Every finding on record at Bedford Care Center of Newton

Based on observation, interview and record review, the facility failed to provide required written notice of its bed hold policy and transfer/discharge notification for a resident who was transferred to an acute care hospital two (2) times for one (1) of one resident reviewed for hospitalizations. Resident #36Findings include:A record review of the facility's policy, Transfer and Discharge, revised 10/01/22 revealed . It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Definitions.'Transfer and discharge' includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not . Policy Explanation and Compliance Guidelines: . 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location .to which the resident is to be transferred or discharged .A record review of the admission Record revealed the facility admitted Resident #36 originally on 10/15/25 with a re-admission on [DATE]. He had diagnoses including Hemiplegia And Hemiparesis Following Cerebral Infarction.A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/25 revealed Resident #36 was discharged to an acute hospital with return anticipated. A review of Section C Staff Assessment for Mental Status revealed Resident #36 had memory problems and moderately impaired cognitive skills for daily decision making. A record review of the Discharge MDS with an ARD of 11/01/25 revealed Resident #36 was discharged to acute hospital with return not anticipated. On 11/19/2025 at 11:33 AM, during an interview with Administrator Assistant, she reported she is the staff member responsible for mailing out hospital transfer and bed hold notifications. She explained for Resident #36 she did not mail a notification to his Resident Representative (RR) because he was discharged each time he was transferred to the hospital. She further explained that Resident #36's RR opted to not pay for bed hold when he was admitted , and confirmed the RR was not provided written notification upon each transfer that occurred on 10/17/25 and 11/1/25. The Administrator Assistant stated she was not aware that if the resident was discharged and chose not to pay bed hold upon admission, that she should provide written notification with each transfer or discharge. On 11/19/2025 at 4:00 PM, during an interview with the Business Office Manager, she confirmed that the Assistant Administrator did not mail or provide written notification regarding resident transfer and bed hold information for Resident #36 for 10/17/25 and 11/1/25. She was not aware that if a resident was discharged , the facility must provide written notification regarding the resident transfer and bed hold information. On 11/19/2025 at 04:25 PM, during a phone interview with Resident #36's RR, she confirmed that she signed on admission for Resident to not have a bed hold due to not having a payment source. She confirmed that she never received written notification regarding the transfers or bed hold information when the resident was transferred to an acute hospital on [DATE] and 11/1/25. On 11/20/2025 at 2:18 PM, during an interview with the Administrator, she reported she had been informed that the facility failed to provide written notification of resident transfer/discharge for Resident #36 on 10/17/25 and 11/1/25. She stated she expected written notification to be provided to the resident and/or the RR at each transfer and discharge.

Based on interviews, record review, and facility policy review, the facility failed to honor a resident's choice to receive visitors, as evidenced by, restricting visitation privileges in the dining room (a common area of the facility) with no reasonable clinical or safety explanation for one (1) of 15 sampled residents, with the potential to affect all residents who are served meals in the dining room. Resident #47 Findings include: Review of the facility's policy, Resident Right to Access and Visitation, revised 10/1/2022, revealed, .It is the policy of this facility to support and facilitate the resident's right to receive visitors of their choosing, at the time of their choosing .Visitation will be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life .Policy Explanation and Compliance Guidelines . 2 .Resident's family member are not subject to visiting hour limitation or other restrictions not imposed by the resident, with the exception of reasonable clinical and safety restrictions .11. The facility will ensure all visitors enjoy full and equal visitation privileges, consistent with resident preferences . During an interview on 5/28/2024 at 10:30 AM, Resident #47's family member explained the facility would not allow her to visit the resident in the dining room. She stated she had been informed by the facility she could visit the resident in the resident's room or the family room, but not in the dining room. She said that not being able to eat with her family in the dining room was concerning and she had communicated with the Social Services Coordinator (SSC) but was told the only visitation options were the resident's room and the family room. During an interview on 5/29/24 at 10:54 AM, with the SSC, she confirmed that no one was allowed to visit residents in the dining room since the COVID-19 public health emergency. The facility continued to try to maintain distance between residents to reduce the spread of COVID-19. During an interview on 5/30/2021 at 10:30 AM, the Administrator stated that it was her decision to restrict visitation for residents to the family room or the resident's room. She explained that she was concerned about the spread of COVID-19, even though the facility was not in a COVID-19 outbreak. She said COVID-19 was still a concern in the community. She stated she had been informed that Resident #47's family member was concerned because she was unable to visit and eat with her family member in the dining room. A record review of the Admission Record revealed the facility admitted Resident #47 on 3/22/23 with diagnoses including Muscle Wasting and Atrophy. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/24 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Surveyor: [NAME] 50751

Based on record review, staff interview, and facility policy review, the facility failed to ensure an advance directive, specifically a durable Power of Attorney (POA), was available and readily retrievable by facility staff for one (1) of 24 residents reviewed for advance directives. (Resident #29). Findings Include: A review of the facility's policy, Residents' Rights Regarding Treatment and Advanced Directives, revised 11/1/22, revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to .formulate an advance directive. Definitions: Advance Directive is a written instruction, such as a . durable power of attorney for health care .Policy Explanation and Compliance Guidelines .3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart . A record review of the Clinical Resident Profile revealed the facility admitted Resident #29 on 5/2/2018 and she had current diagnoses including Alzheimer's Disease with Early Onset. Record review of the facility's document, Acknowledgement of Advance Directives Decisions, Rights, and Information, signed 5/1/2018, indicated Resident #29 had a POA. A record review of the electronic medical record (EMR) revealed there was no copy of a POA on the chart. On 5/28/24 at 1:57 PM, in an interview and record review with Registered Nurse (RN) #1/RN Supervisor, she explained if a resident had a POA, it would be scanned into the Misc tab of the EMR. RN #1 reviewed the EMR for Resident #29 and determined there was no POA in the chart. She confirmed there was no paper charts or any other area at the nurses station where a POA would be kept. RN #1 stated that Medical Records was responsible for scanning POAs into the EMR. On 5/28/24 at 2:00 PM, in an interview and record review with the Medical Records, she confirmed she was responsible for scanning in advance directives and POAs into the EMR. Upon review, she determined the POA was not in the EMR for Resident #29. She commented Resident #29 had lived at the facility for a long time and if the POA had not been scanned in, then it could be located either in the old medical records office or in the front office, which was locked after hours and on weekends. She confirmed the POA was not readily accessible to staff and stated, It just did not get scanned in. On 5/28/24 at 2:15 PM, Medical Records provided a copy of the POA for Resident #29 and stated it was found in the front office. On 5/29/24 at 4:05 PM, in an interview with the Director of Nursing (DON), she stated she was unaware Resident #29's POA was not readily accessible for review by facility staff and she expected all POAs to be scanned into the residents' EMR.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident was free from the use of physical restraints, as evidenced by, an observation of a resident wearing a seat belt with no facility documentation of risk and benefits, physician order, consent, monitoring, assessments or medical symptoms for restraint use for one (1) of 15 sampled residents. (Resident #17) Findings include: Review of the facility's policy, Physical Restraint Application, revised 8/2/22, revealed, The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints .Physical restraints are defined .as any manual method or physical or mechanical devise, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement .The resident must be physically and cognitively able to self-release devices such as .seat belts .If a resident cannot mentally and physically self-release, then the device is considered a restraint . On 05/28/24 at 11:40 AM, during an observation, Resident #17 was sitting in a wheelchair and had a seat belt that was attached to the chair and buckled in the front. His hands were contracted. He kept his hands positioned around his abdominal area. On 05/29/24 at 2:26 PM, in an observation an interview with Certified Nursing Assistant (CNA) #1, she stated Resident #17 was unable to use his hands and could not release the seat belt buckle without assistance. Resident #17 was sitting in his wheelchair with the seat belt device in place. CNA #1 asked Resident #17 to unbuckle his seat belt, but he said that he could not unbuckle it and asked the CNA to do it. Review of the medical record revealed there was no documentation Resident #17 had a wheelchair seat belt restraint, consent, risk and benefits of restraint use, restraint assessment, physician order, medical symptom for use or monitoring for the seat belt. A record review of the Admission Record revealed the facility admitted Resident #17 on 6/18/2022 and he had current diagnoses including Acquired Absence of Right Leg and Left Leg, Above the Knee. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/24 revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. On 05/30/24 at 11:06 AM, in an interview with the Director of Nursing (DON) she stated the facility did not consider the lap belt for Resident #17 as a restraint because they viewed it as a support device for the resident. She confirmed that by definition, it should have been considered a restraint and the facility should have obtained a physician's order for the device.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to a seat belt restraint for one (1) of 15 care plans reviewed. Residents #17 Findings Include: Review of the facility's policy, Comprehensive Care Plans revised 8/24/22, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe .a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . During an observation and interview on 05/29/24 at 2:26 PM, Certified Nursing Assistant (CNA) #1 stated Resident #17 was unable to use his hands and could not release the seat belt buckle without assistance. Resident #17 was sitting in his wheelchair with the seat belt device in place. CNA #1 asked Resident #17 to unbuckle his seat belt, but he said that he could not unbuckle it and asked the CNA to do it. A record review of the Comprehensive Care Plan revealed there was no care plan developed related to the seat belt device worn by Resident #17. During an interview, on 05/30/24 at 11:06 AM, with the Director of Nursing (DON) she stated the facility did not consider the lap belt for Resident #17 as a restraint but rather it was viewed as a support device for the resident. However, it should have been considered a restraint and a care plan should have been developed for the device. On 5/30/24 at 11:26 AM, during an interview with Licensed Practical Nurse (LPN) #1, she reviewed the comprehensive care plan for Resident #17 and confirmed there was no care plan related to the use of the seatbelt. She confirmed the facility should have developed a care plan for the device and stated she was not sure why it was not developed. A record review of the Admission Record revealed the facility admitted Resident #17 on 6/18/2022 and he had current diagnoses including Acquired Absence of Right Leg and Left Leg, Above the Knee.

Based on observation, staff interview, and facility policy review, the facility failed to discard expired medications from one (1) of three (3) medication storage rooms observed. (Central Station) Findings include: Record Review of the facility's Medication Storage, revised 07/17/23, revealed, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the .medication rooms according to the manufacturer's recommendations .Policy Explanation and Compliance Guidelines .8. Unused Medications: The .medication rooms are routinely inspected by the consultant pharmacist for discontinued .medication with worn. In an observation and interview with Registered Nurse (RN) #2, on 5/28/24 at 11:33 AM, on central station there were expired medications in a cubicle in the medication room stored in blister packs (dose packaging for pharmaceutical tablets or capsules) for Resident #36. The medications included Furosemide 40 milligrams (mg) that expired on 1/2/24, Vistaril 25 mg expired on 1/2/24, Aricept 20 mg expired on 10/28/23, and Zoloft 25 mg expired on 2/27/24. RN #2 explained that all nurses should check the medication rooms and medication carts to ensure there were no expired medications. During an interview with the Director of Nursing (DON) on 05/30/24 at 11:39 AM, she stated it was her expectation that the nurses check medications for expiration dates before administering them and to remove expired medications from the medication carts and medication rooms. 50751

