Every finding on record at Carmel Manor

Based on observation, interview, and review of the facility's policies, the facility failed to provide meals at regular times comparable to normal mealtimes in the community or to which they were accustomed and preferred. Observations on 09/16/2025, 09/17/2025, 09/18/2025, and 09/19/2025 revealed breakfast, lunch, and dinner meals were delivered late, some an hour later than the expected time. During subsequent interviews with residents and families, they reported delayed meals negatively altered the remainder of the residents' day and evening routines, which upset the residents for 5 of 14 sampled residents, Resident (R) 26, R28, R51, R62, and R64.The findings include:Review of the facility's policy titled, Resident Rights-Promoting and Maintaining Resident Dignity during Mealtimes, effective date 03/16/2023, revealed the practice of the facility was to treat each resident with respect, dignity, and give care in a manner that maintained or enhanced quality of life, recognizing each resident's individuality and protecting the rights of each resident. Further review revealed staff would allow adequate time for residents to complete their meals and would not rush them, to allow residents the time needed to complete as much as the residents desired of the meal. Review of the facility's policy titled, Serving a Meal, undated, revealed the facility would serve meals that met the needs of residents. Further review revealed staff should remember some residents took a long time to eat and should provide adequate time for the resident to consume the meal. 1. Observation of the supper meal on 09/16/2025 at 5:15 PM revealed residents sitting at the table waiting for the supper meal to be delivered. Further observation revealed the meal did not arrive until 5:58 PM. Then, there was additional time to sort out the delivery of trays to diners at the table. Continued observation at 6:08 PM, revealed R28 was at the table and R64, who required feeding assistance, was still sitting with his meal in front of him but unable to eat. Furthermore, R51 was trying to feed him. Additional observation revealed R26 asked staff why a cold dinner was an hour late. Observation revealed the entree was a dollop each of chicken salad, tuna salad, and egg salad, with melon. Also, some residents had soup. a. During an interview with R28's Family Member (F) 5 on 09/18/2025 at 7:41 PM, he stated when lunch was served so late at 1:15 PM, it was a long haul from breakfast at 7:00 AM, and his wife got really uncomfortable and anxious with hunger. He stated that was more significant, especially since she did not understand what the hunger pangs meant. He stated staff had to be very careful with her medications. He stated she had taken anti-anxiety medication for quite a while, because prior to that, she was very agitated and screaming. He stated it was very important the anti-anxiety medications did not wear off, so she must have her evening medications by 8:00 PM. Thus, he stated if supper was delayed, day shift could not get her to bed, and medications were delayed. b. During an interview with R64's F12 on 09/18/2025 at 1:45 PM, she stated late suppers were especially troublesome for her husband. She stated he typically went to bed by 6:30 PM with assistance from the day shift staff. She stated if supper trays arrived at 6:15 PM, by the time he had eaten and the nursing assistants had helped others and cleared the trays away, it was time for shift change. She stated then the night shift staff needed to make rounds to get started, so that delayed his transfer to bed and preparation for sleep. She stated he was so exhausted he could not help as much to get to bed, making him much more likely to fall. 2. Observation of the lunch meal on 09/17/2025 at 1:15 PM revealed trays were delivered at that time, and R28 received a late meal. 3. Observation of R25 on 09/18/2025 at 8:30 AM revealed she left the dining room without her breakfast being served.During an interview with R25 on 09/18/2025 at 8:30 AM, she stated the late delivery for breakfast meant she missed the meal completely. She stated she had to leave to keep from being late for an appointment.4. Observation of breakfast delivery on 09/19/2025 at 9:15 AM revealed Certified Nurse Aide (CNA) 7 was still delivering meal trays to resident rooms.During interview with CNA7 on 09/19/2025 at 9:06 AM, she stated this morning's breakfast delivery was very late, and the late meals had been really bad. She stated residents got really frustrated when they had to sit and wait when they were so hungry. She stated the residents were used to breakfast earlier. She also stated dietary staff used to bring the tray carts but now the unit staff had to wait for them to call or stop what they are doing when dietary called, to go get the tray carts from the kitchen. She stated trays were not in any particular order, which added to delivery delays.During an interview with R52 on 09/18/2025 at 12:50 PM, he stated late meals were frustrating because it upset the rest of the day. For example, he stated he depended on staff completely for eating and for other Activities of Daily Living (ADL) such as oral care, dressing, and transferring to his wheelchair. He stated he and other dependent diners were the last to get their meals. Then, he stated if breakfast was delivered late, and he was the last to get his tray, he must be fed, teeth brushed, changed and dressed for the day, and transferred to his wheelchair. He stated that might cause him to be late or miss church services. He stated it was very important to him to go to Mass every morning.During an interview with R62's F11 on 09/18/2025 at 12:37 PM, who was feeding R62, she stated meals delivered late affected medication administration. She stated her father had scheduled medication at 12:00 PM. She stated if he received his medicine at noon, but did not eat until later, he was likely to be too sleepy to eat well. During an interview with CNA5 on 09/18/2025 at 8:24 PM, he stated meals were expected on the unit between 7:30 to 8:00 AM for breakfast, 11:30 AM to 12 noon for lunch, and supper was usually delivered around 4:30 PM to 5:00 PM. He stated it was upsetting to residents when meals got delayed, and meals were one of the most important things to residents. He stated it made such a difference for the residents when mealtime went smoothly. He also stated if trays were late or contained food items residents had told staff they did not want, it threw their whole day off, and they became more agitated and upset. He stated meal service was the biggest problem they had on their unit. During an interview with Licensed Practical Nurse (LPN) 1 on 09/18/2025 at 8:35 AM, she stated late meals, especially breakfast, was a real problem for residents with appointments. She stated when it was delayed, the resident must leave the building without eating, which could affect blood sugar for some and cause others not to feel as well because they were hungry. She stated residents with dementia were especially affected, and being hungry increased their anxiety, just like changing to another room or another unit. However, she stated even the residents who did not have dementia became upset and anxious. She stated, if a meal was late, one of the aides would apologize and offer snacks to decrease the upset.During an interview with Unit Manager 1 on 09/19/2025 at 4:45 PM, he stated meal delay affected residents by disrupting their routines, and routine was important with residents, especially those with dementia. He stated residents might not be able to articulate discomfort with hunger and might become agitated and anxious.During an interview with Dietary Manager 1 on 09/18/2025 at 8:44 AM, he stated the timing of the breakfast meal should be from 8:00 AM to 9:00 AM, or he had one hour to serve all the meals. He stated he currently had only nine staff members and needed seven per day to carry out the functions of the department. He stated the Dietary department was down three positions.During an interview with Director of Nursing (DON) 2 on 09/19/2025 at 4:13 PM, she stated delayed mealtimes could really throw the residents' day off. She also stated when residents were happy with meals, they were happier with other things. She stated she found that residents might be more agitated when hungry. During an interview with the Administrator on 09/19/2025 at 2:04 PM, she stated the previous administration changed the way the meals were delivered. She stated there were a lot of staff cut from the Dietary department. She stated the meal ticketing system was difficult to follow now and was not set up in a way to work well in the kitchen. She stated there had never been an organized system for arranging trays. She also stated the impact of late meals could create a lot of stress for residents, threw their day off, and it was important to provide calm in resident care.

Based on observation, interview, and review of the facility's document and policy, the facility failed to store and prepare food in a safe manner. Observation on 09/16/2025 and 09/17/2025 revealed uncovered kitchen utensils and equipment. Also, observation on 09/16/2025 of the resident kitchen unit refrigerators revealed two of the four had resident food products not labeled with the resident's name, date received, and the identity of the food product. The deficient practice had the capability of affecting 80 residents who received food from the kitchen or all residents that had additional food left in the unit kitchenette refrigerators. The findings include:Review of the facility's policy titled, Food: Safe Handling for Foods from Visitors, dated 09/2017, revealed residents would be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. The policy stated when food items were intended for later consumption, the responsible facility staff member would ensure food was stored properly and away from facility food. The policy stated foods were sealed in containers to prevent cross contamination, and foods were labeled with the resident's name and current date received. Per the policy, refrigerators would be equipped with thermometers and their temperatures monitored daily for refrigeration equal to or lesser than 41 degrees Fahrenheit (F). The policy stated freezer temperatures would be equal to or lesser than 0 degrees F.The State Survey Agency (SSA) Surveyor requested the refrigerator logs for monitoring the unit kitchenette refrigerator temperatures on the [NAME] Pavilion and the St. [NAME] Pavilion from Director of Nursing (DON) 2 on 09/19/2025 at 11:04 AM. However, the SSA Surveyor did not receive these logs by time of survey exit.Observation on 09/16/2025 at 2:15 PM of the [NAME] Pavilion unit kitchenette refrigerator revealed it contained a pitcher of orange juice not dated or labeled; two small bowls of broth or soup with no date or label; three cartons in packs of four yogurt in a plastic grocery bag with no name or date; and two frozen food boxes stored in the refrigerator. Further observation revealed the boxes were soft to the touch, and one box contained an unfrozen meatloaf, 280 grams (g), dated 07/2026 and with no name. Further observation revealed the other box contained stuffed peppers, 283 g, dated 07/2027 with no name. Also observed was a large plastic bag of frozen deer meat in butcher paper with no name or date. The refrigerator had a working thermometer, but there was no temperature log visible. Observation on 09/16/2025 at 2:20 PM of the St. [NAME] Pavilion unit kitchenette refrigerator revealed it contained one pitcher of tea and one pitcher of lemonade with no date or label; three separate cups of cranberry juice with no date or label; one box with a small football shaped ice cream cake with no date or name; a 32 ounce plastic cup with a baseball team logo with no name or date; 30 frozen ice cream bars, which appeared refrozen and were soft to the touch with no dates or names; six fruit frozen ice bars dated 10/2026, which appeared melted and refrozen; one container of taco salad with no name or date; one lemon meringue pie outdated with 09/06/2025 sell-by-date and no name; 1/4 bag of organic pita chips with bag date of 10/21/2025 and no name. The refrigerator had a non-working thermometer, and there was no temperature log visible.Observation on 09/17/2025 at 11:20 AM of the kitchen production area revealed, on the bottom shelf under the production table, the nested set of mixing bowls that were turned up and not covered. Further observation revealed the Robo Coupe blade with container was not covered, and the stand mixer on the table with the mixing bowl in place was not covered. In an interview with Certified Nurse Aide (CNA) 6 on 09/18/2025 at 10:13 AM, she stated the residents' food was kept in the kitchen refrigerators on the unit and should be labeled with the resident's name, date received, and identity of the food item. In an interview with the Dietary Manager on 09/18/2025 at 8:44 AM, he stated the equipment needed to be covered because anything could fall into the equipment. He stated the refrigerators in the kitchenette areas were not for storage of resident food items. He stated the residents had a separate refrigerator for each unit. He stated the dietary department was not responsible for the unit kitchenette refrigerators at present.In an interview with Registered Nurse Director of Nursing (DON) 2 on 09/19/2025 at 11:04 AM, she stated her expectation was for food equipment to be covered and resident's food labeled with their name and date. She stated nursing staff monitored the residents' refrigerator on each unit which were like small dorm refrigerators, and there was only one per unit. In an interview with the Administrator on 09/19/2025 at 9:57 AM, she stated her expectation was for the resident's food to be labeled with name and date. She also stated she expected dietary staff to follow state and federal regulations. She stated they were going to open one of the kitchenettes on one unit the next week. She stated the Dietary department would be responsible for the kitchenette refrigerator. She stated before the kitchenettes were opened, they had to be cleaned out and the equipment repaired.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Observation on 09/18/2025 revealed nursing staff instead of dietary staff took breakfast tray carts to the units and served the residents, and resident roommates were regularly served meals more than 27 minutes apart, which angered the resident who had to wait. Also, in an interview with the Dietary Manager on 09/18/2025, he stated he only had nine current dietary employees, and it took seven each day to perform the required dietary functions. This deficient practice affected 80 residents who received their meals from the kitchen. The findings include:Review of the facility's policy titled, Serving a Meal, dated 08/2024, revealed residents should be encouraged to eat in the dining room; however, requests to remain in the room should be honored.1. Observation on 09/18/2025, beginning at 8:00 AM, revealed in the kitchen the breakfast tray line was started to prepare the residents' breakfast trays. Continued observation at 8:20 AM revealed the Dietary Manager (DM) worked on the tray line with a Dietary Aide. The DM called off the tray cards to the Dietary Aide for texture diets, vegan diets, and specific foods for each tray. Also, one staff member from the kitchen office and one cook, who worked in the kitchen, assisted with the tray line. Further observation revealed the DM/or other dietary staff, after the tray carts were complete, called the units to inform staff the tray carts were ready for pick up to take to the units. Continued observation revealed nursing staff from the residential units picked up meal carts from the kitchen and took them to the units. Observation revealed the last breakfast tray cart was sent to one of the units at 8:41 AM. In an interview with Dietary Manager 1 on 09/18/2025 at 8:44 AM, he stated the timing of the breakfast meal should be from 8:00 AM to 9:00 AM, or he had one hour to serve all the meals. He stated he currently had only nine staff members and needed seven per day to carry out the functions of the department. He stated he was allowed two cook positions and five and one-half diet aide positions per day. He stated the Dietary department was down three positions. He stated the meal tickets were specific to each unit; however, there was no specific order of the meal tickets on the trays.Review of the Dietary schedule on 09/18/2025 at 8:40 AM revealed there were only nine staff members listed.In an interview with Dietary [NAME] 1 on 09/18/2025 at 10:21 AM, he stated the meal tickets were for each unit cart and not in any certain order. 2. Observation on 09/18/2025 at 8:30 AM of R74's roommate eating breakfast in the room, revealed approximately 50 percent of the roommate's meal had been consumed, and R74 did not have a breakfast tray. Continued observation revealed at 8:55 AM, a second breakfast cart arrived on the unit, and at 8:57 AM, R74's breakfast tray was delivered.Review of R74's admission Record revealed the facility admitted him on 06/07/2022 with diagnoses of diabetes with long term use of insulin.Review of R74's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/06/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated intact mental cognition.Review of R74's Care Plan Report, last revised 09/06/2025, revealed a focus area for being at risk for alterations in blood glucose due to diagnosis of diabetes, and long-term use of insulin.In an interview with R74 on 09/18/2025 at 8:32 AM, he stated he always took the breakfast meal in his room, and everyday his roommate was done with the meal before his tray had been delivered. R74 stated because of his diagnosis of diabetes, upon waking in the morning he was hungry from not eating since dinner the previous night. He stated it pisses him off having to smell the roommate's meal when he was hungry. He stated he had continually asked staff where his breakfast was and why it was always late, but nobody had provided any explanation or resolution.In an interview with Certified Nurse Aide (CNA) 1 on 09/18/2025 at 8:59 AM, she stated there were three CNAs working on the unit for the day shift for 39 residents. She stated she was the only regular staff, with the other two both being agency, which was very common. CNA1 stated nurse aides were responsible for going to the kitchen to pick up meal carts, bring to the unit, deliver the trays and provide feeding assistance, pick up trays after the meal, and return carts to the kitchen. She stated that routinely was done by her since she was often the only regular staff working the unit that knew the process. She stated the meal carts were not organized in any particular order, and residents got trays at different time intervals, resulting in residents in the same room not getting food at the same time. She stated there were two meal carts so all of the actions were performed a second time. Additionally, she stated R74's roommate's breakfast tray was on the first meal cart, while his was on the second. She stated that meant the whole first cart had to be delivered, with those residents assisted, before going to get the second cart. She stated after meals, nursing staff had to collect the trays, place them back on the carts, and return them to the kitchen. She stated during breakfast and lunch mealtimes at least one nurse aide was off the unit, leaving two to provide care to the 39 residents. She further stated during tray passing, feeding, and tray pickup, staff was doing their best to answer call lights timely. In an interview with the former Dietary Manager 2 on 09/20/2025 at 1:25 PM, she stated the former Administrator cut staffing in Dietary and assigned the nursing staff to pick up the meal tray carts to deliver to the units. She stated the unit kitchenettes where residents could dine had not been opened since COVID, and residents had been eating in their rooms.In an interview with Director of Nursing (DON) 2 on 09/19/2025 at 11:04 AM, she stated her expectation was to hire staff and fill the needed dietary positions. In an interview with the Administrator on 09/19/2025 at 9:57 AM, she stated the former Administrator cut staffing in Dietary. She stated she planned to hire more dietary staff and open all the unit kitchenettes, so residents could eat in the kitchenette and not in their rooms. She stated the decision for nursing staff to pick up the meal carts was the former Administrator's decision.In an additional interview with the Administrator on 09/19/2025 at 2:04 PM, she stated there was concern for residents not getting trays at the same time as others due to the current issues with meal ticketing in the kitchen.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 7 out of 52 sampled residents, Resident (R) 3, R15, R49, R55, R58, R68, and R82. The findings include:Review of the CDC Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. It stated staff should ensure the proper selection and use of personal protective equipment (PPE) based on the nature of the patient/resident interaction and potential for exposure. According to the guidelines, regular and proper handwashing was essential for preventing the spread of infections. Additionally, appropriate PPE must be used according to the level of risk, and surfaces and equipment should be cleaned and disinfected to minimize infection risks.Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], undated, revealed the facility maintained a program to provide a safe, sanitary, and comfortable environment to prevent the transmission of disease and infections consistent with national standards and guidelines. The policy stated staff was responsible to follow the IPCP. Additionally, staff was required to perform hand hygiene, use personal protective equipment, and adhere to cleaning and disinfection of shared equipment according to the policy. Further review revealed staff was required to handle and transport linen in a manner that prevented the spread of infection. Additionally, the policy referred to an established water management program (WMP) to monitor and test the water system and identified the Maintenance Director as the WMP leader.Review of the facility's policy titled, Transmission Based Precautions [TBP], dated 04/21/2025, revealed the facility used appropriate transmission-based precautions based on residents' diagnoses and infection status. Per the policy, these precautions were implemented in addition to standard precautions to control the spread of infections. The policy stated contact precautions were specifically applied for residents suspected or confirmed to have infections that spread through direct or indirect contact, such as C. diff. Per the policy, care providers must wear gowns and gloves before entering the resident's room and practice hand hygiene after removing gloves and before leaving the room.Review of the facility's policy titled, Infection Control - Enhanced Barrier Precautions, dated 04/2025, revealed the facility implemented targeted glove and gown use to prevent the transmission of multi-drug-resistant organisms (MDROs). The policy stated staff used enhanced barrier precautions to provide high-contact care, which included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care, and wound care.Review of the facility's policy titled, Infection Control: Handwashing Policy, dated 04/21/2025, revealed the facility identified hand hygiene as the primary method for preventing the spread of infection. The policy defined hand hygiene as the process of cleaning hands with either soap and water or an alcohol-based hand rub (ABHR). It stated ABHRs should be used in all clinical situations, except when hands were visibly soiled or after caring for a resident with known or suspected infection with Clostridioides difficile (C. diff), a highly contagious bacterium that caused diarrhea and colitis. In these circumstances, staff was instructed to use soap and water.Review of the facility's policy titled, Medication Administration, undated, revealed staff must wash hands prior to administering medications per facility protocol. Further review revealed staff must conclude medication administration by washing hands using the facility's protocol and then sign the Medication Administration Record (MAR).Review of the facility's policy titled, Infection Control-Cleaning and Disinfection of Resident Care Equipment, dated 11/13/2024, revealed it stated, Reusable resident care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection.Review of the facility's policy titled, Oxygen Administration, revised date 04/2023, revealed it stated, Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. The policy also revealed the humidifier bottle should be changed when it was empty, every 72 hours, or per facility policy. 1. Review of R49's Face Sheet revealed the facility admitted R49 on 10/27/2023 with diagnoses of schizophrenia, hypertension, and heart failure.Review of R49's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/26/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, indicating moderate cognitive impairment.Review of R49's Orders, dated 08/07/2025, revealed an order for supplemental oxygen to keep oxygen saturations greater than 90 percent. Another order dated 08/25/2025 was to change and label all tubing and masks for oxygen every Sunday.Observation on 09/16/2025 at 2:30 PM, 09/17/2025 at 9:10 AM, and 09/18/2025 at 8:58 AM revealed R49 had oxygen tubing and humidification dated for 09/07/2025.During an interview on 09/17/2025 at 2:56 PM with Interim Director of Nursing (DON) 1, she stated oxygen tubing and supplies should be changed every Sunday on night shift. She stated the Unit Manager did audits to ensure they were getting changed. She stated it was important to follow the orders and to make sure the oxygen supplies and tubing stayed clean to prevent any further infection. 2. Review of R3's Face Sheet revealed the facility admitted R3 on 06/29/2022 with diagnoses of hemiplegia, diabetes, and vascular dementia. Review of R3's Orders, dated 05/26/2025, revealed EBP was ordered related to a pressure wound.Observation on 09/16/2025 at 5:45 PM revealed Certified Nurse Aide (CNA) 12 exited R3's room with a Hoyer lift, a resident under EBP precautions with EBP precautions signage on the door. CNA12 then placed it in the hallway outside of the room without cleaning or disinfecting it. During an interview on 09/16/2025 at 5:50 PM with CNA12, she stated shared equipment was cleaned after each use with bleach wipes. She stated she did not clean the Hoyer after using it because she did not have any bleach wipes. When asked how the next person would know that it was dirty, she stated it should be cleaned before and after each use. She stated the only education she received at the facility was safety, and it was a packet given to her from the front desk. She stated she read it, took a test, then turned it back into the front desk. During an interview on 09/17/2025 at 2:56 PM with Interim DON1, she stated Hoyer lifts should be cleaned after use with bleach wipes. She stated that was important to ensure infection could not spread.During an interview on 09/19/2025 at 3:23 PM with Director of Nursing (DON) 2, she stated it was her expectation that staff followed the equipment manufacturer's guidelines, including the Hoyer lift. 3. Review of R68's admission Record revealed the facility admitted the resident on 11/23/2022 with diagnoses to include cerebral infarction, muscle weakness, and dysphasia.Review of R68's quarterly MDS, with an ARD of 08/22/2025, revealed the facility assessed the resident to have a BIMS score of eight out of 15, indicating the resident was moderately cognitively impaired.Review of the September 2025 Order Summary Report revealed R68's active orders for 09/18/2025 included contact isolation precautions every shift for methicillin-resistant staphylococcus aureus (MRSA) in urine, with a start date of 09/03/2025.Observation on 09/17/2025 at 9:02 AM revealed Licensed Practical Nurse (LPN) 2 entered a contact precaution isolation room to assist R68 in the restroom. LPN2 did not don (apply) gloves or an isolation gown prior to contact with the resident and/or their environment. LPN2 exited the bathroom and room with bagged trash and linen, but she did not perform hand hygiene before exit. Continued observation revealed LPN2 reentered the room to assist R68 out of the bathroom. Upon exiting the room, LPN2 again failed to perform hand hygiene.During an interview with LPN2 on 09/17/2025 at 9:12 AM, she stated she did not put on gloves or an isolation gown before entering R68's room because she was just helping the resident quickly in the restroom and did not think it was necessary. When asked about hygiene practices, LPN2 stated she forgot to use hand sanitizer after leaving the room, and she should have performed proper hand hygiene. She stated she was aware of the facility's infection control policy, but she did not explain why she did not follow the CDC guidelines for contact precautions.4. Review of R15's Face Sheet revealed the facility admitted R15 on 11/06/2024 with diagnoses of heart failure, overactive bladder, and other disorders of the bladder.Review of R15's quarterly MDS, with an ARD of 08/25/2025, revealed the facility assessed the resident to have a BIMS score of nine out of 15, indicating moderate cognitive impairment.Review of R15's Care Plan, dated 11/06/2024, revealed R15 was care planned for an indwelling suprapubic catheter with an intervention to maintain integrity of the drainage system. Further review revealed the resident had interventions to include EBP, dated 11/20/2024.Review of R15's Orders, dated 01/31/2025, revealed an order which stated, Secure catheter to prevent tension and check placement every shift.Observation on 09/17/025 at 9:08 AM and 09/18/2025 at 8:59 AM revealed R15's indwelling catheter urine collection bag was observed lying on the floor without a barrier underneath.During an interview on 09/17/2025 at 2:56 PM with Interim DON1, she stated indwelling catheter bags should not be on the floor for infection control reasons.During an interview on 09/18/2025 at 5:36 PM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), she stated indwelling catheter collection bags should be hung below the level of the bladder and not touch the floor for infection control purposes. She stated if the collection bag was at risk for touching the floor when the bed was in the lowest position, then she would expect staff to find another way to hang it so it was below the level of the bladder and did not touch the floor. She stated her expectation was for staff to identify the issue and correct it or to make someone aware so that it could be changed out with a clean catheter bag. She stated the facility's staff should be following the facility's policies and the CDC IP guidelines to prevent infection. Observation on 09/18/2025 at 11:00 AM revealed CNA13 was in R15's room and had just finished cleaning her. CNA13 was not wearing any PPE, gown and gloves, and R15 was in enhanced barrier precautions. During an interview on 09/18/2025 at 11:00 AM with CNA13, she stated she should have worn PPE. She stated it was important to wear the proper PPE to prevent introducing any risk of potential bacteria to the residents.5. Review of R58's admission Record revealed the facility admitted the resident on 05/26/2018 with diagnoses to include Parkinson's disease, type 2 diabetes mellitus, and gastrostomy status.Review of R58's quarterly MDS, with an ARD of 07/22/2025, revealed the facility assessed the resident to have a BIMS score of 11 out 15 of, indicating the resident was moderately cognitively impaired.Review of the September 2025 Order Summary Report revealed the R58's active orders for 09/18/2025 included enhanced barrier precautions (EBP) every shift for gastrostomy tube (enteral feeding tube), with a start date of 04/21/2025.Observation on 09/17/2025 at 9:33 AM of CNA2 revealed she entered an enhanced barrier precaution (EBP) room to provide direct care to R58 without donning gloves and an isolation gown prior to contact with the resident and/or their environment. She placed contaminated bagged linen on the floor. Further observation revealed she changed the resident's urine-saturated bed, bagged the linens, and exited the room without performing hand hygiene. Continued observation revealed she took the dirty linen to the dirty utility room; however, she did not hand sanitize when she exited. Per observation, she then reentered R58's room and changed the bed without donning gloves and an isolation gown.Observation of CNA2 on 09/17/2025 at 9:40 AM revealed she removed a contaminated Hoyer lift (a mechanical lift used to transfer residents from one surface to another) after using it on R58 and put it in the clean storage area. CNA2 did not clean and disinfect the Hoyer lift after use on the resident.During an interview with R58 on 09/17/2025 at 9:42 AM, she stated most of the staff don't don gloves or an isolation gown while performing resident care activities such as changing her linens, assisting her out of bed, and providing her enteral feedings. R58 further stated she felt staff should follow facility policies to prevent the spread of infection and keep all residents safe.During an interview with CNA2 on 09/17/2025 at 9:47 AM, she stated she had been employed by the facility for three months and had received education to include IPCP when she reported to work. She