Every finding on record at Brentwood Place Three

Based on interviews and record review, the facility failed to ensure in accordance with applicable state and federal requirements: fire, alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the state Agency) and the administrator of the facility for 1 of 1 residents (Resident #1) reviewed for reporting abuse, in that: The Administrator (Abuse preventionist) and the DON failed to follow the facility's abuse policy by not reporting Resident #1's phone catching on fire while he was in his bed on 05/28/26 to HHS. This failure could place residents at risk for abuse and neglect.Findings included: Record review of Resident #1's face sheet, dated 06/03/26, reflected an [AGE] year-old male admitted to the facility on [DATE] with an initial admission date of 04/24/26 with a diagnoses of cognitive communication deficit (difficulty communicating), Schizophrenia (a chronic brain disorder that impairs how a person interprets reality), Hypertension (high blood pressure), Atherosclerosis of Renal Artery (the narrowing of the arteries supplying blood to the kidneys due to plaque buildup). Record review of Resident #1's Comprehensive Minimum Data Set (MDS) assessment, dated 05/07/26, reflected: Section C Brief Interview for Mental Status (BIMS) score reflected a score of 13 which indicated the resident's cognition was intact. Record Review of progress notes dated 05/28/26, wrote by DON reflected, Resident # 1 stated he was hitting his phone on the table, and the phone blew up with fire. He had a partial burn on his diaper, his bed sheet, and a dip hole (a burn in the mattress) in his mattress. No skin issues were noted. He denied pain.Record Review of the in-service titled Resident's cellphone dated 05/28/26, reflected LVN A and LVN B signed the in-service. Record Review of the in-service titled use of fire extinguisher dated 05/28/26, reflected LVN A and LVN B signed the in-service. In an interview on 06/03/26 at 10:41 AM, Resident #1 stated that his phone caught on fire and burned up. Resident #1 stated the fire department came and took his phone, and he had not seen it since then. Resident #1 stated he wasn't sure what caused the phone to blow up. He stated he needed his phone back to play his games so that he won't be depressed. Resident #1 stated he did not get burned by the phone when it caught fire. In an interview on 06/03/26 at 1:01 PM, LVN A stated she was standing across the hall from Resident #1's room and she heard someone yelling for help. LVN A stated she then called out Who is hollering for help?, and Resident #1 responded I am. LVN A stated when she walked in Resident #1's room she smelled smoke but didn't see any fire. LVN A stated Resident #1 then told her, It's a fire and she asked him where the fire was. LVN A stated Resident #1 raised up his sheet, and his phone was as red as fire and when the air hit phone the fire blazed up, and she told Resident #1 to put the cover back down on the phone so it would lessen the fire. LVN A stated she immediately went and started yelling for help to get some assistance to get Resident #1 out of bed. LVN A stated when she walked back into the Resident #1's room, he had the sheet lifted up causing the fire to [NAME] up again and she told him not to do that because it would spread the fire. LVN A stated that she got some help and then got the resident out of bed and evacuated the room. LVN A stated it was enough smoke to make the roommate walk out of the room. LVN A stated she couldn't get the window open fast enough to ventilate the room, so they had taken Resident #1 to a different room until the smoke cleared. LVN A stated the fire department was not alerted and they were able to smother the fire themselves. LVN A stated Resident #1 had no injuries, and LVN B assessed him. LVN A stated she reported the incident to the ADON, DON, and the Administrator. LVN A stated the risk of not reporting was the resident's safety. In an interview on 06/03/26 at 1:31 PM, LVN B stated Resident #1 had no injuries when he assessed him. LVN B stated he had just finished warming up his food, and he was walking back around to his hallway when he smelled smoke. LVN B stated he smelled the smoke before he reached Resident #1's room. LVN B stated by the time he arrived at Resident #1's room, there was a fan in his room to disseminate the smoke, and the exit door was opened at the back of hallway 300. LVN B stated he was concerned for the resident and asked Resident #1 what happened. He stated Resident #1 responded, he got mad and he started hitting his phone and that's when it caught on fire. LVN B stated incidents such as this one, were reported straight the administrator. LVN B stated the risk of not reporting could cause family issues, injuries, and risk patient safety which was why they must report immediately and take action. In an interview on 06/03/26 at 2:49 PM, the ADON stated she arrived at Resident #1's room at the end of the phone burning. The ADON stated she heard LVN A yelling for assistance, and she was the one to go and help her. The ADON stated the incident happened on 05/28/26 around 1:00 PM. The ADON stated when she made it to the resident's room, she did not see the fire, she only smelled smoke. The ADON stated she gathered the bed sheets with the phone inside of the sheets and took it outside the back door. The ADON stated that she could not remember if the fire alarm was triggered or not, but the fire department did not come out. The ADON stated Resident #1 had no injuries, but he had a burn mark on his brief, but no burns were on the skin. The ADON stated Resident #1 made no reports of pain. The ADON stated staff were expected to immediately get residents out of harm's way and yell for help, then contain the fire after making sure the residents were safe. The ADON stated staff were then expected to report to the abuse coordinator which was the administrator, the DON, the doctor, and the family. The ADON stated the risk of not reporting to HHS was that the state wouldn't be informed of the incident. The ADON stated staff received an in-service on 05/28/26 regarding the correct way to use a fire extinguisher. In an interview on 06/03/26 at 3:43 PM, the DON stated she was in the facility during the incident and she smelled smoke. The DON stated by the time she went to Resident #1's room, he had been moved to a different room. The DON stated she assessed him and she had LVN B assess him because she wanted another set of eyes on him. The DON stated she assessed his room to be sure there were no electrical issues in his room because at the time she thought it was the charger that caused the fire. The DON stated she notified the doctor and psych services. The DON stated she had the maintenance director educate staff on how to use the fire extinguishers. The DON stated that after she in-serviced staff she went back to Resident #1 to ask him what happened and Resident #1 said he was hitting the phone and the phone sparked and he put it back under the sheet, but he did not realize the phone was on fire. The DON stated Resident #1's story changed and at first, he said he was hitting the phone then the story changed to he was playing games on his phone and then he slammed the phone. The DON stated she educated Resident #1 about the phone catching on fire and the overuse of using the phone. The DON stated staff immediately took Resident #1 out of his room and then grabbed his sheets and the phone and took it outside. The DON stated the fire alarm did not go off. The DON stated if the fire alarm started then the fire department would have responded immediately. The DON stated staff were expected to report to the DON and the administrator. The DON stated that she could not really say what the risk was due to her looking up the regulation and it said to only report major fire hazards. In an interview on 06/03/26 at 3:56 PM, the Administrator stated he was in a meeting and he was not at the facility when he received a call that Resident #1's phone melted the bed and the phone overheated and staff smelled smoke. The Administrator said he thought the phone might have heated up from the outlets. The Administrator stated that he told the DON to check the wall outlets to be sure there were no electrical problems, and he was informed that the phone was never plugged into the wall. The Administrator stated he was told Resident #1 was safe and he had no injuries and that he had only had a burn on his brief. The Administrator stated that Resident #1 will not be replaced due to Resident #1 destroying the phone himself. The Administrator stated the fire alarm was not triggered since the sparks were only there for a quick second and then put out right away. The Administrator stated when a lithium battery is damaged, it releases heat, then gases, then a flame. The Administrator stated staff were expected to make sure residents were safe, eliminate the threat, and report to the Administrator. The Administrator stated that he did not report the incident to the state due to the fire coming from a resident's personal property and not the facility; he thought that was something he did not need to report. The Administrator stated the steps were followed to eliminate the threat, so it does not really determine a risk. Record Review of the facility's policy titled, Abuse Prevention and Prohibition Program revised 01/2025, reflected, in part,IX. Reporting/Response.Administrator, or his/her designee, as Abuse CoordinatorIn order to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities.Facility Staff will report known or suspected instances of abuse to the Administrator, or his/her designee. Record Review of the Long-Term Care Regulation Provider Letter dated 08/29/24, reflected, in part,A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements:Abuse, Neglect, Fire, Emergency Situations that pose a threat to resident health and safety. Requested a policy for fires, but the policy was never received.

Based on observation, interview, and record review, the facility failed to provide the Resident Council group a private space for monthly resident council meetings for the facility's only resident council, for 18 of 18 confidential residents reviewed for resident rights. The facility failed to ensure resident council meetings were held in a private meeting space during their monthly scheduled March Resident Council meeting, when staff continued to enter the dining room while the resident council meeting was being held. This failure could place residents at risk of not being able to fully exercise their rights in the facility, which could lead to a lack of trust for staff working in their living environment, and emotional distress.Findings included: An observation of the Resident Council meeting, on 03/17/26 from 2:00 PM to 3:05 PM, revealed a group of eighteen residents were gathered to meet in the facility's dining room. During the meeting, several residents left (exact times unknown), leaving fourteen active participants in the meeting. The room was a large, open space, with tables for seating four people throughout. There were double doors located on each side of the room, which were closed during the time of the meeting. Both sets of double doors had signs printed in a large, red font posted on the outside to inform staff to stay out of the room, due to the resident meeting being held. Residents were seated at tables between the two sets of double doors. The kitchen entrances and a glass door to an outdoor patio area were located along the back wall, opposite the resident meeting. An observation of the Resident Council meeting, on 03/17/26 from 2:00 PM to 3:05 PM., interruptions by staff who were entering the room, sometimes speaking with other staff, sometimes performing noisy tasks, were ongoing throughout the meeting's duration. Observations of interruptions were as follows:- 2:00 PM: to 2:20 PM: Dietary staff intermittently exited the kitchen area into the dining room and noisily handled meal carts and trays from the lunch meal, returning them to the dishwashing portion of the kitchen.- 2:03 PM: A staff member or vendor entered through the double doors and exited through the glass door.-2:19 PM: A staff member started to enter through double doors with a meal cart, which made a loud rumbling sound as it was pushed across the floor. Multiple residents yelled at the staff member to turn around and go back out, and he did.- 2:22 PM: A dietary staff member exited the kitchen and was working by the meal carts near the kitchen doors. The surveyor informed the worker that they were not supposed to be in the room during the resident meeting, and the worker re-entered the kitchen.- 2:23 PM: A dietary staff member walked through the dining room, past the surveyor and residents having a meeting, and when the surveyor told her she was not supposed to be in the dining room at this time, she asked if she could clock out and go home. She exited the dining room through a set of double-doors, and soon after re-entered the dining room, crossed past the meeting participants, and exited through the glass door in the back of the dining room.- 2:28 PM: A dietary staff member exited the kitchen, walked between tables where the residents were seated for the meeting, saying sorry, sorry, and entered a door on the front wall of the dining room, closing the door behind her.- 2:40 PM: The Activity Director entered through a set of double doors, and walked past the meeting participants, apologizing for the interruption, and exited through the glass door in the back of the dining room.- 2:43 PM: two dietary staff members exited the kitchen and started working with the trays and meal carts again.- 2:44 PM: A resident crossed the room to talk to the dietary staff members and told staff they were not supposed to be there during Resident Council meetings Staff told the resident they were told to come out and do their work.2:45 PM:- A nursing staff member entered through a set of double doors, with a pitcher, and walked to the ice machine near one of the kitchen doors. The staff member was trying to scoop ice and was noisily banging on the ice in the machine to break it up, and was talking and laughing with the dietary staff who were working on the carts. 2:46 PM:. The Activity Director entered through the glass doors, walked past the meeting to the double doors, and exited the dining room.-2:59 PM: Staff member entered through double doors and exited through the glass door. Interviews with anonymous residents attending the confidential meeting on 03/17/26 between 2:00 PM and 3:05 PM, anonymous residents attending the meeting commented that there usually were a lot of interruptions in the meeting, and it was not very private. One anonymous resident said during the meeting they saw staff looking in through the small, square windows of the double doors, and not coming in because they saw the surveyor, but on days when the surveyor was not in the meeting, staff just entered when they pleased, and it was even worse. Throughout the meeting multiple residents also commented that the staff had morning meetings, and they were not allowed to interrupt them for any reason because the meetings were private, and they felt they should get the same kind of courtesy. An interview on 03/19/26 at 9:27 AM with the Activity Director revealed she understood the Resident Council meetings were important because were the residents' time to get together and talk about the good, the bad, and the indifferent in the facility, which she said was their home. She said they held the meetings in the dining room for privacy, because it had doors they could close, and she personally tried to find ways to keep the staff out of the room during the meeting. She said sometimes there were not very many people going in and out of the room during the meeting. She said she passed through because she had just gone to the store to get ready for the party they were having, and she thought the meeting was almost over. She said she would work wholeheartedly to make sure the staff knew how important the resident's right to privacy for their meeting was, and she would reconsider the time and location of the meetings. She said that particular meeting time was chosen by the Resident Council President, but she thought they might be able to agree upon a better time and place for the meeting, but they could not stop certain people from doing certain things. An interview on 03/19/26 at 10:00 AM with the Administrator and DON revealed the Administrator was aware of the issue with the Resident Council meeting being interrupted by staff. He said they planned to have the meeting in the conference room, going forward, so they would have more privacy. He said the staff should only be in the meeting when the Resident Council President invites them, because it was the regulation. When asked by the surveyor if he could say why it was in the regulations, he responded that he just followed the (regulations written in) black and white. An interview on 03/19/26 at 11:12 AM with the Dietary Manager revealed she had been informed about the Resident Council meetings being held in the dining room, and that staff needed to stay out during that time. She said she had talked to her staff about it and told them if they needed to break down the meal carts, to do it in the dishwashing area, and if they had to go into the dining room to retrieve a cart, to be very quiet. She said she was aware the residents had a right to privacy in their meeting, so they could talk about anything they were concerned about with each other. She said she was going to talk with her staff so they could plan ahead and be ready to do a better job of accommodating the next meeting. She said she would also talk to the management team about better times to hold the meeting, because at the time the meeting was held on 03/17/26, some of the dietary staff were getting off work, and they were trying to clean everything up after lunch. Review of the Resident Council policy, revised 06/2020, reflected: Purpose; To promote the exercise of a resident's right to organize and participate in resident groups at the Facility. Policy : [.] II. The Facility must provide a resident council with a private space to meet. Review of the Privacy and Dignity policy, revised 06/2020, reflected: Purpose: To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity and overall quality of life. Policy: The Facility promotes resident care in a manner and an environment that maintains or enhancesdignity and respect, in full recognition of each resident's individuality. Procedure: I. Staff assists the resident in maintaining self-esteem and self-worth. [.] IX. The following rights to privacy are a part of the admission agreement and the resident is informed of these rights during the admission process A. Residents are afforded a right to privacy and confidentiality. Review of the Resident Rights policy, revised 08/2020, reflected: Purpose: To promote and protect the rights of all residents at the Facility. Policy: All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source. The Facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the Facility. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. Procedure: I. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to: [.] E. Privacy and confidentiality including the right to privacy in his/her specific oral, written, and electronic communications; F. Voice grievances [.] II. The Facility makes every effort to assist each resident in exercising his/her rights by providing the following services: [.]B. Residents are encouraged to participate in activities of their choice [.] D. Residents are encouraged to participate in resident and family group meetings. E. The Facility does not hamper [.] a resident for exercising his or her rights.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food safety.1. The facility failed to ensure the stand-by freezer food items were dated and labeled.2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and sealed.3. The facility failed to ensure that serving utensils were used when handling food items.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included:During an observation on 03/17/2026 at 8:48 a.m. of the facility's only kitchen revealed:In the stand-by freezer:a package of food with the name covered, dated 4/11/26In the stand-by refrigerator:a used bag of shredded cheese, with no label or datea used bag of hard-boiled eggs, dated 03/16/26 with no use by date During an interview on 03/17/2026 at 8:59 a.m., the Dietary Manager revealed the frozen freezer item was minestrone soup and the date was supposed to read 03/11/26. She said staff were expected to put the date received on food items when they came off the delivery truck. The Dietary Manager said if a food item was opened, staff were expected to add the opened on and use by date, and food items were to be used within 3 days after opening. She indicated the importance of sealing food items after opening was to keep the food items fresh and prevent molding and contamination.During an observation on 03/18/2026 at 12:20 p.m., [NAME] E was observed using the same pair of gloves to handle slices of bread, slices of cheese, and cooked chicken patties to make three sandwiches, and then proceeded to serve food on the steam tray table using serving utensils. At this time, the Corporate RD intervened and said the sandwiches could not be served, and she had the cook clean her hands and change gloves. The Corporate RD informed [NAME] E that it was cross contamination.On 03/19/2026 at 1:30 p.m., the state surveyor attempted to interview [NAME] E, but she was unable to at that time.On 03/19/2026 at 2:10 p.m., the state surveyor attempted to call and interview [NAME] E. She did not answer and a voicemail could not be recorded.During an interview on 03/19/2026 at 2:38 p.m., the Corporate RD said she intervened and stopped the sandwiches from being served because of cross contamination. The Corporate RD said [NAME] E was touching everything (food items with the same gloves) and it could be a risk to residents with allergies. She said staff were expected to date and label food items when delivered and after opening, and food items were to be sealed to prevent them from turning bad. The facility's Kitchen Sanitation - Operation and Cleaning policy, dated 1/1/25, reflected: Purpose: To maintain the highest standard of cleanliness and sanitation in the facility's kitchen and food service areas, ensuring the safety and well-being of our residents by preventing foodborne illness and complying with all state, local, and federal regulations.Policy: This policy applies to all staff in the dietary department, including dietary managers, cooks, dietary aides, registered dietitians, and any other staff or contractors working in or around the kitchen area.Procedure:I. Staff HygieneAll kitchen staff must: .D. Practice proper glove usage during meal preparation and serving when use of hands is required .IV. Food StorageA. All items must be:i. Clearly labeled and dated upon delivery, when opened, and with an expiration or discard date.ii. Stored off the floor and away from walls.iii. Covered and wrapped securely to prevent contamination.

Based on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartment for 1 of 4 carts reviewed for medication and biological storage.The facility failed to ensure a bottle of wound cleaner was not sitting on the side of an unoccupied cart in hall 100.This failure could place residents at risk of adverse reaction and injury. Findings included:During an observation on 3/17/2026 at 8:45 a.m., an unoccupied treatment cart in hall 100 was locked with a bottle of wound cleanser exposed on the side of the treatment cart. The wound cleanser bottle was half empty. There was residents present in hall 100 at the time of observation. During an interview on 3/17/2026 at 8:50 a.m., LVN A stated he was not sure who was using the treatment cart because the cart was shared amongst the nurses. He stated all drugs and biologicals should be stored inside a locked cart to prevent injuries or adverse reactions to residents if they got ahold of biologicals. During an interview on 3/17/2026 at 9:00 a.m., the treatment nurse stated the treatment cart was an extra treatment cart that was shared amongst the nurses to provide wound care when she was not available. She stated all biologicals should be stored in locked compartments. She stated a resident could get ahold of the bottle and could have ingested the fluid inside the bottle, which could cause injury to the resident. During an interview on 3/18/2026 at 12:17 p.m., the DON stated all carts should stay locked and there should be no drugs or biologicals out in the open. She stated she could not state a specific risk. She stated the risk depended on which resident got ahold of the biological and what type of biological it was. She stated both LVN A and the treatment nurse informed her of the incident and an in-service was conducted with all nurses on cart safety.Record review on 3/18/2026 at 1:57 p.m. revealed an in-service on cart safety was conducted on 3/17/2026 by the DON. Record review of facility's Medication storage policy, dated 1/2026, revealed the policy stated, carts must remain locked and always secured. These standards are required to ensure resident safety and regulatory compliance. The policy also stated that access is restricted to authorized, licensed staff.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision 1 of 1 (Resident #2) residents reviewed for microwave use.The facility failed to ensure Resident #2 was not alone in the staff conference room using the microwave to warm up his coffee. This failure could place residents at risk of burning themselves when trying to consume microwaved food and beverages.Findings included:Record review of Resident #2's face sheet, dated 03/18/2026, revealed a [AGE] year-old man admitted to the facility on [DATE] with a primary diagnosis of an infection following a (surgical) procedure.Record review of Resident #2's MDS, dated [DATE] revealed he had a BIMS of 15.Record review of Resident #2's care plan, dated 03/11/2026, revealed he was a risk for falls related to gait/balance problems (walking and balance problems) and had ADL self-care performance deficit related to post right knee arthroplasty (surgery to replace or repair knee). Interventions included physical and occupational therapy and 1-person staff assistance.During an observation on 03/18/2026 at 6:13 a.m., Resident #2 was in the staff conference room, sitting on his walker while using the microwave to warm up his coffee. Resident #2 said he was just warming up his coffee. He indicated staff had previously offered to warm his coffee in the past but not that morning and he did not want to bother them. Resident #2 proceeded to leave the room with steaming coffee in his right hand and pushed his walker with his left hand.Record review of Resident #2's hot liquid safety evaluation, dated 3/6/2026, reflected he had impaired functional mobility, but did not have any other risk factors regarding hot liquids safety risk.During an observation and interview on 03/18/2026 at 7:00 a.m., the ADM revealed residents were not allowed to use the microwave and would remove it from the staff conference room a to an office where it could be secured. He proceeded to remove the microwave from the staff conference room.During an interview on 03/19/2026 9:27 a.m., LVN B revealed residents were not allowed to warm up their own coffee in the microwave because it was a high risk for an accident to occur or burn from liquids being too hot. She indicated Resident #2 would be a high risk for a fall and burn because he used a walker. LVN B indicated residents who had or tried to utilize the microwave were educated on having staff warm their coffee and residents were monitored so they did not use the microwave. During an interview on 03/19/2026 at 1:44 p.m. CNA F revealed residents were not allowed to use the microwaves because they could burn themselves. She indicated if residents wanted coffee warmed up, she would talk with their nurse and warm the coffee for them to meet their needs. During an interview on 03/19/2026 at 2:15 p.m., the ADON revealed when Resident #2 left the staff conference room on 03/18/2026 (after heating up his coffee), she told Resident #2 he could not use it (microwave) and it was care planned. The ADON said he could have spilled the coffee on himself, even if he just went to drink it, he could have burned himself. She said he could have tilted (the walker) and fell. She said she educated Resident #2, and the ADM was working to put a code on the staff conference room door and until then the microwave was removed from the staff conference room. The facility's [Corporate Name] Skilled Management Hot Beverage Protocol, undated, reflected: Do not place [sic] cof f ee or beverage machines with hot surfaces in areas that residents have direct access to (dining room, lobby, activity room, therapy gyms, etc.). The dietary team members must obtain and record the temperature of any hot beverage (e.g., coffee, hot tea, hot cocoa, hot water, etc. ) that leaves the kitchen area, regardless of the amount of hot beverage being provided to a resident or staff member. Hot beverages must not exceed 140 F degrees when delivered to the dining area, to a [sic] sta member, or to a resident. The temperate setting of [sic] co ee machines and brewers located in the kitchen should not exceed 165 F degrees. Hot beverages should not be served directly from the [sic] co ee machine, brewing pot or hot water source. Hot beverages should be provided in carafes, air pot, or other insulated containers. Temperatures should be obtained and recorded for hot beverages prior to meal services.Temperatures should not exceed 140 F degrees. Hot beverage logs should be completed for every meal. Hot water must not be dispensed and given to a resident at any time. If the resident requests hot water, the kitchen will ask the reason. If the resident wants hot tea or hot cocoa, the kitchen will prepare the drink, check the temperature, and then deliver it to [sic] he resident or requestor. All hot beverages will be served in a coffee mug. [sic] Sta must assist residents with the removal of the lid when adding cream and sugar to prevent spillage when the lid is removed, and ensure the lid is placed back on cup tightly. Residents with identified risk factors on the Hot Liquids Assessment should be supervised when consuming hot beverages.

Based on observation, interview, and record review, the facility failed to ensure each resident's right to personal privacy and confidentiality of personal records for 1 of 7 residents (Resident #1) reviewed for resident rights.The facility failed to protect Resident #1's confidential record by placing the resident's pharmacy receipt on top of a treatment cart which was sitting in hall 100 unattended. This failure could place residents at risk of their confidential information exposed to unauthorized personnel.Findings included:During an observation on 3/17/2026 at 8:45 a.m. revealed an unoccupied treatment cart in hall 100. On top of the treatment cart was Resident #1's pharmacy receipt for morphine. The receipt included Resident#1's name, date of birth , medication name (morphine), and the dosage of medication. During an interview on 3/17/2026 at 8:50 a.m., LVN A stated Resident #1 was discharged yesterday. He stated there should not be resident information in open areas because of HIPAA violation. He stated the residents had the right for their information to be kept confidential.During an interview on 3/17/2026 at 9:00 a.m., the treatment nurse stated resident information should not be placed on top of the cart that was visible to everyone because it violated HIPAA. She stated she was not sure who placed the medication receipt on top of the treatment cart. During an interview on 3/18/2026 at 12:17 p.m., the DON stated she was not sure how resident's information was left in open area. She stated the resident was discharged . She stated her expectation of her staff was to keep all residents' information private and secured. She stated residents had a right to keep their information private. She stated an in-service was done on 3/17/2026 regarding confidentiality of resident information.Record review of facility's in-service record, dated 3/17/2026, revealed the DON provided an in-service on HIPAA. In-service topics included Resident information kept in a secured location; discharged resident medication remove from the cart.Record review of facility's Electronic Protected Health Information Security, Medical record manual - HIPAA policy, dated 2/2025, revealed the policy stated resident medical records will be maintained in a system in a manner that protects the [resident] information from unauthorized use, access, modification or destruction.

Based on observation, interview, and record review, the facility failed to respect and value resident's dignified existence for 1 of 6 halls (hall 300) reviewed for resident rights.The CNA failed to knock on residents' doors and introduce themself before entering the room for 4 of 10 rooms on 300 hall.This failure could please residents at risk for a negative psychosocial outcome and impact overall quality of life for residents.Findings included:During an observation on 03/18/2026 at 5:41 a.m. revealed CNA C and CNA D were doing rounds prior to shift change. CNA C was seen walking into 4 of 10 resident rooms on hall 300, without knocking or introducing herself.During an interview on 03/18/2026 at 5:44 a.m., CNA C revealed she was supposed to knock on residents' doors, say her name, and what she was there for before entering the residents' rooms. She said she had just provided ice to residents and was doing rounds one more time before leaving. CNA C indicated it was important to knock and greet residents before entering because residents need to be aware when staff were entering their room, and staff could not just barge in.During an interview on 03/18/2026 at 5:52 a.m., CNA D revealed CNAs do rounds before shift change to make sure residents were okay. She said before entering a resident's room, staff were to knock on the door, wait for residents to respond, announce self, and see what residents needed. She said it was important to knock and announce herself to give privacy because this was the resident's home, and that had to be respected. CNA D said it was the residents' right to have privacy.During an interview on 03/19/2026 9:27 a.m., LVN B revealed staff were to knock, give residents time to respond, introduce themselves, and let residents know why they were at their room before walking in. She said it was important for their privacy, and it was their right.During an interview on 03/19/2026 at 1:18 p.m. with Resident #3, she said sometimes CNAs do not knock on her door before entering. She indicated it bothered her.During an interview on 03/19/2026 at 1:40 p.m. with Resident #4, she said sometimes staff do not knock before entering (her room), but not often. She said if her door was closed and staff just walked in, it bothered her and she indicated she wanted a little respect.During an interview on 03/19/2026 1:44 p.m., CNA F revealed staff were to knock on the resident's door and let the resident know who the staff member was before entering the room. She said this was their home and (staff) could not just walk into their room, it was a respect thing and their right. During an interview on 03/19/2026 at 2:15 p.m., the ADON revealed she expected CNAs to knock on the resident doors, introduce themselves, and let residents know why they were at their room before entering. She said it was their (the residents') home and we were invited in. The facility's Privacy and Dignity policy, dated 06/2020, reflected: PurposeTo ensure that care and services provided by the Facility promote and/or enhance privacy, dignity and overall quality of life.PolicyThe Facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality.Procedure.VI. The Facility respects the resident's private space and property.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for elopement. The facility failed to ensure Resident #1 was adequately supervised when Resident #1 left the faciity on [DATE] and climbed through the fence and walked blocks away from the facility. Resident #1 contacted 911 and was transported to a nearby hospital. Resident #1 was located at a nearby hospital after the previous SW had called around to the closest hospital trying to find Resident #1. Staff did not know what time he left but were aware of his exit-seeking behavior and previous elopement attempt from the facility.An IJ was identified on 02/05/2026. The IJ template was provided to the ADM on 02/05/2026 at 11:29 A.M. While Resident #1 no longer resided at the facility, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that was not immediate. The IJ was removed on 02/06/2026.This failure placed residents at serious risk of getting lost and sustaining injuries.Findings included:Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke) and osteoarthritis (protective cushion at ends of bones wear down, leading to stiffness and pain). Further record review of Resident #1's medical diagnoses revealed on 11/27/2025, the RNC had struck out the primary diagnosis dementia. The diagnosis did not appear on the face sheet. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 13, indicating intact cognitive function and ability to recall information immediately. Active diagnoses included Progressive Neurological Conditions, i.e. stroke (interruption of blood flow to brain) and non-Alzheimer's dementia (can be caused by a stroke and result in cognitive decline, behavioral change, etc.). The MDS assessment revealed Resident #1 did not exhibit wandering behaviors.Record review of Resident #1's BIMS assessments reflected: 10/13/2025 - Moderately impaired 1010/13/2025 - Cognitively intact 1310/24/2025 - Cognitively intact 1512/2/2025 - Cognitively intact 13 Record review of Resident #1's Elopement Risk Evaluations reflected:Date: 10/13/2025; Lock (Completed) Date: 10/13/2025 Resident #1 was a Moderate Risk, and able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs; Patient is cognitive impaired AND 1) ambulates or propels self. Patient may go outdoors on occasion but makes no attempt to leave grounds. Date: 11/02/2025; Lock (Completed) Date: 11/13/2025 Resident #1 was No Risk; and not able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and unable to ambulate or mobilize wheelchairs. Additional information [Resident #1] is at risk for elopement related to Elopement Evaluation risk score.Date: 11/27/2025; Lock (Completed) Date: 02/04/2026 Resident #1 was No Risk; Resident #1 was able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs.Evaluations on 11/02/2025 and 11/27/2025 were not completed, staff only completed the questions in the No Risk section. Questions to evaluate Resident #1 as a Moderate Risk or Imminent Risk were triggered and but not completed for the electronic system to trigger the resident as moderate or imminent risk. There were discrepancies between the resident's elopement risk evaluations regarding his ability to make decisions and ambulate. Record review of Resident #1's care plan, completed 11/07/2025, reflected:was at risk for elopement related to Elopement Evaluation risk score, initiated on 11/02/2025had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025Record review of Resident #1's most recent care plan, revised 11/27/2025, reflected:had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025was (high, moderate, low) risk for falls r/t Gait/balance problems, initiated 10/13/2025was a Potential Safety Risk When Leaving Facility Related to: Resident leaving facility without advance notice; history of similar behaviors in prior facilities. As evidence by: Independent exit, later self-admission to local hospital, initiated on 11/27/2025had psychiatric diagnosis (Schizophrenia/Depression/Anxiety) Related to: Chronic psychotic illness. As evidenced by: History of mental health conditions and preference to direct own care. Self-check in to local hospital, initiated on 11/27/2025 Exercising Autonomy / Independent Decision-Making Related to: Preference for self-directed choice, history of leaving facilities independently. As evidenced by: resident verbally stating he does not want to remain in facility; BIMS 13 demonstrating ability to make decisions; resident independently checking himself into local hospital, initiated on 11/27/2025The care plan revised 11/27/2025 did not reflect Resident #1's elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. Record review of Resident #1's progress notes reflected:Effective Date 10/24/2025: Security personnels at the gate called nurse to come for him because he wants to go home, ambulates with walker. Nurse went to the gate and spoke to him to come and express his concerns to the social worker as he proposed earlier. He agreed and came back with nurse to the building. Nurse accompanied him back in wheelchair with no problems. On q 2 hourly monitoring. Seemed co-operative with staff, calm, no aggressiveness. [sic]Effective Date 11/02/2025: Spoke with the resident's [Family Member #7 and Family Member #9] regarding the resident's exit seeking behavior; the couple stated that they are not surprised because every facility/psychiatric hospital he goes to he either checks himself out or he attempts to leave. The [Family Member #7] stated that his most recent stay was at a psychiatric hospital, he checked himself out, told the Police he wanted to go to [location], they put him on a bus, but he never made it there because he got off in [location] and here we are. The [Family Member #7] stated that he is unable to come and get him or find alternative placement because he doesn't know what is driving [Resident #1] to leave but he stated that he understand the liability the facility is faced with if he attempts to leave. [sic]Effective Date 11/02/2025: Resident sent to [psychiatric hospital]. Resident had two episodes of elopement from the facility. Resident showed signs of aggression and combativeness when asked why he wants to leave facility. Resident said, I want to leave this place, You people are holding me hostage, I want to leave. Resident was unable to articulate where he intends to go. The police were called to help control resident's behavior and outburst. Resident was finally sent to [psychiatric hospital]. The Doctor, Administrator, the don, and the Family Members where notified of the situation. [sic]Effective Date 11/14/2025, Created on 11/27/2025: Resident is a [AGE] year-old male with psychiatric history including schizophrenia, depression, anxiety, cognitive impairment, with a well-documented history of leaving prior facilities without notifying staff. Family members previously confirmed that the resident frequently leaves care settings independently and without authorization, noting this behavior has occurred at multiple facilities and psychiatric hospitals. Staff provided re-education on the facility's Leave of Absence (LOA) process, including expectation for notifying staff, safety procedures, required documentation, and the importance of arranging a responsible party for transport. Resident listened, verbalized understanding of the LOA procedure, and was informed that he may request an LOA appropriately if he chooses to leave temporarily. Resident declined to initiate an LOA at this time and continued to express general dissatisfaction with remaining in the facility but did not articulate a specific plan or destination. Staff attempted redirection, emotional support, and offered to contact family or the medical provider to discuss concerns. Resident declined all offers, stating only that he did not want [sic] tot stay. Resident remained cooperative and did not exhibit physical aggression, behavior escalation, or unsafe elopement attempts. Resident's [Family Member #7 and Family Member #9] were notified of the resident's statements. They reiterated consistent past behaviors of the resident leaving facilities on his own, confirming that this pattern is typical for him. They verbalized understanding of the current situation and did not request additional intervention at this time. The physician/NP were notified. Resident remained under routine supervision with continued monitoring per care plan. [sic]Effective date 11/27/2025, Created on 12/02/2025: [Resident #1] is [AGE] year-old, with admitting diagnosis of Cerebral infarction, history of psychiatric diagnosis of schizophrenia and depression. Before admitting to facility resident has a history of deciding to leave facilities and hospitals due to own personal reasons. Resident is aware of his needs and able to make decisions regarding his care and safety. Resident decided to leave the facility 11/26 facility received information that resident independently checked himself into a local hospital. No injuries were reported. This action is consistent with the resident's baseline pattern of independently leaving prior facilities and making his own arrangements for care or evaluation. Resident's ability to navigate the community, arrive at a hospital, and seek medical attention on his own reflects preserved decision-making capacity and supports his cognitive ability to make autonomous choices regarding his whereabouts and medical. [sic]Effective date 11/29/2025: Resident continue to be on one on one monitoring, resting quietly.Effective date 12/1/2025: Resident continue on one-on-one monitoring as ordered.Records did not show documentation of orders or discussion to change Resident #1's dementia diagnosis and details of elopements.Record review on 02/05/2026 of Resident #1's transfer form to discharge to the hospital, dated 11/02/2025, revealed Resident #1 was alert, disoriented, but cannot follow simple instructions, ambulates with assistive device, and requires assistance for ADLs. Resident #1 was noted to may attempt exit as an additional risk. Record review on the facility's Resident Out On Pass Log dated 10/26-12/01/2025 revealed Resident #1 had been signed out on 10/27 and 11/20 by Family Member #7. Resident #1 never signed out.Record review on 02/05/2026 of Resident #1's psychiatry/therapy visits revealed Resident #1 was seen on 11/07/2025, 11/12/2025, and 11/18/2025. Resident #1 was referred for Depression, Tearfulness, Confusion, Elopement, Adjustment Disorder, High Risk Behavior. Resident #1's history of presenting illness included unreliable historian. does not remember attempting to elope, there was previous behavior for this and patient was placed on 1:1 for this. disoriented to situation. Resident #1 was noted to have been prescribed medications including Donepezil to treat for unspecified symptoms and signs involving cognitive function and awareness. Resident #1 was noted to endorse cognitive impairment symptoms of decreased concentration, forgetfulness, and difficulties with ADLs.During an interview on 02/04/2026 at 11:00 A.M. with CNA B revealed she recalled Resident #1 and he was at facility for a short time. She said she could not recall the exact situation but indicated the resident had left the facility at one point. During an interview on 02/04/2026 at 11:36 A.M. with the Activities Director revealed she remembered Resident #1 well. She said she remembered hearing that Resident #1 tried to leave the facility, but she did not see it. She further stated, If I don't see it, it didn't happen. During an interview on 02/04/2026 at 11:51 A.M. with Resident #2 revealed he was Resident #1's roommate at one point and said Resident #1 constantly wanted to escape. Resident #2 recalled one time when Resident #1 tried to dig out under the fence at the facility but was stopped by facility staff. Resident #2 said Resident #1 walked slow and used a walker, and it wasn't like he was going to get away.During an interview on 02/04/2026 at 2:05 P.M. with LVN D, she said she remembered Resident #1 but could not really recall him eloping. She said she had come back to work, and it was discussed, she said maybe the ADM or staffing coordinator called her, but she did not remember. She said she kept her eye on him 24/7 and he was very tricky because (staff) did not know what he was going to do the next minute, and it was a real issue with him. LVN D said he was on one-on-one observation at one time and that was the key (intervention). She said he was an elopement risk and indicated he showed signs including exit-seeking and verbalizing wanting to leave, and she had to redirect him. During an interview on 02/04/2026 at 2:30 P.M. with RN E, she said she remembered Resident #1, and she remembered she had to get him from the security gate one time, but he did not go out the gate that day. She said he once left and came back from the hospital but did not know if it was elopement because she did not know if someone picked him up. RN E discussed Resident #1 would watch staff movements and times (to find an opportunity to leave). She said nobody knew what time he left (on 11/26/2025), but knew he was not there. RN E said she came in for her shift the next day and he came back from the hospital. She recalled she had done one-on-one monitoring with Resident #1 before 11/26/2025 and indicated he was not safe to be out of the facility by himself. During an interview on 02/04/2026 at 5:16 P.M. with Family Member #7 and Family Member #9, they said Resident #1 had records of a dementia diagnosis, had shown signs of dementia, and could not make decisions for himself. Family Member #9 said Resident #1 had a medical bracelet on his wrist with his diagnoses of dementia and a stroke and Family Member #7 and Family Member #9's phone numbers. They said there were a couple times were Resident #1 left the facility between the bars on the gates and folded up his walker and put it through the gate; one time he had shown police where he did it. Family Member #9 said Resident #1 had called them before the facility did when he had left the facility. Family Member #9 was not sure how Resident #1 got out of the facility, and that another resident may have had a code; but they said by the third time that he took off it was like oh my gosh that's scary. We don't know that area and we would get a call from the hospital or police. They said 11/02/2025 was Resident #1's first time through the gate, and on 11/26/2025 they received a call from Resident #1, and he was possibly transmitted to the hospital by police. They said they received a call from the facility on 11/27/2025 about Resident #1's room change. They said they understood the facility's frustration regarding Resident #1 leaving the facility. Family Member #9 mentioned it had been hard to find a new facility closer to them due to Resident #1's elopement.During an interview on 02/05/2026 at 10:46 A.M. with the RNC revealed she struck out the dementia diagnosis for Resident #1 because he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments. She said she spoke to the MD, and he said it was okay to discontinue the dementia diagnosis. She said she had done a record review for Resident #1 because he had left the building but stated I don't know if I would say he eloped. She then stated she specifically reviewed Resident #1's records on 11/27/2025 because it was a random review. She then said she did record reviews for residents when an event happened, and residents went to the hospital. During an interview on 02/05/2026 at 11:35 A.M. with Resident #1's MD, he stated Resident #1's diagnosis of dementia was discontinued on 11/27/2025 after he was informed by the facility that Resident #1's BIMS score was 13. The MD indicated the facility contacted him and he approved the diagnosis to be discontinued based on the BIMS score. He said he was not aware of Resident #1's exit seeking behaviors or elopement, and there was no documentation regarding Resident #1's exit seeking behaviors in his or his NP's notes. The MD said he did see Resident #1 was on medication for dementia. He said he did not know if Resident #1 was safe to leave the facility or ambulate independently.Attempted phone call interview on 02/05/2026 at 4:29 P.M. with RN F regarding progress notes on 11/02/2025 when Resident #1 was sent to the psych hospital. RN F did not return the state surveyor's phone call.During an interview on 02/05/2026 at 7:23 P.M. with the previous SW, she said she worked at the facility when Resident #1 was there. She said Resident #1 was fuzzy (confused) about how he admitted to the facility and Family Member #7 said his memory was not the best. She said Resident #1 was an elopement risk and he had used a walker; she further said he had dug under the fence of the facility and talked about leaving very often. The previous SW said she recalled when Resident #1 eloped on 11/26/2025. She said she did not know who told the ADM Resident #1 was not in the facility, but it was facility staff because she had called around to the closest hospitals until she found Resident #1 and she contacted the family. During an interview on 02/06/2026 at 9:31 A.M. with the receptionist revealed she worked 11/26/2025 when Resident #1 eloped, and she had let him in and out of the facility multiple times that day and he did not sign out. She said she had never seen Resident #1 elope or attempt to. The receptionist stated there was an elopement binder with a list of residents who can and cannot go outside, and who she cannot open the door for. She indicated she kept an eye on residents who could go outside but had to call a nurse if the resident tried to leave. She said if residents were to leave the facility and go pass the gates, they must have a pass and their nurses were notified they went out on pass.During an interview on 02/05/2026 at 11:19 A.M. with the ADM revealed the facility had conducted a Resident behavior and attempting elopement in-services with 47 signatures and post-tests that were completed regarding Resident #1's elopement on 11/26/2025. He said he did the in-services because Resident #1 left the building, but he did not report it to the state because it was not an elopement due to Resident #1 having a high BIMS score. He stated RN F's notes were not accurate on 11/02/2025 and there were no elopements and Resident #1 was not an elopement risk because he had a high BIMS score, he could make decisions, and he did not have dementia. The ADM was notified on 02/05/2026 at 11:19 A.M. that an IJ was identified, the IJ template was provided at 11:29 A.M. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 02/06/2026 at 12:30 P.M. and reflected the following to Remove the Immediate Jeopardy: Initial Investigation Post Event:The resident's routine included visits to the front porch and gazebo area. On the day of the incident, staff documented that the resident went to the gazebo as usual and returned to the facility on three separate occasions. The receptionist provided door access assistance during these routine visits.Post-Incident Review:Following the incident, the facility conducted a comprehensive review of the exit pathway. The investigation revealed that the resident exited through the front entrance during his routine outdoor visits (approximately 4-5pm timeframe) and subsequently left the campus grounds by navigating the perimeter fencing [NAME]. Upon discovery that the resident had left campus grounds, staff initiated the facility's emergency response protocol. The resident called 911 and requested to be returned to [the facility] upon contact with authorities but was rather transferred to the emergency room.Identify residents who could be affectedAll residents have the potential to be affected. Identify responsible staff/ what action takenResident has been discharged to Assisted Living Facility. No longer in the facility.Other residents with elopement were assessed. One resident with a elopement assessment was identified. No changes in care plan identified.Nursing staff received re-education by the DON on the facility policy and procedure for exit seeking and elopement potential. Employees reeducated on elopement prevention, notification, and management of actual elopementsReeducation includes posttests for confirmation of training.Physician will be notified of elopement potential for timely management of clinical condition.Facility will seek alternate management for residents with active elopement seeking. Alternate placement may include but not be limited to secured unit, or other placement of choice by the resident / responsible party by the IDT (Social worker).Audit of all resident's elopement assessment completed, and care planned by licensed staff on February 5, 2026.Current Security Infrastructure: Delayed egress doors on primary exits Door alarm systems with central monitoring Secured perimeter gates with access control Residents leaving facility will be reviewed by the interdisciplinary team for safety and ability to leave the facility safely. The Gate keepers personnels has been reeducated by the Area Administrator on ensuring that residents leaving the gate have a pass from the facility, and to notify the facility of any concerns related to residents leaving the gate without clearance. Identification of residents deemed at Risk for Elopement with High BIMS Resident who has high BIMs and are at risk for elopement will be referred to the psychiatrist / provide for additional recommendation to validate elopement potential. Residents deemed to be at risk for elopement despite High BIMS by the provider or psychiatrist will reviewed by the IDT for alternate placement. IDT will review provider's recommendation for further care plan.BIMS was one component of our comprehensive elopement risk assessment, not the sole determinant. Our facility utilizes the PointClickCare comprehensive elopement risk assessment tool which evaluates multiple clinical factors.BIMS score is one data point within this comprehensive tool, not the sole or primary determinant. Our clinical decision-making integrates: 1. BIMS results (standardized cognitive screening per MDS 3.0 requirements) 2. Comprehensive elopement risk assessment tool results 3. Direct observation of functional cognitive abilities 4. Behavioral patterns documented during facility stay 5. Interdisciplinary team clinical judgmentFacility will continue to utilize elopement system, but take into account resident's underlying diagnosis with physician's input in resident's care. Dementia diagnosis was integrated into our comprehensive assessment and care planning.Walker use was assessed as part of functional mobility evaluation. How often will assessment take placeResident will be assessed upon admission, readmission, change in condition, new behavior of exit seeking and as clinically determined by the facility.Residents' assessment will be reviewed for changes in assessment that may require additional follow-up. Identification of elopement by nursing staff:Resident will be assessed by licensed nurses upon admission, admission, change in condition, new behavior of exit seeking and as clinically determined by the facility.Residents identified with changes in initial elopement assessment will be reviewed in clinical meeting. IDT will determine need for further follow-up. In-Service conductedIn-service was conducted by Director of Nursing or Administrator on February 5, 2026. The in-service is focused on elopement potentials, resident safety. The details of the in-service include: Assessment of residents with elopement potentialMonitoring of behavioral symptoms Visualizing each resident during rounds Rounding every 2 hours Conduct a midnight headcount census by charge nurse Report Missing resident's immediately to the supervisor and/or charge nurse, administrator, director of nursing, physician, responsible party Immediately search the facility; rooms, common areas, perimeter of the building, [sic]10mile radius of the facility The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide, and Licensed Therapists which include Physical Therapist, Occupational Therapist and Speech therapist. For staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. Inservice will include non-licensed staff on elopement prevention. This in-service was initiated on February 5, 2026. The Regional Nurse will reeducate the Director of Nursing on elopement assessment, follow-up on interventions, and care plan review. The Area administrator will reeducate the facility's administrator on elopement assessment, and /or reporting criteria to the Health and Human Services Commission (HHSC) according to reporting requirements. Implementation of ChangesThe changes were started by the Director of Nursing / Administrator. The changes were implemented effective on February 5, 2026 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of returned questionnaire. Physician Notification and Documentation Requirement The Director of Nursing or Assistant Director of Nursing will oversee the notification of physician for elopement related event. Documentation of elopement potential (actual or potential) will be documented in medical record. Care plan will be reviewed to meet the resident's clinical status. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on February 5, 2026. The Director of Nursing or designee will complete audit tool for monitoring on Elopement Assessment, care plan, follow-up.Director of Nursing/Assistant Director of Nursing will conduct weekly audit of Elopement assessment x4 weeks, then bi-weekly x 2 weeks, then monthly and report any adverse findings during QAPIResidents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the Director of Nursing, Administrator, Physician immediately for appropriate action.Areas of performance improvement identified during audits, or observations will be addressed upon identification. Involvement of Medical DirectorAn HOC QAPI regarding the incident was conducted on February 5, 2026, and the Plan of removal was reviewed and accepted by Medical Director Involvement of QAAn Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on February 5, 2026. Who is responsible for implementation of process?The Director of Nursing will be responsible for implementation of New Process. The New Process/ system was started on February 5, 2026. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on February 5, 2026. [sic] Monitoring the Plan of Removal on 02/05/2026 and 02/06/2026 included: During an interview on 02/05/2026 at 1:34 P.M. with DON revealed Resident #3 was the only current resident identified to be an elopement risk, and she was reassessed that day. Record review at this time of Resident #3's progress notes revealed she was reassessed on 02/05/2026 at 1:06 P.M. and was noted to remains at moderate risk for elopement but has no episodes of actively exit seeking.During an observation on 02/05/2026 at 3:05 P.M. of Resident #3, revealed she wandered the hallway and was confused, but did not exhibit exit seeking behaviors. No other residents demonstrated exit-seeking behaviors; front desk was monitored by receptionist, and the door required a code for exit. During an interview on 02/05/2026 at 5:03 P.M. with the incoming ADM revealed staff had been in-serviced and given the post-test questionnaire in person if they were working or via phone call if they were not in the facility; a mass text message was sent to all staff including the elopement training. He said staff who were in-serviced via phone call could not return to work until they signed the in-service and completed the post-test questionnaire. During an observation on 02/05/2026 5:25 P.M. revealed an elopement binder at nurse's station and front desk by front door, with picture of Resident #3 because she was an elopement risk. The state surveyor pushed the front door without the code entry, and an alarm was triggered and could be heard throughout the facility. Staff looked towards the exits and staff responded to enter the code for the door and allowed state surveyor to open the door. Interviews on 02/05/2026 and 02/06/2026 with RN E, RN G, LVN H, LVN I, RN J, LVN K, CNA L, CNA M, the BOM, staff coordinator, the hospitality aide, the housekeeper, and the receptionist all reported they had received in-service training over abuse and neglect and elopements and a post-test questionnaire regarding exit-seeking/elopement/wandering. Staff reported if a resident was suspected to be missing, they would look inside the building and then outside the building. In the event of an elopement, a code pink alert would be issued and they would notify the proper individuals including the DON, ADM, charge nurse, and physician. Staff reported all doors required codes to enter/exit the facility, and codes were not given to residents. Staff reported they monitor residents and were aware of exit-seeking behaviors, including attempt to leave the facility, pushing on the doors, and statements of wanting to leave the facility, and report these behaviors to the ADM, DON, charge nurse and physician. Direct care staff (RNs, LVNs, CNAs, and hospitality aide) reported they did rounds on residents at least every 2 hours, monitor census, and interventions for exit-seeking behaviors included one-on-one monitoring and redirection. GK N and GK O revealed the gate stayed closed at all times and was opened by a garage clicker. They reported they had received training regarding residents must have a pass for them to open the gate. They reported if a resident did not have a pass and tried to leave, they would try to redirect the resident and notify the facility for assistance. During an interview on 02/06/2026 at 12:53 P.M. with the DON, she stated residents that were actively elopement seeking would have alternate management (placement) sought; hospitalization would be done by her, and other type of placement would be done by the SW. She said the elopement risk assessments were done every 3 months and as needed (i.e. resident exit-seeking). The DON said this was discussed in the daily IDT meetings; additionally, residents with a high BIMS scores and were elopement risks would be discussed the meetings and referred to psychiatric services for recommendations and interventions would be added to resident care plans by her or the ADON. The DON said she reviewed all residents' elopement risk assessments for accuracy and there was no change. Residents' diagnosis and physician/provider input will be discussed every Thursday meeting with the NP present and communication with the physician who was present at least weekly. Dementia diagnosis and functional mobility evaluations would be considered as part of the review with the IDT in making decisions. The DON said residents that want to leave the facility will be reviewed

