Every finding on record at Carlyle Senior Care of Aiken

Based on review of the facility policy, interviews, and record review, the facility failed to ensure Resident (R)3 remained free from sexual abuse. Specifically, on 04/02/26, the facility failed to protect R3, a cognitively impaired female who lacked the capacity to consent, from sexual contact initiated by R2.On 04/21/26 at 3:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 04/21/26 at 3:00 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/02/26. The IJ was related to 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation. On 04/21/26 at 7:00 PM, the facility provided an acceptable IJ Removal Plan. On 04/21/26 at 7:20 PM, the survey team validated the facility's corrective actions and confirmed the IJ had been removed as of 04/03/26. The survey team confirmed the facility had put forth good faith efforts in correcting their noncompliance prior to the start of the survey, warranting the IJ at Past-noncompliance. An extended survey was conducted in conjunction with the Complaint Survey, for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility policy, Abuse, Neglect, Exploitation, with a revision date of 02/05/2026, revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. The Components of the Facility abuse prohibition plan are discussed therein: I. Screening B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. 1. An assessment of the individual's functional and mood/behavioral status.will be reviewed prior to admission III. Prevention of Abuse, Neglect, Exploitation D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents needs and behaviors which might lead to conflict or neglect . Review of R3's Face Sheet revealed she was admitted on [DATE], with diagnoses of but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/26 revealed no Brief Interview for Mental Status (BIMS) score. The resident requires substantial to max assistance with Activities of Daily Living (ADLs). Review of R2's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and other sexual dysfunction not due to a substance or unknown physiological condition. Review of R2's Annual MDS with an ARD of 02/12/26 revealed a BIMS Score of 99, indicating he was unable to complete the interview. The resident requires partial to moderate assistance to supervision assistance with ADLs. Review of R2's medical record revealed Resident has history of periods of inappropriate behavior and inappropriate gestures towards staff during his personal care. Review of R2's Care Plan revealed R2 had a history of a. watched for pulling at penis, inappropriate behavior and inappropriate gestures. Approach to Monitor/record occurrence of for target behavior symptoms - hypersexuality towards staff, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Review of R2's progress notes dated 04/02/26 at 01:00 AM revealed, Staff found patient kneeling on the floor next to bed in the male residents room. Male patient was seen grabbing female's hand and placing it on his penis Review of R2's progress notes dated 04/03/26 at 10:30 AM revealed I consulted with [the Medical Director], concerning the incident that transpired yesterday, in which R2 behaved inappropriately towards a female resident. It is evident that R2 poses a risk to other residents and is not suitable for this environment. During an interview on 04/21/26 at 11:42 AM, CNA2 revealed she was walking down the hall checking on her residents and as she was passing room [ROOM NUMBER], she saw R2 lying naked on the bed and R3 kneeling beside the bed. R2 had his hand over R3's hand putting it on his private area. CNA2 explains that she continued to the nursing station to get help and saw one nurse on the other hall and asked for help, but she was unable to because she was passing medications, then she saw another CNA and asked for her to come witness what she saw, then both went back to the room. Once in the room CNA2 states that she left the room, leaving CNA3 in the room while she went get the Unit Manager (UM). CNA2 states that the UM came back to the room with her and accessed the resident on the floor, then the nurse and the CNA3 got R2 up off the floor and out of the room. During an interview on 04/21/26 at 12:07 PM, CNA3 revealed that she is familiar with both R2 and R3. CNA3 states that she was approached by CNA1, as she was returning from break to come to room [ROOM NUMBER] to witness what was going on. CNA2 states that when she entered the room, she observed R2 naked in his bed with R3 on the floor beside the bed, R2 had his hand on top of R3's hand, on top of his private area and trying to pull her into the bed. CNA3 explains that CNA2 left the room to go get the nurse and that she immediately stepped in between the two residents to try to separate them. CNA3 continues to state that when the nurse came into the room, she and the nurse got R3 up off the floor and removed her from the room. CNA3 further revealed that she has received in-services on abuse before and after the incident. During an interview on 04/21/26 at 12:44 PM, the UM revealed that she is familiar with both residents. The UM explains that R2 is immobile, but could drag himself around some and R3 is mobile and wanders around the facility and has to wear a helmet when out of bed, due to multiple falls. The UM explains that she was in the front office when CNA2 came in and informed her that she needed help in room [ROOM NUMBER]. The UM states she accompanied CNA2 to room [ROOM NUMBER], where she saw CNA3 standing between R2 and R3 trying to keep them apart. The UM further explained that R2 was lying on the bed and R3 was lying on the floor beside the bed. The UM continued to explain that she immediately stepped between CNA3 and the residents and began to assess R3 for injury, while she was on the floor and while she was assessing her, she noticed her hand under R2's cover and noticed the cover moving, and after ensuring R3 was not injured she and CNA3 got R3 off the floor and out of the room. The UM further revealed that R2 was unclothed from the waist down and R3 was fully clothed. The UM states that she reported the incident to the Administrator and they began their investigation which included calling the police, notifying the provider and the resident representatives. During an interview on 04/21/26 at 1:37 PM, the Administrator revealed both residents are nonverbal and unable to have appropriate communication and that R3 wanders around the entire facility and R2 usually remains in his room. The Administrator explains that she was notified about the incident initially when CNA2 came into the office and stated she needed help in room [ROOM NUMBER] with R2 and R3 and that the UM left the office to go assist her. The Administrator states that she was told that CNA2 was going into R2's room to provide care, when R3 was observed in the room on the floor, and R2 was pulling on R3's hand trying to get her in bed. The Administrator further states that CNA3 was in the room and removed R3 from the room and assessed her for visible injuries. The Administrator explains that she was told that R2 was unclothed and R3 was fully clothed. The Administrator further revealed that R2 was care planned for disrobing (taking off his clothes) and reaching and grabbing at staff. During an interview on 04/21/26 at 4:50 PM with Medical Director (MD), Social Services (SS), and Regional Consultant (via phone), the MD revealed, When they admitted R2, they did not know of him having sexual behaviors. The MD further stated the hospital sent a buffed up chart with no indications of behaviors and saying he was mostly non-verbal. The MD explained that Geriatrics is his specialty. The MD further explained that R2 has put himself of the floor, stripped naked, pushed, shoved, pulled, and grabbed his penis during care, as well as when he first assessed him after admission and he is not clear if these are behaviors are an attempt to communicate, since he is non-verbal, or a combination of both. The MD continues to explain that they had no indication he would do this to another resident and they tried to send him back to the hospital after this incident, however the hospital sent him back to them without doing anything, saying it was inappropriate for us to have sent him. The MD then stated, this was the first indication he would have done what he did and he realizes IJs are serious, but in his opinion, they did everything they could to protect other residents prior to this incident. The MD further revealed that places to send geriatric patients with psych problems no longer exist and since the incident, R2 has increased psych involvement and 1:1 supervision. The SS revealed when R2 came to the facility, he was not on any psych medications, and his mother does not want him on any psych medications. SS stated R2 was originally sent to the hospital because the family stated they couldn't manage him and that the hospital staff felt some of the behaviors he had, were triggered by his mother and that he even pulled his penis in front of his mother. The facility's IJ Removal Plan included the following: 1. Identification of Resident Affected or Likely to be Affected: The following actions were taken to prevent [R2] from perpetrating additional abusive behaviors. (Completion: 04/03/26). [R3] evaluated by primary care provider. Resident received psych consult, medication adjustment, and follow-up. 30 minute checks were started on 04/03/26 and then changed to 1:1 supervision on 04/03/26. A stop banner was placed across his door to deter residents who wander from entering his room [ROOM NUMBER]/3/26. Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible. IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident. [R3] was assessed for any injury by the nurses, her Primary care NP, and she was seen by the Psych NP. No physical or psychosocial or mental issues or changes were noted. [R2] was sent to MUSC in [NAME] SC to see if they could assist to get him in for a psych admission 4/4/26. They stated they could not get him placed, and he was returned to the facility and remains on one on one. 4/4/26 Ombudsman is aware of the incident. 4/3/26 Law enforcement was notified of the incident and came to the facility and interviewed staff and both residents. 4/3/26 Both [R3] and [R2] responsible parties were made aware of the incident. 4/3/26 DPH was notified of the incident. 4/3/26 2. Interviews were conducted of residents with BIMS score of 8 or above to determine if they had been victim of any potential abuse and none were noted. Body audits were conducted on residents with BIMS of 8 or less for any signs of injury and no injuries were noted. 3. Actions to Prevent Occurrence/ Recurrence: The facility to the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 4/3/26). Abuse policies were reviewed to include all sources of abuse, including resident to resident and sexual abuse no changes were needed to policy. Abuse investigation procedure and documentation process were reviewed and no changes were needed. DON, In-service coordinator and Administrator re-educated all staff on facility abuse policies on abuse prevention and reporting. DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Care plans will be updated as indicated. Staff will be educated on new intervention either verbally or in written form by the Care Plan Coordinator or designee. IN the event of any future resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluation can be complete. Outcomes of these evaluation will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. 4. All abuse allegations and investigations will be reviewed during QA monthly for appropriate investigation, root cause analysis, and prevention. Education on abuse and abuse prevention and reporting is provided to all newly hired staff, and twice yearly and prn as determined appropriate when any situation indicates the need for further training. All contracted staff have documentation of abuse training prior to working and if further training is needed it is provided based on the situation identified in the facility. Completion date: 04/03/26

Based on review of facility policy, resident records, and interviews, the facility failed to provide adequate supervision to prevent Resident (R)1 from eloping. Specifically, on 10/13/25 R1 had a successful elopement from the facility where he was found across the street, placing the resident at serious risk for injury or harm.On 10/15/25 at 2:15 PM the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 10/15/25 at 2:15 PM, the Facility Administrator was notified that the failure to protect R1 from having a successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689.On 10/15/25 at 2:15 PM, the survey team provided the Facility Administrator with a copy of the Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/13/25. The IJ was related to S483.25 Quality of Care at F689: Free of Accident Hazards/Supervision/Devices.On 10/15/25 at 2:30 PM, the facility provided an acceptable IJ Removal Plan.On 10/15/25, the survey team validated the facility's corrective actions and determined the facility made good faith attempts at correcting the non-compliance. The IJ is considered at Past Non-Compliance as of 10/14/25. The survey team concluded all corrective actions were put in place prior to arrival onsite.An extended survey was conducted in conjunction with the Complaint survey for non-compliance at F689, constituting substandard quality of care.Review of the facility policy titled, Elopements and Wandering Residents, last revised 10/13/25 revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to vascular dementia with behavioral disturbance, psychotic disorder with hallucinations due to a known physiological condition, delusional disorder, psychophysiologic insomnia, and auditory hallucinations. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/02/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, indicating R1 was severely cognitively impaired. Further review revealed R1 wears a wander/elopement alarm daily.Review of R1's Elopement Risk Evaluation dated, 12/04/24, revealed a score of three indicating R1 was at risk for elopement. Review of the facility's statement dated 10/13/25 revealed, 0530 AM Resident was changed by CNA in his room. 0543 AM Resident went out of the building from the service hall doorway. 0615 AM It was noted that the resident was missing and a search began immediately of the entire building. During a second outdoor search the nurse noted the resident across (facility) at the school. After talking to him for a few minutes he agreed to come back to the facility (he said he had to go to work). She returned with him at 0645 AM (no injury was noted). The investigation indicates that Mr. [NAME] exited through the service hall door, with video evidence supporting this claim.Review of a progress note dated 10/13/25 by Licensed Practical Nurse (LPN) 1 revealed, Resident was noted to not be pacing the hallway by his nurse. She then began to look down her hallway. When she did not see him, she called the back to check if he was in the back lobby. When he was not noted there, staff began searching the building. While available staff did a triple check of the building, another nurse started an exterior perimeter check. After the perimeter check she then began walking further down the street. She then observed resident across the street, attempting to go in the door of the school. When asked what he was doing, he stated I'm going to work. He was easily redirected and assisted back into the building. MD aware. Attempted to call RP, it went to voicemail and the voicemail was full. Email was to be sent. Resident was then placed on one on one.Interview with LPN 1 on 10/15/25 at 12:24 PM revealed, R1 is known to pace and frequently walks up and down the facility hallways. He exhibits confusion and decreased safety awareness due to his dementia and other disease processes. R1 has demonstrated some inadvertent exit-seeking behaviors, such as attempting to open closed doors, which staff attribute to his curious nature. However, there were no prior elopement incidents before the current event. Staff report that R1 has consistently worn a functioning WanderGuard for as long as they can recall. On the day of the incident, LPN 1 was informed by another nurse that R1 could not be located and was due for his morning blood sugar check. Nursing staff immediately initiated a search using the facility's triple-check method, inspecting all hallways and resident rooms. R1 was not found inside the facility. LPN 3 expanded the search perimeter and located R1 across the street on high school grounds. When asked why he left the building, R1 stated that he had to go to work. A skin assessment was completed with no injuries noted. At the time of the incident, R1's Wander Guard was functioning properly. Investigation determined that R1 exited through the service door, which was equipped with an alarm sensor. Further inspection of the alarm revealed frayed wiring that rendered the alarm ineffective.Interview with LPN 3 on 10/15/25 at 12:59 PM, revealed, that Early in the morning, another nurse approached LPN 3 and inquired whether she had seen R1. LPN 3 reported that she had seen R1 a few minutes earlier when he asked for assistance with toileting. LPN 3 directed R1 to the CNA on duty, who completed the task. When questioned, the CNA confirmed she had recently taken R1 to the bathroom, after which he got dressed and continued to self-ambulate throughout the facility. Staff then began searching the building when R1 could not be located. Before leaving the facility to search outside, LPN 3 verified the functionality of all alarmed exterior doors. She stated that, to the best of her knowledge, R1's WanderGuard was also functioning at the time. After confirming all alarms were operational, LPN 3 proceeded to check the outside perimeter as a precaution. When R1 was not found immediately outside the facility, LPN 3 extended the search and, due to limited visibility in the early morning darkness, walked beyond facility grounds. R1 was located near the rear entrance of the high school across the street. No injuries were noted. When asked why he left, R1 told LPN 3 he was just trying to go to work. LPN 3 successfully re-directed R1 back to the facility.Interview with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) on 10/15/25 at 1:12 PM, revealed, that elopement risk assessments are conducted upon admission, with any change in condition, and when behavioral changes occur. Residents identified as high risk are care planned accordingly and provided with a WanderGuard device worn on the wrist or ankle. All exit doors are equipped with alarms that emit a loud sound when a WanderGuard-wearing resident approaches. Clinical staff are responsible for monitoring the devices, while maintenance is responsible for door alarm functionality. The LNHA stated that R1 frequently ambulated throughout the facility but had never shown clear exit-seeking behavior. According to the DON, when residents approach exit doors and trigger alarms, they typically turn away without attempting to exit. Facility investigation determined R1 exited through the service door, an area primarily used by dietary, maintenance, and laundry staff, which was not a typical route for him. Inspection revealed damaged wiring in the door alarm system, rendering it ineffective. The LNHA stated the damage may have been accidental due to the high volume of equipment and personnel using the door. R1 was later found across the street on high school grounds and told staff he was going to work. No injuries were noted. Facility leadership expects high-risk residents to be rounded on more frequently, staff to respond promptly to door alarms, and all elopement prevention equipment to be maintained in proper working condition.Attempted Interview with Resident representative (RP) on 10/15/25 at 12:18PM and12:53PM. Unable to leave voicemail as voicemail box is full. Text message left. The facility's Immediate Jeopardy Removal Plan included the following:1. Actions Taken for the Affected Resident:On October 12, 2024, on the 7 pm/7 am shift, the wander guard for Resident DC was checked and found to be fully operational.Upon Resident DC's return to the facility on October 13, 2025, at 6:45 AM, a subsequent check of the wander guard revealed it was still functional.A comprehensive assessment of Resident DC was conducted, and it was documented that there were no injuries or any signs of distress.To enhance safety, Resident DC was placed under 1-on-1 supervision for close observation and monitoring.A detailed inspection of the wander guard system at the facility's service hall exit uncovered that a wire had come loose, which directly impacted the alarm functionality of the door. This issue was promptly addressed, with the maintenance supervisor completing the necessary repairs. To further bolster safety protocols, a backup alarm was installed on the interior door leading to the service area2. Identifying Other Residents at [NAME] comprehensive check was performed on all other residents utilizing wander guards to verify their integrity and functionality, ensuring that no other residents were at risk of elopement. This was done at 6:45 AM on October 13, 2025An accurate headcount of all residents was conducted to confirm that everyone was present and accounted for within the facility, ensuring the safety of all our residents. This was completed on October 13, 2025, at 6:45 AM.All exits were thoroughly inspected to verify that backup alarms were present and operational. This meticulous check confirmed the effective functioning of all backup alarms, adding another layer of security. This was done by the Maintenance Supervisor.An audit was carried out to identify residents who had undergone risk assessments related to potential elopement. This included a review of care plans to ascertain that interventions, such as the use of wander guards, were adequately addressed and implemented. This was completed by the MDS nurse.Resident DC's care plan was updated to reflect the new risks associated with elopement incorporating specific interventions tailored to ensure his safety. This was done by the MDS/care plan nurse. 3. Actions to Prevent Future OccurrencesThe maintenance supervisor will perform daily inspections of the entire wander guard system and all backup alarms for every door to ensure they are functioning correctly. The wander guard alarm on 60 hall does not function, but the backup alarm functions and a stop sign has been placed over this door.All nursing staff across all shifts received extensive training on resident safety protocols, specifically focused on checking alarms and monitoring wander guards. Any staff members on leave will receive this educational briefing upon their return to work. Additionally, agency staff will undergo training on these protocols before commencing their shifts. New hires will receive targeted training during their orientation regarding wander guard monitoring, alarm response procedures, and general resident safety.The Minimum Data Set (MDS) nurse will conduct thorough audits of new admissions for elopement risk and ensure that appropriate safety interventions are put in place without delay.The maintenance supervisor will monitor alarm functionality daily for two consecutive months, moving to a weekly schedule thereafter. The results of this ongoing observation will be meticulously reviewed weekly by the facility administrator to ensure consistent compliance. Newly hired staff will receive dedicated training on topics related to wandering, elopement, and overall resident safety from the in-service coordinator during orientation.4.What practices will be put in place to ensure the deficient practice does not recur:A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) has been implemented to systematically review and analyze all audit findings. Initial findings indicated that the root cause of the incident was related to a loose wire in the wander guard alarm system at the service hall back door, which subsequently prevented the alarm from sounding appropriately on the morning of October 13, 2025.The results of the alarm monitoring will be reviewed in the QA meetings monthly for three months, then quarterly, until it is determined that the deficient practice is not likely to recur.The facility alleges compliance on 10/14/25.