stated she did not know she needed to wear a gown to change linen, make the bed, or transfer a resident under EBPs. According to CNA2, she stated it was only if she changed or bathed a resident. When asked why she did not use an isolation gown when she changed R58, she stated she forgot. She stated she was not educated to clean the Hoyer lift after use, and to her knowledge, she had never seen a shared equipment cleaning policy. During an interview with CNA5 on 09/18/2025 at 8:25 AM, he stated he received education recently on infection control by different nursing leadership. He stated PPE, TBP, and hand hygiene were covered during the training. When asked what should be done to the shared Hoyer lift after use on a resident, CNA5 stated he did not do anything. He stated he was not educated on cleaning and disinfection of shared equipment, but stated, I'm pretty sure you're supposed to wipe it [Hoyer lift] down after each resident use.6. Observation on 09/17/2025 at 9:55 AM revealed CNA1 walked down the hall holding unbagged linen against her person and disposed of them in the dirty utility room. She did not perform hand hygiene. She went immediately to the clean linen closet and pulled multiple bed linens and towels from the shelf and held them against her person.7. Observation on 09/17/2025 at 11:00 AM revealed CNA1 took clean linen out of the linen closet. CNA1 piled the linen on her arm and against her person.During an interview with CNA1 on 09/17/2025 at 9:55 AM, she stated she had never been educated on the process of holding linen away from her person. CNA1 stated the linen was not dirty, but she was cleaning out the unused linen from a resident's room. When asked how linen should be transported, CNA1 stated, I don't know. How am I supposed to do it? CNA1 stated she had received infection control training that included PPE, hand hygiene, and transmission-based precaution (TBP) education upon hire.8. Observation on 09/18/2025 at 8:10 AM revealed LPN1 prepared and administered medications to a resident. She exited the resident's room without washing or sanitizing her hands. Further observation revealed LPN1 moved to R82's room and began preparing her medications without sanitizing her hands. Continued observation revealed she performed hand hygiene only after the State Survey Agency (SSA) Surveyor asked about the expectation for hand washing during medication administration.During an interview with LPN1 on 09/18/2025 at 8:53 AM, she stated it was an expectation to perform hand hygiene between each resident during medication administration, and it was important for infection control.During an interview with Registered Nurse (RN) 1 on 09/18/2025 at 9:07 AM, she stated it was expected that staff giving medications would sanitize their hands between residents due to infection control. During an interview with Unit Manager (UM) 1 on 09/19/2025 4:45 PM, he stated the expectation was to use hand sanitizer between each resident's medication administration. He stated it was important to have correct hand hygiene for infection control. During an interview with Director of Nursing (DON) 2 on 09/19/2025 at 4:13 PM, she stated her expectation with hand hygiene during medication administration was to use hand sanitizer between each resident. She stated it was important to ensure resident safety and for infection control purposes. During an interview with the Administrator on 09/19/2025 at 2:04 PM, she stated she expected the nurses to wash or sanitize hands between each resident during medication administration. She stated that was important and necessary for infection control.9. Review of R55's admission Record revealed the facility admitted the resident on 06/28/2025 with diagnoses to include enterocolitis due to C. diff, chronic obstructive pulmonary disease, and chronic kidney disease.Review of R55's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/05/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15, indicating the resident was moderately cognitively impaired.Review of the September 2025 Order Summary Report revealed the R55's active orders for 09/18/2025 included contact isolation precautions every shift for C. diff, with a start date of 09/15/2025.Observation on 09/18/2025 at 3:20 PM revealed CNA7 was in R55's room, where the resident was on contact isolation precautions for C. diff, and she was not wearing gloves or an isolation gown. CNA7 touched the end of the bed and the overbed table when she was in the room. The CNA did not perform hand-hygiene using soap and water before she exited the room. CNA7 used alcohol-based hand rub after she exited the room.During an interview with CNA7 on 09/18/2025 at 3:28 PM, when asked about the reason for the resident being on contact precautions, CNA7 stated she did not know. CNA7 stated she had not intended to provide direct care to the resident and therefore did not believe she needed to don gloves or an isolation gown. She stated she did not know the CDC guidelines to use soap and water for hand hygiene in the case of a resident with C. diff, rather than an alcohol-based hand rub. Additionally, CNA7 did not state her understanding of the significance of wearing personal protective equipment (PPE) before entering the room of a resident with an active C. diff diagnosis. Furthermore, after the interview, CNA7 walked to the unit's common area and kitchenette and washed her hands in the kitchen sink.10. Review of the facility's documentation related to their water management revealed there was no documentation of a process flow diagram describing the building's water system where water flowed in the cold-water distribution, heating of water distribution, and then waste water; and to help identify areas where legionella could spread and grow.During an interview with the Maintenance Director on 09/19/2025 at 9:08 AM, regarding the facility's water management plan (WMP), he provided a binder with documentation on water temperature monitoring, legionella control documentation, and maintenance logs. He stated a third-party contractor did the disinfecting and testing of the water, but it had not been completed for 2025. He further stated he did not have a water flow diagram, and anything related to the plan, including the flow diagram, would be in the binder if one existed. When asked for the facility's WMP he opened the binder to a copy of the CDC's toolkit for developing a water management plan, which represented a CDC guide to implementing a WMP and not a facility specific WMP. The Maintenance Director stated, Well that's all we have; what's in the book.During an interview with Unit Manager (UM) 1 on 09/18/2025 at 10:56 AM, he stated all staff had been educated on the appropriate use of PPE, different types of TBPs, and hand hygiene. He stated nursing leadership had conducted infection control audits and did not observe non-compliance. He stated it was his expectation for all staff to follow facility policy related to proper PPE while in a TBP/EBP room, the cleaning and disinfection of shared equipment, and to always perform hand hygiene before and after providing care to the resident. He stated it was important to prevent the spread of communicable diseases.During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 09/19/2025 at approximately 1:45 PM, she stated it was her expectation for all staff to follow the facility policies regarding infection prevention and control practices. She stated all staff was educated on facility policies and CDC guidelines. Furthermore, she stated it was her expectation for staff to perform hand hygiene according to CDC standards, use personal protective equipment as required, and follow cleaning and disinfection protocols for shared equipment. The ADON/IP further stated staff was instructed to handle and transport linen according to infection control guidelines. According to the ADON/IP, the Maintenance Director was responsible for the water management plan and to comply with the facility's water management program. The ADON/IP stated it was important for all staff to consistently follow infection prevention and control practices to help prevent the spread of infection among residents, staff, and visitors.During an interview with the Director of Nursing (DON) 2 on 09/19/2025 at 7:45 AM, she stated it was her expectation that all staff follow CDC guidelines and facility policy related to infection control and prevention. She stated her expectation was that staff had the knowledge and understanding of protocols to protect residents, staff, and visitors. The DON stated it was her expectation that nursing leadership had audits and observed staff, observed return demonstrations, and provided guidance related to infection control protocols. She stated it was important to prevent the spread of communicable disease and for the safety and well-being of residents, staff, and visitors.During an interview with the Administrator on 09/19/2025 at 2:04 PM, she stated all staff were expected to follow CDC regulations and facility policies regarding infection prevention and control protocols. She stated it was important to mitigate the spread of infection and disease. She stated nursing leadership had performed random audits of staff and found no issues related to hand hygiene, use of appropriate PPE, or failure to clean shared equipment. The Administrator stated there was no written Water Management Plan (WMP) or water management policy in place, and she was unsure whether a flow diagram existed to describe the building's water system. She stated having a flow diagram was necessary for infection prevention and control, as it would assist in identifying areas where Legionella could spread and grow. Furthermore, she stated the importance of a WMP was to mitigate Legionella and other waterborne illnesses.

Based on observation, interview, and review of the facility's document and policy, the facility failed to provide food at safe serving temperatures. Observation on 09/16/2025 of residents' supper trays on the cart revealed the foods to be served were not at safe temperatures for 5 of 18 sampled residents, Resident (R)14, R46, R57, R63, and R81. The findings include:Review of the facility's policy titled, Dining Services Food Preparation Guideline, dated 07/01/2024, revealed no foods were to remain unrefrigerated for a period of more than one hour to prevent the food's temperature from being in the danger zone, which was 41 degrees Fahrenheit (F) to 135 degrees (F). Per the policy, the Hazard Analysis Critical Control Point (HACCP), was a method that identified the period when potentially hazardous food, (meat, milk, egg products, and pudding etc.) were most likely to be in the temperature's danger zone of 41 degrees F to 135 degrees F. The policy stated the temperature danger zone provided the ideal condition for bacteria and other microorganisms to grow rapidly. The policy stated that could contaminate the food to the point where foodborne illness could result.Review of the facility's document Food Temperature Recording Log, dated 09/16/2025, revealed the food temperatures at the supper time-of-service were chicken salad, 39 degrees F; tuna salad, 38 degrees F; egg salad, 39 degrees F; fruit 38 degrees F; and soup 181 degrees F.Observation of the St. [NAME] Pavilion Unit on 09/16/2025 at 5:30 PM revealed the dinner trays were delivered to the unit. Further observation at 5:45 PM revealed five supper trays were still undelivered and on the food cart. Per staff, the remaining five trays on the cart were for residents who were in a meeting. Observation of the food temperatures on 09/16/2025 at 6:00 PM with the Assistant Dietary Manager of the meal tray with no meal slip, revealed the applesauce was 74 degrees F, the water was 75 degrees F, the lemonade was 74 degrees F, the raspberry sherbert was melted at 23 degrees F, the fresh fruit (honeydew and cantaloupe) was 70 degrees F, the chicken salad was 71 degrees F, the tuna salad was 69 degrees F, the egg salad was 70 degrees F, and broccoli cheddar soup was 101 degrees F.In an interview with the Assistant Dietary Manager on 09/16/2025 at 6:15 PM, he stated hot food in the kitchen on the steam table should be held at 135 degrees F. He stated his expectation was for hot food to reach the units at 100 degrees F and for cold food to reach the units at 55 degrees F [both temperatures in the danger zone]. He stated, on 09/16/2025 for the supper service, the plates were not cold because staff forgot to take the plates out of the warmer prior to service. The State Survey Agency (SSA) Surveyor stopped the Assistant Dietary Manager on 09/16/2025 at 6:20 PM and had him remove the five trays still on the cart and remake them for R14, R46, R57, R63, and R81 who had not returned from the meeting.In an interview with the Dietary Manager on 09/18/2025 at 8:44 AM, he stated for serving, temperatures should not be over 40 degrees F for cold food; at 165 degrees F for hot meat; at 165 degrees F for hot vegetables; and 180 degrees F for hot soup. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on 09/19/2025 at 11:04 AM, she stated the resident's tray should be returned to dietary if the resident was not present for the meal, and a new tray sent to the resident. In an interview with the Administrator on 09/19/2025 at 9:57 AM, she stated new trays should be made for residents when they were not present at mealtime.

Based on interview, record review, and review of the facility's policies, the facility failed to provide resolutions and/or provide documentation on resolutions related to reported missing items in the Resident Council meeting on 08/21/2025 for 2 out of 14 sampled residents, Resident (R) 52 and R57. The findings include:Review of the facility's policy titled, Resident Rights, dated 04/21/2024, revealed the facility would protect and promote the rights of the resident and afford each resident his or her basic right to be treated with dignity and respect. Per the policy, the facility would ensure all residents were afforded their right to a dignified existence, self-determination, and respect. The policy also stated all personnel were required to protect and promote the rights of each resident, as well as encourage and assist each resident in the fullest possible exercise of their rights. Review of the facility's policy titled, Complaint and Grievance Policy, effective 03/14/2024, revealed the Administrator was responsible to ensure the investigation of grievances and complaints. Per the policy, the Administrator might designate the Social Services Director or a different designee who would serve as the Grievance Coordinator. The policy stated the Grievance Official was responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; and issuing written grievance decisions to the resident.Review of the Resident Council minutes for the meeting held on 08/21/2025 at 11:00 AM, revealed R52 reported missing a white tee shirt, polo shirt, and one pair of navy-blue back-flap slacks with broadcloth-like fabric. Per the minutes, R52 had received no resolution. The minutes also stated R57 reported missing a pair of white leather gym shoes for eight months with no resolution.1. Review of R52's Face Sheet revealed the facility admitted the resident on 01/11/2021 with diagnoses of multiple sclerosis, neuromuscular scoliosis thoracolumbar region, and cranial nerve disorders in diseases classified elsewhere.Review of R52's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/03/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 of 15, indicating he was cognitively intact.Review of the facility's form Missing Property, dated 05/28/2025, revealed R52 reported to Social Services he was missing a polo shirt since summer/fall of 2024, with no resolution given.Review of the facility's form Missing Property, dated 08/26/2025, revealed R52 reported to Social Services he was missing one white tee shirt, with no resolution given.Review of the facility's form Missing Property, dated 09/15/2025, revealed R52's sister emailed the facility to report R52 was missing a pair of navy blue, back-flap slacks, with broadcloth fabric. Further review revealed the email was sent to the Director of Housekeeping, with no resolution given.2. Review of R57's Face Sheet revealed the facility admitted the resident on 01/12/2024 with diagnoses of unspecified convulsions, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and general anxiety.Review of R57's quarterly MDS, with an ARD of 05/15/2025, revealed the facility assessed the resident to have a BIMS score of 14 of 15, indicating she was cognitively intact.Review of the facility's form Missing Property, dated 05/09/2025 revealed R57 reported missing two clear shower caddies and a pair of white gym shoes. Per the form, the two-shower caddies were replaced; however, R57's white gym shoes were not replaced with no resolution given to the resident.During an interview with the former Social Services Director (SSD) on 09/19/2025 at 2:06 PM, she stated when she was an employee at the facility, anytime a grievance was reported to her she would immediately document the report, report to the correct department the grievance concerned, and start an investigation. She stated the facility was the resident's home, and if any items were broken, lost, or stolen at the facility, the facility was responsible for the replacement. She stated all residents had the right for a resolution for any grievance filed within one to two business days. During an interview with Director of Nursing (DON) 2 on 09/19/2025 at 3:35 PM, she stated she only had been employed by the facility for two days. She stated she was unsure and did not want to speak out of turn about addressing grievances she had no knowledge about. During an interview with the Administrator on 09/19/2025 at 3:00 PM, she stated she was more familiar with current grievances and was working to provide resolutions to the residents. She stated for the older grievances that had been filed, she planned to review them and provide resolutions to the residents. She stated with the change in staff at the facility recently, a lot of responsibilities had not been completed. She stated all grievances should be documented by staff once a resident expressed a concern. She stated grievances should be turned into her office so she could open an investigation. She stated she believed all staff had been informed how to complete a grievance form. She stated staff knew where the forms were located and knew to bring them to her office.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, including ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 residents sampled for dialysis services, Resident (R) 7. The findings include:Review of the facility's policy titled, Dialysis, dated 08/31/2023, revealed the home [facility] will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; ongoing assessment and oversight of the resident before and after dialysis treatment, including monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practice; [and] ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The policy also stated, The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications.Review of the facility's Dialysis Agreement, dated 11/13/2006, revealed the agreement stated, [The] facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to center. This information, shall include, but is not limited to, where appropriate, the following: designated residents name, address, date of birth , and social security number; name, address, and telephone number of the designated residents next of kin; designated residents third party payor data and copies of cards or certificates evidencing same; appropriate medical records, including history of the designated resident's illness, including laboratory and x ray findings; treatment presently being provided to the designated resident, including medications and any changes in the patient's condition (physical or mental), change of medication, diet, or fluid intake; name, address, and phone number of the nephrologists with admitting privileges at center referring the designated residents to center; any advance directive executive by the designated resident; [and] any information that will facilitate the adequate coordination of care, as reasonably determined by center. Review of the facility's Dialysis Communication form revealed it should be completed by the facility and sent to the dialysis clinic with the resident to include resident name, visit date, vital signs, access assessment, level of consciousness, speech/communication, medications prior to transport to the dialysis clinic, any labs/test results, and time sent to dialysis. Further review revealed the dialysis facility should complete their portion after dialysis to include vital signs, amount of fluid removed, access assessment, level of consciousness, speech/communication, medications prior to transport to the facility, any labs/test results, and time sent back to the facility. The form should be sent back to the facility with the resident.Review of R7's Face Sheet revealed the facility admitted R7 on 08/17/2023 with diagnoses of end stage renal disease (ESRD), diabetes, and depression.Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/17/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating R7 was cognitively intact.Review of R7's Care Plan revealed R7 had hemodialysis added as a focus on 08/17/2023 with an intervention to provide/receive written communication with dialysis center for every treatment. Review of R7's Dialysis Form revealed five completed forms received from the facility over the last three months, dated 06/27/2025, 06/30/2025, 07/02/2025, 07/04/2025, and 09/17/2025.Review of R7's Orders, revealed an order, dated 08/17/2023, for hemodialysis treatments three times per week, every Monday, Wednesday, and Friday.During an interview on 09/18/2025 at 9:02 AM with R7, she stated she was not usually given a form to take to dialysis with her. During an interview on 09/18/2025 at 9:08 AM with Registered Nurse (RN) 1, she stated she had been employed at the facility for about a month and had never heard of a dialysis form. She stated she had never sent anything with R7 to dialysis and had never received anything from dialysis. She stated she had never communicated in any way with the dialysis clinic. During an interview on 09/18/0225 at 10:20 AM with RN2, he stated the facility used dialysis transfer forms that should be sent with R7 to each dialysis treatment. He stated, It is sporadic, a lot of times. He stated the dialysis center did not fill it out, and/or R7 did not bring it back from dialysis. He stated it was important to have communication so the facility would know how R7 did during dialysis or for any medication changes. He stated the binder with the blank forms was kept at the nurse's station. During an interview on 09/19/2025 at 9:12 AM with the dialysis clinic's hemodialysis (HD) RN, she stated R7 came with a form sometimes but not consistently. She stated the communication form would get completed by the dialysis clinic if the form was sent, and R7 only recently started to bring one. She stated the form was not in a binder or folder, and it was usually just a loose piece of paper that was folded up in the resident's purse. She stated the resident did not have it for all dialysis days.During an interview on 09/19/2025 at 3:23 PM with Director of Nursing (DON) 2, she stated it was her expectation that dialysis communication be done for continuity of care. She stated it was also important so the facility staff understand where the resident may be fluid wise and know how much fluid was removed and the overall health of the resident to ensure there is communication back and forth. She stated she had been only briefly at the facility, so she could not comment on R7's lack of Dialysis Communication forms.During an interview on 09/19/2025 at 2:04 PM with the Administrator, she stated the Dialysis Communication forms were important in preventing lapses of communication and for residents' continuity of care. She stated it was her expectation they be completed. She stated she did not know why these forms had not been completed. She stated she had not educated staff regarding this form and had not performed audits on its completion.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with professional standards. This affected 2 of 5 medication carts. The findings include:Review of the facility's policy titled, Medication Storage, undated, revealed the facility would ensure all medications housed on the premises would be stored in the medications rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Further review revealed medications to be administered by mouth were stored separately from other formulations, such as eye drops, ear drops, and injectables. 1. Observation of the [NAME] Unit medication cart on [DATE] at 3:01 PM revealed an unlabeled strip of Dulcolax (bisacodyl, for constipation) tablets in a commercial type of blister pack with nine pills missing and 16 remaining, dated on a strip of tape on the back and stored with R82's medications. Further observation revealed R52's albuterol inhalation Aerosol HFA was stored with oral medications. 2. Observation of the St. [NAME] Unit medication cart on [DATE] at 4:45 PM revealed four insulin pens stored loosely, without a full label and not in separate packaging. During an interview with Licensed Practical Nurse (LPN) 5 on [DATE] at 4:45 PM, she stated her experience was insulin pens were maintained in the cart with the same resealable bag in which it was delivered by pharmacy. She stated this was important for infection prevention and control and that labeling was important for safety.During an interview with LPN5 on [DATE] at 9:19 AM, she stated they did not have any residents with insulin orders on her current unit. However, she stated when they did, they stored insulin pens in the fridge until ready to use, then kept them in the top drawer of the medication cart in the resealable bag with the resident's label the pharmacy sent. She stated this was for infection control, to prevent cross contamination. She stated it was important to store medications for different routes separately, also for infection control.During an interview with Registered Nurse (RN) 4 on [DATE] at 3:01 PM, she stated it was important to have medications correctly labeled to prevent giving a resident medication intended for someone else, as they could be allergic or have an adverse reaction. She stated it was important to store medications, including insulin pens, correctly to prevent cross contamination.During an interview with RN1 on [DATE] at 1:50 PM, she stated she thought the expectation was to store insulin pens in individual bags in the medication cart, and that was important for infection control.During an interview with Unit Manager 1 on [DATE] at 4:45 PM, he stated his expectation was that insulin pens, once opened and dated, should be stored in the cart in its individual bag with the label. During an interview with Director of Nursing (DON) 2 on [DATE] at 4:13 PM, she stated her expectation was medications should be clearly labeled for each resident. She stated if opening a new item that expired, it should be dated. She stated oral medications should be separated from inhalers, eye drops, and topicals, and each had their own separate space in the cart. She stated insulin pens should be clearly labeled with resident name, which was usually done by the pharmacy, pen caps on. She stated she had always stored insulin pens in their own bags. She stated that was for infection control and to prevent cross contamination. During an interview with the Administrator on [DATE] at 2:04 PM, she stated her expectation was that medications were stored properly and that insulin pens were stored in their individual bags for infection control.

Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. Additional information the resident and the resident's representation were not given, and which should have been on the notice included the date, location for the transfer, the resident's appeal rights, and the contact information for the state Long-Term Care Ombudsman. This deficient practice affected 3 of 3 sampled residents, Resident (R) 6, R10, and R66. The findings include: Review of the facility's policy titled, Discharge and Transfer from the Facility, effective date 04/21/2024, revealed for emergency transfers such as when a resident was transferred on an emergency basis to an acute care facility, that type of transfer was considered to be a facility-initiated transfer, and a notice of transfer must be provided to the resident and the resident's representative as soon as practicable. Per the policy, copies of notices for emergency transfer must also be sent to the ombudsman, but they could be sent when practicable, such as a list of residents on a monthly basis. Review of R6's Face Sheet revealed the facility admitted the resident on 05/23/2025 with diagnoses of Alzheimer's disease, type 2 diabetes mellitus with hyperglycemia, and acute kidney disease. Review of R6's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/29/2025, revealed the facility assessed the resident to have a Brief Interview for Minimum Status [BIMS] score of two of 15, indicating severe cognitive impairment. Review of R6's Health Status Note, dated 06/03/2025, revealed he was hospitalized on [DATE] for a fall that resulted in a fracture to his right hip and was status post an open reduction and internal fixation (ORIF) of the right hip fracture.Review of R6's electronic medical record (EMR) revealed there were no copies of a transfer/discharge notice or a bed hold notice.The State Survey Agency (SSA) Surveyor attempted to interview R6 on 09/18/2025 at 8:37 AM, but he was not interviewable.In an interview on 09/19/2025 at 9:18 AM with Family Member (F) 10 for R6, she stated the facility called her about R6's transfer to the hospital and verbally discussed the bed hold option. She stated she could not remember if a letter for the bed holds and transfer/discharge was sent to her.2. Review of R10's Face Sheet revealed the facility admitted the resident on 05/01/2025 with diagnoses of Alzheimer's disease, bipolar disorder, and hypertension.Review of R10's Nursing Home Comprehensive Set Minimum Data Set, dated 07/02/2025, revealed she was assessed as having a BIMS score of seven of 15, severe cognitive impairment. Review of R10's Health Status Note, dated 06/12/2025, revealed she was sent to the emergency room for a mental health evaluation due to behaviors. Review of R10's electronic medical record (EMR) revealed there were no copies of a transfer/discharge notice or a bed hold notice.The SSA Surveyor attempted to interview R10 on 09/18/2025 at 8:43 AM, but she was not interviewable.In an interview on 09/19/2025 at 9:30 AM with F11 for R10, he stated he never received a bed hold and transfer/discharge letter for R10, but the facility did call him and discuss both with him.3. Review of R66's Face Sheet revealed the facility admitted the resident on 05/24/2025 with diagnoses of Alzheimer's disease, dementia, and repeated falls.Review of R66's Nursing Home and Swing Bed MDS, dated 07/17/2025, revealed she was not assessed for a BIMS score. Further assessment of her EMR did not reveal any BIMS assessments. Review of R66's Health Status Note, dated 07/03/2025, revealed she was sent to a mental health facility for behaviors.Review of R66's electronic medical record (EMR) revealed there were no copies of a transfer/discharge notice or a bed hold notice.The SSA Surveyor attempted to interview R66 on 09/18/2025 at 8:48 AM, but she was not interviewable.In an interview on 09/19/2025 at 9:44 AM with F12 for R66, he stated he did not receive a bed hold letter and/or a transfer/discharge letter for R66. He stated the facility only called and told him R66 was being sent to the hospital. In an interview on 09/18/2025 at 10:11 AM with Registered Nurse (RN) 1, she stated she did not know who sent the bed hold and transfer/discharge letters to the family of the resident when they were sent to the hospital. She stated she did send a transfer/discharge letter with the resident to the hospital. In an interview on 09/18/2025 at 11:26 AM with RN2, he stated transfer/discharge letters were sent out to the resident's representative by the Social Services Director (SSD). In an interview with the SSD on 09/18/2025 at 2:22 PM, she stated she did not send out the bed hold and discharge/transfer letters.In an interview with the Assistant Director of Nursing (ADON) on 09/19/2025 at 9:55 AM, she stated she did not know if the bed holds and discharge/transfer letters were mailed to the resident's representative or the ombudsman. In an interview with Director of Nursing (DON) 2 on 09/19/2025 at 10:00 AM, she stated she had only worked at the facility for three days and was also unsure if the facility sent out bed hold and discharge/transfer letters/notices to the resident's representative when they were discharged to the hospital. In an interview with the Administrator on 09/18/2025 at 2:45 PM, she stated she did not have access to the bed hold and/or discharge/transfer letters/notices that were mailed out to the families of residents when the residents were transferred to the hospital. She stated she was unsure who, if anyone, sent those letters. She stated she had only been the Administrator for approximately three months and was unaware of the policy. She stated she had not found copies of the old letters, and she thought the previous Administrator did not send out the letters.