Based on interview and record review, the facility failed to ensure the physician was notified of changes for 1 of 5 residents (Resident #1) reviewed for elopement behaviors. The facility failed to inform the MD of Resident #1's elopement behaviors when requesting to discontinue his medical diagnosis of dementia.The failure could place residents at risk of not receiving the necessary care and treatment to meet their physical, mental, and psychosocial needs.Findings included: Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke) and osteoarthritis (protective cushion at ends of bones wear down, leading to stiffness and pain). Further record review of Resident #1's medical diagnoses revealed on 11/27/2025, the RNC had struck out the primary diagnosis dementia. The diagnosis did not appear on the face sheet. Record review of Resident #1's care plan, completed 11/07/2025, reflected:was at risk for elopement related to Elopement Evaluation risk score, initiated on 11/02/2025had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025Record review of Resident #1's most recent care plan, revised 11/27/2025, reflected:had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025was (high, moderate, low) risk for falls r/t Gait/balance problems, initiated 10/13/2025was a Potential Safety Risk When Leaving Facility Related to: Resident leaving facility without advance notice; history of similar behaviors in prior facilities. As evidence by: Independent exit, later self-admission to local hospital, initiated on 11/27/2025had psychiatric diagnosis (Schizophrenia/Depression/Anxiety) Related to: Chronic psychotic illness. As evidenced by: History of mental health conditions and preference to direct own care. Self-check in to local hospital, initiated on 11/27/2025 Exercising Autonomy / Independent Decision-Making Related to: Preference for self-directed choice, history of leaving facilities independently. As evidenced by: resident verbally stating he does not want to remain in facility; BIMS 13 demonstrating ability to make decisions; resident independently checking himself into local hospital, initiated on 11/27/2025The care plan revised 11/27/2025 did not reflect Resident #1's elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. Record review of Resident #1's Elopement Risk Evaluations reflected: Date: 10/13/2025; Lock (Completed) Date: 10/13/2025 Resident #1 was a Moderate Risk, and able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs; Patient is cognitive impaired AND 1) ambulates or propels self. Patient may go outdoors on occasion but makes no attempt to leave grounds. Date: 11/02/2025; Lock (Completed) Date: 11/13/2025 Resident #1 was No Risk; and not able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and unable to ambulate or mobilize wheelchairs. Additional information [Resident #1] is at risk for elopement related to Elopement Evaluation risk score.Date: 11/27/2025; Lock (Completed) Date: 02/04/2026 Resident #1 was No Risk; Resident #1 was able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs.Evaluations on 11/02/2025 and 11/27/2025 were not completed, staff only completed the questions in the No Risk section. Questions to evaluate Resident #1 as a Moderate Risk or Imminent Risk were triggered and but not completed for the electronic system to trigger the resident as moderate or imminent risk. There were discrepancies between the resident's elopement risk evaluations regarding his ability to make decisions and ambulate. Record review of Resident #1's progress notes reflected:Effective Date 10/24/2025: Security personnels at the gate called nurse to come for him because he wants to go home, ambulates with walker. Nurse went to the gate and spoke to him to come and express his concerns to the social worker as he proposed earlier. He agreed and came back with nurse to the building. Nurse accompanied him back in wheelchair with no problems. On q 2 hourly monitoring. Seemed co-operative with staff, calm, no aggressiveness. [sic]Effective Date 11/02/2025: Spoke with the resident's [Family Member #7 and Family Member #9] regarding the resident's exit seeking behavior; the couple stated that they are not surprised because every facility/psychiatric hospital he goes to he either checks himself out or he attempts to leave. The [Family Member #7] stated that his most recent stay was at a psychiatric hospital, he checked himself out, told the Police he wanted to go to [location], they put him on a bus, but he never made it there because he got off in [location] and here we are. The [Family Member #7] stated that he is unable to come and get him or find alternative placement because he doesn't know what is driving [Resident #1] to leave but he stated that he understand the liability the facility is faced with if he attempts to leave. [sic]Effective Date 11/02/2025: Resident sent to [psychiatric hospital]. Resident had two episodes of elopement from the facility. Resident showed signs of aggression and combativeness when asked why he wants to leave facility. Resident said, I want to leave this place, You people are holding me hostage, I want to leave. Resident was unable to articulate where he intends to go. The police were called to help control resident's behavior and outburst. Resident was finally sent to [psychiatric hospital]. The Doctor, Administrator, the don, and the Family Members where notified of the situation. [sic]Effective Date 11/14/2025, Created on 11/27/2025: Resident is a [AGE] year-old male with psychiatric history including schizophrenia, depression, anxiety, cognitive impairment, with a well-documented history of leaving prior facilities without notifying staff. Family members previously confirmed that the resident frequently leaves care settings independently and without authorization, noting this behavior has occurred at multiple facilities and psychiatric hospitals. Staff provided re-education on the facility's Leave of Absence (LOA) process, including expectation for notifying staff, safety procedures, required documentation, and the importance of arranging a responsible party for transport. Resident listened, verbalized understanding of the LOA procedure, and was informed that he may request an LOA appropriately if he chooses to leave temporarily. Resident declined to initiate an LOA at this time and continued to express general dissatisfaction with remaining in the facility but did not articulate a specific plan or destination. Staff attempted redirection, emotional support, and offered to contact family or the medical provider to discuss concerns. Resident declined all offers, stating only that he did not want [sic] tot stay. Resident remained cooperative and did not exhibit physical aggression, behavior escalation, or unsafe elopement attempts. Resident's [Family Member #7 and Family Member #9] were notified of the resident's statements. They reiterated consistent past behaviors of the resident leaving facilities on his own, confirming that this pattern is typical for him. They verbalized understanding of the current situation and did not request additional intervention at this time. The physician/NP were notified. Resident remained under routine supervision with continued monitoring per care plan. [sic]Effective date 11/27/2025, Created on 12/02/2025: [Resident #1] is [AGE] year-old, with admitting diagnosis of Cerebral infarction, history of psychiatric diagnosis of schizophrenia and depression. Before admitting to facility resident has a history of deciding to leave facilities and hospitals due to own personal reasons. Resident is aware of his needs and able to make decisions regarding his care and safety. Resident decided to leave the facility 11/26 facility received information that resident independently checked himself into a local hospital. No injuries were reported. This action is consistent with the resident's baseline pattern of independently leaving prior facilities and making his own arrangements for care or evaluation. Resident's ability to navigate the community, arrive at a hospital, and seek medical attention on his own reflects preserved decision-making capacity and supports his cognitive ability to make autonomous choices regarding his whereabouts and medical. [sic] Record review on 02/05/2026 of Resident #1's psychiatry/therapy visits revealed Resident #1 was seen on 11/07/2025, 11/12/2025, and 11/18/2025. Resident #1 was referred for Depression, Tearfulness, Confusion, Elopement, Adjustment Disorder, High Risk Behavior. Resident #1's history of presenting illness included unreliable historian. does not remember attempting to elope, there was previous behavior for this and patient was placed on 1:1 for this. disoriented to situation. Resident #1 was noted to have been prescribed medications including Donepezil to treat for unspecified symptoms and signs involving cognitive function and awareness. Resident #1 was noted to endorse cognitive impairment symptoms of decreased concentration, forgetfulness, and difficulties with ADL.During an interview on 02/04/2026 at 5:16 P.M. with Family Member #7 and Family Member #9, they said Resident #1 had records of a dementia diagnosis, had shown signs of dementia, and could not make decisions for himself. Family Member #9 said Resident #1 had a medical bracelet on his wrist with his diagnoses of dementia and a stroke and Family Member #7 and Family Member #9's phone numbers. They said there were a couple times where Resident #1 left the facility between the bars on the gates and folded up his walker and put it through the gate; one time he had shown police where he did it. Family Member #9 said Resident #1 had called them before the facility did when he had left the facility. Family Member #9 was not sure how Resident #1 got out of the facility, and that another resident may have had a code; but they said by the third time that he took off it was like oh my gosh that's scary. We don't know that area and we would get a call from the hospital or police. They said 11/02/2025 was Resident #1's first time through the gate, and on 11/26/2025 they received a call from Resident #1 and was possibly transmitted to the hospital by police. They said they received a call from the facility on 11/27/2025 about Resident #1's room change. They said they understood the facility's frustration regarding Resident #1 leaving the facility. Family Member #9 mentioned it had been hard to find a new facility closer to them due to Resident #1's elopements.During an interview on 02/05/2026 at 10:46 A.M. with the RNC revealed she struck out the dementia diagnosis for Resident #1 because he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments. She said she spoke to the MD, and he said it was okay to discontinue the dementia diagnosis. She said she had done a record review for Resident #1 because he had left the building but stated I don't know if I would say he eloped. She then stated she specifically reviewed Resident #1's records on 11/27/2025 because it was a random review. She then said she did record reviews for residents when an event happened, and residents went to the hospital. During an interview on 02/05/2026 at 11:19 A.M. with the ADM revealed the facility had conducted a Resident behavior and attempting elopement in-services with 47 signatures and post-tests that were completed regarding Resident #1's elopement on 11/26/2025. He said he did the in-services because Resident #1 left the building, but he did not report it to the state because it was not an elopement due to Resident #1 having a high BIMS score. He stated RN F's notes were not accurate on 11/02/2025 and there were no elopements and Resident #1 was not an elopement risk because he had a high BIMS score, he could make decisions, and he did not have dementia.During an interview on 02/05/2026 at 11:35 A.M. with Resident #1's MD, he stated Resident #1's diagnosis of dementia was discontinued on 11/27/2025 after he was informed by the facility that Resident #1's BIMS score was 13. The MD indicated the facility contacted him and he approved the diagnosis to be discontinued based on the BIMS score. He said he was not aware of Resident #1's exit seeking behaviors or elopement, and there was no documentation regarding Resident #1's exit seeking behaviors in his or his NP's notes. The MD said he did see Resident #1 was on medication for dementia. He said he did not know if Resident #1 was safe to leave the facility or ambulate independently. Interviews on 02/05/2026 and 02/06/2026 with RN E, RN G, LVN H, LVN I, RN J, LVN K, CNA L, all reported they had received in-service training over abuse and neglect and elopements and a post-test questionnaire regarding exit-seeking/elopement/wandering. In the event of an elopement, a code pink alert would be issued and they would notify the proper individuals including the DON, ADM, charge nurse, and physician. Staff reported they monitor residents and were aware of exit-seeking behaviors, including attempt to leave the facility, pushing on the doors, and statements of wanting to leave the facility, and report these behaviors to the ADM, DON, charge nurse and physician. During an interview on 02/06/2026 at 12:53 P.M. with the DON revealed staff had been in-serviced over elopements, exit seeking behaviors, and staff expectations, including notifying the physician. She indicated resident diagnoses and conditions will be discussed during Thursday (IDT) meetings with the NP present and communication with the physician who was present at least weekly. The DON said she received training from the RNC on elopement assessments, follow-up on interventions and care plan review, and she will notify the physician for all elopement related events. During an interview on 02/06/2026 at 2:05 P.M. with the ADM revealed all staff had received in-service training on the facility's policy and procedure for exit-seeking and elopement potential, prevention, notification, and management of actual elopements. He said in the event of an elopement, he, the DON, or charge nurse would notify the physician promptly. The ADM said when the doctor called, it should be documented. Record review of the facility's Wandering and Elopement policy, dated 08/2020, reflected: Purpose To enhance the safety of residents of the Facility.Policy The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement.ProcedureI. The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition to determine their risk of wander/elopement.II. The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition.VII. Response to Resident ElopementA. The Facility Staff member who finds that a resident is missing will alert Facility Staff.B. The Charge Nurse will call CODE PINK and organize a search. Facility Staff will search areas of the Facility, including common areas, bathrooms, showers, outside areas, etc.C. If the resident cannot be located, the Charge Nurse will notify:i. Administrator/designeeii. Director of Nursing Services/designee iii. Attending Physician iv. Responsible Partyv. Regional leadership of Clinical and Operations vi. Senior VP Of Operationvii. Senior VP of Clinical.VIII. Return of a ResidentA. When an individual who departed without following proper procedures returns to the Facility, the Director of Nursing Services or Licensed Nurse should:i. Examine the resident for any possible injuries;ii. Notify the Attending Physician; and iii. Notify the resident's responsible party . Record review of the facility's Medical Record Content policy, dated 06/2020, reflected: PurposeTo ensure adequate and accurate documentation of care provided to each resident while at theFacility. ProcedureThe Facility will maintain a medical record for each resident admitted to the Facility that will containsufficient information to identify the resident, support the diagnosis, justify the medical necessity fortreatment, and facilitate continuity of care among health care providers. ProcedureI. The medical record will be accurate, timely and complete and may include the following content: .CC. Notification to Physician - Documentation and notification to the physician promptly of the following:i. admission of a resident;ii. Change of condition;iii. Unusual occurrences involving the resident;iv. Significant change in weight;v. Side effects or reaction to medication/treatment;vi. Any error in administration of medication;vii. The Facility's inability to obtain or administer, on a prompt and timely basis drugs, equipment, supplies, or service as prescribed under conditions which present a risk to the health, safety or security of the resident; andviii. Attempts to notify the physician will be noted, including the time, method of communication, the name of the person acknowledging contact, if any. If the Attending Physician is not readily available, emergency care will be provided.'

Based on interview and record review, the facility failed to ensure medical records were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #1) reviewed for medical record accuracy. The facility failed to ensure there was not a discrepancy in Resident #1's dementia diagnosis that was discontinued, while his records (care plan, orders, psychiatric visits, and MAR) indicated Resident #1 was actively treatment for dementia.The facility failed to document the verbal conversation with Resident #1's MD regarding the discontinuation of dementia diagnosis.The facility failed to accurately and consistently complete Resident #1's Elopement Risk Evaluations when evaluating Resident #1's risk of elopement. This failure could place residents at risk of receiving treatment and care for inactive diagnoses and not receiving treatment and care when necessary to meet clinical, functional, mental, and psychosocial needs. Findings included:Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke) and osteoarthritis (protective cushion at ends of bones wear down, leading to stiffness and pain). Further record review of Resident #1's medical diagnoses revealed on 11/27/2025, the RNC had struck out the primary diagnosis dementia. The diagnosis did not appear on the face sheet. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 13, indicating intact cognitive function and ability to recall information immediately. Active diagnoses included Progressive Neurological Conditions, i.e. stroke (interruption of blood flow to brain) and non-Alzheimer's dementia (can be caused by a stroke and result in cognitive decline, behavioral change, etc.). The MDS assessment revealed Resident #1 did not exhibit wandering behaviors.Record review of Resident #1's BIMS assessments reflected: 10/13/2025 - Moderately impaired 1010/13/2025 - Cognitively intact 1310/24/2025 - Cognitively intact 1512/2/2025 - Cognitively intact 13 Record review of Resident #1's clinical history documentation, dated 10/12/2025, revealed Resident #1's past medical history included Cerebrovascular Accident (stroke, interruption of blood flow to the brain) and dementia, and he used a walker (to ambulate). Record review of Resident #1's Mental Illness/Dementia Resident Review, signed by the MD on 11/11/2025, revealed Resident #1's MD completed the form and marked Yes, the individual has a primary diagnosis or has a dementia diagnosis as defined above. The physician signs and dates the form attesting to the dementia diagnosis. Record review of Resident #1's care plan, completed 11/07/2025, reflected:was at risk for elopement related to Elopement Evaluation risk score, initiated on 11/02/2025had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025Record review of Resident #1's most recent care plan, revised 11/27/2025, reflected:had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025was (high, moderate, low) risk for falls r/t Gait/balance problems, initiated 10/13/2025was a Potential Safety Risk When Leaving Facility Related to: Resident leaving facility without advance notice; history of similar behaviors in prior facilities. As evidence by: Independent exit, later self-admission to local hospital, initiated on 11/27/2025had psychiatric diagnosis (Schizophrenia/Depression/Anxiety) Related to: Chronic psychotic illness. As evidenced by: History of mental health conditions and preference to direct own care. Self-check in to local hospital, initiated on 11/27/2025 Exercising Autonomy / Independent Decision-Making Related to: Preference for self-directed choice, history of leaving facilities independently. As evidenced by: resident verbally stating he does not want to remain in facility; BIMS 13 demonstrating ability to make decisions; resident independently checking himself into local hospital, initiated on 11/27/2025The care plan revised 11/27/2025 did not reflect Resident #1's elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. Record review of Resident #1's progress notes reflected:Effective Date 10/24/2025: Security personnels at the gate called nurse to come for him because he wants to go home, ambulates with walker. Nurse went to the gate and spoke to him to come and express his concerns to the social worker as he proposed earlier. He agreed and came back with nurse to the building. Nurse accompanied him back in wheelchair with no problems. On q 2 hourly monitoring. Seemed co-operative with staff, calm, no aggressiveness. [sic]Effective Date 11/02/2025: Spoke with the resident's [Family Member #7 and Family Member #9] regarding the resident's exit seeking behavior; the couple stated that they are not surprised because every facility/psychiatric hospital he goes to he either checks himself out or he attempts to leave. The [Family Member #7] stated that his most recent stay was at a psychiatric hospital, he checked himself out, told the Police he wanted to go to [location], they put him on a bus, but he never made it there because he got off in [location] and here we are. The [Family Member #7] stated that he is unable to come and get him or find alternative placement because he doesn't know what is driving [Resident #1] to leave but he stated that he understand the liability the facility is faced with if he attempts to leave. [sic]Effective Date 11/02/2025: Resident sent to [psychiatric hospital]. Resident had two episodes of elopement from the facility. Resident showed signs of aggression and combativeness when asked why he wants to leave facility. Resident said, I want to leave this place, You people are holding me hostage, I want to leave. Resident was unable to articulate where he intends to go. The police were called to help control resident's behavior and outburst. Resident was finally sent to [psychiatric hospital]. The Doctor, Administrator, the don, and the Family Members where notified of the situation. [sic]Effective Date 11/14/2025, Created on 11/27/2025: Resident is a [AGE] year-old male with psychiatric history including schizophrenia, depression, anxiety, cognitive impairment, with a well-documented history of leaving prior facilities without notifying staff. Family Members previously confirmed that the resident frequently leaves care settings independently and without authorization, noting this behavior has occurred at multiple facilities and psychiatric hospitals .Effective date 11/27/2025, Created on 12/02/2025: [Resident #1] is [AGE] year-old, with admitting diagnosis of Cerebral infarction, history of psychiatric diagnosis of schizophrenia and depression. Before admitting to facility resident has a history of deciding to leave facilities and hospitals due to own personal reasons. Resident is aware of his needs and able to make decisions regarding his care and safety. Resident decided to leave the facility 11/26 facility received information that resident independently checked himself into a local hospital. No injuries were reported. This action is consistent with the resident's baseline pattern of independently leaving prior facilities and making his own arrangements for care or evaluation. Resident's ability to navigate the community, arrive at a hospital, and seek medical attention on his own reflects preserved decision-making capacity and supports his cognitive ability to make autonomous choices regarding his whereabouts and medical. [sic]Records did not show documentation of orders or discussion to change Resident #1's dementia diagnosis. Record review of Resident #1's Elopement Risk Evaluations reflected: Date: 10/13/2025; Lock (Completed) Date: 10/13/2025 Resident #1 was a Moderate Risk, and able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs; Patient is cognitive impaired AND 1) ambulates or propels self. Patient may go outdoors on occasion but makes no attempt to leave grounds. Date: 11/02/2025; Lock (Completed) Date: 11/13/2025 Resident #1 was No Risk; and not able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and unable to ambulate or mobilize wheelchairs. Additional information [Resident #1] is at risk for elopement related to Elopement Evaluation risk score.Date: 11/27/2025; Lock (Completed) Date: 02/04/2026 Resident #1 was No Risk; Resident #1 was able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs.Evaluations on 11/02/2025 and 11/27/2025 were not completed, staff only completed the questions in the No Risk section. Questions to evaluate Resident #1 as a Moderate Risk or Imminent Risk were triggered and but not completed for the electronic system to trigger the resident as moderate or imminent risk. There were discrepancies between the resident's elopement risk evaluations regarding his ability to make decisions and ambulate. Record review on 02/05/2026 of Resident #1's transfer form to discharge to the hospital, dated 11/02/2025, revealed Resident #1 was alert, disoriented, but cannot follow simple instructions, ambulates with assistive device, and requires assistance for ADLs. Resident #1 was noted to may attempt exit as an additional risk. Record review of Resident #1's psychiatry/therapy visits revealed Resident #1 was seen on 11/07/2025, 11/12/2025, and 11/18/2025. Resident #1 was referred for Depression, Tearfulness, Confusion, Elopement, Adjustment Disorder, High Risk Behavior. Resident #1's history of presenting illness included unreliable historian. does not remember attempting to elope, there was previous behavior for this and patient was placed on 1:1 for this. disoriented to situation. Resident #1 was noted to have been prescribed medications including Donepezil to treat for unspecified symptoms and signs involving cognitive function and awareness. Resident #1 was noted to endorse cognitive impairment symptoms of decreased concentration, forgetfulness, and difficulties with ADLs. During an interview on 02/04/2026 at 1:39 P.M. with the DON, she stated elopement risk was determined by elopement risk evaluation assessments. She explained if the first two questions were determined Yes (e.g. resident able to make decisions and unable to ambulate or mobilize wheelchairs), the evaluation was complete, and the resident was a low risk. The DON said if a resident did not want to be in the facility, they were not a risk because they had the ability to make decisions. She said if residents had a low BIMS score or cognitive impairment and were exit seeking, they were an elopement risk; if residents had a 13-15 BIMS score, they were not an elopement risk. The DON said if a resident had dementia and was able to make decisions for themselves, they were not an elopement risk. During an interview on 02/04/2026 at 2:05 P.M. with LVN D, she said she remembered Resident #1. She said she kept her eye on him 24/7 and he was very tricky because (staff) did not know what he was going to do the next minute, and it was a real issue with him. LVN D said he was on one-on-one observation at one time and that was the key (intervention). She said he was an elopement risk and indicated he showed signs including exit-seeking and verbalizing wanting to leave, and she had to redirect him. LVN D said behaviors like Resident #1's, and even his high BIMS score, made him an elopement risk because he was always seeking to leave and looked for an exit and that was an elopement risk. During an interview on 02/04/2026 at 2:30 P.M. with RN E, she said she remembered Resident #1. She recalled she had done one-on-one monitoring with Resident #1. RN E said Resident #1 could make decisions for himself to an extent, but I would say no. She indicated Resident #1 was not safe to be out of the facility by himself. RN E indicated Resident #1 was forgetful, she would provide medication for pain and he would forget he took the medication, he would forget what happened in the hospital, and if she asked why he left (the facility), he would say he wanted to get out of here (facility). She said his dementia was care planned and when those behaviors (i.e. forgetful, dementia, exit-seeking) were seen, they were documented. During an interview on 02/04/2026 at 5:16 P.M. with Family Member #7 and Family Member #9, they said Resident #1 had records of a dementia diagnosis and had shown signs of dementia. Family Member #9 said Resident #1 could not make decisions for himself. They said the facility had called them about Resident #1 wanting to see a Family Member who had been dead for over 20 years. Family Member #9 said they had documentation from the facility showing Resident #1 had a diagnosis of dementia and they needed the documentation for the social security office. They said they did not want Resident #1 to leave the facility, and it stressed them out when he disappeared. Family Member #9 mentioned it had been hard to find a new facility closer to them due to Resident #1's elopements. During an interview on 02/05/2026 at 10:46 A.M. with the RNC revealed she struck out the dementia diagnosis for Resident #1 because he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments. She said she spoke to the MD and he said it was okay to discontinue the dementia diagnosis. She said she was not aware of the PASRR the MD signed on 11/11/2025 stating Resident #1 had a primary diagnosis of dementia. The RNC said she did not document the conversation or justification for changing the medical records. She said she had done a record review for Resident #1 because he had left the building but stated I don't know if I would say he eloped. She then stated she specifically reviewed Resident #1's records on 11/27/2025 because it was a random review. She then said she did record reviews for residents when an event happened, and residents went to the hospital. RNC indicated she was not aware that Resident #1's was care planned for dementia and dementia medication, and that he was actively medicated for dementia. During an interview on 02/05/2026 at 11:35 A.M. with Resident #1's MD, he stated Resident #1's diagnosis of dementia was discontinued on 11/27/2025 after he was informed by the facility that Resident #1's BIMS score was 13. The MD indicated the facility contacted him and he approved the diagnosis to be discontinued based on the BIMS score. He said he was not aware of Resident #1's exit seeking behaviors or elopement, and there was no documentation regarding Resident #1's exit seeking behaviors in his or his NP's notes. The MD said he did see Resident #1 was on medication for dementia. He said he did not know if Resident #1 was safe to leave the facility or ambulate independently.Attempted phone call interview on 02/05/2026 at 4:29 P.M. with RN F regarding progress notes on 11/02/2025 when Resident #1 was sent to the psych hospital. RN F did not return the state surveyor's phone call.During an interview on 02/05/2026 at 5:00 P.M. with RN G, she revealed residents with high BIMS scores can be an elopement risk. She further said that if residents set their mind to it (leaving), nothing will stop them, and they can get creative. RN G said signs included the resident not wanting to be at the facility, packing a small bag, looking at doors to see if there was potential to run out and leave. During an interview on 02/05/2026 at 7:23 P.M. with the previous SW, she said she worked at the facility when Resident #1 was there. She said Resident #1 was fuzzy (confused) about he admitted to the facility and Family Member #7 said his memory was not the best. She said there was discussion with family about making arrangements for the resident to live closer to them and for Resident to not to just leave and not tell the facility. The previous SW indicated in her experience with Resident #1 his cognitive abilities were good, and he had a high BIMS score, but a BIMS score was not the only determinant of cognitive abilities. She said Resident #1 was an elopement risk and he had used a walker; she further said he had dug under the fence of the facility and talked about leaving very often. She indicated it would be a risk for any resident to leave the facility alone with similar behaviors and conditions to Resident #1. The previous SW said there was discussion with family about Resident #1 leaving being a liability (to the facility) and that he could have hurt himself and anything could have happened. During an interview on 02/06/2026 at 1:09 P.M. with the DON, she revealed it was important for resident medical records to be accurate so staff can provide accurate care, were aware of the residents and their diagnoses, medication, and had been going on prior to their admission. She said when there was a change in a resident, documentation depends on the change; she said it ultimately should be in progress notes and different assessments were used for different things. The DON said the risk if medical records were not accurate was hard to say, depending on the situation and on what was not accurate. She said for Resident #1 he functioned at a high level and was able to do what he wanted to do. The DON said nursing staff were responsible for making sure resident medical records were accurate. During an interview on 02/06/2026 at 2:40 P.M. with the ADM, he stated RN F's notes were not accurate on 11/02/2025 and there were no elopements and that Resident #1 was not an elopement risk because he had a high BIMS score, he could make decisions, and he did not have dementia. He said accurate medical records were important because it helped the facility provide proper care. He said documentation was important to make sure (staff) had a record of elopement and changes in the residents (i.e. change in diagnosis). The ADM said when the doctor called, it should be documented. The ADM said the risk of inaccurate records depended, but staff were required to document, including when orders were given. He said he and the DON were responsible for looking at resident records to make sure they were accurate and documented accurately. During an interview on 02/06/26 at 03:24 P.M. with RN J, she stated the importance of maintaining accurate records or documentation was it is legal and then the next shift can look back and know what is going on with the resident. Record review of the facility's Medical Record Content policy, dated 06/2020, reflected: PurposeTo ensure adequate and accurate documentation of care provided to each resident while at theFacility. ProcedureThe Facility will maintain a medical record for each resident admitted to the Facility that will containsufficient information to identify the resident, support the diagnosis, justify the medical necessity fortreatment, and facilitate continuity of care among health care providers. ProcedureI. The medical record will be accurate, timely and complete and may include the following content: .L. Ancillary Assessmentsi. Assessments will be initiated at the time of admission.ii. Assessments and progress notes should be consistent with Care Plans developed for the residents.iii. Frequency of progress notes and/or assessment will be per state regulation and Facility policy.CC. Notification to Physician - Documentation and notification to the physician promptly of the following:i. admission of a resident;ii. Change of condition;iii. Unusual occurrences involving the resident;iv. Significant change in weight;v. Side effects or reaction to medication/treatment;vi. Any error in administration of medication;vii. The Facility's inability to obtain or administer, on a prompt and timely basis drugs, equipment, supplies, or service as prescribed under conditions which present a risk to the health, safety or security of the resident; andviii. Attempts to notify the physician will be noted, including the time, method of communication, the name of the person acknowledging contact, if any. If the Attending Physician is not readily available, emergency care will be provided.DD. Physician Orders.