Based on observation, interviews, and review of facility policy, the facility failed to ensure the daily nurse staffing information was posted in a manner that residents and visitors had access to the information. This deficient practice has the potential to affect all residents and visitors.Findings include:Review of the facility's policy titled Nurse Staffing Posting Information dated May 2025 revealed, . It is the policy of this facility to make nurse staffing information readily available in a readable format to residents. staff and visitors at any given time.Upon entrance to the facility on [DATE] at 9:00 AM, the daily nurse staffing information was observed posted on a glass bulletin board, with multiple notices behind it inside the case, approximately six feet high. The posting was current for the day, all three shifts, however, was not readable, or accessible, for residents in a wheelchair or with vision problems.Observations on the subsequent survey days of 09/11/25 at 2:30 PM, and 09/12/25 at 10:00 AM revealed the daily nurse staffing information posted on a glass bulletin board, with multiple notices behind it inside the case, approximately six feet high. The posting was current for the day, all three shifts, however, was not readable, or accessible, for residents in a wheelchair or with vision problems.During an interview on 09/12/25 at 3:00 PM, the Director of Nursing (DON) stated she was responsible for posting the daily nurse staff information. She also stated she was not aware it had to be posted in an accessible area for residents and visitors.

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident's nasal cannula was stored properly when not in use for one of two residents reviewed for oxygen therapy (Resident (R) 65) out of a total sample of 21 residents. This failure had the potential to increase the risk of a respiratory infection for residents receiving respiratory therapy.Findings include:Review of the facility's policy titled Oxygen Safety dated 04/2025 revealed, it is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment.Review of R65's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnosis which included quadriplegia.Review of R65's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/25 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was not cognitively impaired. The resident was coded as receiving oxygen therapy.Review of R65's Physician Order dated 02/27/25 in the EMR under the Orders revealed an order for oxygen at 2 Liters per Minute (lpm) via nasal cannula as needed for shortness of breath.Observation on 09/11/25 at 2:35 PM, revealed R65's oxygen nasal cannula was wrapped around the top of the resident's oxygen concentrator and on 09/12/25 at 12:00 PM, R65's nasal cannula was lying at the foot of the resident's bed uncovered.During an observation and interview on 09/11/25 at 2:40 PM, Licensed Practical (LPN)3 verified R65's nasal cannula was left out uncovered and that the nasal cannula should be stored in a bag.During an interview on 09/12/2025 at 11:52 AM, LPN4 verified R65's nasal cannula was lying on the floor uncovered. He stated R65 only used oxygen at night and not during the day and it should not be on the floor LPN4 stated that he did not notice the cannula was on the floor and stated it should be stored in a bag.During an interview on 09/12/25 at 4:35 PM, the Director of Nursing (DON) stated a resident's nasal cannula should be stored in a bag when not in use.

Based on observation, interviews, record review, and policy review, the facility failed to ensure that urinary catheter care was performed for one of one resident (R )65) reviewed for catheters and urinary tract infection. This failure placed the resident at risk for transmission of infection to the urinary tract.Findings include:Review of the facility's policy titled, Catheter Care dated 02/17/24 revealed, .Male:.16. With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis.Review of the Census tab in R65's electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and neuromuscular dysfunction of bladder.Review of R65's Orders tab of the EMR revealed a physician's order dated 07/29/25 which documented, Catheter-Provide catheter care every shift.During catheter care observation with Certified Nursing Assistant (CNA)1 and Licensed Practical Nurse (LPN) 1 on 09/11/25 at 9:06 AM, R65 was lying in his bed. CNA1 removed R65's incontinence brief After doffing gloves, CNA1 took a wipe and retracted the foreskin. CNA1 wiped around the head of the penis, three different times, with three different wipes and changing gloves between each time. After the final wipe, CNA1 then wiped the tubing, removed her gloves, and replaced the same incontinence brief on R65.There was no evidence that the shaft of the penis was cleaned during the care.During an interview on 09/12/25 at 9:30 AM, CNA1 confirmed that she was trained to clean the shaft of the penis and stated that she did not clean the shaft of the penis.During an interview on 09/12/25 at 9:55 AM, the Director of Nursing (DON) stated that the shaft of the penis does not need to be cleaned during catheter care. The DON could not confirm the procedure she stated in the facility's policy.

Based on record review, interview, document review and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure timely completion and submission of the Minimum Data Set Assessments (MDSs) for one of one (Resident (R) 81) reviewed out of 21 sampled residents. This failure had the potential to adversely affect care planning and care provision or payment to other facilities for any residents that may not have had a discharge assessment transmitted.Findings include:Review of the October 2024 RAI Manual revealed, . MDS assessments for Significant Change must be completed no later than 14 days from the ARD and no later than 14 days from the determination date of the significant change. MDS assessments for Entry the MDS completion date must be no later than seven days from the event date. and . Comprehensive assessments must be transmitted electronically within 14 days of the completion of the MDS. For Entry information must be transmitted within 14 days of the event date.Review of R81's undated admission Record located in the electronic medical record (EMR) under the Profile tab indicated an admission date of 12/05/23 and diagnoses of respiratory insufficiency, muscle weakness, and difficulty in walking.Review of R81's entry MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/25/24 revealed the MDS was completed on 12/04/24 and accepted on 12/05/24. The MDS should have been completed and accepted on 12/01/24.Review of R81's discharge return anticipated MDS located in the EMR with an ARD of 02/08/25 was completed on 03/05/25 and accepted on 03/05/25. The MDS should have been completed and submitted on 02/21/25.Review of R81's entry MDS located in the EMR with an ARD of 02/11/25 was completed on 03/05/25 and accepted on 03/05/25. The MDS should have been completed and submitted on 02/24/25.Review of R81's significant change MDS located in the EMR with an ARD of 04/24/25 was completed on 05/08/25 and accepted on 05/08/25. The MDS should have been completed and submitted on 05/07/25.During an interview on 09/12/25 at 2:30 PM, the MDS Coordinator (MDSC)confirmed R81's MDSs were completed and submitted late. The MDSC also stated the facility did not have a specific policy for following the MDS and that the MDS nurses follow the MDS manual for coding.During an interview on 09/12/25 at 3:30 PM, the MDSC provided the MDS validation report for R81 from [DATE] until her discharge in June 2025. The validation report was reviewed and the MDSC confirmed the 11/25/24 and 04/24/25 MDSs reflected a warning message that stated .submitted values listed do not match the IQIES database. The February 2025 MDSs confirmed the .submission date is more than 14 days after the ARD. No corrections or modifications were completed for the 11/25/24 or 04/24/25 MDSs. The MDSC stated she saw the warning messages, but the MDSs were accepted.

Based on record review, interview, and policy review, the facility failed to honor a resident's right to be free from unnecessary physical restraint for one of three residents (Resident (R)5) reviewed for abuse out of seven sampled residents. This had the potential to effect residents functional status.Findings include:Review of the facility's policy titled Resident Rights dated 04/2025 revealed that the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has a right to be treated with respect and dignity, including the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms.Review of R5's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnoses which included dementia and anxiety disorder.Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated the resident was unable to complete the assessment.Review of R5's Care Plan dated 01/25/25 and located in the EMR under the Care Plan tab revealed, At risk for potentially physically and verbally aggressive related to dementia and agitation. Interventions included approach in a non-threatening manner and approach from the front in a calm manner.During an interview on 09/11/25 at 4:52 PM, Registered Nurse (RN)1 stated that on 06/30/25 she observed R5 walk into the lobby and walked over to R21 and hit R21 in the head with the plate cover. She said there was absolutely no provocation by R21. R5 simply hit R21 for no reason. She said Certified Nurse Aide (CNA)2 came over and bear hugged R5 by putting both of her arms around him from the back to prevent him from moving his arms. RN1 said CNA2 guided R5 to a wing chair and sat him down in it. She stated R5 remained in the chair until police and Emergency Medical Service (EMS) arrived. She stated that staff have not received any type of training on this type of technique, but she felt it was appropriate for CNA2 to restrain R5 at that time.During an interview on 09/11/24 at 5:50 PM, CNA2 said she did not see when R5 struck R21 in the head with the plate lid, but she heard the interaction which made her look up. She observed R5 attempting to hit R21 again and she went over to R5 and grabbed him from behind and putboth her arms around him. She stated at first he was trying to still move forward but he stopped resisting, and she was able to walk him over and sit him down in the chair. She waited with him until EMS arrived. She said that she has not received any training by the facility to use that type of technique on a resident and it was not an approved use of restraint.During an interview on 09/11/25 at 7:10 PM, the Director of Nursing (DON) stated she was familiar with abuse and restraint regulations and that CNA2 should not have grabbed and held R5 in the way she did. The DON said it was not appropriate for CNA2 to bear hug R5. She stated that staff should have tried other diversional techniques to try and calm him. She said the bear hug technique could be considered a restraint and was not an approved technique. She stated that staff have not been trained on doing those types of holds.

Based on review of facility policy, interview, and record review, the facility failed to ensure Resident (R)2 was free from misappropriation for 1 of 2 residents reviewed for abuse. Specifically, R2's wallet, which contained his debit card, was allegedly stolen and used at multiple places. The findings include: Review of the facility policy titled Abuse, Neglect and Exploitation with a reviewed/revised date of 01/20/25, documented under definitions: Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to insomnia/malignant neoplasm of prostate/vascular and dementia/anxiety disorder/mood disorder.Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating R2 had severe cognitive impairment. Further review of the MDS revealed R2 was dependent on staff.Review of R2's Progress Note dated 04/06/25 revealed, social Services spoke with RP on 4/4/25 to notify her that [R2's] debit card and wallet had been stolen and used. Social notified her also the card cancelled, and the police notified. Social informed her that the police were investigating along with the facility. She happy with the facility quick response. Social worker informed RP that we would keep her updated on progress of investigation. Social also informed RP that we were going to encourage [R2] to keep his new wallet and cards locked in the safe. Social will continue to monitor. Social Worker.Review of R2's Progress Note dated 04/06/25 revealed, Late Entry for 4/3/25: [R2] made aware that his wallet and debit card were missing and that they had been used. The bank was notified immediately, and card cancelled. The charges are being disputed and refunded to his account, Police notified and at the facility [R2] spoke with police and states he wants to press charges. Investigation by police in process and investigation by facility in process. [R2] is glad that he will get his money back and that it is being investigation but was upset the incident happened. Social worker offers reassurance and support and will continue to monitor. Social Worker.Review of R2's Bank Statement for 03/28/25 - 05/01/25 revealed the following transactions that were allegedly made without R2's consent:On 03/31/25: Sunoco - $13.82, Dollar General - $32.40, Dollar General - $24.84, McDonalds - $16.67, Sunoco - $8.63, KJs Market IGA - $40.78, and Sunoco - $3.93.04/01/25: Dollar General - $32.40 (credit to account), Circle K - $9.50, Popeyes - $30.51, Sunoco - $5.78, Sunoco - $3.93. Sunoco - $6.96, Dominos - $33.77.04/02/25: Nyx*Nayax Vending - $2.10, $2.10, $2.10, $2.10 (4 transactions), CVS/Pharmacy - $24.60, Northside Package - $4.00, $4.00, $4.00, $4.00 (4 transactions), Dollar General - $6.75, Sunoco - $1.50, Sunoco - $8.63, $1.50, $0.99, $10.78, $13.13 (5 transactions), Northside Package - $18.95.04/03/25: Harizone Beauty - $17.95, McDonalds - $10.88, Family Dollar - $26.46, Sunoco - $4.51, $10.13 (2 transactions), Circle K - $3.56.04/04/25: Hairzone Beauty - $3.36.Further review of the Bank Statement revealed LRM CLAIMS ADJ CR SIG which indicated credits to the residents account for the alleged fraudulent purchases, all credits were posted to the resident account on 04/09/25.During an interview on 08/12/25 at 10:44 AM, R2 stated he had 2 or 3 debit cards. R2 could not recall anyone using his cards without his permission.During an interview on 08/12/25 at 1:55 PM, the Social Worker (SW) stated that she has been employed at the facility for two years. She described R2 as being very particular about his personal belongings and wanting them kept close to him, especially his wallet. In December 2024, the facility took R2 to the bank to obtain a debit card as part of his Medicaid spend-down process for his nursing home stay. According to the SW, the resident was very pleased to receive both the debit card and the wallet. The SW explained that all related documents, including the debit card, identification card, and receipts for purchased items, were kept in a legal-size envelope stored in the bottom drawer of her desk, which remained unlocked. This office was shared with the admission Coordinator and the Administrator. The SW revealed that she became aware the resident's wallet was missing on April 3, 2025, when the resident came to her office and she attempted to retrieve the debit card to pay for his room. Upon opening the drawer, she discovered the wallet was no longer inside the folder, although the temporary debit card was found loose at the bottom of the drawer. The SW and other staff searched for the wallet but were unable to locate it. At that point, she informed the resident and contacted the bank to report the card missing. The bank informed her that pending unauthorized purchases had been made on March 30, 2025, at CVS, KJ's Grocery Store, Dollar General, and a local hair store for a total of approximately $300. The bank cancelled the card and later reversed all the unauthorized charges. The SW stated she contacted KJ's and provided staff with the receipt number for the purchases in question. The police were also contacted, and the SW shared the transaction information. Surveillance footage was retrieved from KJ's, and the responding officer described two Black males captured on the video - one younger, taller male wearing khaki pants and a nice watch and a second male with dreadlocks. Based on the description, the SW reviewed who had been working at the facility on March 30 and attempted to follow up with the police officer for several weeks without success. The SW further revealed that toward the end of April or beginning of May, the officer reconnected with her and showed her surveillance footage from Dollar General. The SW identified one of the individuals in the video as a Housekeeping/Laundry Aide employed at the facility. The SW stated that resident valuables are accounted for, the SW explained that she typically opens her drawer daily to verify the folder is still there, but she did not check the folder's contents regularly. She admitted she did not expect anyone would access her drawer and remove a resident's belongings. While the resident was initially upset by the incident, the SW stated he has since returned to his baseline, and she does not believe he fully understood the process involved.During an interview on 08/12/25 at 2:55 PM, the Administrator revealed she became aware of the alleged incident when it was time to pay his bill for his room at the facility. She witnessed the Social Worker going through her desk, unable to find the resident's wallet. The resident was adamant that he did not want to keep his wallet in the safe before the alleged incident.

