will notify the RN on shift with a change in condition. In the event the attending physician does not respond in a reasonable amount of time, the medical director may be contacted. The facility now has a physician call list with alternate MD and phone number to call if unable to reach primary physician. The licensed staff employee roster was reviewed and by 10:00 p.m. on [DATE], the facility had inserviced 20 of the 29 nurses for change in condition policy, MD notification, medical director involvement, legal aspects of documentation; and identifying and reporting change in condition. The remaining staff are not allowed to work until can be reached and have been inserviced. On [DATE], all LPN staff members on duty were interviewed for knowledge from education provided. No issues were identified from these interviews. Random resident records were reviewed for MD and alternate MD phone numbers being present. The immediate jeopardy started [DATE] and was removed on [DATE] at 9:30 p.m. after the surveyors verified the corrective action with staff interviews. The scope and severity was lowered from J to D.

Based on record review, observation, and interview, the facility failed to have an effective Quality Assessment and Assurance (QAA) program to evaluate processes when incidents occur and require investigation for potential quality of care concerns. The QAA program did not ensure care practices were consistently applied, or ensure policy and procedures were followed. The QAA program did not fully assess, investigate, and identify an incident of potential neglect for 1 (Resident #66) of 3 residents reviewed for unexpected death in the facility. The administrative staff did not follow up to determine there was no documentation by nursing of any assessment, or that staff neglected to implement interventions when it was known Resident #66's condition was deteriorating. (Refer to F223). As a result of the failures, Resident #66 expired in the facility. This situation had resulted in immediate jeopardy. The lack of investigation, assessment, and analysis of the events surrounding the incident places all residents at risk for not having appropriate treatment or transfer to a higher level of care when a significant change in condition occurs. (Refer to F309) The QAA program was not effective in ensuring safe sanitation practices were being maintained in the kitchen. The lack of sanitary food practices places all residents at risk for potential food borne illness. (Refer to F371) In addition, an incident involving inappropriate withholding of a medication (Resident #50) was identified as having occurred over time but was not brought to QAA for root cause analysis. The findings included: 1. Records showed Resident #66 was admitted to the facility on [DATE] for rehab services. Her daughter was her health care surrogate. and had signed the Consent To Treat upon admission. An advanced directive was in place appointing her daughter as her health care surrogate. On [DATE] at 11:00 p.m., the nurse documented Resident #66 was lethargic, arousable, confusion and said, I want to die. The resident refused her evening meal and complained abdominal cramps. Blood pressure was ,[DATE]. (According to Understanding Blood Pressure Readings dated [DATE] by the American Heart Association, normal range of blood pressure is ,[DATE].) On [DATE] at 1:00 a.m., Registered Nurse (RN) Staff N noted Resident alert but listless. Unable to sit in chair . On [DATE] at 11:00 a.m., Licensed Practical Nurse (LPN) Staff B documented: Resident remains in bed. fed by staff . noted change in mental status. Alert and disoriented to place and time . Both legs noted with discoloration with [MEDICAL CONDITION] and feet and legs, cool to touch (right) foot and (right) leg more discolored than left leg and foot. There was no RN assessment of these changes. At 11:15 a.m., the LPN called the resident's daughter about the legs and mental status and the resident's medical appointment. At 11:20 a.m., the LPN called attending physician's office, but the physician did not call back. At 12:30 p.m., the resident refused lunch. At 1:30 p.m., the LPN described legs and feet as mottling (blotchy or marbled in appearance, used to describe the skin of patients who are cold or inadequately perfused). No other medical staff was contacted and there was still no documented RN assessment. at 2:20 p.m., the LPN noted that vital signs had ceased. There was no documentation to support Resident #66's condition was routinely monitored or assessed by a RN; no documentation of the physician returning Staff's B call; no documentation Resident #66's daughter was routinely called with an update on Resident #66's clinical condition; and no documentation Resident #66 or her legal representative were provided a detailed explanation of Resident #66's clinical condition which would enable them to make an appropriate healthcare decision on how she wanted to be treated. In an interview on [DATE] at 10:00 a.m., LPN Staff B said did not consult an RN to assist her in evaluating Resident #66. The LPN said she never called the physician's office a second time. In an interview on [DATE] at 10:45 a.m., Resident #66's daughter said her mother was at the facility for her leg wounds and was going to rehab. She remembered getting a call from the LPN about the mental changes. She thought it was in relation to her mother's depression over her legs and being in pain. The staff never told her that her mother was deteriorating. No one asked her if her mother should be sent to the hospital. She said she would've told the facility to send her mother to the hospital. In an interview on [DATE] at 1:10 p.m., the Physician Assistant stated, If anything, she should've gone to the dermatology appointment. If she was as bad as they said she was, the (dermatologist) would have sent her to the hospital. Review of the facility's policies and procedures entitled, Change in Resident Condition included With change of resident status, the Clinical Nurse will gather all subjective and objective assessment information. The nurse is responsible to complete an assessment of the resident's condition to include vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, . The policy does not specify that an RN assess and make judgement calls. Such actions are not within the scope of practice for an LPN in Florida (Florida Statute 464.003). During an interview on [DATE] at 2:45 p.m., the Director of Nurses (DON) said as soon as a change in condition is identified, they should be notifying physician, family and responsible party. She would expect her nurses to notify her to assess the situation if she is in the building and if they need any assistance with assessment or anything they might feel uncomfortable with. It would be her expectation the LPN get the RN to perform an assessment. She said the LPN could make the call to a family member regarding a resident's condition regarding the evaluation of the resident; but LPN's cannot assess. She was aware of Resident #66's death, but because the wound care center said they couldn't treat her anymore and she should be palliative care, she didn't go back to the chart to review. She said, I guess I should have. In an interview on [DATE] at 6:00 p.m., RN Staff N acknowledged she documented Resident #66 as listless on [DATE] at 0100. She said listless meant very weak and tired. She admitted she did not take any vital signs. In an interview on [DATE] at 9:37 a.m., the DON said there were missing details in the chart and some things we should've done differently. On [DATE] at 1:57 p.m., the Administrator confirmed as risk manager he had not identified or been made aware of any issues with the documentation or actions by staff leading up to the death of Resident #66. The facility's last QAA meeting had been held on [DATE]. There was no evidence the facility's QAA committee had identifed any issues surrounding Resident #66. 