Based on interview and record review, the facility failed to ensure alleged violations of neglect were immediately reported to the State Agency within 24 hours for 1 of 5 (Resident #1) reviewed for elopement reporting. The facility failed to report Resident #1's subsequent and actual elopements from the facility on 11/02/2025 and 11/26/2025.This failure could place residents at risk of neglect and lack of oversight by the State Agency.Findings included:Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke) and osteoarthritis (protective cushion at ends of bones wear down, leading to stiffness and pain). Further record review of Resident #1's medical diagnoses revealed on 11/27/2025, the RNC had struck out the primary diagnosis dementia. The diagnosis did not appear on the face sheet. Record review of Resident #1's care plan, completed 11/07/2025, reflected:was at risk for elopement related to Elopement Evaluation risk score, initiated on 11/02/2025had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025Record review of Resident #1's most recent care plan, revised 11/27/2025, reflected:had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025was (high, moderate, low) risk for falls r/t Gait/balance problems, initiated 10/13/2025was a Potential Safety Risk When Leaving Facility Related to: Resident leaving facility without advance notice; history of similar behaviors in prior facilities. As evidence by: Independent exit, later self-admission to local hospital, initiated on 11/27/2025had psychiatric diagnosis (Schizophrenia/Depression/Anxiety) Related to: Chronic psychotic illness. As evidenced by: History of mental health conditions and preference to direct own care. Self-check in to local hospital, initiated on 11/27/2025 Exercising Autonomy / Independent Decision-Making Related to: Preference for self-directed choice, history of leaving facilities independently. As evidenced by: resident verbally stating he does not want to remain in facility; BIMS 13 demonstrating ability to make decisions; resident independently checking himself into local hospital, initiated on 11/27/2025The care plan revised 11/27/2025 did not reflect Resident #1's elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. Record review of Resident #1's Elopement Risk Evaluations reflected: Date: 10/13/2025; Lock (Completed) Date: 10/13/2025 Resident #1 was a Moderate Risk, and able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs; Patient is cognitive impaired AND 1) ambulates or propels self. Patient may go outdoors on occasion but makes no attempt to leave grounds. Date: 11/02/2025; Lock (Completed) Date: 11/13/2025 Resident #1 was No Risk; and not able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and unable to ambulate or mobilize wheelchairs. Additional information [Resident #1] is at risk for elopement related to Elopement Evaluation risk score.Date: 11/27/2025; Lock (Completed) Date: 02/04/2026 Resident #1 was No Risk; Resident #1 was able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs.Evaluations on 11/02/2025 and 11/27/2025 were not completed, staff only completed the questions in the No Risk section. Questions to evaluate Resident #1 as a Moderate Risk or Imminent Risk were triggered and but not completed for the electronic system to trigger the resident as moderate or imminent risk. There were discrepancies between the resident's elopement risk evaluations regarding his ability to make decisions and ambulate. Record review of Resident #1's progress notes reflected:Effective Date 10/24/2025: Security personnels at the gate called nurse to come for him because he wants to go home, ambulates with walker. Nurse went to the gate and spoke to him to come and express his concerns to the social worker as he proposed earlier. He agreed and came back with nurse to the building. Nurse accompanied him back in wheelchair with no problems. On q 2 hourly monitoring. Seemed co-operative with staff, calm, no aggressiveness. [sic]Effective Date 11/02/2025: Spoke with the resident's [Family Member #7 and Family Member #9] regarding the resident's exit seeking behavior; the couple stated that they are not surprised because every facility/psychiatric hospital he goes to he either checks himself out or he attempts to leave. The [Family Member #7] stated that his most recent stay was at a psychiatric hospital, he checked himself out, told the Police he wanted to go to [location], they put him on a bus, but he never made it there because he got off in [location] and here we are. The [Family Member #7] stated that he is unable to come and get him or find alternative placement because he doesn't know what is driving [Resident #1] to leave but he stated that he understand the liability the facility is faced with if he attempts to leave. [sic]Effective Date 11/02/2025: Resident sent to [psychiatric hospital]. Resident had two episodes of elopement from the facility. Resident showed signs of aggression and combativeness when asked why he wants to leave facility. Resident said, I want to leave this place, You people are holding me hostage, I want to leave. Resident was unable to articulate where he intends to go. The police were called to help control resident's behavior and outburst. Resident was finally sent to [psychiatric hospital]. The Doctor, Administrator, the don, and the Family Members where notified of the situation. [sic]Effective Date 11/14/2025, Created on 11/27/2025: Resident is a [AGE] year-old male with psychiatric history including schizophrenia, depression, anxiety, cognitive impairment, with a well-documented history of leaving prior facilities without notifying staff. Family members previously confirmed that the resident frequently leaves care settings independently and without authorization, noting this behavior has occurred at multiple facilities and psychiatric hospitals. Staff provided re-education on the facility's Leave of Absence (LOA) process, including expectation for notifying staff, safety procedures, required documentation, and the importance of arranging a responsible party for transport. Resident listened, verbalized understanding of the LOA procedure, and was informed that he may request an LOA appropriately if he chooses to leave temporarily. Resident declined to initiate an LOA at this time and continued to express general dissatisfaction with remaining in the facility but did not articulate a specific plan or destination. Staff attempted redirection, emotional support, and offered to contact family or the medical provider to discuss concerns. Resident declined all offers, stating only that he did not want [sic] tot stay. Resident remained cooperative and did not exhibit physical aggression, behavior escalation, or unsafe elopement attempts. Resident's [Family Member #7 and Family Member #9] were notified of the resident's statements. They reiterated consistent past behaviors of the resident leaving facilities on his own, confirming that this pattern is typical for him. They verbalized understanding of the current situation and did not request additional intervention at this time. The physician/NP were notified. Resident remained under routine supervision with continued monitoring per care plan. [sic]Effective date 11/27/2025, Created on 12/02/2025: [Resident #1] is [AGE] year-old, with admitting diagnosis of Cerebral infarction, history of psychiatric diagnosis of schizophrenia and depression. Before admitting to facility resident has a history of deciding to leave facilities and hospitals due to own personal reasons. Resident is aware of his needs and able to make decisions regarding his care and safety. Resident decided to leave the facility 11/26 facility received information that resident independently checked himself into a local hospital. No injuries were reported. This action is consistent with the resident's baseline pattern of independently leaving prior facilities and making his own arrangements for care or evaluation. Resident's ability to navigate the community, arrive at a hospital, and seek medical attention on his own reflects preserved decision-making capacity and supports his cognitive ability to make autonomous choices regarding his whereabouts and medical. [sic] Record review on 02/05/2026 of Resident #1's psychiatry/therapy visits revealed Resident #1 was seen on 11/07/2025, 11/12/2025, and 11/18/2025. Resident #1 was referred for Depression, Tearfulness, Confusion, Elopement, Adjustment Disorder, High Risk Behavior. Resident #1's history of presenting illness included unreliable historian. does not remember attempting to elope, there was previous behavior for this and patient was placed on 1:1 for this. disoriented to situation. Resident #1 was noted to have been prescribed medications including Donepezil to treat for unspecified symptoms and signs involving cognitive function and awareness. Resident #1 was noted to endorse cognitive impairment symptoms of decreased concentration, forgetfulness, and difficulties with ADLs.During an interview on 02/04/2026 at 2:30 P.M. with RN E, she said she remembered Resident #1, and she remembered she had to get him from the security gate one time, but he did not go out the gate that day. She recalled when he left the faciity on [DATE] and said nobody knew what time he left but knew he was not there. RN E said she came in for her shift the next day and he came back from the hospital. She recalled she had done one-on-one monitoring with Resident #1 before 11/26/2025 and indicated he was not safe to be out of the facility by himself. RN E said elopements were reportable to the State, and nurses did not report to the State, but the ADM was responsible for reporting to the State.During an interview on 02/04/2026 at 5:16 P.M. with Family Member #7 and Family Member #9, they said Resident #1 had records of a dementia diagnosis, had shown signs of dementia, and could not make decisions for himself. Family Member #9 said Resident #1 had a medical bracelet on his wrist with his diagnoses of dementia and a stroke and Family Member #7 and Family Member #9's phone numbers. They said there were a couple times where Resident #1 left the facility between the bars on the gates and folded up his walker and put it through the gate; one time he had shown police where he did it. Family Member #9 said Resident #1 had called them before the facility did when he had left the facility. Family Member #9 was not sure how Resident #1 got out of the facility, and that another resident may have had a code; but they said by the third time that he took off it was like oh my gosh that's scary. We don't know that area and we would get a call from the hospital or police. They said 11/02/2025 was Resident #1's first time through the gate, and on 11/26/2025 they received a call from Resident #1 and was possibly transmitted to the hospital by police. They said they received a call from the facility on 11/27/2025 about Resident #1's room change. They said they understood the facility's frustration regarding Resident #1 leaving the facility. Family Member #9 mentioned it had been hard to find a new facility closer to them due to Resident #1's elopements.During an interview on 02/05/2026 at 10:46 A.M. with the RNC revealed she struck out the dementia diagnosis for Resident #1 because he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments. She said she spoke to the MD, and he said it was okay to discontinue the dementia diagnosis. She said she had done a record review for Resident #1 because he had left the building but stated I don't know if I would say he eloped. She then stated she specifically reviewed Resident #1's records on 11/27/2025 because it was a random review. She then said she did record reviews for residents when an event happened, and residents went to the hospital. During an interview on 02/05/2026 at 11:35 A.M. with Resident #1's MD, he stated Resident #1's diagnosis of dementia was discontinued on 11/27/2025 after he was informed by the facility that Resident #1's BIMS score was 13. The MD indicated the facility contacted him and he approved the diagnosis to be discontinued based on the BIMS score. He said he was not aware of Resident #1's exit seeking behaviors or elopement, and there was no documentation regarding Resident #1's exit seeking behaviors in his or his NP's notes. The MD said he did see Resident #1 was on medication for dementia. He said he did not know if Resident #1 was safe to leave the facility or ambulate independently.Attempted phone call interview on 02/05/2026 at 4:29 P.M. with RN F regarding progress notes on 11/02/2025 when Resident #1 was sent to the psych hospital. RN F did not return the state surveyor's phone call.During an interview on 02/05/2026 at 7:23 P.M. with the previous SW, she said she worked at the facility when Resident #1 was there. She said Resident #1 was fuzzy (confused) about how he was admitted to the facility, and Family Member #7 said his memory was not the best. She said Resident #1 was an elopement risk and he had used a walker; she further said he had dug under the fence of the facility and talked about leaving very often. The previous SW said she recalled when Resident #1 eloped on 11/26/2025. She said she did not know who told the ADM Resident #1 was not in the facility, but it was facility staff who told him. She said the ADM called her, and she then called around to the closest hospitals until she found Resident #1, and she contacted the family. During an interview on 02/06/2026 at 1:09 P.M. with the DON revealed the facility staff reported to her and the ADM if an incident occurred and expected them to report immediately. She indicated the ADM was responsible for making the decision to determine if an incident was reportable to the State because he was head of the facility. The DON stated reporting incidents to the State was important because it made sure (the facility) abided by regulations of the State, and for the safety of the residents. During an interview on 02/06/2026 at 2:40 P.M. with the ADM, he stated RN F's notes were not accurate on 11/02/2025 and there were no elopements and that Resident #1 was not an elopement risk because he had a high BIMS score, he could make decisions, and he did not have dementia. The ADM said he was responsible for reporting incidents to the State, if he was not available, the DON can report. He said it was important to report incidents to notify HHSC of what was going on in the facility and to make sure the facility was in compliance, but also not to just investigate but (HHSC) support of the facility when they need support and help. The ADM indicated abuse was reported to the State within 2 hours, and incidents (i.e. elopements) without injury were to be reported within 24 hours. He said staff were to report to him immediately, so he had time to ask questions and interview people. During an interview on 02/06/26 at 03:24 P.M. with RN J, she stated she reported any incidents to the Administrator, and they report to the State. If they did not report something to the State, the problem could just continue or even escalate.Record review of the facility's Abuse Prevention and Prohibition Program policy, dated 01/2025, reflected: PurposeTo ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. PolicyI. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, Family Members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. Procedure I. The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the Facility . V. IdentificationA. The Facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect:i. Physical Abuse.ii. Physical Neglect.iii. Possible Signs and Symptoms of Psychological Abuse or Neglect.VI. InvestigationA. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts .B. If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the Facility's management team ( the Investigator) to investigate the alleged incident.I. The Administrator will submit initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies as outlined in Section IX below.IX. Reporting/ResponseA. Facility Staff are Mandatory Reportersi. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults.B. Administrator, or his/her designee, as Abuse Coordinator.C. All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction, or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering.D. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime.i. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).ii. No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).iii. Reporting requirements are based on real (clock) time, not business hours.iv. The Administrator will provide the state survey agency, law enforcement and the Ombudsman (if applicable per state regulation) with a copy of the investigative report within 5 days of the incident .v. If a resident experienced or alleges an instance of abuse at a location other than the Facility, the Administrator, or his/her designee, shall report the instance of abuse to Adult Protective Services agency and the local law enforcement agency.vi. The resident's attending physician and responsible party, if applicable, will also be notified of the of the allegation and outcome of the investigation.vii. Failure to file a report within the required time frames may result in disciplinary action, up to and including termination.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement the care plan for Resident #1's risk of elopement since his initial elopement attempt on 10/24/2025 and subsequent elopement attempt and actual elopement on 11/02/2025 and 11/26/2025.The facility failed to revise the care plan for Resident #1 to reflect his medical diagnosis of dementia.This failure could place residents at risk for not receiving proper care and services. Findings included: Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke) and osteoarthritis (protective cushion at ends of bones wear down, leading to stiffness and pain). Further record review of Resident #1's medical diagnoses revealed on 11/27/2025, the RNC had struck out the primary diagnosis dementia. The diagnosis did not appear on the face sheet. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 13, indicating intact cognitive function and ability to recall information immediately. Active diagnoses included Progressive Neurological Conditions, i.e. stroke (interruption of blood flow to brain) and non-Alzheimer's dementia (can be caused by a stroke and result in cognitive decline, behavioral change, etc.). The MDS assessment revealed Resident #1 did not exhibit wandering behaviors.Record review Resident #1's BIMS assessments reflected: 10/13/2025 - Moderately impaired 1010/13/2025 - Cognitively intact 1310/24/2025 - Cognitively intact 1512/2/2025 - Cognitively intact 13 Record review of Resident #1's care plan, completed 11/07/2025, reflected:was at risk for elopement related to Elopement Evaluation risk score, initiated on 11/02/2025had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025Record review of Resident #1's most recent care plan, revised 11/27/2025, reflected:had impaired cognitive function/dementia or impaired thought processes r/t Dementia, initiated on 10/13/2025required psychotropic medications (Donepezil HCL) for diagnosis of (Dementia), initiated on 10/13/2025was a Potential Safety Risk When Leaving Facility Related to: Resident leaving facility without advance notice; history of similar behaviors in prior facilities. As evidence by: Independent exit, later self-admission to local hospital, initiated on 11/27/2025had psychiatric diagnosis (Schizophrenia/Depression/Anxiety) Related to: Chronic psychotic illness. As evidenced by: History of mental health conditions and preference to direct own care. Self-check in to local hospital, initiated on 11/27/2025 Exercising Autonomy / Independent Decision-Making Related to: Preference for self-directed choice, history of leaving facilities independently. As evidenced by: resident verbally stating he does not want to remain in facility; BIMS 13 demonstrating ability to make decisions; resident independently checking himself into local hospital, initiated on 11/27/2025The care plan revised 11/27/2025 did not reflect Resident #1's elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. Record review of Resident #1's Elopement Risk Evaluations reflected: Date: 10/13/2025; Lock (Completed) Date: 10/13/2025 Resident #1 was a Moderate Risk, and able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs; Patient is cognitive impaired AND 1) ambulates or propels self. Patient may go outdoors on occasion but makes no attempt to leave grounds. Date: 11/02/2025; Lock (Completed) Date: 11/13/2025 Resident #1 was No Risk; and not able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and unable to ambulate or mobilize wheelchairs. Additional information [Resident #1] is at risk for elopement related to Elopement Evaluation risk score.Date: 11/27/2025; Lock (Completed) Date: 02/04/2026 Resident #1 was No Risk; Resident #1 was able to make decisions regarding tasks of daily living, e.g. decisions are consistent and reasonable; and was able to ambulate or mobilize wheelchairs.Evaluations on 11/02/2025 and 11/27/2025 were not completed, staff only completed the questions in the No Risk section. Questions to evaluate Resident #1 as a Moderate Risk or Imminent Risk were triggered and but not completed for the electronic system to trigger the resident as moderate or imminent risk. There were discrepancies between the resident's elopement risk evaluations regarding his ability to make decisions and ambulate. Record review of Resident #1's order summary, dated 02/04/2026 reflected:Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for Dementia Donepezil 5mg qhs x 6wks then increase to 10mg po qhs. Start Date: 11/24/2025Donepezil HCL Oral Tablet 5 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for Dementia for 6 weeks. Start Date: 10/13/2025 End Date:11/24/2025 Record review of Resident #1's MAR reflected:10/13/2025-11/23/2025: Resident #1 was given Donepezil HCL Oral Tablet 5 MG everyday as ordered, except for 10/29/2025, 11/2/2025, and 11/23/2025 due to being hospitalized or other (instructed to see nurses note) during the time of the scheduled dose. 11/24/2025-12/02/2025: Resident #1 was given Donepezil HCL Oral Tablet 10 MG everyday as ordered, except on 11/24/2025 and 11/26/2025 due to being away from the facility during the time of the scheduled dose. Record review of Resident #1's progress notes reflected:Effective Date 10/24/2025: Security personnels at the gate called nurse to come for him because he wants to go home, ambulates with walker. Nurse went to the gate and spoke to him to come and express his concerns to the social worker as he proposed earlier. He agreed and came back with nurse to the building. Nurse accompanied him back in wheelchair with no problems. On q 2 hourly monitoring. Seemed co-operative with staff, calm, no aggressiveness. [sic]Effective Date 11/02/2025: Spoke with the resident's [Family Member #7 and Family Member #9] regarding the resident's exit seeking behavior; the couple stated that they are not surprised because every facility/psychiatric hospital he goes to he either checks himself out or he attempts to leave. The [Family Member #7] stated that his most recent stay was at a psychiatric hospital, he checked himself out, told the Police he wanted to go to [location], they put him on a bus, but he never made it there because he got off in [location] and here we are. The [Family Member #7] stated that he is unable to come and get him or find alternative placement because he doesn't know what is driving [Resident #1] to leave but he stated that he understand the liability the facility is faced with if he attempts to leave. [sic]Effective Date 11/02/2025: Resident sent to [psychiatric hospital]. Resident had two episodes of elopement from the facility. Resident showed signs of aggression and combativeness when asked why he wants to leave facility. Resident said, I want to leave this place, You people are holding me hostage, I want to leave. Resident was unable to articulate where he intends to go. The police were called to help control resident's behavior and outburst. Resident was finally sent to [psychiatric hospital]. The Doctor, Administrator, the don, and the Family Members where notified of the situation. [sic]Effective Date 11/14/2025, Created on 11/27/2025: Resident is a [AGE] year-old male with psychiatric history including schizophrenia, depression, anxiety, cognitive impairment, with a well-documented history of leaving prior facilities without notifying staff. Family Members previously confirmed that the resident frequently leaves care settings independently and without authorization, noting this behavior has occurred at multiple facilities and psychiatric hospitals .Effective date 11/27/2025, Created on 12/02/2025: [Resident #1] is [AGE] year-old, with admitting diagnosis of Cerebral infarction, history of psychiatric diagnosis of schizophrenia and depression. Before admitting to facility resident has a history of deciding to leave facilities and hospitals due to own personal reasons. Resident is aware of his needs and able to make decisions regarding his care and safety. Resident decided to leave the facility 11/26 facility received information that resident independently checked himself into a local hospital. No injuries were reported. This action is consistent with the resident's baseline pattern of independently leaving prior facilities and making his own arrangements for care or evaluation. Resident's ability to navigate the community, arrive at a hospital, and seek medical attention on his own reflects preserved decision-making capacity and supports his cognitive ability to make autonomous choices regarding his whereabouts and medical. [sic]During an interview on 02/04/2026 at 2:30 P.M. with RN E, she said she remembered Resident #1, and she remembered she had to get him from the security gate one time, but he did not go out the gate that day. She recalled when he left the faciity on [DATE] and said nobody knew what time he left but knew he was not there. RN E said she came in for her shift the next day and he came back from the hospital. She recalled she had done one-on-one monitoring with Resident #1 before 11/26/2025 and indicated he was not safe to be out of the facility by himself. During an interview on 02/05/2026 at 10:46 A.M. with the RNC revealed she struck out the dementia diagnosis for Resident #1 because he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments. She said she spoke to the MD and he said it was okay to discontinue the dementia diagnosis. She said she was not aware of the PASRR the MD signed on 11/11/2025 stating Resident #1 had a primary diagnosis of dementia. The RNC said she did not document the conversation or justification for changing the medical records. She said she had done a record review for Resident #1 because he had left the building but stated I don't know if I would say he eloped. She then stated she specifically reviewed Resident #1's records on 11/27/2025 because it was a random review. She then said she did record review for residents when an event happened, and residents went to the hospital. RNC indicated she was not aware that Resident #1 was care planned for dementia and dementia medication. During an interview on 02/05/2026 at 11:35 A.M. with Resident #1's MD, he stated Resident #1's diagnosis of dementia was discontinued on 11/27/2025 after he was informed by the facility that Resident #1's BIMS score was 13. The MD indicated the facility contacted him and he approved the diagnosis to be discontinued based on the BIMS score. He said he was not aware of Resident #1's exit seeking behaviors or elopement, and there was no documentation regarding Resident #1's exit seeking behaviors in his or his NP's notes. The MD said he did see Resident #1 was on medication for dementia. He said he did not know if Resident #1 was safe to leave the facility or ambulate independently.During an interview on 02/06/2026 at 1:09 P.M. with the DON, she said admitting nurses were responsible for opening care plans (when a resident was admitted ), and the managers (DON) and the MDS nurse will make changes or add to it. The DON said care plans were important because care plans show staff how to take care of residents; care plans that were not updated were a risk because staff could miss out on giving specific care or whatever was needed for that resident.During an interview on 02/06/2026 at 2:40 P.M. with the ADM revealed the MDS nurse, the DON, and ADONs were responsible for care plans and nurses could assist with care plans. He said care plans were important because they made sure staff were providing adequate and the right care for residents. The ADM indicated staff discuss changes in residents' care in morning meetings and if there were changes, staff made changes to residents' care plans. He said sometimes staff were late to making changes, but they catch up. The ADM stated the risk of not having an updated care plan depended on the situation, but care plans needed updated and that was why staff monitor every day. He indicated the facility had care plan conferences with families and the SW and constantly updated care plans. The ADM said they could not have a resident without an updated care plan, and it could be like a risk of not giving a resident medication. The ADM indicated he did not know why Resident #1's care plan was not updated, and he continued to be given medication for dementia. He said maybe something happened around that time (i.e. Thanksgiving); but it was not an excuse to not update it. During an interview on 02/06/2026 at 3:24 P.M. with RN J, she stated care plans were important because it's like your guide to care. It gives you something to follow when you are providing care. Record review of the facility's care planning policy, dated 10/24/2022, reflected: PurposeTo ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. PolicyI. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines.II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/[sic]NDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases. Procedure.VIII. A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative.B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan. IX. Each resident's Comprehensive Care Plan will describe the following:A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment. X. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment, and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. XI. The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following individuals:A. The Attending Physician;B. The Resident Assessment Coordinator;C. The Licensed Nurse who has responsibility for the resident;D. The Dietary Supervisor and/or registered dietician;E. Social Service staff member responsible for the resident;F. The Activity Director;G. Therapists as applicable;H. Consultants (as appropriate);I. The Director of Nursing (as applicable);J. Certified Nursing Assistants and/or RNAs responsible for the resident's care;K. The resident and/or his/her family or legal representative;i. If the resident and his/her resident representative participation is determined not practicable for the development of the resident's care plan, an explanation should be included in the resident's medical record.L. Other individuals as appropriate or necessary.a. The resident has the to identify individuals or roles to be included in the care planning process. XI. Resident Rights - Care PlanningA. The resident has a right to be informed, in advance, of changes to the plan of care.B. The resident has the right to receive the services and/or items included in the plan of care.C. The resident has the right to see the care plan, including the right to sign after significant changes are made to the plan of care. XII. IDT MeetingsA. The Facility will invite the resident, if capable, and their family to care planning meetings and use its best efforts to schedule care planning meetings at times convenient for the resident and family.i. When a resident does not have family, or if the resident/family requests it, the IDT will invite the Ombudsman to attend the care planning meeting. B. IDT meetings may be conducted via teleconference. XIII. The IDT will revise the Comprehensive Care Plan as needed at the following intervals:A. Per RAI schedules;B. As dictated by changes in the resident's condition;C. In preparation for discharge;D. To address changes in behavior and care; andE. Other times as appropriate or necessary.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access for four (Resident #1) of ten residents reviewed for medication storage. The facility failed to ensure there was no nasal spray inside Resident #1's room on 10/21/2025. This failure could place residents at risk of misuse of medications that could lead to overdosing or underdosing.Findings included: Record review of Resident #1's Face Sheet, dated 10/21/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with failure to thrive (significant decline in physical and emotional well-being), depression (persistent feeling of sadness or loss of interest), anxiety (intense or excessive fear or worry), and malignant ascites (accumulation of fluid in the belly due to cancer). Record review of Resident #1's Comprehensive MDS Assessment, dated 10/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had cancer, depression, and anxiety. Record review of Resident #1's Comprehensive Care Plan, dated 10/09/2025, reflected the resident had a terminal prognosis related to hepatic malignancy and one of the goals was the resident would be free from depression and anxiety. One of the interventions was to assess the residents coping strategies. The Comprehensive Care Plan did not indicate that the resident can administer his medications. Record review of Resident #1' Physician Order on 10/21/2025 reflected the resident did not have an order for nasal spray. Record review of Resident #1's Assessment Notes on 10/21/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. During an observation and interview on 10/21/2025 at 8:35 AM, revealed Resident #1 was in his bed, awake. it was observed that a nasal spray was on top of his side table in plain view. When asked about the nasal spray, the resident said he got the medication when he was admitted to a hospital and the medication had been on his side table. During an observation and interview on 10/21/2025 at 8:58 AM, LVN B stated there should be no medications inside the rooms of the residents unless they had an assessment that they could self-administer their medications. She said it might result in overmedication. She said the residents might be taking them every hour and nobody would know. She said if the resident was not taking the medication, confused residents might enter the room and might get hold of the medication. She went inside Resident #1's room and saw the nasal spray on the resident's side table. She took the nasal spray and said she would put it inside the medication room. She said she did not notice the medications when she did her rounds. She said the medications should be inside the cart if the resident needed it so the staff could administer it. She said she did not know who left the medications inside the rooms of the residents. She said she would also contact the resident's family member to know if they brought the medication and educate them about letting them know if they were bringing any medication. In an interview on 10/08/2025 at 11:35 AM, ADON A stated there should not be any medications inside the residents' rooms because the resident might be confused and use the medications as often as they want without anybody monitoring it. She said other confused residents might enter the room and use the medication as well. She said the other residents might be allergic to it or use it in a different route. She said the resident might be suffering from any psychological disorder. She said she would also check if Resident #1 needed the nasal spray so they could request an order for the nasal spray so the staff could administer it. She said the expectation was for the staff to always scan the rooms for any medications inside. She said they already started an in-service about medication storage as soon as they were notified that medications were observed inside Resident #1's room. In an interview on 10/21/2025 at 12:06 PM, the DON stated the nasal spray should not be inside Resident #1's room. She said according to Resident #1, the nasal spray was from the hospital when he was admitted . The DON said, even though the resident was not using it, it should not be inside the room. She said she would check with the resident if he needed the nasal spray so she could get an order for it. She said the risk could be the resident using it without any assessment and might be using it more than as ordered, and nobody would know. She said she already started an in-service about medication storage. In an interview on 10/21/2025 at 1:21 PM, the Administrator stated the expectation was for the staff to scan the rooms of the residents when they do their rounds because medications inside the rooms of the residents could be harmful for the residents. He said the DON already started an in-service and he would monitor the staff adherence to the policy. Record review of the facility's policy entitled, Medication Storage in the Facility P & P revised 03/2025 reflected Policy: Medications and biologicals are stored safely, securely . The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 6 residents reviewed for ADL's. The facility failed to ensure Resident #1 had his fingernails trimmed and cleaned.These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Record review of Resident #1's annual MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of lack of coordination, unsteadiness on feet, muscle weakness, and hypertension (elevated blood pressure). He had a BIMS of 10 indicating his cognition was moderately impaired. He required partial/moderate assistance with personal hygiene. Record review of Resident #1's Comprehensive Care Plan last revised 08/31/25 reflected the following. Focus: [Resident#1] has an ADL Self Care Performance Deficit related to Activity Intolerance. Goal: [Resident#1] will improve current level of function in. and Personal Hygiene, ADL Score through the review date. Interventions/Tasks: Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist. An observation on 9/11/25 at 10:40 AM revealed Resident #1 was lying in bed. The nails on both his hands were approximately 0.5cm in length, extending from the tip of his finger, and the fifth fingernails on both hands were chipped. The nails were discolored tan, and the underside had dark brown colored residue. Resident #1 stated he wanted his fingernails trimmed and cleaned. In an interview on 09/11/25 at 10:45 AM, LVN A looked at Resident#1 fingernails and stated they needed to be cleaned and trimmed. LVN A said CNAs and charge nurses were responsible for residents' fingernail care. She stated CNAs were allowed to cut the residents' nails if they were not diabetic. She said she would trim and clean Resident #1's nails right now. LVN A stated the risk to residents was skin break down if they scratched themselves, and infection. In an interview on 09/11/25 at 3:29 PM the DON said all the staff were responsible for making sure residents' fingernails were cleaned and trimmed. The DON further stated nail care should be done as needed and every time aides washed the residents' hands. The DON said nails should be observed daily. The DON said nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON said she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON said if the resident refused, she expected the CNAs to notify the nurse and family. The DON stated the risk to residents they could scratch themselves, and development of infection. Record review of the facility's policy titled, Grooming Care of the Fingernails and Toenails undated, reflected, Purpose: Nail care is given to clean and keep the nails trimmed .

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three (CNA A) staff members and eight of eight residents (Resident #81, #30, #10, #50, #62, #52, #91 and #73) reviewed for infection control procedures. CNA A failed to perform hand hygiene after direct contact with residents #81, #30, #10, #50, #62, #52, #91, and #73 while serving meals on Hall 600. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #81's 5-day [other payment] MDS assessment, dated 10/03/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included: schizoaffective disorder (mental illness), and depressive disorder (mental illness). Resident #81 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #30's quarterly MDS Assessment, dated 11/22/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included: hypertension (high blood pressure) and Cerebral infarction (stroke). Resident #30 was alert and oriented, able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #10's quarterly MDS Assessment, dated 12/07/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: Hypertension (high blood pressure), Parkinson's disease (disease of muscle and nerves), and cerebral vascular disease (stroke). Resident #10 was alert and oriented and able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #50's quarterly MDS Assessment, dated 12/13/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #50 had diagnoses which included: Hypertension (increased blood pressure), depressive disorder (mental illness), and muscle wasting (weakness). Resident #50 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #62's quarterly MDS Assessment, dated 12/11/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #62 had diagnoses which included: Hypertension (increased blood pressure), depressive disorder (mental illness), and muscle wasting (weakness). Resident #62 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #52's quarterly MDS Assessment, dated 12/05/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #52 had diagnoses which included: Hypertension (increased blood pressure), cerebral vascular disease (stroke), and muscle wasting (weakness). Resident #52 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #91's quarterly MDS Assessment, dated 12/06/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #91 had diagnoses which included: Diabetes (increased blood sugar), seizures (brain disorder), and psychotic disorder (mental illness). Resident #91 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #73's quarterly MDS Assessment, dated 12/16/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #73 had diagnoses which included: Hypertension (increased blood pressure), peripheral vascular disease (poor circulation), and osteomyelitis (infection of the bone). Resident #73 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Observation on 01/07/2025 beginning at 8:00 a.m., revealed CNA A had walked down the hallway, did not use hand sanitizer, and served a breakfast tray to Resident #81, touched, and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #81 assisting him to sit up and prepared the meal tray for the resident to eat his breakfast. CNA A did not have on gloves. CNA A was observed to not wash her hands or use hand sanitizer, available in the hallway and in her pocket, that had been provided to her by another staff member. Observation on 01/07/2025 beginning at 8:05 a.m., CNA A was observed to enter Resident #30's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:07 a.m., CNA A was observed to enter Resident #10's room touching the resident on the shoulder and hand, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:08 a.m., CNA A was observed to enter Resident #50's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:10 a.m., CNA A was observed to enter Resident #62's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:11 a.m., CNA A was observed to enter Resident #52's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:12 a.m., CNA A was observed to enter Resident #91's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:15 a.m., CNA A was observed to enter Resident #73's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. An interview on 01/07/2025 at 8:25 a.m., CNA A stated she did not complete hand hygiene after having direct contact with residents. CNA A stated she was supposed to use the hand sanitizer in between serving each tray or wash her hands and she had some hand sanitizer in her pocket that had been provided by another staff member earlier. CNA A said she had been educated on completing hand hygiene. CNA A stated she did not sanitize her hands, after the first meal tray that was served because she had been called in to work and she was trying to get the breakfast trays served and she did not want the food to get cold. CNA A stated she knew she could spread germs if she did not clean her hands. An interview with the DON on 01/08/2025 at 11:00 a.m., revealed that all staff must complete hand hygiene after having contact with residents. She stated CNAs were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray service. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON was the infection control preventionist and she stated they had completed hand washing and hand sanitizing in recent in-services and provided the CNAs with pocket size hand sanitizer. An interview with the Administrator on 01/08/2025 at 11:15 a.m. revealed he could not believe that staff member had not followed their education concerning meal service and hand sanitizer. The Administrator stated he and the DON had both in-serviced and provided personal pocket hand sanitizer to the staff and educating them on the spread of germs, which could happen if they did not practice appropriate hand sanitizing. Record review of an in-service dated November 2024 revealed CNA A received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted in November 2024 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands before starting meal service and use hand sanitizer between each tray served. Record Review of an in-service dated December 2024 revealed CNA A received hand washing and hand sanitizing in-service explaining when to wash hands and when to use hand sanitizing and why to wash your hands and use the hand sanitizer. Further review reflected the use of alcohol gel or washing hands between each meal service tray. Record review of the Facility's Policy titled Hand Hygiene revised June 2020 reflected: To ensure that all individuals use appropriate hand hygiene while at the facility . The facility considers hand hygiene the primary means to prevent the spread of infections . I. Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections III. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . IV. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hands rub, etc.) are readily accessible and convenient for the staff use to encourage compliance with hand hygiene policy. V. Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to . A. Wash hands with soap and water: . vi. Before and after food prep . 8. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. immediately upon entering a resident occupied area (single or multiple bed room, procedures or treatment room) regardless of glove use; .ii. Immediately upon exiting a resident occupied area 9 e.g., before exiting into a common area such as a corridor) regardless of glove use; . iii. Before moving from one resident to another in a multiple-bed room or procedure area regardless of gloves use

Based on interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #36) of seven residents reviewed for abuse. The facility failed to ensure Resident #36 was free from abuse. On 3/07/2024 Hospitality Aide B called Resident #36 trash and used profanity when speaking to Resident #36. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 3/07/2024 and ended on 3/12/2024. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #36's Quarterly MDS dated [DATE] revealed Resident #36 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anxiety, depression, and schizophrenia (a mental disorder). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment) and Section E of the MDS revealed no behavioral symptoms were present. Record review of Resident #36's undated care plan revealed Resident #36 was at risk for altered moods and depression. Record review of the PIR dated 3/07/2024 revealed on 3/07/2024 that Resident #36 reported Hospitality Aide B called him trash and used profanity. In an interview on 1/07/2025 at 8:32 a.m., Resident #36 reported a hospitality aide called him trash three times and used profanity. Resident #36 stated that the staff member was terminated and no one else had ever spoken to him like that again. Resident #36 stated the incident did not hurt him but made him mad. Resident #36 stated it was just words, and once she was gone that it was over with. In an interview on 1/07/2025 at 10:04 a.m., Hospitality Aide B stated Resident #36 came out of nowhere telling her that she was always talking about other people. Hospitality Aide B stated Resident #36 cursed at her and called her names. Hospitality Aide B stated she then asked Resident #36 if she was all of the things he called her, then did that mean that he was white trash. Hospitality Aide B stated she was fed up with Resident #36 and started calling him names like trash. Hospitality Aide B reported she then left the area and reported Resident #36 to the nurse. Hospitality Aide B stated her actions may be abuse, but Resident #36 was abusing her. Record review of witness statements dated 3/7/2024 revealed two residents witnessed the incident and confirmed the Hospitality Aide called Resident #36 trash. In an interview on 1/07/2025 at 10:40 a.m., the ADM reported the two residents that witnessed the incident were not available for interview because one had passed away and the other transferred to another facility. In an interview on 1/07/2025 at 9:46 a.m., the DON reported Hospitality Aide B was immediately suspended when Resident #36 reported the incident. The DON reported Hospitality Aide B acted like the incident was not a big deal because Resident #36 had a BIMS of 15. The DON reported Hospitality Aide B was terminated, safe surveys were completed to ensure no one else was affected by the incident, a trauma assessment was completed on Resident #36 that revealed no harm, and all staff were in-serviced regarding verbal abuse and customer service. The DON stated the risk to the residents depended on their life experiences but could have placed them at risk for trauma. The DON stated prior to this incident that all employees received training over abuse and neglect during orientation and in-services as needed afterwards. The DON stated all staff were responsible for monitoring everyone and reporting any signs or incidents of abuse or neglect to the administrator. In an interview on 1/07/2025 at 10:40 a.m., the ADM reported Hospitality Aide B was immediately suspended after the incident was reported. The ADM reported when he spoke with Hospitality Aide B that she admitted to calling the resident trash. The ADM stated Resident #36 told him he was fine and there was no harm to him. The ADM stated cursing at a resident or calling them names was bad customer service. The ADM stated customer service training included resident rights and abuse and neglect. Record review of facility policy titled Abuse Prevention and Prohibition Program, with a revision date of 10/24/2022, revealed Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse. The facility took the following actions to correct the noncompliance prior to the investigation: In an interview on 1/07/2025 at 9:46 a.m., the DON reported Hospitality Aide B was terminated, safe surveys were completed to ensure no one else was affected by the incident, and all staff were in-serviced regarding verbal abuse and customer service. Record review of Hospitality Aide B's employee file revealed Hospitality Aide B was placed on suspension 3/07/2024 and employment was terminated on 3/12/2024 for violation of policy and procedure. Record review of safe surveys dated 3/12/2024 revealed all residents responded they were not abused, were treated with respect, and felt comfortable telling the staff about their concerns. Record review of in-service titled Abuse and Neglect, with a date of 3/7/2024, revealed 44 staff signatures and the summary listed on the in-service stated, We are not to engage in any type of verbal altercation with any residents, it is a form of verbal abuse. The residents have the right to say what they like. We are to remain professional and walk away, report behaviors to their charge nurse. In an interview on 1/08/2025 at 4:34 p.m., the DON reported they included training specifically for verbal abuse and started checking the staff's knowledge during their in-services by asking the staff questions about abuse and customer service. The DON stated she and the administrator completed daily knowledge checks and education with every shift for 30 days. The DON reported after 30 days they did weekly checks and education for four weeks. The DON stated after that they started doing monthly in-services that included knowledge checks and education that would continue every month from now on. The DON stated she was responsible for ensuring all staff were educated. The DON stated she or the ADM would initial when the checks were completed on a form. In an interview on 1/08/2025 at 4:40 p.m., the ADM confirmed that after this incident knowledge checks and education were performed on every shift for 30 days. The ADM stated they did weekly education and knowledge checks after that, and then monthly education and knowledge checks were completed. The ADM stated he reviewed the education and knowledge check sheets with the DON every month to ensure they were completed. Record review of March calendar with title Resident's Rights, Abuse and Neglect, Customer Service revealed initials daily by the DON and ADM from March 8, 2024, until March 31, 2024. Record review of April calendar with title Resident's Rights, Abuse and Neglect, Customer Service revealed initials daily by the ADM from April 1, 2024, until April 7, 2024. Initials by the DON or ADM were present weekly or more often from April 8, 2024, until April 30, 2024. Record review of May calendar with title Resident's Rights, Abuse and Neglect, Customer Service revealed initials on dates May 3, 15, and 26th by the DON or ADM. Record review of in-service binder revealed in-services titled Abuse and Neglect, were completed monthly from June 2024 until December 2024. In an interview on 1/07/2025 at 7:53 a.m., Housekeeper C reported cursing at a resident would be verbal abuse. Housekeeper C stated he receives training for abuse and neglect about twice a month and was trained before he started working. Housekeeper C stated the DON provides the trainings and asks the staff questions about abuse to make sure they understand. In an interview on 1/07/2025 at 7:55 a.m., Housekeeper D stated she receives training on abuse and neglect at least monthly, and it includes verbal abuse. Housekeeper D described verbal abuse as yelling or cursing at residents. In an interview on 1/07/2025 at 10:24 a.m., Activities Coordinator E stated cursing at a resident would be verbal abuse. Activities Coordinator E stated that getting loud with a resident could be verbal abuse, and if staff was not able to handle a situation, then they should go get someone else. Activities Coordinator E reported she receives training on customer service and abuse monthly. Activities Coordinator E reported customer service training teaches staff how to treat residents with respect. In an interview on 1/07/2025 at 12:44 p.m., RN F stated they do abuse and neglect training monthly that includes verbal abuse. RN F also stated that there is training on customer service. RN F reported customer service is speaking to the resident in a calm tone and not using bad language. In an interview on 1/07/2025 at 1:14 p.m., RN G reported she receives monthly training for abuse and neglect that also included customer service. RN G stated cursing is verbal abuse and that she would immediately intervene if she witnessed any abuse. In an interview on 1/08/2025 at 9:15 a.m., LVN H reported she had monthly training on abuse and neglect. LVN H stated training included customer service and verbal abuse. LVN H described verbal abuse as calling the residents names or speaking to the resident in an offensive way. In an interview on 1/08/2025 at 10:32 a.m., RN I stated she received abuse and neglect training when she first started. RN I reported that abuse and neglect trainings were done monthly and included verbal abuse. RN I stated verbal abuse means you could not talk to residents any way you want to. RN I stated you have to be respectful to the residents. In an interview on 1/08/2025 at 10:37 a.m., MA J reported he had abuse and neglect training monthly that included verbal abuse. MA J stated verbal abuse was spoken words that were inappropriate and offensive to the person that was spoken to. In an interview on 1/08/2025 at 10:40 a.m., CNA K stated she received training for abuse and neglect monthly and it included verbal abuse. CNA K described verbal abuse as someone cursing at a resident or yelling at a resident. In an interview on 1/08/2025 at 10:51 a.m., CNA L reported abuse and neglect training was done monthly with the DON and ADM. CNA L described verbal abuse as swearing at residents or belittling the residents or anything said in a negative form. In an interview on 1/08/2025 at 10:56 a.m., Hospitality Aide M stated she received abuse and neglect training prior to working the floor and received it monthly now. Hospitality Aide M reported verbal abuse was included and that verbal abuse was when you talked to the resident in a mean way that you were not supposed to be doing. In an interview on 1/08/2025 at 11:00 a.m., Hospitality Aide N stated she started working two days ago and received training on abuse and neglect before she worked the floor. Hospitality Aide N stated the training included verbal abuse and stated verbal abuse could be mistreating the resident with your tone or using curse words.