Based on review of facility policy, interviews, and record review, the facility failed to report an allegation of abuse, involving Resident (R)1, within 2 hours, for 1 of 2 residents reviewed for abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation dated 10/24/22 indicated, V. (a) An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur . VII (a) 1a. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g.,) law enforcement when applicable within specified timeframes: immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: major depressive disorder, hyperlipidemia, hypertension, and cerebral infarction. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/23 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R1 was moderately cognitively impaired. Review of an Employee Disciplinary Action Report dated 05/06/24, revealed disciplinary action for Nurse 1 for failure to notify abuse coordinator of an allegation of abuse. During an interview on 05/16/24 at 12:11 PM, Nurse 1 stated R1 told her that a black man came into her room and touched her breast. Nurse 1 stated she didn't think anything of it at the time, because R1 was talking about another incident. Nurse 1 further stated she knew she dropped the ball, because R1 informed her days before. Nurse 1 concluded the incident was discovered when R1 spoke with Social Services. During an interview on 05/16/24 at 1:16 PM, Social Services stated she was doing interviews with residents about abuse, and R1 stated that a gentleman came into her room and touched her breast. Social Services stated she reported the incident immediately. Social Services concluded she was not informed prior to speaking with R1 of any incident occurring with the two residents. During an interview on 05/16/24 at 1:37 PM, the Director of Nursing (DON) verified that the allegation was not reported by Nurse 1. The DON concluded when there is any type of abuse, you have two hours to report, any other allegation is within 24 hours.

Based on observation, interview, record review, and review of the facility policy, the facility failed to update Resident (R)9's Care Plan for 1 of 2 residents reviewed for care plans. Findings include: Review of the facility policy titled Comprehensive Care Plans last revised 10/24/22 revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident right, that includes measure objectives and timeframe's to meet a resident's medical, nursing, and mental/psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will include measurable objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment. The interdisciplinary team will review and revise the comprehensive care plan . Review of R9's Face Sheet revealed R9 was admitted to the facility on [DATE] with the diagnoses including but not limited to; dementia with behaviors, schizophrenia, type 2 diabetes, and cognitive communication deficit. Review of R9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/23, revealed R9 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates R9 is cognitively intact. Further review of the MDS revealed R9 is independent with personal hygiene and toilet use. During an observation on 08/15/23 at 9:45 AM, revealed R9 sitting in his wheelchair, in the hallway of a unit. R9's urinal containing urine was sitting next to him on the floor. During an observation and interview on 08/15/23 at 10:05 AM, R9 was observed sitting in a wheelchair, in the same area, with an empty urinal beside his wheelchair on the floor. An interview with R9 revealed staff allow him to carry his urinal around with him for use and empty it as needed throughout the day. Review of R9's Care Plan on 08/15/23 at 11:45 AM, revealed no care plan or interventions related to the resident's preference of having a urinal with them throughout the day. During an interview on 08/15/23 at 2:49 PM, Licensed Practical Nurse (LPN)1 revealed this was a new behavior for the resident and the resident is not care-planned for that preference. During an interview on 08/15/23 at 3:45 PM, the Director of Nursing revealed R9's care plan should have been updated to reflect their new preference.

Based on review of the facility policy, record review, and interviews, the facility failed to prevent misappropriation of Resident (R)1's funds. The facility also failed to prevent the Activities Director (AD)1 from misappropriating funds that were for residents' activities. Findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation last revised 10/24/22, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property is defined as means to deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Record review on 03/06/23 at 11:30 AM revealed a Witness Statement from R1 dated 10/03/22 which stated, R1 stated she is missing $150 from her lock box and a gift card that had $150 on it. R1 stated that on Sunday 10/02/22 after 7:00 PM, nurse came into her room with her lock box, the resident stated she was unaware that the lock box was missing at the time. R1 stated that she was informed by the nurse that her lock box was in another resident's room (R8) and the nurse knew it was R1's because her name was on the box. R1 stated she knew it was her box as well because her name was on it, but when it was returned it looked like someone tried to rub her name off of the box. R1 stated that it was 2 re-loadable (pre-paid) debit cards inside of the box, but when it was returned those cards were missing. The only items that were inside the box were petty cash (2 quarters, a dime, and a penny 61 cents). R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to; anxiety disorder, chronic pain, major depressive disorder, muscle weakness, and hypertension. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/23 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates they are cognitively intact. An interview on 03/06/23 at 1:30 PM with R1 revealed someone took her locked red box and that it was found in another resident's room (R8), but believes a staff person took it and put it in R8's room because R8 is unable to move without assistance from staff. The box was found, but the money that was inside was gone. When staff searched R8's closet, they were able to locate R1's 2 reloadable gift cards and the facility replaced the money that was missing. R1 further stated she'd given about 100 or more quarters to the AD1 so they could take the quarters to the bank and get dollar bills because it's easier to spend. R1 stated she was texting AD1 about the money (cash/change) and knew that she had read the message because she has an iPad with read receipts (resident was able to see messages were delivered and read). AD1 never responded, so R1 told the Adminstrator about the incident because she still hadn't received her money from AD1. R1 stated she later found out that the facility fired AD1 and R1 was given the reimbursement for the missing money. Record review on 03/06/23 at 1:40 PM of a 2nd Witness Statement dated 10/02/22 revealed small plastic, red, number key safe belonging to R1 (name on safe) was found along with 2 debit cards in R8's room. R8 was unaware that the box was in his room and was unable to tell the writer how the safe got into his room. I exited the room and showed another staff member. Returned the safe to R1 [sic] who was unknown at the time the safe was missing. R1 stated she heard (was shaking) the safe and stated she didn't think anything was missing at the time. R1 opened the safe and discovered that a debit card with a $130 balance available and cash adding to approximately $50 was missing. R1 stated the last time she used the safe was during the week of the 26th of September. R1 keeps her safe in her room either on the tray table or on the floor near her bed. R1 stated the only time she is not in her room would be for activities during the day and has had items taken previously from her room while out of the room. R1 has been seen with money and cards in her bed during care and has been advised to put items in a safe place to ensure they did not get lost or thrown in linen or garbage. Another staff member and self searched R8's room and belongings with permission and did not find any more belongings of R1. Director of Nursing (DON) was notified, along with public safety. Record review on 03/06/23 at 1:45 PM revealed a statement dated 11/17/22 by AD1, which revealed I, AD1, am writing this statement due to some accusations involving invoices and the activity cash box. Any invoices that I turned in were for payment for singers that came 1 time a month mostly. I was able to turn in (invoices) ahead of time for the end-of-the-month billing. The Business Office would ask to turn them in early so I could put the invoice date as the 1st of the month and the due date as the dates the activity was planned on the activity calendar. The activity cash box was used to buy the residents things for activity supplies or anything that was needed. I used around $80 out of the cash box at the dollar stores nearby for decorations and snacks. I've used money from the cash box to buy baking supplies for the something homemade activity. The cash box was also used as a prize for bingo with the residents, they could win up to $5 out of the box. Any money I spent from the cash box was used for activities only, I've also ordered things with my own cards and was reimbursed for it. An attempted phone interview with AD1 on 03/06/23 at 2:06 PM was unsuccessful. An interview on 03/06/23 at 3:40 PM with AD2 (Current Activities Director) revealed they have been at the facility working since September last year (2022). At the time they were hired, they worked under the old Activities Director that misappropriated the activity funds. There would be days residents were expecting outside entertainment (singers/musicians), and there were several days when it was supposed to show up, but didn't. AD1 was responsible for contracting outside activities for residents and at that time, created invoices for the facility and was the only person with a key to the cash box that holds money for the activities funds that were raised by the residents. There would also be many days where AD1 would claim to get items for the residents during the workday, such as getting donuts and coffee for the residents and would show up to work at a later time (10:30 AM or later) with no donuts for the residents. Record review on 03/06/23 at 4:00 PM of a Statement by AD2 revealed I am the assistant for activities, on 11/17/22 at 10:09 AM, I texted AD1 to ask if the singers were still coming for our scheduled 10:30 AM entertainment. I did not get a response back and AD1 did not come to work, so I wasn't sure what to do when the activity was scheduled and no one showed up for entertainment. I also texted her if they were still coming and where could I find the money to give them if they did show up and never got a response that day. I also called her as well, with no response. At 6:04 PM that evening, I received a message back saying they didn't come; call me; hello. She then sent me text 2 times saying hey you need to call me there's something on the 9th. I, (AD2) had a headache so I didn't respond, and AD1 sent another message saying the performers decided not to come back until the nursing home was not at risk for COVID. She also stated she left me a message (I didn't receive) saying that the money was in a binder in the file cabinet, which it wasn't, when I looked the next day at work at 8:30 AM. On 11/18/22 at around 9:00 AM or 9:15 AM, AD1 came in and looked very anxious and hostile and asked me why I took the money box out of the office. I stated that I didn't, she then asked what happened yesterday (11/17/22) and that the money was in the file cabinet. She was also upset that I didn't call her back (didn't receive a call until 6:00 PM). An interview on 03/06/23 at 5:09 PM with the Business Office Manager (BOM) revealed I'm not sure of how many invoices AD1 had misappropriated before the facility was aware of the incident, but AD1 paid the facility back $491 (total money accounted for missed performaces and resident raised money) before they were terminated. AD1 was able to misappropriate the funds under the previous system by giving them invoices for performers before the date of the event and the business office would put the cash in an envelope. Since this incident, we now have the performers sign off on the sheet on the day of the performance and the business office pays them directly. The BOM further stated they checked the activity cash box and were able to locate R1's quarters and the resident signed off for receiving quarters. Record review on 03/06/23 at 5:15 PM of a statement dated 11/18/22, written by the BOM revealed On 11/17/22, the Activities Assistant came to me and stated that the performers were not here and they were scheduled for this morning. She asked me what to do because they (performers) normally come early to set their equipment up. I told her I would get in contact with the performers and eventually was able to locate their number. When I called the performer, he stated that he was told by AD1 that the facility had COVID and was not allowing visitation. I explained to him that was not true because the facility did not have any COVID positive residents or staff, at that time, and asked was he able to perform today, but he wasn't, so we rescheduled for the following week. I then went to the Administrator and and let her know what was going on and told the AD2 to do karaoke with the residents instead. Today on 11/18/22, AD1 caught me in the hallway and asked if AD2 or I had the lock box from the Activity office, and I told her she would have to speak with the Administrator. As I was turning away, she preceded to say they (the performers) weren't coming anyway and the money for them was in the box.

Based on interview, record review, and review of the facility policy, the facility failed to report the abuse of Activities Director (AD)1 misappropriating funds that were for resident activities. Findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation last revised 10/24/22, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property is defined as the means to deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. The facility will have written procedures that include: reporting all alleged violations to the Administrator, state agency, law enforcement, and all other required agencies. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results. Record review on 03/06/23 at 1:45 PM revealed a statement dated 11/17/22 by AD1 which revealed, I AD1 am writing this statement due to some accusations involving invoices and the activity cash box. Any invoices that I turned in were for payment for singers that came 1 time a month, mostly. I was able to turn in (invoices) ahead of time for the end-of-the-month billing. The Business Office would ask me to turn them in early so I could put the invoice date as the 1st of the month and the due date as the dates the activity was planned on the activity calendar. The activity cash box was used to buy the residents things for activity supplies or anything that was needed. I used around $80 out of the cash box at the dollar stores nearby for decorations and snacks. I've used money from the cash box to buy baking supplies for the something homemade activity. The cash box was also used as a prize for bingo with the residents, they could win up to $5 out of the box. Any money I spent from the cash box was used for activities only, I've also ordered things with my own cards and was reimbursed for it. Attempt at a phone interview with AD1 on 03/06/23 at 2:06 PM was unsuccessful. An interview on 03/06/23 at 3:40 PM with AD2 (Current Activities Director) revealed they have been at the facility working since September last year (2022). At the time they were hired, they worked under the old Activities Director that misappropriated the activity funds. There would be days residents were expecting outside entertainment (singers/musicians), and there were several days when it was supposed to show up, but didn't. AD1 was responsible for contracting outside activities for residents and at that time, created invoices for the facility and was the only person with a key to the cash box that holds money for the activities funds that were raised by the residents. There would also be many days where AD1 would claim to get items for the residents during the workday, such as getting donuts and coffee for the residents and would show up to work at a later time (10:30 AM or later) with no donuts for the residents. AD2 stated they didn't think the facility reported this incident to the state agency or law enforcement because AD1 gave the facility back the misappropriated funds. An interview on 03/06/23 at 5:09 PM with the Business Office Manager (BOM) revealed I'm not sure of how many invoices AD1 had misappropriated, but they paid the facility back $491 (total amount accounted for misappropriation) before they were terminated. AD1 was able to misappropriate the funds under the previous system by giving them invoices for performers before the date of the event and the business office would put the cash in an envelope. Since this incident, we now have the performers sign off on the sheet on the day of performance and the business office pays them directly. An interview on 03/06/23 at 5:40 PM with the Director of Nursing (DON) revealed the previous administrator handled the investigation related to the misappropriation of the activity funds. The DON further stated they were unsure if the incident was reported to state agency or law enforcement, but does not believe that it was because the previous Activity Director had given the facility all the money back and was terminated.

Based on observations, interviews, record review, and review of facility policies, the facility failed to provide full visual privacy for 1 Resident (R)14 of 3 residents observed for incontinent care. Specifically, the facility failed to provide privacy by closing the privacy curtain or shutting the door while providing care for R14. Findings include: A review of the facility policy and procedure titled, Perineal Care, dated 11/2021, indicated that the steps in providing perineal care included 5. Provide privacy by pulling privacy curtain or closing room door if a private room. A review of the facility policy and procedure titled, Promoting/Maintaining Resident Dignity, dated 10/2022, indicated it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines included, Maintain resident privacy. A review of R14's Admission Record indicated the facility admitted R14 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R14's annual Minimum Data Set (MDS), dated [DATE], revealed R14 could not complete a Brief Interview for Mental Status (BIMS), so a Staff Assessment of Mental Status was completed which indicated R14 had severe cognitive impairment. The MDS indicated R14 required extensive assistance with dressing, personal hygiene, and toilet use. A review of R14's Care Plan, dated 07/28/21, indicated R14 was incontinent of bowel and bladder. R14 had potential for complications associated with incontinence such as skin breakdown, urinary tract infection, impaired dignity, and constipation. An observation from the hallway on 10/04/22 at 12:11 PM revealed R14 was in bed with no clothing on. Certified Nursing Assistant (CNA)10 was providing care to R14 which was viewable from the hall. The privacy curtain was not pulled, and the door to the room was open. Another resident rolled past R14's doorway in a wheelchair during this time. CNA10 then looked up and observed the surveyor in the hall and pulled R14's privacy curtain. In an interview on 10/04/22 at 12:25 PM, CNA10 stated R14 required assistance with care. CNA10 stated she was just moving fast and forgot to pull the curtain. CNA10 stated that when she saw the surveyor in the hall, she realized that meant the surveyor could see them, so she pulled the curtain closed. CNA10 stated she knew the curtain should have been closed. In an interview on 10/05/2022 at 3:01 PM, CNA6 stated that when providing incontinent care, she would knock on the door, introduce herself, and tell the resident what she was going to do. CNA6 stated she would then pull the curtain, drape the resident with a towel, and provide care. CNA6 stated that not pulling the privacy curtain could affect the resident because they would not have privacy and would be exposed to the public. In an interview on 10/06/2022 at 12:32 PM, Registered Nurse (RN)2 stated CNAs should pull the curtain and close the door prior to providing any care to residents. In an interview on 10/07/2022 at 9:56 AM, Licensed Practical Nurse (LPN)1 stated staff should knock on the door and explain what they were going to do. Staff should then close the resident's door, close the curtain, and close the window blind prior to providing care. LPN1 stated that if staff did not provide privacy, it would cause embarrassment to the resident and affect their pride and dignity. In an interview on 10/07/2022 at 8:36 AM, the Director or Nursing (DON) stated it was her expectation that staff would provide privacy to the resident while providing care. In an interview on 10/07/2022 at 8:40 AM, the facility Administrator stated the privacy curtain should be closed any time care was provided to a resident.