Based on record review, facility policy review, and staff interviews, the facility failed to act upon a Consultant Pharmacy (CP) recommendation for psychotropic medications for two (2) of five (5) residents reviewed for unnecessary medications. Resident #28 and Resident #35 Findings include: A record review of the facility's policy, Medication Regimen Reviews (MRR), with a revised date of 8/2/22, revealed, .8. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains: a. the resident's name b. the name of the medication c. the identified irregularity and d. the pharmacist's recommendation . 14. The consultant pharmacist provides the director of nursing services and medical director with a written signed and dated copy of all medication regimen reports . 15. Copies of the medication regimen review reports, including physician responses, are maintained as part of the permanent medical record . Resident #28 A record review of the Order Summary Report, for Resident #28 revealed, . Active Orders As Of: 11/16/22 . Ativan Tablet 1 MG (LORazepam) Give 1 mg (milligrams) by mouth every 8 hours as needed for anxiety . Order Date 8/11/22 and Start Date 8/11/22 . The physician's orders did not include a specific duration of time for the medication or an automatic stop date. A record review of the Note to Attending Physician/Prescriber dated 9/23/22, and sent by the Consultant Pharmacist (CP) for Resident #28 revealed, .PRN (as needed) PSYCHOTROPIC MEDICATION CONSULT . This resident has an order for Ativan 1 mg (milligram) q8h (every eight hours) prn for anxiety. New federal guidelines require that PRN psychotropic medication orders automatically discontinue after 14 days. The provider must re-write the PRN order every 14 days to continue the medication on a PRN basis . Record review of the significant change Minimum Data Set (MDS) dated [DATE] Section N revealed .Medications Received- Indicate the number of DAYS the resident received the following medications by pharmacological classification .A.Antianxiety . The number of days entered that Resident #28 had received this medication was 7. A record review of the Admission Record, revealed, the facility admitted Resident #28 on 2/21/22, with diagnoses that included Generalized Anxiety, and Schizophrenia. Resident #35 A record review of the Order Summary Report, for Resident #35 revealed, . Active Orders As Of: 11/15/22 . Ativan Tablet 1 MG (LORazepam) Give 1 mg (milligram) by mouth every 12 hours as needed for anxiety . Order Date 2/04/22 and Start Date 2/04/22 . The physician's orders did not include a specific duration of time for the medication or an automatic stop date. A record review of the Note to Attending Physician/Prescriber dated 8/23/22, and sent by the Consultant Pharmacist (CP) for Resident #35 revealed, .PRN (as needed) PSYCHOTROPIC MEDICATION CONSULT . This resident has an order for Ativan 1 mg every 12 hrs (hours) prn for anxiety. New federal guidelines require that PRN psychotropic medication orders automatically discontinue after 14 days. The provider must re-write the PRN order every 14 days to continue the medication on a PRN basis . Record review of the quarterly Minimum Data Set (MDS) dated [DATE] Section N revealed .Medications Received- Indicate the number of DAYS the resident received the following medications by pharmacological classification .B.Antianxiety . The number of days entered that Resident #35 had received this medication was 7. A record review of the Admission Record for Resident #35, revealed the facility admitted the resident on 10/15/19, with the diagnoses that included Alzheimer's Disease and Dementia with other Behavioral Disturbances. During an interview with the Director of Nursing (DON) on 11/16/22 at 1:20 PM, she confirmed the Ativan PRN orders for Resident #28 and Resident #35 did not have a duration time or an automatic stop date. She also confirmed the resident's medical records did not contain clinical documentation with new orders to extend the Ativan beyond the 14 days. During a telephone interview with the facility's CP on 11/16/22 at 1:30 PM, she explained she sent the facility a recommendation regarding the PRN Ativan order for Resident #35 on 8/23/22, and a recommendation regarding the PRN Ativan order for Resident #28 on 9/23/22. She confirmed the PRN orders needed to have a specific duration of time for use and should only be used for 14 days but may be extended beyond 14 days if the provider documents clinical opinion, clinical rationale for extension, and a specific duration of time for the use of the PRN medication. She reported she has strongly encouraged this, but the facility does not always respond, and she keeps sending the recommendations. During an interview with the facility's Nurse Practitioner on 11/16/22 at 1:45 PM, she explained when the CP sends the Pharmacy recommendation regarding the PRN use, she will provide appropriate diagnosis, rationale for extension, and duration of use of either 30, 60, or 90 days. She reported she does not remember seeing the CP recommendations for Resident #28 and Resident #35. During an interview with the DON on 11/16/22 at 3:00 PM, she confirmed the CP resent the Pharmacy recommendations for the PRN Ativan for both Residents #28 and #35 but the facility could not locate the original Pharmacy recommendations and the recommendations had not been addressed by the prescriber.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure as-needed (PRN) psychotropic medications were discontinued or documented as necessary after 14 days for two (2) of five (5) residents reviewed for unnecessary medications. Residents #28 and #35. Findings include: A record review of the facility's policy Use of Psychotropic Medication, with revision date of 10/01/2022, revealed Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition . Policy Explanation and Compliance Guidelines: . 8. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e.14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order . Resident #28 A record review of the Order Summary Report, for Resident #28 revealed, . Active Orders As Of: 11/16/2022 . Ativan Tablet 1 MG (milligram) (LORazepam) Give 1 mg by mouth every 8 hours as needed for anxiety . Order Date 08/11/2022 and Start Date 08/11/2022 . The order did not include a specific duration of time for the medication. A record review of the Note to Attending Physician/Prescriber, dated 09/23/22, and sent by the Consultant Pharmacist (CP) for Resident #28 revealed, .PRN (as needed) PSYCHOTROPIC MEDICATION CONSULT . This resident has an order for Ativan 1 mg (milligram) q8h (every eight hours) prn for anxiety. New federal guidelines require that PRN psychotropic medication orders automatically discontinue after 14 days. The provider must re-write the PRN order every 14 days to continue the medication on a PRN basis . There was no response in the Physician/Prescriber Response section of the pharmacy recommendations. A record review of the Admission Record, revealed, the facility admitted Resident #28 on 02/21/2022, with diagnoses that included Generalized Anxiety and Schizophrenia. Resident #35 A record review of the Order Summary Report, for Resident #35 revealed, . Active Orders As Of: 11/15/2022 . Ativan Tablet 1 MG (LORazepam) Give 1 mg by mouth every 12 hours as needed for anxiety . Order Date 02/04/2022 and Start Date 02/04/2022 . The order did not include a specific duration of time. A record review of the Note to Attending Physician/Prescriber, dated 08/23/2022, and sent by the CP for Resident #35 revealed, .PRN (as needed) PSYCHOTROPIC MEDICATION CONSULT . This resident has an order for Ativan 1 mg (milligram) q8h (every eight hours) prn for anxiety. New federal guidelines require that PRN psychotropic medication orders automatically discontinue after 14 days. The provider must re-write the PRN order every 14 days to continue the medication on a PRN basis . There was no response in the Physician/Prescriber Response section of the pharmacy recommendations. A record review of the Admission Record, for Resident #35 revealed the facility admitted the resident 10/15/2019, with diagnoses that included Alzheimer's Disease and Dementia with other Behavioral Disturbances. On 11/16/2022 at 1:20 PM, during an interview with the DON, she confirmed the Ativan PRN order for Resident #35 does not have a specific duration time or a reason for continuation and she confirmed the Ativan PRN order for Resident #28 did not have an identified end date or the required prescriber documentation to extend the PRN order beyond 14 days. She reported psychotropic PRN medications can only be prescribed for 14 days and if needed longer, the prescriber must re-evaluate the resident and provide clinical documentation to support the extension. The facility's CP reported during a telephone interview on 11/16/2022 at 1:30 PM, on 08/23/2022 she sent the facility a recommendation regarding the PRN Ativan order for Resident #35 and on 09/23/2022 a recommendation regarding the PRN Ativan order for Resident #28. She confirmed the PRN orders needed to have a duration of use and should only be used for 14 days but may be extended beyond 14 days if the provided documents clinical opinion, clinical rationale for extension, and a specific duration of time for the use of the PRN medication. She reported she has strongly encouraged this, but the facility does not always respond. On 11/16/2022 at 1:45 PM, during an interview with the facility's Nurse Practitioner, she explained when the CP sends the Pharmacy recommendation regarding the PRN use, she will provide appropriate diagnosis, rationale for extension, and duration of use of either 30, 60, or 90 days. She reported she does not remember seeing the CP recommendations for Resident #28 and Resident #35.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by a nurse placing a biohazard bag containing soiled items on the floor, not performing hand hygiene after removing a soiled dressing and changing gloves, and by cleaning a tube of wound treatment medication with hand sanitizer and a tissue, for one (1) of 14 residents reviewed for infection control. Resident #7 Findings Include: Review of the facility's policy, Infection Control Guidelines for All Nursing Procedures, revised on 8/2/22, revealed, Purpose .To provide guidelines for general infection control while caring for residents .General Guidelines .4 .the preferred method of hand hygiene is with an alcohol-based hand rub .for all the following situations .h. After handling used dressing, contaminated equipment, etc.j. After removing gloves . A record review of the Admission Record revealed the facility originally admitted Resident #7 on 5/16/2022. Diagnoses included Type 2 Diabetes Mellitus and Peripheral Vascular Disease. On 11/15/22 at 2:55 PM, during an observation of wound care for Resident #7 with RN #3, he reviewed the treatment orders and collected supplies to perform wound care. RN #3 removed the soiled dressing, removed his gloves, and applied a clean pair of gloves without washing or sanitizing his hands. After completing wound care, RN #3 removed the red plastic container that contained his supplies, tape, and tube of Medi-honey from the resident's room. He placed the red biohazard bag that contained soiled items on the floor in the hallway near the treatment cart. He discarded the tape in the garbage. He explained that he was going to wipe down the items he brought out of the resident's room. RN #3 went to the nurse's station and applied hand sanitizer to a tissue. He then began to wipe down the tube of Medi-honey with the tissue. Licensed Practical Nurse (LPN) #1 observed RN #3 using the tissue with hand sanitizer and brought him a container of Super Sani-Cloth Germicidal Disposable Wipes, also known as Purple Top wipes. RN #3 then wiped down the red plastic container and the top of his treatment cart with the Purple Top wipes. On 11/15/22 at 3:20 PM, during an interview with the Director of Nursing (DON), she explained RN #3 had been trained on wound care and had completed a skills competency check-off. She stated that RN #3 should have either washed his hands or used hand sanitizer after removing his gloves and before applying clean gloves, and he should have not cleaned the tube of Medi-honey with a tissue and hand sanitizer. She also confirmed that the red biohazard bag containing soiled items should not have been placed on the floor in the hallway to prevent the spread of infection. On 11/15/22 at 3:35 PM, during an interview with RN #3, he explained he should have washed or sanitized his hands after removing gloves his gloves and should have only taken the amount of Medi-honey needed into the resident's room, instead of the entire tube. He also confirmed that he should have used the Purple Top wipes to clean any items and not a tissue with hand sanitizer and that his actions related to infection control and did not prevent the spread of infection. On 11/16/22 at 10:50 AM, during an interview with the facility's Infection Preventionist (IP) nurses, (RN #1 and RN #2) RN #1 confirmed that RN #3 should not have placed a biohazard bag containing soiled items on the floor and that it should have been taken straight to the biohazard room. She stated that placing the bag directly on the floor is an infection control issue and could spread infection throughout the facility. RN #2 explained that when cleaning supplies brought out of a resident's room, all supplies should be cleaned with Purple Top wipes to prevent the spread of infection. RN #2 said that the purpose of cleaning the items is to limit the contact of bacterial, blood, or body fluids on the items and spreading infections. RN #2 also commented that when RN #3 did not wash or sanitizer his hands after removing his gloves, he could have caused bacterial infections and the wound not to heal. A record review of the Nurse Orientation and Skills Checklist, dated 6/17/2022, revealed RN #3 received training on the Infection Control and Prevention Program. A record review of the Treatment/Skin Care Skills Checklist dated 6/17/2022, revealed RN #3 passed the skill checklist.

Based on observation, staff interview, facility policy review, and record review, the facility failed to prevent the likelihood of the spread of COVID-19 as evidenced by the lack of social distancing and wearing masks by residents in the Alzheimer's unit for six (6) of six (6) tours of the unit and lack of social distancing and wearing masks by the staff for one (1) of one (1) tour of the employee dining room. Findings include: Review of the facility's Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures policy, dated April 2020, revealed it was the policy statement that this facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility. The Policy Interpretation and Implementation revealed: #1. This policy is based on current recommendations for standard precautions and transmission-based precautions, environmental cleaning, and social distancing for COVID-19. #8. Group outings, group activities, and communal dining are canceled until further notice. 9. Social distancing is enforced among residents. An interview, on 8/25/20 at 10:10 AM, with the Administrator, revealed the facility has had 12 COVID-19 positive residents and 18 COVID-19 positive employees. An observation, on 8/25/20 at 10:40 AM, revealed 16 residents was in the Alzheimer's unit sitting at tables in the dining area with one (1) to four (4) residents at each table. The residents were eating and drinking snacks and talking. They were not socially distanced and none were wearing masks. At no time did any of the three (3) staff members present attempt to distance the residents or apply masks. An interview, on 8/25/20 at 10:42 AM, with Licensed Practical Nurse (LPN) #1, confirmed the residents were not socially distanced. An observation, on 8/25/20 at 11:20 AM, revealed residents in the Alzheimer's unit sitting at the dining tables, not socially distanced and no masks on. The Social Service Director and two (2) Certified Nursing Assistants were present on the unit. An observation, on 8/25/20 at 11:40 AM, revealed lunch had been served on the Alzheimer's unit. The residents were still sitting at the tables eating and talking and not socially distanced. An observation and interview, on 8/25/20 at 12:00 PM, with LPN #1, confirmed the residents were not socially distanced. She stated that the residents at the tables were not as far apart as they should be. LPN #1 stated that they should be six (6) feet apart for safety reasons, in case one resident was sick, it would prevent others from getting sick easily. She stated they did try for a little while to socially distance the residents, but didn't know why they stopped. An observation and interview, on 8/25/20 at 12:45 PM, with Registered Nurse #1, the Infection Preventionist confirmed the residents in the Alzheimer's unit should not be sitting so close during the meal. She stated that there are two rooms on the unit, and they should try to split them up in the two (2) areas. She stated she thinks they may have tried at one time, but some of the residents were not compliant. She stated the residents not being six (6) feet apart was not good because, if they coughed or sneezed they are at risk to possibly spread germs to all of them. An observation, on 8/25/20 at 1:00 PM, with RN #1, the Infection Preventionist, revealed 14 employees in the front area of the dining room eating lunch and not socially distanced. The observation revealed two (2) to five (5) employees at each of the tables. Observation of the back dining area revealed four (4) employees eating lunch, two (2) were socially distanced at separate tables alone and two (2) were sitting together at a table not six (6) feet apart. An observation and interview, at 1:02 PM, in the presence of Registered Nurse (RN) #1 revealed Licensed Practical Nurse (LPN) #1, LPN #2, Certified Nursing Assistant (CNA) #1, CNA #2, and CNA #3 sitting together at a table with no masks on and not at least six (6) feet apart. During an interview with LPN #2, concerning social distancing, she held her arm up and out to her side and stated she thought they should be about that far apart, but when questioned she confirmed that would not be six (6) feet. LPN #1 and #2, CNA #1, CNA #2, and CNA #3 confirmed they had attended in-services that addressed being six feet apart to prevent the spread of COVID. An observation and interview, at 1:05 PM in the presence of RN #1, revealed Dietary Staff #1, Dietary Staff #2, and Dietary Staff #3 sitting at a dining table eating lunch and talking. Dietary Staff #1 stated that they usually go out to their cars to eat lunch, but didn't today because it was raining. Dietary staff #3 stated they keep their masks down when they are eating and put them back up when they finish eating and talk. Dietary Staff #1, #2, and #3 confirmed they had attended in-services on social distancing. An interview, on 8/25/20 at 1:10 PM, with the Administrator revealed that all staff had been in-serviced on social distancing. She stated they know five (5) people at the table is too many and that this could cause the spread of COVID. An observation and interview, on 8/25/20 at 1:15 PM, with the Director of Nursing (DON) revealed residents in the Alzheimer's unit at the dining tables not wearing masks or socially distancing. The DON stated they had attempted in the beginning to get the residents to stay in their rooms, wear masks, and socially distance, but it didn't work. The DON stated she guessed they were going to have to try something. An interview, on 8/25/20 at 1:20 PM, with LPN #1, revealed when COVID first started she thought they tried social distancing with the Alzheimer residents. She stated the only time she had seen any of those (Alzheimer) residents with a mask on was when they came out of the unit for something. During an observation and interview, on 8/26/20 at 1:26 PM, with the Nurse Practitioner, she confirmed the residents were not socially distanced. She stated it would be good if the staff tried to keep the residents six (6) feet apart. She stated the staff should follow CDC (Centers for Disease Control and Prevention) guidelines. Review of the facility's in-service sign-in sheets revealed LPN #1 and #2, CNA #1 and #3, and Dietary Staff #1, #2, and #3 had attended in-service education on COVID-19.