Based on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 4 residents (Resident #1 and Resident #3) reviewed for accuracy of assessments. 1. Resident #1's discharge MDS assessment dated [DATE] did not address his BIMS (Section C), his Mood (Section D), Behaviors (Section E), The MDS did not address the resident's Pain (Section J) to accurately reflect his current MD order for pain management. 2. Resident #1's quarterly MDS assessment dated [DATE] did not address Mood (Section D), Behaviors (Section E), The MDS did not address the resident's Pain (Section J) to accurately reflect his current MD order for pain management. 3. Resident #3's admissions MDS assessment dated [DATE] did not address Section I medical diagnosis of anxiety and depression, Section N did not address active diagnosis for depression and anxiety. Section O special treatments did not address her Central PICC line catheter, while a resident and at discharge. 4. Resident #3's admissions MDS Discharge MDS dated [DATE] did not address her BIMS in Section C, Section D for Mood. Section I did not address anxiety. Section N did not address anti-anxiety medication. Section O did not address Resident #3's Isolation and quarantine, oxygen treatment, IV medications, Vasoactive mediations, Anticoagulant, Antibiotics, IV access of a central PICC line catheter, use of Vasoactive medications, antibiotics, and anticoagulant, at the time of discharge. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #1 The resident was not observed or interviewed as he was discharged on [DATE]. In a record Review of Resident #1 face sheet dated 11/07/24 reflected he was a [AGE] year-old male that was admitted on [DATE] and discharged home on 04/03/24. Resident's current DX: Poly Substance Abuse, Schizophrenia, Lymphedema, insomnia (trouble sleeping) Type 2 DM, Schizophrenia In a record review of Resident #1 discharge MDS dated [DATE] completed by MDSC R reflected that the section for the BIMS score was empty. Sections D and E did not address mood or behaviors. Section GG reflected that resident #1 required supervision and touching for eating, oral hygiene, toileting, shower, dressing, and general hygiene. The resident uses a motorized wheelchair for mobility. Section I addressed his diagnosis of Schizophrenia. Section N use of antidepressant. Resident refused a referral for placement and discharge. The MDS was approved by the DON on 04/17/24. In a record review of Resident #1 (q) MDS dated [DATE], reflected he had unclear speech, communicate his needs; BIMS score of 15 indicating he was cognitively intact. the MDS did not indicate any behaviors or moods scoring 0. Resident active DX of Schizophrenia was addressed DM3; Heart failure, and HBP. Pressure reducing mattress for bed takes antidepressant. Section J did not address his diagnosis of pain. In a record review of Resident #1's revised Care plan dated 03/06/24 reflected resident has a history of making false allegations as evidenced by previously offering staff money for sexual acts .interventions investigate, if allegations are false the staff will reorient and redirect as needed with reassurance and reality orientation. The staff will investigate allegations/statements as per facility policy. The resident has a behavior problem r/t (offering staff money for inappropriate sexual behaviors. interventions discuss the resident behaviors. Explain/reinforce why behaviors are inappropriate and/or unacceptable. Monitor behaviors and attempt to determine the underlying cause. Take a second person in the room, when available. In a record review of Resident #1's MD progress note dated 03/08/24 reflected he had a history of substance abuse; VS have remained stable .complained of chronic knee pain. t Normal cognition, Psychologic Oriented X 3, Clear and Lucid (clear and understand), Normal Mood (state of mind)/affect. DX: Insomnia (trouble sleeping) poly substance abuse (illegal drug use), Schizophrenia (mental disorder hallucinations.) per records not treated, and major depressive disorder (mental disorder that includes low mood) (not being treated). MD E informed nurse to contact Pain management. Nursing denies any changes in conditions or any new issues. In an interview with MD E on 11/08/24 at 1:00 PM she stated that Resident #1 was not treated for his mental illness of MDD and Schizophrenia. She had no concerns about his behaviors. She stated that he does not appear to be using illegal substances or suspected at the time of her visits. In a record review of Resident #1's Hospital PASSR Screening Level 1 dated reflected he had a Mental Illness in Section C. The PL1 is completed with suspicion of positive PASSR eligibility and therefore submitted with the Preadmission type of admission because the LA is the submitter. In a record review of the document titled undated Active Residents with PASSR Positive PE provided by the ADM on 11/08/24, did not list Resident #1. Resident #3 In a record review of Resident #3's face sheet dated 11/07/24 reflected he was a [AGE] year-old female that was admitted on [DATE] and she was discharged on [DATE] at 7:20 AM to the hospital. Resident's current DX were COPD (lung disease that damages the lungs and airway) Severe Asthma, Methicillin Resistant Staphylococcus Aureus (MRSA - Infection of skin and soft tissues). In a record review of Resident # 3's Admission evaluation, completed by RN J and dated 04/11/24, reflected resident had oxygen equipment to be administered 3 LPM by nasal cannula. In a record review of Resident # 3's Admission MDS assessment dated [DATE] completed by LVN R reflected she had a BIMS score of 13 indicating she was cognitively intact. Section GG addressed Resident #3's functional capabilities reflecting she used a wheelchair for mobility. Resident #3 required supervision and touching assistance for eating. She required partial staff assistance for oral hygiene, and she was dependent on staff for showers and ADL hygiene care Section I medical diagnosis did not address diagnosis for anxiety. Section N did not address Resident #3's active diagnosis. Section O special treatments did not address her Central PICC line catheter, while a resident and at discharge. In a record review of Resident # 3's discharge MDS dated [DATE] completed by LVN R reflected Resident #3 was discharged on [DATE] to a hospital. Section C cognitive patterns, C0500 BIMS summary score was left blank. Section E behaviors E 0800 rejection of care. did not address Resident #3's behavior of resisting care. Section I titled Active Diagnosis did not address Resident #3's diagnoses of anti-anxiety, DM 2, Section N titled Medications N0415 high risk drug classes did not address Resident #3's anti-anxiety medication use. Section O titled special treatments, procedures, and programs was left blank, and did not address Resident #3's oxygen treatment, H1. IV medications IV intravenous therapy medications (a way to administer fluids directly into a vein), O1 IV Access, O4, central (PICC Percutaneous Indwelling Central Catheter) (catheter device that enters the boy through the skin and remains for a period of time), isolation quarantine for active infections, IV medications Vasoactive medications), while a resident or at discharge. In a record review of Resident # 3's care plan dated 04/11/24 reflected Resident #3 has a DX of MRSA Colonization. Intervention contact isolation wear gowns, mask, changing contaminated linen. Give antibiotic therapy as ordered standard precautions for infection control. Resident has oxygen therapy r/t respiratory illness monitor for s/sx of distress and report to MD. Resident has impaired cognition function/dementia or impaired thought process. Administer medication as ordered, discuss concerns of confusion and disease process, consistent routine for resident. Resident is resistive to care. Allow the resident to make decisions about treatment regime. In a record review of Resident # 3's physician order dated 04/11/24 reflected respiratory evaluation before and after nebulizer (device used to administer medications into the lungs) treatments every shift. Order dated 04/12/24 for PICC Flush 5mL of NS every shift. Order dated 04/12/24 Vancomycin Intravenous Solution use 250 ml intravenously (by use of needle) every 8 hours for pneumonia. In a record review of Resident # 3's April 2024 MAR reflected resident entry on 04/11/24 and oxygen was checked every shift .SOB, order O2 at 2 liters per minute via NC every shift 04/12/24 at 12:36 AM. In a record review of Resident #3's hospital records dated 04/08/24 reflected a past medical history or severe persistent asthma and COPD on 2L NC at baseline admitted to the ICU on 3/14 for acute respiratory failure due to status asthmaticus requiring intubation. Initial concern for fungal infection started on voriconazole (anti-fungal medications used to treat infections. Respiratory cultures reflected she was + (positive) MRSA on 3/20/24. She required prolonged intubation and finally extubated on 4/2/24. Post-extubating developed new pulmonary opacity with fever and repeat cultures still + (positive) MRSA. She was restarted on cefepime and vancomycin (antibiotic). Currently on 4L NC. In an interview on 11/12/24 at 12:00 PM, the MDSC H stated that the MDS for Resident #1 and Resident #3 was completed by the previous MDSC, MDSC R. MDSC H stated she was not employed at the time of Resident #1 and 3's admission or discharge. MDSC H would not answer any more questions about MDS. In an interview on 11/12/24 at 12:08 PM, the ADON revealed she was new employee. The ADON stated that the MDS Coordinator was responsible for ensuring the assessment accurately reflected the resident medical conditions, level of functioning, diagnosis, and treatment for care while at the facility. She stated that an inaccurate assessment could lead to residents decline in care. In an interview on 11/12/24 at 12:15 PM, the SW revealed she was responsible for completed the sections D Mood, E Behaviors, and C Cognitive on MDS. She stated that MDSC R completed the discharge MDS and quarterly MDS for Resident #1 and Resident #3 at the time. The SW said it would have been the responsibility of the MDS C to completed, review, and correct other sections of the MDS. The SW stated if the assessment was not accurate, the current status of the resident would not be correct, therefore, it could result in the resident not getting the appropriate care needed. In an interview on 11/12/24 at 12:30 PM, the DON, revealed she was familiar with Resident #1 and Resident #3. She stated the MDSC was responsible for completing and updating MDS assessments. She stated Resident #1 exhibited behaviors during the MDS look back and Resident #3 was admitted and discharged with orders for oxygen treatment via NC, PICC line, IV, and antibiotic use. The DON stated she updated Resident # 1's care plan on 03/28/24 to reflect his behaviors. She also completed Resident #3's care plan addressing her medical treatments for infection and oxygen. She stated that failing to accurately address the resident's care would be diminished due to incorrect documentation. In an interview with the ADM on 11/12/24 at 1:58 PM revealed he was familiar with both Residents #1 and #3. He stated confirmed proving the MDS dated [DATE] via email as the most recent assessment. The ADM stated that Resident #1 demonstrated verbal aggression with inappropriate sexually provocative language to female staff while being a resident and at the time of his discharge date [DATE]. He stated it was his expectation for the MDS to be accurate and reflect resident care and medical conditions. The ADM stated the MDS Coordinator was responsible for completing the MDS assessment. In a record review of facility policy dated 08/22/24 titled RAI Process reflected Policy: The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual. Each MDS section will be completed by the responsible individual. Each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed. All information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD) Validation: Verify that all MDS assessments in the file were transmitted. Check the Final Validation Report for critical and data integrity errors. In a record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1 dated October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts . In addition, the assessment must represent an accurate picture of the resident's status during the observation period of the MDS. appropriate participation of health professionals must be based on the physical, mental, and psychosocial condition of each resident. This includes an appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments reference SUBPART - Subpart B-Requirements for Long Term Care Facilities.

Based on observation, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (300 and 600 hall shower rooms) of three shower rooms reviewed for environmental conditions. The facility failed to ensure the shower rooms on the 300 hall and 600 hall were free of a black substance in between the tiles. This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Observations on 03/12/24 from 3:10 p.m. to 3:20 p.m., of the shower rooms on the 300 and 600 halls revealed the following: - The 300-hall shower room had a black substance, about 6 inches in length, on the left wall of the shower in between the grout where the wall tile and floor tile met. - The 300-hall shower room had a black substance, about 15 inches in length, on the back wall of the shower in between the grout of the tiles. - The shower room on the 600-hall had a black substance, about 4 inches in length, on the back wall of the shower in between the grout where the wall tile and floor tile met. In an interview on 03/12/24 at 3:53 p.m., the HSKS stated the RD showed her the areas of black substance in the 300 and 600 hall shower rooms. The HSKS stated housekeeping staff cleaned the showers with bleach and no-rinse sanitation solution. The HSKS stated staff would clean the shower rooms twice daily and after each use. The HSKS stated she believed the black substance was a buildup of soap scum. The HSKS stated she and her staff had tried to clean the showers grout by scrubbing them, but they were unable to scrub the substance off, so the showers would be regrouted. The HSKS stated residents were not affected by the black substances in the showers because the showers were sanitized after every use with a sanitizers that killed all organisms. The HSKS stated she would in-service her staff on cleaning and when to report conditions to herself and the maintenance director. In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the expectation for the facility be clean and sanitary at all times, which was a responsibility of all facility staff. The ADMIN stated if facility staff noticed a needed repair, it was expected of them to report the issue, so it could be repaired. The ADMIN stated the residents were not affected by the black substances in the shower because the showers were cleaned daily and after each use with a sanitizer solution. The ADMIN stated the facility in-service facility staff on facility cleanliness, and maintenance request submission. The ADMIN stated he would monitor the condition of the shower rooms in the future to ensure the shower rooms were clean and in sanitary condition. Record review of the facility's policy entitled Resident Room and Environment, revised in August of 2020, read in part: Purpose: To provide resident with a safe, clean, comfortable and homelike environment. Policy: The facility provides residents with a safe, clean, comfortable and homelike environment . Procedure: I. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; .

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for one (Resident #1) of six residents reviewed for ADLs. The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, resulting in the resident smearing fecal matter on his mattress, bed linens, window ledge and throwing the fecal matter on the floor of his bedroom. This failure could place residents at risk for discomfort, infection, and dignity issues. The findings included: Record review of Resident #1's face sheet, printed on 03/12/24, reflected Resident #1 admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (the loss of cognitive functioning), lack of coordination, apraxia following cerebral infarction (cognitive disorder that can occur after stroke), lack of coordination, obesity, hyperlipidemia (in excess of lipids or fats in your blood), essential (primary) hypertension (high blood pressure), heart failure, aphasia following cerebral infarction (a disorder that affects how you communicate), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body), muscle weakness, dysphagia - oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). Record review of Resident #1's quarterly MDS assessment, dated 02/25/24, reflected Resident #1 was not recommended for the brief interview for mental status. Section C - Cognitive Patterns, revealed Resident #1 had short-term and long-term memory problems and had severely impaired cognitive skills for decision making. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care indicated Resident #1 required substantial physical assistance in ADLs of oral hygiene, toileting, dressing and personal hygiene and was completely dependent on facility staff in ADLs of bathing. Record review of Resident #1's care plan, last reviewed on 12/12/23, revealed the following: [Resident #1] has bowel and bladder incontinence r/t Right sided paresis secondary to Multiple CVA . Interventions - INCONTINENT: Check [Resident #1] frequently and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes [Resident #1 has an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance . Interventions . Toilet use: self-performance Extensive assistance. Toilet use: support provided One-person physical assist. Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist. In an observation and interview on 03/12/24 at 2:32 p.m., Resident #1 was observed lying in his bed. Resident #1 stated he was well. Resident #1's room had a pungent smell of urine and stool. Fecal matter was observed on Resident #1's hands, on the floor, near the foot of his bed, on his bed linens and on the window seal near his bed. Resident #1 stated he did not know how long he had been left soiled. On 03/12/24 at 2:36 p.m., the surveyor notified RN A, which was the nurse assigned to Resident #1, of Resident #1's condition. RN A accompanied the surveyor to Resident #1's room and stated, he was not like this. RN A stated she was not sure where Resident #1's aide was, but she would ensure the resident was cleaned. On 03/12/24 at approximately 2:45 p.m., the ADMIN, DON, RD, and RN A, were observed to enter Resident #1's room. Shortly after their entrance, the ADMIN and RD exited, and Resident #1 could be heard yelling no. On 03/12/24 at 3:08 p.m., the RD stated to the surveyor, Resident #1 began to display a behavior of throwing his fecal matter around his room and refused to be changed. The RD stated Resident #1 would be referred for psychiatric services for the newly onset behavior. In an interview on 03/12/24 at 4:21 p.m., RN A stated it was the facility's expectation for residents to be dry at all times. RN A stated aides were to ensure residents were checked every 2 hours and incontinent care be provided, as needed. RN A stated she conducted rounds at roughly 2:15 p.m. and did not recall a stool smell in Resident #1's room. RN A stated residents would experience skin breakdown, if they were left soiled for too long. RN A stated she would conduct rounds on residents more often, to ensure incontinent care was provided at all times. In an interview on 03/12/24 at 5:53 p.m., the DON stated it was the facility's expectation that facility aides and nurses checked on resident every 2 hours and provided incontinent care when needed. The DON stated failing to provide incontinent care promptly could increase residents' chances of skin breakdown. The DON stated Resident #1's recently increased his refusals of care and this incident was his first time throwing his fecal matter. The DON stated she would begin to Inservice nursing staff on incontinent care and refusals. In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the facility's expectation for nursing staff to round every 2 hours, answer call lights as they are pressed and provide incontinent care when a resident was wet. The ADMIN stated not providing incontinent care when needed could cause a resident to have skin breakdown. The ADMIN stated if a resident was observed to be soiled, they were to be changed immediately. The ADMIN stated it was the responsibility of facility aides to provide incontinent care but, the nurse was also responsible for ensuring care was provided to residents as needed. The ADMIN stated the facility would begin to Inservice nursing staff on ADL care and incontinent care. Record review of the facility's policy entitle Perineal Care, revised in June 2020, read in part: Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need.

Based on observation, interview and record review, the facility failed to ensure all patient care equipment was in safe, clean, comfortable environment and maintainance services for six (Residents #52, #85, #38, #11, #16 and #27) of 18 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #52, #85, #38, #11, #16, and #27. These failures could place residents at risk for equipment that is in unsafe operating condition. Findings included: Review of Resident #52's quarterly MDS assessment, dated 11/04/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of CVA (Stroke) and limited range of motion lower limbs. Review of the Resident #52's plan of care dated 11/04/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:00 a.m. revealed Resident #52 was sitting in his wheelchair with no skin problems, the wheelchair's left armrest was cracked, and foam was exposed. Resident #52 stated the breaks did not work. The surveyor checked the brakes and they did not work. Resident #52 said that was the wheelchair he had been provided when he came to live at the facility. Review of Resident #85's quarterly MDS assessment, dated 11/09/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses lack of coordination and weakness. Review of the Resident #85's plan of care dated 11/09/23 with updates reflected goals and approaches to include wheelchair mobility. Observation on 11/13/23 at 10:21 a.m. revealed Resident #85 was in her wheelchair, and the wheelchair's left and right armrest had duct tape over the entire armrests. Resident #85 was asked about her wheelchair and she stated, It's bad. Review of Resident #38's readmission MDS assessment, dated 10/24/23, reflected she was a [AGE] year-old female readmitted to the facility on [DATE], with diagnoses of lack of coordination and weakness. Review of the Resident #38's updated plan of care dated 10/27/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:25 a.m. revealed Resident #38 was in her wheelchair, and the wheelchair's right armrest and lower support area were missing. Resident #38 stated the wheelchair was nice, but it was missing the right side. She said she had told the CNA, but couldnot recall who, about a week ago, but nothing had happened. Review of Resident #11's quarterly MDS assessment, dated 09/11/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses with schizophrenia and lack of coordination and weakness. Review of the Resident #11's updated plan of care dated 09/12/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:30 a.m. revealed Resident #11 was in her wheelchair with no skin problems, and the wheelchair's right armrest was missing and the left armrest was cracked with the foam exposed . Resident #11 was asked about the wheelchair, and she stated for the surveyor to go away. Review of Resident #16's quarterly MDS assessment, dated 09/29/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses with senile degeneration of the brain, and lack of coordination and weakness. Review of the Resident #16's updated plan of care dated 09/30/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:45 a.m. revealed Resident #16 was in her wheelchair with no skin problems, and the wheelchair's left armrest was cracked with the foam exposed . Resident #11 was unable to be interviewed. Review of Resident #27's annual MDS assessment, dated 09/25/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses with diabetes, muscle wasting and atrophy, and lack of coordination and weakness. Review of the Resident #27's updated plan of care dated 09/30/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 11:00 a.m. revealed Resident #27 was in her wheelchair with skin problems, and the wheelchair's left armrest was cracked with the foam exposed. Resident #27 stated her wheelchair was fine; she did not have any problems with the wheelchair . In an interview on 11/15/23 at 12:27 p.m. CNA D stated when a resident's wheelchair needed repair the staff were to write it in the maintenance log at the nurse's station. CNA D stated she had never written anything in the log though she usually told the maintenance man . In an interview on 11/15/23 at 12:30 p.m. LVN A stated when a resident's wheelchair needed repair the staff were to write it in the maintenance log at the nurse's station, tell the maintenance man and try to find a new wheelchair that was not being used . In an interview on 11/15/23 at 1:46 p.m. the Maintenance Director stated he repaired the wheelchairs when there was needed repairs. He stated staff were to place the needed repairs in the maintenance log located at the nurse's station. The Maintenance Director was informed about the residents' wheelchairs condition, and he stated if the wheelchairs had not been placed in the maintenance log,for repair he would not know. A review of the Maintenance log at the nurse's stations reflected there were no entries that indicated residents' wheelchairs needed the armrest repaired. A review of the facility's policy and procedure Maintenance Services dated December 2020 reflected maintenance services shall be provided to all areas of the building, grounds, and equipment . 1. The Maintenance Department is responsible for maintaining the .equipment in a safe and operable manner at all times .the Maintenance Director is responsible for developing and maintaining a schedule of maintenance serve to assure that the . equipment are maintained in a safe and operable manner

Based on observation, interview, and record review the facility failed to ensure certified nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care, for one (Resident #1) of five residents reviewed for accidents. CNA A failed to utilize her training knowledge when providing care for Resident #1 and ask for the appropriate amount of assistance the resident required, per her comprehensive assessment and plan of care. As a result, Resident #1 rolled out of the bed and onto the floor, landing on her face, suffering a periorbital and frontal soft tissue hematoma. This failure placed residents at risk for injury. Findings included: Review of Resident #1's facility admission record dated 01/24/19 reflected the resident was a [AGE] year-old female who admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 received tube feedings via gastrostomy tube, was severely cognitively impaired and required total assistance of 2 staff members for activities of daily living (ADL), including incontinence care. Review of the Care Plan dated 01/10/19 revealed Resident #1 had goals and approaches for impaired communication, and ADL needs requiring total assistance of two staff with all ADLs. Review of the CNAs plan of care for Resident #1 dated 01/10/19 revealed Resident #1 required a 2-person assist for toileting and bed mobility. Review of the CNAs documentation in the facility's database for the following dates 01/22/19 through 01/24/19 revealed CNAs checked marked that Resident #1 received assistance by 2 staff for incontinence and bed mobility. Review of the Fall with Injury Report dated 01/24/19 revealed Resident #1's assessment noted there was bleeding from the mouth, some bruising and swelling to the left side of the face, hematoma to the left eye, no loose teeth, no lacerations to the face or arms, and the resident was gasping like for breath, with an oxygen saturation of 96%. Further review revealed the statement of CNA A at this time reflected she was performing incontinence care without assistance of another staff member. Review of the hospital records for Resident #1, dated 01/24/19, reflected a Cat Scan of the head or brain (imaging of the brain) revealed an impression of a large, left periorbital and frontal soft tissue hematoma (black eye). Observation on 01/29/19 at 8:00 a.m. revealed Resident #1 in a hospital not intubated, oxygen mask on, sleeping, she had a large hematoma noted on her eye and her lips appear to be swollen. Interview on 01/29/19 at 10:00 a.m. with CNA A revealed she went into Resident #1's room on 01/24/19 around 10:45 p.m. to provide incontinence care without the assistance of another staff member. CNA A said she did not lock the brakes on the bed, and the bed was placed in a high position with the siderails down. The bed moved during repositioning and Resident #1 fell out of the bed, landing on her face. CNA A said she was concerned about the resident lying on her face since she had a gastrostomy tube, so she got her up against the wall and then went and got the nurse. CNA A said she did not try to get another staff member to help her. Interview on 01/30/19 at 2:27 p.m. with CNA A revealed she had never been able to lock the wheels on the bed that Resident #1 had been in. She could not recall if she had told anyone she could not lock the wheels. CNA A said that she had been working at the facility for about three months, and when she had cared for Resident #1 she had never asked for any help. She said she had never read the care plan in the CNA kiosk because she did not know how to work the kiosk, though she also said she was required to, and did, document resident care she provided in the kiosk. CNA A said she had completed orientation regarding resident care with another CNA. Interview on 01/25/19 at 8:50 a.m. with LVN B revealed she was at the nurse's station when CNA A came out of Resident #1's room and said she needed help with Resident #1. LVN B said when she entered the room Resident #1 was sitting up against the wall. The bed was in the highest position with the siderails down. LVN B said she was confused because CNA A said Resident #1 had fallen out of the bed when she was providing incontinence care. LVN B said there were pillows on the floor and blood on the face of Resident #1, with a large amount of swelling to the left side of her face. LVN B, with assistance, was able to place Resident #1 into the bed. Following her assessment, 911 was called, and Resident #1 was sent to the hospital. LVN B said she asked CNA A if she was providing incontinence care without assistance, and the CNA A said, yes. LVN B said she asked the CNA why she did not ask for assistance, and the CNA said everyone was busy and she was running behind so she just did it. Interview on 01/25/19 at 11:00 a.m. with LVN C revealed he had entered the room of Resident #1 with the other charge nurse (LVN B), and Resident #1 was propped up on the wall next to the door. After LVN B and LVN C assessed Resident #1, they placed her in the bed. The bed was in the highest position, but LVN C said she did not notice if the bed was locked. The bed did not move when the resident was placed in the bed. CNA A had said she was rolling Resident #1 to the side of the bed during incontinence care when the bed moved and the resident rolled out of the bed. The CNA said she had no assistance in the room. LVN C said Resident #1 required a 2-person assistance for incontinence care as she had spastic movements. Interview on 01/30/19 at 12:15 p.m. with the DON revealed CNA A had been working at the facility since (MONTH) (YEAR). The DON said the CNA had been working at another facility on campus and had asked to transfer to the building. The DON said she conducted an interview and allowed the CNA to transfer. CNA A was shown by another CNA how to use the kiosk for resident information and was oriented on the floors concerning the care of the residents. The DON said CNA A had been suspended when the incident occurred and had received one-on-one training concerning the kiosk, repositioning, and incontinence care. The DON said CNA A had a proficiency check-off while she was working at the other building. Review of the employee file for CNA A revealed an original hire date 08/16/18, with a transfer hire date of 10/17/18. The Certified Nursing Assistant Job Description reflected . perform all duties as assigned in accordance with facility's established policies/procedures, nursing care procedures and safety rules and regulations and was signed by CNA A when she was hired on 08/16/18. Further review of the employee file reflected on 08/16/18, CNA A had compliance training including abuse/neglect with post training and CNA duties including incontinence care with proficiency check off (including total care residents), fall prevention, body mechanics, and resident safety. Review of the policy/procedure CNA Duties dated (MONTH) (YEAR) revealed . check special assignments, document ADLs, check on the resident at the end of each shift . and are safe Review of the policy/procedure Falls Evaluation and Prevention dated (MONTH) (YEAR) . education of staff related to fall prevention providing a safe environment for residents, cause and risk factors or as the interventions to manage risk, safe transferring technique Observation on 01/29/19 at 9:00 a.m. revealed the bed that Resident #1 was in would not move when the brakes were locked. Interview on 01/29/19 at 8:43 a.m. with the Maintenance Director revealed he had inspected the resident's bed the following day after the accident occurred. The bed had four locks, one on each leg, and three of the four locks were fully functional. The lock on the top, right-hand corner of the bed would not completely lock. The Maintenance Director said at the time of his inspection, with the three brakes locked, he could not move the bed without dragging it. The Maintenance Director said he had not been made aware of the bed not locking prior to his inspection. The Maintenance Director said the Technician for the bed company had been contacted and was coming to inspect the bed. Review of the Service Visit from the bed technician, dated 01/31/19, revealed, . aftermarket wheels, some wear on the brakes, bed will not move, with no problems found

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision/assistance to prevent accidents for one (Resident #1) of five residents reviewed for accidents. CNA A failed to utilize the appropriate safety precautions and amount of assistance Resident #1 required while providing incontinence care for the resident, as documented in the resident's assessment and plan of care. As a result, Resident #1 rolled out of the bed and onto the floor, landing on her face, suffering a periorbital and frontal soft tissue hematoma. This failure placed residents at risk for accidents and injury. Findings included: Review of Resident #1's facility admission record dated 01/24/19 reflected the resident was a [AGE] year-old female who admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 received tube feedings via gastrostomy tube, was severely cognitively impaired and required total assistance of 2 staff members for activities of daily living (ADL), including incontinence care. Review of the Care Plan dated 01/10/19 revealed Resident #1 had goals and approaches for impaired communication, and ADL needs requiring total assistance of two staff with all ADLs. Review of the CNAs plan of care for Resident #1 dated 01/10/19 revealed Resident #1 required a 2-person assist for toileting and bed mobility. Review of the CNAs documentation in the facility's database for the following dates 01/22/19 through 01/24/19 revealed CNAs checked marked that Resident #1 received assistance by 2 staff for incontinence and bed mobility. Review of the Fall with Injury Report dated 01/24/19 revealed Resident #1's assessment noted there was bleeding from the mouth, some bruising and swelling to the left side of the face, hematoma to the left eye, no loose teeth, no lacerations to the face or arms, and the resident was gasping like for breath, with an oxygen saturation of 96%. Further review revealed the statement of CNA A at this time reflected she was performing incontinence care without assistance of another staff member. Review of the hospital records for Resident #1, dated 01/24/19, reflected a Cat Scan of the head or brain (imaging of the brain) revealed an impression of a large, left periorbital and frontal soft tissue hematoma (black eye). Observation on 01/29/19 at 8:00 a.m. revealed Resident #1 in a hospital not intubated, oxygen mask on, sleeping, she had a large hematoma noted on her eye and her lips appear to be swollen. Interview on 01/29/19 at 10:00 a.m. with CNA A revealed she went into Resident #1's room on 01/24/19 around 10:45 p.m. to provide incontinence care without the assistance of another staff member. CNA A said she did not lock the brakes on the bed, and the bed was placed in a high position with the siderails down. The bed moved during repositioning and Resident #1 fell out of the bed, landing on her face. CNA A said she was concerned about the resident lying on her face since she had a gastrostomy tube, so she got her up against the wall and then went and got the nurse. CNA A said she did not try to get another staff member to help her. Interview on 01/30/19 at 2:27 p.m. with CNA A revealed she had never been able to lock the wheels on the bed that Resident #1 had been in. She could not recall if she had told anyone she could not lock the wheels. CNA A said that she had been working at the facility for about three months, and when she had cared for Resident #1 she had never asked for any help. She said she had never read the care plan in the CNA kiosk because she did not know how to work the kiosk, though she also said she was required to, and did, document resident care she provided in the kiosk. CNA A said she had completed orientation regarding resident care with another CNA. Interview on 01/25/19 at 8:50 a.m. with LVN B revealed she was at the nurse's station when CNA A came out of Resident #1's room and said she needed help with Resident #1. LVN B said when she entered the room Resident #1 was sitting up against the wall. The bed was in the highest position with the siderails down. LVN B said she was confused because CNA A said Resident #1 had fallen out of the bed when she was providing incontinence care. LVN B said there were pillows on the floor and blood on the face of Resident #1, with a large amount of swelling to the left side of her face. LVN B, with assistance, was able to place Resident #1 into the bed. Following her assessment, 911 was called, and Resident #1 was sent to the hospital. LVN B said she asked CNA A if she was providing incontinence care without assistance, and the CNA A said, yes. LVN B said she asked the CNA why she did not ask for assistance, and the CNA said everyone was busy and she was running behind so she just did it. Interview on 01/25/19 at 11:00 a.m. with LVN C revealed he had entered the room of Resident #1 with the other charge nurse (LVN B), and Resident #1 was propped up on the wall next to the door. After LVN B and LVN C assessed Resident #1, they placed her in the bed. The bed was in the highest position, but LVN C said she did not notice if the bed was locked. The bed did not move when the resident was placed in the bed. CNA A had said she was rolling Resident #1 to the side of the bed during incontinence care when the bed moved and the resident rolled out of the bed. The CNA said she had no assistance in the room. LVN C said Resident #1 required a 2-person assistance for incontinence care as she had spastic movements. Interview on 01/30/19 at 12:15 p.m. with the DON revealed CNA A had been working at the facility since (MONTH) (YEAR). The DON said the CNA had been working at another facility on campus and had asked to transfer to the building. The DON said she conducted an interview and allowed the CNA to transfer. CNA A was shown by another CNA how to use the kiosk for resident information and was oriented on the floors concerning the care of the residents. The DON said CNA A had been suspended when the incident occurred and had received one-on-one training concerning the kiosk, repositioning, and incontinence care. The DON said CNA A had a proficiency check-off while she was working at the other building. Review of the employee file for CNA A revealed an original hire date 08/16/18, with a transfer hire date of 10/17/18. The Certified Nursing Assistant Job Description reflected . perform all duties as assigned in accordance with facility's established policies/procedures, nursing care procedures and safety rules and regulations and was signed by CNA A when she was hired on 08/16/18. Further review of the employee file reflected on 08/16/18, CNA A had compliance training including abuse/neglect with post training and CNA duties including incontinence care with proficiency check off (including total care residents), fall prevention, body mechanics, and resident safety. Review of the policy/procedure CNA Duties dated (MONTH) (YEAR) revealed . check special assignments, document ADLs, check on the resident at the end of each shift . and are safe Review of the policy/procedure Falls Evaluation and Prevention dated (MONTH) (YEAR) . education of staff related to fall prevention providing a safe environment for residents, cause and risk factors or as the interventions to manage risk, safe transferring technique Observation on 01/29/19 at 9:00 a.m. revealed the bed that Resident #1 was in would not move when the brakes were locked. Interview on 01/29/19 at 8:43 a.m. with the Maintenance Director revealed he had inspected the resident's bed the following day after the accident occurred. The bed had four locks, one on each leg, and three of the four locks were fully functional. The lock on the top, right-hand corner of the bed would not completely lock. The Maintenance Director said at the time of his inspection, with the three brakes locked, he could not move the bed without dragging it. The Maintenance Director said he had not been made aware of the bed not locking prior to his inspection. The Maintenance Director said the Technician for the bed company had been contacted and was coming to inspect the bed. Review of the Service Visit from the bed technician, dated 01/31/19, revealed, . aftermarket wheels, some wear on the brakes, bed will not move, with no problems found