Amended 12/22/2021 Based on record review, interview, interview statements, and policy review, the facility failed to ensure seven residents (Resident (R) 22, R37, R14, R73, R65, R61, and R26) were free from resident-to-resident abuse of 25 sampled residents. The facility failed to provide sufficient monitoring, supervision, and interventions to prevent resident-to-resident abuse from occurring. Specifically, the facility failed to protect Resident (R) 22, R37, R14, and R73 from abuse by R63. R63 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the facility failed to protect R65 and R61 from abuse by R17 and an altercation between R26 and R14; the facility failed to identify that abuse occurred and initiate care plan interventions to prevent future abuse. On 11/19/21 at 11:10 AM, the Administrator and the Director of Nursing (DON) were notified that the failure to ensure residents were free from resident-to-resident abuse from R63, who was known to have aggressive behavior toward staff and residents with no revisions to the behavior care plan, constituted an immediate jeopardy at F600-K: Abuse: Resident-to Resident Abuse. The immediate jeopardy began on 02/08/21 when R63 struck R14. The facility provided an acceptable plan for removal of the immediate jeopardy on 11/20/21 at 12:00 AM. The survey team validated the removal plan through observations, interviews, and review of policy and in-service documentation. The immediate jeopardy was removed on 11/20/21 at 12:00 AM. The deficient practice remained at a E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation revised on 11/29/18 defined 'Abuse' as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . This includes resident to resident abuse of any kind. Review of R63's face sheet under the Face Sheet tab in the electronic medical record (EMR) revealed R63 was admitted to the facility on [DATE] for long term care. Review of R63's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/25/21 revealed that R63 was nonverbal and had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview and staff assessed R63 with moderate cognitive impairment. Review of R63's Care Plan tab of the EMR documented a care plan for behaviors related to dementia and [CONDITION(S)], dated 05/19/20, and documented R63 was nonverbal and becomes agitated when he cannot make his needs known, paranoid when meal ticket is taken off the meal tray, and may strike out and resist care with a goal to decrease episodes of striking out at others, and for his behaviors to not cause harm to himself or others. Care plan interventions included direction to remove R63 from situations that increase agitation or combativeness, psychiatric consult as ordered, provide as much control to R63 as possible in daily routines and activities, try and constructively channel to physical and social activities when the R63 resident becomes agitated, aggressive, and combative. The facility's DON who was also the facility's Abuse Coordinator, provided the following documentation on resident-to-resident altercations for R63 from the past year: 1. Review of the facility's Final Investigatory Report dated 02/12/21 for a witnessed event on 02/08/21 revealed R63 punched R14 (BIMS score of 11 out of 15 (BIMS 11), moderate cognitive impairment), in face without provocation. The facility's conclusion did not identify abuse and changes were made to R63's Care Plan to redirect him from other resident's exhibiting delusional distress or outbursts. 2. Review of the facility's Final Investigatory Report dated 09/25/21 for an event on 09/22/21 revealed R63 and R37 (BIMS 07, severe cognitive impairment), who were roommates were punching each other. LPN1 separated the residents and R37 sustained a superficial bruise over his right eye. The facility's conclusion did not identify abuse and R37 was moved to a different room. R63's care plan was not updated following the incident. 3. Review of the facility's Final Investigatory Report dated 10/18/21 for an event that occurred on 10/14/21 revealed R22 shielded Certified Nursing Assistant (CNA) 1 from R63 who had raised his hand and was about to strike her. R22 was struck by R63 and sustained two skin tears. The facility's conclusion did not identify abuse; however, documented that R63 was sent to the emergency department (ED) for admission to a Behavioral Health Unit but was returned to the facility the next day. No changes were made to R63's plan of care or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Review of the facility's Final Investigatory Report dated 11/16/21 for an occurrence on 11/12/21 revealed R63 struck R73 (BIMS 03, severe cognitive impairment) in the head with a ball point pen. Staff intervened and sent him to the ED for possible admission to the Behavioral Health Unit. R73 did not sustain a significant injury. The facility's conclusion did not identify abuse. Review of a nursing progress note in the notes tab of R63's EMR dated 11/12/21 revealed R63 was admitted to the Behavioral Health Unit. Review of a nursing progress note in the Notes tab in the EMR dated 11/06/21 at 3:46 AM revealed at approximately 2:45 AM R63 chased CNA4 down the hall, snatching a pull-up out of her hand and began punching her. R63 redirected, and later went down same hall attempting to enter a resident room. Registered Nurse (RN) 1 blocked R63's entry to the room. R63 began punching staff, staff were unable to calm him, police were notified, and placed R63 in handcuffs. R63 continued to exhibit aggressive behavior kicking the police. Police restrained R63 until the ambulance arrived. He returned to the facility on [DATE] at 2:47 PM with no new orders. An ED report was not in R63's hard chart or EMR and no changes were made to his plan of care. Review of the facility's Resident-to-Resident Investigations for the past 6 months revealed the following three events provided by the DON: 1. Review of the facility's Final Investigatory Report dated 07/23/21 for an event that occurred on 07/19/21 documented that R65 (BIMS 03, severe cognitive impairment), was pushing a snack cart down the hall and R17 (BIMS 15, cognitively intact) kicked him in the chest. The facility conclusion documented no abuse was substantiated and no resident was injured. No changes were made to the residents' plans of care or physician orders. 2. Review of the facility's Final Investigation Report dated 08/21/21 for an event that occurred on 08/17/21 documented that R17 kicked R61 (BIMS 03) in the stomach when he was wandering in lobby. Review of the facility's conclusion documented No abuse or neglect was substantiated. No new care plan interventions were identified in the investigation report. 3. Review of the facility's Final Investigation Report dated 01/10/21 revealed R26 (BIMS 99) scratched R14's face, and R14 struck R26 with his fist. The facility conclusion documented no abuse was substantiated and no care plan changes were made for either resident. During an interview on 11/18/21 at 12:01 PM, the Director of Nursing (DON) acknowledged she was the facility's Abuse Coordinator, she conducted all the facility's abuse investigations, and that the occurrences of resident-to-resident abuse occurred as documented. The DON stated she did not perceive the residents' actions were willful at the time she investigated the incidents for F63, R17, R14, and R26. In addition, the DON said she was frustrated about the inability to get R63 admitted to the Behavioral Health Unit prior to 11/12/21 event, and the general lack of psychiatric services, despite having a contract, to their rural community, and did not know what else she could do. The DON reported she had contacted psychiatric services for R63 on multiple occasions without response. The DON acknowledged that the ED did not provide a comprehensive psychiatric evaluation and/or provide medication to the resident. The DON acknowledged R63's aggressive behaviors were erratic and not constant; it would just depend on if something triggered him. The DON confirmed there was no increased supervision for R63 following the resident-to-resident altercations.