Based on staff interview, facility investigation review, and facility policy review, the facility failed to conduct a thorough investigation for possible sexual abuse, when Resident #2, a cognitively impaired resident, with no history of Trichomonas, tested positive for Trichomonas (a [MEDICAL CONDITION]), for one (1) of 22 residents reviewed for investigating abuse, Resident #2. The facility's failure to conduct a thorough investigation put Resident #2, and all other cognitively impaired residents at risk for possible sexual abuse, when it was reported to the facility by the hospital, on 7/9/19, that Resident #2 tested positive for Trichomonas. This placed Resident #2 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/9/19, when the hospital notified the facility that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION]. The facility's Administrator was notified of the IJ and SQC on 8/7/19 at 10:25 AM, and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 8/9/19, in which the facility alleged all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 8/10/19, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s) 483.12 (c)(2-4)-F610, Investigate/Prevent/Correct Alleged Violations, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, Abuse Prevention, Investigation and Reporting, undated, revealed the facility shall comply with all Regulations, Laws, Policies, Procedures and guidelines for prevention, investigation and reporting suspected Abuse. Review of a written complaint, reported by an outside source, on 7/10/19, revealed Resident #2 tested positive for Trichomonas on 7/9/19, and had previously tested negative for Trichomonas on 6/20/19. Record review revealed Urinalysis results for Resident #2 on 6/20/19, 9/2/18, and 7/6/18, tested negative for Trichomonas. A review of the Urinalysis result on 7/9/19, for Resident #2, tested positive for Trichomonas. Review of the documented facility investigation, dated 7/12/19, revealed the facility was notified that Resident #2 was diagnosed with [REDACTED]. There was no documentation that the facilty notified local law enforcement of a possible sexual crime, no documentation that Resident #2 was placed on close observation after return from the hospital, no documentation that other residents/staff were tested or reviewed for [MEDICAL CONDITION], and no documentation that all staff were educated for investigating allegations of abuse related to a positive result of a [MEDICAL CONDITION] (STD). Resident #2 was cognitively impaired and unable to give consent for sexual relations. In an interview on 8/5/19 at 4:00 PM, the Director of Nursing (DON) confirmed that Resident #2 was transferred to the hospital on [DATE], for shortness of breath and when a urinalysis was done, it showed a positive result for Trichomonas, a [MEDICAL CONDITION]. The DON confirmed Resident #2's previous urinalysis results were negative for Trichomonas. The DON stated when she spoke with Resident #2's Primary Care Physician (PCP), he stated that Resident #2 could have had Trichomonas a long time. The DON also stated when she talked to Resident #2, she denied having sex with anyone, but confirmed Resident #2 is confused and not a good historian. The DON stated Resident #2's brother, the Responsible Party (RP), reported he had not been aware of Resident #2 ever having a [MEDICAL CONDITION] or Trichomonas. The DON stated the facility considered abuse, because that is what you think of with a [MEDICAL CONDITION] of a cognitively impaired resident. The DON stated, I don't think she was abused, but we looked at it as best we could. The DON said if someone is positive for Trichomonas, then you look for sexual assault when they can't give permission. In an interview on 08/06/19 at 03:09 PM, Resident #2's Physician stated he had been Resident #2's physician since 1990, and Resident #2 had not ever had a positive UA for Trichomonas, and had not been treated for [REDACTED]. He stated Resident #2 had no indication of sexual trauma. On 08/07/19 at 9:40 AM, interview with the DON revealed that in the verbal hospital report, the ER Nurse told her there was no visible signs of vaginal trauma on exam, but there was no documentation found in the record. On 08/07/19 at 10:10 AM, interview with the Facility Administrator revealed she first became aware that Resident #2 was positive for Trichomonas when the Hospital called on 7/9/19, from their Social Service Department and reported it to the DON. The Administrator stated she and the DON are both responsible for conducting the investigation. The Administrator stated they talked to the staff, viewed the video, talked to the Medical Director/Resident #2's Physician, and called the nurse on the floor at the hospital. The Administrator confirmed both she and the DON talked to the ER Nurse that collected the sample of urine in the ER, who denied having seen any signs of bruising or trauma to Resident #2. The Administrator confirmed the facility requested the hospital repeat the Urinalysis, but was told they couldn't because they had already started the antibiotic. The Administrator confirmed Resident #2's brother/RP denied having knowledge of Resident #2 ever being sexually abused or being positive for a [MEDICAL CONDITION]. The Administrator stated that Resident #2's PCP told her that Trichomonas could have been dormant, then all of the sudden flair up. The Administrator confirmed she did not call the local health department for guidance on Trichomonas. The Administrator stated that no employees were tested at that time and no other residents were tested . The Administrator stated, We felt like it didn't happen (no sexual assault), so we didn't do anything else. In an interview on 08/07/19 at 10:40 AM, the Hospital Social Worker (SW) confirmed the hospital reported to the SA hotline, for the ER Physician, regarding Resident #2 testing positive for Trichomonas on 7/9/19. The SW stated when she interviewed Resident #2 she was told that she lived at home with her mother. She stated that Resident #2 was confused and disoriented and unable to answer questions regarding any sexual activity and was not a reliable historian. In a phone interview on 08/07/19 at 2:00 PM, the Criminal Investigator for the AG's Office stated that the facility informed him that Resident #2's Physician had said that Trichomonas can be dormant and not active and undetectable, then flair up. He also stated the facility had informed him there was no evidence of forceful sex seen for Resident #2. The facility admitted Resident #2 on 9/26/16, with the diagnoses which included, High Blood Pressure, Non-Alzheimer's Dementia, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Non-rheumatic Aortic (Valve) Stenosis and [MEDICAL CONDITION]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 7/16/19 revealed Resident #2 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated Resident #2 was severely cognitively impaired. The facility submitted an acceptable Removal Plan on 8/9/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. On (MONTH) 9, 2019, Resident #2 was sent out to a local hospital for low Oxygen saturation. The hospital called to notify the Director of Nursing at the facility on (MONTH) 9, 2019 at approximately 4:30 PM, that the resident was positive for Trichomonas. The State Agency notified the Administrator that the facility had been placed in Immediate Jeopardy at 10:25 AM, on (MONTH) 7, 2019, for Failure to protect the resident due to alleged incident of abuse, Failure to report to the local law enforcement, and Failure to investigate thoroughly, once informed of the allegation and positive test results. Corrective actions: 1) An investigation was begun on (MONTH) 9, 2019 at 5:00 PM, by the Administrator and the Director of Nursing. 2) A Chart review on Resident #2 occurred by the Director of Nursing on (MONTH) 9, 2019 at 4:45 PM. This review included looking for previous urinalysis and review of diagnosis. It revealed that urinalysis on (MONTH) 20, 2019, indicated no Trichomonas seen. 3) On (MONTH) 9, 2019, at 4:50 PM, an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse (LPN)# 1. The Medical Director was made aware of reported positive test results. After the discussion of the positive Trichomonas test there were no changes made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4) Resident #2's brother was called by the DON and Administrator on (MONTH) 9, 2019 at approximately 5:15 PM, and informed that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION]. 5) Staff interviews began at approximately 5:30 PM on (MONTH) 9, 2019, by the DON, and were completed on (MONTH) 10, 2019 at approximately 5:00 PM. Six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA # 3 stated: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4 stated: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. During the interview the staff was asked if they had noticed any change in Resident #2's behavior. Their responses were negative. 6) Notification was made to the SA at approximately 6:00 PM on (MONTH) 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 7) The Attorney General's office was notified via eform on (MONTH) 9, 2019 at 6:10 PM, of a report of Resident #2 testing positive for Trichomonas. 8) A Review of video footage occurred on (MONTH) 10, 2019, by the Administrator at approximately 9:30 AM. Coverage reviewed started at (MONTH) 3, 2019 at 10:00 PM, to (MONTH) 9, 2019, when she was sent out. There was no unusual visitors or suspicious activity observed during the review of the video. This video footage was the only footage available for review. 9) Resident #2 returned to the facility on (MONTH) 10, 2019 at 4:45 PM. Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on (MONTH) 10, 2019 at approximately 5:00 PM, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview by the DON and the Administrator with Resident #2 occurred at approximately 10:00 AM on (MONTH) 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. No other Resident interviews were done at this time. 10) To protect other residents from harm, the facility provided education on (MONTH) 19, 22 and (MONTH) 23, 2019 on Dignity, Respect, and Abuse. Nineteen (19) of 53 CNA's, nine (9) of 22 LPN's, seven (7) of nine (9) RN's, six (6) of six (6) Housekeeping, two (2) of three (3) Laundry, two (2) of two (2) Social Services, two (2) of two (2) Business Office, two (2) of four (4) Activity, ten (10) of 13 Dietary, two (2) of two (2) Floor Techs , one (1) of one (1) Central Supply, one (1) of one (1) Medical Records, zero (0) of one (1) Maintenance, one (1) of one (1) Courtyard Director, and zero (0) of three (3) Monitor Techs were trained. 11) At 10:58 AM on (MONTH) 7, 2019, the local police department was called by the Administrator. They arrived at 11:05 AM to speak with the Administrator and Director of Nursing. They were provided a copy of the facility investigation and stated they would contact us on (MONTH) 8, 2019, with a report and/or request for further action. 12) Education of all employees was conducted by Registered Nurse #5 beginning on (MONTH) 7, 2019 at 2:30 PM, and concluded on (MONTH) 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The Staff educated as of August, 8 2019 at 5:00 PM are as follows: Eighteen (18) of 22 LPN's, nine (9) of nine (9) RN's, 34 of 53 CNA's, three (3) of three (3) Laundry staff, six (6) of six (6) Housekeeping staff, three (3) of four (4) Activity staff, 13 of thirteen 13 Dietary staff, two (2) of two (2) Floor Technicians, one (1) of one (1) Maintenance staff, one (1) of one (1) Medical Records staff, one (1) of one (1) Central Supply staff, two (2) of two (2) Business Office staff, one (1) of one (1) Administrator, two (2) of two (2) Social Service staff, one (1) of one (1) Courtyard Director, and one (1) of three (3) Monitor Technicians. 13) No employee will be allowed to work until they are trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14) The Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on (MONTH) 7, 2019 at approximately 3:00 PM to determine what type of testing of male employees needs to be done for Trichomonas. She stated the type of test would be a urine test. 15) Testing of all male employees for Trichomonas began (MONTH) 8, 2019. Ten (10) of ten (10) results have returned with negative findings. 16) Ambulatory Resident #19 was tested for Trichomonas on (MONTH) 8, 2019 at approximately 1:20 PM, and the result was negative. Resident #19 was tested for Trichomonas due to having recently being observed kissing a consenting female Resident #50. Resident #19 has a BIMS score of 15 and Resident #50 has a BIMS score of 15. There were no other reports to the Administrator or DON of any other male Residents exhibiting sexual behaviors or expressions between (MONTH) 20, 2019 and (MONTH) 9, 2019. 17) On (MONTH) 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results of 34 of 34 negative for Trichomonas. 18) On (MONTH) 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results of 21 of 21 negative for Trichomonas. 19) A 100% chart audit was conducted on (MONTH) 9, 2019, which focused on the most recent urinalysis and [DIAGNOSES REDACTED]. 20) On (MONTH) 9, 2019 at approximately 2:30 PM cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service Assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21) The QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented (MONTH) 9, 2019 at 4:00 PM, to protect Residents from sexual abuse. The QA Committee met on (MONTH) 9, 2019 at 4:00 PM, with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The facility asserts that the likelihood of serious harm in this matter will be removed effective (MONTH) 10, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The SA validated through interviews and record review the facility conducted an investigation which began on (MONTH) 9, 2019 by the Administrator and the Director of Nursing. 2. The SA validated by interviews and record review a chart review on Resident #2 occurred by the Director of Nursing on (MONTH) 9, 2019. This review included looking for previous urinalysis and review of diagnosis. Interview with the DON revealed the urinalysis on (MONTH) 20, 2019, indicated no Trichomonas seen. 3. The SA validated by interviews and sign in sheets on (MONTH) 9, 2019, that an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse(LPN)# 1. Interview revealed the Medical Director was made aware of reported positive test results, no changes were made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4. The SA validated through interviews that Resident #2's brother was called by the DON and Administrator on (MONTH) 9, 2019, and informed that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION]. 5. The SA validated through interviews and record reviews that the facility began staff interviews on (MONTH) 9, 2019, by the DON and were completed on (MONTH) 10, 2019. Documentation included six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA #3's documented statement: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4's documented statement: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. Staff had not noticed any change in Resident #2's behavior. 6. The SA validated through record review and interview that the facility notified the SA on (MONTH) 9, 2019 of a report of Resident #2 testing positive for Trichomonas. 7. The SA validated through interviews and record review the facility notified the Attorney General's office via eform on (MONTH) 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 8. The SA validated through interviews and facility investigation review that the facility reviewed the video footage on (MONTH) 10, 2019 by the Administrator, covering (MONTH) 3, 2019 at 10:00 PM to (MONTH) 9, 2019, when the resident was sent out. Interview with the Administrator revealed there was no unusual visitors or suspicious activity observed during the review of the video. 9. The SA validated documentation that Resident #2 returned to the facility on (MONTH) 10, 2019 at 4:45 PM. Interview with administrative staff revealed Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on (MONTH) 10, 2019, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview with the DON and the Administrator revealed interviews with Resident #2 occurred at approximately 10:00 am on (MONTH) 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. Interview with the Administrator and DON validated that no other Resident interviews were done at this time. 10. The SA validated through interviews, sign-in sheets, and record review, that the facility provided education on (MONTH) 19, 22 and (MONTH) 23, 2019 on Dignity, Respect, and Abuse, with staff attendance by signature. 11. The SA validated through interview with the Administrator that on (MONTH) 7, 2019, the local police department was notified, and came to the facility. They were provided a copy of facility investigation and stated they would contact the facility with a report and/or request for further action. 12. The SA validated through interview, sign-in sheets, and record review, that education of all employees was conducted by Registered Nurse #5 beginning on (MONTH) 7, 2019 and concluding on (MONTH) 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The SA validated that all staff were educated as of August, 8, 2019. 13. The SA validated through interviews that no employee was allowed to work until they were trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14. The SA validated by interview with the Administrator, that the Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on (MONTH) 7, 2019 to determine what type of testing of male employees needs to be done for Trichomonas and was informed the type of test would be a urine test. 15. The SA validated by record review and interviews that the facility initiated testing of all male employees for Trichomonas beginning (MONTH) 8, 2019, and ten (10) of ten (10) results returned with negative findings. 16. The SA validated by record review and interviews that the facility tested Ambulatory Resident #19 for Trichomonas on (MONTH) 8, 2019, with a negative result. Interview with administrative staff revealed there were no other reports of any other male Residents exhibiting sexual behaviors or expressions between (MONTH) 20, 2019 and (MONTH) 9, 2019. 17. The SA validated by interviews and record review that on (MONTH) 9, 2019, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results negative for Trichomonas. 18. The SA validated by interviews that on (MONTH) 9, 2019, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results negative for Trichomonas. 19. The SA validated through interviews and record reviews that the facility conducted 100% chart audit on (MONTH) 9, 2019, which focused on the most recent urinalysis and [DIAGNOSES REDACTED]. 20. The SA validated by interviews that on (MONTH) 9, 2019, cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21. The SA validated through interviews and sign-in sheets that the QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented (MONTH) 9, 2019, to protect Residents from sexual abuse. Interview validated that the QA Committee met on (MONTH) 9, 2019 at 4:00 PM with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The SA validated that all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19.