Based on interview, record review, review of the facility's investigation, and review of the facility's policies, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 23 sampled residents, Resident (R) 7.The findings include:Review of the facility's policy titled, Accidents and Supervision, no date, revealed it stated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.Review of the facility's policy titled, Resident Care-Safe Resident Handling/Transfers, dated 10/01/2024, revealed it stated, It is the policy of this home to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy also revealed two staff members must be used to transfer residents with a mechanical lift. Review of R7's Face Sheet revealed the facility admitted the resident on 08/17/2023 with diagnoses of end stage renal disease (ESRD), diabetes, and depression.Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/17/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating intact cognition.Review of R7's Care Plan, dated 06/30/2025, revealed R7 had an Activities of Daily Living (ADL) self-care performance deficit related to weakness, with an intervention for transfers requiring a mechanical lift with two staff assistance.Review of R7's Investigation, dated 08/02/2025, revealed the incident with R7 occurred on 08/01/2025 at 7:56 PM. Further review revealed a witness statement, with no date or time listed, by Certified Nurse Aide (CNA) 16 that stated CNA16 was asked to assist with R7. Per the statement, CNA16 reported when he entered R7's room, R7 was up in the Hoyer [a mechanical lift used to transfer residents from one surface to another]. Additional review revealed a witness statement from R7, with no date or time listed. Per the statement, R7 reported she was left in the air in the Hoyer lift, while CNA14 and CNA15 left to get assistance from CNA16.During an interview on 09/18/2025 at 9:02 AM with R7, she stated both aides (CNA14 and CNA15) walked out of her room while she was suspended in the air in the Hoyer lift on 08/01/2025.During an interview on 09/17/2025 at 6:11 PM with CNA16, he stated that 08/01/2025 was a rough day. He stated he was working with two aides that did not normally work in his area, and they refused to do any weights or any showers. He stated he was in the middle of doing his rounds, and the aides came to him and told him that R7 was requesting him. He stated when he entered R7's room, along with CNA15, he saw R7 in the air in the Hoyer lift. He stated he did not recall any staff member being in there with her. He stated he assisted R7 to her chair, and CNA15 continued to argue with R7 before leaving the room. He stated he reported the incident to Director of Nursing (DON) 2 at the time.During an interview on 09/17/2025 at 4:33 PM with CNA14, she stated R7's complaint was false, and she was terminated for the accusations. CNA14 stated, No residents were left in a Hoyer lift on my shifts.During an interview on 09/17/2025 at 6:21 PM with CNA15, she stated when she walked out to ask CNA16 for assistance, she left CNA14 in the room. CNA15 denied walking out of R7's room, leaving R7 alone in the Hoyer lift.During an interview on 09/17/2025 at 2:56 PM with Director of Nursing (DON) 2, she stated the R7 Investigation determined CNA14 and CNA15 did leave R7 in the Hoyer lift and walked out of her room. She stated, based on this, they were both terminated, CNA15 on 07/31/2025 and CNA14 on 08/13/2025. She stated two staff members should be with a resident anytime a Hoyer lift was being used for the resident's and staff's safety. During an additional interview on 09/19/2025 at 3:23 PM with DON2, she stated her expectation was for staff to follow the manufacturer's guidelines for equipment, to be checked off on competency skills, and be able to perform tasks appropriately while maintaining the safety of the residents. During an interview on 09/19/2025 at 2:04 PM with the Administrator, she stated she was aware of gaps and deficits with the facility staff. She stated she would expect the facility to identify concerns and improve the process of onboarding to ensure staff had 100 percent competencies. She stated that was important for resident safety.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 29 sampled residents, Resident (R) 15, R16, and R80. The findings include: Review of the facility's policy titled, Catheter Care, revised date 04/24/2025, revealed residents with indwelling catheters maintained their dignity and privacy. The policy stated, Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of the facility's policy titled, Resident Rights-Promoting and Maintaining Resident Dignity, dated 03/16/2023 and revised on 06/16/2025, revealed it stated, It is the practice of this home [facility] to provide 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 residents' quality of life by recognizing each resident's individuality. The policy also revealed that resident privacy would be maintained. Review of the facility's policy titled, Resident Rights-Promoting and Maintaining Resident Dignity During Mealtimes, dated 03/16/2023, revealed it stated, Residents should be served one table at a time. Per the policy, all staff members involved in providing feeding assistance to the residents promoted and maintained resident dignity during mealtimes. 1. Observations on 09/16/2025 at 2:35 PM, 09/17/2025 at 9:08 AM, and 09/18/2025 at 8:59 AM, revealed R15's indwelling urinary catheter bag did not have a dignity cover. Review of R15's Face Sheet revealed the facility admitted R15 on 11/06/2024 with diagnoses of heart failure, overactive bladder, and other disorders of the bladder. Review of R15's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/25/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating R15 had moderate cognitive impairment. Review of R15's Care Plan, dated 11/06/2024, revealed the resident was care planned for an indwelling suprapubic catheter with an intervention to maintain integrity of drainage system. Review of R15's Orders, revealed an order, dated 01/31/2025, stating secure catheter to prevent tension and check placement and catheter care every shift. The SSA Surveyor attempted to interview R15 on 09/17/2025 at 9:08 AM and on 09/18/2025 at 8:59 AM. However, the resident was sleeping both days, and the catheter was on the left side of the bed (door side) on the floor with no dignity bag. During an interview on 09/17/2025 at 2:56 PM with the Interim Director of Nursing (DON) 1, she stated indwelling catheters should have a dignity bag in place for resident privacy. During an interview on 09/18/2025 at 11:00 AM with Certified Nurse Aide (CNA) 13, she stated she had not seen a dignity bag in the facility and was not aware of where they were kept. During an interview on 09/19/2025 at 3:23 PM with DON2, she stated it was her expectation that all catheters had a dignity bag in place for the privacy of the residents. During an interview on 09/19/2025 at 2:03 PM with the Administrator, she stated every catheter bag should be covered for resident dignity. 2. Observation of the dinner meal service on 09/16/2025 revealed the first round of dinner trays were delivered to the 100 Unit at 5:24 PM. Six residents were seated at one table, and trays were delivered to five of them. The sixth resident, R80, was not given her tray until 5:47 PM. Review of R80's Face Sheet revealed the facility admitted R80 on 11/29/2022 with diagnoses of dementia, stroke, and anxiety. Review of R80's annual MDS, with an ARD of 08/04/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. During an interview on 09/18/2025 at 10:59 AM with R80, she stated she always received her meals later than her tablemates. When asked how she felt about that she declined to answer. During an interview on 09/19/2025 at 3:23 PM with DON2, she stated it was a dignity concern if a resident had to sit and watch other people eat. She also stated food palatability became a concern with a delay in service. During an interview on 09/19/2025 at 2:04 PM with the Administrator, she stated she was not sure if there was ever a solid system in place with the dietary department and passing of meal trays. She stated a resident not being served at the same time as their tablemates was a problem because that resident was the only one who got served late. She stated R80 did not get to eat with other residents. 3. Observation on 09/18/2025 at 8:55 AM revealed Certified Nurse Aide (CNA)10 loudly calling R16 a feeder in the dining room in front of other staff and residents. Review of R16's Face Sheet, revealed the facility admitted the resident on 12/09/2023 with diagnoses of late onset Alzheimer's disease, degenerative disease of the nervous system, and nontraumatic subarachnoid hemorrhage. Review of R16's quarterly MDS, with an ARD of 08/09/2025, revealed it had no BIMs score listed. An interview was attempted with R16 on 09/18/2025 at 9:10 AM, but she was unable to carry on a conversation due to her Alzheimer's disease. During an interview with CNA10 on 09/18/2025 at 10:28 AM, she stated she did not think that calling a resident a feeder was a dignity issue. During an interview with Licensed Practical Nurse (LPN) 2 on 09/18/2025 at 10:11 AM, she stated calling a resident a feeder out loud and in front of them and other staff and residents was a dignity issue. During an interview with Registered Nurse (RN) 2 on 09/18/2025 at 11:26 AM, he stated calling a resident a feeder was a dignity issue. During an interview with the Assistant Director of Nursing (ADON) on 09/19/2025 at 9:55 AM, she stated she did not like the terminology feeder, and the staff member that used it should be corrected. In an interview with Director of Nursing (DON) 2 on 09/19/2025 at 10:00 AM she said calling a resident a feeder was a dignity issue. She stated some staff had been in the healthcare industry so long they remember when that was what they called residents who needed assistance feeding themselves or needed to be fed. In an interview with the Administrator on 09/19/2025 at 10:05 AM, she stated it was not her expectation of staff for them to call those residents who needed to be fed a feeder, and it was a dignity issue.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure that all residents were informed and provided written information concerning the right, at the resident's option, to formulate an advance directive for 2 of 29 sampled residents, Resident (R) 2 and R37. Review of the residents' electronic medical records revealed there was no advance directive information for R2 and R37, and the facility did not produce documentation demonstrating advance directive information had been provided.The findings include: Review of the facility's policy titled Advance Directive and Care Planning Policy, effective 04/21/2024, revealed the facility would provide residents with information and education of their rights as well as to promote the residents' right to formulate an advance directive and to assist the resident in the exercise of those rights. Further review revealed resident choices would be incorporated into their plan of treatment, care, and services. Continued review revealed upon admission, the facility would identify if the resident had an advance directive and if not, determine if the resident wished to formulate one. The review also revealed a resident had the option to execute an advance directive but was not required to do so, and examples included a Living Will, a Directive to the Attending Physician, a Durable Power of Attorney for Health Care, a Medical Power of Attorney, a pre-existing medical order for Do Not Resuscitate or another document directing the residents' health care. Additional review revealed the facility was permitted to contract with other entities to furnish the information, but the legal responsibility remained with the facility to ensure the requirement was met. Further review revealed the facility would identify the primary decision maker and assess the resident's decision-making capacity through accepted standards of practice and according to regulation and plan for an appropriate resident representative for the resident assessed as unable to make health care decisions. Further review revealed if a resident was incapacitated at admission and unable to receive information or articulate whether an advance directive was previously executed, the facility would give advance directive information to the resident representative in accordance with state law. Continued review revealed all advance directive document copies must be obtained and located in the Electronic Medical Record (EMR), be readily retrievable, and all copies would be communicated in the care plan.1.Review of R2's admission Record revealed the facility admitted the resident on 07/02/2025 with diagnoses including acute and chronic respiratory failure with hypoxia, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and malignant neoplasm of larynx. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/09/2025, revealed no score for Section C, Cognitive Patterns. Review of the Advance Directive tab in R2's electronic medical record (EMR), revealed a signed Do Not Resuscitate [DNR] document. However, there was no documentation of R2's Advance Directive.Review of R2's Care Plan revealed a focus, dated 07/07/2025, indicating he had chosen specific advance directives and a goal that his advance directives would be honored through the next review date. The Care Plan also had an intervention that stated, Resident is a DNR.Interview with R2 was unsuccessful due to his non-verbal status. The State Survey Agency (SSA) Surveyor attempted to interview R2's Representative Party in R2's room on 09/16/2025 at 4:04 PM. However, the attempt failed due to the representative being occupied with a hospice consult and admission for R2. 2. Review of R37's admission Record revealed the facility admitted the resident on 05/29/2025 with diagnoses including psychotic disturbance, mood disturbance and anxiety, monoplegia of upper limb following cerebral infarction affecting right dominant side, and bipolar disorder. Review of R37's quarterly MDS, with an ARD of 09/05/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated she was cognitively intact. Review of R37's Care Plan revealed a focus, dated 05/30/2025, indicating she had chosen specific advance directives and a goal that her advance directives would be honored through the next review date. Further review revealed an intervention for the goal which stated, Discussed Advanced Directives/DNR with resident and/or appointed health representative. Also, in the Care Plan was a revised intervention, dated 06/11/2025, which stated, Resident is a DNR.Review of the Advance Directive tab in R37's electronic medical record (EMR), revealed a signed Do Not Resuscitate [DNR] document. However, there was no documentation of R37's Advance Directive. The SSA Surveyor requested a copy of R2's and R37's Advance Directive on 09/18/2025 at 3:07 PM from the facility's staff, but neither were provided by survey exit.During interview with Unit Manager 1 on 09/19/2025 at 4:45 PM, he stated it was important to have advance directives documented so staff could follow the resident's wishes in the event of a death.During interview with the Director of Nursing (DON) on 09/19/2025 at 4:13 PM, she stated an advance directive was important so staff was aware of the resident's wishes and could act on them appropriately.During interview with the Administrator on 09/19/2025 at 2:04 PM, she stated there should be a conversation about advance directives at admission, and it should be documented. She stated it was important, so staff knew how to respond in the event of an emergency.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to take steps to prevent sexual abuse from occurring for 2 of 15 sampled residents, Resident (R) 2 and R3.R2 and R3, two cognitively impaired residents, were observed having intercourse. Instead of separating the residents, staff were told to close the resident's door and provide the cognitively impaired residents privacy. Staff stated the residents were not assessed to have the ability to consent to the sexual activity, and interviews with staff revealed they did not know what to do for R2 and R3.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F600) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600). The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F600) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.The findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/01/2025 at 5:09 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury. Review of the final report Facility Internal Investigation [FII], dated 07/07/2025 at 4:45 PM, initial report dated 07/01/2025 at 5:00 PM, revealed on 06/30/2025, no time given, staff and the Administrator became aware of the incident between R2 and R3, and the physician and the families were notified on 07/01/2025, no time given. Additional review of the FII indicated no other notifications were made on 06/30/2025. The findings of the FII revealed both residents were found disrobed under blankets; they were immediately separated; R2 was then placed on 1:1 monitoring; and R2 and R3 had no injuries. Further review revealed the FII findings concluded sexual abuse did not occur based on staff interviews, stating the residents were able to voice understanding and consequences of their activity. The State Survey Agency (SSA), however, determined through observation, interviews, and record review that R2 and R3 were observed on 06/30/2025, earlier during the day, to be holding hands, hugging, and kissing on each other and was redirected by staff throughout the day. Later in the evening, staff found R2 in R3's room and they were observed having sex. Instead of separating the residents, LPN5 told staff to let them finish, clean them up, and provide supervision later. The residents were allowed to continue for another 15 minutes before STNA13 separated the residents. Though R2 was placed on 1:1 supervision, the supervision did not last and had not been cared planned, which placed R2 and other residents at risk for continued abuse. The facility's report addresses the residents being able to consent, however, there was no documentation to support the residents were assessed to be capable of consenting. Further, the facility waited two days before reporting the allegations to State Agencies, which should have occurred immediately, but no later than two hours.Review of taped audio conversation sent to the SSA by the facility's staff [STNA13] via text on 07/21/2025 at 7:49 AM revealed, the DON's instructions to staff related to their statements. The DON stated this was an open investigation. The DON stated staff could not speak to anyone, and it was serious. The DON stated not to make any assumptions and give nothing but facts. During continued listening of the taped audio conversation, one employee asked if she should put in the comment from the nurse telling them to shut the door and let them finish. The DON stated, absolutely not. The DON stated this was a dementia unit, and staff was to keep residents safe and provide a safe environment. The DON stated if staff placed that in their statement it would open another can of worms. 1. Review of R2's Face Sheet in R2's electronic health record (EHR) revealed the facility admitted the resident on 05/30/2025 after his health declined and wife was unable to provide care. Admitting diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and heart disease. Continued review of R2's EHR revealed he was transferred to the Memory Care Unit (MCU) on 06/01/2025 for exit seeking behavior.Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated severe cognitive impairment.Review of R2's Behavior Note, dated 06/10/2025 at 7:00 PM, in the progress notes, revealed LPN15 charted R2 requested to call his wife several times, and at 9:00 PM, he became very upset when not done immediately. Review of R2's Comprehensive Care Plan [CCP], dated 06/11/2025, revealed a focus was identified as R2 being at risk for behaviors related to depression, mood disorder, and Alzheimer's. Further review revealed the goal was for R2 to display reduction of cognitive behaviors; however specific interventions were not placed addressing behaviors.Further review of R2's CCP, dated 06/11/2025, revealed a focus was placed on 07/01/2025 indicating R2 experienced loneliness and sought companionship with goals of finding companionship through holding hands, sitting close, and one on one conversations. Interventions were placed on 07/01/2025 to include monitoring for ability to make own decisions and monitor as needed for resident's capacity to consent. However, there was no documentation to support the resident was assessed to have the capacity to consent for sexual activity. Additionally, the resident was not care planned for increased supervision, though the resident was placed on 1:1 supervision after the 06/30/2025 incident.Review of R2's Behavior Note, dated 06/30/2025 at 9:25 PM, in the progress notes, revealed LPN6 charted that R2 was in his room at this time with a sitter on 1:1 supervision. The note stated there was an earlier incident with him going into a female resident's room, and he was found under the sheets with the female resident. Review of the Nurse Practitioner (NP) Progress Note, dated 07/01/2025 and signed at 11:54 AM, revealed R2's visit was for an assessment after finding R2 in bed undressed with another resident. Per the note, staff was unable to confirm if any inappropriate activity occurred but reported R2 had nocturnal wandering which might have led to the incident. The note stated psychological findings revealed R2 was oriented to person and had no bruising or pain.Observation and interview, on 07/10/2025 at 6:30 AM, revealed R2 exiting his room without any supervision. The resident stated he was going to get breakfast and coffee. Observation on 07/24/2025 at 8:32 AM revealed STNA12 providing R2's 1:1 supervision; however, in brief interview with STNA12, she stated she was performing other duties. Continued observation revealed STNA12 left R2 in the common area and went into the pantry area, and the door closed behind her. STNA12 stated when asked what 1:1 meant, she stated to always keep eyes on the resident, but she was helping to get coffee. The SSA Surveyor was unable to reach R2's Power-of-Attorney (POA) after two attempts, on 07/10/2025 at 5:46 PM and on 07/15/2025 at 6:45 PM.2. Review of R3's Face Sheet, in R3's EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness; R3 had been living with her sister. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Per the EHR, R3 was transferred to the MCU on 06/04/2025 for exit seeking behavior.Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident had severe cognitive impairment.Review of R3's Comprehensive Care Plan [CCP], dated 03/31/2025, revealed a focus of R3 wandering in and out of other residents' rooms. Interventions placed on 03/31/2025 included to monitor behavior and attempt to determine underlying causes.Review of R3's Health Status Note, dated 06/30/2025 at 10:00 AM, in the progress notes, revealed LPN 5 charted she redirected R3 with mutual intentions away from the male resident, taking walks and sitting together.Further review of R3's CCP, dated 07/01/2025, revealed a focus which indicated the resident experienced loneliness with a goal to find companionship by holding hands, rubbing and patting backs, and one on one conversations and activities with other residents. Further review of R3's CCP revealed interventions, dated 07/01/2025, to include to monitor the resident's ability to make own decisions and to consult appropriate services to monitor and re-evaluate for resident's capacity to consent; however, there was no documentation to support the resident was assessed to be able to have the capacity to consent to sexual activity. Additionally, the care plan was not person-centered or individualized to address the resident's need for increased supervision. Review of the Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:41 AM, revealed staff requested a head-to-toe exam after staff found R3 in bed undressed with another resident last night. Per the note, there was no confirmation if any sexual intercourse took place, and her diagnosis of dementia limited the exam. Additional review revealed the exam revealed excoriation to the groin likely associated with brief use, and no bruising was noted. Review of Psychotherapy Note, dated 07/02/2025 signed by provider (Psychotherapist) at 4:14 PM revealed the referral was for the resident exhibiting new behaviors, not saying what they were, and R3 was a poor historian due to cognitive and psychiatric impairment. Further review revealed cognition was assessed as oriented to person, poor short- and long-term memory. In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in sexual activity or having an ongoing relationship with a married man. Per the interview, R3's FM stated she voiced her concerns to the facility and staff told her R2 would be transferred from the MCU if it happened again. R3's family member stated she did not want R3 moved because it seemed like every time her environment changed, we lose a piece of her.During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported the incident to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them [the residents] finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as the nurse told her.In an interview with LPN5 on 07/11/2025 at 8:30 AM, she stated she worked on 06/30/2025 from 7:00 AM to 7:00 PM. She stated an aide came to the desk at the end of the shift and told her to come to R3's room immediately. She stated upon arriving to R3's room, she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. LPN5 stated staff left them to continue since she was unsure of what to do. She stated she notified Unit Manager (UM) 1 and House Supervisor (HS) 2. She stated she did not stop them from engaging in the activity and the residents continued for approximately 15 minutes until the aides stopped them. LPN5 stated she never went back in R3's room before going home at the end of her shift. She stated R2 and R3 had been trying to get together all day, and staff had to continually separate them. LPN5 added she felt like it would happen again since R2 was lost in space.In an interview on 07/11/2025 at 5:04 PM with LPN6, she stated 06/30/2025 was her first 7:00 PM until 7:00 AM shift at the facility, and she was an agency nurse. She stated she was getting report from day shift staff when a nurse aide came to the end of the hall and started yelling for a nurse. She stated when she and the day shift nurse, LPN5, got to R3's room, R2 was lying flat on his back with R3's head on his chest. Per the interview, she stated R2 was not wearing a shirt but R3 was wearing one. She stated a sheet covered both residents, and she was unsure what clothes they wore. Further, she stated LPN5 told staff to close the resident's door, let them finish, and then clean them up. She stated LPN5 told them someone would need to supervise them the rest of the night, but she did not recall any extra staff called in. LPN6 stated LPN5 told her that R2 and R3 had been at it all day with kissing, hugging, sitting next to each other, with R3 trying to go into R2's room. LPN6 stated she told LPN5, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is. She stated she did not notify anyone related to the incident and did not complete any assessments on the residents, other than completing the residents' vitals. The LPN stated the House Supervisor came to the MCU unit and called the Director of Nursing (DON. LPN6 stated she was just going by what the House Supervisor told her to do. In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8:00 PM, STNA14 told her she had something to show her. However, she stated the day shift nurse interrupted and told them to let it continue, but STNA14 stated she needed to know. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated HS2 called, and she explained the situation to her over the phone. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger. She stated she told R2 he could not do that and touched his arm to guide him off R3. She stated R3, however, kept pulling him back towards her. She stated R3 was completely confused as to why they had to stop. STNA13 stated once R2 was dressed he patted R3's back and told her Thank You, and he was taken back to his room. In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she notified HS2.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025 and recalled the nurse close to her office upstairs had received a call from nurse aides on the MCU that they needed me to come to the MCU. She stated when she arrived at the MCU, she was told by STNA13 and STNA14 that R2 and R3 were in bed together. She stated she called the DON to report the incident and then saw the aides bring the two residents to the dining/common area. She stated she did not go to R3's room, so she could not say what was going on and did not know. She stated she did not contact the families or the provider because she thought the DON would have done that. Further, HS2 stated she never performed an assessment on the residents, thinking the nurse on the unit would have completed that task. She stated the only part she had in the incident was gathering the staff to write statements, and she forwarded the statements to the DON. In an interview with the facility's Social Worker on 07/21/2025 at 1:35 PM, she stated management reported to her that R2 and R3 engaged in sexual activity. Further, she stated she had not performed an evaluation or interviewed the residents following the incident. In an interview with the Nurse Practitioner on 07/10/2025 at 2:10 PM, she stated it had been reported to her R2 and R3 were together undressed, and the facility management had requested she perform an evaluation of R2 and R3 for the capacity to consent. She stated she informed them psych would need to be consulted for that evaluation. In an interview with the Psychotherapist on 07/10/2025 at 3:08 PM, she stated the facility had asked her to perform an assessment for R2 and R3 but had not told her the reason other than there had been some inappropriate behavior toward each other, but did not communicate with her what the inappropriate behavior was. Further, she stated the residents were only capable of answering yes or no questions.In an interview with the DON on 07/14/2025 at 4:20 PM, she stated she was contacted by HS2, who did not say that much. She stated she was told the residents were found in bed. Per the interview, she stated she requested the staff working that night to write a statement listing the facts. She stated an investigation was immediately started. R2 was placed on 1:1 supervision, which ensured R3's safety. The DON stated her expectations of staff during the incident was for staff to separate the residents until everything was sorted out. During an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated the DON had called her the night of 06/30/2025, no time specified, stating R2 and R3 were found in bed with each other under the covers. She stated she was told that both residents were assessed, and R2 was placed on a 1:1 supervision. Per the interview, she defined sexual abuse as a forcible act on someone, and one might not be willing to engage in the activity. She stated the two residents had been in high school together, and they knew each other. She stated she felt that was why the incident happened. She further stated the police were not contacted that night and was unsure of the facility's policy related to reporting notifications. In continued interview, on 07/17/2025 at 12:02 PM, the Administrator stated she was never told LPN5 advised staff to close the resident's door to provide privacy, but if privacy was needed, then staff would close the door, she added. She stated she was not sure if the residents were separated immediately. Further, the State Survey Agency (SSA) surveyor reviewed the FII with the Administrator and she confirmed the reporting day [of the incident] to the SSA was on 07/01/2025 at 5:00 PM [approximately two days after the incident] and on 07/07/2025 at 4:45 PM [approximately six days after the facility had completed their investigationThe SSA Surveyor continued the Review of the FII, with the Administrator on 07/17/2025 at 12:02 PM and identified a discrepancy within the investigation. The FII noted notifications to families, as one note stated both families were notified on 06/30/2025, and another stated they were notified on 07/01/2025. The Administrator stated she was unable to explain the discrepancy in the report. Further, she stated she was unsure when R2's 1:1 monitoring ended. In an interview with the facility's Medical Director on 07/16/2025 at 2:30 PM, she stated she had just started as the Medical Director and had not evaluated or seen either R2 or R3. She stated she could not elaborate on either being able to consent for any type of relationship and or sexual relationship. She stated the residents should have been separated and all parties notified immediately, and the facility should have done a self-report immediately. Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