Based on observation, interview, and record review, it was determined the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for one (Resident #1) of 4 residents reviewed for infections and the facility's infection control procedures. The facility failed to utilize infection control procedures to prevent the potential spread of Resident #1's infection. The facility failed to properly dispose of towels soiled with feces and other bodily fluids that Resident #1 carried about the facility and disposed of in various areas of the facility to include the dining room and designated smoke area. The facility failed to educate staff on infection control measures addressing cleaning, housekeeping, laundry and care of residents with infection. Resident #1 had resided in the facility since 05/04/15 and had [DIAGNOSES REDACTED]. The resident experienced drainage from the rectal mass as well as drainage of fecal matter. Although, the Administrator, the DON, Wound Care Nurse (ADON-C) and the staff were aware of Resident #1's infectious condition, he was allowed to freely walk about the facility carrying a soiled towel to sit on and then freely dispose of the contaminated towel in common areas on the floor or in linen barrels on various halls. An Immediate Jeopardy (IJ) was identified on 05/27/15. While the IJ was lowered on 05/29/15, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of widespread, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures placed all facility 101 residents at risk for cross-contamination, allowing for possible transmission of microorganisms that could result in the development of an infection and/or life threatening disease. Finding included: Resident #1's MDS assessment, signed as complete on 05/15/15 by the DON, revealed Resident #1 admitted to the facility on [DATE], at the age of 50. His [DIAGNOSES REDACTED]. A search for fungating wounds from http:/www.clinimed.co.uk/Wound-Care/Education/Indication-Classificaton/Fungating-Wound.aspx on 06/11/15, reflected a fungating lesions are known as masses or ulcerative lesions and are a result of cancerous cells infiltraing [MEDICATION NAME] tissue. An admission/readmission hospital facility report, dated 05/04/15, revealed a discharge [DIAGNOSES REDACTED]. At the side of the work sheet, was a handwritten note that reflected, homeless, amb (ambulatory) ad (sic) (adlib), change dressing to rectal mass qd and prn. Resident #1's interdisciplinary notes, dated 05/05/15, no time, revealed an assessment by the WCN who was also ADON-C/LVN). She noted Resident #1 had an anal mass and further noted the cancerous mass, fungating and anal thickening, no bleeding was observed at that time. She noted the mass measurement was 8.0 x 5.0 NM (non-measurable) . She noted he refused to allow her to use normal saline to clean the area and that he refused to allow her to place any ointment on the area, She noted Resident #1 told her to only keep any, and swats at her with his hands and pushed his body away from her. The note reflected the resident would continue to be monitored for any changes. A Physician Assessment, dated 05/06/15, reflected Resident #1 was assessed in an area hospital due to perirectal bleed, diagnosed with [REDACTED]. The assessment reflected Resident #1 was alert and oriented to person, place and time with appropriate mood and effect. The MDS assessment, dated 05/15/15, reflected Resident #1 ' s BIMS score was five and he was severely impaired cognitively. It noted Resident #1 required limited assistance of one person in the area of transfers, locomotion, dressing, toileting and personal hygiene. Resident #1 was independent with eating and was always continent of bowel and bladder. The care plan, initiated and dated 05/10/15, reflected Resident #1 had HIV - At risk for infection R/T (related to) inadequate immune system defenses, malnutrition and side effects of medications. The goal was, resident will be free of additional infections over the next 90 days. The approaches identified for this problem included: Assess for s/s (signs and symptoms) of opportunistic infection: fever, chills, cough, and diarrhea. Assist resident with meticulous personal hygiene to reduce spread of organisms into skin breaks. The care plan also reflected Resident #1 had the potential for incontinence related to impaired toileting self-performance. The approaches identified for this problem included to use incontinent briefs on resident as needed. Do not use incontinent briefs on resident and to place a urinal within the resident's reach. The care plan further identified Resident #1 had open area perianal mass. The approaches for care for this problem included: a) follow house protocol/regimen for treating breaks in skin integrity/pressure ulcers. b) Monitor skin daily and report all breaks in skin integrity. Treatment to:.Perianal area.as ordered by MD. In addition, the care plan reflected, rejection of care - Non compliant with wearing briefs and wound care. The approaches identified for this problem included to talk with resident in a calm voice when behavior was disruptive. Encourage resident to verbalize through one-to-one interactions. Discuss with resident implications of not complying with therapeutic regimen. Walks around with a towel due to perianal mass leaking; staff in-serviced on cleaning with antibacterial cleaner in chair resident sits after smoking. On 05/21/15 at 11:30 a.m., Resident #1 was observed walking down a hall. He was noted to have a foul pungent odor. During the interview with Resident #2 on 05/21/15 at 11:40 a.m. it was revealed that Resident #1 smelled like death. Resident #2 stated Resident #1 had a pressure ulcer and refused treatment and would not allow staff to put a dressing on his buttocks. Resident #2 stated the drainage from the pressure ulcer got on Resident #1's clothes and on the general-use chairs. She stated Resident #1 goes out to smoke with the other residents, and brings a towel to sit on. She said when he gets up, the towel is saturated with feces and bloody drainage. She said Resident #1 would sometimes leave the towel behind while other times he would take it and put it in the linen basket on one of the halls. She added that when Resident #1 went to the dining room, he would handle his dirty towel and then touch the handles of the coffee pot, he touched the creamer and sugar containers. She stated, Oh, it's gross. Resident #2 stated she had spoken to the DON and the Administrator and she filled out a grievance report. Resident #2 added that she had infections on both feet and did not want to be infected with whatever Resident #1 had. She also stated she was going to be discharged soon and was very afraid of contracting another infection. Review of the Grievance Log for the last three months revealed a grievance form, dated 05/11/15, from Resident #2. The grievance reflected Resident #1 constantly has feces and blood on the rear of his pants and is refusing to wear a bandage or a pamper. He sits on the cloth chairs and touches the cups, creamer, sugar, coffee spout, door handle, and who knows what else. I believe that he is putting the entire population here at risk for serious infections. I have an open wound on my leg (as do many other residents) and a history of MRSA (Methicillin Resistant Staphylococcus Aureus). I simply cannot afford to get another infection. I don't understand why he is allowed to stay here when he is consistently refusing treatment. I really hate to be the on (sic) to complain, but I know for a fact that I speak for several residents as I make this complaint. I'm close to being able to possibly go home, so I would hate for some sort of infection to jeopardize that. Thank you for your time and I hope you understand my concern. The grievance form included a hand written statement that noted Resident #1's BIMS demonstrated the resident was incapable of making informed decisions. The recommendation or corrective action taken reflected, Smoke Attendants educated to sanitize furniture after use. MD notified.Care plan updated. An area reflecting, was complaint resolved to the satisfaction of all concerned noted that Yes was checked. The form was signed and dated by the Administrator on 05/21/15 (10 days after the grievance was filed and on the first day of the survey). An interview with the DON on 05/21/15 at 12:30 p.m. revealed Resident #1 had cancer of the rectum, ambulated around the facility on his own, and had good and bad days. He was non-compliant with teaching, and wearing incontinent briefs due to rectal discharge. He used towels and wax paper to catch the discharge from his rectum. The DON also stated he had in-serviced staff to wipe down and disinfect chair surfaces after Resident #1 had sat down outside to smoke with the other residents. The DON stated Resident #1 was very private and desired to do his wound care himself. When asked what he had done to protect the other residents from this drainage and odor residents were complaining about, the DON stated Resident #1 had the right not to wear a incontinent brief. He stated he had asked Resident #1 several times to wear an incontinent brief and he had refused, and he could not force him because it would be infringing on his rights. When asked if he had considered the other residents' rights, the DON stated, What would you do if you were the DON? When asked how the other residents were protected from the odor and drainage to prevent infection to the others, the DON stated staffs were to do good hand-washing and he treated everyone alike. He stated he did not use isolation set ups (gowns, gloves, masks) to avoid the stigma of the other residents seeing the set up or sign of infection. On 05/21/15 at 12:40 p.m., the DON and the surveyor entered Resident #1's room. A small wet area was observed at the back side or bottom area of the shirt. When asked about the open area or drainage at his bottom, Resident #1 stated, It's there. When asked why he had not allowed staffs to clean and care for area, Resident #1 stated he did not want anyone putting their hands into his rectum and he would and could do it by himself. When asked how and with what did he clean the area, Resident #1 made a fist with his right hand and stated he put his hand there and cleaned it. When asked to please allow the males or the DON to do his wound care, Resident #1 shrugged his shoulder and said, No. When asked to allow the wound care nurse to do it, Resident #1 stated he did not trust them. Resident #1 was informed that there were some concerns about the drainage he was having and would he wear an adult brief to catch the drainage so he would not need to use the towel, Resident #1 stated he was not going to wear any diaper that was for children he stated. The resident was informed the surveyor was not referring to diapers, but an adult brief like underwear, and the adult brief would catch all the drainage where he would not worry about using towels. Resident #1 agreed to wear the adult brief. On 05/21/15 at 4:40 p.m., Resident #1 was observed resting in his bed. He was asked if he tried the adult brief, and he stated, Yes, and pulled down his pants from the waistline exposing the band of the adult brief. On 05/22/15 at 11:00 a.m., observation revealed two ambulance staff by the door of Resident #1's room. Ambulance staff asked Resident #1 if he was going back to the hospital for the same reason as the last time, bleeding? Resident #1 responded by saying he was going for a psych evaluation at an area hospital. Observation at that time revealed Resident #1 arguing and demanding from the Ambulance staff to give him his cigarette. When the male staff stated he would not be allowed to smoke in the emergency room Resident #1 stated to him that after he was checked in, the emergency room staff would allow him to go outside and smoke. Staff went to his room and got his cigarettes and gave to him. Resident #1 also realized he had no shoes on and he requested from the Ambulance staff to give him one of the five shoes under his bed. Resident #1's roommate Resident #5 was observed at that time, on 05/22/15 at 11:00 a.m., in his wheelchair between the curtain separating the two beds with no shoes or socks. An interview with the Charge Nurse, LVN D on 05/22/15 at 11:05 a.m. revealed Resident #1 was been transferred to an area hospital for a psychiatric evaluation. In another interview with Charge Nurse LVN D on 05/22/15 at 3:30 p.m., he stated he had never observed Resident #1's rectal mass. He said Resident #1 would not allow him to assess the area and would not allow the WCN to treat the area. He said the resident was offered a disposable brief and he refused it. He just wanted to use towels and he took a towel with him to smoke and sat on the towel. LVN D stated the area would drain and had a foul odor. When asked what was the facility care plan for the drainage. LVN D stated he had not seen any care plan for this issue and care plans were kept in the MDS office. He further stated he was concerned Resident #1 had HIV walked around with the soiled towel and could infect others. An interview with Charge Nurse LVN D on 05/27/15 at 1:40 p.m. revealed he had never observed Resident #1 with bleeding, but had observed the resident walking around the facility holding the towel he used for the drainage which had a foul odor. Resident #1 would place the towel on seats, picks it up when leaving an area and then place it in the dirty hamper in the hallway or anywhere on any hall he chose. LVN D was asked knowing the resident's [DIAGNOSES REDACTED]. An interview with RN E on 05/22/15 at 3:36 p.m. revealed she had never seen Resident #1's rectal mass and the resident refused to be assessed by the WCN. When asked if she had tried to assess the resident, RN E stated she had not tried to assess him. RN E stated Resident #1 would not allow staff to clean him when he had bloody drainage on his clothes and/or the mattress. RN E further stated the Medication Aides (MA) had informed her that the resident had also refused his medications. When asked how she cleaned the blood on the linen and mattress, RN E stated she cleaned the mattress with soap and water and sometimes she would use the housekeeping spray on the mattress. She also stated she had no concerns about Resident #1, had him for two to three days when he was first admitted before he was moved to another hall. An interview with RN F on 05/22/15 at 4:20 p.m. revealed Resident #1 had refused care, refused to wear pull ups (disposable briefs) and refused to allow dressing to his rectal mass. He had never allowed her and/or LVN D to observe the area. She stated Resident #1 carried a towel he placed on the seat of a chair and then place, the towel in a hamper or anywhere he chose. RN F stated she had observed Resident #1 one day after he sat down but she did not observe any drainage. She further stated the resident's room had a foul odor, and she had notified the Administrator of the odor. When asked what the facility had done regarding his refusals and the drainage, RN F stated the facility had not done anything different she was aware of until yesterday, 05/21/15. RN F stated on the evening of 05/21/15, evening she had received a call saying they would like to come evaluate Resident #1. She was directed by the DON to direct all calls regarding the resident to him (DON). RN F further stated Resident #1 had HIV, and the WCN was aware of the rectal mass/wound drainage and she told the aides on her hall to ensure they wore gloves during care and making his bed. Further review of Resident #1's clinical record revealed on the Interdisciplinary Note, an entry by the DON, dated 05/21/15 at 1:00 p.m. The entry revealed on attempting to get Resident #1 to wear a disposable brief for infection control concerns, the resident continuously refused to wear briefs, and continued to refuse to allow staff to provide care to his rectal mass. The Medical Director was notified of resident's current condition at that time. New order received to transfer to a Psych facility ASAP (as soon as possible). The interdisciplinary notes, dated 05/21/15 at 6:00 p.m., reflected four different psychiatric facilities had denied admitting Resident #1 for medication adjustment due to increased paranoia. Staffs were re-educated on the importance for Resident #1 to wear a brief and to redirect negative behavior such as refusing medications, refusing to wear a brief and walking around the facility with a soiled towel. The note reflected that the resident was instructed to wash his hands frequently and to use alcohol-based hand sanitizer afterward. The clinical records did not reflect Resident #1 had been provided this education previously. Review of Resident #1's telephone orders revealed an order dated 05/21/15 to refer/transfer resident to Psych facility as soon as possible. Another telephone order, dated 05/22/15, reflected to send Resident #1 to emergency room due to increased psychosis. The WCN/ADON C was interviewed on 05/27/15 at 2:20 p.m. and revealed Resident #1 had refused her trying to clean the draining mass on his anal/rectal area. She stated Resident #1 did not have an open wound, but around the anus he had a fungated area. Interview also revealed she had not observed the drainage, but staff had informed her of the drainage. The WCN stated she did not do anything else as the resident had the right to refuse care. The interview also revealed she did not notify the physician of the resident refusing assessment and care to the anal/rectal fungating mass area. There were no further assessments of the anal/rectal fungating mass area was attempted by the WCN after the resident refused the initial assessment. When asked if Resident #1's roommate had an open wound area, ADON C/WCN stated Resident #5 had no open areas, but his feet were macerated. (Maceration: The softening and breaking down of skin resulting from prolonged exposure to moisture; (n.d.) Mosby's Medical Dictionary, 8th edition. (2009). Retrieved June 4 2015 from <http://medical-dictionary.thefreedictionary.com/maceration>.) ADON C/WCN was asked to notify the surveyor when wound care was performed on Resident #5. During an interview with Resident #3 on 05/28/15 at 12:12 p.m., she stated Resident #1's drainage looked like old poop mixed with blood; and laundry could not wash his clothes because of the blood stains, so they kept giving him new clothes. He/she said Resident #1 refused to wear disposable briefs. He/she said Resident #1 used a towel and the towel had poop and blood, he would put the towel on his shoulder and then used it to wipe his face. He would go into the kitchen and touch the coffee pot, microwave, and other things in the dining room. During an interview with Resident #4 on 05/28/15 at 12:15 p.m., he/she stated Resident #1's body odor was atrocious like defecation and urination combined. He stated Resident #1 walked around with large stains on his clothes that looked like blood and feces, and Resident #1 had a stench that lingered on 10 to 15 minutes after he left. He stated Smoke Aide L would clean the seat where Resident #1 sat, but others did not. He added that in the dining room there was no cleaning of the chairs only if someone noticed it. During an interview with Smoking Aide L on 05/28/15 at 12:10 p.m., he confirmed Resident #1 would come out to smoke with the other residents and bring a towel to sit on. He stated he never saw the drainage, but other residents in the smoking area would complain about Resident #1's foul odor. He stated he was unable to detect odors due to a sinus condition. He added that he had observed blood on Resident #1's towel one time. He stated the resident took the towel with him when he left the area and he knew nothing else about the issue. During an interview with Resident #5 on 05/27/15 at 1:35 p.m., he was observed in his room and soaking his feet in a basin. Resident #5 said he was soaking his feet due to the sores he had on his feet. He said Resident #1 had been his roommate for about two weeks and that he had an odor. Resident #5 stated they shared the same bathroom. He stated he was not sure how often housekeeping cleaned the room or bathroom. He added that staff had told him Resident #1 had an air-borne illness. During an interview with CNA G on 05/27/15 at 1:45 p.m., she stated she observed drainage on Resident #1's clothes like bowel movement smears. She stated wherever Resident #1 sat he left a soiled area from his rectal drainage when he gets up. She stated she saw the drainage several times and it was feces and it smelled very bad, it was terrible. When she reported the problem, the DON told them the odor was coming from the Resident #1's colon cancer. The interview revealed there were no special instructions provided to the staff about care of the colon cancer and the drainage problems. During an interview with CNA I on 05/27/15 at 1:55 p.m. it was revealed that Resident #1 ambulated around the facility, ate in the dining room and went outside to smoke. She never saw any drainage, but could smell the odor around him. CNA I stated Resident #1 smelled like death, a god (sic) awful smell. CNA I also stated Resident #1 refused to take baths. The interview did not revealed instruction were provided to staff on sanitization/disinfecting bathrooms, chairs, beds and linens that were soiled and/or how to handle the items soiled. During an interview with CNA J on 05/27/15 at 2:00 p.m., she stated she had observed Resident #1's anal mass once in the shower room and when he saw her looking at it, he quickly crabbed a towel and covered himself. The drainage she saw on the area was old blood and brown in color. CNA J stated Resident #1 took towels from the linen carts, placed it on seats and then took it to his room and tossed it on the floor or under the bed. She stated she used Awesome (a brand of sanitizer/dish washer) to spray the resident's bed to kill the odor. However, observation of the housekeeping sanitizer K-Quart Select, revealed the product was a sanitizer. The label on the bottle reflected it was a neutral Disinfectant, Cleaner, Detergent, Virucide and Funicide. CNA J stated the odor was like dead rotten flesh and light brown in color. CNA J further stated Resident #1 wore a brief on 05/21/15, and again before leaving the facility on 05/22/15. CNA J stated she was not informed Resident #1 had an infection rather that he had an open wound and refused care. During an interview with Resident #6 on 05/27/15 at 2:15 p.m., he stated Resident #1 had lived across the hall from him and would have feces and urine on the back of his shirt. He stated Resident #1 used a towel that would have feces stains. He stated Resident #1 would touch the towel and then the coffee pots, water jug, ice tea jug, ice chest, and microwave in the dining room area. Resident #6 stated he had also observed Resident #1 scratch his backside without washing his hands and then touch items in the dining room. When asked what Resident #1 did with the towels, Resident #6 stated sometimes he would leave the towel behind and other residents would remove it and clean the chair with the disinfectant. He stated most of the staff did not clean behind Resident #1. Housekeeper (HK) K was interviewed on 05/27/15 at 2:25 p.m. The interview revealed housekeepers were not informed of rooms that had residents with infections. HK K stated sometimes she would see a room with an isolation set up by the door or a sign identifying the room with an infection then she would know. Interview revealed she used the same mop and water for all the rooms. However, she used the disinfectant K-Quart to clean rooms with no special attention to rooms. An interview with HK Manager on 05/27/15 at 2:55 p.m. on 05/27/15 revealed he did not receive any notification of isolation or infections in rooms. He also stated he was not aware of any infections on the hall Resident #1 resided. On 05/27/15 at 1:00 p.m., documentation requests were made of the DON that included staff training/education regarding infection control within the one year period. However, the training record was not provided to the surveyor. Review of the facility's infection control policy from 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf) reflected the Infection control and prevention program was a multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcare-associated infections are implemented and followed by HCWs (Health Care Workers), making the healthcare setting safe from infection for patients and healthcare personnel. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the following five components of an infection control program for accreditation: 1) surveillance: monitoring patients and healthcare personnel for acquisition of infection and/or colonization; 2) investigation: identification and analysis of infection problems or undesirable trends; 3) prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device- and procedure-related infections; 4) control: evaluation and management of outbreaks; and 5) reporting: provision of information to external agencies as required by state and federal law and regulation (www.jcaho.org). The infection control program staff has the ultimate authority to determine infection control policies for a healthcare organization with the approval of the organization's governing body. A research for HIV transmission and testing, Survival outside the body on Namaidsmap.com on 06/11/15 revealed: In certain conditions, the virus can survive outside the body for several weeks. Laboratory studies which have looked at the survival of HIV have found that: Levels of virus remain relatively stable in blood at room temperature, and HIV may persist for at least a week in dried blood at 4°C. Blood containing HIV used for laboratory experiments is stored at -70°C without any loss of viral activity. --HIV may survive in dried blood at room temperature for up to five or six days provided that the optimum pH level is maintained; drying of blood does not seem to affect the infectivity of HIV.<http://mobile.aidsmap.com/Survival-outside-the-body/page/ 78> --Sewage is highly unlikely to pose a risk because infectious HIV has never been isolated from feces or urine.<http://mobile.aidsmap.com/Survival-outside-the-body/page/ 78> However, research by Thames Water has shown that HIV can survive for several days in sewage in the laboratory. Research of the CDC Recommendations for Prevention of HIV Transmission in Health-Care Settings revealed under Laundry that Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of persons handling the linen. All soiled linen should be bagged at the location where it was used; it should not be sorted or rinsed in patient-care areas. Linen soiled with blood or body fluids should be placed and transported in bags that prevent leakage. The reference was accessed online at http://www.cdc.gov/mmwr/preview/mmwrhtml/ 587.htm on 06/12/15. On 05/27/15 at 1:00 p.m., the Administrator and DON were notified of the Immediate Jeopardy and a Plan of Removal was requested. An interview with the Administrator on 05/27/15 at 4:10 p.m. regarding why the IJ occurred, revealed he could not find placement for Resident #1; he referred him to their psychiatrist and then the grievance from Resident #2. He tried to send the resident out of the facility to a psychiatric hospital. He stated Resident #1 was ambulatory and he should have recognized the situation, the issue with the HIV and the drainage thereof and sent him back to the emergency room . He also stated he had dropped the ball and he should have acted quickly. The Administrator stated from now on he was going to implement any resident refusing care or being non-compliant with care for staff to notify him immediately for immediate action. The Administrator stated he should have acted quickly to contain the drainage or remove the resident from the facility. During an interview with the DON on 05/27/15 at 4:45 p.m., he stated the situation with Resident #1 was an IJ for the other residents. He stated he learned that if facility had a non-compliant resident and was aware of it he would discharge the resident. He would be in-servicing staffs to identify and be aware of such issues and to act on it quickly. The interview also revealed all residents were treated the same. All linens were treated the same by double bagging it before sending it to the laundry. He also stated the facility did not practice contact isolation procedures because of the stigma attached to isolations. During an interview with the Medical Director on 05/27/15 at 5:15 p.m., he stated he was aware of Resident #1's admission. He stated the resident was admitted with a history of schizophrenia and was non-compliant with care, not wearing disposable briefs and they discussed about the best way to handle the issue. The interview revealed the Medical Director was informed of Resident #1's issues on 05/21/15. The interview also revealed that if he had been made aware of the situation earlier he would have sent Resident #1 out for evaluation or to another alternative care facility somewhere else. The Medical Director further stated staffs were to be educated on strict hygiene and to identify infection control areas with proper hygiene. The Medical Director was asked if the drainage as described by the staffs could be contagious. He stated, Yes, it could be. It might affect other residents and it should be treated very cautiously, and with this issue facility was to protect the other residents from being infected. During an interview with Resident #1's Primary Care Physician (PCP) on 05/29/15 at 12:15 p.m., he stated he was not aware the anal/rectal mass was draining. He saw and assessed the resident on 05/05/15; he had a history of [REDACTED]. No one had informed him the mass was draining. The facility called and notified him of the IJ, but now he knew why they had the IJ. The PCP stated he heard Resident #1 was walking around with a towel (for drainage) and he was not made aware the resident was doing that. The PCP stated Resident #1 was a non-compliant resident. The PCP stated he was not happy about the situation with the resident not taking his medications, refusing wound care and walking around with a soiled wet towel and having HIV. He stated it was troubling; and he was not happy about it. On 05/28/15 at 5:53 p.m., Adm and DON were notified the Plan of Removal was accepted. The Plan of Removal documented the following: ---Administrator and Director of Nursing were re-educated regarding facility practice of applying standard precautions per Centers of Disease Control (CDC) Steps sanitizing resident rooms, identifying residents at risk of contagion regarding noncompliance of infection control, placing the resident population at risk 05/22/15 by the Director of Clinical Services: ---In-services were begun by the re-educated Director of Nursing (DON) with the majori

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of four residents reviewed for change in condition. ADON C/WCN/ LVN failed to assess and/or thoroughly assess Resident#1's rectal fungating mass on admission and weekly. ADON C failed to assess Resident #1 for pain, after pulling away from her during the initial assessment, however she documented he refused assessment of the anal/rectal mass and never reassessed area. After the CNAs informed the DON and the WCN/ADON C of Resident #1's foul odor drainage from his rectal mass, The facility failed to assess and educate resident and staffs on care of area and care for the linens and failed to provide treatment to the area. Facility failed to notify Resident #1's Physician of resident refusing care, failed to assess and notify the physician of the change in condition of the rectal mass and resident refusing treatments. An Immediate Jeopardy (IJ) was identified on 05/27/15 at 1:00 p.m. While the IJ was removed on 05/29/14, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimum harm that is not immediate jeopardy and a scope of widespread due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the 88 residents who were not bed-bound, according to the facility's census report dated 05/21/15, 13 residents were bed-bound, and Resident #1 walked around in the facility and also went outside to smoke with other residents. Finding included: Resident #1's MDS assessment, signed as complete on 05/15/15 by the DON, revealed Resident #1 admitted to the facility on [DATE], at the age of 50. His [DIAGNOSES REDACTED]. A search for fungating wounds from http:/www.clinimed.co.uk/Wound-Care/Education/Indication-Classificaton/Fungating-Wound.aspx on 06/11/15, reflected a fungating [MEDICAL CONDITION] are known as masses or ulcerative [MEDICAL CONDITION] and are a result [MEDICAL CONDITION] cells infiltraing [MEDICATION NAME] tissue. An admission/readmission hospital facility report, dated 05/04/15, revealed a discharge [DIAGNOSES REDACTED]. At the side of the work sheet, was a handwritten note that reflected, homeless, amb (ambulatory) ad (sic) (adlib), change dressing to rectal mass qd and prn. Resident #1's interdisciplinary notes, dated 05/05/15, no time, revealed an assessment by the WCN who was also ADON-C/LVN). She noted Resident #1 had an anal mass and further noted [MEDICAL CONDITION] mass, fungating and anal thickening, no bleeding was observed at that time. She noted the mass measurement was 8.0 x 5.0 NM (non-measurable) . She noted he refused to allow her to use normal saline to clean the area and that he refused to allow her to place any ointment on the area, She noted Resident #1 told her to only keep any, and swats at her with his hands and pushed his body away from her. The note reflected the resident would continue to be monitored for any changes. A Physician Assessment, dated 05/06/15, reflected Resident #1 was assessed in an area hospital due to perirectal bleed, diagnosed with [REDACTED]. The assessment reflected Resident #1 was alert and oriented to person, place and time with appropriate mood and effect. The MDS assessment, dated 05/15/15, reflected Resident #1 ' s BIMS score was five and he was severely impaired cognitively. It noted Resident #1 required limited assistance of one person in the area of transfers, locomotion, dressing, toileting and personal hygiene. Resident #1 was independent with eating and was always continent of bowel and bladder. The care plan, initiated and dated 05/10/15, reflected Resident #1 had HIV - At risk for infection R/T (related to) inadequate immune system defenses, malnutrition and side effects of medications. The goal was, resident will be free of additional infections over the next 90 days. The approaches identified for this problem included: Assess for s/s (signs and symptoms) of opportunistic infection: fever, chills, cough, and diarrhea. Assist resident with meticulous personal hygiene to reduce spread of organisms into skin breaks. The care plan also reflected Resident #1 had the potential for incontinence related to impaired toileting self-performance. The approaches identified for this problem included to use incontinent briefs on resident as needed. Do not use incontinent briefs on resident and to place a urinal within the resident's reach. The care plan further identified Resident #1 had open area perianal mass. The approaches for care for this problem included: a) follow house protocol/regimen for treating breaks in skin integrity/pressure ulcers. b) Monitor skin daily and report all breaks in skin integrity. Treatment to:.Perianal area.as ordered by MD. In addition, the care plan reflected, rejection of care - Non compliant with wearing briefs and wound care. The approaches identified for this problem included to talk with resident in a calm voice when behavior was disruptive. Encourage resident to verbalize through one-to-one interactions. Discuss with resident implications of not complying with therapeutic regimen. Walks around with a towel due to perianal mass leaking; staff in-serviced on cleaning with antibacterial cleaner in chair resident sits after smoking. On 05/21/15 at 11:30 a.m., Resident #1 was observed walking down a hall. He was noted to have a foul pungent odor. During the interview with Resident #2 on 05/21/15 at 11:40 a.m. it was revealed that Resident #1 smelled like death. Resident #2 stated Resident #1 had a pressure ulcer and refused treatment and would not allow staff to put a dressing on his buttocks. Resident #2 stated the drainage from the pressure ulcer got on Resident #1's clothes and on the general-use chairs. She stated Resident #1 goes out to smoke with the other residents, and brings a towel to sit on. She said when he gets up, the towel is saturated with feces and bloody drainage. She said Resident #1 would sometimes leave the towel behind while other times he would take it and put it in the linen basket on one of the halls. She added that when Resident #1 went to the dining room, he would handle his dirty towel and then touch the handles of the coffee pot, he touched the creamer and sugar containers. She stated, Oh, it's gross. Resident #2 stated she had spoken to the DON and the Administrator and she filled out a grievance report. Resident #2 added that she had infections on both feet and did not want to be infected with whatever Resident #1 had. She also stated she was going to be discharged soon and was very afraid of contracting another infection. Review of the Grievance Log for the last three months revealed a grievance form, dated 05/11/15, from Resident #2. The grievance reflected Resident #1 constantly has feces and blood on the rear of his pants and is refusing to wear a bandage or a pamper. He sits on the cloth chairs and touches the cups, creamer, sugar, coffee spout, door handle, and who knows what else. I believe that he is putting the entire population here at risk for serious infections. I have an open wound on my leg (as do many other residents) and a history [MEDICAL CONDITIONS]. I simply cannot afford to get another infection. I don't understand why he is allowed to stay here when he is consistently refusing treatment. I really hate to be the on (sic) to complain, but I know for a fact that I speak for several residents as I make this complaint. I'm close to being able to possibly go home, so I would hate for some sort of infection to jeopardize that. Thank you for your time and I hope you understand my concern. The grievance form included a hand written statement that noted Resident #1's BIMS demonstrated the resident was incapable of making informed decisions. The recommendation or corrective action taken reflected, Smoke Attendants educated to sanitize furniture after use. MD notified.Care plan updated. An area reflecting, was complaint resolved to the satisfaction of all concerned noted that Yes was checked. The form was signed and dated by the Administrator on 05/21/15 (10 days after the grievance was filed and on the first day of the survey). An interview with the DON on 05/21/15 at 12:30 p.m. revealed Resident #1 [MEDICAL CONDITION] of the rectum, ambulated around the facility on his own, and had good and bad days. He was non-compliant with teaching, and wearing incontinent briefs due to rectal discharge. He used towels and wax paper to catch the discharge from his rectum. The DON also stated he had in-serviced staff to wipe down and disinfect chair surfaces after Resident #1 had sat down outside to smoke with the other residents. The DON stated Resident #1 was very private and desired to do his wound care himself. When asked what he had done to protect the other residents from this drainage and odor residents were complaining about, the DON stated Resident #1 had the right not to wear a incontinent brief. He stated he had asked Resident #1 several times to wear an incontinent brief and he had refused, and he could not force him because it would be infringing on his rights. When asked if he had considered the other residents' rights, the DON stated, What would you do if you were the DON? When asked how the other residents were protected from the odor and drainage to prevent infection to the others, the DON stated staffs were to do good hand-washing and he treated everyone alike. He stated he did not use isolation set ups (gowns, gloves, masks) to avoid the stigma of the other residents seeing the set up or sign of infection. On 05/21/15 at 12:40 p.m., the DON and the surveyor entered Resident #1's room. A small wet area was observed at the back side or bottom area of the shirt. When asked about the open area or drainage at his bottom, Resident #1 stated, It's there. When asked why he had not allowed staffs to clean and care for area, Resident #1 stated he did not want anyone putting their hands into his rectum and he would and could do it by himself. When asked how and with what did he clean the area, Resident #1 made a fist with his right hand and stated he put his hand there and cleaned it. When asked to please allow the males or the DON to do his wound care, Resident #1 shrugged his shoulder and said, No. When asked to allow the wound care nurse to do it, Resident #1 stated he did not trust them. Resident #1 was informed that there were some concerns about the drainage he was having and would he wear an adult brief to catch the drainage so he would not need to use the towel, Resident #1 stated he was not going to wear any diaper that was for children he stated. The resident was informed the surveyor was not referring to diapers, but an adult brief like underwear, and the adult brief would catch all the drainage where he would not worry about using towels. Resident #1 agreed to wear the adult brief. On 05/21/15 at 4:40 p.m., Resident #1 was observed resting in his bed. He was asked if he tried the adult brief, and he stated, Yes, and pulled down his pants from the waistline exposing the band of the adult brief. On 05/22/15 at 11:00 a.m., observation revealed two ambulance staff by the door of Resident #1's room. Ambulance staff asked Resident #1 if he was going back to the hospital for the same reason as the last time, bleeding? Resident #1 responded by saying he was going for a psych evaluation at an area hospital. Observation at that time revealed Resident #1 arguing and demanding from the Ambulance staff to give him his cigarette. When the male staff stated he would not be allowed to smoke in the emergency room Resident #1 stated to him that after he was checked in, the emergency room staff would allow him to go outside and smoke. Staff went to his room and got his cigarettes and gave to him. Resident #1 also realized he had no shoes on and he requested from the Ambulance staff to give him one of the five shoes under his bed. Resident #1's roommate Resident #5 was observed at that time, on 05/22/15 at 11:00 a.m., in his wheelchair between the curtain separating the two beds with no shoes or socks. An interview with the Charge Nurse, LVN D on 05/22/15 at 11:05 a.m. revealed Resident #1 was been transferred to an area hospital for a psychiatric evaluation. In another interview with Charge Nurse LVN D on 05/22/15 at 3:30 p.m., he stated he had never observed Resident #1's rectal mass. He said Resident #1 would not allow him to assess the area and would not allow the WCN to treat the area. He said the resident was offered a disposable brief and he refused it. He just wanted to use towels and he took a towel with him to smoke and sat on the towel. LVN D stated the area would drain and had a foul odor. When asked what was the facility care plan for the drainage. LVN D stated he had not seen any care plan for this issue and care plans were kept in the MDS office. He further stated he was concerned Resident #1 [MEDICAL CONDITION] around with the soiled towel and could infect others. An interview with Charge Nurse LVN D on 05/27/15 at 1:40 p.m. revealed he had never observed Resident #1 with bleeding, but had observed the resident walking around the facility holding the towel he used for the drainage which had a foul odor. Resident #1 would place the towel on seats, picks it up when leaving an area and then place it in the dirty hamper in the hallway or anywhere on any hall he chose. LVN D was asked knowing the resident's [DIAGNOSES REDACTED]. An interview with RN E on 05/22/15 at 3:36 p.m. revealed she had never seen Resident #1's rectal mass and the resident refused to be assessed by the WCN. When asked if she had tried to assess the resident, RN E stated she had not tried to assess him. RN E stated Resident #1 would not allow staff to clean him when he had bloody drainage on his clothes and/or the mattress. RN E further stated the Medication Aides (MA) had informed her that the resident had also refused his medications. When asked how she cleaned the blood on the linen and mattress, RN E stated she cleaned the mattress with soap and water and sometimes she would use the housekeeping spray on the mattress. She also stated she had no concerns about Resident #1, had him for two to three days when he was first admitted before he was moved to another hall. An interview with RN F on 05/22/15 at 4:20 p.m. revealed Resident #1 had refused care, refused to wear pull ups (disposable briefs) and refused to allow dressing to his rectal mass. He had never allowed her and/or LVN D to observe the area. She stated Resident #1 carried a towel he placed on the seat of a chair and then place, the towel in a hamper or anywhere he chose. RN F stated she had observed Resident #1 one day after he sat down but she did not observe any drainage. She further stated the resident's room had a foul odor, and she had notified the Administrator of the odor. When asked what the facility had done regarding his refusals and the drainage, RN F stated the facility had not done anything different she was aware of until yesterday, 05/21/15. RN F stated on the evening of 05/21/15, evening she had received a call saying they would like to come evaluate Resident #1. She was directed by the DON to direct all calls regarding the resident to him (DON). RN F further stated Resident #1 [MEDICAL CONDITION].and the WCN was aware of the rectal mass/wound drainage and she told the aides on her hall to ensure they wore gloves during care and making his bed. Further review of Resident #1's clinical record revealed on the Interdisciplinary Note, an entry by the DON, dated 05/21/15 at 1:00 p.m. The entry revealed on attempting to get Resident #1 to wear a disposable brief for infection control concerns, the resident continuously refused to wear briefs, and continued to refuse to allow staff to provide care to his rectal mass. The Medical Director was notified of resident's current condition at that time. New order received to transfer to a Psych facility ASAP (as soon as possible). The interdisciplinary notes, dated 05/21/15 at 6:00 p.m., reflected four different psychiatric facilities had denied admitting Resident #1 for medication adjustment due to increased paranoia. Staffs were re-educated on the importance for Resident #1 to wear a brief and to redirect negative behavior such as refusing medications, refusing to wear a brief and walking around the facility with a soiled towel. The note reflected that the resident was instructed to wash his hands frequently and to use alcohol-based hand sanitizer afterward. The clinical records did not reflect Resident #1 had been provided this education previously. Review of Resident #1's telephone orders revealed an order dated 05/21/15 to refer/transfer resident to Psych facility as soon as possible. Another telephone order, dated 05/22/15, reflected to send Resident #1 to emergency room due to increased [MEDICAL CONDITION]. The WCN/ADON C was interviewed on 05/27/15 at 2:20 p.m. and revealed Resident #1 had refused her trying to clean the draining mass on his anal/rectal area. She stated Resident #1 did not have an open wound, but around the anus he had a fungated area. Interview also revealed she had not observed the drainage, but staff had informed her of the drainage. The WCN stated she did not do anything else as the resident had the right to refuse care. The interview also revealed she did not notify the physician of the resident refusing assessment and care to the anal/rectal fungating mass area. There were no further assessments of the anal/rectal fungating mass area was attempted by the WCN after the resident refused the initial assessment. When asked if Resident #1's roommate had an open wound area, ADON C/WCN stated Resident #5 had no open areas, but his feet were macerated. (Maceration: The softening and breaking down of skin resulting from prolonged exposure to moisture; (n.d.) Mosby's Medical Dictionary, 8th edition. (2009). Retrieved June 4 2015 from <http://medical-dictionary.thefreedictionary.com/maceration>.) ADON C/WCN was asked to notify the surveyor when wound care was performed on Resident #5. During an interview with Resident #3 on 05/28/15 at 12:12 p.m., she stated Resident #1's drainage looked like old poop mixed with blood; and laundry could not wash his clothes because of the blood stains, so they kept giving him new clothes. He/she said Resident #1 refused to wear disposable briefs. He/she said Resident #1 used a towel and the towel had poop and blood, he would put the towel on his shoulder and then used it to wipe his face. He would go into the kitchen and touch the coffee pot, microwave, and other things in the dining room. During an interview with Resident #4 on 05/28/15 at 12:15 p.m., he/she stated Resident #1's body odor was atrocious like defecation and urination combined. He stated Resident #1 walked around with large stains on his clothes that looked like blood and feces, and Resident #1 had a stench that lingered on 10 to 15 minutes after he left. He stated Smoke Aide L would clean the seat where Resident #1 sat, but others did not. He added that in the dining room there was no cleaning of the chairs only if someone noticed it. During an interview with Smoking Aide L on 05/28/15 at 12:10 p.m., he confirmed Resident #1 would come out to smoke with the other residents and bring a towel to sit on. He stated he never saw the drainage, but other residents in the smoking area would complain about Resident #1's foul odor. He stated he was unable to detect odors due to a sinus condition. He added that he had observed blood on Resident #1's towel one time. He stated the resident took the towel with him when he left the area and he knew nothing else about the issue. During an interview with Resident #5 on 05/27/15 at 1:35 p.m., he was observed in his room and soaking his feet in a basin. Resident #5 said he was soaking his feet due to the sores he had on his feet. He said Resident #1 had been his roommate for about two weeks and that he had an odor. Resident #5 stated they shared the same bathroom. He stated he was not sure how often housekeeping cleaned the room or bathroom. He added that staff had told him Resident #1 had an air-borne illness. During an interview with CNA G on 05/27/15 at 1:45 p.m., she stated she observed drainage on Resident #1's clothes like bowel movement smears. She stated wherever Resident #1 sat he left a soiled area from his rectal drainage when he gets up. She stated she saw the drainage several times and it was feces and it smelled very bad, it was terrible. When she reported the problem, the DON told them the odor was coming from the Resident #1's [MEDICAL CONDITION]. The interview revealed there were no special instructions provided to the staff about care of the [MEDICAL CONDITION] and the drainage problems. During an interview with CNA I on 05/27/15 at 1:55 p.m. it was revealed that Resident #1 ambulated around the facility, ate in the dining room and went outside to smoke. She never saw any drainage, but could smell the odor around him. CNA I stated Resident #1 smelled like death, a god (sic) awful smell. CNA I also stated Resident #1 refused to take baths. The interview did not revealed instruction were provided to staff on sanitization/disinfecting bathrooms, chairs, beds and linens that were soiled and/or how to handle the items soiled. During an interview with CNA J on 05/27/15 at 2:00 p.m., she stated she had observed Resident #1's anal mass once in the shower room and when he saw her looking at it, he quickly crabbed a towel and covered himself. The drainage she saw on the area was old blood and brown in color. CNA J stated Resident #1 took towels from the linen carts, placed it on seats and then took it to his room and tossed it on the floor or under the bed. She stated she used Awesome (a brand of sanitizer/dish washer) to spray the resident's bed to kill the odor. However, observation of the housekeeping sanitizer K-Quart Select, revealed the product was a sanitizer. The label on the bottle reflected it was a neutral Disinfectant, Cleaner, Detergent, Virucide and Funicide. CNA J stated the odor was like dead rotten flesh and light brown in color. CNA J further stated Resident #1 wore a brief on 05/21/15, and again before leaving the facility on 05/22/15. CNA J stated she was not informed Resident #1 had an infection rather that he had an open wound and refused care. During an interview with Resident #6 on 05/27/15 at 2:15 p.m., he stated Resident #1 had lived across the hall from him and would have feces and urine on the back of his shirt. He stated Resident #1 used a towel that would have feces stains. He stated Resident #1 would touch the towel and then the coffee pots, water jug, ice tea jug, ice chest, and microwave in the dining room area. Resident #6 stated he had also observed Resident #1 scratch his backside without washing his hands and then touch items in the dining room. When asked what Resident #1 did with the towels, Resident #6 stated sometimes he would leave the towel behind and other residents would remove it and clean the chair with the disinfectant. He stated most of the staff did not clean behind Resident #1. Housekeeper (HK) K was interviewed on 05/27/15 at 2:25 p.m. The interview revealed housekeepers were not informed of rooms that had residents with infections. HK K stated sometimes she would see a room with an isolation set up by the door or a sign identifying the room with an infection then she would know. Interview revealed she used the same mop and water for all the rooms. However, she used the disinfectant K-Quart to clean rooms with no special attention to rooms. An interview with HK Manager on 05/27/15 at 2:55 p.m. on 05/27/15 revealed he did not receive any notification of isolation or infections in rooms. He also stated he was not aware of any infections on the hall Resident #1 resided. On 05/27/15 at 1:00 p.m., documentation requests were made of the DON that included staff training/education regarding infection control within the one year period. However, the training record was not provided to the surveyor. Review of the facility's infection control policy from 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf) reflected the Infection control and prevention program was a multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcare-associated infections are implemented and followed by HCWs (Health Care Workers), making the healthcare setting safe from infection for patients and healthcare personnel. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the following five components of an infection control program for accreditation: 1) surveillance: monitoring patients and healthcare personnel for acquisition of infection and/or colonization; 2) investigation: identification and analysis of infection problems or undesirable trends; 3) prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device- and procedure-related infections; 4) control: evaluation and management of outbreaks; and 5) reporting: provision of information to external agencies as required by state and federal law and regulation (www.jcaho.org). The infection control program staff has the ultimate authority to determine infection control policies for a healthcare organization with the approval of the organization's governing body. A research [MEDICAL CONDITION] and testing, Survival outside the body on Namaidsmap.com on 06/11/15 revealed: In certain conditions, [MEDICAL CONDITION] can survive outside the body for several weeks. Laboratory studies which have looked at the survival [MEDICAL CONDITION] found that: Levels of virus remain relatively stable in blood at room temperature, [MEDICAL CONDITION] persist for at least a week in dried blood at 4°C. Blood [MEDICAL CONDITION] for laboratory experiments is stored at -70°C without any loss of [MEDICAL CONDITION] activity. --HIV may survive in dried blood at room temperature for up to five or six days provided that the optimum pH level is maintained; drying of blood does not seem to affect the infectivity of HIV.<http://mobile.aidsmap.com/Survival-outside-the-body/page/ 78> --Sewage is highly unlikely to pose a risk because [MEDICAL CONDITION] never been isolated from feces or urine.<http://mobile.aidsmap.com/Survival-outside-the-body/page/ 78> However, research by Thames Water has shown [MEDICAL CONDITION] survive for several days in sewage in the laboratory. Research of the CDC Recommendations for Prevention [MEDICAL CONDITION] in Health-Care Settings revealed under Laundry that Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of persons handling the linen. All soiled linen should be bagged at the location where it was used; it should not be sorted or rinsed in patient-care areas. Linen soiled with blood or body fluids should be placed and transported in bags that prevent leakage. The reference was accessed online at http://www.cdc.gov/mmwr/preview/mmwrhtml/ 587.htm on 06/12/15. On 05/27/15 at 1:00 p.m., the Administrator and DON were notified of the Immediate Jeopardy and a Plan of Removal was requested. An interview with the Administrator on 05/27/15 at 4:10 p.m. regarding why the IJ occurred, revealed he could not find placement for Resident #1; he referred him to their psychiatrist and then the grievance from Resident #2. He tried to send the resident out of the facility to a psychiatric hospital. He stated Resident #1 was ambulatory and he should have recognized the situation, the issue with [MEDICAL CONDITION] the drainage thereof and sent him back to the emergency room . He also stated he had dropped the ball and he should have acted quickly. The Administrator stated from now on he was going to implement any resident refusing care or being non-compliant with care for staff to notify him immediately for immediate action. The Administrator stated he should have acted quickly to contain the drainage or remove the resident from the facility. During an interview with the DON on 05/27/15 at 4:45 p.m., he stated the situation with Resident #1 was an IJ for the other residents. He stated he learned that if facility had a non-compliant resident and was aware of it he would discharge the resident. He would be in-servicing staffs to identify and be aware of such issues and to act on it quickly. The interview also revealed all residents were treated the same. All linens were treated the same by double bagging it before sending it to the laundry. He also stated the facility did not practice contact isolation procedures because of the stigma attached to isolations. During an interview with the Medical Director on 05/27/15 at 5:15 p.m., he stated he was aware of Resident #1's admission. He stated the resident was admitted with a history of [MEDICAL CONDITION] and was non-compliant with care, not wearing disposable briefs and they discussed about the best way to handle the issue. The interview revealed the Medical Director was informed of Resident #1's issues on 05/21/15. The interview also revealed that if he had been made aware of the situation earlier he would have sent Resident #1 out for evaluation or to another alternative care facility somewhere else. The Medical Director further stated staffs were to be educated on strict hygiene and to identify infection control areas with proper hygiene. The Medical Director was asked if the drainage as described by the staffs could be contagious. He stated, Yes, it could be. It might affect other residents and it should be treated very cautiously, and with this issue facility was to protect the other residents from being infected. During an interview with Resident #1's Primary Care Physician (PCP) on 05/29/15 at 12:15 p.m., he stated he was not aware the anal/rectal mass was draining. He saw and assessed the resident on 05/05/15; he had a history of [REDACTED]. No one had informed him the mass was draining. The facility called and notified him of the IJ, but now he knew why they had the IJ. The PCP stated he heard Resident #1 was walking around with a towel (for drainage) and he was not made aware the resident was doing that. The PCP stated Resident #1 was a non-compliant resident. The PCP stated he was not happy about the situation with the resident not taking his medications, refusing wound care and walking around with a soiled wet towel and [MEDICAL CONDITION].He stated it was troubling; and he was not happy about it. On 05/28/15 at 5:53 p.m., Adm and DON were notified the Plan of Removal was accepted. The Plan of Removal documented the following: ---Administrator and Director of Nursing were re-educated regarding facility practice of applying standard precautions per Centers of Disease Control (CDC) Steps sanitizing resident rooms, identifying residents at risk of contagion regarding noncompliance of infection control, placing the resident population at risk 05/22/15 by the Director of Clinical Services: ---In-services were begun by the re-educated Director of Nursing (DON) with the majority of all staff on CDC guidelines for Standard Precautions 05/22/15. Facility staff will be educated on Standard Precautions and best practice of sanitation, and implementation in daily routine. In-services are to be completed by 5/29/15. ---Staff will be educated abo