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards for nine residents of 16 residents (Resident (R)7, R20, R21, R26, R27, R44, R54, R73, and R74) reviewed for accidents and hazards. Specifically, four residents (R21, R26, R44, and R74) who had bed (side) rails installed had falls (with injuries for three residents (R21, R26 and R44)) while the bed rails were present and up in position. Following the falls the facility failed to complete root cause analysis/investigations of falls or reassess the use of bed rails. Additionally, three residents (R54, R7, and R73) assessed as not requiring bed rails were observed to have bed rails in use; and two residents (R20 and R27) had bed rail assessments but bed rails in use did not align with the assessment. Furthermore, the facility failed to assess for the use of the least restrictive devices or no devices; and implement care plans to ensure the safety of residents. The failure to put interventions in place to respond to this issue has resulted in a potential for increased risks of falls, entrapments, and death related to the facility's continued use of bed rails for these residents and other vulnerable residents. On 11/18/21 at 6:00 PM, the Administrator was notified an Immediate Jeopardy (IJ) was identified at F689 related to the facility's failure to ensure residents were provided an environment safe from accidents and hazards, specifically related to the use of bed rails. F689 was determined to be at a scope and severity of K, pattern with serious likelihood of serious injury, harm, impairment, or death. The facility provided an acceptable plan for removal of the IJ on 11/19/21 at 10:08 PM. The survey team validated the IJ was removed on 11/19/21 at 10:20 PM following the facility's implementation of the plan for removal of the Immediate Jeopardy. The removal was validated by observations, chart reviews, and interviews of steps taken by the facility to protect residents from accidents related to bed rails. These measures included: All residents were assessed for the need of the side rails. This was confirmed per interview and record review. Observations conducted of the beds that have removable side rails and the residents had been assessed as not requiring these side rails, the side rails were observed as removed. Residents that reside in beds that the side rails are non-removable and did not require side rails or did not require all four side rails per assessment, these side rails were secured in a down position with zip-ties. Residents requiring side rails were confirmed as having side rails per the physician orders. The risk and benefits were reviewed with the resident and/or resident representatives, and consents obtained. Policies for side rail use, risk and benefits, and fall risks and prevention were reviewed and revised per facility and are deemed acceptable. Training was based on the risk and benefits of the use of side rails, prevention, reporting, and investigating falls. Reviewed facility staff sign in sheets for training. A sample of residents updated care plans and evaluations were reviewed and were complete. Interviews were conducted with facility staff to verify training The facility was notified that the IJ was removed on 11/19/21 at 10:20 PM. After the immediacy removal, the noncompliance remained at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that was not immediate jeopardy). Findings Include: 1. Review of R21's undated face sheet located in R21's electronic medical record (EMR), under the Face Sheet tab, indicated R21 was admitted to the facility on [DATE]. R21's diagnoses included muscle weakness, history of falling, abnormalities of gait and mobility, unsteadiness on feet, dementia without behavioral disturbance. Review R21's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/05/21, revealed R21's Brief Interview for Mental Status (BIMS) score was seven out of 15, indicating R21 had severe cognitive impairment. R21 was assessed as independent with bed mobility with a one person assist. Review of R21's care plan located in R21's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. Observation conducted on 11/16/21 at 9:00 AM revealed R21 was in bed with four quarter bed rails up. R21's head was resting against the left upper bed rail and her left arm was between the upper and lower left sided bed rail, hanging to the floor. R21 was not interviewable. Observation on 11/16/21 at 9:49 AM revealed R21 was observed in the same position, the Assistant Director of Nursing (ADN) stated, this is the resident's norm. The ADN did not attempt to reposition resident. Observation on 11/16/21 at 10:13 AM revealed Certified Nursing Assistant (CNA) 2 and CNA 3 repositioned R21 in bed, stating, the resident favors her left side. Observation conducted on 11/16/21 at 4:26 PM revealed R21 was still in bed with all four bed rails in place. Throughout 11/16/21 from 10:27 AM to 7:30 PM, and 11/17/21 from 9:00 AM to 7:00 PM, R21's four bed rails remained up at all times, whether the resident was in or out of bed. Review of R21's Evaluation for Use of Side Rails dated 06/01/08, located in R21's EMR, under the Assess tab, documented the reason for the side rails was for safety and security. Further review of the evaluation form revealed the alternatives were discussed with the resident representative, there was no indication the precautions were discussed with the resident and/or resident representative. Review of R21's Resident Incident Report dated 06/30/21, provided by the facility documented alerted by CNA to [R21's] room, resident lying on floor and complaining of head pain to back of head. Fall was not witnessed, but resident was heard hitting the floor by CNA passing by. Bed rails was checked as ordered and up. Further review of R21's EMR and paper chart revealed the facility did not review the use of the bed rails following the fall and did not determine a root cause analysis for the fall. The investigation listed Medical risk factors possibly related to incident: Fall history; Inability to understand directions, confusion/disorientation, and incontinency. Review of R21's Resident Incident Report, dated 08/10/21, provided by the facility, documented resident was noted on floor by bed, scooting to the bathroom. No injury. Bed rails was checked as ordered and up. The facility did not review the use of bed rails following the fall and did not determine a root cause analysis for the fall. The report listed Medical risk factors possibly related to incident: Fall history, arthritis/[CONDITION(S)], confusion/disorientation, B&B (bowel/bladder) urgency, tremors/[CONDITION(S)]. During an interview on 11/18/21 at 10:54 AM, Licensed Practical Nurse (LPN) 2 stated R21 used bed rails to reposition herself. LPN 2 was questioned based on the observation made on 11/16/21, if the bed rails could be an entrapment risk? LPN 2 stated, No, I don't see any entrapment issues. 2. Review of R26's undated face sheet located in R26's EMR under the Face Sheet tab, indicated R26 was admitted to the facility on [DATE]. R26's diagnoses included moderate intellectual disabilities, anxiety disorder, and fractured right clavicle. Review of R26's admission MDS with an ARD of 08/08/21, BIMS score was 11 out of 15 indicating R26 had moderate cognitive impairment. R26's bed mobility was assessed as limited assistance of one staff member. Review of R26's care plan located in R26's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. On 11/16/21 at 9:35 AM, R26 was observed in the hallway sitting in her wheelchair. R26 was observed with blood on her face and forehead where there was a laceration. R26 was not interviewable. During an interview conducted on 11/16/21 at 10:00AM at the R26's bedside, LPN 2 stated, she [R26] got that [laceration] from falling. Review of R26's Resident Incident Report dated 08/01/21, provided by the facility, documented resident attempting to transfer self out of bed. Holding on to side rails and sat on floor. No injury. Bed rails was checked as present. The facility did not reassess the bed rail use following the fall and did not conduct a root cause analysis of the fall. The report listed Medical Risk factors possibly related to incident: Fall history, [CONDITION(S)] history, confusion/disorientation, incontinency. Review of R26's Resident Incident Report dated 10/20/21, provided by the facility, documented staff responded to resident crying in her room and resident had got out of bed without assistance and was on the floor. Laceration above right eyebrow was reopened. Bed rails were checked as ordered, present, and up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis for the fall. The report listed Medical risk factors possibly related to incident: Fall history, [CONDITION(S)] history, confusion/disorientation, incontinency, B&B urgency. Review of R26's Resident Incident Report dated 11/02/21, provided by the facility, documented Resident heard crying, upon entering room, resident was observed lying on the impact mat between her and her roommate's bed with her head on the tile floor. Small amount of blood noted from nares, and shallow/superficial laceration to the middle of her forehead. Bed rails was checked as ordered, present, and up. The facility did not re-assess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: Fall history, [CONDITION(S)] history, confusion/disorientation, incontinency, B&B urgency. During an interview conducted on 11/18/21 at 10:56 AM, LPN 2 was questioned why R26 no longer has bed rails? LPN 2 stated the resident now has a low bed because she (R26) would throw herself out of the bed. 3. Review of R44's undated face sheet, located in R44's EMR under the Face Sheet tab, indicated R44 was admitted to the facility on [DATE]. R44's diagnoses included difficulty in walking, unsteadiness on feet, and dementia. Review of R44's quarterly MDS with an ARD of 09/26/21, revealed R44's BIMS score was six out of 15 indicating R44 had severely impaired cognition. The resident's bed mobility was assessed as independent. Review of R44's care plan located in R44's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. Observation conducted on 11/16/21 at 11:34 AM, revealed R44 was in bed with bilateral quarter bed rails in the up position, located at the head of the bed. The bed rails were observed throughout the rest of 11/16/21 from 11:34 AM to 7:30 PM and 11/17/21 from 9:00 AM to 7:00 PM. Review of R44's Resident Incident Report dated 12/06/20, provided by the facility, documented R44 was observed on impact mat beside bed sustained a skin tear to left wrist and elbow, and discoloration to left forearm. Bed rails was checked as ordered, present, and up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: Fall history, hard of hearing, confusion/disorientation, B&B urgency. Review of R44's Resident Incident Report dated 12/10/20, documented R44 was noted sitting on her safety mat next to the bed at about 3AM [3:00 AM] by the CNA. She was incontinent of urine and upset, but not hurt. She said she had been attempting to go to the toilet independently. Bed rails was checked off on incident report as up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical Med risk factors possibly related to incident: Fall history, fatigue, arthritis/[CONDITION(S)], confusion/disorientation, incontinency, B&B urgency. Review of R44's Resident Incident Report dated 08/08/21, provided by the facility, documented resident told this writer that she fell when she was transferring to the bed, hit her head on the floor, and then put herself back in the chair. Sustained contusion with discoloration noted to left occipital area. Bed rails was checked off on incident report as up. The facility did not re-assess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: arthritis/[CONDITION(S)], incontinency. During an interview on 11/18/21 at 10:53 AM, LPN 2 stated R44 used her bed rails to reposition herself. LPN 2 stated R44 needed supervision of one person for bed mobility. 4. Review of R74's undated face sheet located in R74's EMR under the Face Sheet tab, indicated R74 was admitted to the facility on [DATE]. R74's diagnoses included Alzheimer's disease, muscle weakness, need for assistance with personal care, and dysphagia. Review of R74's quarterly MDS with an ARD of 10/24/21, BIMS revealed R74's score was assessed as 99 indicating the resident was unable to complete the assessment questions. The resident's bed mobility was assessed as bed fast, self-position. An observation was conducted on 11/16/21 at 10:27 AM of R74 in bed with four quarter bed rails up, resident was moving from side to side independently. At 11:52 AM, R74 was observed in bed with all four bed rails up. The four bed rails were observed on bed and up throughout 11/16/21 from 10:27 AM to 7:30 PM and 11/17/21 from 9:00 AM to 7:00 PM. Review of R74's care plan located in R74's EMR under the Care Plan tab, revealed the R74's bed rails had not been care planned for monitoring, interventions, and risks. Review of R74's Resident Incident Report dated 02/18/21, provided by the facility documented resident was found beside bed by CNA. Roommate stated she [R74] climbed out of bed to floor. No injuries noted. Bed rails was checked as ordered, present, and up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: fall history, inability to understand directions, confusion/disorientation, incontinency. During an interview conducted on 11/18/21 at 10:36 AM at R74's bedside, CNA6 was questioned why R74 has four bed rails up and two wedges in her bed? CNA6 stated, the bed rails are to keep the wedges from falling off the bed. Not sure why she has wedges. When asked if the resident has ever attempted to climb over the bed rails? CNA6 stated, I don't know if she has ever climbed out of bed. During an interview on 11/18/21 at 10:40 AM, LPN3 stated, the bedrails are for safety and assisting for repositioning and the wedges are to help keep her in position. LPN3 stated the resident is dependent on the staff [for bed mobility] but does have non- purposeful movement. LPN3 was questioned if the resident has ever fallen or climbed out of bed? LPN3 stated, not that I am aware of. LPN3 stated she had worked for the facility for nine years and her primary assignment was the day shift for R74's hall. 5. Review of R20's face sheet in the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] for long term care. Review of R20's quarterly MDS with an ARD of 08/03/21 revealed R20 had a BIMS score of 11 out of 15 which indicated the resident had moderate cognitive impairment. Review of R20's care plan under the Care Plan tab in the EMR revealed on 08/28/21 two upper side rails were added to at the head of the bed for bed mobility. Review of the CNA Care Sheet, on 11/17/21, located in the resident's closet in the room revealed it did not address the inclusion of side rails in the R20's care. Review of a Side Rail Assessment in the Assessments tab in the EMR dated 08/23/21 revealed a recommendation for R20 to have had two quarter upper rails for turning and positioning. Observation on 11/16/21 at 12:00 PM revealed R20 was in bed with all four quarter side rails up; however, R20's Side Rail Assessment only indicated two quarter side rails were needed. Observation on 11/17/21 at 12:53 PM revealed R20 was in bed with all four quarter side rails up. During an interview with CNA 1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA 1 acknowledged that each resident had a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. 6. Review of R54's face sheet in the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] for long term care. Review of R54's annual ''MDS'' with an ARD of 10/03/21 revealed R54 had a BIMS score of five out of 15 which indicated the resident had severe cognitive impairment. Review of R54's care plan in the Care Plan tab in the EMR revealed the use of two upper side rails as an undated intervention for fall prevention. Review of R54's CNA Care Sheet located in the resident's closet in the room revealed it did not include use of side rails in the resident's care. Review of R54's most recent Side Rail Assessment in the Assessments tab in R54's EMR dated 06/28/21 revealed side rails were not recommended for use for R54. Observation on 11/16/21 at 11:30 AM revealed R54 was in bed with two upper quarter side rails in use. An additional observation on 11/17/21 at 11:31 AM revealed R54 had two upper quarter side rails while the resident was lying in bed. During an interview with CNA1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA1 acknowledged that each resident had a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. 7. Review of R27's face sheet in the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] for long term care. Review of R27's admission MDS with an ARD of 09/27/21 revealed R27 had a BIMS score of seven out of 15 which indicated the resident had severe cognitive impairment. Review of the care plan in the Care Plan tab in R27's EMR revealed there was not a care plan for the use of side rails for the resident's care. No CNA Care Sheet, usually located in the resident's closet in the room was available in R27's room nor was one provided by the Director of Nursing (DON) upon request on 11/16/21 at 1:00 PM. Review of a Side Rail Assessment in the Assessments tab in R27's EMR, dated 09/11/21, revealed the use of two upper quarter rails was discussed with the responsible party; however, the assessment did not document a reason for use; if the responsible party consented to the use of side rails; or a determination for the use of side rails. Observation on 11/16/21 at 11:42 AM revealed R27 was in bed with all four quarter side rails up. An additional observation on 11/17/21 at 11:31 AM revealed R27 was in bed with all four side rails up. During an interview with CNA1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA1 acknowledged that each resident had a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. 8. Review of R7's face sheet in the Face Sheet tab of the EMR revealed the resident was readmitted on [DATE] for long term care. Review of R7's quarterly ''MDS'' with an ARD of 08/15/21 revealed R7 had severe cognitive impairment per staff assessment. Review of the care plan in the Care Plan tab in R7's EMR revealed an undated approach for side rails up at the head of the bed to assist with bed mobility as inclusion for an activities of daily living (ADL) self-care deficit problem identified on 12/21/19. Review of the CNA Care Sheet located in R7's closet in the room revealed directions for the use of two half rails for the resident's care. Review of a Side Rail Assessment in the Assessments tab in R7's EMR dated 11/01/21 revealed side rails were not recommended for use for R7. Observation on 11/16/21 at 12:00 PM revealed R7 was in bed with four quarter side rails in use. An additional observation on 11/17/21 at 11:31 AM revealed R7 was in bed with four side rails up. 9. Review of R73's face sheet in the Face Sheet tab of the EMR revealed R73 was admitted to the facility on [DATE] for long term care. Review of R73's quarterly ''MDS'' with an ARD of 10/24/21 revealed R73 had a BIMS score of three out of 15 which indicated the resident had severe cognitive impairment. Review of the CNA Care Sheet located in R73's closet in the room revealed side rails were not included in the resident's care. Review of a Side Rail Assessment in the Assessments tab in R73's EMR dated 02/03/21 revealed side rails were not recommended for use for R73. Observation on 11/16/21 at 12:00 PM revealed R73 was in bed with two upper quarter rails and one lower quarter rail up. An additional observation on 11/17/21 at 11:31 AM revealed R73 was in bed with four quarter side rails up. During an interview with CNA1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA1 acknowledged that each resident has a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. During an interview conducted on 11/18/21 at 11:00 AM, the DON stated, the nurses monitor the use of bed rails every shift; resident evaluations are in the resident charts and residents are reevaluated at least annually. The Care Plan team which consists of therapy, social services, activities, MDS coordinator, floor nurse and CNA, evaluates the effectiveness in discontinuing the use of bed rails. Training for bedrails is conducted in orientation and at least, annually, to include the risks and benefits. The Care Plan team assesses residents for bed mobility. The Admission Coordinator and Care Plan team initiate the evaluation for bed rails. Depending on the resident's clinical picture the bed rails may need to initiate during the admission process, and they obtain the consent at the same time. The DON confirmed bed rail use should have been re-evaluated following falls where bed rails were in use. The DON acknowledged the falls did not have a root cause analysis. During an interview on 11/18/21 at 2:25 PM, the DON stated that usually the MDS nurse formulates the Care Plans; however, the facility has had three 3 different MDS nurses in the past year and she has had to fill in. The DON acknowledged that the CNA Care Sheets are probably not up to date and the CNA's get their direction for resident care from the CNA Care Sheets and verbal report. Review of the facility's policy titled, Proper Use of Side Rails dated 11/27/17, revealed it is the policy of this facility to utilize a person-centered approach when determining the use of side rails, also known as bed rails. Alternatives are attempted prior to installing a side or bed rail .the facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need, and determination when the side rail/bed rail will be discontinued .Direct care staff will be responsible for care and treatment in accordance with the plan of care .the interdisciplinary team will make decisions regarding when the side/bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the rail.

Based on record review, interview, and facility policy review, the facility failed to thoroughly investigate allegations of abuse and/or implement corrective action following investigations of abuse for four of seven abuse investigations reviewed. Specifically, Resident (R) 63 engaged in multiple resident-to-resident altercations where R14, R37, R22, and R73 were victims of his abuse and the facility failed to identify the abuse and implement preventative measures. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation revised on 11/29/18 directs Prevention of Abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: a. Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. b. Observe resident behavior and their reaction to other residents, roommates, tablemates. Place residents in accommodations and environments that keep them calm. d. Provide education on what constitutes abuse, neglect. f. Take appropriate actions when abuse, neglect or exploitation is suspected. j. Provide instructions to staff on care needs of residents. l. Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's rooms, residents with self-injurious behaviors, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. Resident Protection after Alleged Abuse, Neglect and Exploitation - The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include, but are not limited to: Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse. involve family members to sit with resident Temporary one on one supervision of a resident Engage a resident in diversionary activities. Review R63's face sheet under the Face Sheet tab in the electronic medical record (EMR) revealed R63 was admitted to the facility on [DATE] for long-term care. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/25/21 revealed that R63 was nonverbal and had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview and staff assessed R63 with moderate cognitive impairment. Review of R63's care plan located in the Care Plan tab of the EMR included a care plan for behaviors related to dementia and [CONDITION(S)], dated 05/19/20, and documented R63 was nonverbal and became agitated when he cannot make his needs known, paranoid when meal ticket is taken off the meal tray, and may strike out and resist care with a goal to decrease episodes of striking out at others, and for his behaviors to not cause harm to himself or others. Care plan interventions included direction to remove R63 from situations that increase agitation or combativeness, psychiatric consult as ordered, provide as much control to R63 as possible in daily routines and activities, try and constructively channel to physical and social activities when the R63 resident becomes agitated, aggressive, and combative. The facility's Director of Nursing (DON), who was also the facility's Abuse Coordinator, provided the following resident-to-resident altercations for R63 from the past year: 1. Review of the facility's Final Investigatory Report dated 02/12/21 for a witnessed event on 02/08/21 revealed R63 punched R14, whose Brief Interview for Mental Status (BIMS) score was 11 (BIMS 11) indicated moderate cognitive impairment; in face without provocation. The facility's conclusion did not identify abuse and changes were made to R63's Care Plan to redirect him from other residents exhibiting delusional distress or outbursts. In addition, a review of the nursing progress notes in the Notes tab in the EMR revealed there was no documented evidence of increased supervision of R63 to prevent future incidents. 2. Review of the facility's Final Investigatory Report dated 09/25/21 for an event on 09/22/21 revealed R63 and R37 (BIMS seven, severe cognitive impairment), who were roommates were punching each other. Licensed Practical Nurse (LPN) 1 separated the residents and R37 sustained a superficial bruise over his right eye. The facility's conclusion did not identify abuse and R37 was moved to a different room. R63's care plan was not updated following the incident. In addition, a review of the nursing progress notes in the Notes tab in the EMR revealed there was no documented evidence of increased supervision of R63 to prevent future incidents. 3. Review of the facility's Final Investigatory Report dated 10/18/21 for an event that occurred on 10/14/21 revealed R22 shielded CNA1 from R63 who had raised his hand and was about to strike her. R22 was struck by R63 and sustained two skin tears. The facility's conclusion did not identify abuse; however, documented that R63 was sent to the emergency department (ED) for admission to a Behavioral Health Unit but was returned to the facility the next day. No changes were made to R63's plan of care or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Review of the facility's Final Investigatory Report dated 11/16/21 for an occurrence on 11/12/21 revealed R63 struck R73 (BIMS three, severe cognitive impairment) in the head with a ballpoint pen. Staff intervened and sent him to the ED for possible admission to the Behavioral Health Unit. R73 did not sustain a significant injury. The facility's conclusion did not identify abuse. Review of a nursing progress note in the notes tab of the EMR dated 11/12/21 revealed R63 was admitted to the Behavioral Health Unit. Review of a nursing progress note in the Notes tab in the EMR dated 11/06/21 at 3:46 AM, revealed at approximately 2:45 AM, R63 chased CNA4 down the hall, snatching a pull-up out of her hand and began punching her. R63 redirected and later went down the same hall attempting to enter a resident room. Registered Nurse (RN) 1 blocked R63's entry to the room. R63 began punching staff, staff were unable to calm him, police were notified, and placed R63 in handcuffs. R63 continued to exhibit aggressive behavior kicking the police. Police restrained R63 until the ambulance arrived. He returned to the facility on [DATE] at 2:47 PM with no new orders. An ED report was not in R63's hard chart or EMR, and no changes were made to his plan of care. In addition, a review of the nursing progress notes in the Notes tab in the EMR from 11/06/21 to 11/12/21 revealed there was no documented evidence of increased supervision of the resident. During an interview on 11/18/21 at 12:01 PM, the Director of Nursing (DON) stated that R63's triggers were random and erratic. The DON stated following the altercations they continued to follow R63's care plan. The DON acknowledged that R63 was not placed on one of one supervision or increased monitoring to prevent additional altercations after any of the resident-to-resident events. The DON confirmed R63 was sent to the emergency department with the intent of getting him admitted to the Behavioral Health Unit and was frustrated about the inability to get R63 admitted to the Behavioral Health Unit before 11/12/21 event, and the general lack of psychiatric services, despite having a contract, in their rural community, and did not know what else she could do.

Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for nine of 16 residents (Residents(R) 21, R23, R26, R27, R29, R44, R47, R62, and R74) reviewed for the use of bed rails. Specifically, nine residents were not care planned for the interventions, risks, and benefits for the use of bed rails. The failure to complete and initiate a comprehensive care plan for the use of bed rails places the residents at risk for falls, entrapments, and injuries related to the facility's continued use of bed rails for these residents and other vulnerable residents. Findings Include: Review of the facility's policy titled Comprehensive Care Plans dated 12/01/17 revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the facility's policy titled, Proper Use of Side Rails dated 11/27/17, revealed it is the policy of this facility to utilize a person-centered approach when determining the use of side rails, also known as bed rails. Alternatives are attempted prior to installing a side or bed rail . the facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need, and determination when the side rail/bed rail will be discontinued . Direct care staff will be responsible for care and treatment in accordance with the plan of care . the interdisciplinary team will make decisions regarding when the side/bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the rail. 1. Observation conducted on 11/16/21 at 9:00 AM revealed R21 was in bed with four, quarter bed rails up. R21's head was resting against the left upper bed rail and her left arm was between the upper and lower left-sided bed rail, hanging to the floor. R21 was not interviewable. Review of R21's undated face sheet located in R21's electronic medical record (EMR), under the Face Sheet tab, indicated R21 was admitted to the facility on [DATE]. R21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/05/21, revealed a Brief Interview for Mental Status (BIMS) score of seven out of fifteen, which indicated R21 had severe cognitive impairment. Further review of the R21's MDS did not indicate the resident had bed rails. Review of R21's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R21's care plan located in R21's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. 2. Observation on 11/16/21 at 10:05 AM, revealed R23 in bed with four quarter side rails raised. Review of R23's undated face sheet located in R23's EMR under the Face Sheet tab indicated R23 was admitted to the facility on [DATE]. R23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R23's annual MDS with an ARD of 09/05/21 revealed R23's BIMS score was fourteen out of fifteen, indicating R23 was cognitively intact. Further review of the R23's MDS did not indicate the resident had bed rails. Review of R23's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R23's care plan located in R23's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. 3. Review of R26's undated face sheet located in R26's EMR under the Face Sheet tab, indicated R26 was admitted to the facility on [DATE]. R26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R26's admission MDS with an ARD of 08/08/21 revealed BIMS score was eleven out of fifteen indicating R26 had moderate cognitive impairment. Further review of R26's MDS did not indicate the resident had bed rails. Review of R26's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R26's care plan located in R26's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. 4. Observation on 11/16/21 at 11:42 AM revealed R27 was in bed with all four side rails up. Review of R27's face sheet in the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] for long-term care. Review of R27's admission MDS with an ARD of 09/27/21 revealed R27 had a BIMS score of seven out of 15 which indicated the resident had severe cognitive impairment. Review of the care plan in the Care Plan tab in R27's EMR revealed there was not a care plan for the use of side rails for the resident's care. 5. Observation on 11/16/21 at 11:42 AM, revealed R29 was in bed with both upper bed rails raised. Review of R29's undated face sheet located in R29's EMR under the Face Sheet tab, indicated R29 was admitted to the facility on [DATE]. R29's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R29's quarterly MDS with an ARD of 09/12/21 revealed R29's BIMS score was ten out of fifteen indicating R29's cognition was moderately impaired. Further review of R29's MDS did not indicate the resident had bed rails. Review of R29's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R29's care plan located in R29's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. 6. Observation on 11/16/21 at 11:34 AM, revealed R44 was in bed with bilateral quarter bed rails in the up position, located at the head of the bed. Review of R44's undated face sheet, located in R44's EMR under the Face Sheet tab, indicated R44 was admitted to the facility on [DATE]. R44's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R44's quarterly MDS with an ARD of 09/26/21, BIMS revealed R44's score was six out of fifteen indicating R44 had severe cognitive impairment. Further review of R44's MDS did not indicate the resident had bed rails. Review of R44's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R44's care plan located in R44's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. 7. Observation on 11/17/21 at 9:35 AM, revealed R47 was asleep in bed with all four bed rails raised. The bed rails were padded with a green foam cover. Review of R47's undated face sheet located in R47's EMR under the Face Sheet tab, indicated R47 was admitted to the facility on [DATE]. R47's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R47's quarterly MDS with an ARD of 10/03/21, BIMS revealed R47's scored ten out of fifteen indicating R47's cognition was moderately impaired. The MDS did not indicate the resident had bed rails. Review of R47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R47's Care Plan located in R47's EMR under the care plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. 8. On 11/16/21 at 5:02 PM, R62 was observed asleep in bed with all four quarter side rails raised. Review of R62's undated face sheet located in R62's EMR under the Orders tab, indicated R62 was admitted to the facility on [DATE]. R62's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R62's quarterly MDS with an ARD of 10/10/21 revealed R62's BIMS score was ninety-nine, indicating R62 was unable to complete the assessment questions. Review of R62's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R62's care plan located in R62's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. 9. An observation was conducted on 11/16/21 at 10:27 AM of R74 in bed with four quarter bed rails up, resident was moving from side to side independently. Review of R74's undated face sheet located in R74's EMR under the Face Sheet tab, indicated R74 was admitted to the facility on [DATE]. R74's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R74's quarterly MDS with an ARD of 10/24/21, BIMS revealed R74's score was assessed as 99 indicating the resident was unable to complete the assessment questions. Further review of R74's MDS did not indicate the use of bed rails. Review of R74's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R74's care plan located in R74's EMR under the Care Plan tab, revealed the R74's bed rails had not been care planned for monitoring, interventions, and risks. During an interview on 11/18/21 at 2:25 PM, the Director of Nursing (DON) stated usually the MDS Nurse formulates the care plans; however, the facility has had three different MDS Nurses in the past year and she has had to fill in. The DON acknowledged that the CNA Care Sheets are probably not up to date and the CNAs get their direction for resident care from the CNA Care Sheets and verbal report, and was not caught up on care plans for the facility.

Based on observation, interview, and facility policy review, the facility failed to ensure that one unit (Front Hall) of two units observed in the facility was free of pests. This deficient practice had the potential to affect all 22 residents residing in the Front Hall; the facility census was 73. Findings include: Review of the facility's policy titled Pest control Program dated 11/27/17 directs It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Review of the facility's 01/01/00 housekeeping duties list titled JOB TO BE DONE: DAILY PATIENT ROOM CLEANING listed duties including Use dust mop to gather all trash & debris on floor. Sweep to the door; pick up with dust pan [sic]. During an observation on 11/16/21 at 11:03 AM, a pink wash basin with cloudy water with black pests was on the floor under a bedside table in Room 133. During an observation on 11/16/21 at 11:17 AM, flying gnats were noted in the bathroom and room 120. During an observation on 11/16/21 at 11:47 AM, six flying gnats were observed flying in resident Room 130. During an observation on 11/16/21 at 12:28 PM in Room 130 flying gnats were noted around the residents' food during delivery of meal trays. Additional observations on 11/17/21 at 10:30 AM and 3:04 PM revealed the pink wash basin with cloudy water with black pests remained on the floor under a bedside table in Room 133. During an interview on 11/17/21 at 3:28 PM, the Maintenance Director stated he had a problem with gnats in the facility from Room 120 and he called pest control to take care of the issue; however, there have been no recent problems with gnats. Additional observation on 11/18/21 at 11:00 AM revealed the pink wash basin with cloudy water with black pests remained on the floor under a bedside table in Room 133. During an interview and observation on 11/18/21 at 4:17 PM, Certified Nursing Assistant (CNA) 8 viewed the pink basin of stagnant cloudy water with live gnats in and around the basin in Room 133, recoiled with a repulsed expression on her face, and acknowledged that it was the responsibility of the CNAs to clean the residents' wash basins. During an interview and observation on 11/18/21 at 4:22 PM, the Maintenance Director viewed the pink basin of stagnant cloudy water with live gnats in and around the basin in Room 133 and exclaimed Oh Lord it's a gnat reservoir! The Maintenance Director stated that he had just returned to work after having three weeks off and no one had informed him of any problems with gnats on the Front Hall Unit. During an interview on 11/18/21 at 4:27 PM, the Housekeeping Director stated that no one informed him of gnats in the Front Hall and acknowledged that the facility did not keep a record of those issues typically staff just tell him and they would call pest control. During an additional interview on 11/18/21 at 4:52 PM, the Housekeeping Director stated that the housekeeping staff was responsible to clean and sweep the floor daily. While the housekeeping staff cannot move the residents' belongings, they were supposed to inform the CNAs to get the clothes and articles off the floor, if they cannot clean and mop the rooms from clutter and acknowledge that the assigned housekeeper should have dealt with the wash basin.

Based on record review and interview statements, the facility failed to notify the responsible party of one of four residents (Resident (R) 73) reviewed for abuse regarding an episode of resident-to-resident abuse. Findings include: Review of the facility's policy titled Notification of Changes dated 11/27/17 directs the facility must inform the resident, and/or notify the resident's family member or legal representative when there is a change requiring such notification .circumstances requiring notification include .a change in the resident's rights. Review of R73's face sheet in the Face Sheet tab of the electronic medical record (EMR) revealed R73 was admitted to the facility on [DATE] for long-term care. Review of R73's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/24/21 revealed R73 had a Brief Interview for Mental Status Score of three out of 15 which indicated the resident had severe cognitive impairment. Review of the facility's Final Investigatory Report dated 11/16/21 for an occurrence on 11/12/21 revealed R63 struck R73 in the head with a ballpoint pen. Staff intervened and sent R63 to the Emergency Department (ED) for possible admission to the Behavioral Health Unit and documented that R73 did not sustain a significant injury. Review of the nursing progress notes in the Notes tab in R73's EMR revealed there was no documentation of the 11/12/21 incident and no documentation that the responsible party was notified. During an interview on 11/18/21 at 5:24 PM, Family Member (F) 1 stated she was F73's responsible party who would receive notification regarding a change in the resident and she was last notified about an incident for R73 three weeks ago when he fell out of bed. During an interview on 11/19/21 at 11:30 PM, the Director of Nursing acknowledged that R73's responsible party was not contacted about the physical abuse by R63 on 11/12/21.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure that residents who required feeding assistance were able to dine with dignity. One of two residents (Resident (R) 6) observed that were dependent on staff for feeding assistance were observed to receive assistance from staff who were standing and not properly cuing the resident while placing food in the resident's mouth. Findings include: Review of the facility's policy titled DIGNITY - PROMOTING/MAINTAINING dated 11/29/18 directs protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Review of R6's face sheet under the Face Sheet tab in the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] for long-term care. Review of R6's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/15/21 revealed the resident had a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated the resident had severe cognitive impairment. Facility staff documented R6 as totally dependent on staff for eating. Review of R6's care plan in the EMR under the Care Plan tab identified on 03/18/21 that R6 had a self-care deficit and was dependent on staff assistance for eating. During an observation on 11/16/21 at 12:45 PM, Certified Nursing Aide (CNA) 1 delivered R6's tray of pureed food. The resident was seated in a Geri chair (a medical recliner chair) at a 45-degree fowlers position. While feeding R6, CNA1 was observed to be standing and above R6's eye level, looking down on her. CNA1 fed R6 two spoons of food. When CNA1 delivered the third spoonful, R6 said she did not want anymore; however, CNA1 fed her the food anyway. CNA1 continued to feed the resident four more spoons without cuing R6 and at the ninth spoonful the resident said, stop it. CNA1 continued to attempt to feed R6 without cuing and R6 moved her face away from the spoon. CNA1 asked R6 if she wanted tomato soup with the spoon in her mouth; however, R6 said no. CNA1 then stopped feeding the resident. During an interview on 11/16/21 at 12:56 PM, CNA1 stated R6 was a picky eater and acknowledged she was standing while feeding R6. CNA1 stated she was taught during CNA training that she should be seated when providing feeding assistance; however, there was not a chair in the room, and staff don't do that here. During an interview on 11/19/21 at 10:30 PM, the Director of Nursing (DON) acknowledged it was undignified for staff to feed a resident that required feeding assistance while standing up. The DON stated staff should be seated and cue the resident while providing feeding assistance.

Based on record review, interviews, and observations, the facility failed to provide the care and services necessary to prevent accidents for 1 of 3 residents reviewed for accidents. The facility failed to provide Mechanical Lift for all transfers to have assist of two people required for use of lift for Resident #16. The findings included: Record review revealed Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. Non ambulatory and very frail with muscle loss. Observation revealed Resident #16 who has contractures to all the extremities, fingers, with foot drop on both feet. Call bell was observed by her right hand, and the call bell is a squeezable, round-shape that can be rung using her fingers. Resident requires total assistance for all ADL skills and requires a two staff transfer Resident#16's bedroom revealed low bed, bed alarm and floor mat in place. Resident #16 declined to be interviewed. A review of the nurse's notes revealed the following entries; 09/20/2017-- At 8:30pm, CNA called the nurse to Resident #16's room. Nurse observed Resident #16 had a right knee swollen and bruise with knee dislocated. Notified Doctor, DON, and family. 09/21/2017 - Resident #16 returned from the hospital at 12:30 am -- ER reported femur fracture -X-ray reported. Pain meds were given and leg splint in place. Continue to monitor. Review of the Physicians Orders revealed dated 09/20/2017 -Order ® knee immobilizer Apply to ® leg Check skin and circulation, shift R/T fracture. A review of the resident's Care Plans revealed the following; Resident #16 will have reduced risk of falls with injury thru the 90 days. Attend to lower extremities during daily care. Evaluate falls risk quarterly and prn. Attend to resident's needs promptly. Keep bed in lowest position. When care isn't being provided, ensure call bell is within reach. Mechanical Lift for all transfers. Assist of two people required for use of lift (05/02/2016). Place in supervised area when up as necessary. On 10/11/2017 at approximately 8:37 am, this surveyor interviewed the Director of Nursing (DON), who stated that Certified Nursing Assistant (CNA #1) was involved in the incident with Resident #16. The DON stated that the CNA's first written statement was not true because the CNA claimed that she and another CNA lifted Resident #16 from the geri chair to the bed, but when asked for the other CNA's name, CNA #1 recanted and stated that she was alone and did the pivoting of Resident #1 by herself/himself from the geri chair to the bed. On 10/11/2017 at approximately 10:30am, this surveyor interviewed the CNA #1 by telephone, who stated that she picked-up Resident #16 from her geri-chair to her bed. When changing the resident, the CNA removed the resident's pants and noticed a bump that had a shape of a light bulb. CNA #1 asked a CNA to get a nurse. Two nurses looked at the resident and decided to send Resident #16 to the hospital. CNA #1 stated that she did not know Resident #16 required a two person transfer. She did not see the policy on the two person transfer because it was hidden behind the closet door. CNA #1 further stated that Resident #16 was not CNAs' resident, and CNA #1 was just helping out. When asked about the first statement which said there was another CNA involved, CNA #1 stated that she was confused.