2. A record review of the Dietary Services Agreement dated [DATE] with Healthcare Services Group (HCSG) to provide dietetic services for the facility revealed the following: Section 3 paragraph (j) on page 4 noted HCSG shall prepare, distribute and serve food under sanitary conditions in accordance with generally accepted policies and procedures. In paragraph (m), HCSG shall participate in Facility's Quality Assurance Program. During the initial tour of the kitchen with the Certified Dietary Manager (CDM) on [DATE] at 9:25 a.m. and during the survey, the following were observed: Floors were soiled and slippery floors with trash on them; door handles, counters, shelves, and dish machine were soiled; there was a lack of waste cans and missing thermometers; there were expired and undated food in coolers; ceiling vents located above food were dripping; the ice machine was soiled and corroded and a wall was crumbling; kitchen staff failed to meet sanitary food handling standards; and there was an ongoing flying insect problem. On [DATE], following the initial tour, the CDM confirmed the findings and said, I know it's really bad; it's hard to know where to start. At 11:30 a.m., the CDM said that Quality Assurance meetings addressed kitchen cleaning. On [DATE] at 12:55 p.m., Maintenance Director identified the flying insects as fruit flies. He said he did not know about them until now. At [DATE] at 1:03 p.m. Dietary Staff Q said they had 2 cleaning parties this week to get rid of pests in the back of the kitchen and scrubbing lots of mold. Dietary Staff Q said the conditions here make it difficult to work. On [DATE] at 12:00 p.m., the CDM said she had been making a list for maintenance, but was not aware of the water damaged crumbling wall. On [DATE] at 1:57 p.m., the Administrator confirmed he was aware of ongoing issues in the kitchen with sanitation and was working with the contracted company to get these addressed. Concerning flies present in the kitchen, no one alerted Maintenance or pest control. 3. Resident #50 had an order written [REDACTED]. The resident had an order for [REDACTED]. On [DATE] the consultant pharmacist recommenced to the physician that they stop the blood pressure parameter on the potassium chloride. A new order was written at that time. On [DATE] the resident had a potassium level of 3.2 (low). The physician ordered potassium 20 meq daily. The resident went in the hospital on [DATE] to have a pacemaker placed and on [DATE] returned to the facility. The hospital ordered potassium 10 meq daily on return to the facility. The nurse transcribed potassium 10 meq daily hold for systolic blood pressure greater than 120. This medication was held 7 times during the month of [DATE]. The medication was held four days in a row on [DATE] through [DATE]. Resident #50 continued to receive a diuretic [MEDICATION NAME] 40 mg every other day. This combination had a potential to deplete her potassium even lower. There was no documentation nurses notified the physician they had held the medication 4 days in a row. There is no follow up monitoring of the resident's potassium level. On [DATE] the consultant pharmacist again recommended to stop holding the potassium for blood pressure parameters. The pharmacist records the last potassium level of 3.2. The recommendation does not get signed by the physician assistant (PA) until [DATE]. The order does not take effect until [DATE]. There was no follow up labs completed even after the error was found. The PA said he had never seen potassium held with blood pressure parameters. He said it would have been good practice to have obtained a potassium level after the medication was held with the resident's last potassium level being low. The primary physician said he had never seen an order to hold potassium for blood pressure parameters in the time he had practiced medicine. He said he would want staff to call him if they held any medication for four days in a row. Both the PA and the primary physician had signed for the resident to have the medication with parameters. This medication error was found in [DATE] and on [DATE]. The facility failed to QAA review this error even though it had passed nursing, pharmacy, and medical staff without being caught in a timely manner. In an interview on [DATE] at 9:28 a.m., the Administrator said he is also the risk manager but did not recall an investigation on Resident #50's medications to determine root cause or the issue being brought to QAA. 4. The Administrator was informed of the immediate jeopardy on [DATE] at 10:30 a.m. The facility amended their policies and provided education to nurses, nursing assistants, nurse managers, attending physician, and medical director. The facility's policy for change in resident condition now included the LPN will notify the RN on shift with a change in condition. In the event the attending physician does not respond in a reasonable amount of time, the medical director may be contacted. The facility now has a physician call list with alternate MD and phone number to call if unable to reach primary physician. The licensed staff employee roster was reviewed and by 10:00 p.m. on [DATE], the facility had inserviced 20 of the 29 nurses for change in condition policy, MD notification, medical director involvement, legal aspects of documentation; and identifying and reporting change in condition. The remaining staff are not allowed to work until can be reached and have been inserviced. On [DATE], all LPN staff members on duty were interviewed for knowledge from education provided. No issues were identified from these interviews. Random resident records were reviewed for MD and alternate MD phone numbers being present. The immediate jeopardy started [DATE] and was removed on [DATE] at 9:30 p.m. after the surveyors verified the corrective action with staff interviews. The scope and severity was lowered from J to D.