Based on staff interview, facility investigation review, and facility policy review, the facility failed to notify the local law enforcement of possible sexual abuse crime when Resident #2, a cognitively impaired resident, tested positive for Trichomonas, a [MEDICAL CONDITION], for one (1) of 22 residents reviewed for reporting abuse. Resident #2. The facility's failure to report to the local law enforcement of a possible sexual crime, when it was reported to the facility by the hospital, on 7/9/19, that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION], placed Resident #2 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 7/9/19, when the hospital notified the facility that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION], and the facility failed to notify local law enforcement of a possible sex crime. The facility's Administrator was notified of the IJ and SQC on 8/7/19 at 10:25 AM, and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 8/9/19, in which the facility alleged all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 8/10/19, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR (s): 483.12 (b)(5)(i-iii)-F608, Reporting of Reasonable Suspicion of a Crime, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, Abuse Prevention, Investigation and Reporting, undated, revealed the facility shall comply with all Regulations, Laws, Policies, Procedures and guidelines for prevention, investigation and reporting suspected Abuse. This policy noted the facility would report all reportable incidents to the local law enforcement pursuant to the Elder Justice Act of 2010. Review of the facility investion report, dated 7/12/19, revealed the facility was notified that Resident #2 was diagnosed with [REDACTED]. There was no documentation that the facilty notified local law enforcement of a possible sexual crime, related to a resident who tested possitive for a [MEDICAL CONDITION], who had no history of the disease. Resident #2 was cognitively impaired and unable to give consent for sexual relations. Review of a hospital Discharge Summary, dated 7/10/19, revealed Resident #2 had a [DIAGNOSES REDACTED]. Review of a urinalysis for Resident #2, with a documented collection time of 7/9/19 at 04:55, revealed Rare A Trichomonas was present in Resident #2's urine, with a normal reference range of none seen. A comparative finding of a urinalysis for Resident #2, dated 6/20/19, revealed no Trichomonas was seen. During the interview with the State Epidemiologist on 8/5/19 at 03:32 PM, he stated based on the previous negative urine results for Resident #2, and then a positive result for Trichomonas was determined on 7/9/19, you would have to treat it as Trichomonas. He stated that the only way to contact Trichomonas is through sexual contact. In an interview with the Director of Nursing (DON) on 8/5/19 at 4:00 PM, she stated that Resident #2 was diagnosed with [REDACTED]. The DON stated she talked to the Attorney General's (AG)'s office, the facility looked at possible abuse, because that is what you think of when a resident suddenly becomes positive for a [MEDICAL CONDITION]. The DON stated, I don't think she was abused, but we looked at it as best we could. The DON stated if someone is positive for Trichomonas, and the resident can't give permission, then you look for sexual assault. The DON stated the facility reported this to the family, the AG's office, and the State Agency (SA) hotline, but did not include the local Law Enforcement. During an interview on 8/6/19 at 9:37 AM, the DON stated that Resident #2 had not been out on pass in (YEAR) or 2019. Interview with the DON on 8/6/19 at 10:54 AM, revealed she spoke with the AG's office on the phone, but the local Law Enforcement had not been notified. Further interview with the DON on 08/06/19 at 4:21 PM, revealed law enforcement was not called regarding Resident #2, because they felt like there was nothing to report (no crime) after the investigation. On 08/07/19 10:10 AM, the Administrator confirmed the Attorney General's (AG's) Office, the State Agency (SA), the Medical Director/Resident #2's PCP and Resident #2's Responsible Party (RP) were notified of Resident #2's positive test for Trichomonas, but the local police was not notified. The Administrator stated, We felt like it didn't happen (no sexual assault), so we didn't do anything else. The facility admitted Resident #2 on 9/26/16, with the diagnoses which included, [MEDICAL CONDITION], Hypertension (High Blood Pressure), Non-Alzheimer's Dementia, [MEDICAL CONDITION] Disorder, Non-rheumatic Aortic (Valve) Stenosis and [MEDICAL CONDITION]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 7/16/19, revealed Resident #2 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated Resident #2 was severely cognitively impaired. The facility submitted an acceptable Removal Plan on 8/9/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. On (MONTH) 9, 2019, Resident #2 was sent out to a local hospital for low Oxygen saturation. The hospital called to notify the Director of Nursing at the facility on (MONTH) 9, 2019 at approximately 4:30 PM, that the resident was positive for Trichomonas. The State Agency notified the Administrator that the facility had been placed in Immediate Jeopardy at 10:25 AM, on (MONTH) 7, 2019, for Failure to protect the resident due to alleged incident of abuse, Failure to report to the local law enforcement, and Failure to investigate thoroughly, once informed of the allegation and positive test results. Corrective actions: 1) An investigation was begun on (MONTH) 9, 2019 at 5:00 PM, by the Administrator and the Director of Nursing. 2) A Chart review on Resident #2 occurred by the Director of Nursing on (MONTH) 9, 2019 at 4:45 PM. This review included looking for previous urinalysis and review of diagnosis. It revealed that urinalysis on (MONTH) 20, 2019, indicated no Trichomonas seen. 3) On (MONTH) 9, 2019, at 4:50 PM, an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse (LPN)# 1. The Medical Director was made aware of reported positive test results. After the discussion of the positive Trichomonas test there were no changes made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4) Resident #2's brother was called by the DON and Administrator on (MONTH) 9, 2019 at approximately 5:15 PM, and informed that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION]. 5) Staff interviews began at approximately 5:30 PM on (MONTH) 9, 2019, by the DON, and were completed on (MONTH) 10, 2019 at approximately 5:00 PM. Six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA # 3 stated: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4 stated: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. During the interview the staff was asked if they had noticed any change in Resident #2's behavior. Their responses were negative. 6) Notification was made to the SA at approximately 6:00 PM on (MONTH) 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 7) The Attorney General's office was notified via eform on (MONTH) 9, 2019 at 6:10 PM, of a report of Resident #2 testing positive for Trichomonas. 8) A Review of video footage occurred on (MONTH) 10, 2019, by the Administrator at approximately 9:30 AM. Coverage reviewed started at (MONTH) 3, 2019 at 10:00 PM, to (MONTH) 9, 2019, when she was sent out. There was no unusual visitors or suspicious activity observed during the review of the video. This video footage was the only footage available for review. 9) Resident #2 returned to the facility on (MONTH) 10, 2019 at 4:45 PM. Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on (MONTH) 10, 2019 at approximately 5:00 PM, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview by the DON and the Administrator with Resident #2 occurred at approximately 10:00 AM on (MONTH) 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. No other Resident interviews were done at this time. 10) To protect other residents from harm, the facility provided education on (MONTH) 19, 22 and (MONTH) 23, 2019 on Dignity, Respect, and Abuse. Nineteen (19) of 53 CNA's, nine (9) of 22 LPN's, seven (7) of nine (9) RN's, six (6) of six (6) Housekeeping, two (2) of three (3) Laundry, two (2) of two (2) Social Services, two (2) of two (2) Business Office, two (2) of four (4) Activity, ten (10) of 13 Dietary, two (2) of two (2) Floor Techs , one (1) of one (1) Central Supply, one (1) of one (1) Medical Records, zero (0) of one (1) Maintenance, one (1) of one (1) Courtyard Director, and zero (0) of three (3) Monitor Techs were trained. 11) At 10:58 AM on (MONTH) 7, 2019, the local police department was called by the Administrator. They arrived at 11:05 AM to speak with the Administrator and Director of Nursing. They were provided a copy of the facility investigation and stated they would contact us on (MONTH) 8, 2019, with a report and/or request for further action. 12) Education of all employees was conducted by Registered Nurse #5 beginning on (MONTH) 7, 2019 at 2:30 PM, and concluded on (MONTH) 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The Staff educated as of August, 8 2019 at 5:00 PM are as follows: Eighteen (18) of 22 LPN's, nine (9) of nine (9) RN's, 34 of 53 CNA's, three (3) of three (3) Laundry staff, six (6) of six (6) Housekeeping staff, three (3) of four (4) Activity staff, 13 of thirteen 13 Dietary staff, two (2) of two (2) Floor Technicians, one (1) of one (1) Maintenance staff, one (1) of one (1) Medical Records staff, one (1) of one (1) Central Supply staff, two (2) of two (2) Business Office staff, one (1) of one (1) Administrator, two (2) of two (2) Social Service staff, one (1) of one (1) Courtyard Director, and one (1) of three (3) Monitor Technicians. 13) No employee will be allowed to work until they are trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14) The Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on (MONTH) 7, 2019 at approximately 3:00 PM to determine what type of testing of male employees needs to be done for Trichomonas. She stated the type of test would be a urine test. 15) Testing of all male employees for Trichomonas began (MONTH) 8, 2019. Ten (10) of ten (10) results have returned with negative findings. 16) Ambulatory Resident #19 was tested for Trichomonas on (MONTH) 8, 2019 at approximately 1:20 PM, and the result was negative. Resident #19 was tested for Trichomonas due to having recently being observed kissing a consenting female Resident #50. Resident #19 has a BIMS score of 15 and Resident #50 has a BIMS score of 15. There were no other reports to the Administrator or DON of any other male Residents exhibiting sexual behaviors or expressions between (MONTH) 20, 2019 and (MONTH) 9, 2019. 17) On (MONTH) 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results of 34 of 34 negative for Trichomonas. 18) On (MONTH) 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results of 21 of 21 negative for Trichomonas. 19) A 100% chart audit was conducted on (MONTH) 9, 2019, which focused on the most recent urinalysis and [DIAGNOSES REDACTED]. 20) On (MONTH) 9, 2019 at approximately 2:30 PM cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service Assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21) The QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented (MONTH) 9, 2019 at 4:00 PM, to protect Residents from sexual abuse. The QA Committee met on (MONTH) 9, 2019 at 4:00 PM, with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The facility asserts that the likelihood of serious harm in this matter will be removed effective (MONTH) 10, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The SA validated through interviews and record review the facility conducted an investigation which began on (MONTH) 9, 2019 by the Administrator and the Director of Nursing. 2. The SA validated by interviews and record review a chart review on Resident #2 occurred by the Director of Nursing on (MONTH) 9, 2019. This review included looking for previous urinalysis and review of diagnosis. Interview with the DON revealed the urinalysis on (MONTH) 20, 2019, indicated no Trichomonas seen. 3. The SA validated by interviews and sign in sheets on (MONTH) 9, 2019, that an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse(LPN)# 1. Interview revealed the Medical Director was made aware of reported positive test results, no changes were made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4. The SA validated through interviews that Resident #2's brother was called by the DON and Administrator on (MONTH) 9, 2019, and informed that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION]. 5. The SA validated through interviews and record reviews that the facility began staff interviews on (MONTH) 9, 2019, by the DON and were completed on (MONTH) 10, 2019. Documentation included six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA #3's documented statement: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4's documented statement: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. Staff had not noticed any change in Resident #2's behavior. 6. The SA validated through record review and interview that the facility notified the SA on (MONTH) 9, 2019 of a report of Resident #2 testing positive for Trichomonas. 7. The SA validated through interviews and record review the facility notified the Attorney General's office via eform on (MONTH) 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 8. The SA validated through interviews and facility investigation review that the facility reviewed the video footage on (MONTH) 10, 2019 by the Administrator, covering (MONTH) 3, 2019 at 10:00 PM to (MONTH) 9, 2019, when the resident was sent out. Interview with the Administrator revealed there was no unusual visitors or suspicious activity observed during the review of the video. 9. The SA validated documentation that Resident #2 returned to the facility on (MONTH) 10, 2019 at 4:45 PM. Interview with administrative staff revealed Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on (MONTH) 10, 2019, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview with the DON and the Administrator revealed interviews with Resident #2 occurred at approximately 10:00 am on (MONTH) 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. Interview with the Administrator and DON validated that no other Resident interviews were done at this time. 10. The SA validated through interviews, sign-in sheets, and record review, that the facility provided education on (MONTH) 19, 22 and (MONTH) 23, 2019 on Dignity, Respect, and Abuse, with staff attendance by signature. 11. The SA validated through interview with the Administrator that on (MONTH) 7, 2019, the local police department was notified, and came to the facility. They were provided a copy of facility investigation and stated they would contact the facility with a report and/or request for further action. 12. The SA validated through interview, sign-in sheets, and record review, that education of all employees was conducted by Registered Nurse #5 beginning on (MONTH) 7, 2019 and concluding on (MONTH) 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The SA validated that all staff were educated as of August, 8, 2019. 13. The SA validated through interviews that no employee was allowed to work until they were trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14. The SA validated by interview with the Administrator, that the Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on (MONTH) 7, 2019 to determine what type of testing of male employees needs to be done for Trichomonas and was informed the type of test would be a urine test. 15. The SA validated by record review and interviews that the facility initiated testing of all male employees for Trichomonas beginning (MONTH) 8, 2019, and ten (10) of ten (10) results returned with negative findings. 16. The SA validated by record review and interviews that the facility tested Ambulatory Resident #19 for Trichomonas on (MONTH) 8, 2019, with a negative result. Interview with administrative staff revealed there were no other reports of any other male Residents exhibiting sexual behaviors or expressions between (MONTH) 20, 2019 and (MONTH) 9, 2019. 17. The SA validated by interviews and record review that on (MONTH) 9, 2019, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results negative for Trichomonas. 18. The SA validated by interviews that on (MONTH) 9, 2019, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results negative for Trichomonas. 19. The SA validated through interviews and record reviews that the facility conducted 100% chart audit on (MONTH) 9, 2019, which focused on the most recent urinalysis and [DIAGNOSES REDACTED]. 20. The SA validated by interviews that on (MONTH) 9, 2019, cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21. The SA validated through interviews and sign-in sheets that the QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented (MONTH) 9, 2019, to protect Residents from sexual abuse. Interview validated that the QA Committee met on (MONTH) 9, 2019 at 4:00 PM with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The SA validated that all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19.