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident's right to be free from sexual abuse was implemented for three (Resident #1, #2 and #3) of seven residents reviewed for abuse. Three residents alleged sexually inappropriate behavior against RN A to the Administrator. The facility: 1. Failed to remove RN A from working directly with the facility's residents and allowed contact from 10/02/12 through 11/02/12. 2. Failed to thoroughly investigate the incidents by interviewing facility residents and staff. Potential witnesses were not questioned. 3. A previous allegation of sexually inappropriate behavior against RN A by Resident #4 was not investigated, the residents were not protected and it was not reported to the State agency. An Immediate Jeopardy (IJ) was identified on 11/01/12. While the IJ was removed on 11/02/12, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern." The facility continued to in-service and monitor staff to ensure allegations of abuse were being reported, investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect all residents residing in the facility, including Residents #1, #2 and #3, by placing them at risk for further abuse, which could result in serious mental health complications and/or physical injuries. Findings included: Per adminstrative review, surveyors returned to the facility on [DATE] to further investigate the allegations of sexual abuse by RN A. 1) Review of the facility's grievance log revealed a grievance report, dated 10/02/12, which reflected: "Allegation of RN (RN A), making residents feel uncomfortable October 02, 2012 Complainants: (Resident #1, Resident #2, and Resident #3) At approximately 12:30 PM it was reported to me (the Administrator) the three ladies above were very concerned and wanted to talk with me about (RN A) by (ADON B), LVN. (Resident #2) admitted her concerns arose after hearing a fell ow resident (Resident #4) describe an incident during smoke break this morning that had reportedly occurred with (RN A), but had been investigated and unsubstantiated by the Administrator... (Resident #2) became concerned that she had awakened on more than one occasion when (RN A) was bringing her meds in the middle of the night and he had raised her shirt tail slightly. (Resident #3) was concerned that she had awakened on several occasions to him (RN A) raising her shirt and when she would ask him what he was doing, he would respond that he was there to give her medications or draw blood. Her central line was on the other side. (Resident #1) stated that he had come into her room to give her medications and she was awakened to him pulling her covers off of her. She stated that she wasn't sure if it happened or not, so she had not mentioned it, but felt one night she was awakened by (RN A) playing with her breast and nipple. (Resident #1) was encouraged to file a police report if she felt she had been assaulted in any manner (by the Administrator). She declined, stating she "didn't want it to go that far." I (the Administrator) spoke individually with each of them and they all agreed to meet with (RN A) and discuss with him their concerns and what he was doing that made them feel uncomfortable. The social worker was given a questionnaire (satisfaction survey) to complete with other interviewable female residents while we visited with (RN A) and residents. Before speaking with them and (RN A), I spoke with them as a group to ensure they were comfortable with this meeting in the conference room and they all assured me they were. (RN A) came into the conference room and sat across the table from all of them. I explained to the residents the seriousness of their allegations. They stated they did not want (RN A) to lose his job, just wanted him to stop making them feel uncomfortable. Each resident was allowed to share with (RN A) the behaviors that bothered them... All three take heavy medications that make them sleep very soundly. They all agreed with this. They also agreed that (RN A) may not have realized they were not fully awake when he proceeded in his nursing processes - (Resident #2) has a fairly new [MEDICAL CONDITION] and raising her shirt to check to ensure it was intact and not needing attention would have been a nursing function while he was there; (Resident #3) has an abdominal wound with a dressing, it would be logical that a prudent nurse was assessing her dressing for excessive drainage; (Resident #1) sleeps with ear plugs and a concentrator running at the head of her bed, it would be very difficult to wake her with the medications she takes at night, thus he may have been simply pulling back the covers in an effort to disturb her sleep enough to wake her. When these possibilities were mentioned, they all felt that maybe they had misread some of his actions, but stood their ground that they were uncomfortable with this approach. (RN A) was directed if he cannot get them awake by calling their name, he will get a female employee to wake them if they have to be touched. All residents were agreeable to this resolution. (RN A) apologized for frightening them and assured them he would work hard not to in the future. He shook hands with all three and all agreed they were satisfied with the resolution. They were informed that some of the allegations met the criteria for reportable incident. They all agreed and stated they did not want this called to the State. They were happy with the outcome. All three were given the business card with the Administrator's personal cell number and encouraged to call any time, day or night, if they feel uncomfortable or dissatisfied with their help. All agreed that they would." This grievance report was signed by Residents #1, #2, and #3. It was also signed by the Administrator and RN A. 2) Review of Resident #1's Face Sheet, dated 09/28/12, revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident's BIMS score was 13, which indicated the resident's cognitive status was intact. On 10/18/12 at 2:00 PM, an interview was conducted with Resident #1. Resident #1 stated she and two other residents met with ADON B and the Administrator regarding the grievance. When asked about her specific allegations, Resident #1 stated she woke up one night, and she had a "strange" feeling RN A had been playing with her breasts and nipples. Resident #1 stated on another occasion, RN A pulled the covers off her while she was asleep, and when she woke up, he "shoved" pills in her mouth. Resident #1 stated, during the meeting with the Administrator, the Administrator informed her (Resident #1), her statement alone could cause RN A to lose his job or go to jail. Resident #1 stated she and the two other female residents had to sign a statement they would not bring the allegations against RN A. After their meeting with the Administrator, Resident #1 stated she (the Administrator) called RN A into her office to meet with him. Since the meeting with the Administrator, Resident #1 stated RN A had come to her room to give her medications. RN A was alone at those times. She stated he had not touched her again since they reported the allegations. The Administrator was interviewed regarding this grievance report on 10/18/12 at 1:20 PM. The Administrator explained the residents did not want her to report it to the State, and she did not report the allegation to the State agency. The Administrator stated RN A was not suspended before, during or following the investigation. However, the Administrator was unable to provide evidence the incident had been investigated or the statedments written by the residents. This statement was reiterated during the Exit Conference on 10/19/12 at 3:40 PM. The Administrator stated, "The residents did not want me to call the state...it's a resident rights issue." During an interview with Resident #1 on 11/01/12 at 3:15 PM, the resident stated she never agreed to anything related to not calling/reporting the incidents to "State" and never knew it was an option. Resident #1 stated, "I didn't want him (RN A) to keep it up, but didn't want to be the one who got him fired. He could ...find me and hurt me." The resident further stated she would shortly be moving into an apartment on her own and was afraid RN A might find and hurt her. Resident #1 added she felt she was being retaliated against due to the 30-day discharge notice she received effective 10/05/12, because of RN A reporting her smoking outside. Resident #1 stated RN A had seen her smoke "hundreds" of times before and had never reported her. 3) Review of Resident #2's Face Sheet, dated 08/15/12, reflected the resident was admitted to the facility on [DATE] and was readmited on 06/29/12 with the following Diagnoses: [REDACTED]. The Face Sheet also reflected Resident #2 was her own responsible party. Review of Resident #2's MDS assessment, dated 08/07/12, revealed an additional active [DIAGNOSES REDACTED]. The MDS assessment reflected the resident's BIMS score was 12, which indicated the resident's cognitive status was intact. Further review revealed Resident #2 had the ability to understand others. Resident #2 was interviewed on 10/18/12 at 2:15 PM regarding the allegations. Resident #2 stated several of the residents complained about RN A, who was the nurse on duty at night. She stated RN A raised her shirt up while she was asleep in her room one night. She stated when she woke up, he gave her medications and hurried out of the room. Resident #2 stated she was afraid to say anything. She stated when she and the other residents reported the allegations to the Administrator, they went to a little room and "wrote papers out," and the Administrator stated she would take care of the matter. Resident #2 stated she had to sign her paper. The resident stated the Administrator told them she wanted RN A to keep his job, and she did not want him to lose his job. Resident #2 stated RN A did not say anything during the meeting. Resident #2 stated the Administrator told them if they said anything about what happened, then she would have to call the police. Resident #2 stated the police were not called. Resident #2 stated they were worried about the other girls (residents) in the facility. She stated RN A did not deny the allegations, and he did not apologize. She stated he had not touched her since they reported the allegations. Resident #2 stated she felt "very uncomfortable" because the Administrator told them, "I don't want him (RN A) to get in trouble." Resident #2 stated Resident #1 spoke to RN A directly, and he did not say anything. Resident #2 stated she knew a police officer would have investigated the matter. Resident #2 added, "I'm afraid she'll (the Administrator) evict me." She stated she did not want the Administrator to get mad at her. Resident #2 stated they did not do anything about RN A. She stated she had a "weird feeling" having him at the facility at nighttime, and now he no longer spoke to her. At that point, Resident #2 began to cry. An interview on 11/01/12 at 3:30 PM with Resident #2 revealed the first time "I woke up to find (RN A) standing over my bed with my shirt up, but not above my breast. (RN A) was just standing there looking at me. It really did scare me." Resident #2 stated, "I asked him what was 'up.' " (RN A) replied it was time for her medication, so "I got ready to take it, but (RN A) said he had to go and get it. (RN A) left and came back with the medication, and I took it." Resident #2 stated after RN A left, "I started crying because I wonder if this had happened before and I had not woken up." Resident #2 stated the same thing happened again and she was upset about it. She stated, "I cried a lot after that. I felt really bad." Resident #2 stated she was in the smoking section after that and two other ladies were talking about the same nurse (RN A) doing the same typeof thing to them. She stated one of the ladies was really scared, because when it first happened with her, she could not help herself very well and she was afraid of him. Resident #2 stated she (Resident #2) said something to the other residents about what had happened to her. She said, "We talked about what to do for about two days, and then we decided to tell it. When we told it, we were told to go to our rooms and write out a statement." When the surveyor asked Resident #2 about the meeting the Administrator had arranged for the residents, including Resident #2, in regard to their allegations, Resident #2 stated the Administrator told them to come, and they were going to resolve this. Resident #2 stated she did not say too much in the meeting, because she was fifth on the list to get a CBA, and she did not want to hurt her chances for that. She stated the other two ladies wanted the police called, but the Administrator reminded them of the possibility of RN A losing his job, so they agreed they did not want that to happen. Resident #2 stated, "I am really not sure what was accomplished during this meeting, other than now (RN A) will not look at me or even act like I am around. He used to check on me for my medications, and now I have to go and find him to get those medications, if I need them." Resident #2 stated she felt like she was being "punished." She stated, (RN A) treats me like I am not even there. (RN A) just ignores me now, and this makes me feel like I am being punished for something he did wrong to me." Resident #2 stated she did not want to say too much, because she might not get her CBA, and "I have been waiting a long time for that." Observation of Resident #2 during the interview revealed she was tearing up, and her bottom lip was quivering at the end of the interview. Review of Resident #3's Face Sheet, dated 09/11/12, reflected Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Further review reflected Resident #3 was her own responsible party. 4) Review of Resident #3's MDS assessment, dated 09/13/12, reflected additional [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #3 had the ability to understand others with no signs of [MEDICAL CONDITION], disorganized thinking or altered level of consciousness and had a BIMS score of 15, which indicated the resident's cognitive functioning was intact. An interview on 11/02/12 at 7:20 PM with Resident #3 revealed multiple times she had awakened when RN A pulling her shirt up over her breast or had already pulled her bed covers off her. Resident #3 stated she would ask RN A what was happening, and RN A would tell Resident #3 he needed to check her central line or draw blood. Resident #3 stated what bothered her was her central line was in her "shoulder" and all RN A had to do was pull the tubing out of her shirt sleeve, like the other nurses did. Resident #3 stated RN A was always on the wrong side of the bed to be checking or doing anything with her central line when she woke up. She stated RN A would be on the left side of the bed, and her central line was on the right side. Resident #3 stated she and the other two residents (Residents #1 and #2) talked about reporting the incident for two days, but Resident #2 was very uncomfortable. Resident #3 stated she assured Resident #2 she was uncomfortable also and she felt if she "pushed" too much, she would be retaliated against by RN A. She stated if she had not gotten to go home right after they reported this, she would have asked for another nurse for the remainder of her stay at the facility. She stated the Administrator told them the State or the police would not be called, because if she called them, then RN A could possibly be arrested and lose his job. Resident #3 stated the Administrator came to her individually and later she found out she had come to each of them by themselves, then went back to her and told her they were going to have a meeting and resolve this problem. 5) An interview on 11/01/12 at 1:45 PM with the Administrator revealed she had been told by one of the ADONs about the concerns Residents #1, #2, and #3 had regarding RN A. The Administrator stated she put it in her grievance log and began to "gather" information. The Administrator stated she told Residents #1, #2, and #3 she would have to call the state and the police regarding their concerns. She stated the residents told her they did not want that to happen. The Administrator stated she told the residents she had to do something, and that was when she decided they would just have a meeting and work this all out. She stated the residents agreed to have the meeting, and the residents said they were nervous about meeting RN A face to face and afraid of retaliation. The Administrator stated she told the residents she would have to call the "state" to report problem, call the police, and suspend RN A. She stated she told the residents RN A might be arrested, put in jail and lose his job, so they agreed, and she assured them there would be no retaliation. When the surveyor informed the Administrator it was required to report any allegation of abuse or neglect to the State, the Administrator responded, "So the state does not want us to problem solve anything anymore. They just want us to report it?" The surveyor explained any allegation of abuse had to be investigated and reported to the State. The Administrator stated she thought it was the residents' right if they did not want state called. She stated she guessed she could not have problem-solving meetings and work everything out anymore. 6) During a telephone interview with RN A on 11/01/12 at 4:35 PM, the nurse stated he was shocked when Residents #1, #2 and #3 made allegations against him. RN A was queried during this interview about the possibility of the residents misinterpreting physical assessments or other nursing care he may have been performing. RN A stated he had never performed any assessments or care for the residents while they were asleep. He stated all assessments and nursing care, including medications, was provided while the residents were fully awake and alert. RN A stated he only checked on/or provided care to Resident #2's [MEDICAL CONDITION] in the past when the [MEDICAL CONDITION] was new. RN A stated prior to the allegations, he had no disagreements with Residents #1, #2 and #3 and did not know why they would make such allegations. During this interview, RN A was adamant he had never provided any care or assessments for Residents #1, #2 and #3 while they were sleeping. RN A stated the only time he had touched Resident #2's [MEDICAL CONDITION] was in the past when the [MEDICAL CONDITION] was new, and he was providing the resident with teaching related to [MEDICAL CONDITION] care. 7) ADON B was interviewed on 11/01/12 at 2:50 PM regarding the allegations made by Residents #1, #2 and #3. ADON B stated the residents initially came to her and said, "We have something to tell you." the ADON stated she told the residents to "hold on." ADON B stated she did not want the residents to feed off each other, so she separated them. The ADON stated she instructed them they would have to write statements. ADON B then siad she did not know if the residents wrote statements. She siad she reported to the Administrator about Residents #1, #2, and #3 wanting to speak with her (the Administrator) without ever hearing what the residents had to say. "The Administrator got right on it." 8) Review of a facility Grievance/Complaint Investigation Report dated 09/20/12 revealed Resident #4 had made a complaint regarding RN A about an incident, which occurred on 09/19/12. Resident #4 reported RN A was "fresh. The resident stated RN A came into her room when she (Resident #4) was receiving a bath from the hospice CNA. Resident #4 reported when she told RN A "to get the hell out," he then walked to the foot of the bed, and rubbed his finger up and down the sole of her foot. The section of the Grievance/Complaint Investigation Report entitled "Summary of Interviews" reflected the following: Resident #4 was offended and did not want RN A back in her room. The resident stated she did not feel threatened or initimidated or fearful of any of the facility staff. Resident #4 stated she did not want RN A to come in her room, because "he's a jackass!" RN A stated he heard Resident #4 screaming at about 4:00 AM, and he went into the resident's room where the hospice CNA was bathing her (Resident #4). RN A stated the privacy curtain was pulled with Resident #4 and the hospice CNA on the other side of the curtain. He said he remained on the side of the curtain and asked the resident if she was alright. RN A stated Resident #4 asked who it was and upon hearing it was him (RN A), told him to "get the hell out." The Administrator documented she confirmed the hospice CNA did not feel RN A had been inappropriate with Resident #4 and the resident had been properly covered when the RN was in the room. The Administrator spoke with Resident #4 on 09/21/12 at 2:00 PM. The Administrator documented Resident #4 was agreeable to allowing RN A with a witmess to continue to give her medications and check on her while she slept. On 11/01/12 a 3:10 PM, an interview was conducted with Resident #4. When queried about any problems with male staff or feelings of discomfort, Resident #4 told the surveyor about problems with a man who was a nurse. The resident described RN A as the male nurse, who worked at night. Resident #4 stated RN A used to come into her room and watch when the "hospice nurse" was bathing her. She stated, "I told him to get the hell out. I went a long time before I told on (RN A), because you just have to really make me mad." Resident #4 stated she got mad and reported him because he made her uncomfortable with him "standing at the end of the bed staring at me. They told me that (RN A) was trying to see if I was breathing or not. How strange is that?" Resident #4 stated RN A would now just "get in and out" of her room since she had reported his staring when she had her bath. The resident stated RN A was not accompanied by anyone. During an intereview with the Administrator on 11/01/12 at 2:10 PM, she stated Resident #4 had a "pattern of spinning tales." The Administrator stated she did not interview the resident in regard to her complaint about RN A, because of Resident #4's "history of telling families things that are not true." The Administrator provided the incident involving Resident #4 and RN A and indicated the incident had been called in to the state related to sexual abuse. However, there was no evidence the incident was investigated, the resident was not interviewed in regard to the allegation of sexual abuse and no facility residents or other staff were interviewed, who might have potentially been witnesses. 9) The facility's current Abuse/Neglect Prevention Policy, dated September 2006, reflected the following: "Key Component #1 - Prevention ...The Grievance Procedure: Every complaint presented to the Administrator will be thoroughly investigated to determine if an individual's rights were violated and whether acts of abuse/neglect were involved... Key Component #5 - Protect ...Protecting the Resident: If abuse/neglect is suspected, or there has been an allegation of abuse/neglect reported, management will suspend the accused abuser while conducting an investigation... ...Protecting the Reporter: BWP III protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment. We encourage our employees to report report abuse/neglect, so we do not want to retaliate against those individuals that do report. ...Key Component #6 - Investigate ...The facility follows Provider Letter 00-22 - Guidelines for Reporting Incidents when investigating suspected/alleged abuse/neglect. See attached. When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents. See Key Component #5. This may require the suspension of facility staff pending the results of the investigation. The Administrator would begin an investigation. ...The Initial Evaluation and Interview: All involved persons should be identified, including the alleged victim, perpetrator, witnesses, and others with knowledge of the of the (sic) allegation or incident. Interviews should be done as soon as possible, and the person interviewed should prepare a written statement. The interview should be documented...Local law enforcement should be notified per Provider Letter 00-22. ...Reporting the Results of the Investigation: The results of the investigation will be reported according to Provider Letter -- 00-22 -- Guidelines for Reporting Incidents. ...Definitions Abuse - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. These include: ...Sexual Abuse - Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault." 10) On 11/01/12 at 5:30 PM, the Administrator was informed an IJ had been identified in the area of Resident Behavior and Facility Practice. The Administrator was requested to provide a Plan of Removal for the IJ. 11) On 11/02/12 at 9:15 AM, the Administrator provided surveyors with a statement identified as written by RN A on 11/01/12. The statement reflected RN A had written it related to the interview questions conducted by the surveyor on 11/01/12 at 4:35 p.m. The written statement reflected RN A had never provided any care and/or assessments for Residents #1, #2 and #3 while they were asleep. At that time, the surveyors reminded the Administrator the facility's plan of removal included a facility interview with RN A and not a recap of the interview conducted with the surveyor. The Administrator stated she would have RN A return to the facility, conduct and document an interview with him. 12) An interview on 11/02/12 at 10:10 AM with the Social Worker revealed she had not been informed of the allegations of sexual abuse by Residents #1, #2, and #3, and had not been made aware of any problems. The Social Worker stated she found out about the incident when she was in an office typing on a computer, and the people in the office were discussing what had happened. The Social Worker stated when she inquired about the incident, the Administrator informed her it had been resolved. The Social Worker stated she became curious and spoke to Resident #1, who had been involved in the meeting. When she spoke to Resident #1, the resident told her she did not want to discuss it anymore, because she had already been issued a 30-day discharge and she did not want to cause any more trouble, because she might not get her CBA. The Social Worker stated during the interview with Resident #1, she could tell the resident was very uncomfortable talking about it. The Social Worker said Resident #1 then asked why she (the Social Worker) had conducted the satisfaction survey. The Social Worker stated she told the resident the Administrator had given her the questions and was told to conduct the survey with the designated residents. The Social Worker stated she was unaware the questions were involved in any way with the allegations of sexual abuse. The Social Worker stated if she had known she was asking satisfaction questions in response to allegations of sexual abuse, she would have developed her own set of questions and would also have wanted to know why the allegations of sexual abuse had not been reported (to the state). 13) On 11/02/12 at 2:03 PM, the Administrator provided the surveyors with a document entitled, "Purpose of meeting with (RN A) on 10/02/12," which reflected Residents #1, #2, and #3 did not want to call DADs or the police. The document reflected: "I, as the administrator could not just take the complaint and do nothing. I (the Administrator) asked if they (Residents #1, #2 and #3) would consider meeting with (RN A) and IDT (interdisciplinary team members) and all (three residents) expressed concerns about retaliation. I (the Administrator) assured them (Residents #1, #2 and #3) that there would no retaliation and they (Residents #1, #2 and #3) could all be together. All three (residents) agreed to the meeting. (I) Shared their (Residents #1, #2 and #3) concerns with (RN A), who was very apologetic after hearing their (Residents #1, #2 and #3) concerns." On 11/02/12 at 4:25 PM, the Administrator provided another written statement identified as written by RN A on 11/01/02. The statement reflected RN A denied ever having touched any resident inappropriately. According to this statement, Resident #1's pain medication made her "very" sleepy and the resident always slept with ear plugs, and the oxygen concentrator caused some amount of noise. Resident #1 may have misunderstood the purpose of RN A being in her room as her ear plugs remained in place, and the oxygen concentrator in use was causing noise. The new statement further reflected RN A had touched Resident #2 during nursing assessments of her [MEDICAL CONDITION] site for any abnormality and to enable him to do so, he had to raise her pajamas to assess the site. Additionally, the statement reflected RN A's basic nursing duties included routine assessments of residents with wounds, incisions and IV PICC (A peripherally inserted central catheter for IV access) line. RN A's new statement reflected Resident #3 had a lower abdominal wound with a wound vac, and the wound vac would sometimes malfunction. RN A would lift the resident's gown to assess the wound site for leakage. The statement reflected the resident "must" have misinterpreted his nursing action, because she took narcotics, which made her drowsy. The statement also reflected if RN A found a resident asleep, he tapped them on their feet while standing by the foot of the bed until the resident responded by speaking to him, and he concluded the resident was fully awake. Along with the new statement dated 11/01/12, the Administrator provided another statement written by RN A on 11/02/12. This statement reflected Resident #5 was a friend of Resident #3. According to RN A's statement, Resident #5 informed RN A, Resident #3 told him Resident #1 had "made up" the allegation. On 11/02/12 at 4:40 PM, Resident #5 was interviewed. He stated he was friends with Resident #3. Resident #5 stated Resident #3 visited and brought him food/snacks. The resident further stated he was aware of the "situation" with RN A, and he did not believe Resident #3 would lie. At that time, Resident #5 stated he believed "it" had gotten all blown out of proportion. Resident #5 had no knowledge about the allegation having been "made up." 14) During an intervew on 11/02/12 at 12:30 PM with the DON, she stated the facility's policy was to follow the chain of command and report any allegation of abuse and/or neglect to the Administrator. The DON stated Resident #3 stood out in her mind and had not alleged any abuse. The DON stated, "As far as I know, she (Resident #3) did not feel comfortable" when RN A was in her room. At that time, the surveyor provided the DO

Based on obsevation, interview and record review, it was determined the facility failed to implement it's written Abuse Prohibition Policy and Procedure when three (Residents #1, #2, and #3) of seven residents reviewed for abuse alleged RN A sexually abused them. Three residents alleged sexually inappropriate behavior against RN A to the Administrator. The facility: 1. Failed to remove RN A from working directly with the facility's residents and allowed contact from 10/02/12 through 11/02/12. 2. Failed to thoroughly investigate the incidents by interviewing facility residents and staff. Potential witnesses were not questioned. 3. A previous allegation of sexually inappropriate behavior against RN A by Resident #4 was not investigated, the residents were not protected and it was not reported to the State agency. An Immediate Jeopardy (IJ) was identified on 11/01/12. While the IJ was removed on 11/02/12, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern." The facility continued to in-service and monitor staff to ensure allegations of abuse were being reported, investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect all residents residing in the facility, including Residents #1, #2 and #3, by placing them at risk for further abuse, which could result in serious mental health complications and/or physical injuries. Findings included: Per adminstrative review, surveyors returned to the facility on [DATE] to further investigate the allegations of sexual abuse by RN A. 1) Review of the facility's grievance log revealed a grievance report, dated 10/02/12, which reflected: "Allegation of RN (RN A), making residents feel uncomfortable October 02, 2012 Complainants: (Resident #1, Resident #2, and Resident #3) At approximately 12:30 PM it was reported to me (the Administrator) the three ladies above were very concerned and wanted to talk with me about (RN A) by (ADON B), LVN. (Resident #2) admitted her concerns arose after hearing a fell ow resident (Resident #4) describe an incident during smoke break this morning that had reportedly occurred with (RN A), but had been investigated and unsubstantiated by the Administrator... (Resident #2) became concerned that she had awakened on more than one occasion when (RN A) was bringing her meds in the middle of the night and he had raised her shirt tail slightly. (Resident #3) was concerned that she had awakened on several occasions to him (RN A) raising her shirt and when she would ask him what he was doing, he would respond that he was there to give her medications or draw blood. Her central line was on the other side. (Resident #1) stated that he had come into her room to give her medications and she was awakened to him pulling her covers off of her. She stated that she wasn't sure if it happened or not, so she had not mentioned it, but felt one night she was awakened by (RN A) playing with her breast and nipple. (Resident #1) was encouraged to file a police report if she felt she had been assaulted in any manner (by the Administrator). She declined, stating she "didn't want it to go that far." I (the Administrator) spoke individually with each of them and they all agreed to meet with (RN A) and discuss with him their concerns and what he was doing that made them feel uncomfortable. The social worker was given a questionnaire (satisfaction survey) to complete with other interviewable female residents while we visited with (RN A) and residents. Before speaking with them and (RN A), I spoke with them as a group to ensure they were comfortable with this meeting in the conference room and they all assured me they were. (RN A) came into the conference room and sat across the table from all of them. I explained to the residents the seriousness of their allegations. They stated they did not want (RN A) to lose his job, just wanted him to stop making them feel uncomfortable. Each resident was allowed to share with (RN A) the behaviors that bothered them... All three take heavy medications that make them sleep very soundly. They all agreed with this. They also agreed that (RN A) may not have realized they were not fully awake when he proceeded in his nursing processes - (Resident #2) has a fairly new [MEDICAL CONDITION] and raising her shirt to check to ensure it was intact and not needing attention would have been a nursing function while he was there; (Resident #3) has an abdominal wound with a dressing, it would be logical that a prudent nurse was assessing her dressing for excessive drainage; (Resident #1) sleeps with ear plugs and a concentrator running at the head of her bed, it would be very difficult to wake her with the medications she takes at night, thus he may have been simply pulling back the covers in an effort to disturb her sleep enough to wake her. When these possibilities were mentioned, they all felt that maybe they had misread some of his actions, but stood their ground that they were uncomfortable with this approach. (RN A) was directed if he cannot get them awake by calling their name, he will get a female employee to wake them if they have to be touched. All residents were agreeable to this resolution. (RN A) apologized for frightening them and assured them he would work hard not to in the future. He shook hands with all three and all agreed they were satisfied with the resolution. They were informed that some of the allegations met the criteria for reportable incident. They all agreed and stated they did not want this called to the State. They were happy with the outcome. All three were given the business card with the Administrator's personal cell number and encouraged to call any time, day or night, if they feel uncomfortable or dissatisfied with their help. All agreed that they would." This grievance report was signed by Residents #1, #2, and #3. It was also signed by the Administrator and RN A. 2) Review of Resident #1's Face Sheet, dated 09/28/12, revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident's BIMS score was 13, which indicated the resident's cognitive status was intact. On 10/18/12 at 2:00 PM, an interview was conducted with Resident #1. Resident #1 stated she and two other residents met with ADON B and the Administrator regarding the grievance. When asked about her specific allegations, Resident #1 stated she woke up one night, and she had a "strange" feeling RN A had been playing with her breasts and nipples. Resident #1 stated on another occasion, RN A pulled the covers off her while she was asleep, and when she woke up, he "shoved" pills in her mouth. Resident #1 stated, during the meeting with the Administrator, the Administrator informed her (Resident #1), her statement alone could cause RN A to lose his job or go to jail. Resident #1 stated she and the two other female residents had to sign a statement they would not bring the allegations against RN A. After their meeting with the Administrator, Resident #1 stated she (the Administrator) called RN A into her office to meet with him. Since the meeting with the Administrator, Resident #1 stated RN A had come to her room to give her medications. RN A was alone at those times. She stated he had not touched her again since they reported the allegations. The Administrator was interviewed regarding this grievance report on 10/18/12 at 1:20 PM. The Administrator explained the residents did not want her to report it to the State, and she did not report the allegation to the State agency. The Administrator stated RN A was not suspended before, during or following the investigation. However, the Administrator was unable to provide evidence the incident had been investigated or the statedments written by the residents. This statement was reiterated during the Exit Conference on 10/19/12 at 3:40 PM. The Administrator stated, "The residents did not want me to call the state...it's a resident rights issue." During an interview with Resident #1 on 11/01/12 at 3:15 PM, the resident stated she never agreed to anything related to not calling/reporting the incidents to "State" and never knew it was an option. Resident #1 stated, "I didn't want him (RN A) to keep it up, but didn't want to be the one who got him fired. He could ...find me and hurt me." The resident further stated she would shortly be moving into an apartment on her own and was afraid RN A might find and hurt her. Resident #1 added she felt she was being retaliated against due to the 30-day discharge notice she received effective 10/05/12, because of RN A reporting her smoking outside. Resident #1 stated RN A had seen her smoke "hundreds" of times before and had never reported her. 3) Review of Resident #2's Face Sheet, dated 08/15/12, reflected the resident was admitted to the facility on [DATE] and was readmited on 06/29/12 with the following Diagnoses: [REDACTED]. The Face Sheet also reflected Resident #2 was her own responsible party. Review of Resident #2's MDS assessment, dated 08/07/12, revealed an additional active [DIAGNOSES REDACTED]. The MDS assessment reflected the resident's BIMS score was 12, which indicated the resident's cognitive status was intact. Further review revealed Resident #2 had the ability to understand others. Resident #2 was interviewed on 10/18/12 at 2:15 PM regarding the allegations. Resident #2 stated several of the residents complained about RN A, who was the nurse on duty at night. She stated RN A raised her shirt up while she was asleep in her room one night. She stated when she woke up, he gave her medications and hurried out of the room. Resident #2 stated she was afraid to say anything. She stated when she and the other residents reported the allegations to the Administrator, they went to a little room and "wrote papers out," and the Administrator stated she would take care of the matter. Resident #2 stated she had to sign her paper. The resident stated the Administrator told them she wanted RN A to keep his job, and she did not want him to lose his job. Resident #2 stated RN A did not say anything during the meeting. Resident #2 stated the Administrator told them if they said anything about what happened, then she would have to call the police. Resident #2 stated the police were not called. Resident #2 stated they were worried about the other girls (residents) in the facility. She stated RN A did not deny the allegations, and he did not apologize. She stated he had not touched her since they reported the allegations. Resident #2 stated she felt "very uncomfortable" because the Administrator told them, "I don't want him (RN A) to get in trouble." Resident #2 stated Resident #1 spoke to RN A directly, and he did not say anything. Resident #2 stated she knew a police officer would have investigated the matter. Resident #2 added, "I'm afraid she'll (the Administrator) evict me." She stated she did not want the Administrator to get mad at her. Resident #2 stated they did not do anything about RN A. She stated she had a "weird feeling" having him at the facility at nighttime, and now he no longer spoke to her. At that point, Resident #2 began to cry. An interview on 11/01/12 at 3:30 PM with Resident #2 revealed the first time "I woke up to find (RN A) standing over my bed with my shirt up, but not above my breast. (RN A) was just standing there looking at me. It really did scare me." Resident #2 stated, "I asked him what was 'up.' " (RN A) replied it was time for her medication, so "I got ready to take it, but (RN A) said he had to go and get it. (RN A) left and came back with the medication, and I took it." Resident #2 stated after RN A left, "I started crying because I wonder if this had happened before and I had not woken up." Resident #2 stated the same thing happened again and she was upset about it. She stated, "I cried a lot after that. I felt really bad." Resident #2 stated she was in the smoking section after that and two other ladies were talking about the same nurse (RN A) doing the same typeof thing to them. She stated one of the ladies was really scared, because when it first happened with her, she could not help herself very well and she was afraid of him. Resident #2 stated she (Resident #2) said something to the other residents about what had happened to her. She said, "We talked about what to do for about two days, and then we decided to tell it. When we told it, we were told to go to our rooms and write out a statement." When the surveyor asked Resident #2 about the meeting the Administrator had arranged for the residents, including Resident #2, in regard to their allegations, Resident #2 stated the Administrator told them to come, and they were going to resolve this. Resident #2 stated she did not say too much in the meeting, because she was fifth on the list to get a CBA, and she did not want to hurt her chances for that. She stated the other two ladies wanted the police called, but the Administrator reminded them of the possibility of RN A losing his job, so they agreed they did not want that to happen. Resident #2 stated, "I am really not sure what was accomplished during this meeting, other than now (RN A) will not look at me or even act like I am around. He used to check on me for my medications, and now I have to go and find him to get those medications, if I need them." Resident #2 stated she felt like she was being "punished." She stated, (RN A) treats me like I am not even there. (RN A) just ignores me now, and this makes me feel like I am being punished for something he did wrong to me." Resident #2 stated she did not want to say too much, because she might not get her CBA, and "I have been waiting a long time for that." Observation of Resident #2 during the interview revealed she was tearing up, and her bottom lip was quivering at the end of the interview. Review of Resident #3's Face Sheet, dated 09/11/12, reflected Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Further review reflected Resident #3 was her own responsible party. 4) Review of Resident #3's MDS assessment, dated 09/13/12, reflected additional [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #3 had the ability to understand others with no signs of [MEDICAL CONDITION], disorganized thinking or altered level of consciousness and had a BIMS score of 15, which indicated the resident's cognitive functioning was intact. An interview on 11/02/12 at 7:20 PM with Resident #3 revealed multiple times she had awakened when RN A pulling her shirt up over her breast or had already pulled her bed covers off her. Resident #3 stated she would ask RN A what was happening, and RN A would tell Resident #3 he needed to check her central line or draw blood. Resident #3 stated what bothered her was her central line was in her "shoulder" and all RN A had to do was pull the tubing out of her shirt sleeve, like the other nurses did. Resident #3 stated RN A was always on the wrong side of the bed to be checking or doing anything with her central line when she woke up. She stated RN A would be on the left side of the bed, and her central line was on the right side. Resident #3 stated she and the other two residents (Residents #1 and #2) talked about reporting the incident for two days, but Resident #2 was very uncomfortable. Resident #3 stated she assured Resident #2 she was uncomfortable also and she felt if she "pushed" too much, she would be retaliated against by RN A. She stated if she had not gotten to go home right after they reported this, she would have asked for another nurse for the remainder of her stay at the facility. She stated the Administrator told them the State or the police would not be called, because if she called them, then RN A could possibly be arrested and lose his job. Resident #3 stated the Administrator came to her individually and later she found out she had come to each of them by themselves, then went back to her and told her they were going to have a meeting and resolve this problem. 5) An interview on 11/01/12 at 1:45 PM with the Administrator revealed she had been told by one of the ADONs about the concerns Residents #1, #2, and #3 had regarding RN A. The Administrator stated she put it in her grievance log and began to "gather" information. The Administrator stated she told Residents #1, #2, and #3 she would have to call the state and the police regarding their concerns. She stated the residents told her they did not want that to happen. The Administrator stated she told the residents she had to do something, and that was when she decided they would just have a meeting and work this all out. She stated the residents agreed to have the meeting, and the residents said they were nervous about meeting RN A face to face and afraid of retaliation. The Administrator stated she told the residents she would have to call the "state" to report problem, call the police, and suspend RN A. She stated she told the residents RN A might be arrested, put in jail and lose his job, so they agreed, and she assured them there would be no retaliation. When the surveyor informed the Administrator it was required to report any allegation of abuse or neglect to the State, the Administrator responded, "So the state does not want us to problem solve anything anymore. They just want us to report it?" The surveyor explained any allegation of abuse had to be investigated and reported to the State. The Administrator stated she thought it was the residents' right if they did not want state called. She stated she guessed she could not have problem-solving meetings and work everything out anymore. 6) During a telephone interview with RN A on 11/01/12 at 4:35 PM, the nurse stated he was shocked when Residents #1, #2 and #3 made allegations against him. RN A was queried during this interview about the possibility of the residents misinterpreting physical assessments or other nursing care he may have been performing. RN A stated he had never performed any assessments or care for the residents while they were asleep. He stated all assessments and nursing care, including medications, was provided while the residents were fully awake and alert. RN A stated he only checked on/or provided care to Resident #2's [MEDICAL CONDITION] in the past when the [MEDICAL CONDITION] was new. RN A stated prior to the allegations, he had no disagreements with Residents #1, #2 and #3 and did not know why they would make such allegations. During this interview, RN A was adamant he had never provided any care or assessments for Residents #1, #2 and #3 while they were sleeping. RN A stated the only time he had touched Resident #2's [MEDICAL CONDITION] was in the past when the [MEDICAL CONDITION] was new, and he was providing the resident with teaching related to [MEDICAL CONDITION] care. 7) ADON B was interviewed on 11/01/12 at 2:50 PM regarding the allegations made by Residents #1, #2 and #3. ADON B stated the residents initially came to her and said, "We have something to tell you." the ADON stated she told the residents to "hold on." ADON B stated she did not want the residents to feed off each other, so she separated them. The ADON stated she instructed them they would have to write statements. ADON B then siad she did not know if the residents wrote statements. She siad she reported to the Administrator about Residents #1, #2, and #3 wanting to speak with her (the Administrator) without ever hearing what the residents had to say. "The Administrator got right on it." 8) Review of a facility Grievance/Complaint Investigation Report dated 09/20/12 revealed Resident #4 had made a complaint regarding RN A about an incident, which occurred on 09/19/12. Resident #4 reported RN A was "fresh. The resident stated RN A came into her room when she (Resident #4) was receiving a bath from the hospice CNA. Resident #4 reported when she told RN A "to get the hell out," he then walked to the foot of the bed, and rubbed his finger up and down the sole of her foot. The section of the Grievance/Complaint Investigation Report entitled "Summary of Interviews" reflected the following: Resident #4 was offended and did not want RN A back in her room. The resident stated she did not feel threatened or initimidated or fearful of any of the facility staff. Resident #4 stated she did not want RN A to come in her room, because "he's a jackass!" RN A stated he heard Resident #4 screaming at about 4:00 AM, and he went into the resident's room where the hospice CNA was bathing her (Resident #4). RN A stated the privacy curtain was pulled with Resident #4 and the hospice CNA on the other side of the curtain. He said he remained on the side of the curtain and asked the resident if she was alright. RN A stated Resident #4 asked who it was and upon hearing it was him (RN A), told him to "get the hell out." The Administrator documented she confirmed the hospice CNA did not feel RN A had been inappropriate with Resident #4 and the resident had been properly covered when the RN was in the room. The Administrator spoke with Resident #4 on 09/21/12 at 2:00 PM. The Administrator documented Resident #4 was agreeable to allowing RN A with a witmess to continue to give her medications and check on her while she slept. On 11/01/12 a 3:10 PM, an interview was conducted with Resident #4. When queried about any problems with male staff or feelings of discomfort, Resident #4 told the surveyor about problems with a man who was a nurse. The resident described RN A as the male nurse, who worked at night. Resident #4 stated RN A used to come into her room and watch when the "hospice nurse" was bathing her. She stated, "I told him to get the hell out. I went a long time before I told on (RN A), because you just have to really make me mad." Resident #4 stated she got mad and reported him because he made her uncomfortable with him "standing at the end of the bed staring at me. They told me that (RN A) was trying to see if I was breathing or not. How strange is that?" Resident #4 stated RN A would now just "get in and out" of her room since she had reported his staring when she had her bath. The resident stated RN A was not accompanied by anyone. During an intereview with the Administrator on 11/01/12 at 2:10 PM, she stated Resident #4 had a "pattern of spinning tales." The Administrator stated she did not interview the resident in regard to her complaint about RN A, because of Resident #4's "history of telling families things that are not true." The Administrator provided the incident involving Resident #4 and RN A and indicated the incident had been called in to the state related to sexual abuse. However, there was no evidence the incident was investigated, the resident was not interviewed in regard to the allegation of sexual abuse and no facility residents or other staff were interviewed, who might have potentially been witnesses. 9) The facility's current Abuse/Neglect Prevention Policy, dated September 2006, reflected the following: "Key Component #1 - Prevention ...The Grievance Procedure: Every complaint presented to the Administrator will be thoroughly investigated to determine if an individual's rights were violated and whether acts of abuse/neglect were involved... Key Component #5 - Protect ...Protecting the Resident: If abuse/neglect is suspected, or there has been an allegation of abuse/neglect reported, management will suspend the accused abuser while conducting an investigation... ...Protecting the Reporter: BWP III protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment. We encourage our employees to report report abuse/neglect, so we do not want to retaliate against those individuals that do report. ...Key Component #6 - Investigate ...The facility follows Provider Letter 00-22 - Guidelines for Reporting Incidents when investigating suspected/alleged abuse/neglect. See attached. When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents. See Key Component #5. This may require the suspension of facility staff pending the results of the investigation. The Administrator would begin an investigation. ...The Initial Evaluation and Interview: All involved persons should be identified, including the alleged victim, perpetrator, witnesses, and others with knowledge of the of the (sic) allegation or incident. Interviews should be done as soon as possible, and the person interviewed should prepare a written statement. The interview should be documented...Local law enforcement should be notified per Provider Letter 00-22. ...Reporting the Results of the Investigation: The results of the investigation will be reported according to Provider Letter -- 00-22 -- Guidelines for Reporting Incidents. ...Definitions Abuse - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. These include: ...Sexual Abuse - Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault." 10) On 11/01/12 at 5:30 PM, the Administrator was informed an IJ had been identified in the area of Resident Behavior and Facility Practice. The Administrator was requested to provide a Plan of Removal for the IJ. 11) On 11/02/12 at 9:15 AM, the Administrator provided surveyors with a statement identified as written by RN A on 11/01/12. The statement reflected RN A had written it related to the interview questions conducted by the surveyor on 11/01/12 at 4:35 p.m. The written statement reflected RN A had never provided any care and/or assessments for Residents #1, #2 and #3 while they were asleep. At that time, the surveyors reminded the Administrator the facility's plan of removal included a facility interview with RN A and not a recap of the interview conducted with the surveyor. The Administrator stated she would have RN A return to the facility, conduct and document an interview with him. 12) An interview on 11/02/12 at 10:10 AM with the Social Worker revealed she had not been informed of the allegations of sexual abuse by Residents #1, #2, and #3, and had not been made aware of any problems. The Social Worker stated she found out about the incident when she was in an office typing on a computer, and the people in the office were discussing what had happened. The Social Worker stated when she inquired about the incident, the Administrator informed her it had been resolved. The Social Worker stated she became curious and spoke to Resident #1, who had been involved in the meeting. When she spoke to Resident #1, the resident told her she did not want to discuss it anymore, because she had already been issued a 30-day discharge and she did not want to cause any more trouble, because she might not get her CBA. The Social Worker stated during the interview with Resident #1, she could tell the resident was very uncomfortable talking about it. The Social Worker said Resident #1 then asked why she (the Social Worker) had conducted the satisfaction survey. The Social Worker stated she told the resident the Administrator had given her the questions and was told to conduct the survey with the designated residents. The Social Worker stated she was unaware the questions were involved in any way with the allegations of sexual abuse. The Social Worker stated if she had known she was asking satisfaction questions in response to allegations of sexual abuse, she would have developed her own set of questions and would also have wanted to know why the allegations of sexual abuse had not been reported (to the state). 13) On 11/02/12 at 2:03 PM, the Administrator provided the surveyors with a document entitled, "Purpose of meeting with (RN A) on 10/02/12," which reflected Residents #1, #2, and #3 did not want to call DADs or the police. The document reflected: "I, as the administrator could not just take the complaint and do nothing. I (the Administrator) asked if they (Residents #1, #2 and #3) would consider meeting with (RN A) and IDT (interdisciplinary team members) and all (three residents) expressed concerns about retaliation. I (the Administrator) assured them (Residents #1, #2 and #3) that there would no retaliation and they (Residents #1, #2 and #3) could all be together. All three (residents) agreed to the meeting. (I) Shared their (Residents #1, #2 and #3) concerns with (RN A), who was very apologetic after hearing their (Residents #1, #2 and #3) concerns." On 11/02/12 at 4:25 PM, the Administrator provided another written statement identified as written by RN A on 11/01/02. The statement reflected RN A denied ever having touched any resident inappropriately. According to this statement, Resident #1's pain medication made her "very" sleepy and the resident always slept with ear plugs, and the oxygen concentrator caused some amount of noise. Resident #1 may have misunderstood the purpose of RN A being in her room as her ear plugs remained in place, and the oxygen concentrator in use was causing noise. The new statement further reflected RN A had touched Resident #2 during nursing assessments of her [MEDICAL CONDITION] site for any abnormality and to enable him to do so, he had to raise her pajamas to assess the site. Additionally, the statement reflected RN A's basic nursing duties included routine assessments of residents with wounds, incisions and IV PICC (A peripherally inserted central catheter for IV access) line. RN A's new statement reflected Resident #3 had a lower abdominal wound with a wound vac, and the wound vac would sometimes malfunction. RN A would lift the resident's gown to assess the wound site for leakage. The statement reflected the resident "must" have misinterpreted his nursing action, because she took narcotics, which made her drowsy. The statement also reflected if RN A found a resident asleep, he tapped them on their feet while standing by the foot of the bed until the resident responded by speaking to him, and he concluded the resident was fully awake. Along with the new statement dated 11/01/12, the Administrator provided another statement written by RN A on 11/02/12. This statement reflected Resident #5 was a friend of Resident #3. According to RN A's statement, Resident #5 informed RN A, Resident #3 told him Resident #1 had "made up" the allegation. On 11/02/12 at 4:40 PM, Resident #5 was interviewed. He stated he was friends with Resident #3. Resident #5 stated Resident #3 visited and brought him food/snacks. The resident further stated he was aware of the "situation" with RN A, and he did not believe Resident #3 would lie. At that time, Resident #5 stated he believed "it" had gotten all blown out of proportion. Resident #5 had no knowledge about the allegation having been "made up." 14) During an intervew on 11/02/12 at 12:30 PM with the DON, she stated the facility's policy was to follow the chain of command and report any allegation of abuse and/or neglect to the Administrator. The DON stated Resident #3 stood out in her mind and had not alleged any abuse. The DON stated, "As far as I know, she (Resident #3) did not feel comfortable" when RN A was in her room. At that time, the s