Based on interview, record review, review of the facility's investigation, review of the facility's job descriptions, and review of the facility's policy, the facility failed to develop and implement policies and procedures to prohibit and prevent abuse and failed to establish policies and procedures to thoroughly investigate allegations of abuse for 2 of 15 residents, Resident (R) 2 and R3. R2 and R3, both cognitively impaired, were observed having sexual intercourse.Additionally, the facility failed to promote a culture of safety and open communication in the work environment through prohibiting retaliation against an employee for reporting abuse. The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F607) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F607). The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F607) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.Cross-reference F600The findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Additional review revealed the procedures included reporting all alleged violations to the Administrator, state agency, adult protective services (APS), and other required agencies, such as law enforcement, immediately but not later than two hours after the allegation was made.Review of the facility's job description Nursing Assistant Job Description and Performance Appraisal, revision date 07/2023, revealed staff would strive for excellence in performance and adherence to professional and regulatory standards. Further review revealed the job summary included to ensure the highest degree of quality resident care was delivered to residents, including recognition and reporting a resident's change of condition. The nursing assistant job duties included reporting all allegations of abuse, neglect, mistreatment, and misappropriation, and making any required reports and statements within required timeframes while keeping residents safe. The job description revealed the nurse aide worked within the scope of practice for the state of practice and followed established policies and procedures at all times. Review of the facility's document, Job Description and Performance Appraisal Administrator, dated 03/2023, revealed the Administrator was responsible for assuring the highest degree of quality resident care was delivered at all times. Further review revealed the Administrator maintained responsibility for all accident and incident report investigations and reviewed and ensured timely reporting when necessary to maintain the effectiveness of the facility's risk management program. Additional review revealed the Administrator was to act with integrity and honesty in all matters and demonstrated uncompromising adherence to ethical principles and organizational values.Review of the facility's final report Facility Internal Investigation (FII), dated 07/07/2025 at 4:45 PM, the initial report was dated 07/01/2025 at 5:00 PM, revealed the date staff and the Administrator was made aware of the incident between R2 and R3 was 06/30/2025, no time given. Per the report, the physician and families were notified 07/01/2025, no time given. Additional review indicated no other notifications were made on 06/30/2025. The report revealed both residents were found disrobed under blankets, they were immediately separated, R2 was then placed on 1:1 supervision, and R2 and R3 had no injuries. Per the report, it concluded sexual abuse did not occur based on staff interviews, stating the residents were able to voice understanding and consequences of the activity. Additional review revealed both residents willingly engaged in the activity and had the ability to consent as determined by the Interdisciplinary team (IDT), Nurse Practitioner (NP), and counselor [therapist]. Continued review revealed the resident representatives agreed and consented to participation in an intimate relationship, and the facility would re-evaluate the residents' capacity to consent as needed. Per the report, the reporting party was the Administrator, and the residents' care plans were to be reviewed and updated.The State Survey Agency (SSA), however, determined through observation, interviews, and record review that R2 and R3 were observed on 06/30/2025, earlier during the day, to be holding hands, hugging, and kissing on each other and was redirected by staff throughout the day. Later in the evening, staff found R2 in R3's room and they were observed having sex. Instead of separating the residents, LPN5 told staff to let them finish, clean them up, and provide supervision later. The residents were allowed to continue for another 15 minutes before STNA13 separated the residents. Though R2 was placed on 1:1 supervision, the supervision did not last and had not been cared planned, which placed R3 and other residents at risk for continued abuse. The facility's report addresses the residents being able to consent, however, there was no documentation to support the residents were assessed to be capable of consenting. Further, the facility waited two days before reporting the allegations to State Agencies, which should have occurred immediately, but no later than two hours.Review of the facility's clinical notes revealed no documentation to support Resident (R)2 or R3 had the capacity to consent to sexual intercourse. Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/02/2025 at 1:07 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury.1. Review of R2's Face Sheet, found in the electronic health record (EHR) revealed the facility admitted the resident on 05/30/2025 after his health declined and his wife was unable to provide care. Admitting diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and heart disease. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's Physician's Orders, dated 05/30/2025, revealed an order for staff to monitor behavior every shift, document, and notify the physician as needed.2. Review of R3's Face Sheet, found in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Continued review of the EHR revealed R3 was transferred to the Memory Care Unit (MCU) on 06/04/2025 for exit seeking behavior. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's Physician's Orders, dated 01/31/2025, revealed an order placed to monitor behavior every shift and notify the physician as needed. In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in sexual activity or having an ongoing relationship with a married man. Per the interview, R3's FM stated she voiced her concerns to the facility and staff told her R2 would be transferred from the MCU if it happened again. R3's family member stated she did not want R3 moved because it seemed like every time her environment changed, we lose a piece of her.In an interview with Licensed Practical Nurse (LPN) 5 on 07/11/2025 at 8:30 AM, she stated she worked the 7:00 AM to 7:00 PM (day shift) on 06/30/2025. She stated an aide came to the desk at the end of the day shift and told her to come to R3's room immediately, and she thought someone had fallen. She stated upon arriving to R3's room she saw R2 on top of R3 under a blanket, and it looked like they were doing something because of the physical motions being made. She stated staff left the residents to continue since she was unsure of what to do. She stated she notified House Supervisor (HS) 2. She stated she did not do any immediate intervention to stop them from engaging. She stated probably 15 minutes elapsed, and she thought the aides stopped them. She stated she never went back in R3's room and went home.In an interview with LPN6 on 07/11/2025 at 5:04 PM, she stated the night shift, 7:00 PM to 7:00 AM, on 06/30/2025 was her first night shift at the facility, and she was from an agency. She stated she was getting report from day shift when a nurse aide came to the end of the hall and started yelling for a nurse. She stated when she and the day shift nurse, LPN5, got to R3's room, R2 was lying flat on his back with R3's head on his chest. She stated a sheet covered both, and she was unsure if all clothes were on. She stated the day shift nurse, LPN5, told staff to close the door and let them finish, and then clean them up. She stated LPN5 told staff someone would need to supervise them the rest of the night, but she did not recall any extra staff called in.Further interview with LPN6 on 07/11/2025 at 5:04 PM, revealed LPN5 told her R2 and R3 had been at it all day kissing, hugging, sitting next to each other, and R3 trying to go into R2's room. LPN6 stated she did not notify anyone, and she did not do any assessments other than getting a set of vitals on R2 and R3. LPN6 stated the House Supervisor came to the unit, called the Director of Nursing (DON), and did not tell her if the provider had been contacted. She stated the DON gave instructions to staff to not put any extra details in statements and to not add or take away anything. LPN6 stated staff was made to re-write statements and could not put in any details of earlier incidents two weeks ago, but she did not know what that was about.Review of the picture of the original written statement of staff member State Trained Nurse Aide (STNA) 13, dated 06/30/2025 with time stamp of 9:22 PM revealed the wording was changed from putting fingers in R3's private area to fondling R3's genitalia area.Review of a taped audio conversation sent to the SSA by the facility's staff [STNA13] via text on 07/21/2025 at 7:49 AM revealed, concerning the DON's instructions to staff for statements, the DON stated this was an open investigation. The DON stated staff could not speak to anyone, and it was serious. The DON stated not to make any assumptions and give nothing but facts. The DON stated she did not understand how this happened. The DON stated staff had been on top of their behavior, and the residents should never have been left alone. Continued listening of the taped audio conversation revealed the DON instructed the House Supervisor (HS) to call her once the statements were gathered, and they would review them. During continued listening of the taped audio conversation, one employee asked if she should put in the comment from the nurse telling them to shut the door and let them finish. The DON stated absolutely not. The DON stated this was a dementia unit, and staff was to keep residents safe and provide a safe environment. The DON stated if staff placed that in their statement it would open another can of worms. The DON stated if staff did not see the residents having sex, staff could not use the word sex. Further listening revealed a staff member informed the DON that R2 was fingering R3. Then, the DON stated she was not telling staff to withhold any information but to state just what they saw.In a telephone interview with Registered Nurse (RN) 1 on 07/16/2025 at 12:37 PM, she stated she did not feel comfortable talking in the facility about the incident that happened between R2 and R3 when they were found in the bed naked. She stated she had worked day shift on another unit and was giving LPN3 report when the nurse aides contacted LPN3. RN1 stated HS2 had told her not to say anything about what had happened to anyone related to R2 and R3. RN1 stated R2 had behaviors before the incident on 06/30/2025 of kissing R3, and he should not have been around R3. She stated she was told by the DON not to say anything about another incident, and she feared losing her job if the DON found out she talked about the incident.In an interview with the DON on 07/17/2025 at 12:40 PM, she stated the strike outs in R2's progress notes were incorrect documentation on that resident, and some was hearsay and should not have been charted. She stated she was unsure who performed the strike outs, she would need to look at additional notes.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025. She stated her tasks included to make sure everything ran smoothly in the evening. She stated that meant she rounded every two hours, checking on staff and assuring documentation was being performed. She stated there had been an incident on 06/30/2025 on the MCU involving a male and female resident. She stated the nurse close to her office upstairs had received a call from nurse aides on the MCU and told her staff needed me to come to the MCU. She stated when she got to the MCU, STNA13 and STNA14 told her that R2 and R3 were in bed together. She stated she called the DON to report that, and she then saw the aides bring the two residents to the dining/common area. She stated she did not go to R3's room, and she could not say what was going on and did not really know. She stated she did not contact family or the provider because she thought the DON did, and she never performed an assessment, thinking the nurse did. She stated the only part she had in the incident was gathering the staff to write statements and forwarding them to the DON.In an additional interview with the DON on 07/14/2025 at 4:20 PM, she stated she had been the DON since January 2025, and her tasks included oversight of the nursing department. She stated, concerning the incident with R2 and R3, she was called by House Supervisor (HS) 2, who did not tell her much, only that they were in R3's bed. She stated she did not come to the facility after the call. She stated she had talked to staff and requested they each write a statement just listing the facts. She stated an investigation was immediately started, the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision, which ensured R3's safety too. She stated extra staff was not brought in for the 1:1 supervision, but she thought other staff was shuffled to cover. She stated she was unsure if the abuse policy was implemented, and if any skin assessments were performed on any resident, but she thought the nurse had done that since that would be the normal process. She stated the only person she called that night was the Administrator, and she had not contacted the provider and families but thought the nurse had done so.In further interview with the DON, on 07/14/2025 at 4:20 PM, she stated it would be the Administrator's task to notify the police. She stated staff statements about the incident were in her mailbox the next morning. When asked how the investigation determined it was not sexual abuse, she stated they felt like it was not since R2 and R3 enjoyed each other's company, and they made each other happy. She stated no one saw any penetration, so she did not think a sexual act happened, and she felt the residents knew what they were doing. However, review of the DON's taped conversation, provided to the SSA on 07/21/2025 at 7:49 AM, revealed she stated, the residents should never have been left alone .this is a dementia unit, and staff was to keep residents safe and provide a safe environment. In an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated she had been the Administrator since May 2025, and the job task was to provide for the overall function of the facility and to serve as the Abuse Coordinator (AC). She stated as the AC she opened an investigation when there was an allegation of abuse following the facility's policy and reporting immediately. She further explained she did not know what immediately meant, adding, whatever the definition is. She stated she may not be the first to get the report, depending on her availability, but the Director of Nursing (DON) or House Supervisor (HS) would be contacted. She stated the DON called her the night of 06/30/2025 and told her R2 and R3 were found in bed with each other under the covers. She stated she did not remember whose room and did not state the time contacted. She stated both residents were assessed, and R2 was placed on a 1:1 supervision.Per continued interview, with the Administrator on 07/17/2025 at 12:02 PM, She stated she had abuse training and defined sexual abuse as an act when someone forced another person to do something they might not be willing to do. In further interview, the State Survey Agency (SSA) Surveyor informed the Administrator there were no entries from the clinicians stating the residents understanding of their actions, or their ability to consent, the Administrator stated she was unable to provide the additional documentation to support that but was sure she had something stating that. Further, she stated the police were not contacted that night and was unsure if the police should have been contacted, after reviewing the facility's Abuse Policy with the SSA surveyor.In continued interview, on 07/17/2025 at 12:02 PM, with the Administrator, she stated she did not know if extra staff was brought in the night of 06/30/2025, for R2's supervision, and she would have to ask the DON. She stated she told the residents' families that they were found in bed together naked, and both families were ok with that. Further, she stated R2's wife, however, was never contacted, but R3's family knew R2 was married and was okay with the relationship. However, interview with R3's family member, on 07/10/2025 at 5:47 PM revealed the resident would never have engaged in any relationship, with R2, because he was a married man. Further, she was asked what she told the family had happened between the residents and she stated she would have to check for any notes she had made. Review of the FII continued, and a discrepancy was noted for notifications to families, as one note stated both families were notified on 06/30/2025, and another note stated they were notified on 07/01/2025. However, the Administrator was unable address the discrepancy. The Administrator stated the facility had completed a thorough investigation. In review of the facility's investigation, the SSA surveyor pointed out to the Administrator a witness statement that stated R2 was fondling R3's private area. The SSA surveyor asked the Administrator if this would have been considered sexual abuse? She stated it would not have been considered sexual abuse because it was consensual. However, review of the facility's clinical notes revealed no documentation to support Resident (R)2 or R3 had the capacity to consent to sexual intercourse.Further interview on 07/17/2025 at 12:02 PM, with the Administrator, she stated that in the process of the facility's investigation, she was never informed by anyone that LPN5 instructed other staff members to close R3's room door so they could complete the sexual activity, but added, if privacy was needed, then staff would close the door. The FII was reviewed with the Administrator, and she confirmed the reporting day and time was correct as 07/01/2025 at 5:00 PM; however, review of a Self-Reporting form provided by the facility, by way of email, revealed the facility reported on 07/01/2025, which was a failure to report to state agencies timely and implement the facility's policy. Observation and Interview on 07/18/2025 at 12:58 PM revealed a police vehicle parked in the facility's parking lot. The Administrator stated she never contacted the police the night of R2 and R3's incident and thought she should call the police now. Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

Based on observation, interview, record review, review of the facility's job descriptions, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure, in response to an incident of witnessed sexual abuse, it had evidence of a thorough investigation, to include reporting the incident to the state agency timely, and protecting the residents during and after the investigation for 2 of 15 sampled residents, Resident (R) 2 and R3. On 06/30/2025, R2 and R3 were found by staff in R3's bed naked. The residents were not separated immediately, and based on interview, the room door was closed. Review of medical records and interviews revealed immediate assessments had not been performed. Additional review and interview revealed the families and medical providers of R2 and R3, authorities, and state agencies had not been contacted immediately on 06/30/2025.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F610) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610). The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F610) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.Cross reference F600The findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Additional review revealed the procedures included reporting all alleged violations to the Administrator, state agency, adult protective services (APS), and other required agencies, such as law enforcement, immediately but not later than two hours after the allegation was made.Review of the facility's investigation revealed R3's Incident Report [IR], dated 07/01/2025 at 9:30 AM, revealed a male resident [R2] came into R3's room, and both were found under the sheets. Further review revealed both residents were immediately assessed for injury and distress, and the male resident was placed on a 1:1 observation.Review of the facility's investigation revealed R2's IR, dated 07/01/2025 at 9:45 AM, revealed R2 was found in a female resident's [R3] bed under sheets, residents were separated and assessed for injuries, and R2 was then placed on 1:1 supervision.Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/02/2025 at 1:07 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury.Review of the facility's final report, Facility Internal Investigation (FII), dated 07/07/2025 at 4:45 PM, the initial report was dated 07/01/2025 at 5:00 PM, revealed the date staff and the Administrator was aware of the incident between R2 and R3 was 06/30/2025, no time given. Per the report, the physician was notified on 07/01/2025, no time given. Additional review revealed no other notifications were made on 06/30/2025. Per the report, both residents were found disrobed under blankets, they were immediately separated. R2 was then placed on 1:1 supervision. The report determined sexual abuse did not occur based on staff interviews.However, review of the State Survey Agency (SSA) investigation, through observation, interviews, and record review, revealed the facility failed to conduct a thorough investigation. Interviews with staff revealed the residents were not separated immediately and though the facility's investigative documentation states R2 was provided 1:1 supervision during the investigation, additional staff was not provided to complete the 1:1 protection/supervision. Further, there was no documentation to support the residents were assessed for physical or psychosocial harm on 06/30/2025, after the incident was observed by staff. Further, the facility reported the allegation of abuse to the state survey agency on 07/01/2025 at 5:09 PM, approximately 1 day after the alleged abuse and should have reported immediately, but no later than two hours after learning of the abuse, as per the facility's policy. Review of the facility's schedule for the Memory Care Unit (MCU), where R2 and R3 resided, dated 06/30/2025, did not list any additional staff for R2's close 1:1 observation after the sexual incident. Further review of the facility's documentation revealed, however, no documentation to support R3 was provided increased supervision, for her safety.1. Review of R2's Face Sheet, in the electronic health record (EHR), revealed the facility admitted the resident on 05/30/2025 after his health declined and his wife was unable to provide care. Admitting diagnoses to include Alzheimer's disease, chronic obstructive heart disease (COPD) and heart disease. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's Physician's Orders, dated 05/30/2025 revealed an order for staff to monitor behavior every shift, document, and notify the physician as needed.Review of R2's June 2025 skin assessments did not reveal a skin assessment, dated 06/30/2025, the date the alleged incident occurred. Review of R2's 1:1 Close Observation forms revealed they were initiated on 06/30/2025 at 8:30 PM. Observations were recorded on this form for 15-minute checks. Further review revealed missing documentation from 07/04/2025 at 11:15 PM through 07/05/2025 at 6:45 AM; 07/05/2025 at 11:15 PM through 07/06/2025 at 6:45 AM; 07/07/2025 at 12:00 AM through 3:15 PM and 3:45 PM through 6:45 PM; 07/07/2025 at 11:15 PM through 07/08/2025 6:45 AM; and no entries after 11:15 PM on 07/08/2025. Additional observation forms were given, and their review revealed 15-minute checks were initiated on 07/09/2025 at 7:00 AM. However, there were no entries for 6:15 AM, 6:30 AM, or 6:45 AM. Further review revealed on 07/10/2025 at 7:00 AM, 30-minute checks were initiated and ended at 6:30 AM on 07/11/2025; then at 7:00 AM, hourly checks for 12 hours were initiated. These hourly checks ended on 07/11/2025 at 7:00 PM. No additional forms were provided by the facility. Review of R2's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:54 AM, revealed the visit was for an assessment after finding R2 in bed undressed with another resident. The note stated staff was unable to confirm if any inappropriate activity occurred but reported R2 had nocturnal wandering which might have led to the incident.Observation and interview, on 07/10/2025 at 6:30 AM, R2 was observed exiting his room without any supervision. The resident stated he was going to get breakfast and coffee. In interviews with STNA13 at 12:41 PM on 07/10/2025 and STNA14 at 4:41 PM on 07/11/2025, they stated no extra staff was brought in for 1:1 supervision on the night of the incident, 06/30/2025. They both stated they had to take turns watching R2 between performing other tasks.Observation and interview, on 07/24/2025 at 8:32 AM, State Tested Nurse Aide (STNA) 12 was observed providing R2 1:1 supervision. STNA12 stated she was performing other duties as well. Further observation revealed STNA12 left R2 in the common area, by himself, and went in the pantry area, with the door closed behind her. She stated she was supposed to always keep eyes on the resident, but she had to assist with getting coffee for the residents. 2. Review of R3's Face Sheet, in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Further review of the EHR revealed R3 was transferred to the Memory Care Unit (MCU) on 06/04/2025 for exit seeking behavior. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's skin assessments did not reveal one was performed on 06/30/2025, after the incident with R2. Review of R3's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:41 AM, revealed staff requested a head-to-toe exam after staff found R3 in bed undressed with another resident last night. Further review of the note revealed R3 was not taking any medications for dementia and was not being followed by psychiatry. Per the note, there was no confirmation that any sexual intercourse took place, and her diagnosis of dementia limited the exam. Additional review of the exam revealed excoriation to the groin likely associated with brief use, and no bruising was noted.In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in any type of relationship with a married man.In an interview with LPN5 on 07/11/2025 at 8:30 AM, she stated an aide came to the desk at the end of the shift and told her to come to R3's room immediately. She stated upon arriving to R3's room, she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. LPN5 stated staff left them to continue since she was unsure of what to do. She stated she notified the House Supervisor (HS) 2. She stated she did not stop them from engaging in the activity and the residents continued for approximately 15 minutes until the aides stopped them.In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8:00 PM, STNA14 told her she had something to show her. However, she stated the day shift nurse interrupted and told them to let it continue, but STNA14 stated she needed to know. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated HS2 called, and she explained the situation to her over the phone. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger.During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as she was told by the nurse.In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she notified HS2.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025 and recalled the nurse close to her office upstairs had received a call from nurse aides on the MCU that they needed me to come to the MCU. She stated when she arrived at the MCU, she was told by STNA13 and STNA14 that R2 and R3 were in bed together. She stated she called the DON to report the incident and then saw the aides bring the two residents to the dining/common area.In an interview with the DON on 07/14/2025 at 4:20 PM, she stated her tasks included oversight of the nursing department. She stated she was called by the House Supervisor (HS) 2, who did not say much about the incident with R2 and R3, except R2 and R3 were in R3's bed. She stated she did not come to the facility after the call, but stated an investigation was immediately started. She stated the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision, which also ensured R3's safety. Further, she stated staff assured other residents' safety by having the nursing management talk to the staff about R2 and R3. The DON stated she did not place R3 on 1:1 supervision because R2 was more mobile than R3. She stated she was unsure if the other residents were assessed after the incident. Further, she stated she was unsure if any skin assessments were performed on any resident, but she thought the nurse had done that since that would be the normal process [for conducting an abuse investigation]. She stated the only person she called the night of the incident was the Administrator, and she had not contacted the provider or family but thought the nurse had done so. She stated it was the Administrator's responsibility to notify police if needed. The DON, per the interview, stated she had not notified the police.In an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated she served as the Abuse Coordinator (AC). She stated as the AC she opened an investigation when there was an allegation of abuse following facility policy and reporting [the allegations] immediately [to state agencies]. She stated the DON had called her the night of 06/30/2025 (she did not state the time) and informed her that R2 and R3 were found in bed with each other under the covers. She stated both were assessed, and R2 was placed on a 1:1 supervision. The Administrator stated it was her expectation that an assessment would have been completed on the residents immediately following the incident, but was unsure it that was completed, adding, she would have to check with the DON. Per the interview, she stated the police were not contacted the night of the incident and was uncertain if they should have been. The Administrator stated she thought the facility completed a thorough investigation and identified no deficient practice. The State Survey Agency (SSA) surveyor reviewed the facility's documentation with the Administrator, and she confirmed she reported the allegation of abuse initially on 07/01/2025 at 5:09 PM, approximately one day after the incident occurred.Observation and interview, on 07/18/2025 at 12:58 PM, revealed a police vehicle parked in the facility's parking lot. The Administrator stated she had contacted the police since she never called the police the night of the incident between R2 and R3.In an interview with the facility's Medical Director, on 07/16/2025 at 2:30 PM, she stated she had just started as the facility's Medical Director, had not evaluated or seen either R2 or R3, and could not elaborate on either being able to consent for any type of relationship and/or sexual relationship. She stated the residents should have been separated and all parties notified immediately, and the facility should have done a self-report immediately.Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/02/2025 at 1:07 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury. Review of the facility's final report, Facility Internal Investigation (FII), dated 07/07/2025 at 4:45 PM, the initial report was dated 07/01/2025 at 5:00 PM, revealed the date staff and the Administrator was aware of the incident between R2 and R3 was 06/30/2025, no time given. Per the report, the physician was notified on 07/01/2025, no time given. Additional review revealed no other notifications were made on 06/30/2025. Per the report, both residents were found disrobed under blankets, they were immediately separated. R2 was then placed on 1:1 supervision. The report determined sexual abuse did not occur based on staff interviews. However, review of the State Survey Agency (SSA) investigation, through observation, interviews, and record review, revealed the facility failed to conduct a thorough investigation. Interviews with staff revealed the residents were not separated immediately and though the facility's investigative documentation states R2 was provided 1:1 supervision during the investigation, additional staff was not provided to complete the 1:1 protection/supervision. Further, there was no documentation to support the residents were assessed for physical or psychosocial harm on 06/30/2025, after the incident was observed by staff. Further, the facility reported the allegation of abuse to the state survey agency on 07/01/2025 at 5:09 PM, approximately 1 day after the alleged abuse and should have reported immediately, but no later than two hours after learning of the abuse, as per the facility's policy. Review of the facility's schedule for the Memory Care Unit (MCU), where R2 and R3 resided, dated 06/30/2025, did not list any additional staff for R2's close 1:1 observation after the sexual incident. Further review of the facility's documentation revealed, however, no documentation to support R3 was provided increased supervision, for her safety. 1. Review of R2's Face Sheet, in the electronic health record (EHR), revealed the facility admitted the resident on 05/30/2025 after his health declined and his wife was unable to provide care. Admitting diagnoses to include Alzheimer's disease, chronic obstructive heart disease (COPD) and heart disease. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's Physician's Orders, dated 05/30/2025 revealed an order for staff to monitor behavior every shift, document, and notify the physician as needed.Review of R2's June 2025 skin assessments did not reveal a skin assessment, dated 06/30/2025, the date the alleged incident occurred. Review of R2's 1:1 Close Observation forms revealed they were initiated on 06/30/2025 at 8:30 PM. Observations were recorded on this form for 15-minute checks. Further review revealed missing documentation from 07/04/2025 at 11:15 PM through 07/05/2025 at 6:45 AM; 07/05/2025 at 11:15 PM through 07/06/2025 at 6:45 AM; 07/07/2025 at 12:00 AM through 3:15 PM and 3:45 PM through 6:45 PM; 07/07/2025 at 11:15 PM through 07/08/2025 6:45 AM; and no entries after 11:15 PM on 07/08/2025. Additional observation forms were given, and their review revealed 15-minute checks were initiated on 07/09/2025 at 7:00 AM. However, there were no entries for 6:15 AM, 6:30 AM, or 6:45 AM. Further review revealed on 07/10/2025 at 7:00 AM, 30-minute checks were initiated and ended at 6:30 AM on 07/11/2025; then at 7:00 AM, hourly checks for 12 hours were initiated. These hourly checks ended on 07/11/2025 at 7:00 PM. No additional forms were provided by the facility. Review of R2's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:54 AM, revealed the visit was for an assessment after finding R2 in bed undressed with another resident. The note stated staff was unable to confirm if any inappropriate activity occurred but reported R2 had nocturnal wandering which might have led to the incident.Observation and interview, on 07/10/2025 at 6:30 AM, R2 was observed exiting his room without any supervision. The resident stated he was going to get breakfast and coffee.In interviews with STNA13 at 12:41 PM on 07/10/2025 and STNA14 at 4:41 PM on 07/11/2025, they stated no extra staff was brought in for 1:1 supervision on the night of the incident, 06/30/2025. They both stated they had to take turns watching R2 between performing other tasks.Observation and interview, on 07/24/2025 at 8:32 AM, State Tested Nurse Aide (STNA) 12 was observed providing R2 1:1 supervision. STNA12 stated she was performing other duties as well. Further observation revealed STNA12 left R2 in the common area, by himself, and went in the pantry area, with the door closed behind her. She stated she was supposed to always keep eyes on the resident, but she had to assist with getting coffee for the residents. 2. Review of R3's Face Sheet, in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Further review of the EHR revealed R3 was transferred to the Memory Care Unit (MCU) on 06/04/2025 for exit seeking behavior. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's skin assessments did not reveal one was performed on 06/30/2025, after the incident with R2. Review of R3's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:41 AM, revealed staff requested a head-to-toe exam after staff found R3 in bed undressed with another resident last night. Further review of the note revealed R3 was not taking any medications for dementia and was not being followed by psychiatry. Per the note, there was no confirmation that any sexual intercourse took place, and her diagnosis of dementia limited the exam. Additional review of the exam revealed excoriation to the groin likely associated with brief use, and no bruising was noted. In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in any type of relationship with a married man.In an interview with LPN5 on 07/11/2025 at 8:30 AM, she stated an aide came to the desk at the end of the shift and told her to come to R3's room immediately. She stated upon arriving to R3's room, she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. LPN5 stated staff left them to continue since she was unsure of what to do. She stated she notified the House Supervisor (HS) 2. She stated she did not stop them from engaging in the activity and the residents continued for approximately 15 minutes until the aides stopped them.In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8:00 PM, STNA14 told her she had something to show her. However, she stated the day shift nurse interrupted and told them to let it continue, but STNA14 stated she needed to know. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated HS2 called, and she explained the situation to her over the phone. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger.During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as she was told by the nurse.In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she notified HS2.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025 and recalled the nurse close to her office upstairs had received a call from nurse aides on the MCU that they needed me to come to the MCU. She stated when she arrived at the MCU, she was told by STNA13 and STNA14 that R2 and R3 were in bed together. She stated she called the DON to report the incident and then saw the aides bring the two residents to the dining/common area.In an interview with the DON on 07/14/2025 at 4:20 PM, she stated her tasks included oversight of the nursing department. She stated she was called by the House Supervisor (HS) 2, who did not say much about the incident with R2 and R3, except R2 and R3 were in R3's bed. She stated she did not come to the facility after the call, but stated an investigation was immediately started. She stated the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision, which also ensured R3's safety. Further, she stated staff assured other residents' safety by having the nursing management talk to the staff about R2 and R3. The DON stated she did not place R3 on 1:1 supervision because R2 was more mobile than R3. She stated she was unsure if the other residents were assessed after the incident. Further, she stated she was unsure if any skin assessments were performed on any resident, but she thought the nurse had done that since that would be the normal process [for conducting an abuse investigation]. She stated the only person she called the night of the incident was the Administrator, and she had not contacted the provider or family but thought the nurse had done so. She stated it was the Administra[TRUN

Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop person-centered care plan interventions for 4 of 7 sampled residents, Resident (R) 1, R2, R3, and R11. 1. The facility failed to follow interventions placed on R1's Comprehensive Care Plan [CCP] and Kardex to prevent an accident on 06/19/2025, resulting in a compound fracture of R1's right lower extremity, which required surgical intervention.2. The facility failed to develop R11's CCP with person-centered interventions to prevent falls for R11. On 07/14/2025, R11 fell out of bed and sustained a right shoulder fracture.3. The facility failed to develop R2's and R3's CCP with person-centered interventions to address the residents' behaviors, assessments, ability to consent to sexual activity, or supervision needs following the sexual encounter. R2 and R3, both cognitively impaired were found in bed naked on 06/30/2025 and engaging in sexual activity. Staff stated the residents were not assessed to have the ability to consent to the sexual activity, and interviews with staff revealed they did not know what to do for R2 and R3.The facility's failure to have an effective system in place to ensure residents' CCP were developed with person-centered interventions to protect them from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFRS483.21 Comprehensive Care Plans (F656) at the highest Scope and Severity (S/S) of a J. The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFRS483.21 Comprehensive Care Plans (F656) at a S/S of a G while the facility monitors the effectiveness of systemic changes and quality assurance activities.Cross reference F600 and F689The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 02/09/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with residents' rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in each resident's comprehensive assessment. Further review revealed guidelines included services would be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing, and alternate interventions would be documented as needed. Additional review revealed the care plan could be prepared by any interdisciplinary team which included but was not limited to include registered nurses and nurse aides. Additional review revealed qualified staff responsible for carrying out interventions would be notified of their roles and responsibilities for carrying out interventions initially and when changes were made. Record review and interviews revealed Resident (R)2 and R3 resided on the Memory Care Unit (MCU) and were assessed to have severe cognitive impairment. On 06/30/2025, earlier during the day, staff reported redirecting the residents and separating the residents due to kissing, hugging, and mutual intentions. However, staff did not fully develop the residents' care plans to include increased supervision and monitoring. Later, that evening, R2 was found in R3's room, in her bed and was observed on top of R3 having sex. Licensed Practical Nurse (LPN)5 told staff to close the door and provide the residents privacy with agency nurse, LPN6 stating, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is. The residents' care plans failed to instruct staff on how to care for the cognitively impaired residents.Cross Reference F600 and F689Review of taped audio conversation sent to the State Survey Agency (SSA) surveyor by the facility's staff [STNA13] via text on 07/21/2025 at 7:49 AM revealed the Director of Nursing (DON) stated the residents were on a dementia unit and staff were to keep the residents safe and provide a safe environment. 1. a. Review of R2's Face Sheet, found in the electronic health record (EHR), revealed the facility admitted the resident on 05/30/2025 after his health declined, and his wife was unable to provide care with diagnoses to include Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and heart disease. Review of R2's Minimum Data Set [MDS], with an ARD of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's 'Physician's Orders, dated 05/30/2025, revealed an order for staff to monitor behavior every shift, document, and notify physician as needed.Review of R2's Comprehensive Care Plan [CCP], dated 06/11/2025, revealed a focus was identified as R2 being at risk for behaviors related to depression, mood disorder, and Alzheimer's. Further review revealed the goal was for R2 to display reduction of cognitive behaviors. Further review of the resident's care plan revealed it had not been fully developed to include monitoring or supervision of the resident for his behaviors, as noted in the resident's physician's orders. Review of R2's Health Status Note, dated 06/30/2025 at 10:57 AM, in the progress notes, revealed LPN5 charted R2 was encouraged and redirected from a female resident, for mutual walks and sitting together. On the same day at 4:59 PM, LPN5 charted R2 was redirected from a female resident from walking and sitting together. Though staff redirected the resident from a female resident on 06/30/2025, his care plan was not fully developed to include increased supervision and monitoring of his observed behaviors. Review of R2's Behavior Note, dated 06/30/2025 at 9:25 PM, in the progress notes, revealed LPN6 charted that R2 was in his room at this time with a sitter on 1:1 supervision. The note stated there was an earlier incident with him going into a female resident's room, and he was found under the sheets with the female resident [R3], with no distress noted. Per the note, it stated to continue to monitor this resident closely, and the supervisor had been informed.Review of R2's revised CCP revealed intervention placed on 07/01/2025 included to encourage the resident to express feelings, and to monitor and document signs of loneliness and depression. Though the resident's care plan was revised after the 06/30/2025 incident, the care plan failed to include the 1:1 supervision and to monitor the resident closely. b. Review of R3's Face Sheet, in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness, with diagnoses which included encephalopathy, vascular dementia, and stroke without deficits. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's Physician's Orders, dated 01/31/2025, revealed an order to monitor behavior every shift and notify physician as needed. Review of R3's CCP, dated 03/31/2025, revealed a focus of R3 wandering in and out of other residents' rooms and refusal of care with a goal of fewer episodes of refusal of care. Interventions placed on 03/31/2025 included to monitor behavior and attempt to determine underlying causes. Further review of the resident's care plan revealed it had not been fully developed to include increased supervision of the resident for her behaviors, to include wandering in and out of other residents' rooms. Review of R3's Health Status Note, dated 06/30/2025 at 10:00 AM, in the progress notes, revealed LPN 5 charted she redirected R3 with mutual intentions away from the male resident, taking walks and sitting together. Though staff redirected the resident from a male resident on 06/30/2025, her care plan was not fully developed to include increased supervision and monitoring of her observed behaviors. During an interview with State Tested Nurse Aide (STNA)14, on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as the nurse told her.In an interview with Licensed Practical Nurse (LPN)5, on 07/11/2025 at 8:30 AM, she stated R2 and R3 had been trying to get together all day, and staff had to continually separate them. Per the interview, LPN 5 stated she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. She stated she notified Unit Manager (UM) 1 and House Supervisor (HS) 2. LPN5 stated she did not intervene to stop the residents, and they continued for approximately 15 minutes until the aides went in to stop them.In an interview on 07/11/2025 at 5:04 PM with LPN6, she stated she was an agency nurse and worked on 06/30/2025 from 7:00 PM until 7:00 AM shift. She stated she was getting report from day shift staff when a nurse aide came to the end of the hall and started yelling for a nurse. She stated when she and the day shift nurse, LPN5, got to R3's room, R2 was lying flat on his back with R3's head on his chest. She stated R2 was not wearing a shirt, but R3 was wearing one. She stated a sheet covered both residents, and she was unsure what clothes they wore. LPN6 stated LPN5 told staff to close the door and let them finish and then clean them up. She stated LPN5 told them someone would need to supervise them the rest of the night, but she did not recall any extra staff called in. LPN6 stated LPN5 told her that R2 and R3 had been at it all day with kissing, hugging, sitting next to each other, with R3 trying to go into R2's room. LPN6 stated to the SSA surveyor, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is.In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8 PM, STNA14, told her she had something to show her. She stated the day shift nurse interrupted and told them to let it continue. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger. She stated she told R2 he could not do that and touched his arm to guide him off R3. She stated R3 was completely confused as to why they had to stop.In an interview with the Psychotherapist on 07/10/2025 at 3:08 PM, she stated the facility had asked her to perform an assessment for R2 and R3 but had not told her the reason other than there had been some inappropriate behavior toward each other, not saying what the behavior was.During an interview with the Director of Nursing (DON) on 07/17/2025 at 12:40 PM, she stated that after reviewing the Progress notes, related to R2's behaviors, she stated the CCP should have been developed to include interventions towards his behaviors.2. Review of the facility's policy titled, Resident Care-Safe Handling/Transfers, dated 09/12/2024, revealed the facility was to take measures to ensure residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines. Further review revealed guidelines included ensuring the sling designed for the mechanical lift (a device used to transfer a resident from one surface to another) was utilized with that specific lift, and two staff members must be utilized when transferring residents with a mechanical lift. Additional review revealed staff was to be educated upon hire, annually, and as the need arose or changes in equipment occurred. The policy stated staff must demonstrate competency in the use of the mechanical lift prior to using and annually. Continued review revealed staff was to follow the resident's individual plan of care and manufacturer's instructions, and staff was expected to maintain compliance with them.Review of R1's face sheet revealed the facility admitted the resident on 08/24/2018, with diagnoses to include Alzheimer's Disease, contracture of right knee, and peripheral vascular disease. Review of the Hospice Plan of Care revealed R1 was admitted to Hospice on 05/07/2025 for early onset of Alzheimer's. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2025 revealed the resident was not given a Brief Interview for Mental Status (BIMS) score. Review of the Physician's Order, dated 11/18/2024 revealed an order was placed for mechanical lift for all transfers. Activities of daily living (ADLs) upon admission, 08/24/2018 revealed independent with minimum assist and Review of the Quarterly MDS dated [DATE] revealed activities of daily living (ADLs) to be assessed as needing extensive assist of 2, wheelchair (W/C), and Hoyer lift for transfers with impairments bilaterally.Review of the Comprehensive Care Plan (CCP) dated 07/19/2023, revealed R1's focus was having insomnia with a goal to report feeling rested. Interventions placed 06/23/2025 included the resident prefers to not get up until after breakfast and before lunch. Added review of CCP revealed R1 required two (2) staff assistance for transfers. However, per staff interviews, R1 was transferred from the bed to the chair and placed in the common area at approximately 5:00 AM.Review of R1's Kardex (a tool used by nurse aides that summarizes patient care), dated 06/19/2025, revealed under special instructions, daughter does not want resident out of bed until after 7:00 AM. Additional review revealed two staff for transfers with Hoyer lift. However, based on staff interviews, R1 was transferred with the Hoyer lift with only one person assist.During an interview with LPN1on 07/09/2025 at 10:23 AM, she stated she had worked that day and was unsure who on night shift had gotten R1 up to chair and the night shift nurse had not reported any incidents to her.During an interview with RN2, on 07/08/2025 at 9:48 AM she stated she had worked night shift on 06/18/2025 to 06/19/2025. She stated she had not helped with the transfer and did not see the transfer.Review of R1's radiology report on 06/19/2025 at 12:42 PM revealed displaced fractures of the distal one third of the right tibia and fibula (broken lower leg bones toward ankle) and a computed tomography scan (CT) revealed osteoporotic bone.Review of the hospital note dated 06/19/2025 revealed R1 had bruising to right anterior shin and laceration tracking down to the bone and treated as open fracture. Further review of orthopedic note revealed surgical intervention performed on 06/19/2025.In an interview with State Tested Nurse Aide (STNA) 1 on 07/08/2025 at 3:40 PM, she stated R1 was always cared planned not to be up before 10:00 AM, but when she arrived to work on 06/19/2025 around 7:00 AM, the resident was in a Broda chair (a specialized chair designed to provide comfortable, supportive, and safe seating for persons with mobility limitations) in the common area. She stated she was trained to always have two people for Hoyer transfers. She stated she did not know why staff got R1 out of bed so early since everyone knew the daughter preferred this to happen with her after breakfast, and it was always on R1's CCP. She stated she did not know who got R1 up.In an additional interview with STNA1 on 07/22/2025 at 11:40 PM, she stated care plans were important, so staff was familiar with the care to provide. She stated if she felt an intervention was not on the resident's CCP, she would report it to the nurse immediately. In an interview with STNA2 on 07/08/2025 at 2:15 PM, she stated when she got to work on 06/19/2025, she clocked in at 6:53 AM, R1 was already in a Broda chair in the common area. She stated she thought that was weird since she knew R1was care planned, and the daughter did not want R1 up until after 7:00 AM. STNA2 stated she knew to always check the Hoyer lift for proper functioning and to always have two staff for transfers. The State Survey Agency (SSA) Surveyor was unable to reach the night shift aide, STNA4, that worked 06/18/2025 after three attempts, on 07/08/2025 at 8:37 AM; on 07/09/2025 at 11:03 AM; and on 0712/2025 at 12:09 PM.3. Review of R11's Face Sheet, in the EHR, revealed the facility admitted the resident on 12/04/2019 with diagnoses to include Alzheimer's disease, dementia, and repeated falls. Review of R11's quarterly MDS, with an ARD of 06/02/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, which indicated the resident was severely cognitively impaired. Review of R11's Physician's Orders, dated 01/17/2025, revealed an order for a soft touch call light. An additional order was placed on 07/14/2025, for bed to be in the lowest position while the resident was in bed. Review of R11's CCP identified R11 as a fall risk on 12/04/2019 with the goal to be free of falls. Further review revealed additional intervention placed on 01/08/2024 for a soft touch call light in reach. Continued review revealed an intervention placed on 07/14/2025 stating no Description provided without additional entries, perimeter mattress in place for positioning and safety, to evaluate fall risk on admission and as needed. In an interview with House Supervisor (HS) 3 on 07/15/2025 at 3:16 PM, she stated for two months she had only worked part-time. She stated she worked night shift on 07/13/2025 and received a call about 6:00 AM, on 07/14/2025, to come to the Memory Care Unit (MCU), and she arrived on the MCU at 6:08 AM. She said she saw R11 lying on the floor. She stated R11 had a knot in the center of her forehead, and her right shoulder had bruising. She stated when she got into R11's room the bed was about waist high, and not in low position. She stated the aide, (agency) State Tested Nurse Aide (STNA) 6, told her the bed was not in low position. She stated she obtained statements from everyone. She stated the STNA6 told her the last time he was in R11's room was about 4:00 AM, and he thought the bed was not placed in low position, but R11 had a perimeter mattress. In an interview with STNA6 on 07/17/2025 at 5:02 PM, he stated he worked the night shift on 07/13/2025, and R11 sustained a fall from the bed. He stated he did not know what happened, and he had checked on her around 3:30 AM or 4:00 AM. He stated the bed was not in high position but was not in the lowest position either. He stated if the bed was in the lowest position, it pretty much sat on the floor, and that made it impossible to provide care. He stated R11 had a huge perimeter mattress on the bed, and he could not figure out how she got out of the bed. He stated he saw a bruise to the front of R11's head and a scratch to her hand and knee, but he did not recall if they were on her right or left side.In an additional interview with STNA6 on 07/18/2025 at 8:40 AM, he stated R11 was found on the left side of the bed and could not remember if the fall mat was there or not, but he was unsure how she got up over the hump of the perimeter mattress since it was so huge. In an interview with the MDS Nurse on 07/18/2025 at 3:07 PM, she stated she had been in the position for less than three months, remotely and not on site. She stated she relied on the facility's documentation including hospital records to assist her with care planning for the resident. The MDS Nurse stated care plans should be developed and updated with any acute issues immediately by nurses. She stated the Interdisciplinary Team (IDT) reviewed care plans for appropriateness and to see if anything needed to be added. She stated care plans were important because they dictated all care and preferences of the residents. Further, she stated the revisions were performed on an as needed basis and quarterly, aligning with the MDS assessments. During an interview with the Director of Nursing (DON) on 07/17/2025 at 12:40 PM, she stated her expectations were for staff to follow and update care plans. She stated care plans existed, so staff knew how to care for a resident.During an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated it was her expectation for staff to follow facility policy and procedures related to the development and revision of care plans. Immediate Jeopardy (IJ) Removal Plan verbatim:Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residents?R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to include their capacity to make decisions regarding sexual interactions.Comprehensive assessments (cognitive, physical, psychosocial and sexual consent capacity) were completed for both residents by Social Services and Interim Director of Nursing on 7/23/2025.2. Actions taken to identify other residents at risk?Sexual Competency Consent Screening was completed on all residents in the Memory Care Unit by the Social Service Director on 7/22/2025.Care plans updated on 7/23/2025 by Clinical Consultant for residents who are unable to make decisions regarding sexual interactions.Starting on 7/24/2025 the social service director will complete a sexual consent screen on all cognitively impaired residents. Care plans will be updated as screens are completed.Starting on 7/23/2025, routine staff on the dementia unit will be interviewed related to resident behaviors, supervision, and sexual encounters. Care plans will be updated based on staff observations. This will be completed by the Clinical Consultant, System Director of Clinical Education and Infection Prevention, and Interim Director of Nursing. 2 out of 5 completed.3. Actions taken to prevent recurrence of the deficient practice?Corporate staff reviewed the following policies on 7/21/2025.Comprehensive Care Plans Policy and ProcedureThe policy was reviewed and determined no revisions were necessary by:1. Carmelite System CEO2. Carmelite System Director of Quality, Safety, and Risk3. RN Clinical Consultant - [NAME] Clinical4. Carmelite System Interim CEO of Carmel ManorEducation provided by Clinical Consultant to licensed staff on updating care plans beginning on 7/23/2025. 10 out of 31 completed.The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift.The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Education will include:Updating care plans following events that demonstrate the need for a changeWriting person-centered care plans with interventions that relate to the resident, their specific conditions and interventions that arespecific to the resident's needs4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained?By 7/23/2025, The Internal Clinical Consultant and Outside Clinical Consultant will review and edit all residents' care plans on the memory care unit to ensure personalized interventions for behaviors.The Internal Clinical Consultant and Outside Clinical Consultant will review care plans for updates following events, and for personalization starting on 7/24/2025.There will be ongoing monitoring of care plan revisions 4 days a week for any residents related to behaviors and sexual abuse.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025The facility asserts that Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident by failing to follow the abuse policy and procedures related to protecting residents and conducting a thorough investigation of abuse after two cognitively impaired residents were observed having sexual intercourse, Resident (R) 2 and R3.On 06/30/2025, R2 and R3 were found in R3's bed naked, engaging in sexual activity, and neither had been assessed for ability to consent to activity.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.70 Administration (F835) at the highest Scope and Severity (S/S) of a J. The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.70 Administration (F835) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.The findings include:Review of the facility document titled, Job Description and Performance Appraisal - Administrator, dated 03/2023, revealed the Administrator is responsible for assuring the highest degree of quality resident care is delivered at all times. Further review revealed the Administrator maintains responsibility for all accident and incident report investigations and reviews and ensures timely reporting when necessary to maintain the effectiveness of the facility's risk management program. Additional review revealed the Administrator is to act with integrity and honesty in all matters and demonstrate uncompromising adherence to ethical principles and organizational values.Review of the facility document titled, Job Description and Performance Appraisal - Director of Nursing (DON), dated 03/2023, revealed the DON is responsible for planning, organizing, developing, and directing the operations of the Nursing Services Department in accordance with local, state, and federal regulation and established home policies and procedures. Further review revealed job duties include overseeing resident accidents, incidents, and concerns and identifies potential indicators of abuse, neglect, or misappropriation daily and reports promptly to the Administrator and state agency and actively participates in a thorough investigation. Additional review revealed job duties included ensuring a robust education program that provides staff with necessary competencies.Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred; and defining sexual abuse as non-consensual sexual contact of any type with a resident. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Additional review revealed the procedures included reporting all alleged violations to the Administrator, state agency, adult protective services (APS), and other required agencies, such as law enforcement, immediately but not later than two hours after the allegation was made. Continued review of facility policy revealed prevention measures for abuse, neglect, and exploitation included providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. Further review revealed the facility would promote a culture of safety and open communications in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. 1.Interviews and record review revealed staff were asked to change their statements when reporting allegations of abuse. Staff stated they changed their interviews out of fear of retaliation. During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as the nurse told her. She stated the DON asked her to change her written statement and she changed her report out of fear of losing her job, adding, I just caved, cause I need a job. In an interview with STNA13 on 07/10/2025 at 12:41 PM , she stated she was told by the Director of nursing (DON) to change her statement. STNA13 stated during the conversation with the DON, she witnessed STNA14 ask the DON if she should include within her statement that LPN5 asked staff to close the resident's door for the residents to continue the activity. She stated the DON stated, absolutely not. STNA13 stated she recorded the DON's conversation on her phone. She stated around 9:30 PM on 06/30/2025, she was asked to come to the House Supervisor's (HS) office. She stated when she arrived, HS2 called the DON, and she was instructed to change her statement because her documentation were not the facts. She stated when she told the DON they were the facts and that was what she saw, the DON started yelling. She stated she was in the HS's office for about one to two hours re-writing her statement, then she took a picture of the original one and still had it. She stated the DON told her if she left all that in the statement, it would open a can of worms that did not need to be opened.In a telephone interview with Registered Nurse (RN) 1 on 07/16/2025 at 12:37 PM, she stated she did not feel comfortable talking in the facility about the incident that happened between R2 and R3 when they were found in the bed naked. She stated she had worked day shift on another unit and was giving LPN3 report when the nurse aides from Memory Care Unit contacted LPN3. RN1 stated HS2 had told her not to say anything about what had happened to anyone related to R2 and R3. RN1 stated R2 had behaviors before the incident on 06/30/2025 of kissing R3, and he should not have been around R3. She stated she was told by the DON not to say anything about another incident, and she feared losing her job if the DON found out she talked about either incident and that was reason for the telephone call.In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she informed HS2. She stated HS2 called the DON, and she could hear the DON yelling over the phone for HS2 to get to the MCU. LPN3 stated when HS2 got back to the unit, she told LPN3 that the DON had asked her to get statements from staff and soft file them, meaning the facility conducted its own investigation. LPN3 stated she stepped outside the facility at that time and reported the incident anonymously, adding, I knew I was at risk of losing my job. She stated she had told HS1 after she reported it and HS1 told her to watch her back. Further interview with LPN3, on 07/16/2025 at 10:56 AM, revealed she could hear the DON yelling in the HS office later that evening, but was unable to tell what was being said or who was in office. She stated sometime later, STNA13 came out of the office and told her she could not talk about it right now. She stated she had worked the MCU but was unable to say when, and R2 was having behaviors of touching and kissing R3, and staff was continuously redirecting. She stated after the incident on 06/30/2025, the DON told staff to be very careful what they charted and to call her if they had any questions about what to chart concerning R2. She stated the DON had called her agency and requested not to send her back to the facility. LPN3 added she felt like the DON somehow found out she had reported the incident and that was why she was asked not to come back but could not say for sure.Review of the picture of the original written statement of staff member [STNA13], dated 06/30/2025 with time stamp of 9:22 PM, revealed wording was changed from putting fingers in R3's private area to fondling R3's genitalia area.Review of taped audio conversation sent to the SSA by the facility's staff [STNA13], via text message on 07/21/2025 at 7:49 AM, revealed the DON's instructions to staff for statements and the DON stated it was an open investigation. The DON stated staff could not speak to anyone, and it was serious. The DON stated not to make any assumptions and give nothing but facts. The DON stated she did not understand how this happened, but she did because the residents were quick. The DON stated staff had been on top of their behavior, and the residents should never have been left alone. Continued listening of the taped audio conversation revealed the DON instructed the HS to call her once the statements were gathered, and they would review them. During continued listening of the taped audio conversation, one employee asked if she should put in the comment from the nurse telling them to shut the door and let them finish, and the DON stated absolutely not. The DON stated this was a dementia unit, and staff was to keep residents safe and provide a safe environment. The DON stated if staff placed that in their statement it would open another can of worms. The DON stated if staff did not see the residents having sex, staff could not use the word sex. Further listening revealed a staff member informed the DON that R2 was fingering R3. Then, the DON stated she was not telling staff to withhold any information but to state just what they saw.In an interview with State Tested Nurse Aide/Kentucky Medication Aide (STNA/KMA)18 on 07/21/2025 at 7:38 PM, she stated she had charted R2 behaviors, and the DON had made her change it, saying it was inappropriate charting. Further, she stated she was terminated without notice for not charting correctly.Review of R2's Alert Note, dated 06/15/2025 at 2:05 PM, in the progress notes, revealed State Tested Nurse Aide, Kentucky Medication Aide (STNA/KMA)18 charted R2 was holding hands with another resident, and a visitor reported R2 was kissing another resident. Further review revealed STNA/KMA18 at 2:30 PM charted an aide reported a female resident was in R2's room, and R2 was in bed naked under a blanket. Per the note, R2 stated they were praying together, and the female resident was removed from the room. However, the entry was struck out on 06/16/2025 at 5:37 PM with reason as incorrect documentation. In further interview with STNA/KMA18, on 07/21/2025 at 7:38 PM, she stated R2 had always had behaviors such as kissing female residents' hands and wandering in and out of female residents' rooms. She