Based on resident interview, staff interview, record review, hospital record review, hospital staff interview, facility investigation review, and facility policy review, the facility failed to investigate and put measures in place to protect residents from possible sexual abuse, when the facility was notified that Resident #2, a cognitively impaired resident, tested positive for Trichomonas, a [MEDICAL CONDITION] for one (1) of 22 residents reviewed for abuse, Resident #2. The facility's failure to protect Resident #2, and all other cognitively impaired residents, from possible sexual abuse, placed Resident #2 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/9/19, when the hospital notified the facility that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION], and Resident #2 returned to the facility without thorough investigation or protective measures put in place. The facility's Administrator was notified of the IJ and SQC on 8/7/19, at 10:25 AM, and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 8/9/19, in which the facility alleged all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 8/10/19, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR (s): 483.12 (a)(1), F600, Free from Abuse and Neglect, was lowered from a scope and severity of J to a scope and severity of D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's Resident Rights policy, undated, noted the resident has the right to be free from mental and physical abuse. The facility's policy, Abuse Prevention, Investigation and Reporting, dated 2/15/10, revealed the facility shall comply with all Regulations, Laws, Policies, Procedures and guidelines for prevention, investigation and reporting suspected Abuse. All employees shall report any suspected or alleged Resident mistreatment, suspicious bruising, neglect, mental or physical abuse, or injuries of unknown origin to the Nurse Supervisor or Department Head Appropriate action will be taken based on results of the investigation. All incidents of possible abuse will be initially investigated by the Administrator and/or designated facility staff. Review of a written complaint, reported by an outside source, on 7/10/19, revealed Resident #2 tested positive for Trichomonas on 7/9/19, and had previously tested negative for Trichomonas on 6/20/19. Record review revealed Resident #2 was transferred to the hospital on [DATE], for respiratory issues; and returned to the facility on [DATE]. The Discharge Summary revealed a [DIAGNOSES REDACTED]. I discussed with the ID specialist, she recommended treatment and reporting the case {to} the social services for further evaluation. Patient denies sexual contact or sexual abuse of any kind . Review of a urinalysis, for Resident #2, with a documented collection time of 7/9/19 at 04:55, revealed Rare A Trichomonas was present in the urine, with a normal reference range of none seen. The medical record revealed this was a catheterized specimen. A urinalysis, dated 6/20/19, revealed no Trichomonas was seen. Review of the local hospital record revealed Resident #2 received [MEDICATION NAME] ([MEDICATION NAME]) 2000 milligrams by mouth (po) at 1:20 PM on 7/9/19, which is a treatment for [REDACTED]. Record review revealed urinalysis results for Resident #2 on 6/20/19, 9/2/18, and 7/6/18, were all negative for Trichomonas. The Urinalysis result on 7/9/19, for Resident #2, tested positive for Trichomonas. In an interview on 8/5/19 at 3:32 PM, the State Epidemiologist stated that the only way to contact Trichomonas is through sexual contact. He stated based on the positive Trichomonas result for Resident #2 on 7/9/19, with a previous negative result, you had to treat the resident for Trichomonas. Interview with the Director of Nursing (DON) on 8/5/19 at 4:00 PM, revealed Resident #2 went to the hospital on [DATE], for respiratory issues and they diagnosed and treated her for Trichomonas. The DON confirmed the Urinalysis results from the admitting hospital on [DATE], showed Resident #2 tested positive for Trichomonas, and her previous urinalysis results were negative for Trichomonas, prior to 7/9/19. The DON stated she talked to Resident #2's Primary Care Physician (PCP), who is also the Medical Director, who stated Resident #2 could have had Trichomonas a long time. The DON stated she talked to Resident #2, who denied having sex with anyone, but stated Resident #2 is confused. The DON stated she talked with Resident #2's brother, the resident's Responsible Party (RP), who reported he had not been aware of Resident #2 ever having a [MEDICAL CONDITION]. The DON stated she reviewed past video footage at Resident #2's door/hallway, and there was no unusual activity noted regarding other residents visiting, and only the brother visited the resident. The DON stated there was only one (1) male nurse who worked the 11:00 PM-7:00 AM shift and one (1) male Certified Nursing Assistant (CNA) who worked the 3:00 PM-11:00 PM shift. There had been no testing of either staff member for Trichomonas. The DON stated the facility looked at abuse, because that is what you think of (with a positive Trichomonas test). The DON stated, I don't think she was abused, but we looked at it as best we could. The DON stated if someone is positive for Trichomonas, then you look for sexual assault when the resident can't give permission. The DON stated it is against a resident's rights if they have been abused. The DON stated no other residents had tested positive for Trichomonas. She also stated there was nothing out of the ordinary when viewing the video and interactions with other residents and no male residents were paying particular attention to Resident #2. The DON stated she was not sure if there had been any abuse training after this event. Further interview with the DON on 8/6/19 at 9:37 AM, confirmed Resident #2 had not been out on pass at any time during 2019, and as far as she could tell, had not been out in (YEAR). Facility letter-head documents, dated 8/6/19, and signed by the DON, reflected this data. Interview with the Administrator on 8/6/19 at 9:42 AM, revealed the facility had not tested male staff for Trichomonas since Resident #2 tested positive. Interview with the DON on 8/6/19 at 10:54 AM, revealed she had initially asked the hospital to repeat a UA after the first showed Trichomonas, but the hospital did not repeat the UA. The DON stated during the investigation, some of the nurses stated Resident #2 had a foul vaginal odor, but not sure for how long. The DON stated all findings were discussed during the Quality Assurance (QA) meeting. The DON stated she requested from Resident #2's PCP to repeat the UA here at the facility, but he stated not to repeat it since Resident #2 had already been treated. A message was left on 08/06/19 at 11:46 AM, for the Hospital Laboratory (Lab) Director to return a call to the surveyor at the facility. On 08/06/19 at 11:52 AM, a call was placed to the Hospital emergency room (ER) to speak with the ER Nurse Manager, and no one answered the page. On 08/06/19 at 1:26 PM, interview with Registered Nurse (RN) #6, revealed she did remember Resident #2 having a foul vaginal odor at one time, and stated a UA was sent for testing. Interview with RN #1, on 08/06/19 at 1:30 PM, revealed there was only one (1) resident on the unit that was being monitored for sexual behavior, Resident #11. RN #1 stated Resident #11 would touch others and touch employees. Review of Resident #11's medical record revealed the last UA was 8/23/17, which was negative for Trichomonas. During a phone interview, on 08/06/19 at 1:51 PM, Certified Nursing Assistant (CNA) #2 confirmed writing a statement on 7/9/19 at 5:30 PM, regarding Resident #2 and the foul/strong vaginal odor prior to her going to the hospital in (MONTH) 2019. CNA #2 stated she was not aware of any male residents paying attention to Resident #2 or being in her room. On 08/06/19 at 02:10 PM, an attempt was made to interview the Nurse Manager for the hospital ER and the ER Nurse that collected the sample of urine from Resident #2. The Nurse Manager stated that the nurse who provided care to Resident #2 was on vacation and would not be back for a couple of weeks. The Nurse Manager referred questions to the hospital Risk Management Department. Per the Risk Manager, no further interview would be allowed per advice of their legal counsel. On 08/06/19 at 2:44 PM, a phone interview with Resident #2's PCP, revealed he had been the resident's doctor for years, not just in the nursing home, and would pull her chart and return the call. In a further interview on 08/06/19 at 3:09 PM, Resident #2's PCP stated he has treated Resident #2 since 1990, and Resident #2 had never had a positive UA for Trichomonas, and had not been treated for [REDACTED]. He also stated there was no indication of sexual trauma when he examined her. In an interview on 08/06/19 at 3:06 PM, CNA #4 confirmed a written statement on 7/9/19, that Resident #2 previous had a strong foul odor to her vaginal area that she had not noticed before. On 08/06/19 at 04:21 PM, in an interview with the DON, she stated law enforcement was not called regarding Resident #2, because they felt like there was nothing to report (no crime) after the investigation. In an interview, on 08/07/19 at 9:40 AM, the DON stated the ER Nurse had told her there was no visible signs of vaginal trauma on exam at the hospital, but no documentation was found for support. During an interview, on 08/07/19 at 10:10 AM, the Facility Administrator stated she first became aware that Resident #2 was positive for Trichomonas when the Hospital called on 7/9/19, from their Social Service Department, and notified the DON. The Administrator stated she and the DON were both responsible for conducting investigations. The Administrator stated they talked to the staff, viewed the video, talked to the Medical Director/Resident #2's PCP, and called the nurse on the floor at the hospital. The Administrator stated they talked to the ER Nurse that collected the sample of urine in the ER, and the ER nurse denied having seen any signs of bruising or trauma to Resident #2. The Administrator stated the facility requested that the hospital repeat the test, but had been told they couldn't, because the antibiotic had been started. The Administrator confirmed the AG's Office, the State Agency (SA), the Medical Director/Resident #2's PCP, and Resident #2's Responsible Party (RP) were notified, but the local law enforcement was not notified. The Administrator stated Resident #2's brother/RP denied having knowledge of Resident #2 ever being sexually abused or being positive for a [MEDICAL CONDITION]. The Administrator stated that Resident #2's PCP had said that Trichomonas could have been dormant, then all of the sudden flair up. The Administrator stated she did not call the local health department for guidance. The Administrator stated that no employees were tested at that time and no other residents were tested for Trichomonas. The Administrator stated, We felt like it didn't happen (no sexual assault), so we didn't do anything else. The facility did not put any monitors in place, nor further investigate to determine the possible source of the Trichomonas for Resident #2. In an interview, on 08/07/19 at 10:40 AM, the hospital Social Worker (SW) confirmed Resident #2 had a negative urine at the nursing home on 6/20/19, and on 7/9/19 at the hospital ER, Resident #2 tested positive for Trichomonas. The SW stated when she interviewed Resident #2, she was told by Resident #2 that she lived at home with her mother. The SW stated the resident was unable answer questions regarding any sexual activity, was confused and disoriented, and was not a reliable historian. During a phone interview, on 08/07/19 at 02:00 PM, the Criminal Investigator for the AG's Office stated that the facility informed him that Resident #2's PCP had told them that Trichomonas can be dormant and not active and undetectable, then flair up. He also stated the facility had informed him there was no evidence of forceful sex seen for Resident #2. Record review revealed a repeat Urinalysis for Resident #2, after antibiotic treatment, that was collected on 8/6/19 at 6:19 PM, with no Trichomonas seen. On 08/08/19 at 10:34 AM, interview with the District Ombudsman revealed that she nor the local Ombudsman was aware of the incident involving Resident #2 being positive for a STD. She stated that she had not had any other complaints from other residents regarding sexual abuse. In a phone interview on 08/08/19 at 02:42 PM, the Lab Director at the Hospital reported that as advised per Risk Management, that they would be allowed to talk with the surveyor later, but not this week, after an interview was attempted. In a post exit interview on 8/13/19 at 12:24 PM, the hospital Lab Director and Risk Manager revealed the lab reports to the doctor any unusual findings. The Lab Director confirmed a Urinalysis for Resident #2 was not repeated after the finding of Trichomonas being present on 7/9/19. The Lab Director also stated a test is either Positive or Negative, if Trichomonas was seen, then it is Positive. The Risk Manager stated as far as the hospital could tell, proper collection/labeling of the urine sample was done and the emergency room Nurse that collected the sample is on vacation and unavailable for interview at this time. The Risk Manager stated the emergency room Physician is also unavailable at this time for an interview. The facility admitted Resident #2 on 9/26/16, with the diagnoses which included, High Blood Pressure, Non-Alzheimer's Dementia, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Non-rheumatic Aortic (Valve) Stenosis and [MEDICAL CONDITION]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 7/16/19, revealed Resident #2 scored 3 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The facility submitted an acceptable Removal Plan on 8/9/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. On (MONTH) 9, 2019, Resident #2 was sent out to a local hospital for low Oxygen saturation. The hospital called to notify the Director of Nursing at the facility on (MONTH) 9, 2019 at approximately 4:30 PM, that the resident was positive for Trichomonas. The State Agency notified the Administrator that the facility had been placed in Immediate Jeopardy at 10:25 AM, on (MONTH) 7, 2019, for Failure to protect the resident due to alleged incident of abuse, Failure to report to the local law enforcement, and Failure to investigate thoroughly, once informed of the allegation and positive test results. Corrective actions: 1) An investigation was begun on (MONTH) 9, 2019 at 5:00 PM, by the Administrator and the Director of Nursing. 2) A Chart review on Resident #2 occurred by the Director of Nursing on (MONTH) 9, 2019 at 4:45 PM. This review included looking for previous urinalysis and review of diagnosis. It revealed that urinalysis on (MONTH) 20, 2019, indicated no Trichomonas seen. 3) On (MONTH) 9, 2019, at 4:50 PM, an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse (LPN)# 1. The Medical Director was made aware of reported positive test results. After the discussion of the positive Trichomonas test there were no changes made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4) Resident #2's brother was called by the DON and Administrator on (MONTH) 9, 2019 at approximately 5:15 PM, and informed that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION]. 5) Staff interviews began at approximately 5:30 PM on (MONTH) 9, 2019, by the DON, and were completed on (MONTH) 10, 2019 at approximately 5:00 PM. Six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA # 3 stated: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4 stated: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. During the interview the staff was asked if they had noticed any change in Resident #2's behavior. Their responses were negative. 6) Notification was made to the SA at approximately 6:00 PM on (MONTH) 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 7) The Attorney General's office was notified via eform on (MONTH) 9, 2019 at 6:10 PM, of a report of Resident #2 testing positive for Trichomonas. 8) A Review of video footage occurred on (MONTH) 10, 2019, by the Administrator at approximately 9:30 AM. Coverage reviewed started at (MONTH) 3, 2019 at 10:00 PM, to (MONTH) 9, 2019, when she was sent out. There was no unusual visitors or suspicious activity observed during the review of the video. This video footage was the only footage available for review. 9) Resident #2 returned to the facility on (MONTH) 10, 2019 at 4:45 PM. Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on (MONTH) 10, 2019 at approximately 5:00 PM, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview by the DON and the Administrator with Resident #2 occurred at approximately 10:00 AM on (MONTH) 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. No other Resident interviews were done at this time. 10) To protect other residents from harm, the facility provided education on (MONTH) 19, 22 and (MONTH) 23, 2019 on Dignity, Respect, and Abuse. Nineteen (19) of 53 CNA's, nine (9) of 22 LPN's, seven (7) of nine (9) RN's, six (6) of six (6) Housekeeping, two (2) of three (3) Laundry, two (2) of two (2) Social Services, two (2) of two (2) Business Office, two (2) of four (4) Activity, ten (10) of 13 Dietary, two (2) of two (2) Floor Techs , one (1) of one (1) Central Supply, one (1) of one (1) Medical Records, zero (0) of one (1) Maintenance, one (1) of one (1) Courtyard Director, and zero (0) of three (3) Monitor Techs were trained. 11) At 10:58 AM on (MONTH) 7, 2019, the local police department was called by the Administrator. They arrived at 11:05 AM to speak with the Administrator and Director of Nursing. They were provided a copy of the facility investigation and stated they would contact us on (MONTH) 8, 2019, with a report and/or request for further action. 12) Education of all employees was conducted by Registered Nurse #5 beginning on (MONTH) 7, 2019 at 2:30 PM, and concluded on (MONTH) 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The Staff educated as of August, 8 2019 at 5:00 PM are as follows: Eighteen (18) of 22 LPN's, nine (9) of nine (9) RN's, 34 of 53 CNA's, three (3) of three (3) Laundry staff, six (6) of six (6) Housekeeping staff, three (3) of four (4) Activity staff, 13 of thirteen 13 Dietary staff, two (2) of two (2) Floor Technicians, one (1) of one (1) Maintenance staff, one (1) of one (1) Medical Records staff, one (1) of one (1) Central Supply staff, two (2) of two (2) Business Office staff, one (1) of one (1) Administrator, two (2) of two (2) Social Service staff, one (1) of one (1) Courtyard Director, and one (1) of three (3) Monitor Technicians. 13) No employee will be allowed to work until they are trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14) The Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on (MONTH) 7, 2019 at approximately 3:00 PM to determine what type of testing of male employees needs to be done for Trichomonas. She stated the type of test would be a urine test. 15) Testing of all male employees for Trichomonas began (MONTH) 8, 2019. Ten (10) of ten (10) results have returned with negative findings. 16) Ambulatory Resident #19 was tested for Trichomonas on (MONTH) 8, 2019 at approximately 1:20 PM, and the result was negative. Resident #19 was tested for Trichomonas due to having recently being observed kissing a consenting female Resident #50. Resident #19 has a BIMS score of 15 and Resident #50 has a BIMS score of 15. There were no other reports to the Administrator or DON of any other male Residents exhibiting sexual behaviors or expressions between (MONTH) 20, 2019 and (MONTH) 9, 2019. 17) On (MONTH) 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results of 34 of 34 negative for Trichomonas. 18) On (MONTH) 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results of 21 of 21 negative for Trichomonas. 19) A 100% chart audit was conducted on (MONTH) 9, 2019, which focused on the most recent urinalysis and [DIAGNOSES REDACTED]. 20) On (MONTH) 9, 2019 at approximately 2:30 PM cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service Assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21) The QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented (MONTH) 9, 2019 at 4:00 PM, to protect Residents from sexual abuse. The QA Committee met on (MONTH) 9, 2019 at 4:00 PM, with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The facility asserts that the likelihood of serious harm in this matter will be removed effective (MONTH) 10, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The SA validated through interviews and record review the facility conducted an investigation which began on (MONTH) 9, 2019 by the Administrator and the Director of Nursing. 2. The SA validated by interviews and record review a chart review on Resident #2 occurred by the Director of Nursing on (MONTH) 9, 2019. This review included looking for previous urinalysis and review of diagnosis. Interview with the DON revealed the urinalysis on (MONTH) 20, 2019, indicated no Trichomonas seen. 3. The SA validated by interviews and sign in sheets on (MONTH) 9, 2019, that an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse(LPN)# 1. Interview revealed the Medical Director was made aware of reported positive test results, no changes were made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4. The SA validated through interviews that Resident #2's brother was called by the DON and Administrator on (MONTH) 9, 2019, and informed that Resident #2 tested positive for Trichomonas, a [MEDICAL CONDITION]. 5. The SA validated through interviews and record reviews that the facility began staff interviews on (MONTH) 9, 2019, by the DON and were completed on (MONTH) 10, 2019. Documentation included six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA #3's documented statement: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4's documented statement: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. Staff had not noticed any change in Resident #2's behavior. 6. The SA validated through record review and interview that the facility notified the SA on (MONTH) 9, 2019 of a report of Resident #2 testing positive for Trichomonas. 7. The SA validated through interviews and record review the facility notified the Attorney General's office via eform on (MONTH) 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 8. The SA validated through interviews and facility investigation review that the facility reviewed the video footage on (MONTH) 10, 2019 by the Administrator, covering (MONTH) 3, 2019 at 10:00 PM to (MONTH) 9, 2019, when the resident was sent out. Interview with the Administrator revealed there was no unusual visitors or suspicious activity observed during the review of the video. 9. The SA validated documentation that Resident #2 returned to the facility on (MONTH) 10, 2019 at 4:45 PM. Interview with administrative staff revealed Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on (MONTH) 10, 2019, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview with the DON and the Administrator revealed interviews with Resident #2 occurred at approximately 10:00 am on (MONTH) 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. Interview with the Administrator and DON validated that no other Resident interviews were done at this time. 10. The SA validated through interviews, sign-in sheets, and record review, that the facility provided education on (MONTH) 19, 22 and (MONTH) 23, 2019 on Dignity, Respect, and Abuse, with staff attendance by signature. 11. The SA validated through interview with the Administrator that on (MONTH) 7, 2019, the local police department was notified, and came to the facility. They were provided a copy of facility investigation and stated they would contact the facility with a report and/or request for further action. 12. The SA validated through interview, sign-in sheets, and record review, that education of all employees was conducted by Registered Nurse #5 beginning on (MONTH) 7, 2019 and concluding on (MONTH) 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The SA validated that all staff were educated as of August, 8, 2019. 13. The SA validated through interviews that no employee was allowed to work until they were trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14. The SA validated by interview with the Administrator, that the Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on (MONTH) 7, 2019 to determine what type of testing of male employees needs to be done for Trichomonas and was informed the type of test would be a urine test. 15. The SA validated by record review and interviews that the facility initiated testing of all male employees for Trichomonas beginning (MONTH) 8, 2019, and ten (10) of ten (10) results returned with negative findings. 16. The SA validated by record review and interviews that the facility tested Ambulatory Resident #19 for Trichomonas on (MONTH) 8, 2019, with a negative result. Interview with administrative staff revealed there were no other reports of any other male Residents exhibiting sexual behaviors or expressions between (MONTH) 20, 2019 and (MONTH) 9, 2019. 17. The SA validated by interviews and record review that on (MONTH) 9, 2019, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results negative for Trichomonas. 18. The SA validated by interviews that on (MONTH) 9, 2019, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results negative for Trichomonas. 19. The SA validated through interviews and record reviews that the facility conducted 100% chart audit on (MONTH) 9, 2019, which focused on the most recent urinalysis and [DIAGNOSES REDACTED]. 20. The SA validated by interviews that on (MONTH) 9, 2019, cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21. The SA validated through interviews and sign-in sheets that the QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented (MONTH) 9, 2019, to protect Residents from sexual abuse. Interview validated that the QA Committee met on (MONTH) 9, 2019 at 4:00 PM with the Medical Direct (TRUNCATED)