Based on observation, interview and record review, it was determined the facility failed to ensure all alleged violations involving abuse were reported immediately to the State survey and certification agency, were thoroughly investigated and prevented further potential abuse while the investigation was in progress for three (Residents #1, #2 and #3) of seven residents reviewed for abuse. Three residents alleged sexually inappropriate behavior against RN A to the Administrator. The facility: 1. Failed to remove RN A from working directly with the facility's residents and allowed contact from 10/02/12 through 11/02/12. 2. Failed to thoroughly investigate the incidents by interviewing facility residents and staff. Potential witnesses were not questioned. 3. A previous allegation of sexually inappropriate behavior against RN A by Resident #4 was not investigated, the residents were not protected and it was not reported to the State agency. An Immediate Jeopardy (IJ) was identified on 11/01/12. While the IJ was removed on 11/02/12, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern." The facility continued to in-service and monitor staff to ensure allegations of abuse were being reported, investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect all residents residing in the facility, including Residents #1, #2 and #3, by placing them at risk for further abuse, which could result in serious mental health complications and/or physical injuries. Findings included: Per adminstrative review, surveyors returned to the facility on [DATE] to further investigate the allegations of sexual abuse by RN A. 1) Review of the facility's grievance log revealed a grievance report, dated 10/02/12, which reflected: "Allegation of RN (RN A), making residents feel uncomfortable October 02, 2012 Complainants: (Resident #1, Resident #2, and Resident #3) At approximately 12:30 PM it was reported to me (the Administrator) the three ladies above were very concerned and wanted to talk with me about (RN A) by (ADON B), LVN. (Resident #2) admitted her concerns arose after hearing a fell ow resident (Resident #4) describe an incident during smoke break this morning that had reportedly occurred with (RN A), but had been investigated and unsubstantiated by the Administrator... (Resident #2) became concerned that she had awakened on more than one occasion when (RN A) was bringing her meds in the middle of the night and he had raised her shirt tail slightly. (Resident #3) was concerned that she had awakened on several occasions to him (RN A) raising her shirt and when she would ask him what he was doing, he would respond that he was there to give her medications or draw blood. Her central line was on the other side. (Resident #1) stated that he had come into her room to give her medications and she was awakened to him pulling her covers off of her. She stated that she wasn't sure if it happened or not, so she had not mentioned it, but felt one night she was awakened by (RN A) playing with her breast and nipple. (Resident #1) was encouraged to file a police report if she felt she had been assaulted in any manner (by the Administrator). She declined, stating she "didn't want it to go that far." I (the Administrator) spoke individually with each of them and they all agreed to meet with (RN A) and discuss with him their concerns and what he was doing that made them feel uncomfortable. The social worker was given a questionnaire (satisfaction survey) to complete with other interviewable female residents while we visited with (RN A) and residents. Before speaking with them and (RN A), I spoke with them as a group to ensure they were comfortable with this meeting in the conference room and they all assured me they were. (RN A) came into the conference room and sat across the table from all of them. I explained to the residents the seriousness of their allegations. They stated they did not want (RN A) to lose his job, just wanted him to stop making them feel uncomfortable. Each resident was allowed to share with (RN A) the behaviors that bothered them... All three take heavy medications that make them sleep very soundly. They all agreed with this. They also agreed that (RN A) may not have realized they were not fully awake when he proceeded in his nursing processes - (Resident #2) has a fairly new [MEDICAL CONDITION] and raising her shirt to check to ensure it was intact and not needing attention would have been a nursing function while he was there; (Resident #3) has an abdominal wound with a dressing, it would be logical that a prudent nurse was assessing her dressing for excessive drainage; (Resident #1) sleeps with ear plugs and a concentrator running at the head of her bed, it would be very difficult to wake her with the medications she takes at night, thus he may have been simply pulling back the covers in an effort to disturb her sleep enough to wake her. When these possibilities were mentioned, they all felt that maybe they had misread some of his actions, but stood their ground that they were uncomfortable with this approach. (RN A) was directed if he cannot get them awake by calling their name, he will get a female employee to wake them if they have to be touched. All residents were agreeable to this resolution. (RN A) apologized for frightening them and assured them he would work hard not to in the future. He shook hands with all three and all agreed they were satisfied with the resolution. They were informed that some of the allegations met the criteria for reportable incident. They all agreed and stated they did not want this called to the State. They were happy with the outcome. All three were given the business card with the Administrator's personal cell number and encouraged to call any time, day or night, if they feel uncomfortable or dissatisfied with their help. All agreed that they would." This grievance report was signed by Residents #1, #2, and #3. It was also signed by the Administrator and RN A. 2) Review of Resident #1's Face Sheet, dated 09/28/12, revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident's BIMS score was 13, which indicated the resident's cognitive status was intact. On 10/18/12 at 2:00 PM, an interview was conducted with Resident #1. Resident #1 stated she and two other residents met with ADON B and the Administrator regarding the grievance. When asked about her specific allegations, Resident #1 stated she woke up one night, and she had a "strange" feeling RN A had been playing with her breasts and nipples. Resident #1 stated on another occasion, RN A pulled the covers off her while she was asleep, and when she woke up, he "shoved" pills in her mouth. Resident #1 stated, during the meeting with the Administrator, the Administrator informed her (Resident #1), her statement alone could cause RN A to lose his job or go to jail. Resident #1 stated she and the two other female residents had to sign a statement they would not bring the allegations against RN A. After their meeting with the Administrator, Resident #1 stated she (the Administrator) called RN A into her office to meet with him. Since the meeting with the Administrator, Resident #1 stated RN A had come to her room to give her medications. RN A was alone at those times. She stated he had not touched her again since they reported the allegations. The Administrator was interviewed regarding this grievance report on 10/18/12 at 1:20 PM. The Administrator explained the residents did not want her to report it to the State, and she did not report the allegation to the State agency. The Administrator stated RN A was not suspended before, during or following the investigation. However, the Administrator was unable to provide evidence the incident had been investigated or the statedments written by the residents. This statement was reiterated during the Exit Conference on 10/19/12 at 3:40 PM. The Administrator stated, "The residents did not want me to call the state...it's a resident rights issue." During an interview with Resident #1 on 11/01/12 at 3:15 PM, the resident stated she never agreed to anything related to not calling/reporting the incidents to "State" and never knew it was an option. Resident #1 stated, "I didn't want him (RN A) to keep it up, but didn't want to be the one who got him fired. He could ...find me and hurt me." The resident further stated she would shortly be moving into an apartment on her own and was afraid RN A might find and hurt her. Resident #1 added she felt she was being retaliated against due to the 30-day discharge notice she received effective 10/05/12, because of RN A reporting her smoking outside. Resident #1 stated RN A had seen her smoke "hundreds" of times before and had never reported her. 3) Review of Resident #2's Face Sheet, dated 08/15/12, reflected the resident was admitted to the facility on [DATE] and was readmited on 06/29/12 with the following Diagnoses: [REDACTED]. The Face Sheet also reflected Resident #2 was her own responsible party. Review of Resident #2's MDS assessment, dated 08/07/12, revealed an additional active [DIAGNOSES REDACTED]. The MDS assessment reflected the resident's BIMS score was 12, which indicated the resident's cognitive status was intact. Further review revealed Resident #2 had the ability to understand others. Resident #2 was interviewed on 10/18/12 at 2:15 PM regarding the allegations. Resident #2 stated several of the residents complained about RN A, who was the nurse on duty at night. She stated RN A raised her shirt up while she was asleep in her room one night. She stated when she woke up, he gave her medications and hurried out of the room. Resident #2 stated she was afraid to say anything. She stated when she and the other residents reported the allegations to the Administrator, they went to a little room and "wrote papers out," and the Administrator stated she would take care of the matter. Resident #2 stated she had to sign her paper. The resident stated the Administrator told them she wanted RN A to keep his job, and she did not want him to lose his job. Resident #2 stated RN A did not say anything during the meeting. Resident #2 stated the Administrator told them if they said anything about what happened, then she would have to call the police. Resident #2 stated the police were not called. Resident #2 stated they were worried about the other girls (residents) in the facility. She stated RN A did not deny the allegations, and he did not apologize. She stated he had not touched her since they reported the allegations. Resident #2 stated she felt "very uncomfortable" because the Administrator told them, "I don't want him (RN A) to get in trouble." Resident #2 stated Resident #1 spoke to RN A directly, and he did not say anything. Resident #2 stated she knew a police officer would have investigated the matter. Resident #2 added, "I'm afraid she'll (the Administrator) evict me." She stated she did not want the Administrator to get mad at her. Resident #2 stated they did not do anything about RN A. She stated she had a "weird feeling" having him at the facility at nighttime, and now he no longer spoke to her. At that point, Resident #2 began to cry. An interview on 11/01/12 at 3:30 PM with Resident #2 revealed the first time "I woke up to find (RN A) standing over my bed with my shirt up, but not above my breast. (RN A) was just standing there looking at me. It really did scare me." Resident #2 stated, "I asked him what was 'up.' " (RN A) replied it was time for her medication, so "I got ready to take it, but (RN A) said he had to go and get it. (RN A) left and came back with the medication, and I took it." Resident #2 stated after RN A left, "I started crying because I wonder if this had happened before and I had not woken up." Resident #2 stated the same thing happened again and she was upset about it. She stated, "I cried a lot after that. I felt really bad." Resident #2 stated she was in the smoking section after that and two other ladies were talking about the same nurse (RN A) doing the same typeof thing to them. She stated one of the ladies was really scared, because when it first happened with her, she could not help herself very well and she was afraid of him. Resident #2 stated she (Resident #2) said something to the other residents about what had happened to her. She said, "We talked about what to do for about two days, and then we decided to tell it. When we told it, we were told to go to our rooms and write out a statement." When the surveyor asked Resident #2 about the meeting the Administrator had arranged for the residents, including Resident #2, in regard to their allegations, Resident #2 stated the Administrator told them to come, and they were going to resolve this. Resident #2 stated she did not say too much in the meeting, because she was fifth on the list to get a CBA, and she did not want to hurt her chances for that. She stated the other two ladies wanted the police called, but the Administrator reminded them of the possibility of RN A losing his job, so they agreed they did not want that to happen. Resident #2 stated, "I am really not sure what was accomplished during this meeting, other than now (RN A) will not look at me or even act like I am around. He used to check on me for my medications, and now I have to go and find him to get those medications, if I need them." Resident #2 stated she felt like she was being "punished." She stated, (RN A) treats me like I am not even there. (RN A) just ignores me now, and this makes me feel like I am being punished for something he did wrong to me." Resident #2 stated she did not want to say too much, because she might not get her CBA, and "I have been waiting a long time for that." Observation of Resident #2 during the interview revealed she was tearing up, and her bottom lip was quivering at the end of the interview. Review of Resident #3's Face Sheet, dated 09/11/12, reflected Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Further review reflected Resident #3 was her own responsible party. 4) Review of Resident #3's MDS assessment, dated 09/13/12, reflected additional [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #3 had the ability to understand others with no signs of [MEDICAL CONDITION], disorganized thinking or altered level of consciousness and had a BIMS score of 15, which indicated the resident's cognitive functioning was intact. An interview on 11/02/12 at 7:20 PM with Resident #3 revealed multiple times she had awakened when RN A pulling her shirt up over her breast or had already pulled her bed covers off her. Resident #3 stated she would ask RN A what was happening, and RN A would tell Resident #3 he needed to check her central line or draw blood. Resident #3 stated what bothered her was her central line was in her "shoulder" and all RN A had to do was pull the tubing out of her shirt sleeve, like the other nurses did. Resident #3 stated RN A was always on the wrong side of the bed to be checking or doing anything with her central line when she woke up. She stated RN A would be on the left side of the bed, and her central line was on the right side. Resident #3 stated she and the other two residents (Residents #1 and #2) talked about reporting the incident for two days, but Resident #2 was very uncomfortable. Resident #3 stated she assured Resident #2 she was uncomfortable also and she felt if she "pushed" too much, she would be retaliated against by RN A. She stated if she had not gotten to go home right after they reported this, she would have asked for another nurse for the remainder of her stay at the facility. She stated the Administrator told them the State or the police would not be called, because if she called them, then RN A could possibly be arrested and lose his job. Resident #3 stated the Administrator came to her individually and later she found out she had come to each of them by themselves, then went back to her and told her they were going to have a meeting and resolve this problem. 5) An interview on 11/01/12 at 1:45 PM with the Administrator revealed she had been told by one of the ADONs about the concerns Residents #1, #2, and #3 had regarding RN A. The Administrator stated she put it in her grievance log and began to "gather" information. The Administrator stated she told Residents #1, #2, and #3 she would have to call the state and the police regarding their concerns. She stated the residents told her they did not want that to happen. The Administrator stated she told the residents she had to do something, and that was when she decided they would just have a meeting and work this all out. She stated the residents agreed to have the meeting, and the residents said they were nervous about meeting RN A face to face and afraid of retaliation. The Administrator stated she told the residents she would have to call the "state" to report problem, call the police, and suspend RN A. She stated she told the residents RN A might be arrested, put in jail and lose his job, so they agreed, and she assured them there would be no retaliation. When the surveyor informed the Administrator it was required to report any allegation of abuse or neglect to the State, the Administrator responded, "So the state does not want us to problem solve anything anymore. They just want us to report it?" The surveyor explained any allegation of abuse had to be investigated and reported to the State. The Administrator stated she thought it was the residents' right if they did not want state called. She stated she guessed she could not have problem-solving meetings and work everything out anymore. 6) During a telephone interview with RN A on 11/01/12 at 4:35 PM, the nurse stated he was shocked when Residents #1, #2 and #3 made allegations against him. RN A was queried during this interview about the possibility of the residents misinterpreting physical assessments or other nursing care he may have been performing. RN A stated he had never performed any assessments or care for the residents while they were asleep. He stated all assessments and nursing care, including medications, was provided while the residents were fully awake and alert. RN A stated he only checked on/or provided care to Resident #2's [MEDICAL CONDITION] in the past when the [MEDICAL CONDITION] was new. RN A stated prior to the allegations, he had no disagreements with Residents #1, #2 and #3 and did not know why they would make such allegations. During this interview, RN A was adamant he had never provided any care or assessments for Residents #1, #2 and #3 while they were sleeping. RN A stated the only time he had touched Resident #2's [MEDICAL CONDITION] was in the past when the [MEDICAL CONDITION] was new, and he was providing the resident with teaching related to [MEDICAL CONDITION] care. 7) ADON B was interviewed on 11/01/12 at 2:50 PM regarding the allegations made by Residents #1, #2 and #3. ADON B stated the residents initially came to her and said, "We have something to tell you." the ADON stated she told the residents to "hold on." ADON B stated she did not want the residents to feed off each other, so she separated them. The ADON stated she instructed them they would have to write statements. ADON B then siad she did not know if the residents wrote statements. She siad she reported to the Administrator about Residents #1, #2, and #3 wanting to speak with her (the Administrator) without ever hearing what the residents had to say. "The Administrator got right on it." 8) Review of a facility Grievance/Complaint Investigation Report dated 09/20/12 revealed Resident #4 had made a complaint regarding RN A about an incident, which occurred on 09/19/12. Resident #4 reported RN A was "fresh. The resident stated RN A came into her room when she (Resident #4) was receiving a bath from the hospice CNA. Resident #4 reported when she told RN A "to get the hell out," he then walked to the foot of the bed, and rubbed his finger up and down the sole of her foot. The section of the Grievance/Complaint Investigation Report entitled "Summary of Interviews" reflected the following: Resident #4 was offended and did not want RN A back in her room. The resident stated she did not feel threatened or initimidated or fearful of any of the facility staff. Resident #4 stated she did not want RN A to come in her room, because "he's a jackass!" RN A stated he heard Resident #4 screaming at about 4:00 AM, and he went into the resident's room where the hospice CNA was bathing her (Resident #4). RN A stated the privacy curtain was pulled with Resident #4 and the hospice CNA on the other side of the curtain. He said he remained on the side of the curtain and asked the resident if she was alright. RN A stated Resident #4 asked who it was and upon hearing it was him (RN A), told him to "get the hell out." The Administrator documented she confirmed the hospice CNA did not feel RN A had been inappropriate with Resident #4 and the resident had been properly covered when the RN was in the room. The Administrator spoke with Resident #4 on 09/21/12 at 2:00 PM. The Administrator documented Resident #4 was agreeable to allowing RN A with a witmess to continue to give her medications and check on her while she slept. On 11/01/12 a 3:10 PM, an interview was conducted with Resident #4. When queried about any problems with male staff or feelings of discomfort, Resident #4 told the surveyor about problems with a man who was a nurse. The resident described RN A as the male nurse, who worked at night. Resident #4 stated RN A used to come into her room and watch when the "hospice nurse" was bathing her. She stated, "I told him to get the hell out. I went a long time before I told on (RN A), because you just have to really make me mad." Resident #4 stated she got mad and reported him because he made her uncomfortable with him "standing at the end of the bed staring at me. They told me that (RN A) was trying to see if I was breathing or not. How strange is that?" Resident #4 stated RN A would now just "get in and out" of her room since she had reported his staring when she had her bath. The resident stated RN A was not accompanied by anyone. During an intereview with the Administrator on 11/01/12 at 2:10 PM, she stated Resident #4 had a "pattern of spinning tales." The Administrator stated she did not interview the resident in regard to her complaint about RN A, because of Resident #4's "history of telling families things that are not true." The Administrator provided the incident involving Resident #4 and RN A and indicated the incident had been called in to the state related to sexual abuse. However, there was no evidence the incident was investigated, the resident was not interviewed in regard to the allegation of sexual abuse and no facility residents or other staff were interviewed, who might have potentially been witnesses. 9) The facility's current Abuse/Neglect Prevention Policy, dated September 2006, reflected the following: "Key Component #1 - Prevention ...The Grievance Procedure: Every complaint presented to the Administrator will be thoroughly investigated to determine if an individual's rights were violated and whether acts of abuse/neglect were involved... Key Component #5 - Protect ...Protecting the Resident: If abuse/neglect is suspected, or there has been an allegation of abuse/neglect reported, management will suspend the accused abuser while conducting an investigation... ...Protecting the Reporter: BWP III protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment. We encourage our employees to report report abuse/neglect, so we do not want to retaliate against those individuals that do report. ...Key Component #6 - Investigate ...The facility follows Provider Letter 00-22 - Guidelines for Reporting Incidents when investigating suspected/alleged abuse/neglect. See attached. When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents. See Key Component #5. This may require the suspension of facility staff pending the results of the investigation. The Administrator would begin an investigation. ...The Initial Evaluation and Interview: All involved persons should be identified, including the alleged victim, perpetrator, witnesses, and others with knowledge of the of the (sic) allegation or incident. Interviews should be done as soon as possible, and the person interviewed should prepare a written statement. The interview should be documented...Local law enforcement should be notified per Provider Letter 00-22. ...Reporting the Results of the Investigation: The results of the investigation will be reported according to Provider Letter -- 00-22 -- Guidelines for Reporting Incidents. ...Definitions Abuse - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. These include: ...Sexual Abuse - Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault." 10) On 11/01/12 at 5:30 PM, the Administrator was informed an IJ had been identified in the area of Resident Behavior and Facility Practice. The Administrator was requested to provide a Plan of Removal for the IJ. 11) On 11/02/12 at 9:15 AM, the Administrator provided surveyors with a statement identified as written by RN A on 11/01/12. The statement reflected RN A had written it related to the interview questions conducted by the surveyor on 11/01/12 at 4:35 p.m. The written statement reflected RN A had never provided any care and/or assessments for Residents #1, #2 and #3 while they were asleep. At that time, the surveyors reminded the Administrator the facility's plan of removal included a facility interview with RN A and not a recap of the interview conducted with the surveyor. The Administrator stated she would have RN A return to the facility, conduct and document an interview with him. 12) An interview on 11/02/12 at 10:10 AM with the Social Worker revealed she had not been informed of the allegations of sexual abuse by Residents #1, #2, and #3, and had not been made aware of any problems. The Social Worker stated she found out about the incident when she was in an office typing on a computer, and the people in the office were discussing what had happened. The Social Worker stated when she inquired about the incident, the Administrator informed her it had been resolved. The Social Worker stated she became curious and spoke to Resident #1, who had been involved in the meeting. When she spoke to Resident #1, the resident told her she did not want to discuss it anymore, because she had already been issued a 30-day discharge and she did not want to cause any more trouble, because she might not get her CBA. The Social Worker stated during the interview with Resident #1, she could tell the resident was very uncomfortable talking about it. The Social Worker said Resident #1 then asked why she (the Social Worker) had conducted the satisfaction survey. The Social Worker stated she told the resident the Administrator had given her the questions and was told to conduct the survey with the designated residents. The Social Worker stated she was unaware the questions were involved in any way with the allegations of sexual abuse. The Social Worker stated if she had known she was asking satisfaction questions in response to allegations of sexual abuse, she would have developed her own set of questions and would also have wanted to know why the allegations of sexual abuse had not been reported (to the state). 13) On 11/02/12 at 2:03 PM, the Administrator provided the surveyors with a document entitled, "Purpose of meeting with (RN A) on 10/02/12," which reflected Residents #1, #2, and #3 did not want to call DADs or the police. The document reflected: "I, as the administrator could not just take the complaint and do nothing. I (the Administrator) asked if they (Residents #1, #2 and #3) would consider meeting with (RN A) and IDT (interdisciplinary team members) and all (three residents) expressed concerns about retaliation. I (the Administrator) assured them (Residents #1, #2 and #3) that there would no retaliation and they (Residents #1, #2 and #3) could all be together. All three (residents) agreed to the meeting. (I) Shared their (Residents #1, #2 and #3) concerns with (RN A), who was very apologetic after hearing their (Residents #1, #2 and #3) concerns." On 11/02/12 at 4:25 PM, the Administrator provided another written statement identified as written by RN A on 11/01/02. The statement reflected RN A denied ever having touched any resident inappropriately. According to this statement, Resident #1's pain medication made her "very" sleepy and the resident always slept with ear plugs, and the oxygen concentrator caused some amount of noise. Resident #1 may have misunderstood the purpose of RN A being in her room as her ear plugs remained in place, and the oxygen concentrator in use was causing noise. The new statement further reflected RN A had touched Resident #2 during nursing assessments of her [MEDICAL CONDITION] site for any abnormality and to enable him to do so, he had to raise her pajamas to assess the site. Additionally, the statement reflected RN A's basic nursing duties included routine assessments of residents with wounds, incisions and IV PICC (A peripherally inserted central catheter for IV access) line. RN A's new statement reflected Resident #3 had a lower abdominal wound with a wound vac, and the wound vac would sometimes malfunction. RN A would lift the resident's gown to assess the wound site for leakage. The statement reflected the resident "must" have misinterpreted his nursing action, because she took narcotics, which made her drowsy. The statement also reflected if RN A found a resident asleep, he tapped them on their feet while standing by the foot of the bed until the resident responded by speaking to him, and he concluded the resident was fully awake. Along with the new statement dated 11/01/12, the Administrator provided another statement written by RN A on 11/02/12. This statement reflected Resident #5 was a friend of Resident #3. According to RN A's statement, Resident #5 informed RN A, Resident #3 told him Resident #1 had "made up" the allegation. On 11/02/12 at 4:40 PM, Resident #5 was interviewed. He stated he was friends with Resident #3. Resident #5 stated Resident #3 visited and brought him food/snacks. The resident further stated he was aware of the "situation" with RN A, and he did not believe Resident #3 would lie. At that time, Resident #5 stated he believed "it" had gotten all blown out of proportion. Resident #5 had no knowledge about the allegation having been "made up." 14) During an intervew on 11/02/12 at 12:30 PM with the DON, she stated the facility's policy was to follow the chain of command and report any allegation of abuse and/or neglect to the Administrator. The DON stated Resident #3 stood out in her mind and had not alleged any abuse.