stated staff continually redirected R2. In an interview with Licensed Practical Nurse (LPN)3 on 07/16/2025 at 10:56 AM, she stated she had worked the MCU but was unable to say when, and R2 was having behaviors of touching and kissing R3, and staff was continuously redirecting. She stated after the incident on 06/30/2025, the DON told staff to be very careful what they charted and to call her if they had any questions about what to chart concerning R2. She stated the DON had called her agency and requested not to send her back to the facility.In an interview with the DON on 07/17/2025 at 12:40 PM, she stated the strike outs in R2's progress notes were incorrect documentation on that resident, and some was hearsay and should not have been charted. She stated she was unsure who performed the strike outs, she would need to look at additional notes.2. Additionally, the Administration Failed to report the allegation of abuse and investigate in a timely manner. Interviews and record review revealed the allegation of abuse occurred on 06/30/2025. The facility failed to notify the appropriate State Agencies timely and local law authorities on the alleged abuse allegations. Review of the final report Facility Internal Investigation [FII], dated 07/07/2025 at 4:45 PM, initial report dated 07/01/2025 at 5:00 PM, revealed on 06/30/2025, no time given, staff and the Administrator became aware of the incident between R2 and R3, and the physician and the families were notified on 07/01/2025, no time given. Additional review of the FII indicated no other notifications were made on 06/30/2025. Review of the Intake Information revealed an Entity Self-Reported allegation of Resident/Patient/Client Abuse with category listed as sexual was reported to the State Survey Agency (SSA) on 07/01/2025 at 5:09 PM via E-mail (electronic mail). Further review revealed two residents, identified as cognitively impaired, were found disrobed under blankets. Further review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury. In an interview with the DON on 07/14/2025 at 4:20 PM, she stated her tasks included to offer oversight of the nursing department and helping with education. She stated she did not come to the facility after the incident [between R2 and R3] was reported to her, and she had talked to staff and requested they each write a statement just listing the facts. She stated an investigation was immediately started, the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision. She stated R3 was not placed on 1:1 because she was not as mobile as R2. The DON stated she reviewed the staffs' statements related to the incident the next morning, when they were first sent to her in her mailbox. She stated the facility's investigation determined sexual abuse did not occur since R2 and R3 enjoyed each other's company. Further interview revealed the DON was unsure if a psychiatrist had assessed the residents to determine if the residents were capable of consenting to sexual activity. During an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated the job task was to oversee all the functions of the facility and to serve as the Abuse Coordinator (AC). She stated as the AC she opened an investigation when there was an allegation of abuse following the facility's policy and reporting it immediately. When asked what immediately meant, she stated she did not know, whatever the definition is. She stated she might not be the first to get the report, but the DON or HS would be contacted. She stated the DON had called her the night of 06/30/2025, no time specified, stating R2 and R3 were found in bed with each other under the covers. She stated she was told that both residents were assessed, and R2 was placed on a 1:1 supervision. The Administrator stated R2 was placed on 1:1 supervision out of an abundance of caution but was unable to state what the caution was. During continued interview with the Administrator, on 07/17/2025 at 12:02 PM, she stated the investigation was thorough, and no deficient practice was identified since there was no negative outcome. She stated she had not interviewed any of the witnesses, but she sat in on the interviews staff had with the DON, which occurred the next day. She stated statements were obtained from staff by the DON, and when asked if she thought the statements were accurate, she stated she would not know, anybody can write anything. When the Administrator was informed by the SSA Surveyor one of the statements revealed that R2 was fondling R3's private area, she stated if it was consensual, then one would not consider that sexual abuse. In continued interview, on 07/17/2025 at 12:02 PM, the Administrator stated she was never told LPN5 advised staff to close the resident's door to provide privacy, but if privacy was needed, then staff would close the door. She stated she was not sure if the residents were separated immediately. Further, the State Survey Agency (SSA) surveyor reviewed the FII with the Administrator and she confirmed the reporting day [of the incident] to the SSA was on 07/01/2025 at 5:09 PM [approximately one day after the incident]; however, it should have been completed immediately, but no later than two hours after staff became aware of the incident.Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed for accidents, Resident (R)1, R7, and R11.1) On 06/19/2025, R1 sustained a compound fracture to right lower extremity during a transfer, requiring surgical interventions. However, review of the facility's investigation, they determined it was an injury of unknow origin and the cause was unable to be determined.2) On 07/14/2025, R11 was found in her room on the floor and was transferred to local hospital. Hospital records revealed R11 sustained a broken shoulder.3) On 07/09/2025, observation during an interview with R7 revealed a medication cup with 2 pills in it on the overbed table. Additional observation revealed one pill lying on the over bed table. During an immediate interview, Registered Nurse (RN)3 stated she had not given any medication to R7, they must have been left by the previous shift.The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 02/09/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with residents' rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in each resident's comprehensive assessment. Further review revealed guidelines included services would be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing, and alternate interventions would be documented as needed. Additional review revealed the care plan could be prepared by any interdisciplinary team which included but was not limited to include registered nurses and nurse aides. Additional review revealed qualified staff responsible for carrying out interventions would be notified of their roles and responsibilities for carrying out interventions initially and when changes were made. Record review and interviews revealed Resident (R)2 and R3 resided on the Memory Care Unit (MCU) and were assessed to have severe cognitive impairment. On 06/30/2025, earlier during the day, staff reported redirecting the residents and separating the residents due to kissing, hugging, and mutual intentions. However, staff did not fully develop the residents' care plans to include increased supervision and monitoring. Later, that evening, R2 was found in R3's room, in her bed and was observed on top of R3 having sex. Licensed Practical Nurse (LPN)5 told staff to close the door and provide the residents privacy with agency nurse, LPN6 stating, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is. The residents' care plans failed to instruct staff on how to care for the cognitively impaired residents.Cross Reference F600 and F689Review of taped audio conversation sent to the State Survey Agency (SSA) surveyor by the facility's staff [STNA13] via text on 07/21/2025 at 7:49 AM revealed the Director of Nursing (DON) stated the residents were on a dementia unit and staff were to keep the residents safe and provide a safe environment. 1. a. Review of R2's Face Sheet, found in the electronic health record (EHR), revealed the facility admitted the resident on 05/30/2025 after his health declined, and his wife was unable to provide care with diagnoses to include Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and heart disease. Review of R2's Minimum Data Set [MDS], with an ARD of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's 'Physician's Orders, dated 05/30/2025, revealed an order for staff to monitor behavior every shift, document, and notify physician as needed.Review of R2's Comprehensive Care Plan [CCP], dated 06/11/2025, revealed a focus was identified as R2 being at risk for behaviors related to depression, mood disorder, and Alzheimer's. Further review revealed the goal was for R2 to display reduction of cognitive behaviors. Further review of the resident's care plan revealed it had not been fully developed to include monitoring or supervision of the resident for his behaviors, as noted in the resident's physician's orders.Review of R2's Health Status Note, dated 06/30/2025 at 10:57 AM, in the progress notes, revealed LPN5 charted R2 was encouraged and redirected from a female resident, for mutual walks and sitting together. On the same day at 4:59 PM, LPN5 charted R2 was redirected from a female resident from walking and sitting together. Though staff redirected the resident from a female resident on 06/30/2025, his care plan was not fully developed to include increased supervision and monitoring of his observed behaviors. Review of R2's Behavior Note, dated 06/30/2025 at 9:25 PM, in the progress notes, revealed LPN6 charted that R2 was in his room at this time with a sitter on 1:1 supervision. The note stated there was an earlier incident with him going into a female resident's room, and he was found under the sheets with the female resident [R3], with no distress noted. Per the note, it stated to continue to monitor this resident closely, and the supervisor had been informed.Review of R2's revised CCP revealed intervention placed on 07/01/2025 included to encourage the resident to express feelings, and to monitor and document signs of loneliness and depression. Though the resident's care plan was revised after the 06/30/2025 incident, the care plan failed to include the 1:1 supervision and to monitor the resident closely.b. Review of R3's Face Sheet, in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness, with diagnoses which included encephalopathy, vascular dementia, and stroke without deficits. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's Physician's Orders, dated 01/31/2025, revealed an order to monitor behavior every shift and notify physician as needed. Review of R3's CCP, dated 03/31/2025, revealed a focus of R3 wandering in and out of other residents' rooms and refusal of care with a goal of fewer episodes of refusal of care. Interventions placed on 03/31/2025 included to monitor behavior and attempt to determine underlying causes. Further review of the resident's care plan revealed it had not been fully developed to include increased supervision of the resident for her behaviors, to include wandering in and out of other residents' rooms.Review of R3's Health Status Note, dated 06/30/2025 at 10:00 AM, in the progress notes, revealed LPN 5 charted she redirected R3 with mutual intentions away from the male resident, taking walks and sitting together. Though staff redirected the resident from a male resident on 06/30/2025, her care plan was not fully developed to include increased supervision and monitoring of her observed behaviors. During an interview with State Tested Nurse Aide (STNA)14, on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as the nurse told her.In an interview with Licensed Practical Nurse (LPN)5, on 07/11/2025 at 8:30 AM, she stated R2 and R3 had been trying to get together all day, and staff had to continually separate them. Per the interview, LPN 5 stated she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. She stated she notified Unit Manager (UM) 1 and House Supervisor (HS) 2. LPN5 stated she did not intervene to stop the residents, and they continued for approximately 15 minutes until the aides went in to stop them.In an interview on 07/11/2025 at 5:04 PM with LPN6, she stated she was an agency nurse and worked on 06/30/2025 from 7:00 PM until 7:00 AM shift. She stated she was getting report from day shift staff when a nurse aide came to the end of the hall and started yelling for a nurse. She stated when she and the day shift nurse, LPN5, got to R3's room, R2 was lying flat on his back with R3's head on his chest. She stated R2 was not wearing a shirt, but R3 was wearing one. She stated a sheet covered both residents, and she was unsure what clothes they wore. LPN6 stated LPN5 told staff to close the door and let them finish and then clean them up. She stated LPN5 told them someone would need to supervise them the rest of the night, but she did not recall any extra staff called in. LPN6 stated LPN5 told her that R2 and R3 had been at it all day with kissing, hugging, sitting next to each other, with R3 trying to go into R2's room. LPN6 stated to the SSA surveyor, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is.In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8 PM, STNA14, told her she had something to show her. She stated the day shift nurse interrupted and told them to let it continue. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger. She stated she told R2 he could not do that and touched his arm to guide him off R3. She stated R3 was completely confused as to why they had to stop.In an interview with the Psychotherapist on 07/10/2025 at 3:08 PM, she stated the facility had asked her to perform an assessment for R2 and R3 but had not told her the reason other than there had been some inappropriate behavior toward each other, not saying what the behavior was.During an interview with the Director of Nursing (DON) on 07/17/2025 at 12:40 PM, she stated that after reviewing the Progress notes, related to R2's behaviors, she stated the CCP should have been developed to include interventions towards his behaviors.2. Review of the facility's policy titled, Resident Care-Safe Handling/Transfers, dated 09/12/2024, revealed the facility was to take measures to ensure residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines. Further review revealed guidelines included ensuring the sling designed for the mechanical lift (a device used to transfer a resident from one surface to another) was utilized with that specific lift, and two staff members must be utilized when transferring residents with a mechanical lift. Additional review revealed staff was to be educated upon hire, annually, and as the need arose or changes in equipment occurred. The policy stated staff must demonstrate competency in the use of the mechanical lift prior to using and annually. Continued review revealed staff was to follow the resident's individual plan of care and manufacturer's instructions, and staff was expected to maintain compliance with them.Review of R1's face sheet revealed the facility admitted the resident on 08/24/2018, with diagnoses to include Alzheimer's Disease, contracture of right knee, and peripheral vascular disease. Review of the Hospice Plan of Care revealed R1 was admitted to Hospice on 05/07/2025 for early onset of Alzheimer's. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2025 revealed the resident was not given a Brief Interview for Mental Status (BIMS) score. Review of the Physician's Order, dated 11/18/2024 revealed an order was placed for mechanical lift for all transfers. Activities of daily living (ADLs) upon admission, 08/24/2018 revealed independent with minimum assist and Review of the Quarterly MDS dated [DATE] revealed activities of daily living (ADLs) to be assessed as needing extensive assist of 2, wheelchair (W/C), and Hoyer lift for transfers with impairments bilaterally.Review of the Comprehensive Care Plan (CCP) dated 07/19/2023, revealed R1's focus was having insomnia with a goal to report feeling rested. Interventions placed 06/23/2025 included the resident prefers to not get up until after breakfast and before lunch. Added review of CCP revealed R1 required two (2) staff assistance for transfers. However, per staff interviews, R1 was transferred from the bed to the chair and placed in the common area at approximately 5:00 AM.Review of R1's Kardex (a tool used by nurse aides that summarizes patient care), dated 06/19/2025, revealed under special instructions, daughter does not want resident out of bed until after 7:00 AM. Additional review revealed two staff for transfers with Hoyer lift. However, based on staff interviews, R1 was transferred with the Hoyer lift with only one person assist.During an interview with LPN1on 07/09/2025 at 10:23 AM, she stated she had worked that day and was unsure who on night shift had gotten R1 up to chair and the night shift nurse had not reported any incidents to her.During an interview with RN2, on 07/08/2025 at 9:48 AM she stated she had worked night shift on 06/18/2025 to 06/19/2025. She stated she had not helped with the transfer and did not see the transfer.Review of R1's radiology report on 06/19/2025 at 12:42 PM revealed displaced fractures of the distal one third of the right tibia and fibula (broken lower leg bones toward ankle) and a computed tomography scan (CT) revealed osteoporotic bone.Review of the hospital note dated 06/19/2025 revealed R1 had bruising to right anterior shin and laceration tracking down to the bone and treated as open fracture. Further review of orthopedic note revealed surgical intervention performed on 06/19/2025.In an interview with State Tested Nurse Aide (STNA) 1 on 07/08/2025 at 3:40 PM, she stated R1 was always cared planned not to be up before 10:00 AM, but when she arrived to work on 06/19/2025 around 7:00 AM, the resident was in a Broda chair (a specialized chair designed to provide comfortable, supportive, and safe seating for persons with mobility limitations) in the common area. She stated she was trained to always have two people for Hoyer transfers. She stated she did not know why staff got R1 out of bed so early since everyone knew the daughter preferred this to happen with her after breakfast, and it was always on R1's CCP. She stated she did not know who got R1 up.In an additional interview with STNA1 on 07/22/2025 at 11:40 PM, she stated care plans were important, so staff was familiar with the care to provide. She stated if she felt an intervention was not on the resident's CCP, she would report it to the nurse immediately. In an interview with STNA2 on 07/08/2025 at 2:15 PM, she stated when she got to work on 06/19/2025, she clocked in at 6:53 AM, R1 was already in a Broda chair in the common area. She stated she thought that was weird since she knew R1was care planned, and the daughter did not want R1 up until after 7:00 AM. STNA2 stated she knew to always check the Hoyer lift for proper functioning and to always have two staff for transfers. The State Survey Agency (SSA) Surveyor was unable to reach the night shift aide, STNA4, that worked 06/18/2025 after three attempts, on 07/08/2025 at 8:37 AM; on 07/09/2025 at 11:03 AM; and on 0712/2025 at 12:09 PM.3. Review of R11's Face Sheet, in the EHR, revealed the facility admitted the resident on 12/04/2019 with diagnoses to include Alzheimer's disease, dementia, and repeated falls. Review of R11's quarterly MDS, with an ARD of 06/02/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, which indicated the resident was severely cognitively impaired. Review of R11's Physician's Orders, dated 01/17/2025, revealed an order for a soft touch call light. An additional order was placed on 07/14/2025, for bed to be in the lowest position while the resident was in bed. Review of R11's CCP identified R11 as a fall risk on 12/04/2019 with the goal to be free of falls. Further review revealed additional intervention placed on 01/08/2024 for a soft touch call light in reach. Continued review revealed an intervention placed on 07/14/2025 stating no Description provided without additional entries, perimeter mattress in place for positioning and safety, to evaluate fall risk on admission and as needed. In an interview with House Supervisor (HS) 3 on 07/15/2025 at 3:16 PM, she stated for two months she had only worked part-time. She stated she worked night shift on 07/13/2025 and received a call about 6:00 AM, on 07/14/2025, to come to the Memory Care Unit (MCU), and she arrived on the MCU at 6:08 AM. She said she saw R11 lying on the floor. She stated R11 had a knot in the center of her forehead, and her right shoulder had bruising. She stated when she got into R11's room the bed was about waist high, and not in low position. She stated the aide, (agency) State Tested Nurse Aide (STNA) 6, told her the bed was not in low position. She stated she obtained statements from everyone. She stated the STNA6 told her the last time he was in R11's room was about 4:00 AM, and he thought the bed was not placed in low position, but R11 had a perimeter mattress. In an interview with STNA6 on 07/17/2025 at 5:02 PM, he stated he worked the night shift on 07/13/2025, and R11 sustained a fall from the bed. He stated he did not know what happened, and he had checked on her around 3:30 AM or 4:00 AM. He stated the bed was not in high position but was not in the lowest position either. He stated if the bed was in the lowest position, it pretty much sat on the floor, and that made it impossible to provide care. He stated R11 had a huge perimeter mattress on the bed, and he could not figure out how she got out of the bed. He stated he saw a bruise to the front of R11's head and a scratch to her hand and knee, but he did not recall if they were on her right or left side.In an additional interview with STNA6 on 07/18/2025 at 8:40 AM, he stated R11 was found on the left side of the bed and could not remember if the fall mat was there or not, but he was unsure how she got up over the hump of the perimeter mattress since it was so huge. In an interview with the MDS Nurse on 07/18/2025 at 3:07 PM, she stated she had been in the position for less than three months, remotely and not on site. She stated she relied on the facility's documentation including hospital records to assist her with care planning for the resident. The MDS Nurse stated care plans should be developed and updated with any acute issues immediately by nurses. She stated the Interdisciplinary Team (IDT) reviewed care plans for appropriateness and to see if anything needed to be added. She stated care plans were important because they dictated all care and preferences of the residents. Further, she stated the revisions were performed on an as needed basis and quarterly, aligning with the MDS assessments.During an interview with the Director of Nursing (DON) on 07/17/2025 at 12:40 PM, she stated her expectations were for staff to follow and update care plans. She stated care plans existed, so staff knew how to care for a resident.During an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated it was her expectation for staff to follow facility policy and procedures related to the development and revision of care plans. Immediate Jeopardy (IJ) Removal Plan verbatim:Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residents?R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to include their capacity to make decisions regarding sexual interactions.Comprehensive assessments (cognitive, physical, psychosocial and sexual consent capacity) were completed for both residents by Social Services and Interim Director of Nursing on 7/23/2025.2. Actions taken to identify other residents at risk?Sexual Competency Consent Screening was completed on all residents in the Memory Care Unit by the Social Service Director on 7/22/2025.Care plans updated on 7/23/2025 by Clinical Consultant for residents who are unable to make decisions regarding sexual interactions.Starting on 7/24/2025 the social service director will complete a sexual consent screen on all cognitively impaired residents. Care plans will be updated as screens are completed.Starting on 7/23/2025, routine staff on the dementia unit will be interviewed related to resident behaviors, supervision, and sexual encounters. Care plans will be updated based on staff observations. This will be completed by the Clinical Consultant, System Director of Clinical Education and Infection Prevention, and Interim Director of Nursing. 2 out of 5 completed.3. Actions taken to prevent recurrence of the deficient practice?Corporate staff reviewed the following policies on 7/21/2025.Comprehensive Care Plans Policy and ProcedureThe policy was reviewed and determined no revisions were necessary by:1. Carmelite System CEO2. Carmelite System Director of Quality, Safety, and Risk3. RN Clinical Consultant - [NAME] Clinical4. Carmelite System Interim CEO of Carmel ManorEducation provided by Clinical Consultant to licensed staff on updating care plans beginning on 7/23/2025. 10 out of 31 completed.The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift.The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Education will include:Updating care plans following events that demonstrate the need for a changeWriting person-centered care plans with interventions that relate to the resident, their specific conditions and interventions that arespecific to the resident's needs4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained?By 7/23/2025, The Internal Clinical Consultant and Outside Clinical Consultant will review and edit all residents' care plans on the memory care unit to ensure personalized interventions for behaviors.The Internal Clinical Consultant and Outside Clinical Consultant will review care plans for updates following events, and for personalization starting on 7/24/2025.There will be ongoing monitoring of care plan revisions 4 days a week for any residents related to behaviors and sexual abuse.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025The facility asserts that Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 sampled residents, Resident (R) 27 and R28The findings include:Review of the CDC's guidelines titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care is completed. Further review revealed to ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials.Review of the facility's policy titled, Infection Prevention and Control Plan, undated, revealed the facility maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections per CDC guidelines. The policy stated its goal was to limit unprotected exposure to pathogens through the use of hand hygiene and PPE isolation precautions and improving compliance within work practices. Additionally, the policy stated that it would limit the transmission of infections associated with the use of medical equipment devices and supplies through the cleaning and disinfection of equipment.1. Review of R27's admission Record revealed the facility admitted R27 on 07/23/2025 with diagnoses that included COVID-19, epilepsy, and chronic kidney disease. R27 did not have a Brief Interview for Mental Status (BIMS) assessment as he was a new admit.Review of R27's baseline Care Plan Report, dated 07/23/2025, revealed the facility care planned the resident for a COVID-19 infection. Goals included the infection would be resolved without complications. Interventions included placing R27 in droplet isolation precautions. Additional interventions included that the resident would be redirected back to her room if she wandered out while in isolation.Review of R27's physician Order Summary Report, revealed R27 was placed in droplet isolation precautions on 07/23/2025 for COVID-19.Observation of R27's room on 07/23/2025 at 11:48 AM revealed there was no CDC signage displayed on the entrance door indicating the resident was under droplet isolation precautions. Outside of the room, there was a container holding PPE. Additionally, R27, who was diagnosed with COVID-19, was not in her room; R27 was self-ambulating in her wheelchair in the living room area and was not wearing a mask. Staff were walking in the area but did not redirect the resident back to her room until the SSA surveyor asked why the resident was not in her room.During an interview with State Tested Nursing Assistant (STNA12) on 07/24/2025 at 11:25 AM, she stated that R27 tested positive for COVID-19 and was currently in isolation in a single room. However, the STNA stated there was no droplet isolation precaution sign on the door to indicate the type of transmission-based precautions (TBP) in place. STNA12 stated she served breakfast to R27 without wearing PPE because there were no signs on the door indicating droplet precautions were in effect. Additionally, she stated that the nursing staff provided reports at the beginning of each shift, but the reports were often not detailed enough, making it difficult to get a complete understanding of the resident's status. STNA12 stated that during her orientation, she received training on infection prevention and control practices (IPCP), which included instructions for wearing gowns and gloves when providing direct care for residents under enhanced barrier (EBP) and TBP. She stated full PPE was required to enter the room of residents who were under droplet precautions.During an interview with STNA1 on 07/24/2025 at 4:49 PM, she stated she had received IPCP training upon hire and periodically throughout the year. The STNA stated that there should be a PPE bin outside all TBP rooms. She stated that she had observed there was neither a PPE container nor a sign on R27's door yesterday when the resident was admitted . She confirmed there was still no sign on the door today. Additionally, STNA1 stated R27 should remain in the room with the door closed and should not be allowed to ambulate in the hallway. When asked how she knew it was a droplet isolation room without the required CDC signage, she stated, Usually, the nurse would stop you before you entered. However, she also stated that yesterday, if the nurse had not been present, she would have entered the room because there was no sign on the door or PPE container outside of the room.During an interview with LPN2 on 07/24/2025 at 11:55 AM, she stated R27 should not be out of her room. She stated the resident had to be educated on staying in her room while she was under droplet isolation precautions. LPN2 stated staff were given report every morning on each resident's status, and all staff were made aware that R27 was COVID-19 positive and under TBP. LPN2 stated it was the responsibility of housekeeping and the Infection Preventionist (IP) to ensure the proper signage and PPE was available outside of the room. She stated she had made staff aware of R27's isolation status in report. LPN2 stated it was important to follow CDC guidelines to prevent the spread of infection.During an interview with the Interim Director of Nursing (DON)/IP on 07/24/2025 at 12:45 PM, she stated she did not know why R27 did not have a droplet isolation sign on her door. She stated she did not know why the resident was not in her room. She stated it was her expectation that IPCP were followed and that staff should ensure that the residents in TBP isolation remained in their rooms or had the proper PPE on when in common areas. She stated following IPCP was important to prevent the spread of disease. The IDON/IP stated it was the nursing staff's responsibility to ensure appropriate signage was placed on the doors of all TBP and EBP rooms.2. Review of R28's admission Record revealed the facility admitted R28 on 07/27/2022 with diagnoses that included type 2 diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease (COPD).Review of R28 annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/19/2025, revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact.During an observation of the St. [NAME] Unit on 07/24/2025 at 8:00 AM, LPN2 exited R28's room carrying a contaminated glucometer, along with two medicine cups that contained a used alcohol pad and a used lancet on her clipboard. She then set the clipboard on the medication cart. LPN2 did not clean and disinfect the glucometer after use. Furthermore, the nurse left the glucometer on top of the clipboard on the medication cart and walked away without returning to clean the device during the observation period. During an interview with LPN2 on 07/24/2025 at 5:09 PM, she stated she had received IPCP training. She stated the glucometer should be cleaned with a disinfectant wipe before and after each use, and the glucometer needed to remain wet for two minutes before being allowed to dry. She stated, For the most part, everyone has their own glucometer. Additionally, LPN2 stated after the glucometer was dry, it should be placed in a plastic bag. She stated she had not cleaned the glucometer after performing a fingerstick on R28. She stated she did clean it before putting it away. The LPN stated placing contaminated equipment down without a barrier cloth could cause cross-contamination. LPN2 stated it was important to clean shared equipment to prevent the spread of infection.During an interview with the Medical Director on 07/24/2025 at 11:30 AM, she stated it was her second day in the facility, and she could not answer questions without further reviewing the policies. However, the Medical Director stated following CDC guidelines was important for the safety and well-being of residents and staff.During an interview with the IDON/IP on 07/22/2025 at 10:48 AM, she stated the facility followed the CDC's recommendation and the facility's infection prevention and control policies. The IDON/IP stated the importance of adhering to the CDC's guidelines for infection prevention and control was to help prevent the spread of diseases and infections. According to the IDON/IP, all staff members, including those from the agency, received education related to IPCP. She stated all staff were trained upon hire in the use of PPE and isolation precautions. The IDON/IP stated each TBP room should be equipped with a CDC sign to indicate the type of PPE staff were required to wear. Additionally, each precaution room should have an individual PPE cart located outside the door. She stated the appropriate PPE must be worn when providing care to residents in isolation precautions. The IDON/IP stated it was her expectation that all staff adhered to facility policies and procedures to help prevent the spread of infections. She stated it was important for the health and safety of the residents.During an interview with the Interim Administrator on 07/24/2025 at 7:28 PM, she stated the IP nurse was responsible for infection control oversight, but everyone must follow policies. She stated that following policy and CDC guidelines was important for the safety of residents and staff.