Based on observation, record review, facility policy review, and staff interview, the facility failed to prevent the possible spread of infection for one (1) of three (3) residents during wound observation, Resident #18. Findings include: Review of the facility policy tilted, Infection Control Guidelines for All Nursing Procedures, dated (MONTH) (YEAR), revealed the purpose of this policy is to provide guidelines for general infection control while caring for residents. The facility policy noted that standard precautions will be used in the care of all residents in all situations, regardless of suspected or confirmed presence of infectious diseases. The facility policy noted that standard precautions apply to blood, body fluids, secretions, and excretions. During an observation, on 8/5/2019 at 10:15 AM, incontinent care was provided to Resident #18 by Certified Nursing Assistant (CNA) #5. CNA #6 assisted CNA #5 by positioning Resident #18 on to her side. During the incontinent care, CNA #5 pulled back on a loose dressing, with a soiled gloved hand, located on Resident #18's coccyx area. CNA #5 held the dressing with a gloved hand and with the other gloved hand she cleaned the area that was covered by the dressing with a soiled wipe. CNA #5 used her soiled gloved hand to put the dressing back in place. CNA #5 used the soiled gloved hand to hold the dressing in place while she secured the Resident #18's brief. During an interview, on 8/5/2019 at 10:31 AM, Certified Nursing Assistant (CNA) #5 confirmed that she should have not cleaned under the dressing. CNA #5 stated, I didn't change gloves or wash my hand when I pulled the dressing back. CNA#5 also stated that cleaning in the wound area with a soiled wipe and handling the dressing with soiled gloves could cause an infection. During an interview, on 8/5/2019 at 10:39 AM, Certified Nursing Assistant (CNA) #6 confirmed that if you touch a dressing or clean close to the wound with dirty gloves, the wound could get infected. CNA #6 stated, You should always stop and report the loose dressing to the nurse. During an interview on 8/7/2019 at 3:05 PM, Registered Nurse (RN) #7/Treatment Nurse revealed that when CNA #5 pulled the dressing away from the wound with her soiled gloved hand, and wiped with a soiled wipe, it could have allowed bacteria into the wound area. RN #7 stated, This could cause the area to become infected. RN #7 stated, The CNAs should have made the nurse aware, so the dressing could be changed, but definitely not wipe into the wound area or touch the inside of the dressing with soiled gloves. During an interview, on 8/8/2019 at 1:50 PM, Registered Nurse (RN) #5/Staff Development Nurse, confirmed that a CNA should not clean the area under a dressing at any time. RN #5 stated, Wiping in the area of a wound with a soiled wipe and handling the wound dressing with a dirty glove, is an infection control problem. RN stated, That's definitely a problem. During an interview, on 8/9/2019 at 11:46 AM, the Director of Nursing (DON) stated the CNA should not have cleaned in the area under a wound dressing and should not have touched the inside of a dressing. The DON stated the CNA should have notified the nurse that the wound dressing was coming off. Review of the Face Sheet revealed the facility admitted Resident #18 on 2/5/2019, with [DIAGNOSES REDACTED]. Resident #47 During an Observation of a Percutaneous Endoscopic Gastrostomy (PEG) tube dressing change, with License Practical Nurse (LPN) #2, revealed LPN #2 washed her hands, pulled gloves out of her lab [NAME]et pocket, and removed the old dressing. She cleansed the PEG area with soap and water. LPN #2 Left room to get more gloves. LPN #2 put gloves into her lab [NAME]et pocket, washed her hands, applied gloves from out of pocket, and put on a new dressing to the PEG site. During an interview on 08/06/19 at 2:51 PM, LPN #2 confirmed she put the gloves in her pocket and didn't think about it. LPN #2 said that she should not have put the gloves in her pocket, because they can become contaminated by touching other things in her pocket. LPN #2 said she did not think about infection control. During an interview on 08/06/19 at 2:51 PM, RN # 5 confirmed that LPN #2 should not put gloves in her pocket, then use them for patient care. RN #5 said it could cause infection and LPN #2 did not follow the facility policy. A review of the facility's face sheet revealed the facility admitted Resident #47 on 8/02/2017, with diagnoses, which included Hypertension, Diabetese Mellitus and [MEDICAL CONDITION] Disorder. Review of Resident #47's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2019, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment.

Based on record review, facility policy review, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) related to a resident being at risk for pressure ulcers/injuries for one (1) of 25 MDS reviews. (Resident #18) Findings include: Review of the facility policy titled, Resident Assessment Instrument, dated (MONTH) (YEAR), revealed that it is the policy of this facility that a comprehensive assessment of a resident's needs shall be made upon the resident's admission and periodically as mandated by the Omnibus Budget Reconciliation Act (OBRA) and Medicare guidelines. The facility policy noted that the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. The facility policy noted that the nursing department will be responsible for completing and entering into the computer system MDS sections A, G, GG, H, I, J, M, N, O, P, S, V, and Z. The facility policy also noted that all persons who have completed any portion of the MDS Resident Assessment Form, must sign such document attesting to the accuracy of such information. Review of the facility policy titled, Pressure Ulcer Risk Assessment, dated (MONTH) 2012, revealed that it is the policy of this facility that the purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The facility policy also noted that during the risk assessment, the Braden Scale pressure ulcer risk assessment will be completed upon admission, weekly times (x) four (4) weeks and with each additional assessment; quarterly, annually, and with significant changes. The facility policy states that because a resident at risk can develop a pressure ulcer within two (2) to six (6) hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Review #18 Review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/2019, revealed Section M0150 was coded 0, which indicated that Resident #18 was not at risk of developing pressure ulcers/injury. The MDS also revealed that in subsection A of the Z0400 Section, Licensed Practical Nurse (LPN) #1, the MDS Nurse signed as having completed the M section of the MDS. Review of an Initial Wound Assessment 2, dated 7/22/2019, revealed that Resident #18 had an excoriation to the coccyx area. Resident #18's wound assessment noted that there was only partial depth of tissue injury. Resident #18's wound assessment noted a treatment plan to clean with Baby Shampoo and H2O (water), pat dry, cover with [MEDICATION NAME] foam dressing daily and as needed. Resident #18's wound assessment was completed by Registered Nurse (RN) #2/ Resident Care Coordinator on 7/22/2019. Review of Resident #18's Plan of Care - Current, dated 8/8/2019, revealed a focused problem of a bleachable excoriation to the coccyx with potential for pressure ulcers and a history of pressure ulcers had an effective date of 07/22/2019. During an interview on 8/8/2019 at 1:55 PM, Licensed Practical Nurse (LPN) #1 and the MDS Nurse confirmed that the Quarterly MDS dated for 7/30/2019, was coded 0 in the M0150 section, indicating that Resident #18 is not at risk for pressure ulcers/injuries. LPN #1 stated Resident #18 is at risk for pressure ulcers and a one 1 should have been coded on the MDS, section M0150. LPN #1 stated, It's an error, just a slip up. LPN stated, I can fix that right now. During an interview on 08/09/2019 at 11:46 AM, the DON stated that Resident #18 is at risk for pressure ulcers and it should have been coded on the Quarterly MDS dated [DATE]. Review of the Face Sheet revealed the facility admitted Resident #18 on 2/5/2019, with [DIAGNOSES REDACTED].

Based on resident and staff interview, the facility failed to ensure Resident #63 had access to her Trust Fund account after business hours, and on the weekends. This affected one (1) of 26 sampled residents out of 84 residents with Trust Fund accounts. Finding include: On 09/05/18 at 11:00 AM, an interview with Resident #63, revealed she did not have access to her money anytime she wanted/needed it. On 09/06/18 at 4:43 PM, an interview with the Business Office Manager (BOM) revealed the residents do not have access to their money on evenings and weekends because the Business Office was closed. Review of the facility's document titled, Trial Balance, with a print date of 09/06/18 at 5:55 PM, revealed a total of 84 residents who participated in the facility's Trust Fund accounts. Resident #63's name was included on the list. Review of Resident #63's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/18, revealed the resident's Basic Interview for Mental Status (BIMS) score was 15, which indicated no cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure Resident #86's Minimum Data Set (MDS) was accurately coded for the identification date of an unstageable Deep Tissue Injury (DTI) for one (1) of 22 Resident MDS assessments reviewed. Findings include: A review of the facility's policy titled, Resident Assessment Instrument, with an effective date of (MONTH) 2012 and latest revision date of (MONTH) (YEAR), revealed: 4. Nursing will be responsible for completing, and entering into the computer system MDS sections, which included Section M Skin Conditions. 9. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 10. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 14. All persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information. An observation, on 09/06/18 at 2:55 PM, revealed Registered Nurse (RN) #2, assisted by RN #1, provided Resident #86's wound care to the left heel. The wound bed had a purplish colored center with pink surrounding tissue, and intact skin. Record review of Resident #86's Significant Change MDS assessment, with an Assessment Reference Date (ARD) of 06/04/18, revealed section M for Skin Condition M0300-G was coded for an unstageable Deep Tissue Injury (DTI). Review of the facility's QA (Quality Assurance) Weekly Skin Report Pressure Ulcers revealed Resident #86's DTI to the left heel was identified on 06/05/18, and the treatments were to apply the A&D Ointment every shift, and float heels every shift. On 09/06/18 at 4:50 PM, an interview with the Director of Nursing, (DON) revealed, Resident #86's left heel pressure ulcer was identified, on 06/05/18, after he was transfered to the hospital on [DATE] for wet lung sounds, and then admitted to Hospice on 05/28/18. Review of Resident #86's (MONTH) (YEAR) physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of Resident #86's (MONTH) (YEAR) Medication Record revealed the staff's documentation the A&D Ointment to both heels was applied every shift starting on 06/06/18, and both heels were floated started on 06/07/18. On 09/07/18 at 1:30 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed, I realize, I shouldn't have done that (referring to the coding of the MDS on 06/04/18). LPN #1 also stated the MDS coded on 06/04/18 for the DTI was not an accurate assessment, because Resident #86's DTI was not identified unitl 06/05/18. A review of the facility's Face Sheet for Resident #86 revealed he was admitted , by the facility on 10/27/08, with the included [DIAGNOSES REDACTED]. Review of Resident #86's Significant Change MDS, with an ARD of 06/04/18, revealed the resident's cognitive skills for daily decision making was coded 3, which indicated severe impairment, never/rarely made decisions. Further review of the MDS revealed Resident #86 required extensive or total staff assistance, with one to two persons with his Activities of Daily Living (ADLs).

Based on observation, staff interview, and facility policy review, the facility failed to pass ice in a manner to prevent cross contamination, for one of four (1 of 4) days of survey observations. Findings include: A review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, with a revised date of (MONTH) 2012, and review date of (MONTH) (YEAR), revealed: Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. On 09/05/18 at 2:40 PM, an observation revealed Certified Nursing Assistant (CNA) #1 placed the ice scooper into the cooler of ice, instead of the ice scooper holder. On 09/05/18 at 2:45 PM, an interview with CNA #1 revealed, she placed the ice scooper into the ice chest with the ice in it. CNA #1 stated that could cause bacteria to get in it (referring to the ice). On 09/07/18 at 1:05 PM, an interview with Registered Nurse (RN) #1 revealed, she stated it is a problem to put the ice scooper into the ice chest, and not the holder. RN #1 stated it was contaminating the ice in the chest. On 09/07/18 at 1:10 PM, an interview with RN #2 revealed, That's cross contamination and an infection control issue. RN #2 stated she had done trainings in the past on infection control. Review of the facility's Training Sign-In Sheets, dated 12/14/17, 12/15/18, 12/19/17, 12/20/17, 12/21/17, and 12/27/17, which included Courses for Infection Control and Standard Precautions, revealed CNA #1's signature was not identified on the sign in sheets. On 09/07/18 at 1:20 PM, an interview with the Director of Nursing (DON), revealed that was a problem with the CNA putting the ice scooper back into the ice chest instead of the holder, and that is an infection control issue.