Based on record review and interview the facility failed to implement written policies and procedures that prohibit neglect of residents. Resident #3 received a fracture when s/he fell while being transferred with a mechanical lift. The Certified Nurse Aide who transferred the resident did not have a second staff member in the room per facility policy. One of three residents reviewed for falls. The findings of included: Review of the Unusual Occurrence Report dated 3/10/16 for Resident #3 revealed the nurse was called to the resident's room and noted the mechanical lift tilted over with the resident lying on the floor on his/her left side. The steps taken to prevent recurrence was to ensure two staff members present at all times during transfers. Review of the physician progress notes [REDACTED]. They obtained x-rays, which showed an old fracture deformity of the proximal tibia and fibula. Further review of the x-rays reveals a possible old distal fibular fracture with what sounds like possibly an acute proximal tib-fib fracture, which is nondisplaced. Review of Resident #3's Transfer/Lift - Data Collection Tool revealed the resident was assessed as requiring a mechanical lift on 9/23/15, 12/19/15 and 3/4/16. Review of Resident #3's Nurse's Notes dated 3/10/16 at 11:45 AM revealed the nurse was called to the resident's room and noted the mechanical lift tilted over with the resident lying on his/her left side with no injuries noted. On 3/10/16 at 10:30 PM the Nurse's Note indicated Resident #3 moaned during repositioning in the bed and stated his/her left leg hurt when moved. The nurse noted bruising to the left inner knee and lower leg with [MEDICAL CONDITION]. The nurse elevated the resident's left leg on a pillow and repositioned him/her for comfort. The nurse also noted some [MEDICAL CONDITION] to the resident's left hand with bruising noted to the outer left forearm and elbow area. The Director of Nursing was notified. On 3/11/16 at 11:00 the Nurse's Note indicated Resident #3's was noted with left lower leg [MEDICAL CONDITION] from the knee down, bruising was noted on the inner aspect of the knee and it was warm to the touch. Resident #3 complained of pain with passive range of motion and the physician was made aware. An order was received to x-ray the resident's left knee, tibia/fibula and ankle. The nurse noted there was no [MEDICAL CONDITION] to the left hand/wrist and there were 3 ecchymotic areas to the resident's left forearm. On 3/11/16 at 1:20 PM, (Portable x-ray) was in the facility to x-ray the resident. On 3/11/16 at 5:30 PM the Director of Nursing and physician were notified of the x-ray results. On 3/15/16 the Nurse's Note at 11:00 AM indicated the physician was in to visit and an appointment was scheduled for ortho to evaluate possible tib/fib fracture. Review of the Radiology Report dated 3/11/15 revealed the conclusion was non-displaced fractures of the proximal tibia and fibula. Review of Resident #3's Physician order [REDACTED]. Review of the report from the orthopedist dated 3/15/16 revealed Resident #3 had a fracture of shaft of the left tibia. Review of the facility's Summary of Unusual Occurrence for Resident #3 dated 3/17/16 revealed on 3/10/16 at approximately 11:30 AM the nursing assistant assigned to the resident was transferring the resident from the bed to the chair. The mechanical lift tilted to the side and fell over depositing the resident on the floor. The resident did not complain of pain and did not have physical evidence of an injury. The CNA opened the valve to lower the sling and the sling began lowering much faster than expected. The CNA grabbed the sling and pulled up on it, attempting to keep the resident from falling, and the Hoyer lift tipped over. There was no evidence of abuse apparent during the investigation. The CNA performing the transfer was counseled and given repeat training on lift operation. Review of the Employee Re-Education Report dated 3/11/16 revealed the CNA required re-education for failure to widen the legs of the lift for stability prior to operation, failure to control lift decent and failure to operate the lift with a second employee present. In an interview with the surveyor on 4/26/16 at approximately 5:05 PM, the Director of Nursing stated the CNA was transferring Resident #3 from the bed to the chair with the total lift. S/he opened the valve to let the sling down and s/he opened it too far and the sling started going to fast so s/he grabbed the sling and tried to pull it over the chair and the whole thing flipped over. Resident #3 fell to the floor when the lift tipped over. The CNA was also on the floor. Resident #3 was over the chair but not quite over the seat. So the CNA tried to grab the resident and the lift tipped and everybody fell . There was only one CNA in the room. Resident #3 fractured his/her left proximal tib/fib. The CNA was supposed to have two people for transfer with a mechanical lift. The facility policy is for two people for a total lift. The CNA was counseled and they did in-service training with all the CNAs to ensure competency. The DON had maintenance check all the lifts in the building to make sure they were working properly. All the lifts were working properly. The Director of Nursing stated s/he reported the incident to licensing but not to certification because they knew how the fracture occurred. When asked if s/he had considered reporting the incident to certification for neglect s/he stated no. In an interview with the surveyor on 4/26/16 at approximately 6:45 PM, the Director of Nursing and Nurse Consultant stated they had amended the lift policy to include that lifts require two staff members. When asked when the policy was amended they stated they were not sure exactly when and stated approximately six months ago they changed the policy that two people are required to operate lifts and educated staff on the policy. When asked if the inservice they provided the surveyor was when they changed the policy and educated staff they replied yes. Review of the in-service revealed it was completed April 27, 2015. Review of the in-service revealed the CNA who transferred Resident #3 attended the in-service.

Based on record review and interview the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #3 received a fracture when s/he fell while being transferred with a mechanical lift. The Certified Nurse Aide who transferred the resident did not have a second staff member in the room per facility policy. One of three residents reviewed for falls. The findings of included: Review of the Unusual Occurrence Report dated 3/10/16 for Resident #3 revealed the nurse was called to the resident's room and noted the mechanical lift tilted over with the resident lying on the floor on his/her left side. The steps taken to prevent recurrence was to ensure two staff members present at all times during transfers. Review of the physician progress notes [REDACTED]. They obtained x-rays, which showed an old fracture deformity of the proximal tibia and fibula. Further review of the x-rays reveals a possible old distal fibular fracture with what sounds like possibly an acute proximal tib-fib fracture, which is nondisplaced. Review of Resident #3's Transfer/Lift - Data Collection Tool revealed the resident was assessed as requiring a mechanical lift on 9/23/15, 12/19/15 and 3/4/16. Review of Resident #3's Nurse's Notes dated 3/10/16 at 11:45 AM revealed the nurse was called to the resident's room and noted the mechanical lift tilted over with the resident lying on his/her left side with no injuries noted. On 3/10/16 at 10:30 PM the Nurse's Note indicated Resident #3 moaned during repositioning in the bed and stated his/her left leg hurt when moved. The nurse noted bruising to the left inner knee and lower leg with edema. The nurse elevated the resident's left leg on a pillow and repositioned him/her for comfort. The nurse also noted some edema to the resident's left hand with bruising noted to the outer left forearm and elbow area. The Director of Nursing was notified. On 3/11/16 at 11:00 the Nurse's Note indicated Resident #3's was noted with left lower leg edema from the knee down, bruising was noted on the inner aspect of the knee and it was warm to the touch. Resident #3 complained of pain with passive range of motion and the physician was made aware. An order was received to x-ray the resident's left knee, tibia/fibula and ankle. The nurse noted there was no edema to the left hand/wrist and there were 3 ecchymotic areas to the resident's left forearm. On 3/11/16 at 1:20 PM Mobilix was in the facility to x-ray the resident. On 3/15/16 the Nurse's Note at 11:00 AM indicated the physician was in to visit and an appointment was scheduled for ortho to evaluate possible tib/fib fracture. Review of the Nurse's Notes dated 3/11/16 at 5:30 PM indicated the director of nursing, physician, and responsible party were notified of x-ray results. There was no documentation that new orders were received. Review of the Nurse's Notes dated 3/11-3/15/16 revealed no documentation the resident had a leg immobolizer in place. Further review of the Nurse's Notes revealed an entry on 3/15/16 at 11:00 AM that the physician was in to visit the resident, to schedule appointment with orthopedist for evaluation of possible tib-fib fracture. Review of the Nurse's Notes dated 3/15/16 revealed the resident went out to see an Orthopedist. The resident returned to the facility with a left leg immobilizer in place with ace wrap noted to the left foot. The Nurse's Notes on 3/15/16 at 6:00 PM indicated the resident's niece arrived with orders, prescriptions and follow-up appointment. The left leg immobilizer was to be in place at all times and to log roll the resident while in bed. Review of the Radiology Report dated 3/11/15 revealed the conclusion was non-displaced fractures of the proximal tibia and fibula. Review of the Physician ' s Telephone Orders dated 4/13/16 revealed continue to elevate both feet & immobilizer to left leg. On 3/15/16 an order was noted for left leg knee immobilizer at all times. On 3/11/16 an order for [REDACTED]. Review of the report from the orthopedist dated 3/15/16 revealed Resident #3 had a fracture of shaft of the left tibia. Review of the facility's Summary of Unusual Occurrence for Resident #3 dated 3/17/16 revealed on 3/10/16 at approximately 11:30 AM the nursing assistant assigned to the resident was transferring the resident from the bed to the chair. The mechanical lift tilted to the side and fell over depositing the resident on the floor. The resident did not complain of pain and did not have physical evidence of an injury. The CNA opened the valve to lower the sling and the sling began lowering much faster than expected. The CNA grabbed the sling and pulled up on it, attempting to keep the resident from falling, and the Hoyer lift tipped over. There was no evidence of abuse apparent during the investigation. The CNA performing the transfer was counseled and given repeat training on lift operation. Review of the Employee Re-Education Report dated 3/11/16 revealed the CNA required re-education for failure to widen the legs of the lift for stability prior to operation, failure to control lift decent and failure to operate the lift with a second employee present. In an interview with the surveyor on 4/26/16 at approximately 5:05 PM, the Director of Nursing stated the CNA was transferring Resident #3 from the bed to the chair with the total lift. S/he opened the valve to let the sling down and s/he opened it too far and the sling started going to fast so s/he grabbed the sling and tried to pull it over the chair and the whole thing flipped over. Resident #3 fell to the floor when the lift tipped over. The CNA was also on the floor. Resident #3 was over the chair but not quite over the seat. So the CNA tried to grab the resident and the lift tipped and everybody fell . There was only one CNA in the room. Resident #3 fractured his/her left proximal tib/fib. The CNA was supposed to have two people for transfer with a mechanical lift. The facility policy is for two people for a total lift. The CNA was counseled and they did in-service training with all the CNAs to ensure competency. The DON had maintenance check all the lifts in the building to make sure they were working properly. All the lifts were working properly. The Director of Nursing stated s/he reported the incident to licensing but not to certification because they knew how the fracture occurred. When asked if s/he had considered reporting the incident to certification for neglect s/he stated no. In an interview with the surveyor on 4/26/16 at approximately 6:45 PM, the Director of Nursing and Nurse Consultant stated they had amended the lift policy to include that lifts require two staff members. When asked when the policy was amended they stated they were not sure exactly when and stated approximately six months ago they changed the policy that two people are required to operate lifts and educated staff on the policy. When asked if the inservice they provided the surveyor was when they changed the policy and educated staff they replied yes. Review of the in-service revealed it was completed April 27, 2015. Review of the in-service revealed the CNA who transferred Resident #3 attended the in-service. In a telephone interview with the surveyor on 5/9/16 at approximately 10:00 AM, the Director of Nursing stated s/he reviewed Resident #3's x-ray report on 3/11/16 and read it as a negative finding. The Director of Nursing stated s/he reviewed the conclusion that was on the last page and noted the findings of an old fracture. S/he did not note the other conclusions on the report that indicated Resident #3 had a non-displaced fracture of the proximal tibia and fibula. The Director of Nursing stated that the physician came to see Resident #3 on 3/15/16 and reviewed the x-ray report from 3/11/16. The physician noted the resident had an acute fracture. The Director of Nursing confirmed Resident #3's x-ray report was positive for a fracture and misread as negative.

Based on record review and interview the facility failed to implement written policies and procedures that prohibit neglect of residents. Resident #3 received a fracure when s/he fell while being transferred with a mechanical lift. The Certified Nurse Aide who transferred the resident did not have a second staff member in the room per facility policy. The facility did not report the incident to the State Agency as possible neglect. One of three residents reviewed for falls. The findings of included: Review of the Unusual Occurrence Report dated 3/10/16 for Resident #3 revealed the nurse was called to the resident's room and noted the mechanical lift tilted over with the resident lying on the floor on his/her left side. The steps taken to prevent recurrence was to ensure two staff members present at all times during transfers. Review of the physician progress notes [REDACTED]. They obtained x-rays, which showed an old fracture deformity of the proximal tibia and fibula. Further review of the x-rays reveals a possible old distal fibular fracture with what sounds like possibly an acute proximal tib-fib fracture, which is nondisplaced. Review of Resident #3's Transfer/Lift - Data Collection Tool revealed the resident was assessed as requiring a mechanical lift on 9/23/15, 12/19/15 and 3/4/16. Review of Resident #3's Nurse's Notes dated 3/10/16 at 11:45 AM revealed the nurse was called to the resident's room and noted the mechanical lift tilted over with the resident lying on his/her left side with no injuries noted. On 3/10/16 at 10:30 PM the Nurse's Note indicated Resident #3 moaned during repositioning in the bed and stated his/her left leg hurt when moved. The nurse noted bruising to the left inner knee and lower leg with [MEDICAL CONDITION]. The nurse elevated the resident's left leg on a pillow and repositioned him/her for comfort. The nurse also noted some [MEDICAL CONDITION] to the resident's left hand with bruising noted to the outer left forearm and elbow area. The Director of Nursing was notified. On 3/11/16 at 11:00 the Nurse's Note indicated Resident #3's was noted with left lower leg [MEDICAL CONDITION] from the knee down, bruising was noted on the inner aspect of the knee and it was warm to the touch. Resident #3 complained of pain with passive range of motion and the physician was made aware. An order was received to x-ray the resident's left knee, tibia/fibula and ankle. The nurse noted there was no [MEDICAL CONDITION] to the left hand/wrist and there were 3 ecchymotic areas to the resident's left forearm. On 3/11/16 at 1:20 PM Mobilix was in the facility to x-ray the resident. On 3/11/16 at 5:30 PM the Director of Nursing and physician were notified of the x-ray results. On 3/15/16 the Nurse's Note at 11:00 AM indicated the physician was in to visit and an appointment was scheduled for ortho to evaluate possible tib/fib fracture. Review of the Radiology Report dated 3/11/15 revealed the conclusion was non-displaced fractures of the proximal tibia and fibula. Review of Resident #3's Physician order [REDACTED]. Review of the report from the orthopedist dated 3/15/16 revealed Resident #3 had a fracture of shaft of the left tibia. Review of the facility's Summary of Unusual Occurrence for Resident #3 dated 3/17/16 revealed on 3/10/16 at approximately 11:30 AM the nursing assistant assigned to the resident was transferring the resident from the bed to the chair. The mechanical lift tilted to the side and fell over depositing the resident on the floor. The resident did not complain of pain and did not have physical evidence of an injury. The CNA opened the valve to lower the sling and the sling began lowering much faster than expected. The CNA grabbed the sling and pulled up on it, attempting to keep the resident from falling, and the Hoyer lift tipped over. There was no evidence of abuse apparent during the investigation. The CNA performing the transfer was counseled and given repeat training on lift operation. Review of the Employee Re-Education Report dated 3/11/16 revealed the CNA required re-education for failure to widen the legs of the lift for stability prior to operation, failure to control lift decent and failure to operate the lift with a second employee present. In an interview with the surveyor on 4/26/16 at approximately 5:05 PM, the Director of Nursing stated the CNA was transferring Resident #3 from the bed to the chair with the total lift. S/he opened the valve to let the sling down and s/he opened it too far and the sling started going to fast so s/he grabbed the sling and tried to pull it over the chair and the whole thing flipped over. Resident #3 fell to the floor when the lift tipped over. The CNA was also on the floor. Resident #3 was over the chair but not quite over the seat. So the CNA tried to grab the resident and the lift tipped and everybody fell . There was only one CNA in the room. Resident #3 fractured his/her left proximal tib/fib. The CNA was supposed to have two people for transfer with a mechanical lift. The facility policy is for two people for a total lift. The CNA was counseled and they did in-service training with all the CNAs to ensure competency. The DON had maintenance check all the lifts in the building to make sure they were working properly. All the lifts were working properly. The Director of Nursing stated s/he reported the incident to licensing but not to certification because they knew how the fracture occurred. When asked if s/he had considered reporting the incident to certification for neglect s/he stated no. In an interview with the surveyor on 4/26/16 at approximately 6:45 PM, the Director of Nursing and Nurse Consultant stated they had amended the lift policy to include that lifts require two staff members. When asked when the policy was amended they stated they were not sure exactly when and stated approximately six months ago they changed the policy that two people are required to operate lifts and educated staff on the policy. When asked if the inservice they provided the surveyor was when they changed the policy and educated staff they replied yes. Review of the in-service revealed it was completed April 27, 2015. Review of the in-service revealed the CNA who transferred Resident #3 attended the in-service.