Based on interview, record review, review of the Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's 'QSO-21-19-NH Memo''', and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current Coronavirus Disease 2019 (COVID-19) vaccination status for 3 of 4 sampled staff, Registered Nurse (RN) 7, Licensed Practical Nurse (LPN) 11, and LPN12.The findings include:Review of the CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's QSO-21-19-NH Memo, dated 05/01/2021, revealed Long-term Care (LTC) facilities must offer staff vaccination against COVID-19 when vaccine supplies were available to the facility. LTC's must screen staff prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine whether they were appropriate candidates for vaccination. Per the guidance, the vaccine might be offered and provided directly by the LTC facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity.Review of the facility's policy titled, Infection Prevention and Control Plan, undated, revealed the facility would implement and maintain an active organization wide program for the prevention control and investigation of infections and communicable diseases to reduce the risk of infections in residents, and health care workers. Per the policy, the employee health program would include education and monitoring of staff for COVID-19 immunizations to minimize the risk of acquiring transmitting disease. 1. Review of RN7's employee file revealed no documented evidence noting RN7 was offered the COVID-19 vaccination. Additionally, there was no documentation that education regarding the benefits, risks, and potential side effects of the vaccine was provided to the employee. RN7 was unavailable for interview.2. Review of LPN11's employee file revealed no documented evidence the facility had provided LPN11 with education regarding the benefits, risks, and potential side effects of the COVID-19 vaccination. LPN11 was unavailable for interview.3. Review of LPN12's employee file revealed no documented evidence the facility had provided LPN12 with education regarding the benefits, risks, and potential side effects of the COVID-19 vaccination.LPN12 was unavailable for interview.During an interview with State Tested Nursing Assistant (STNA) 12 on 07/24/2025 at 11:25 AM, she stated she had not been educated about or asked regarding her COVID-19 vaccination status. She further stated she had not signed any forms related to this issue and was not required to present a COVID-19 vaccination card or sign any documentation.During an interview with the Medical Director on 07/24/2025 at 1:00 PM, she stated it was only her second day in the facility and that she could not answer questions without further reviewing the policies. However, she stated following CDC guidelines was important for the safety and well-being of residents and staff.During an interview with the Interim Director of Nurses (IDON)/Infection Preventionist (IP) on 07/22/2025 at 10:48 AM, she stated the facility followed the recommendation of the Centers for Disease Control and Prevention (CDC) for all immunizations and vaccines but had not provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine immunization education to all its employees. Furthermore, she stated she did not have documentation for staff related to the employee's COVID-19 vaccine education documentation. The IDON/IP stated it was important for the facility to educate staff about and offer the COVID-19 vaccine. Additionally, the IDON/IP stated the facility should maintain documentation of each staff member's immunization status or their decision to decline the vaccine in their personnel files. She stated the importance of adhering to the CDC's guidelines for infection prevention and control to help prevent the spread of diseases and infections.During an interview with the Interim Administrator on 07/24/2025 at 7:28 PM, she stated it was important that the facility maintained the appropriate documentation to reflect that it provided the required COVID-19 vaccine education to employees to comply with CDC recommendations and adhere to the facility's infection control program. She stated the IP Nurse was responsible for infection control oversight, but everyone must follow policies. She stated further that following policy and CDC guidelines was important for the safety of residents and staff.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights and provide services required to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 sampled residents, Resident (R)1 and R24. 1. On 02/25/2025, R1, who resided on the facility's locked Memory Care Unit (MCU), and was care planned to wear a wanderguard (a monitoring device that triggers door alarms to alert staff when a resident was near a door or going out a door) was observed entering the facility through the main door which was equipped with an alarming device. However, the door did not alarm when R1 entered the facility. During interviews with the MCU staff, they stated they had last seen the resident at approximately 4:00 PM, and were unaware R1 left the building without staff's knowledge until they received a phone call from Receptionist 2, alerting them R1 was entering the facility. Receptionist 2 stated R1 was not wearing the wanderguard bracelet when he returned to the facility at approximately 5:15 PM, although the resident's Comprehensive Care Plan (CCP) dated 05/20/2024, revealed an intervention for the use of a wanderguard to the right wrist to prevent him from leaving the facility unattended. 2. R24 (hospice resident) was care planned with interventions for pain medication as ordered; and monitor for effectiveness of the pain medication. However, R24's family had a surveillance device in the resident's room that did not detect any staff members administering medication or providing care to her from 03/11/2025 at 6:03 PM, until 03/12/2025 at 5:41 AM, approximately 12 hours. The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan is developed and implemented is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 03/07/2025, was determined to exist on 02/25/2025 in the area of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/12/2025, alleging removal of the IJ on 03/10/2025. The State Survey Agency (SSA) validated the IJ was removed on 03/15/2025, prior to exit. Remaining non-compliance continues at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F658 and F689 The findings include: Review of the facility's policy titled, Comprehensive Care Plans (CCP), undated, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the resident's comprehensive assessment. Per policy, the CCP would describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The policy stated the CCP would include resident specific interventions that reflected the resident's needs and preferences. 1. Review of R1's Admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 04/16/2024 with diagnoses which included mild cognitive impairment/severe vascular dementia with agitation, moderate malnutrition, and the need for assistance with personal care. On 09/05/2024, R1 was diagnosed with wandering. Review of R1's CCP, dated 05/20/2024, located in the resident's EMR, revealed the resident was an elopement risk/wanderer related to impaired safety awareness and wandered aimlessly. The goal stated the resident would not leave the facility unattended. Interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: photography, and outdoor activities. There was also an intervention for wanderguard to the right wrist with the nurse to check placement each shift with an initiation date of 05/20/2024. Review of R1's Clinical Orders, dated 05/20/2024, revealed orders for R1 to wear a wanderguard bracelet to the right wrist and to check every shift. Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/23/2025, located in the resident's EMR, revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Additional review revealed the facility assessed the resident as wandering one to three days during the look back period. Review of R1's Clinical Orders, dated 01/31/2025, revealed orders for R1 to wear a wanderguard bracelet to the right wrist and to check every shift. Review of R1's Treatment Administration Record (TAR), dated 02/2025, revealed the placement of R1's wanderguard had been charted as checked and charted as present on 02/25/2025 by Licensed Practical Nurse (LPN)1. However, there was no intervention on the TAR to check functionality of the wanderguard and there was no documented evidence a check of functionality of the wanderguard had been completed. Review of R1's Progress Note, dated 02/25/2025 at 11:05 PM, signed by the MDS Nurse, located in the resident's EMR, revealed R1 followed visitors through the exit doors on the MCU. Per the note, R1 exited the facility for a short time, and then returned through the front doors. R1 told the receptionist he needed to sign back in, and he was out looking for his dog. According to the note, the receptionist recognized R1 and assisted the resident back to the locked MCU. Further review, revealed the nurse completed a head-to-toe assessment with no injuries noted at the time. Per the note, R1 had no complaints of pain with touch and vital signs were within normal range. The note further stated R1 was placed on one on one (1:1) observation for safety, and his family was in the facility and was given notification. During an interview, on 03/06/2025 at 4:11 PM, with Receptionist 2, she stated on the evening R1 eloped (02/25/2025), it was very busy with people going in and out with the phones ringing when she saw R1 walk in through the front facility door at approximately 5:15 PM. She stated she knew who he was because he had attempted to leave the facility before. Receptionist 2 stated R1's wanderguard was not visible, and no alarm sounded when he re-entered the facility. She stated she recalled R1 was wearing shorts and a t-shirt and it was warm that day. Receptionist 2 further stated she did not witness nor did she hear R1 go out the front door. She stated there was always 24/7 coverage in place at the main entrance reception desk, even before R1 eloped. During an interview, on 03/06/2025 at 2:35 PM, with State Trained Nurse Assistant (STNA)1, he stated he was assigned to R1 the day he eloped (02/25/2025). STNA1 stated the last time he remembered seeing R1 that day was about 3:45 PM to 4:00 PM when the resident was in the Common Room. After that, he was giving another resident a shower and did not hear any alarms sounding on the unit. STNA1 further stated he was made aware R1 was returning to the unit on the elevator. STNA1 stated he did not recall seeing the wanderguard on R1 at the beginning of the shift, but he was not looking for it specifically. He stated the nurses checked placement of the wanderguards. During an interview, on 03/06/2025 at 2:49 PM, with LPN1, she stated she was assigned to R1 on the day he eloped. LPN1 stated the last time she saw R1 was around 4:00 PM in the Common Room that day. LPN1 further stated she was caring for another resident, and did not hear an alarm. In continued interview, LPN1 stated there was an order to check the placement of R1's wanderguard every shift which she did that day prior to the elopement. She stated she observed it on his wrist, but she could not recall the exact time she checked the placement of the wanderguard. LPN1 stated after R1 returned she questioned the resident as to where his wanderguard was and he stated, I took it off and threw it. LPN1 stated staff searched R1's room, the MCU, and the garbage and did not find the wanderguard. During further interview with LPN1 on 03/06/2025 at 2:49 PM, she stated prior to R1's eloping, she checked the residents' wanderguard devices weekly by pushing the resident's wheelchair near to the door or walking the resident up near the door and making sure the alarm would sound. LPN1 further stated she did not have a wand or device to test the wanderguard alarm on the unit. In continued interview, she stated the charting for the alarm check for the wanderguards used to be a task on the resident's Medication/Treatment Administration Record (MAR/TAR), but at some point the intervention to test the wanderguard bracelets for function no longer showed up on the MAR/TAR, and therefore she did not document the checks anywhere. During an interview, on 03/07/2025 at 10:32 AM, with the MDS Nurse, she stated the floor nurses, the unit managers, and the Director of Nursing (DON) could update a resident's care plan, and then she reviewed the entire care plan with each MDS assessment. The MDS nurse stated the care plan should be developed with interventions to provide the best possible outcome for the resident and the care plan was to be person-centered. She stated the care plan was important as it provided staff information on how to care for the resident. Further, she stated information from the care plan flowed to the resident's Kardex (a nurse aide care plan which indicated a resident's specific care needs which was visible on the resident's EMR) so all staff would have access to the information on the resident's activities of daily living. The MDS Nurse stated this included information such as how the resident transferred and if the resident used an alarming device for wandering, etc. She further stated if the care plan was not followed, it could lead to harm for the resident, as the care plan was the main tool used for direction of resident care. During an interview, on 03/06/2025 at 5:30 PM, with the Interim Administrator and the Director of Nursing (DON), the Interim Administrator stated going forward, the function of the residents' wanderguards was to be checked every day instead of weekly, and placement of the residents' wanderguards was to be checked every shift and charted on the TAR and in the Progress Notes. They both stated if a resident had a wanderguard, the wanderguard should be marked on the resident's care plan and Kardex in order to alert all staff the resident had a wanderguard. Both stated the resident's care plan directed resident care, and it was important for the care plan to be followed to ensure the safety of the residents and to also ensure the resident's care needs would be met. They stated going forward, there would be an intervention to check placement and functionality on R1's care plan and that would flow to the STNA Kardex. 44001 2. Review of R24's Admission Record, located in R24's EMR, revealed the facility admitted R24 on 07/02/2024 with diagnoses to include Parkinson's disease, spondylosis (degeneration of the vertebral column), and spinal stenosis (narrowing of the spaces in the spine) with sciatica (pain along the sciatic nerve). Review of R24's quarterly MDS with an ARD of 01/28/2025, located in R24's EMR, revealed the resident's BIMS was not assessed. A staff assessment for mental status indicated R24 had short and long-term memory problems. Further review of the MDS revealed the facility assessed the resident as being a substantial/maximum assist (helper did more than half of the effort) for transfers, mobility, and activities of daily living (ADL). Review of R24's CCP, undated, revealed the resident was care planned for being at risk for alteration in comfort and pain. Goals included R24 would be free of any discomfort or adverse side effects from pain medication. Interventions included administer pain medication as ordered; monitor for effectiveness of the pain medication; document all interventions; and report any unrelieved pain or condition change to the primary care provider. Review of R24's Physician Orders, located in R24's EMR, revealed an order, dated 01/16/2025, for Hospice (end of life) Care due to her Parkinson's diagnosis. Further review revealed an order dated 01/25/2025, for tramadol HCl oral tablet 50 milligrams (mg), one tablet by mouth three times a day for pain/comfort (narcotic pain reliever). Review of R24's Medication Administration Report (MAR), found in R24's EMR, dated March 2025, revealed Registered Nurse (RN) 6 documented in the MAR that she administered R24's 9:00 PM tramadol at 9:21 PM. During an interview with Family (F)2, on 03/14/2025 at 3:35 PM, he stated after reviewing video from the family's surveillance device in R24's room, it showed no person or staff member had entered R24's room from 03/11/2025 at approximately 6:03 PM to 03/12/2025 at 5:45 AM to provide essential care for R24. F2 stated he was concerned the resident was not observed for pain, repositioned to decrease pain, or administered her 9:00 PM pain medications (tramadol). Review of R24's family surveillance video, on 03/14/2024 at 3:35 PM, by the SSA Surveyor, provided by the family, revealed captured video of the resident's room, including the resident in the bed and a full view of the entrance door to the room. The video showed the resident's room, from 03/11/2025 at 5:45 PM to 03/12/2025 at 5:45 AM. The video confirmed the last staff person left R24's room on 03/11/2025 at 6:03 PM, and no facility staff returned to the room until 5:41 AM on 03/12/2025. During a telephone interview with STNA22, on 03/13/2024 at 2:39 PM, he stated he rounded on R24 every hour during the time from 11:00 PM on 03/11/2025 to 7:00 AM on 03/12/2025. When the SSA Surveyor questioned how he monitored R24 throughout the night, he stated every other hour he opened the door to her room enough to see her and make sure she was in bed. However, he verified during these checks, he did not always go into the room and did not turn on the room lights. During the next hour, he stated he entered the room and checked R24's brief for wetness, but the resident was not wet until last rounds. He stated R24 could not move around on her own but could move a little while in bed and often attempted to crawl out. He further stated he checked her and repositioned her every two hours. Additionally, STNA22 stated nurses rounded every other hour, checking on residents by opening doors to ensure everyone was sleeping well. During an interview, with SRNA23, on 03/13/2024 at 4:27 PM, she stated she worked the 7:00 PM to 11:00 PM shift on 03/11/2025. She stated she rounded on R24 in her room at around 6:45 PM, but did not provide care at that time. However, she stated she continued to round on the resident until end of shift at 11:00 PM. Telephone interview with RN6 was attempted by the SSA Surveyor on 03/13/2025 at 2:27 PM, 2:38 PM, and 3:14 PM. A voicemail was left each time to return the SSA Surveyor's call. No return call was received. During an interview with the DON, on 03/13/2025 at 11:30 AM, she stated F3 complained on the morning of 03/12/2025, that the resident had not been cared for during the night, and F3 had video surveillance showing R24 was left alone all night. The DON stated she notified the Administrator, and an investigation was initiated. She stated R24 should have been checked on at least every two hours. Further, R24 should have been monitored for pain. The DON stated it was her expectation that clinical staff rounded on residents throughout the night and that nursing staff provided care for residents as per the CCP. She further stated following the plan of care was important to provide appropriate, resident-specific care. During an interview with the Interim Administrator, on 03/15/2025 at 11:46 AM, she stated she was notified of the staff's failure to round on R24 by the DON. The Interim Administrator stated F3 showed her the complete recording of video footage using the monitoring application on her iPhone. The Interim Administrator stated she initiated an investigation and suspended the staff members involved. She stated it was her expectation clinical staff rounded on residents and provided care as ordered and as per the CCP. During an interview with the Medical Director on 03/13/2025 at 3:08 PM, he stated he was notified about a video from R24's family, which revealed the resident was not monitored by clinical staff throughout the night. He further stated it appeared R24 did not receive any of her evening medications. He stated it was his expectation nursing staff implemented the CCP to ensure the facility maintained the resident's highest practicable level of functioning and well-being.