Based on observation, staff interview and facility policy review the facility failed to follow infection control techniques during care as evidenced by failure to perform hand hygiene, cleans equipment or use barriers to ensure a clean field for three (3) of eight (8) care observations for Residents #2, #6, and #7. Findings Include: Review of facility policy entitled Infection Control Policies/Practices (Reviewed January 2013) revealed the primary purpose of this facility's infection control policies and practice are to establish guidelines to follow in providing a safe, sanitary and comfortable environment and to aid in preventing the development and transmission of diseases and infections. Review of facility policy entitled Hand washing and hand hygiene (updated September 2013) revealed the facility considers hand hygiene the primary means to prevent the spread of infections. The policy read: Employees must wash their hands for at least twenty (20) seconds using anti microbial or non-antimicrobial soap and water under the following conditions: Before moving from a contaminated body site to a clean body site during resident care; After removing gloves; Before and after direct contact; Before and after assisting a resident with personal care; Before and after performing invasive procedures; Before and after handling peripheral vascular catheters and other invasive devices; Before and after inserting indwelling catheters; Upon and after coming in contact with a residents intact skin; Before and after assisting a resident with toileting; After handling soiled or used linens, dressings, bedpans, catheters and urinals. Resident #2 On 06/15/17 at 2:00 PM, observation revealed Certified Nursing Assistant (CNA) #2 providing catheter care to Resident #2. When catheter care was completed, CNA #2 touched Resident #2's shirt, shoulder, and covers without washing hands or changing gloves. During an interview on 6/14/17 at 3:15 PM, CNA #2 said she thought she did wash her hands, but then confirmed she did not. She said she knows to wash hands. During an interview on 6/16/17 at 11:45 AM, the facility Director of Nursing (DON) stated the staff should always wash hands and change gloves when moving from a dirty area to a clean area. The facility admitted Resident #2 on 05/22/16 with [DIAGNOSES REDACTED]. Resident #2 During a family interview on 06/14/17 at 10:19 AM in the room of Resident #2, Licensed Practical Nurse (LPN) # 4 walked in the room with a cup of medication in her hand and carrying a purple basket containing a glucometer and lancets under her arm. She placed the purple basket on Resident #2's bed and handed Resident #2 his medication. After caring for Resident #2, LPN #4 took the purple basket out of the resident's room and placed it into the drawer of her medication cart without disinfecting the basket. During an interview on 6/14/17 at 10:25 AM, LPN #4 confirmed she placed the basket on Resident #2's bed without a barrier. During an interview on 6/16/16 at 10:30 AM, the DON stated the nurse should have used a barrier on the bed. The DON said the nurse should not have even brought the basket in the room if she was not going to use it. The basket is supposed to remain in the cart just to store lancets, and the nurse should just take out what is needed. The facility admitted Resident #2 on 05/22/16 with [DIAGNOSES REDACTED]. Resident #7 Review of the facility's policy entitled Perineal Care dated 09/13, revealed the purposes of this procedure is to provide cleanliness and comfort to the resident, to prevent infections, skin irritation and to observe the resident's skin condition. When performing this procedure place the equipment and supplies needed to perform this procedure on the bedside stand. Change gloves and wash hands any time gloves are contaminated. A review of the Perineal Care Skills Sheet Using Wipes dated 06/07/17, 02/22/17 and 01/11/17 revealed CNA #1 passed her skills check off. Items checked off included not placing items on bed and changing gloves any time gloves are contaminated. Observation of incontinent care on 06/14/17 at 1:35 PM revealed Certified Nursing Assistant (CNA) #1 placing disposable wipes and tube of barrier cream on Resident #7's bedspread prior to performing incontinent care. During incontinent care, CNA #1 touched Resident #7's bed linens with dirty gloves. Interview on 06/14/17 at 1:50 PM with CNA #1 revealed she placed the barrier cream and disposable wipes on the bed and did not change her gloves before touching Resident #7's bed linens. CNA #1 stated It could cause an infection. An interview on 06/14/17 at 3:30 PM with the interim Director of Nursing (DON) revealed incontinent supplies should not be placed on the bed. The interim DON stated it is an infection control issue. Review of the Face Sheet revealed the facility admitted Resident #7 on 07/01/13 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/17 revealed Resident #7 scored 14 on the Brief Interview for Mental Status (BIMS) which indicated cognitively intact. Resident #6 Review of the facility's document, entitled Wound Care, revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. The first step listed in the procedure was to use a clean barrier to establish clean field on resident's over bed table. Step 20 in the procedure instructed wipe reusable supplies with germicidal wipes (i.e., outsides of containers that were touched by unclean hands, scissors, etc.). During an observation of wound care to Resident #6's coccyx wound, on 06/14/17 at 2:15 PM, performed by Registered Nurse (RN) #1, assisted by Licensed Practical Nurses (LPNs) #2 and #3, RN#1 did not clean the table prior to placing the supplies on it. She picked supplies up off the uncovered area of the table and placed them on the barrier. LPN #3 took a pair of scissors from her uniform pocket and handed them to RN #1, who then used the scissors to cut the [MEDICATION NAME] AG to size. She handed the scissors back to LPN #3 who returned them to her pocket. RN #1 placed the Aquacet into the wound bed and covered the decubitus with an [MEDICATION NAME] foam dressing. In an interview with LPNs #2 and #3, on 06/14/17 at 2:30 PM, LPN #3 confirmed the scissors came from her uniform pocket. LPN #3 admitted that she had not cleaned the scissors prior to giving them to RN #1. LPN #2 stated that this was an infection control concern because the scissors had come from a uniform pocket that be considered dirty. They both agreed that it could cause an infection in the decubitus. Interview with RN #1, on 06/14/17 at 2:30 PM revealed, RN #1 stated she knew she should not have used contaminated scissors during the wound care. Interview with RN #2, Resident Care Co-coordinator and Infection Control Nurse, on 06/15/17 at 3:00 PM, revealed RN #2 agreed that using dirty scissors to trim dressings would go against infection control policy and could cause infection. Review of the facility's face sheet revealed the facility admitted Resident #6 on 08/14/15. The resident's [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set (MDS), with and Assessment Reference Date (ARD) of 03/30/17, revealed the resident had a score of 14 on the Brief Interview for Mental Status (BIMS) indicating Resident #6 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide privacy during wound care for two (2) of four (4) wound care observations out of a total of eight (8) care observations, Residents #4 and #6. Findings Include: Review of the facility's document, entitled Residents' Rights and Policies, revealed The resident's rights, policies and procedures shall ensure that each Bedford Care Center Resident is treated with considerations, respect and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. Review of the facility's document, titled Quality of life - Dignity, revealed staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Resident # 4 During an observation of decubitus care for Resident #4 on 06/14/17 at 10:00 AM, by Registered Nurse (RN) #1, assisted by Licensed Practical Nurses (LPN) #2, and observed by LPN #3, LPN #2 pulled down the covers and turned the resident on to her left side exposing the resident's back, buttocks and legs. The RN nor the LPNs provided a drape to cover the resident. RN #1 left the resident uncovered from back down to the thighs while she washed her hands, donned gloves, and provided care. LPN#2 did not attempt to cover the resident. RN #1 and LPN #2 left the resident exposed during the care. Interview with the Director of Nursing (DON), on 06/14/17 at 4:00 PM, revealed the DON stated nurses knew to use a drape for the resident when providing care. In an interview with RN #1 and LPN #2, on 06/15/17 at 10:00 AM, they acknowledged that they did not use a drape during wound care for Resident's #4. Review of the facility's in-service training document with a title of Resident's Rights, Abuse and Dignity revealed LPN #2 received training on 03/13/17 and RN #1 on 03/17/17 on promoting, maintaining and protecting resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the facility's face sheet revealed the facility admitted Resident #4 on 08/05/14. The resident's [DIAGNOSES REDACTED]. Review of the resident's most recent Minimal Data Set (MDS), with an Assessment Reference Date (ARD) of 05/04/17, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Resident #6 During an observation of decubitus care for Resident #6, on 06/14/17 at 2:15 PM, provided by RN#1 and LPN #2, observed by LPN #3, LPN #2 positioned the resident on her left side, opened the resident's brief and exposed the residents back, buttocks and legs while RN #1 set up supplies, washed her hands and donned gloves. No drape was provided for the resident by the nurses. RN #1 removed the old dressing which revealed the resident had stool under the dressing and in the brief. RN #1 rolled the brief under the resident and waited while LPN #3 went to get a clean brief. When LPN #3 returned with the brief, RN #1 washed her hands and changed gloves while the resident remained exposed. She then dressed the wound. LPN #2 did not attempt to drape or cover the resident. Once the staff completed wound care, the RN left the resident uncovered while LPN #2 left the room to search for someone to provide incontinent care for the resident. The resident was left uncovered until Certified Nursing Assistants (CNAs) came into the room to do incontinent care. Once the CNA's entered the room they draped the resident. In an interview with RN #1 and LPN #2 on 06/14/17 at 2:30 PM, they acknowledged that they did not use a drape during wound care for Resident's #6. Review of the facility's face sheet revealed the facility admitted Resident #6 on 08/14/15. The resident's [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set (MDS), with and Assessment Reference Date (ARD) of 03/30/17, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #6 was cognitively intact.

Based on record review, staff interview and policy review, the facility failed to ensure that one (1) of four (4) resident's reviewed was not neglected by failing to use a lift for Resident #1 when she was being transferred. Resident #1 was transferred manually without the use of a lift and sustained a fracture to the right ankle. Findings Include: Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/04/11 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was severely impaired. The transfer section was coded as total dependence with two (2) plus persons to assist. Review of the "RESIDENT ASSESSMENT FOR LIFT/TRANSFERS/ASSISTANCE" dated 10/19/10 revealed that Resident #1 was dependent on staff "Patient requires more than 50% assistance by staff, or is unpredictable in the amount of assistance offered." "Patients weight: 144 # (pounds)" "Height: 5' (foot) 4" (inches); "Transfer to and from: Bed-to-chair, Chair-to-toilet, Chair-to-chair." "EQIPMENT (EQUIPMENT)/ASSISTIVE DEVICES total lift" and "N2 STAFF x 2". Review of the computerized Physician order [REDACTED]. Review of the Nursing Kardex for 01/11/2011 revealed: "Transfers Total lift x 2" Review of an "ALLEGED ABUSE INCIDENT REPORT" provided by the facility and dated 01/31/11 revealed: "Synopsis: On 1/28/11, at 1:20 p.m., (name of facility) received a report from (name of hospital) that (name of Resident #1), a Resident of (name of facility) had sustained a fracture." "Details: (name of Resident) is a [AGE] year-old female Resident of (name of facility) since 2007. She has a history of [MEDICAL CONDITIONS],[MEDICAL CONDITION](Gastro [MEDICAL CONDITION] Reflux Disease), Chronic [MEDICAL CONDITIONS], Dysphagia, [MEDICAL CONDITION], Diabetes, Hypertension, CVS ([MEDICAL CONDITION] Disease), MI ([MEDICAL CONDITION] Infarction) and [MEDICAL CONDITION]. The resident is non-ambulatory and is up in geri-chair as tolerated. She requires total assistance x 1 person for bed mobility, locomotion on and off unit per geri-chair, dressing, and personal hygiene and (name of Resident #1) Care Plan requires a total Mechanical Lift x 2 person assist for transfers and baths. Ms. She is incontinent of bowel and bladder. She is alert and oriented to person and place. She is able to verbalize her needs and understand others." "On 1/27/11, I was informed that on the previous evening, 1/26/11 at 8 p.m., (Resident #1) sustained an injury during a transfer by two CNAs. (Name of Licensed Practical Nurse #1) reported she went into the Resident's room to give the Resident medication and two CNAs, (name of CNA's) were in the room changing the Resident's clothes while the Resident was sitting up in the geri-chair." "(LPN #1) states she gave the Resident her medications, turned to wash her hands and heard (Resident #1) loudly state her foot was hurting. (LPN #1) states she turned to see what happened and saw the CNAs had their arms under (Resident #1) arms and the Resident was sitting on the bed with her foot stuck in the side rail that was let down to the floor. (LPN #1) states she asked the CNAs why they did not use the total lift as stated on her ADL (Activities of Daily Living) care plan. (LPN #1) says (CNA#2) stated she did not use it because there was not a lift pad under the Resident at the time. (LPN #1) states she told (CNA #2) that a lift pad could have been put under the Resident by turning her side to side in the geri-chair." "(CNA #1) was later interviewed and stated she did come to the room to help transfer the Resident. She reported the lift was outside the room in the hall. (CNA #1) states she was talking with the nurse and turned to find (CNA #2) transferring the Resident. (CNA #1) says the Resident was "going down" and saw the Residents foot stuck in the siderail. (CNA #1) says she intervened to try to prevent the Resident from going to the floor. (CNA #1) states she reminded (CNA #2) the Resident was supposed to have a total lift." "(CNA #2) reported in her statement and interview that she was "rushing" trying to get the Resident to bed and she did not realize that (Resident #1) did not have a lift pad under her. She states she and (CNA #1) put the Resident to bed without using the lift pad and her foot got stuck in the siderail." "Both CNAs reported that the nurse was in the room facing the sink washing her hands when the incident occurred." "The assessment of the Resident revealed swelling, discoloration and pain of the right ankle. On 1/26/11 the MD (Medical Doctor) was notified and an order for [REDACTED]. assessed again on /27/11 and orders were written to apply ice and ace wrap as well as give [MEDICATION NAME] for pain and inflammation. The Resident was later transferred to (Name) hospital for eval (evaluation) of the ankle and returned to the facility same day (evening) with a [DIAGNOSES REDACTED]. "On 1/28/11 at 1:05 p.m. , (name) Hospital staff called to report x-ray obtained on 1/27 (2011) revealed fracture to distal right fibula. The x-ray report was faxed to facility and the finding included: "Non-displaced acute fracture involve the distal right fibula. Soft tissue swelling overlies the lateral malleolus" and "prior [MEDICAL CONDITION] left fibula, no acute injury is definitively demonstrated on the left". When asked about the [MEDICAL CONDITION] fibula, the Resident states "I broke my foot years ago. I remember I couldn't walk on it". Review of the POS Conclusions: Was this incident avoidable?" "Yes" was checked. "If yes, how? CNA did not follow plan of care for lifting". Observation of Resident #1 was conducted on 02/22/11 at 08:10 a.m. with LPN #3 in attendance. The resident was in a supine position in bed and there was a blue "Dorsiwedge" on the residents right foot/ankle. The resident stated that she did not know how she hurt her leg. She stated: "It just got sore". A demonstration of the incident was conducted with the assistance of CNA #1 and with the DON in attendance on 02/22/11 at 11:05 a.m. to show that Resident #1's foot was caught in between the side rail when the resident complained of pain. Review of the facility's "Policy and Procedures For Alleged Abuse Prevention, Investigation and Reporting" with a revision date of November 9, 2006 revealed: "Policy - It is the policy of (Name of Nursing Home) to promote dignity and overall quality of life for each Resident."

Based on record review, staff interview and policy review, the facility failed to ensure that staff followed physician orders [REDACTED].#1). Resident #1 was transferred manually and not by a lift as ordered by the Physician and as stated on the care plan. Resident #1's foot was caught in the siderail and she sustained a fracture to the right ankle. This was considered as an avoidable accident. Findings Include: Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/04/11 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was severely impaired. The transfer section was coded as total dependence with two (2) plus persons to assist. Review of the "RESIDENT ASSESSMENT FOR LIFT/TRANSFERS/ASSISTANCE" dated 10/19/10 revealed that Resident #1 was dependent on staff "Patient requires more than 50% assistance by staff, or is unpredictable in the amount of assistance offered." "Patients weight: 144 # (pounds)" "Height: 5' (foot) 4" (inches); "Transfer to and from: Bed-to-chair, Chair-to-toilet, Chair-to-chair." "EQIPMENT (EQUIPMENT)/ASSISTIVE DEVICES total lift" and "N2 STAFF x 2". Review of the computerized Physician order [REDACTED]. Review of the Nursing Kardex for 01/11/2011 revealed: "Transfers Total lift x 2" Review of an "ALLEGED ABUSE INCIDENT REPORT" provided by the facility and dated 01/31/11 revealed: "Synopsis: On 1/28/11, at 1:20 p.m., (name of facility) received a report from (name of hospital) that (name of Resident #1), a Resident of (name of facility) had sustained a fracture." "Details: (name of Resident) is a [AGE] year-old female Resident of (name of facility) since 2007. She has a history of [MEDICAL CONDITIONS],[MEDICAL CONDITION](Gastro [MEDICAL CONDITION] Reflux Disease), Chronic [MEDICAL CONDITIONS], Dysphagia, [MEDICAL CONDITION], Diabetes, Hypertension, CVS ([MEDICAL CONDITION] Disease), MI ([MEDICAL CONDITION] Infarction) and [MEDICAL CONDITION]. The resident is non-ambulatory and is up in geri-chair as tolerated. She requires total assistance x 1 person for bed mobility, locomotion on and off unit per geri-chair, dressing, and personal hygiene and (name of Resident #1) Care Plan requires a total Mechanical Lift x 2 person assist for transfers and baths. Ms. She is incontinent of bowel and bladder. She is alert and oriented to person and place. She is able to verbalize her needs and understand others." "On 1/27/11, I was informed that on the previous evening, 1/26/11 at 8 p.m., (Resident #1) sustained an injury during a transfer by two CNAs. (Name of Licensed Practical Nurse #1) reported she went into the Resident's room to give the Resident medication and two CNAs, (name of CNA's) were in the room changing the Resident's clothes while the Resident was sitting up in the geri-chair." "(LPN #1) states she gave the Resident her medications, turned to wash her hands and heard (Resident #1) loudly state her foot was hurting. (LPN #1) states she turned to see what happened and saw the CNAs had their arms under (Resident #1) arms and the Resident was sitting on the bed with her foot stuck in the side rail that was let down to the floor. (LPN #1) states she asked the CNAs why they did not use the total lift as stated on her ADL (Activities of Daily Living) care plan. (LPN #1) says (CNA#2) stated she did not use it because there was not a lift pad under the Resident at the time. (LPN #1) states she told (CNA #2) that a lift pad could have been put under the Resident by turning her side to side in the geri-chair." "(CNA #1) was later interviewed and stated she did come to the room to help transfer the Resident. She reported the lift was outside the room in the hall. (CNA #1) states she was talking with the nurse and turned to find (CNA #2) transferring the Resident. (CNA #1) says the Resident was "going down" and saw the Residents foot stuck in the siderail. (CNA #1) says she intervened to try to prevent the Resident from going to the floor. (CNA #1) states she reminded (CNA #2) the Resident was supposed to have a total lift." "(CNA #2) reported in her statement and interview that she was "rushing" trying to get the Resident to bed and she did not realize that (Resident #1) did not have a lift pad under her. She states she and (CNA #1) put the Resident to bed without using the lift pad and her foot got stuck in the siderail." "Both CNAs reported that the nurse was in the room facing the sink washing her hands when the incident occurred." "The assessment of the Resident revealed swelling, discoloration and pain of the right ankle. On 1/26/11 the MD (Medical Doctor) was notified and an order for [REDACTED]. assessed again on /27/11 and orders were written to apply ice and ace wrap as well as give [MEDICATION NAME] for pain and inflammation. The Resident was later transferred to (Name) hospital for eval (evaluation) of the ankle and returned to the facility same day (evening) with a [DIAGNOSES REDACTED]. "On 1/28/11 at 1:05 p.m. , (name) Hospital staff called to report x-ray obtained on 1/27 (2011) revealed fracture to distal right fibula. The x-ray report was faxed to facility and the finding included: "Non-displaced acute fracture involve the distal right fibula. Soft tissue swelling overlies the lateral malleolus" and "prior [MEDICAL CONDITION] left fibula, no acute injury is definitively demonstrated on the left". When asked about the [MEDICAL CONDITION] fibula, the Resident states "I broke my foot years ago. I remember I couldn't walk on it". Review of the POS Conclusions: Was this incident avoidable?" "Yes" was checked. "If yes, how? CNA did not follow plan of care for lifting". Observation of Resident #1 was conducted on 02/22/11 at 08:10 a.m. with LPN #3 in attendance. The resident was in a supine position in bed and there was a blue "Dorsiwedge" on the residents right foot/ankle. The resident stated that she did not know how she hurt her leg. She stated: "It just got sore". A demonstration of the incident was conducted with the assistance of CNA #1 and with the DON in attendance on 02/22/11 at 11:05 a.m. to show that Resident #1's foot was caught in between the side rail when the resident complained of pain.