Based on observation, interview and record review, the Administrator and the DON failed to administer the facility in a manner, which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable mental and psychosocial well-being for three (Residents #1, #2 and #3) of seven residents reviewed for abuse. Three residents alleged sexually inappropriate behavior against RN A to the Administrator. The Administrator and the DON failed to implement the facility's abuse prevention policy and procedure by: 1. Failing to remove RN A from working directly with the facility's residents and allowed contact from 10/02/12 through 11/02/12. 2. Failing to thoroughly investigate the incidents by interviewing facility residents and staff. Potential witnesses were not questioned. 3. Failing to investigate and report to the State agency a previous allegation of sexually inappropriate behavior against RN A by Resident #4 and failing to protect the facility's residents. An Immediate Jeopardy (IJ) was identified on 11/01/12. While the IJ was removed on 11/02/12, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern." The facility continued to in-service and monitor staff to ensure allegations of abuse were being reported, investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect all residents residing in the facility, including Residents #1, #2 and #3, by placing them at risk for further abuse, which could result in serious mental health complications and/or physical injuries. Findings included: Per adminstrative review, surveyors returned to the facility on [DATE] to further investigate the allegations of sexual abuse by RN A. 1) Review of the facility's grievance log revealed a grievance report, dated 10/02/12, which reflected: "Allegation of RN (RN A), making residents feel uncomfortable October 02, 2012 Complainants: (Resident #1, Resident #2, and Resident #3) At approximately 12:30 PM it was reported to me (the Administrator) the three ladies above were very concerned and wanted to talk with me about (RN A) by (ADON B), LVN. (Resident #2) admitted her concerns arose after hearing a fell ow resident (Resident #4) describe an incident during smoke break this morning that had reportedly occurred with (RN A), but had been investigated and unsubstantiated by the Administrator... (Resident #2) became concerned that she had awakened on more than one occasion when (RN A) was bringing her meds in the middle of the night and he had raised her shirt tail slightly. (Resident #3) was concerned that she had awakened on several occasions to him (RN A) raising her shirt and when she would ask him what he was doing, he would respond that he was there to give her medications or draw blood. Her central line was on the other side. (Resident #1) stated that he had come into her room to give her medications and she was awakened to him pulling her covers off of her. She stated that she wasn't sure if it happened or not, so she had not mentioned it, but felt one night she was awakened by (RN A) playing with her breast and nipple. (Resident #1) was encouraged to file a police report if she felt she had been assaulted in any manner (by the Administrator). She declined, stating she "didn't want it to go that far." I (the Administrator) spoke individually with each of them and they all agreed to meet with (RN A) and discuss with him their concerns and what he was doing that made them feel uncomfortable. The social worker was given a questionnaire (satisfaction survey) to complete with other interviewable female residents while we visited with (RN A) and residents. Before speaking with them and (RN A), I spoke with them as a group to ensure they were comfortable with this meeting in the conference room and they all assured me they were. (RN A) came into the conference room and sat across the table from all of them. I explained to the residents the seriousness of their allegations. They stated they did not want (RN A) to lose his job, just wanted him to stop making them feel uncomfortable. Each resident was allowed to share with (RN A) the behaviors that bothered them... All three take heavy medications that make them sleep very soundly. They all agreed with this. They also agreed that (RN A) may not have realized they were not fully awake when he proceeded in his nursing processes - (Resident #2) has a fairly new [MEDICAL CONDITION] and raising her shirt to check to ensure it was intact and not needing attention would have been a nursing function while he was there; (Resident #3) has an abdominal wound with a dressing, it would be logical that a prudent nurse was assessing her dressing for excessive drainage; (Resident #1) sleeps with ear plugs and a concentrator running at the head of her bed, it would be very difficult to wake her with the medications she takes at night, thus he may have been simply pulling back the covers in an effort to disturb her sleep enough to wake her. When these possibilities were mentioned, they all felt that maybe they had misread some of his actions, but stood their ground that they were uncomfortable with this approach. (RN A) was directed if he cannot get them awake by calling their name, he will get a female employee to wake them if they have to be touched. All residents were agreeable to this resolution. (RN A) apologized for frightening them and assured them he would work hard not to in the future. He shook hands with all three and all agreed they were satisfied with the resolution. They were informed that some of the allegations met the criteria for reportable incident. They all agreed and stated they did not want this called to the State. They were happy with the outcome. All three were given the business card with the Administrator's personal cell number and encouraged to call any time, day or night, if they feel uncomfortable or dissatisfied with their help. All agreed that they would." This grievance report was signed by Residents #1, #2, and #3. It was also signed by the Administrator and RN A. 2) Review of Resident #1's Face Sheet, dated 09/28/12, revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident's BIMS score was 13, which indicated the resident's cognitive status was intact. On 10/18/12 at 2:00 PM, an interview was conducted with Resident #1. Resident #1 stated she and two other residents met with ADON B and the Administrator regarding the grievance. When asked about her specific allegations, Resident #1 stated she woke up one night, and she had a "strange" feeling RN A had been playing with her breasts and nipples. Resident #1 stated on another occasion, RN A pulled the covers off her while she was asleep, and when she woke up, he "shoved" pills in her mouth. Resident #1 stated, during the meeting with the Administrator, the Administrator informed her (Resident #1), her statement alone could cause RN A to lose his job or go to jail. Resident #1 stated she and the two other female residents had to sign a statement they would not bring the allegations against RN A. After their meeting with the Administrator, Resident #1 stated she (the Administrator) called RN A into her office to meet with him. Since the meeting with the Administrator, Resident #1 stated RN A had come to her room to give her medications. RN A was alone at those times. She stated he had not touched her again since they reported the allegations. The Administrator was interviewed regarding this grievance report on 10/18/12 at 1:20 PM. The Administrator explained the residents did not want her to report it to the State, and she did not report the allegation to the State agency. The Administrator stated RN A was not suspended before, during or following the investigation. However, the Administrator was unable to provide evidence the incident had been investigated or the statedments written by the residents. This statement was reiterated during the Exit Conference on 10/19/12 at 3:40 PM. The Administrator stated, "The residents did not want me to call the state...it's a resident rights issue." During an interview with Resident #1 on 11/01/12 at 3:15 PM, the resident stated she never agreed to anything related to not calling/reporting the incidents to "State" and never knew it was an option. Resident #1 stated, "I didn't want him (RN A) to keep it up, but didn't want to be the one who got him fired. He could ...find me and hurt me." The resident further stated she would shortly be moving into an apartment on her own and was afraid RN A might find and hurt her. Resident #1 added she felt she was being retaliated against due to the 30-day discharge notice she received effective 10/05/12, because of RN A reporting her smoking outside. Resident #1 stated RN A had seen her smoke "hundreds" of times before and had never reported her. 3) Review of Resident #2's Face Sheet, dated 08/15/12, reflected the resident was admitted to the facility on [DATE] and was readmited on 06/29/12 with the following Diagnoses: [REDACTED]. The Face Sheet also reflected Resident #2 was her own responsible party. Review of Resident #2's MDS assessment, dated 08/07/12, revealed an additional active [DIAGNOSES REDACTED]. The MDS assessment reflected the resident's BIMS score was 12, which indicated the resident's cognitive status was intact. Further review revealed Resident #2 had the ability to understand others. Resident #2 was interviewed on 10/18/12 at 2:15 PM regarding the allegations. Resident #2 stated several of the residents complained about RN A, who was the nurse on duty at night. She stated RN A raised her shirt up while she was asleep in her room one night. She stated when she woke up, he gave her medications and hurried out of the room. Resident #2 stated she was afraid to say anything. She stated when she and the other residents reported the allegations to the Administrator, they went to a little room and "wrote papers out," and the Administrator stated she would take care of the matter. Resident #2 stated she had to sign her paper. The resident stated the Administrator told them she wanted RN A to keep his job, and she did not want him to lose his job. Resident #2 stated RN A did not say anything during the meeting. Resident #2 stated the Administrator told them if they said anything about what happened, then she would have to call the police. Resident #2 stated the police were not called. Resident #2 stated they were worried about the other girls (residents) in the facility. She stated RN A did not deny the allegations, and he did not apologize. She stated he had not touched her since they reported the allegations. Resident #2 stated she felt "very uncomfortable" because the Administrator told them, "I don't want him (RN A) to get in trouble." Resident #2 stated Resident #1 spoke to RN A directly, and he did not say anything. Resident #2 stated she knew a police officer would have investigated the matter. Resident #2 added, "I'm afraid she'll (the Administrator) evict me." She stated she did not want the Administrator to get mad at her. Resident #2 stated they did not do anything about RN A. She stated she had a "weird feeling" having him at the facility at nighttime, and now he no longer spoke to her. At that point, Resident #2 began to cry. An interview on 11/01/12 at 3:30 PM with Resident #2 revealed the first time "I woke up to find (RN A) standing over my bed with my shirt up, but not above my breast. (RN A) was just standing there looking at me. It really did scare me." Resident #2 stated, "I asked him what was 'up.' " (RN A) replied it was time for her medication, so "I got ready to take it, but (RN A) said he had to go and get it. (RN A) left and came back with the medication, and I took it." Resident #2 stated after RN A left, "I started crying because I wonder if this had happened before and I had not woken up." Resident #2 stated the same thing happened again and she was upset about it. She stated, "I cried a lot after that. I felt really bad." Resident #2 stated she was in the smoking section after that and two other ladies were talking about the same nurse (RN A) doing the same typeof thing to them. She stated one of the ladies was really scared, because when it first happened with her, she could not help herself very well and she was afraid of him. Resident #2 stated she (Resident #2) said something to the other residents about what had happened to her. She said, "We talked about what to do for about two days, and then we decided to tell it. When we told it, we were told to go to our rooms and write out a statement." When the surveyor asked Resident #2 about the meeting the Administrator had arranged for the residents, including Resident #2, in regard to their allegations, Resident #2 stated the Administrator told them to come, and they were going to resolve this. Resident #2 stated she did not say too much in the meeting, because she was fifth on the list to get a CBA, and she did not want to hurt her chances for that. She stated the other two ladies wanted the police called, but the Administrator reminded them of the possibility of RN A losing his job, so they agreed they did not want that to happen. Resident #2 stated, "I am really not sure what was accomplished during this meeting, other than now (RN A) will not look at me or even act like I am around. He used to check on me for my medications, and now I have to go and find him to get those medications, if I need them." Resident #2 stated she felt like she was being "punished." She stated, (RN A) treats me like I am not even there. (RN A) just ignores me now, and this makes me feel like I am being punished for something he did wrong to me." Resident #2 stated she did not want to say too much, because she might not get her CBA, and "I have been waiting a long time for that." Observation of Resident #2 during the interview revealed she was tearing up, and her bottom lip was quivering at the end of the interview. Review of Resident #3's Face Sheet, dated 09/11/12, reflected Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Further review reflected Resident #3 was her own responsible party. 4) Review of Resident #3's MDS assessment, dated 09/13/12, reflected additional [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #3 had the ability to understand others with no signs of [MEDICAL CONDITION], disorganized thinking or altered level of consciousness and had a BIMS score of 15, which indicated the resident's cognitive functioning was intact. An interview on 11/02/12 at 7:20 PM with Resident #3 revealed multiple times she had awakened when RN A pulling her shirt up over her breast or had already pulled her bed covers off her. Resident #3 stated she would ask RN A what was happening, and RN A would tell Resident #3 he needed to check her central line or draw blood. Resident #3 stated what bothered her was her central line was in her "shoulder" and all RN A had to do was pull the tubing out of her shirt sleeve, like the other nurses did. Resident #3 stated RN A was always on the wrong side of the bed to be checking or doing anything with her central line when she woke up. She stated RN A would be on the left side of the bed, and her central line was on the right side. Resident #3 stated she and the other two residents (Residents #1 and #2) talked about reporting the incident for two days, but Resident #2 was very uncomfortable. Resident #3 stated she assured Resident #2 she was uncomfortable also and she felt if she "pushed" too much, she would be retaliated against by RN A. She stated if she had not gotten to go home right after they reported this, she would have asked for another nurse for the remainder of her stay at the facility. She stated the Administrator told them the State or the police would not be called, because if she called them, then RN A could possibly be arrested and lose his job. Resident #3 stated the Administrator came to her individually and later she found out she had come to each of them by themselves, then went back to her and told her they were going to have a meeting and resolve this problem. 5) An interview on 11/01/12 at 1:45 PM with the Administrator revealed she had been told by one of the ADONs about the concerns Residents #1, #2, and #3 had regarding RN A. The Administrator stated she put it in her grievance log and began to "gather" information. The Administrator stated she told Residents #1, #2, and #3 she would have to call the state and the police regarding their concerns. She stated the residents told her they did not want that to happen. The Administrator stated she told the residents she had to do something, and that was when she decided they would just have a meeting and work this all out. She stated the residents agreed to have the meeting, and the residents said they were nervous about meeting RN A face to face and afraid of retaliation. The Administrator stated she told the residents she would have to call the "state" to report problem, call the police, and suspend RN A. She stated she told the residents RN A might be arrested, put in jail and lose his job, so they agreed, and she assured them there would be no retaliation. When the surveyor informed the Administrator it was required to report any allegation of abuse or neglect to the State, the Administrator responded, "So the state does not want us to problem solve anything anymore. They just want us to report it?" The surveyor explained any allegation of abuse had to be investigated and reported to the State. The Administrator stated she thought it was the residents' right if they did not want state called. She stated she guessed she could not have problem-solving meetings and work everything out anymore. 6) During a telephone interview with RN A on 11/01/12 at 4:35 PM, the nurse stated he was shocked when Residents #1, #2 and #3 made allegations against him. RN A was queried during this interview about the possibility of the residents misinterpreting physical assessments or other nursing care he may have been performing. RN A stated he had never performed any assessments or care for the residents while they were asleep. He stated all assessments and nursing care, including medications, was provided while the residents were fully awake and alert. RN A stated he only checked on/or provided care to Resident #2's [MEDICAL CONDITION] in the past when the [MEDICAL CONDITION] was new. RN A stated prior to the allegations, he had no disagreements with Residents #1, #2 and #3 and did not know why they would make such allegations. During this interview, RN A was adamant he had never provided any care or assessments for Residents #1, #2 and #3 while they were sleeping. RN A stated the only time he had touched Resident #2's [MEDICAL CONDITION] was in the past when the [MEDICAL CONDITION] was new, and he was providing the resident with teaching related to [MEDICAL CONDITION] care. 7) ADON B was interviewed on 11/01/12 at 2:50 PM regarding the allegations made by Residents #1, #2 and #3. ADON B stated the residents initially came to her and said, "We have something to tell you." the ADON stated she told the residents to "hold on." ADON B stated she did not want the residents to feed off each other, so she separated them. The ADON stated she instructed them they would have to write statements. ADON B then siad she did not know if the residents wrote statements. She siad she reported to the Administrator about Residents #1, #2, and #3 wanting to speak with her (the Administrator) without ever hearing what the residents had to say. "The Administrator got right on it." 8) Review of a facility Grievance/Complaint Investigation Report dated 09/20/12 revealed Resident #4 had made a complaint regarding RN A about an incident, which occurred on 09/19/12. Resident #4 reported RN A was "fresh. The resident stated RN A came into her room when she (Resident #4) was receiving a bath from the hospice CNA. Resident #4 reported when she told RN A "to get the hell out," he then walked to the foot of the bed, and rubbed his finger up and down the sole of her foot. The section of the Grievance/Complaint Investigation Report entitled "Summary of Interviews" reflected the following: Resident #4 was offended and did not want RN A back in her room. The resident stated she did not feel threatened or initimidated or fearful of any of the facility staff. Resident #4 stated she did not want RN A to come in her room, because "he's a jackass!" RN A stated he heard Resident #4 screaming at about 4:00 AM, and he went into the resident's room where the hospice CNA was bathing her (Resident #4). RN A stated the privacy curtain was pulled with Resident #4 and the hospice CNA on the other side of the curtain. He said he remained on the side of the curtain and asked the resident if she was alright. RN A stated Resident #4 asked who it was and upon hearing it was him (RN A), told him to "get the hell out." The Administrator documented she confirmed the hospice CNA did not feel RN A had been inappropriate with Resident #4 and the resident had been properly covered when the RN was in the room. The Administrator spoke with Resident #4 on 09/21/12 at 2:00 PM. The Administrator documented Resident #4 was agreeable to allowing RN A with a witmess to continue to give her medications and check on her while she slept. On 11/01/12 a 3:10 PM, an interview was conducted with Resident #4. When queried about any problems with male staff or feelings of discomfort, Resident #4 told the surveyor about problems with a man who was a nurse. The resident described RN A as the male nurse, who worked at night. Resident #4 stated RN A used to come into her room and watch when the "hospice nurse" was bathing her. She stated, "I told him to get the hell out. I went a long time before I told on (RN A), because you just have to really make me mad." Resident #4 stated she got mad and reported him because he made her uncomfortable with him "standing at the end of the bed staring at me. They told me that (RN A) was trying to see if I was breathing or not. How strange is that?" Resident #4 stated RN A would now just "get in and out" of her room since she had reported his staring when she had her bath. The resident stated RN A was not accompanied by anyone. During an intereview with the Administrator on 11/01/12 at 2:10 PM, she stated Resident #4 had a "pattern of spinning tales." The Administrator stated she did not interview the resident in regard to her complaint about RN A, because of Resident #4's "history of telling families things that are not true." The Administrator provided the incident involving Resident #4 and RN A and indicated the incident had been called in to the state related to sexual abuse. However, there was no evidence the incident was investigated, the resident was not interviewed in regard to the allegation of sexual abuse and no facility residents or other staff were interviewed, who might have potentially been witnesses. 9) The facility's current Abuse/Neglect Prevention Policy, dated September 2006, reflected the following: "Key Component #1 - Prevention ...The Grievance Procedure: Every complaint presented to the Administrator will be thoroughly investigated to determine if an individual's rights were violated and whether acts of abuse/neglect were involved... Key Component #5 - Protect ...Protecting the Resident: If abuse/neglect is suspected, or there has been an allegation of abuse/neglect reported, management will suspend the accused abuser while conducting an investigation... ...Protecting the Reporter: BWP III protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment. We encourage our employees to report report abuse/neglect, so we do not want to retaliate against those individuals that do report. ...Key Component #6 - Investigate ...The facility follows Provider Letter 00-22 - Guidelines for Reporting Incidents when investigating suspected/alleged abuse/neglect. See attached. When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents. See Key Component #5. This may require the suspension of facility staff pending the results of the investigation. The Administrator would begin an investigation. ...The Initial Evaluation and Interview: All involved persons should be identified, including the alleged victim, perpetrator, witnesses, and others with knowledge of the of the (sic) allegation or incident. Interviews should be done as soon as possible, and the person interviewed should prepare a written statement. The interview should be documented...Local law enforcement should be notified per Provider Letter 00-22. ...Reporting the Results of the Investigation: The results of the investigation will be reported according to Provider Letter -- 00-22 -- Guidelines for Reporting Incidents. ...Definitions Abuse - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. These include: ...Sexual Abuse - Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault." 10) On 11/01/12 at 5:30 PM, the Administrator was informed an IJ had been identified in the area of Resident Behavior and Facility Practice. The Administrator was requested to provide a Plan of Removal for the IJ. 11) On 11/02/12 at 9:15 AM, the Administrator provided surveyors with a statement identified as written by RN A on 11/01/12. The statement reflected RN A had written it related to the interview questions conducted by the surveyor on 11/01/12 at 4:35 p.m. The written statement reflected RN A had never provided any care and/or assessments for Residents #1, #2 and #3 while they were asleep. At that time, the surveyors reminded the Administrator the facility's plan of removal included a facility interview with RN A and not a recap of the interview conducted with the surveyor. The Administrator stated she would have RN A return to the facility, conduct and document an interview with him. 12) An interview on 11/02/12 at 10:10 AM with the Social Worker revealed she had not been informed of the allegations of sexual abuse by Residents #1, #2, and #3, and had not been made aware of any problems. The Social Worker stated she found out about the incident when she was in an office typing on a computer, and the people in the office were discussing what had happened. The Social Worker stated when she inquired about the incident, the Administrator informed her it had been resolved. The Social Worker stated she became curious and spoke to Resident #1, who had been involved in the meeting. When she spoke to Resident #1, the resident told her she did not want to discuss it anymore, because she had already been issued a 30-day discharge and she did not want to cause any more trouble, because she might not get her CBA. The Social Worker stated during the interview with Resident #1, she could tell the resident was very uncomfortable talking about it. The Social Worker said Resident #1 then asked why she (the Social Worker) had conducted the satisfaction survey. The Social Worker stated she told the resident the Administrator had given her the questions and was told to conduct the survey with the designated residents. The Social Worker stated she was unaware the questions were involved in any way with the allegations of sexual abuse. The Social Worker stated if she had known she was asking satisfaction questions in response to allegations of sexual abuse, she would have developed her own set of questions and would also have wanted to know why the allegations of sexual abuse had not been reported (to the state). 13) On 11/02/12 at 2:03 PM, the Administrator provided the surveyors with a document entitled, "Purpose of meeting with (RN A) on 10/02/12," which reflected Residents #1, #2, and #3 did not want to call DADs or the police. The document reflected: "I, as the administrator could not just take the complaint and do nothing. I (the Administrator) asked if they (Residents #1, #2 and #3) would consider meeting with (RN A) and IDT (interdisciplinary team members) and all (three residents) expressed concerns about retaliation. I (the Administrator) assured them (Residents #1, #2 and #3) that there would no retaliation and they (Residents #1, #2 and #3) could all be together. All three (residents) agreed to the meeting. (I) Shared their (Residents #1, #2 and #3) concerns with (RN A), who was very apologetic after hearing their (Residents #1, #2 and #3) concerns." On 11/02/12 at 4:25 PM, the Administrator provided another written statement identified as written by RN A on 11/01/02. The statement reflected RN A denied ever having touched any resident inappropriately. According to this statement, Resident #1's pain medication made her "very" sleepy and the resident always slept with ear plugs, and the oxygen concentrator caused some amount of noise. Resident #1 may have misunderstood the purpose of RN A being in her room as her ear plugs remained in place, and the oxygen concentrator in use was causing noise. The new statement further reflected RN A had touched Resident #2 during nursing assessments of her [MEDICAL CONDITION] site for any abnormality and to enable him to do so, he had to raise her pajamas to assess the site. Additionally, the statement reflected RN A's basic nursing duties included routine assessments of residents with wounds, incisions and IV PICC (A peripherally inserted central catheter for IV access) line. RN A's new statement reflected Resident #3 had a lower abdominal wound with a wound vac, and the wound vac would sometimes malfunction. RN A would lift the resident's gown to assess the wound site for leakage. The statement reflected the resident "must" have misinterpreted his nursing action, because she took narcotics, which made her drowsy. The statement also reflected if RN A found a resident asleep, he tapped them on their feet while standing by the foot of the bed until the resident responded by speaking to him, and he concluded the resident was fully awake. Along with the new statement dated 11/01/12, the Administrator provided another statement written by RN A on 11/02/12. This statement reflected Resident #5 was a friend of Resident #3. According to RN A's statement, Resident #5 informed RN A, Resident #3 told him Resident #1 had "made up" the allegation. On 11/02/12 at 4:40 PM, Resident #5 was interviewed. He stated he was friends with Resident #3. Resident #5 stated Resident #3 visited and brought him food/snacks. The resident further stated he was aware of the "situation" with RN A, and he did not believe Resident #3 would lie. At that time, Resident #5 stated he believed "it" had gotten all blown out of proportion. Resident #5 had no knowledge about the allegation having been "made up." 14) During an intervew on 11/02/12 at 12:30 PM with the DON, she stated the facility's policy was to follow the chain of command and report any allegation of abuse and/or neglect to the Administrator. The DON stated Residen

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (Resident #1, a closed clinical record) of five residents reviewed for quality of care. Resident #1, an unresponsive, tube-fed, insulin-dependent Diabetic, was admitted to the facility on [DATE] at 4:00 PM, but his physician-ordered tube feeding, his only source of nutrition was not initiated until 12/10/11 at approximately 3:40 PM. The facility administered Resident #1's scheduled insulin on 12/08/11 and 12/09/11, despite the resident's lack of nutrition. On 12/10/11 at 9:00 AM, the resident's blood sugar was 44. The resident was given orange juice but no [MEDICATION NAME] and the weekend supervisor was informed; the resident's blood sugar was not rechecked in 15 minutes, but an hour later. On 12/10/11 at 1:00 PM, the resident's blood sugar was 29 and he was given orange juice and [MEDICATION NAME]. There was no follow-up FSBS and the resident's physician-ordered tube feeding was not administered. On 12/10/11 at 3:40 PM, Resident #1's blood sugar was 37, he was given [MEDICATION NAME] and his tube feeding was initiated. At 3:49 PM, the resident's blood sugar was 44 and 911 was called. The Physician/NP was not informed of the resident's change of condition until a text message was sent on 12/10/11 at approximately 3:49 PM. These failures resulted in Resident #1 developing severe [DIAGNOSES REDACTED], receiving [MEDICATION NAME] 50% injections in the ER, being admitted to the hospital's ICU on 12/10/11, and requiring a continuous IV drip of 10% [MEDICATION NAME] with his insulin discontinued. These failures could affect the nine residents identified with a [DIAGNOSES REDACTED]. Findings included: 1) Resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission/Readmission Assessment and Plan of Care dated 12/08/11 revealed the resident was admitted on [DATE] at 2:30 PM with [DIAGNOSES REDACTED]. Documentation reflected the resident "cannot communicate," he was marked as being unable to speak, "Has [DEVICE], [MEDICAL CONDITION] drainage and flushing in one tube," and the resident had an indwelling catheter. The diagram of a body on the form reflected the resident had multiple dressings on the trunk, multiple scars, a Foley catheter, a [DEVICE], chronic ulcers on both feet and the resident was wearing "Bunny (podus) Boots" on both feet. Review of Resident #1's Nurse's Notes dated 12/08/11 revealed the resident was admitted to the facility at 4:00 PM. Review of the hospital discharge medication list from the hospital dated 12/08/11 revealed, "Nephro Cal (tube feeding formula) 40/cc/hr." Review of Resident #1's facility admission orders Diet Order: Nova source renal (tube feeding formula)." Note: There was no amount, rate or time on the order. Further review of the admission orders [REDACTED]. The orders dated 12/08/11 also reflected for a FSBS of less than 60 mg/dl, the resident was to receive "40 (sic) oz." of orange juice and the FSBS was to be rechecked in 15 minutes. The orders further reflected if the resident was unresponsive and had a FSBS of less than 60 mg/dl, the nurse was to give [MEDICATION NAME] 1 mg SQ x 1 dose and notify the doctor. Review of Resident #1's Social Progress Notes dated 12/09/11 revealed, "...The resident has a dx (diagnosis) of [MEDICAL CONDITION]/[MEDICAL CONDITION] & he's not responding to any verbal communication. Staff reports that he's non-responsive." Review of a physician's history and physical dated 12/09/11 for Resident #1 revealed: It appeared Resident #1 suffered [MEDICAL CONDITION] and barely communicated. The resident was "barely able to look at me and does not make consistent eye contact. He is not even able to tell me his name... patient has a long-standing history of uncontrolled diabetes and hypertension... dysphagia/feeding problem patient (Resident #1) is being kept alive artificially with artificial nutrition ...diabetes, uncontrolled-patient (Resident #1) is on [MEDICATION NAME] (medication for diabetes) at this time according to hospital. Prevention of episodes of life-threatening [DIAGNOSES REDACTED] is more important than perfect euglycemia (a normal level of glucose) in this patient... LVN was told to monitor patient closely and alert providers for any significant changes in condition." Review of a Physician's Telephone Order dated 12/09/11 for Resident #1 revealed, "Nova Source Renal (tube feeding formula) @ 40 cc/hour x (times) 16 hours." Note: This order was written the day after the resident was admitted to the facility. Resident #1's admission orders [REDACTED]. The record reflected the resident received [MEDICATION NAME] at 9:00 PM on 12/08/11 and 12/09/11. During an interview on 12/23/11 at 10:20 AM, ADON A stated he copied the facility admission orders [REDACTED]. ADON A verified the orders included tube-feeding orders, Resident #1's only source of nutrition. During an interview on 12/23/11 at 10:50 AM, LVN B stated she worked 12/09/11 from 6:00 AM - 2:00 PM. LVN B stated Resident #1 was a new resident, and she took care of Resident #1 on 12/09/11. LVN B stated she did not hang or take down any tube feeding for Resident #1. LVN B explained when a tube feeding was ordered to run for 16 hours, it was hung (started) on the 2:00 PM - 10:00 PM shift between 3:00 PM and 4:00 PM (per facility policy). LVN B was queried what she would do if a diabetic resident had a change in orientation or was sweating. She stated she would be concerned and would check the resident's BS. If the level was low, she would give orange juice and give a [MEDICATION NAME] (single, large dose) tube feeding. She further stated she would recheck the BS in 30 minutes, document the events and notify the physician. Review of the Admission Order-Administration Record revealed the following order, "Nova Source 23 @ 40 cc/(hour)...X (times) 16 (hours)." Initials for the date 12/09/11 were beside the 6:00 AM - 2:00 PM shift, 2:00 PM - 10:00 shift and the 10:00 PM - 6:00 AM shift. There were also initials beside the 10:00 PM - 6:00 AM shift for 12/10/11. During an interview on 12/23/11 at 11:49 AM, the surveyor reviewed the Admission Order-Administration Record with LVN B. LVN B verified she initialed 6:00 AM - 2:00 PM shift on 12/09/11, but stated, "When I initial the tube feed for 16 hours, I'm just saying that's what the order was. It doesn't mean I hung it (tube feeding)." LVN B was queried as to whether she documented when she did hang a tube feeding. She replied, "No." During an interview on 12/23/11 at 1:48 PM, the DON stated when a tube feeding was ordered to run for 16 hours, it was hung on the 2nd shift (2:00 PM - 10:00 PM) (per facility policy). During a telephone interview on 12/23/11 at 12:40 PM, RN C stated she took care of Resident #1 on 12/08/11 and 12/09/11 from 2:00 PM - 10:00 PM. RN C stated ADON A hung Resident #1's tube feeding on 12/08/11 at approximately 6:00 PM, and she (RN C) hung the tube feeding on 12/09/11 at approximately 4:00 PM. RN C stated ADON A told her on Friday (12/09/11) he got the physician's telephone order for the tube feeding. The surveyor queried RN C why she did not document Resident #1's tube feedings as being hung or infusing. RN C had no response. Note: If the formula was hung at 4:00 PM, it should have infused until the next day at 8:00 AM. The nurse on that shift, LVN B, stated there was no tube feeding hanging for her to take down. During an interview on 12/23/11 at 3:18 PM, ADON A stated he did not hang Resident #1's tube feeding on 12/08/11. During a telephone interview on 12/23/11 at 12:02 PM, LVN D stated she worked 12/10/11 and was assigned to care for Resident #1. LVN D stated she checked Resident #1's FSBS "between 9 AM and 10 AM and it was 44 (scheduled for 6:30 AM). I (LVN D) gave ____ (Resident #1) orange juice and told the weekend supervisor." LVN D stated she rechecked the FSBS an hour later, and it was 72. "Everything was ok." She stated around 1:00 PM, she was looking in Resident #1's chart for tube feeding orders, and Resident #1's family was looking for the resident's nurse, because the resident was almost out of the bed. LVN D stated she checked the resident's FSBS then, and it was 29. She stated she again gave orange juice and also [MEDICATION NAME] at that time. LVN D stated, "The resident's (family member) was asking me a lot of questions. ____ (He/She) said I was rude. I was going to hang the tube feeding, but the weekend supervisor said 'no' because the family didn't want me in there (the resident's room) any more. I tried to finish my charting and they (management) told me to leave (the building) ...I did put the blood sugars on the 24 hour report." The surveyor queried LVN D if she notified the doctor of Resident #1's change in condition or low blood sugars, and LVN D stated, "We (the charge nurses) are not supposed to call the doctors." We give the information to the weekend supervisor, and the weekend supervisor calls the doctors and then she (the weekend supervisor) tells us (the charge nurses) what the doctor said and what the new orders are." Review of Resident #1's "Nurse's Notes" dated 12/10/11 revealed at 1:05 AM "Resident ...restless and confused. Attempting to get out of bed. GT (gastrostomy tube) in place - patent. [MEDICAL CONDITION] tube intact...." There was no further entry until 3:40 PM (more than 12 hours later). The entry reflected, "Family stated to this nurse that res (resident's) eyes look different and color paler. BS (checked) results 37. normal ranges 70-99 mg/dL <http://www.webmd.com/hw-popup/milligrams-per-deciliter-mgdl> per http://diabetes.webmd.com/blood-glucose?page=3). Skin moist color paler resp (respirations) even & non labored res lethargic. 1 mg [MEDICATION NAME] (medication to increase glucose level) S/C (Subcutaneously) given @ 3:42 pm. Res lying in supine position ...[DEVICE] feeding just started...." At 3:49 PM, Resident #1's blood sugar was rechecked and was 44. ____ Ambulance here - family @ bedside and requesting for res to go to the hospital." During an interview on 12/23/11 at 1:47 PM, the DON, who verified she was the weekend supervisor on 12/10/11, stated, on 12/10/11 around 1:00 PM, she entered Resident #1's room to listen to the family's concerns. The DON stated Resident #1 was lying sideways in the bed, was restless and required frequent repositioning. Resident #1's family stated the resident's eyes rolled back into his head. The DON stated, "I would assume she (LVN D) gave the orange juice and [MEDICATION NAME], for her (LVN D's) sake. I went to the 100 hall and got the ____ ambulance driver and they took him (Resident #1)." When queried regarding the time the ambulance took Resident #1, the DON stated, "About 1:30 PM." The surveyor and DON reviewed Resident #1's nurses notes dated 12/10/11 with entries at 3:40 PM and 3:49 PM from LVN E. The DON stated, "We didn't wait around here for 3 hours. I'm going to check with the ambulance. I would believe them (the ambulance drivers) before the nurse (LVN E)." A few minutes later the DON returned to the interview and stated the ambulance company stated Resident #1 was transported to the hospital at 3:49 PM. The surveyor asked the DON if she checked the blood sugar between 1:30 PM and 3:30 PM or hung Resident #1's tube feeding and she stated, "No." The surveyor queried the DON if she should have checked the blood sugar, and the DON stated, "Yeah." When asked if she should have hung Resident #1's tube feeding, the DON stated, "Sure appears like it." The DON stated it was the facility policy if the FSBS was low to give [MEDICATION NAME] and call the MD. The surveyor queried the DON if anyone notified the physician, and the DON stated she texted the Nurse Practitioner while she was in the resident's room, preparing him to be sent out to the hospital (at approximately 3:49 PM), the only time an attempt was made to inform the Physician/Nurse Practitioner of the resident's status. During a telephone interview on 12/23/11 at 3:30 PM, LVN E stated on 12/10/11, the weekend supervisor (the DON) asked her to hang the tube feeding for Resident #1. LVN E stated she was not aware the resident had a low FSBS. LVN E said, while she was in Resident #1's room, the resident's eyes rolled back, and the family informed her the resident's FSBS was low. LVN E checked the resident's FSBS at 3:40 PM, and it was 37. LVN E gave [MEDICATION NAME] and rechecked the FSBS in 9 minutes, and the level was 44. At that time, the resident's family requested the resident be sent to the hospital. The surveyor queried LVN E if the weekend supervisor was in Resident #1's room with her, and she stated, "No." When queried, LVN E stated there were standing orders: if the FSBS was less than 60, give orange juice or [MEDICATION NAME], repeat the FSBS in 15 minutes, if less than 60 for a second time, call the doctor. She further stated if the resident was unresponsive during the second low FSBS, 911 was called. Review of Resident #1's entire clinical record revealed no care plans. Review of the hospital Discharge Summary dated 12/14/11 revealed, "...He (Resident #1) was transferred from the nursing home with altered mental status/unresponsiveness and was found to be severely hypoglycemic with a blood sugar as low as 20. He required repeated D50 ([MEDICATION NAME] to increase blood sugar) injections and was admitted to the intensive care unit (ICU) for close monitoring. We had him on a D10 drip (Intravenous [MEDICATION NAME]) and stopped all of his insulin. Apparently... the patient was not getting his feeds but continued getting his insulin...." During an interview on 12/23/11 at 1:05 PM, ADON A stated when the nurses needed to share information or changes in residents' conditions to the doctors, they gave the information to the lead nurse, and the lead nurse called the doctors. ADON A further stated, on the weekends, the nurses were to tell the weekend supervisor the information that needed to be relayed to the doctors, and the weekend supervisor was responsible for notifying the doctor. ADON A verified the current DON was the weekend supervisor the weekend of 12/10/11. 2) "In general, a blood glucose reading lower than 70 mg/dL is too low. If you take insulin or diabetes pills...you can have low blood glucose...(also called [DIAGNOSES REDACTED]...). Low blood glucose is usually caused by eating less or later than usual, being more active than usual, or taking too much diabetes medicine. Drinking beer, wine, or liquor may also cause low blood glucose or make it worse...If you have any signs that your glucose may be low, test it right away. If it's less than 60 to 70 mg/dL, you need to treat it right away....Waiting to treat low blood glucose is not safe. You may be in danger of passing out. If you get confused, pass out, or have a [MEDICAL CONDITION], you need emergency help...." Retrieved on 01/06/12 at http://www.cdc.gov/diabetes/pubs/tcyd/ktrack.htm. Manufacturer's guidelines retrieved at http://products.sanofi.us/[MEDICATION NAME]/[MEDICATION NAME].html#section-6.1 on 12/09/11 reflected, "An excess of insulin relative to food intake, energy expenditure, or both may lead to severe and sometimes prolonged and life-threatening [DIAGNOSES REDACTED]... More severe episodes of [DIAGNOSES REDACTED] with coma, [MEDICAL CONDITION], or neurologic impairment may be treated with intramuscular/subcutaneous [MEDICATION NAME] or concentrated intravenous glucose. After apparent clinical recovery from [DIAGNOSES REDACTED], continued observation and additional carbohydrate intake may be necessary to avoid recurrence of [DIAGNOSES REDACTED]." 3) Review of the facility's Tube Feeding Guidelines For Hang Times (identified as the current policy by the Director of Clinical Services) dated 12/23/11 revealed, "The charge nurses are responsible for ensuring that tube feedings are administered in accordance with the physician orders... Tube feedings are hung as follows based on hang time: ...16 hours or MORE, hung between 11 AM - 12 PM on 6/2 (6:00 AM - 2:00 PM shift). The DON and administrator must be notified immediately when tube feedings are found not to be in compliance with the physician's orders [REDACTED]. Review of the facility's Low Blood Sugar Standing Orders, identified as the current policy by the Director of Clinical Services, dated 04/29/09 revealed, "For BS < 60 and alert, hold insulin/oral hypoglycemic agent. Give 4 oz. orange juice, recheck FSBS in 15 mins (minutes). If resident does not respond > 60, notify MD immediately. For BS < 60 and unresponsive, hold insulin/oral agent, give [MEDICATION NAME] 1 mg SQ x 1 dose, call 911 and notify physician...." 4) Review of a list provided by the Director of Clinical Services on 12/23/11 revealed there were 35 diabetic residents and 21 residents, who were receiving tube feedings in the facility. Comparison of the lists revealed there were nine residents, who were both diabetic and receiving tube feedings.

Based on interview and record review, it was determined the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of five residents reviewed for quality of care. Resident #1 was admitted to the facility on [DATE] at 4:00 PM and did not receive his physician-ordered tube feedings, his only source of nutrition, until 12/10/11 at 3:40 PM. The resident was administered his scheduled [MEDICATION NAME] on 12/08/11 and 12/09/11. On 12/10/11 Resident #1's morning FSBS was 44 and orange juice was given. The FSBS was checked an hour later and was 72. At approximately 1:00 PM, the resident was trying to get out of his bed. The resident's FSBS was 29. Orange juice and [MEDICATION NAME] were given. His FSBS was not rechecked. When the resident's tube-feeding was started at 3:40 PM, the resident's eyes rolled back, and his FSBS was 37. [MEDICATION NAME] was given. At 3:49 PM, the FSBS was 44. 911 was called. The Physician/Nurse Practitioner, who had not been consulted, was then texted when the resident was being prepared to be sent to the hospital. These failures resulted in Resident #1 receiving injections of [MEDICATION NAME] 50%, being admitted to the hospital's ICU, receiving a continuous IV drip with [MEDICATION NAME] 10% and having his insulin discontinued. These failures could affect the nine residents, who were identified as Diabetics with tube feedings, and placed them at risk for the potential of further complications when their physician was not contacted immediately when they experienced a change of condition with a delay in treatment and placed them at risk for metabolic imbalances, [MEDICAL CONDITION], coma or death. Findings included: 1) Resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission/Readmission Assessment and Plan of Care dated 12/08/11 revealed the resident was admitted on [DATE] at 2:30 PM with [DIAGNOSES REDACTED]. Documentation reflected the resident "cannot communicate," he was marked as being unable to speak, "Has [DEVICE], [MEDICAL CONDITION] drainage and flushing in one tube," and the resident had an indwelling catheter. The diagram of a body on the form reflected the resident had multiple dressings on the trunk, multiple scars, a Foley catheter, a [DEVICE], chronic ulcers on both feet and the resident was wearing "Bunny (podus) Boots" on both feet. Review of Resident #1's "Nurse's Notes" dated 12/08/11 revealed the resident was admitted to the facility at 4:00 PM. Review of Resident #1's "Social Progress Notes" dated 12/09/11 revealed, "...The resident has a dx (diagnosis) of [MEDICAL CONDITION]/[MEDICAL CONDITION] & he's not responding to any verbal communication. Staff reports that he's non-responsive." Review of a physician's progress note dated 12/09/11 for Resident #1 revealed, "...dysphagia/feeding problem patient (Resident #1) is being kept alive artificially with artificial nutrition ...diabetes, uncontrolled-patient (Resident #1) is on [MEDICATION NAME] (medication for diabetes) at this time according to hospital. Prevention of episodes of life-threatening [DIAGNOSES REDACTED] is more important than perfect euglycemia (a normal level of glucose) in this patient...." Review of Resident #1's discharge medication list from the hospital dated 12/08/11 revealed, "Nephro Cal (tube feeding) 40/cc/hr." Review of Resident #1's facility "admission orders Diet Order: Nova source (peg tube) renal." Note: There was no amount, rate or time listed. Further review of the "admission orders [REDACTED]. Review of Resident #1's "admission orders [REDACTED]. Review of a physician's history and physical dated 12/09/11 for Resident #1 revealed: It appeared Resident #1 suffered [MEDICAL CONDITION] and barely communicated. The resident was "barely able to look at me and does not make consistent eye contact. He is not even able to tell me his name... patient has a long-standing history of uncontrolled diabetes and hypertension... dysphagia/feeding problem patient (Resident #1) is being kept alive artificially with artificial nutrition ...diabetes, uncontrolled-patient (Resident #1) is on [MEDICATION NAME] (medication for diabetes) at this time according to hospital. Prevention of episodes of life-threatening [DIAGNOSES REDACTED] is more important than perfect euglycemia (a normal level of glucose) in this patient... LVN was told to monitor patient closely and alert providers for any significant changes in condition." Review of a "Physician's Telephone Order" dated 12/09/11 for Resident #1 revealed Nova Source (type of tube feeding) Renal @ 40 cc/hour x 16 hours. Note: This order was written the day after the resident was admitted to the facility. During an interview on 12/23/11 at 10:20 AM, ADON A stated he copied the admission orders [REDACTED]. ADON A verified he wrote Resident #1's admission orders [REDACTED]. During an interview on 12/23/11 at 10:50 AM, LVN B stated she worked 12/09/11 on the 6 AM - 2 PM. LVN B stated she took care of Resident #1 and it was the first time she had seen the resident. LVN B stated she did not hang or take down a tube feeding for Resident #1. LVN B further stated when a tube feeding was ordered to run for 16 hours it was hung between 3:00 and 4:00 PM on the 2 PM - 10 PM shift. During a telephone interview on 12/23/11 at 12:40 PM RN C stated she took care of Resident #1 on 12/08/11 and 12/09/11 from 2 PM - 10 PM. RN C stated ADON A hung Resident #1's tube feeding on 12/08/11 around 6:00 PM and she hung the tube feeding on 12/09/11 around 4:00 PM. RN C stated ADON A told her on Friday (12/09/11) he got the physician's orders [REDACTED].#1's tube feedings were hung or infusing, and she had no response. In an interview on 12/23/11 at 3:18 PM, ADON A stated he did not hang Resident #1's tube feeding on 12/08/11. Review of the "admission orders [REDACTED]. Review of Resident #1's "Nurse's Notes" dated 12/10/11 revealed at 1:05 AM "Resident ...restless and confused. Attempting to get out of bed. GT (gastrostomy tube) in place - patent. [MEDICAL CONDITION] tube intact...." There was no further entry until 3:40 PM (more than 12 hours later). The entry reflected, "Family stated to this nurse that res (resident's) eyes look different and color paler. BS (checked) results 37. Skin moist color paler resp (respirations) even & non labored res lethargic. 1 mg [MEDICATION NAME] (medication to increase glucose level) S/C (Subcutaneously) given @ 3:42 pm. Res lying in supine position ...[DEVICE] feeding just started...." At 3:49 PM, Resident #1's blood sugar was rechecked and was 44. ____ Ambulance here - family @ bedside and requesting for res to go to the hospital." The normal ranges of FSBS are 70-99 mg/dL. Retrieved on 01/06/12 from <http://www.webmd.com/hw-popup/milligrams-per-deciliter-mgdl> per http://diabetes.webmd.com/blood-glucose?page=3). During an interview on 12/23/11 at 10:50 AM, LVN B stated she would be concerned if a diabetic resident had a change in orientation or was sweating. The surveyor queried LVN B what she would do and LVN B stated she would check the resident's FSBS, if the level was low she would give orange juice and give a [MEDICATION NAME] (single, large dose) tube feeding. She further stated she would recheck the FSBS in 30 minutes, document the events and notify the doctor. During a telephone interview on 12/23/11 at 12:02 PM, LVN D stated she worked 12/10/11 and was assigned to the 400 and 600 halls. This was the first time she took care of Resident #1, who resided on the 600 hall. LVN D stated she took Resident #1's FSBS (scheduled for 6:30 AM) "between 9 AM and 10 AM and it was 44. I (LVN D) gave (Resident #1) orange juice and told the weekend supervisor." LVN D stated she rechecked the FSBS an hour later and it was 72. "Everything was ok." She stated around 1 PM she was looking in Resident #1's chart for tube feeding orders and Resident #1's family was looking for the resident's nurse (LVN D) because the resident was almost out of the bed. LVN D checked the residents FSBS and it was 29, she (LVN D) gave orange juice and [MEDICATION NAME]. "The resident's ___ (family member) was asking me a lot of questions, (he/she) said I was rude. I was going to hang the tube feeding, but the weekend supervisor said 'no' because the family didn't want me in there (the resident's room) any more. I tried to finish my charting and they (management) told me to leave (the building) ...I did put the BSs on the 24 hour report." The surveyor queried LVN D if she notified the doctor of Resident #1's change in condition or low blood sugars and LVN D stated "We (the charge nurses) are not supposed to call the doctors. We give the information to the weekend supervisor and the weekend supervisor calls the doctors and then she (weekend supervisor) tells us (the charge nurses) what the doctor said and what the new orders are." Review of the "admission orders [REDACTED]. For blood sugars less than 60 and unresponsive, give [MEDICATION NAME] 1 mg SQ x 1 dose and notify the doctor. During an interview on 12/23/11 at 1:05 PM, ADON A stated when the nurses needed to share information or changes in residents' conditions to the residents' doctors, they gave the information to the lead nurse and the lead nurse called the doctors. ADON A further stated on the weekends, the nurses were to tell the weekend supervisor the information, which needed to be relayed to the doctors, and the weekend supervisor called the doctors. During an interview on 12/23/11 at 1:47 PM the DON, who verified she was the weekend supervisor on 12/10/11, stated on 12/10/11 around 1:00 PM she entered Resident #1's room to listen to the family's concerns. The DON stated Resident #1 was lying sideways in the bed and restless and required frequent repositioning. Resident #1's family member stated the resident's eyes rolled back into his head. "I (the DON) would assume she (LVN D) gave the orange juice and [MEDICATION NAME], for her (LVN D) sake. I (the DON) went to the 100 hall and got the _____ ambulance driver and they took him (Resident #1)." The surveyor queried the DON what time the ambulance took Resident #1, and the DON stated "about 1:30 PM." The surveyor showed the DON Resident #1's nurses notes with entries at 3:40 PM and 3:49 PM from LVN E. The DON stated, "We didn't wait around here for 3 hours. I'm going to check with the ambulance. I would believe them (the ambulance drivers) before the nurse (LVN E)." A few minutes later the DON returned to the interview and stated the ambulance company stated Resident #1 was transported to the hospital at 3:49 PM. The surveyor asked the DON if she checked the blood sugar between 1:30 PM and 3:30 PM or hung Resident #1's tube feeding and she stated "No." The surveyor queried the DON if she should have checked the blood sugar, and the DON stated "yYeah." The surveyor queried the DON if she should have hung Resident #1's tube feeding, and the DON stated "Sure appears like it." The DON stated it was the facility policy if the BS was low to give [MEDICATION NAME] and call the MD. The surveyor queried the DON if anyone notified the physician, and the DON stated she texted the Nurse Practitioner while she was in the resident's room, preparing him to be sent out to the hospital (at approximately 3:40 PM), the only time an attempt was made to inform the Physician/Nurse Practitioner of the resident's status. During a telephone interview on 12/23/11 at 3:30 PM, LVN E stated the weekend supervisor asked her to hang the tube feeding for Resident #1. LVN E stated she was not aware the resident had been having low blood sugars. While LVN E was in Resident #1's room, the resident's eyes rolled back, and the family said he was having low blood sugars. LVN E stated she checked the resident's FSBS at 3:40 PM and it was 37. LVN E gave [MEDICATION NAME] and rechecked the FSBS in nine minutes, and the level was 44. The resident's family requested the resident be sent to the hospital. The surveyor queried LVN E if the weekend supervisor was in Resident #1's room with her and she stated "No." The surveyor queried LVN E what she would do if she checked a resident's FSBS, and it was less than 60. LVN E stated there were standing orders: if the BS was less than 60 give orange juice or [MEDICATION NAME], repeat the FSBS in 15 minutes, if less than 60 for a second time call the doctor. She further stated if the resident was unresponsive during the second low blood sugar, call 911. Review of the hospital "Discharge Summary" dated 12/14/11 revealed, "...He (Resident #1) was transferred from the nursing home with altered mental status/unresponsiveness and was found to be severely hypoglycemic with a blood sugar as low as 20. He required repeated D50 (a high concentration of a [MEDICATION NAME] solution to increase blood sugar) injections and was admitted to the intensive care unit for close monitoring. We had him on a D10 drip (Intravenous solution of [MEDICATION NAME] and water to increase blood sugar) and stopped all of his insulin...." 2) "In general, a blood glucose reading lower than 70 mg/dL is too low. If you take insulin or diabetes pills...you can have low blood glucose...(also called [DIAGNOSES REDACTED]...). Low blood glucose is usually caused by eating less or later than usual, being more active than usual, or taking too much diabetes medicine. Drinking beer, wine, or liquor may also cause low blood glucose or make it worse...If you have any signs that your glucose may be low, test it right away. If it's less than 60 to 70 mg/dL, you need to treat it right away....Waiting to treat low blood glucose is not safe. You may be in danger of passing out. If you get confused, pass out, or have a [MEDICAL CONDITION], you need emergency help...." Retrieved on 01/06/12 at http://www.cdc.gov/diabetes/pubs/tcyd/ktrack.htm. Manufacturer's guidelines retrieved at http://products.sanofi.us/[MEDICATION NAME]/[MEDICATION NAME].html#section-6.1 on 12/09/11 reflected, "An excess of insulin relative to food intake, energy expenditure, or both may lead to severe and sometimes prolonged and life-threatening [DIAGNOSES REDACTED]... More severe episodes of [DIAGNOSES REDACTED] with coma, [MEDICAL CONDITION], or neurologic impairment may be treated with intramuscular/subcutaneous [MEDICATION NAME] or concentrated intravenous glucose. After apparent clinical recovery from [DIAGNOSES REDACTED], continued observation and additional carbohydrate intake may be necessary to avoid recurrence of [DIAGNOSES REDACTED]." 3) Review of the facility's "Low Blood Sugar Standing Orders" (identified as the current policy by the Director of Clinical Services) dated 04/29/09 revealed, "For BS < 60 and alert, hold insulin/oral hypoglycemic agent. Give 4 oz. orange juice, recheck FSBS in 15 mins. If resident does not respond > 60, notify MD immediately. For BS <60 and unresponsive, hold insulin/oral agent, give [MEDICATION NAME] 1 mg SQ x 1 dose, call 911 and notify physician...." 4) Review of a list, provided by the Director of Clinical Services, revealed there 35 diabetic residents and 21 residents who were receiving tube feedings in the facility. Comparing the lists revealed there were nine residents, who were both diabetic and received tube feedings.