On the days of the Recertification and Survey, based on observations and interviews and review of the facility's Policy and Procedure entitled Pharmacy Services Policy and of the Medical Arts Pharmacy Policy and Procedures entitled IA2: Consultant Pharmacist Services Provider Requirements, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility Administration failed to ensure policies and procedures were monitored and followed to ensure safe and secure storage of all medications. The failure to do so placed residents at significant risk for serious harm. The findings included: On 10/25/11 at 3:20 PM, while checking the stock medications, the DON revealed an unlocked metal cabinet in her office. The DON confirmed the cabinet was unlocked and her door was open. An inventory of the contents of the cabinet revealed multiple Over the Counter and Prescription medications. Review of the facility's Policy and Procedure, dated October 18, 2010, entitled Pharmacy Services Policy 483.60 revealed the following "All drugs and biologicals are stored in locked compartments under proper temperature controls. Only authorized personnel are permitted to have access to the medication keys." Review of the Medical Arts Pharmacy Policy and Procedures entitled IA2: Consultant Pharmacist Services Provider Requirements, revealed Section F. "Specific activities that the consultant pharmacist performs includes, but is not limited to: ...4) Checking the medication storage areas, and the medication carts, for proper storage and labeling of medications, ... 6) Submitting a written report and recommendations for each review of medication storage which may be performed by a consultant or consultant agent (see Form 5: MEDICATION ROOM INSPECTION/NURSING STATION INSPECTION REPORT)." On 10/26/11 at 11:30, the Nursing Home Administrator (NHA) was interviewed and stated he had been the NHA for [AGE] years. He further stated that the corporate office developed any policies and procedures and that the NHA was responsible for implementing them. The NHA confirmed that he was not aware that drugs were being stored in the office of the DON and stated he thought the Registered Nurse should know it was common practice to keep medications locked in a secure location. He further stated that he was aware of the pharmacy's process and that it was part of the process to review the medication rooms and carts. In addition, he stated that he received the pharmacy reports and kept them on file. He stated he did not recall seeing medication storage addressed in the reports. On 10/26/11 at 11:00 AM, during a telephone interview, the Pharmacy Consultant stated that the routine practice for the storage of medications was to keep them under lock and key unless in eye sight of the nurse. He confirmed that overflow stock should be locked in the medication room and "cut" drugs should be returned to the pharmacy. The Pharmacist stated that one of the Pharmacy Consultants performed a medication review monthly and that the monthly report provided by the pharmacy does not include inspection of medication storage. He stated he was not aware that drugs were being stored in the DON's office or were unsecured but would assume that, if medications were stored in the office, the cabinet should be locked and the door should be locked if the DON was not in the office. On 10/25/11 at 5:15 PM the facility was notified that Immediate Jeopardy and/or Substandard Quality of Care related to the facility's failure to secure all medications in a locked storage area, which posed a significant risk of accidental ingestion of medications that, could result in the potential for clinically significant adverse consequences. On 10/26/11 an acceptable allegation of compliance was submitted, reviewed, and accepted by the survey team. On 10/26/11 prior to exiting the facility, the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citations of F323, F431, F490, and F501 were reduced in scope and severity from "L" to an "E". Cross refer to F323 as it relates to the accessibility of medications to cognitively impaired, mobile residents. Cross refer to F431 as it relates to the improper storage of medications. Cross refer to F501 as it relates to the knowledge of the Medical Director that medications were being stored in the office of the Director of Nursing and the failure to develop, implement and evaluate policies and procedures that reflect safe drug storage.

On the days of the Recertification and Extended Survey, based on observations, interviews, and review of the facility's Policy and Procedure entitled Pharmacy Services Policy and of the Medical Arts Pharmacy Policy and Procedures entitled IA2: Consultant Pharmacist Services Provider Requirements, the facility failed to store all medications in a locked storage area and to limit access to authorized personnel. The facility stored multiple Over The Counter (OTC) medications and resident Prescription medications unsecured in the office of the Director of Nursing (DON). The findings included: On 10/25/11 at 3:20 PM, inspection of an unlocked cabinet in the Director of Nursing office, (with an unlocked door) revealed stock OTC medications and bottles of liquid medications including Aspirin, Acetaminophen, Vitamins, Laxatives, Antidiarrheals, Zantac and Carafate, a bottle of 1200 milliliters of Potassium Chloride and (8) - 900 milliliter bottles of Tegretol (100 milligrams per 5 milliliters). In 2 other boxes were additional resident prescription medications. The DON stated she had moved the medications into her office so that she could monitor expiration dates to ensure no expired medications were administered to residents. At 3:50 PM, Registered Nurse (RN) #1 opened the unlocked door of the Director of Nursing office and, upon request, opened the 2 door metal cabinet to reveal the stock drugs. When the surveyor asked about a lock, the RN stated the cabinet had "never been locked as long as I have been here". She stated she had worked at the facility for 2 and 1/2 years. RN # 1 also stated that residents went in and out of the office "all the time". At 4:10 PM, an inventory of the cabinet was conducted by 2 surveyors and witnessed by the DON. In addition to the above listed OTC medication the inventory revealed 94 boxes and 24 vials of residents' prescription medications including: Acetylcysteine, Apresoline, Aricept, Clonidine, Cozaar, Creon, Depakote tablets and sprinkles, Ditropan, Duonebs, Effexor, Hydrochlorothiazide, KDur, Lasix, Lipitor, Lisinopril, Lopressor, Lotrel, Meloxicam, Metformin, Namenda, Norvasc, Pepcid, Potassium, Sinemet, Reglan, Toprol, Transderm/ Scopolamine, Trileptal, Ultram, Valproic Acid, Vasotec, Zenpep, Zocor and Zyloprim. There were also two STAT/Emergency Medication boxes in the cabinet that were secured with a zip lock. The facility provided a list of cognitively impaired residents as requested by the survey team that revealed 35 residents were cognitively impaired and self-mobile. In addition, 23 of the 35 residents on the list were noted as having a WanderGuard. Review of the facility's Policy and Procedure, dated October 18, 2010, entitled Pharmacy Services Policy 483.60 revealed the following "All drugs and biologicals are stored in locked compartments under proper temperature controls. Only authorized personnel are permitted to have access to the medication keys." Review of the Medical Arts Pharmacy Policy and Procedures entitled IA2: Consultant Pharmacist Services Provider Requirements, Section E stated "The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes, but is not limited to: ... 2) Evaluating the process of receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, and using and/or disposing of all medications, biologicals, and chemicals." Further review revealed Section "F. Specific activities that the consultant pharmacist performs includes, but is not limited to: ...3) Checking the emergency medication supply to ascertain that it is properly sealed and stored and that the contents are not outdated, which duties may be assigned to a consultant's agent. 4) Checking the medication storage areas, and the medication carts, for proper storage and labeling of medications, cleanliness, and removal of expired medications, which duties may be assigned to a consultant's agent. ... 6) Submitting a written report and recommendations for each review of medication storage which may be performed be a consultant or consultant agent (see Form 5: MEDICATION ROOM INSPECTION/NURSING STATION INSPECTION REPORT)." Review of the Pharmacy's Policy and Procedures entitled IC3: Ordering and Receiving Medications From the Dispensing Pharmacy revealed in Section B "1) A licensed nurse: d. Immediately delivers the medications to the appropriate secure storage area." On 10/26/11 at 11:03 AM, during a telephone interview, the Pharmacy Consultant stated he was aware that the policies and procedures were updated annually but was not sure if they had been reviewed and/or updated for this year. He further stated that the routine practice for the storage of medications was to keep them under lock and key unless in eye sight of the nurse. He confirmed that overflow stock should be locked in the medication room and "cut" drugs should be returned to the pharmacy. The Pharmacist stated that one of the Pharmacy Consultants performed a medication review monthly and that the monthly report provided by the pharmacy but does not include inspection of medication storage. The Pharmacy Consultant stated he was not aware that drugs were being stored in the DON's office or were unsecured but would assume that, if medications were stored in the office, the cabinet should be locked and the door should be locked if the DON was not in the office. When asked what potential harm could result from resident access to the medications, he stated, "You wouldn't want that to happen, obviously" and further stated it would "not be a good outcome, to say the least." He also stated that accidental ingestion of the antihypertensives that were stored in the unsecured cabinet "would have a very negative outcome." At 11:15 AM on 10/26/11, a telephone interview was conducted with the Medical Director. He stated he was involved with resident care policies and confirmed he was aware of the medication storage policy and procedure. The Medical Director verified he was aware that mediations were stored in the office of the DON but was not aware that they were not secured. He further stated he reviewed the Pharmacy reports but medication storage was not addressed in the reports "to my recollection." The Medical Director stated that the outcome of a resident's accidental ingestion of the medications "would depend on the medication." On 10/26/11 at 11:30, the Nursing Home Administrator (NHA) was interviewed. He stated corporate office developed policies and procedures and that the NHA was responsible for implementing them. The NHA stated that he was not aware that drugs were being stored in the office of the DON and stated he thought the Registered Nurse should know it was common practice to keep medications locked in a secure location. He further stated that he was aware of the pharmacy's process and that it was part of the process to review the medication rooms and carts. In addition, he stated that he received the pharmacy reports and kept them on file. He stated he did not recall seeing medication storage addressed in the reports. He stated he had never seen the cabinet open and that generally someone was in the office though he also stated he knew "there are times when there is nobody in there." On 10/25/11 at 5:15 PM the facility was notified that Immediate Jeopardy and/or Substandard Quality of Care related to the facility's failure to secure all medications in a locked storage area, which posed a significant risk of accidental ingestion of medications that, could result in the potential for clinically significant adverse consequences. On 10/25/10 at 5:15 PM, the door to the office of the Director of Nursing was closed and locked. At 5:30 PM, facility staff was seen moving the medications into a secure Medication Room at the front Nurses Station. On 10/26/11 an acceptable allegation of compliance was submitted, reviewed, and accepted by the survey team. On 10/26/11 prior to exiting the facility, the allegation of compliance was verified when inspections revealed the cabinet in the DON's office was empty, all narcotics were locked in a metal box in a locked drawer in the medication cart and the prescription medications and STAT boxes had been moved to a locked medication room. The Immediate Jeopardy citations of F323, F431, F490, and F501 were reduced in scope and severity from "L" to an "E". Cross refer to F 323 as it relates to the accessibility of medications to cognitively impaired, mobile residents. Cross refer to F490 related to Nursing Home Administrators failure to ensure Policies and Procedures were implemented and followed related to the storage of medications. Cross refer to F501 as it relates to the knowledge of the Medical Director that medications were being stored in the office of the Director of Nursing and the failure to develop, implement and evaluate policies and procedures that reflect safe drug storage.

On the days of the Recertification and Extended Survey, based on observation and interviews, the Medical Director failed to implement and coordinate policies and procedures that reflect current standards of practice related to safe drug storage. The findings included: At 11:15 AM on 10/26/11, a telephone interview was conducted with the Medical Director. He stated this was his second year as Medical Director. He stated he was involved with resident care policies and confirmed he was aware of the medication storage policy and procedure. The Medical Director stated that he was aware that medications were stored in the office of the Director of Nurses (DON) but was not aware that they were not secured. He further stated he received the Pharmacy reports but medication storage was not addressed in the reports "to my recollection." The Medical Director stated that the outcome of a resident's accidental ingestion of the medications "would depend on the medication." On 10/26/11 at 11:30, the Nursing Home Administrator (NHA) was interviewed and stated that the corporate office developed any policies and procedures and that the NHA was responsible for implementing them. He confirmed that the Medical Director was not really involved in the development of the policies and procedures. On 10/25/11 at 5:15 PM the facility was notified that Immediate Jeopardy related to the facility's failure to secure all medications in a locked storage area, which posed a significant risk of accidental ingestion of medications that, could result in the potential for clinically significant adverse consequences. On 10/26/11 an acceptable allegation of compliance was submitted, reviewed, and accepted by the survey team. On 10/26/11 prior to exiting the facility, the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citations of F323, F431, F490, and F501 were reduced in scope and severity from "L" to an "E". Cross refer to F 323 as it relates to the accessibility of medications to cognitively impaired, mobile residents. Cross refer to F 431 as it relates to the failure of the facility to appropriately store medications. Cross refer to F490 as it relates to the Nursing Home Administrators failure to ensure Policies and Procedures were implemented and followed related to the storage of medications.

On the days of the survey, based on observation and interview, the facility failed to ensure that the resident's environment was free from accident hazards as possible. The facility was observed to store medications in an unsecured area while having knowledge that cognitively impaired mobile residents resided on the unit, thereby placing the residents at risk for serious harm. The findings included: On 10/25/11 at 3:20 PM, Licensed Practical Nurse #2 stated that stock medications were kept in the nursing office. The Director of Nurses (DON) revealed an unlocked metal cabinet in her office where medications were stored. The DON confirmed the cabinet was unlocked and her office door open. Inspection of the cabinet revealed over the counter (OTC) medications and bottles of liquid medications including Aspirin, Acetaminophen, Vitamins, Laxatives, Antidiarrheals, Zantac and Carafate, a bottle of 1200 milliliters of Potassium Chloride and (8) - 900 milliliter bottles of Tegretol (100 milligrams per 5 milliliters). In 2 other boxes were additional resident prescription medications. At 3:50 PM, Registered Nurse (RN) #1 was asked to open the DON's office door. The RN opened the unlocked door and, upon request, opened the 2 door metal cabinet to reveal the stock drugs. When the surveyor asked if there wasn't a lock, the RN stated the cabinet had "never been locked as long as I have been here" and informed the surveyor she had been there for 2 and 1/2 years. She also stated that residents went in and out of the office all the time. At 4:10 PM, an inventory of the cabinet was conducted by 2 surveyors and witnessed by the DON. In addition to the above listed OTC medication the inventory revealed 94 boxes and 24 vials of residents' prescriptions including: Acetylcysteine, Apresoline, Aricept, Clonidine, Cozaar, Creon, Depakote tablets and sprinkles, Ditropan, Duonebs, Effexor, Hydrochlorothiazide, KDur, Lasix, Lipitor, Lisinopril, Lopressor, Lotrel, Meloxicam, Metformin, Namenda, Norvasc, Pepcid, Potassium, Sinemet, Reglan, Toprol, Transderm/ Scopolamine, Trileptal, Ultram, Valproic Acid, Vasotec, Zenpep, Zocor and Zyloprim. In addition, there were two STAT/Emergency Medication boxes in the cabinet that were secured with a zip lock. Review of a list of cognitively impaired residents, requested by the survey team and provided by the facility, revealed that 35 residents were cognitively impaired and self-mobile. In addition, 23 of the 35 residents on the list were noted as having a WanderGuard. On 10/26/11 at 11:03 AM, during a telephone interview, the Pharmacy Consultant stated that the routine practice for the storage of medications was to keep them under lock and key unless in eye sight of the nurse. He confirmed that overflow stock should be locked in the medication room and "cut" drugs should be returned to the pharmacy. He stated he was not aware that drugs were being stored in the DON's office or were unsecured but would assume that, if medications were stored in the office, the cabinet should be locked and the door should be locked if the DON was not in the office. When asked what potential harm could result from resident access to the medications, he stated, "You wouldn't want that to happen, obviously" and further stated it would "not be a good outcome, to say the least." He also stated that accidental ingestion of the antihypertensives that were stored in the unsecured cabinet "would have a very negative outcome." At 11:15 AM on 10/26/11, a telephone interview was conducted with the Medical Director who confirmed that he was aware that medications were stored in the office of the DON but was not aware that they were not secured. The Medical Director stated that the outcome of a resident's accidental ingestion of the medications "would depend on the medication." On 10/26/11 at 11:30, the Nursing Home Administrator (NHA) was interviewed and stated he knew "there are times when there is nobody in there." (The Director of Nursing office.) On 10/25/11 at 5:15 PM the facility was notified that Immediate Jeopardy and/or Substandard Quality of Care related to the facility's failure to secure all medications in a locked storage area, which posed a significant risk of accidental ingestion of medications that, could result in the potential for clinically significant adverse consequences. On 10/25/10 at 5:15 PM, the door to the office of the Director of Nursing was closed and locked. At 5:30 PM, facility staff was seen moving the medications into a secure Medication Room at the front Nurses Station. On 10/26/11 an acceptable allegation of compliance was submitted, reviewed, and accepted by the survey team. On 10/26/11 prior to exiting the facility, the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citations of F323, F431, F490, and F501 were reduced in scope and severity from "L" to an "E". Cross refer to F 431 as it relates to the failure of the facility to appropriately store medications. Cross refer to F490 as it relates to the Nursing Home Administrators failure to ensure Policies and Procedures were implemented and followed related to the storage of medications. Cross refer to F501 as it relates to the knowledge of the Medical Director that medications were being stored in the office of the Director of Nursing and the failure to develop, implement and evaluate policies and procedures that reflect safe drug storage.