Based on record review, staff interview and policy review, the facility failed to ensure that two (2) of four (4) resident's reviewed were protected from accidents. This is for Resident #1 and Resident #4. Resident #1 was transferred manually without the use of a lift. Resident #1 had a fall and sustained a nondisplaced fracture to the distal right fibula. Resident #4 had a fall and sustained a hematoma to the head and a fracture to the clavicle. Resident #4 had alarms that did not sound when she sustained the fall. Findings Include: RESIDENT #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/04/11 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was severely impaired. The transfer section was coded as total dependence with two (2) plus persons to assist. Review of the "RESIDENT ASSESSMENT FOR LIFT/TRANSFERS/ASSISTANCE" dated 10/19/10 revealed that Resident #1 was dependent on staff "Patient requires more than 50% assistance by staff, or is unpredictable in the amount of assistance offered." "Patients weight: 144 # (pounds)" "Height: 5' (foot) 4" (inches); "Transfer to and from: Bed-to-chair, Chair-to-toilet, Chair-to-chair." "EQUIPMENT (EQUIPMENT)/ASSISTIVE DEVICES total lift" and "N2 STAFF x 2". Review of the computerized Physician order [REDACTED]. Review of the Nursing Kardex for 01/11/2011 revealed: "Transfers Total lift x 2" Review of an "ALLEGED ABUSE INCIDENT REPORT" provided by the facility and dated 01/31/11 revealed: "Synopsis: On 1/28/11, at 1:20 p.m., (name of facility) received a report from (name of hospital) that (name of Resident #1), a Resident of (name of facility) had sustained a fracture." "Details: (name of Resident) is a [AGE] year-old female Resident of (name of facility) since 2007. She has a history of CHF (Congestive Heart Failure), GERD (Gastro esophageal Reflux Disease), Chronic Renal Insufficiency, Osteoarthritis, Dysphagia, Glaucoma, Diabetes, Hypertension, CVS (Cerebrovascular Disease), MI (Myocardial Infarction) and Bradycardia. The resident is non-ambulatory and is up in geri-chair as tolerated. She requires total assistance x 1 person for bed mobility, locomotion on and off unit per geri-chair, dressing, and personal hygiene and (name of Resident #1) Care Plan requires a total Mechanical Lift x 2 person assist for transfers and baths. Ms. She is incontinent of bowel and bladder. She is alert and oriented to person and place. She is able to verbalize her needs and understand others." "On 1/27/11, I was informed that on the previous evening, 1/26/11 at 8 p.m., (Resident #1) sustained an injury during a transfer by two CNAs. (Name of Licensed Practical Nurse #1) reported she went into the Resident's room to give the Resident medication and two CNAs, (name of CNA's) were in the room changing the Resident's clothes while the Resident was sitting up in the geri-chair." "(LPN #1) states she gave the Resident her medications, turned to wash her hands and heard (Resident #1) loudly state her foot was hurting. (LPN #1) states she turned to see what happened and saw the CNAs had their arms under (Resident #1) arms and the Resident was sitting on the bed with her foot stuck in the side rail that was let down to the floor. (LPN #1) states she asked the CNAs why they did not use the total lift as stated on her ADL (Activities of Daily Living) care plan. (LPN #1) says (CNA #2) stated she did not use it because there was not a lift pad under the Resident at the time. (LPN #1) states she told (CNA #2) that a lift pad could have been put under the Resident by turning her side to side in the geri-chair." "(CNA #1) was later interviewed and stated she did come to the room to help transfer the Resident. She reported the lift was outside the room in the hall. (CNA #1) states she was talking with the nurse and turned to find (CNA #2) transferring the Resident. (CNA #1) says the Resident was "going down" and saw the Residents foot stuck in the siderail. (CNA #1) says she intervened to try to prevent the Resident from going to the floor. (CNA #1) states she reminded (CNA #2) the Resident was supposed to have a total lift." "(CNA #2) reported in her statement and interview that she was "rushing" trying to get the Resident to bed and she did not realize that (Resident #1) did not have a lift pad under her. She states she and (CNA #1) put the Resident to bed without using the lift pad and her foot got stuck in the siderail." "Both CNAs reported that the nurse was in the room facing the sink washing her hands when the incident occurred." "The assessment of the Resident revealed swelling, discoloration and pain of the right ankle. On 1/26/11 the MD (Medical Doctor) was notified and an order for [REDACTED]. A portable x-ray was obtained on 1/27/11 which did not reveal any acute fracture but was somewhat inconclusive due to an "overlap of the structures as the patient could not achieve proper positioning" The Resident was assessed again on /27/11 and orders were written to apply ice and ace wrap as well as give Motrin for pain and inflammation. The Resident was later transferred to (Name) hospital for eval (evaluation) of the ankle and returned to the facility same day (evening) with a [DIAGNOSES REDACTED]. "On 1/28/11 at 1:05 p.m. , (name) Hospital staff called to report x-ray obtained on 1/27 (2011) revealed fracture to distal right fibula. The x-ray report was faxed to facility and the finding included: "Non-displaced acute fracture involve the distal right fibula. Soft tissue swelling overlies the lateral malleolus" and "prior fracture of the distal left fibula, no acute injury is definitively demonstrated on the left". When asked about the fracture of the left fibula, the Resident states "I broke my foot years ago. I remember I couldn't walk on it". Review of the POST INCIDENT REVIEW for Resident #1 dated 01/27/11 revealed "Conclusions: Was this incident avoidable?" "Yes" was checked. "If yes, how? CNA did not follow plan of care for lifting". Observation of Resident #1 was conducted on 02/22/11 at 08:10 a.m. with LPN #3 in attendance. The resident was in a supine position in bed and there was a blue "Dorsiwedge" on the residents right foot/ankle. The resident stated that she did not know how she hurt her leg. She stated: "It just got sore". A demonstration of the incident was conducted with the assistance of CNA #1 and with the DON in attendance on 02/22/11 at 11:05 a.m. to show that Resident #1's foot was caught in between the side rail when the resident complained of pain. RESIDENT #4 Record review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 10/26/10 revealed the BIMS score was 01 which was defined as severely impaired. Resident #4's transfer status, walk in corridor, locomotion on and off the unit was coded as 2/2 which is defined as limited assistance with the assistance of one (1) person. Resident #4 was coded as having two (2) or more falls since admission with no injury. Review of the Care Area Assessment (CAA) Summary revealed: "Care Area Assessment Documentation Notes" stated: "02/01/11 (Resident #4 Name) had a fall 1/15/11 and sustained fracture to left clavicle. She has been non compliant with plan of care. She hes (has) non skid strips in front of her closet and cabinet to help reduce falls, she has recently gotten some non skid shoes. She has a floor alarm to right side of bed to alert atafff (staff) of resident getting up unassisted. She has an electric hi low bed, w/c (wheelchair) seat alarm and couch seat alarm, and a bed alarm with care giver key to alert staff. Tag alarm added to sofa, and bed and w/c. A soft roll belt restraint has been ordered while up in wheelchair r/t (related to) history of falls and potential for further falls." Interview with the Director of Nursing (DON) on 02/23/11 at 09:00 a.m. revealed that a caregiver key was put in place because the staff would have to reset the alarm if it was sounding. She stated that staff had reported to her that Resident #4 often turned her alarm off so with the use of the caregiver key the resident could not reset it herself. Review of the January 2011 computerized physician orders [REDACTED]. "03/10/10 NONSKID STRIPS IN FRONT OF CLOSET AND CABINET TO HELP REDUCE FALLS. 06/17/10 BED ALARM T (TO) BED RT (related to) FALL AND GETTING UP UNASSISSTED (ASSISTED). 06/22/10 W/C SEAT ALARM, COUCH SEAT ALARM AND BED ALARM WITH CARE GIVER KEY TO ALERT STAFF. 07/26/10 ELECTRIC HI/LOW BED RT H/O (HISTORY OF) FALLS, ALZ (ALZHEIMER'S) , CONFUSION. 07/28/10 FLOOR ALARM TO RIGHT SIDE OF BED TO ALERT STAFF OF RESIDENT GETTING UP UNASSISTED R/T ALZHEIMERS." Review of the "FALL RISK ASSESSMENT" dated 10/24/10 and 01/25/11 for Resident #4 revealed a score of 17 which indicated that Resident #4 was at high risk for falls. Review of Nurses Notes for Resident #4 revealed: On 1/15/11 at 1:15 p (p.m.) "Visitor from Rm (room) 58B saw resident scooting to the door and called for assist. Found resident in a sitting position on the floor with profuse bleeding coming from (L) {left} side of head. Also noted blood on floor from foot board of bed to doorway to hall. Also found a muffin on the floor at foot-board. Large hematoma to (L) side of head, c/o (complains of) severe pain on (L) shoulder. Area cleansed & (and) wrapped. Called for ambulance to transfer to (name of hospital) ER (emergency room ) for evaluation & treatment." Review of the Radiology Report for Resident #4 dated 01/15/11 revealed: "CLINICAL Trauma after falling injury with left side of the head swelling; Shoulder pain" "CT (Computerized Tomography) OF THE BRAIN: FINDINGS: No evidence of intracranial hemorrhage, mass, mass effect, midline shift, or evidence of acute infarction demonstrated. The cerebral atrophy and white matter changes are similar to the previous study. There is a large are of soft tissue hemorrhage and contusion overlying the left parietal bone. No evidence of cranial or skull base fracture is seen. IMPRESSION: LARGE HEMATOMA ADJACENT TO LEFT PARIETAL BONE. NO OTHER EVIDENCE OF ACUTE INJURY DEMONSTRATED." "TWO VIEWS, LEFT SHOULDER Findings: there is fracture of the distal clavicle with slight superior displacement of the distal fragment relative to the remaining clavicle. No other fractures are seen. Shoulder alignment appears within normal limits. IMPRESSION: FRACTURE OF DISTAL CLAVICLE AS DESCRIBED ABOVE." Review of documentation written by Registered Nurse (RN) #1 and provided by the facility revealed: "Notified by (name of staff) that (name of Resident #4) had fallen. Upon arrival to room, found resident on the floor in a sitting position c (with) blood on head, clothing, and floor dripping from foot board of bed to door opening. Also found a muffin on the floor between the footboard of the bed and the TV (television) entertainment center. Resident stated "I bent over to the floor." Mental status unchanged from prior to incident. W/C between TV entertainment center and doorway. No alarms sounding. C/o pain in (L) shoulder. Assessment done to see where the blood was coming from. Pressure applied to head, area cleaned and wrapped. Ambulance arrived within 15 minutes to transport resident to (name of hospital) ER for evaluation and treatment." Interview with RN #1 on 02/23/11 at 08:15 a.m. confirmed that she had written the statement and that no alarms were sounding when she got to the residents room. Review of documentation written by Licensed Practical Nurse (LPN) #2 and provided by the facility revealed: "CNA (Certified Nursing Assistant) {note LPN #2 could not remember the CNA that alerted her to the fall} came & (and) got writer out of Rm (Room) saying come to Rm 61, (name of Resident #4) is on the floor, Got to room res (resident) sitting facing doorway on buttock with lg (large) amt (amount) of blood over L) side of head,noted lg puddle of blood at foot of bed between footboard & sink, a muffin was on floor between entertainment center & foot of bed. W/c was on the L) side of door between door and entertainment center no alarm was sounding when writer entered room. A Trail of blood was noted from near doorway always (all the way) to foot of bed. Blood smear on footboard of bed & sheet. Resident head was cleansed up lg hematoma to L) side bandage applied Left in position on floor, res c/o L) shoulder pain, shoulder not moved, et (and) ambulance was made aware of L) shoulder pain. If no mistake resident was seen scooting to doorway by 58B Family member. Res AAO (awake, alert and oriented) to self & surrounding and voiced she scooted to door." Interview with Resident #4 on 02/23/11 at 08:40 a.m. with RN #1 in attendance revealed that she remembered falling and stated: "I was laying on sofa and wanted to do something and came here to get something out of table and came back and my chair (wheel) turned over and I fell . Lay there a good while and finally I slid from down here all way up to here and I couldn't get up so I slid and couldn't reach a place to open door. I kicked and kicked and nobody came. Finally got to door and when they got here I was laying in a bunch of blood. They got busy then." Interview with Resident #4 with the DON in attendance revealed: "I wanted something, rolled back there, was trying to reach it and turned chair over. Nobody came and I slid to door and it was closed and I just had to make some noise. This was for about 10 or 20 minutes or more. I kicked as hard as I could (on the door). They pushed door open and saw me." Attempts to contact other staff who were on duty at the time of the incident were unsuccessful. Observation of Resident #4 on 02/23/11 at 09:45 a.m. revealed that she was seated in the wheelchair with a blue splint on the left arm and an alarm and a waist belt was noted on the chair. Review of the "Transfer" policy (with no implementation date) revealed: "(2) Based on the assessment, the care plan, minimum data set and CNA care plan should reflect the amount of assistance required transferring the resident." "Assistive Devices Used to Assist With Transfers" revealed "(3) Lof and weight stand and weight device - used for resident who are too heavy to lift or those who are sensitive to manual lifting." "The guidelines presented above are used to protect the resident and yourself from injuries. Check each resident's care plan for any restrictions, and ensure the resident's safety and well being whenever you lift, move or position anyone."