Based on observation, interview, record review, review of the RoamAlert Resident Safety User Guide, and review of the facility's documents and policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and properly functioning assistance devices to prevent unsafe wandering, elopement, and falls for 3 of 11 sampled residents, Resident (R)1, R12, and R13. 1. R1's Clinical orders, initiated 05/20/2024, revealed orders for the resident to wear a wanderguard bracelet (an electronic device that caused an alarm to sound when the resident tried to exit a door that had an accompanying device installed) to his right wrist and to check every shift. Per R1's Progress Note, dated 06/25/2024, R1 was exit-seeking, went outside the exit door, and was brought back into the facility immediately. However, per the 06/25/2024 note, the wanderguard was not on R1's right wrist upon staff bringing the resident back inside. Subsequently, on 02/25/2025, R1 who resided on the locked Memory Care Unit (MCU) was observed entering the facility through the main door which was equipped with an alarming device, but the door did not alarm when the resident entered the building as R1 was again not wearing the wanderguard bracelet upon return to the facility. Interviews were conducted with MCU staff who were on duty during the time of the 02/25/2025 elopement, and they stated they had last seen the resident at approximately 4:00 PM, and were unaware R1 left the building unsupervised until they received a phone call from Receptionist 2, alerting them R1 was entering the facility. Also, there was no documented evidence the facility had checked R1's wanderguard for functionality, and on 02/28/2025, the vendor for the alarm system found it was not working properly. 2. On 06/07/2024, R12 was transferred without the use of a gait belt, as per policy. The resident sustained a wound to the left knee, a wound to the left arm, and bruising with scratches on the left ribcage. Additionally, a CT of the Chest was performed on 06/08/2024, which revealed an age-indeterminate nondisplaced left 8th rib fracture. There was no documented evidence of a root cause analysis or investigation related to the fall. 3. On 06/06/2024, R13 sustained an unwitnessed fall, resulting in a hematoma and three lacerations on the right side of the resident's forehead requiring seven sutures to close the lacerations. There was no documented evidence of a root cause analysis or investigation related to the fall. Additionally, there was no documented evidence the CCP was updated in an attempt to prevent future potential falls. The facility's failure to have an effective system in place to ensure residents' safety is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 03/07/2025, was determined to exist on 02/25/2025 in the area of 42 CFR 483.25 Quality of Care, F689, and Substandard Quality of Care (SQC) at 42 CFR 483.25. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/12/2025, alleging removal of the IJ on 03/10/2025. The State Survey Agency (SSA) validated the IJ was removed on 03/15/2025, prior to exit. Remaining non-compliance continues at a Scope and Severity of a G while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F656 and F657 The findings include: 1. Review of the facility's policy titled, Elopements and Wandering Residents, dated 04/18/2024, revealed the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents. The policy further stated residents received care in accordance with their person-centered care plan of addressing their unique factors contributing to wandering or elopement risk. Per policy, the facility was equipped with door locks/alarms to help avoid resident elopements, but alarms were not a replacement for necessary supervision. Further review revealed devices used to prevent elopement were checked for functionality and placement, and this would be documented every shift on the Treatment Administration Record (TAR). The policy stated a system would be in place for systematic and frequent checks of all critical components of the electronic alarm system with clear designation of responsibility for monitoring and maintaining the system. Per policy, a basic check of the system was to be done every 24 hours to assure proper functioning. Additionally, the policy stated maintenance of the system must be consistent with the manufacturer's guidelines, and a complete systems check must be performed at least annually. Review of the website's manual (found at https://jmacfiles.s3.amazonaws.com/docs_Roam_Alert_User_Guide.pdf) RoamAlert Resident Safety User Guide, dated 01/2010, revealed monthly testing and maintenance was essential to ensure the program was operating correctly. It also stated the failure to do regular testing and maintenance would increase the risk of system failure and the failure to detect resident wandering. The State Survey Agency (SSA) Surveyor requested the log of the wanderguard system/electronic alarm system checks from the Maintenance Director on 03/05/2025 at 3:28 PM and from the Interim Administrator on 03/06/2025 at 9:07 AM and 03/07/2025 at 8:30 AM. However, the log was not provided. Review of the facility's document titled, Service Orders for [Facility Name] Nursing Home, dated 02/26/2025 to 03/07/2025, revealed the vendor for the wanderguard system had serviced the facility on 02/26/2025 to reprogram the RoamAlert/wanderguard keypad passcode; on 02/28/2025 for wanderguard not recognizing when someone went through the door; on 03/06/2025 for wanderguard alarming on its own; and on 03/10/2025 to confirm the order for two new door controllers. Review of the Weather underground.com temperature history for the facility area on 02/25/2025, revealed a temperature of 65 degrees Fahrenheit from 3:30 PM until 5:30 PM. Review of R1's Admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted R1 on 04/16/2024 with diagnoses including mild cognitive impairment/severe vascular dementia with agitation, moderate malnutrition, and need for assistance with personal care. On 09/05/2024, R1 was diagnosed with wandering. Per the EMR, the resident resided on the locked MCU. Review of R1's Comprehensive Care Plan (CCP), dated 05/20/2024, located in the resident's EMR, revealed R1 was an elopement risk/wanderer related to impaired safety awareness and wandered aimlessly. The goal stated R1 would not leave the facility unattended. Interventions included resident to wear wanderguard to his right wrist and for the nurse to check placement each shift. Review of R1's Clinical Orders, dated 05/20/2024 and 01/31/2025, located in the resident's EMR, revealed orders for R1 to wear a wanderguard bracelet to his right wrist and to check every shift. Review of R1's Progress Notes, from 04/16/2024 to 02/25/2025, revealed instances where R1 had been noted to be wandering and required redirection. These dates included: 04/19/2024, 04/26/2024, 06/25/2024, 06/30/2024, 09/04/2024, 09/05/2024, 09/06/2024, 09/09/2024, 09/16/2024, 11/13/2024, and 01/21/ 2025. Review of R1's Progress Note, dated 06/25/2024 at 3:44 PM, revealed R1 was exit-seeking, went outside the exit door, and was brought back into the facility immediately. However, per the note, the wanderguard was not on his right wrist, and R1 stated he lost it at some point during the night. The note stated a new wanderguard was applied to R1's right wrist and checked to ensure it was working properly. Further review revealed an order was in place to ensure the wanderguard was checked each shift. Review of R1's Elopement Risk Assessment, dated 01/23/2025, revealed a score of seven which indicated he was at high risk for elopement. Per the legend, any score above three was considered high risk. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/2025, located in the resident's EMR, revealed the facility assessed R1 to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating moderate cognitive impairment. Further review revealed the facility assessed the resident to have wandered one to three days during the look back period. Review of R1's Treatment Administration Record (TAR), dated 02/2025, located in the resident's EMR, revealed the placement of R1's wanderguard had been charted as checked and charted as present on 02/25/2025 on day shift by Licensed Practical Nurse (LPN) 1. However, there was no documented evidence a check of functionality had been completed. Review of R1's Progress Note, dated 02/25/2025 at 11:05 PM, signed by the MDS Nurse, located in the resident's EMR, revealed R1 had followed visitors through the exit doors on the MCU, exited the facility for a short time, and returned through the front doors. Per the note, R1 told the receptionist he needed to sign back in, and he was out looking for his dog. The receptionist recognized the resident and assisted the resident back to the locked MCU. The note stated the nurse completed a head-to-toe assessment with no injuries noted. Per the note, R1 had no complaints of pain with touch and vital signs were within normal range. The note stated R1 was placed on one on one (1:1) observation for safety, and R1's family was in the facility and was given notification. Observation on 03/05/2025 at 12:10 PM, revealed R1 was ambulating independently with his son and entered the facility through the main doors. R1's wanderguard was visible on his right wrist, and the alarm was sounding as he entered. Observation on 03/05/2025 at 12:13 PM, revealed R1 was in his room, in bed. R1 stated he wore a wristwatch and this other one, while pointing at the wanderguard. R1 denied knowing the purpose of the wanderguard bracelet. During an interview, on 03/05/2025 at 12:19 PM, with R1's Power of Attorney (POA), he stated the facility notified him of the resident leaving the facility unaccompanied on 02/25/2025, within 30 minutes of the resident returning to the facility. He further stated he understood R1 had returned on his own, walked through the facility's front door, and signed himself in as Me. R1's POA stated no harm had come to R1, and he was not sure if R1's wanderguard was in place the last time he visited. He further stated, It was like a wristwatch, and I just got used to seeing it on him. In continued interview, R1's POA stated the facility told him R1 was not wearing the wanderguard when he returned to the facility, and to his knowledge, the facility had not been able to locate it. He stated he asked R1 what happened to it, and R1 told him he was in the field and a girl had cut it off. R1's POA stated he observed staff replacing the wanderguard while he was visiting R1. During an interview, on 03/06/2025 at 2:35 PM, with State Trained Nurse Assistant (STNA) 1, he stated he had worked at the facility since 04/02/2024 and was assigned to R1 the day he eloped. STNA1 stated the last time he remembered seeing R1 was about 3:45 PM to 4:00 PM that day in the Common Room, and after that, he was giving another resident a shower and did not hear any alarms sounding on the unit. STNA1 stated he was made aware R1 was returning to the unit on the elevator and did not recall specifically seeing a wanderguard on R1, but if R1 had come within about six feet of the door, it would have alarmed. STNA1 stated the alarm was loud and audible over the whole unit, but since he was in the shower room with another resident he might not have heard it sound. STNA1 also stated the alarm for the side fire door off the unit and next to the elevators was also very loud, and he was able to hear it on the memory care unit if it sounded. During an interview, on 03/06/2025 at 2:49 PM, with Licensed Practical Nurse (LPN)1, she stated she had worked at the facility since 03/13/2006 and was assigned to R1 on the day he eloped. LPN1 stated the last time she saw R1 was around 4:00 PM in the Common Room where the residents were listening to music and watching television. LPN1 stated she received a readmission from the hospital at about 4:15 PM and was providing care for that resident in the resident's room, and did not hear any alarms sound on the unit during that time. LPN1 stated she received a call from Receptionist 2 and was told R1 was returning to the facility alone through the front entrance, and she would assist him to the elevator and send him down to the MCU. LPN1 stated that happened around 5:00 PM to 5:15 PM, and she knew that because supper meal trays were out. In continued interview, LPN1 stated there was an order to check the placement of R1's wanderguard every shift. She stated she checked the placement of R1's wanderguard on 02/25/2025, and it was on his wrist, but she could not remember the exact time she checked the wanderguard for placement. LPN1 stated when a resident with a wanderguard got close to the door, it would alarm, but not too loud, then it would beep for about 30 seconds, and then would turn off by itself. LPN1 stated there was no code for staff to shut the alarm off. During continued interview with LPN1, on 03/06/2025 at 2:49 PM, she stated R1 had previously complained his wanderguard was too tight, but he had not complained about it on 02/25/2025 or the day before and she had never cut his wanderguard off. LPN1 stated a new one had been placed on R1 when he returned to the unit on 02/25/2025. LPN1 stated she asked R1 where his wanderguard was when he returned and he stated, I took it off and threw it. LPN1 stated the staff searched the unit, R1's room, and the garbage, but could not find the missing device. She stated prior to R1 eloping, she checked the function of the residents' wanderguard devices weekly by pushing the resident's wheelchair near to or walking the resident up near the door and making sure the alarm would sound. LPN1 stated she did not have a wand or device to test the wanderguard alarm on the unit. Further, she stated she did not document checking the function of the residents' wanderguard. LPN1 stated the day R1 eloped, it was supper time, the television was on, the music was loud, and since she was in a room with another resident, she did not hear any alarms go off. LPN1 further stated the double doors to the MCU had a delay in closing. During an interview, on 03/05/2025 at 3:28 PM, with the Maintenance Director, he stated he had been at the facility for [AGE] years and had reviewed the facility's video footage of the front door. He stated he observed R1 coming back to the facility through the front door but was not able to identify him leaving the facility through the front door. He further stated the camera was situated to record the main entrance between the outside door and the locked facility door in the vestibule. He also stated it was difficult to tell R1 from other visitors, and he might have been able to follow a group of visitors out the front door. The Maintenance Director stated none of the staff heard an alarm go off around the time R1 left the facility, and therefore thought R1 must have tailgated with the visitors out the double doors of the MCU, rode the elevator up to the main floor, and then exited out the front door. The Maintenance Director stated prior to R1 leaving the facility unattended, family members were given the code to the locked double doors to the MCU and could come and go without staff assistance. Further, he stated that since the incident, the codes to the doors had been changed and were given to staff only. During an interview, on 03/05/2025 at 3:52 PM, the Interim Administrator stated she had been at the facility since 02/17/2025, and the Director of Nursing (DON) stated she had been at the facility for eight weeks. They both stated they felt R1 had followed visitors out the locked double doors to the MCU and then exited out the side fire door next to the gated garden area near Elevators 6 and 7. The Interim Administrator stated she was new to the facility and had only been in the facility for a week when R1 eloped. She stated if she had been aware family members and visitors had the code to the locked MCU doors, she would have had the codes changed sooner. The Interim Administrator further stated the facility's investigation revealed R1's elopement happened right before supper service, during a time when a resident activity was happening which often included a movie or music, and staff did not hear the side fire door alarm when R1 left. Additionally, the Interim Administrator stated Emergency Medical Services (EMS) was in the building at the time R1 eloped which added to the traffic/activity on and off the unit. The Interim Administrator stated the codes to all the locked doors had been changed, and a letter went out to the residents' families explaining the need for the doors to stay locked and the need for the codes to be changed. The Interim Administrator stated going forward, staff would have to assist visitors in and out of the facility. The Interim Administrator further stated her plan was to have a telephone/intercom system installed outside the MCU double doors to replace the push pad so visitors would have to call into the unit for entry. In additional interview, with the Interim Administrator, on 03/06/2025 at 9:07 AM, she stated the contractor/vendor for the wanderguard sensors was contacted on 02/26/2025, for a system check, to evaluate the alarm and how it responded when the wanderguard bracelet was near it. She stated, on 02/28/2025, the contractor/vendor found the main wanderguard unit, which was housed in the ceiling just inside the double doors to the MCU near the nurses' station, was not receiving information from the exciter sensors. The Interim Administrator stated the other control boxes for the other facility doors were functioning, but not the one for MCU, and the unit would need to be replaced. In further interview, on 03/06/2025 at 5:30 PM, with the Interim Administrator and the DON, they stated the MCU was a very busy unit, especially at the time of day R1 eloped. They stated often the Common area was full of residents and staff engaged in activities, music and/or watching television, and it could be loud. The Interim Administrator stated depending on the time of day and the environment, alarm audibility could vary. The Interim Administrator stated going forward, the function of the residents' wanderguards was to be checked every day, and placement of the residents' wanderguards was to be checked every shift and charted on the MAR/TAR and in the Progress Notes. Observation on 03/13/2025 at 9:57 AM, revealed R1 was sitting at a table in the MCU Common area with staff in the general area. STNA14, the staff person assigned to R1 as his 1:1 monitor for today, was observed in R1's room sitting in the recliner on her phone (at the opposite corner of the unit and out of eyesight/earshot of R1) The Interim Administrator was rounding on the MCU and was made aware by the SSA Surveyor. During an interview, on 03/13/2025 at 10:05 AM, with STNA14, she stated she had been educated related to elopement and 1:1 observation and was expected to have eyes on R1 at all times. STNA14 further stated she had just gone back to R1's room to get her phone, and she had told RN4 and STNA15 she was going there and asked them to keep eyes on R1. During an interview, on 03/13/2025 at 10:09 AM, with RN4, she denied STNA14 telling her she was going to R1's room or asking her to keep eyes on R1. During an interview, on 03/13/2025 at 10:15 AM, with STNA15, she stated she had not been told to watch R1 while STNA14 went to R1's room. She further stated she had told STNA14 not to leave R1 unattended on two other occasions and had made LPN1 and the Weekend Supervisor aware. During a telephone interview, on 03/14/2024 at 4:20 PM, with the Weekend Supervisor, she denied being made aware by any staff that STNA14 was observed leaving R1 unattended while she was responsible for his 1:1 observation. During an interview, on 03/15/2024 at 1:05 PM, with LPN1, she stated to be a 1:1 sitter meant the staff person had eyes on the resident at all times, and if they needed a break, she would have the resident sit with her in the Common area. LPN1 denied any staff ever told her STNA14 left R1 unsupervised. During an interview with RN1, on 03/13/2025 at 10:25 AM, he stated STNA14 was being escorted out of the building at this time, and RN4 had been told to keep eyes on R1 while R1 was in the Common area. RN1 stated he was told if R1 got up to leave the Common area, either RN4 or STNA15 were to accompany R1. On 03/14/2025 at 12:09 PM, RN1 accompanied the SSA Surveyor to the second floor unit, on the [NAME] Unit, and activated the wanderguard alarm on the second floor near the entrance/exit to the unit. An audible alarm sounded for 41 seconds with no staff response. The alarm silenced with no staff entry of a code. After a second immediate activation and after the alarm sounded for 10 seconds, a staff member was overheard to ask, What is that sound? Then, per observation, a second staff person answered, That's the door. The audible alarm sounded for an additional 67 seconds, with no staff response. The total alarm time was 77 seconds, with no staff [LPN4 or STNA19] response. Interview was conducted, on 03/14/2025 at 2:15 PM, with LPN4, who had been employed by the facility for [AGE] years and STNA19, who had been employed by the facility for two years, and they both stated they only had one resident on the unit that used a wanderguard on the [NAME] unit. They stated, if the alarm went off and they had eyes on her, they did not worry about the alarm. LPN4 and STNA19 also stated it was not always easy to hear alarms in the back hall. Observation and interview with STNA17, on 03/15/2025 at 10:00 AM, on the MCU, revealed STNA17 was assigned 1:1 monitoring for R1 and was posted outside R1's room with eyes on him. STNA17 stated she had received continued education on elopement, missing resident, and additional information on the response to alarms yesterday and this morning. During interview on 03/15/2025 at 10:05 AM, with STNA18, who was monitoring the entry doors to the MCU, he stated he had received education on elopement, a missing resident, and response to alarms. During interview on 03/15/2025 at 10:24 AM, with LPN5, on the [NAME] Unit, located on the second floor, she stated she received education on elopement and new education During interview on 03/15/2025 at 10:26 AM, with RN1, he stated there was a whole house test yesterday on door alarms and wanderguards, and the policy was reviewed. RN1 also stated all the alarms on all the units had been made louder. During interview on 03/15/2025 at 12:00 PM, with the Interim Administrator and the DON, they stated it was their expectation the facility would have an elopement and wandering system in place with immediate staff response, a head count of residents completed, and for staff to report to a manager/supervisor on duty when concerns occur, to ensure resident safety. Further, the DON stated the facility should have been checking placement and functionality of the resident's wanderguards and documenting both in the resident record and the system functionality should have also been checked regularly and documented. 44001 Review of the facility's Fall Prevention Program policy, undated, revealed each resident would be assessed for fall risk, and care and services would be provided according to each resident's individualized level of risk to minimize the likelihood of falls. Per policy, fall risk protocols included to implement environmental interventions that decreased the risk of falling; provide routine rounding; wear footwear with non-slip soles while ambulating (residents); complete a fall risk assessment upon admission, quarterly, and as indicated for significant condition changes or after each fall; and provide interventions that addressed risk factors as directed by the resident's assessment. Further review revealed when a resident fell , the facility would assess them, complete a post-fall assessment, and generate an incident report. The policy stated the physician and family would be notified, and the care plan would be updated as needed. Per policy, all actions would be documented, witness statements collected if there was an injury, and the interdisciplinary team (IDT) would review the interventions and conduct a complete investigation. 2. Review of the facility's Use of Gait Belts policy, undated, revealed gait belts were to be used for any resident who could not independently walk or transfer, ensuring their safety. Additionally, per policy, all employees received training on the proper use of gait belts during their orientation and annually. Review of R12's Admission Record, located in the resident's EMR, revealed the facility admitted the resident on 10/23/2023 with diagnoses to include myasthenia gravis (neuromuscular disorder causing muscle weakness), transient cerebral ischemic attack (mini stroke) and type 2 diabetes. Review of R12's CCP, dated 10/24/2023, located in the resident's EMR, revealed R12 was care planned for being at increased risk for falls related to impaired mobility and a self-care performance deficit. Interventions included keeping the resident's call light within reach and follow fall protocols. Review of R12's quarterly MDS with an ARD of 04/09/2024, located in the resident's EMR, revealed the facility assessed R12 to have a BIMS score of nine out of 15, which indicated moderate cognitive impairment. Further review revealed the resident was assessed as not having any falls during the look back period. Continued review revealed the facility assessed R12 as requiring substantial/maximum assist (helper did more than half of the effort) for transfers. Review of R12's Health Status Note, dated 06/07/2024 at 10:46 PM, located in the resident's EMR, revealed at approximately 8:00 PM, R12 was sitting in the living room recliner when STNA12 assisted her into a wheelchair. During the transfer, R12 fell , landing on top of STNA12. Per the note, the resident sustained three injuries: a wound on the left knee, a wound on the left arm, and bruising with scratches on the left ribcage. The note further stated R12 reported pain at an intensity of eight out of 10 on a pain scale with 10 being the worst. R12 was transported to the local hospital. Review of R12's Incident Report, dated 06/07/2024 at 8:47 PM, revealed STNA12 acknowledged he did not use a gait belt when transferring R12 from the recliner to her wheelchair. Per the report, STNA12 stated it was an accidental fall, and he attempted to break the fall with his own body. According to the report, R12 leaned back into him, causing him to lose his balance and fall backward, with the resident landing on top of him. Review of R12's ED Provider Notes, dated 06/08/2024 at 7:52 AM, located in the resident's EMR, revealed R12 presented to the local ED after a fall. Per the note, R12 complained of chest wall and back pain and a skin tear to the right arm. Review of R12's Computed Tomography (CT) (x-ray imaging) of the Chest, dated 06/08/2024 at 7:11 AM, located in R12's EMR, revealed an age-indeterminate nondisplaced left 8th rib fracture. Additional review of R12's CCP, dated 10/24/2023, located in the EMR, revealed R12's care plan was updated on 06/08/2024 to state the resident required extensive assistance by two staff to move between surfaces; however, the CCP was not revised to include transfer using a gait belt. Review of the facility's Schedule, for 06/07/2024, at the time of R12's fall, revealed the unit where R12 resided was fully staffed with one nurse and two STNAs, and STNA13 was orienting STNA12 The nurse on duty the evening of R12's fall was no longer an employee at the facility. During an interview with Human Resources (HR), on 03/12/2024 at 8:35 AM, she stated on 06/07/2024, STNA12 was on orientation in the facility and was shadowing STNA13. She stated STNA12 should not have been left alone to provide care. The State Survey Agency (SSA) Surveyor attempted a telephone interview with STNA13, on 03/12/2025 at 9:04 AM and 9:07 AM, with no success, and a voicemail could not be left. The SSA Surveyor attempted a telephone interview with STNA12, on 03/12/2025 at 9:05 AM, with no success, and a message stated the phone number dialed did not have voicemail set up. During an interview with STNA11 (agency), on 03/11/2024 at 10:55 AM, she stated it was the facility's policy to use a gait belt with all residents who required assistance with transfers. During an interview with STNA20, on 03/13/2025 at 2:35 PM, she stated she used a gait belt for all resident transfers. During an interview with the Infection Prevention and Staff Development Coordinator (IP/SDC), on 03/12/2024 at 10:30 AM, she stated employees received education upon hire, which included training for safe resident transfers. She stated STNAs did not receive gait belt training during the facility's orientation, as this training was part of their nursing aide course curriculum. Additionally, the IP/SDC stated staff members received orientation on the floor and were paired with a senior staff member for preceptorship. She stated new employees completed a checklist during that orientation, which the preceptor and employee were required to sign. She further stated it typically took three to four days to finish the checklist. Further, while being oriented on the floor, new hires were not allowed to perform resident care independently. She stated she did not know why STNA12 independently transferred R12. The IP/SDC stated it was her expectation that staff followed facility policy in an attempt to prevent falls and used gait belts for all assisted transfers to ensure resident and staff safety. During an interview with the DON on 03/13/2025 at 11:30 AM, she stated gait belts were to be used for all transfers with residents who were not independent. She stated it was her expectation that staff followed the facility's policy and use gait belts on all residents requiring transfer assistance. The DON stated this was important for the safety and well-being of the residents. In further interview, the DON stated she was unable to locate IDT notes nor was she able to find an investigation related to R12's 06/07/2024 fall. 3. Review of R13's Admission Record, located in the resident's EMR, revealed the facility admitted R13 on 06/29/2023 with diagnoses to include Alzheimer's disease, muscle weakness, and reduced mobility. Review of R13's CCP, dated 06/29/2023, located in the resident's EMR, revealed R13 was care planned for being at increased risk for falls related to a history of falls. Interventions included keeping the resident's call light in reach, encouraging the resident to participate in activities, ensuring the resident was wearing appropriate footwear, and following fall protocol. Review of R13's Occurrence History report provided by the facility, revealed she had one fall on 06/09/2024 resulting in a minor injury, and four non-injury falls on 07/17/2024, 09/06/2024, 02/25/2025, and 03/09/2025. Furthermore, a witnessed non-injury fall, on 03/04/2024, was not noted on this report. Review of R13's Fall Checklist, provided by the facility and dated 02/25/2025 at 4:02 AM, revealed an intervention to initiate an exercise program for gait training was documented; however, the intervention was not added to the CCP. Review of R13's Fall Checklist, provided by the facility and dated 03/04/2025 at 6:10 PM, revealed there was no initiated intervention added to the CCP after R13 experienced a non-injury fall. Further review of R13's EMR revealed no documented evidence th [TRUNCATED]

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for 2 of 12 sampled residents, Resident (R)12 and R13. 1. On 06/07/2024, R12 was transferred without the use of a gait belt, as per policy. The resident sustained wounds to the left knee, and left arm, and bruising with scratches on the left ribcage. Additionally, a CT of the Chest performed on 06/08/2024, revealed an age-indeterminate nondisplaced left 8th rib fracture. R12's care plan was updated on 06/08/2024 to state the resident required extensive assistance by two staff to move between surfaces; however, the CCP was not revised to include an intervention for the use of a gait belt during transfers. 2. R13 sustained 6 falls from 03/04/2024 through 03/09/2025. However, there was no documented evidence the CCP was revised with new interventions to prevent recurrence. On 06/06/2024, R13 sustained an unwitnessed fall, resulting in a hematoma and 3 lacerations on the right side of the resident's forehead requiring 7 sutures. Again, there was no documented evidence the CCP was revised with new interventions to prevent recurrence. Refer to F689 The findings include: Review of the facility's policy titled, Interdisciplinary: Comprehensive Care Plan, dated 01/01/2023, revealed the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The objectives would be utilized to monitor the resident's progress. Per the policy, alternative interventions would be documented, as needed. Review of the facility's Fall Prevention Program policy, undated, revealed each resident would be assessed for fall risk, and care and services would be provided according to each resident's individualized level of risk to minimize the likelihood of falls. Per policy, fall risk protocols included to complete a fall risk assessment after each fall and to provide interventions that addressed risk factors as directed by the resident's assessment. 1. Review of the facility's Use of Gait Belts policy, undated, revealed gait belts were to be used for any resident who could not independently walk or transfer, ensuring their safety. Review of R12's Admission Record, located in the resident's Electronic Medical Record (EMR), revealed the facility admitted R12 on 10/23/2023 with diagnoses including myasthenia gravis (neuromuscular disorder causing muscle weakness), transient cerebral ischemic attack (mini stroke) and type 2 diabetes. Review of the quarterly Minimum Data Set (MDS), located in R12's EMR, with an Assessment Reference Date (ARD) of 04/09/2024, revealed the facility assessed R12 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Further review of the MDS revealed the facility assessed the resident as requiring substantial/maximum assist (helper did more than half of the effort) for transfers; and as having no falls during the look back period. Review of R12's CCP, dated 10/24/2023, located in R12's EMR, revealed the resident was care planned for being at increased risk for falls related to impaired mobility and self-care performance deficit. Interventions included keeping the resident's call light placed within reach and to follow fall protocols. However, the CCP did not include an intervention for the use of a gait belt during transfers. Review of R12's Health Status Note, dated 06/07/2024 at 10:46 PM, located in the resident's EMR, revealed at approximately 8:00 PM, R12 was sitting in the living room recliner when State Trained Nurse Assistant (STNA)12 assisted her into a wheelchair. During the transfer, R12 fell , landing on top of STNA12. According to the note, the resident sustained three injuries: a wound on the left knee, a wound on the left arm, and bruising with scratches on the left ribcage. The note further stated R12 reported pain at an intensity of eight out of 10 on a pain scale with 10 being the worst, and was transported to the local hospital. Review of R12's Incident Report, dated 06/07/2024 at 8:47 PM, revealed STNA12 stated he failed to use a gait belt while transferring R12 from a recliner to her wheelchair. STNA12 described the incident as an accidental fall. Review of R12's Emergency Department (ED) Provider Notes, dated 06/08/2024 at 7:52 AM, located in the resident's EMR, revealed the resident presented to the local ED after sustaining a fall. According to the note, R12 complained of chest wall and back pain and a skin tear to the right arm. Review of R12's Computed Tomography (CT) (x-ray imaging) of the Chest, dated 06/08/2024 at 7:11 AM, located in R12's EMR, revealed an age-indeterminate nondisplaced left 8th rib fracture. Additional review of R12's CCP, dated 10/24/2023, located in the EMR, revealed R12's care plan was updated on 06/08/2024 to state the resident required extensive assistance by two staff to move between surfaces; however, the CCP was not developed to include transfer using a gait belt. During an interview with the MDS Nurse, on 03/11/2025 at 3:41 PM, she stated R12's CCP should have been revised to include the use of a gait belt with all transfers. 2. Review of the Admission Record, located in R13's EMR, indicated the facility admitted the resident on 06/29/2023 with diagnoses to include Alzheimer's disease, muscle weakness, and reduced mobility. Review of R13's CCP, dated 06/29/2023, located in the resident's EMR, revealed R13 was care planned for being at increased risk for falls related to a history of falls. Listed interventions included to keep the resident's call light in reach, encourage the resident to participate in activities, ensure the resident was wearing appropriate footwear, and follow fall protocol. All the above interventions were dated 06/29/2023. Review of an Occurrence History report for R13, provided by the facility, revealed she had one fall on 06/09/2024 resulting in a minor injury, and four non-injury falls on 07/17/2024, 09/06/2024, 02/25/2025, and 03/09/2025. Additionally, a witnessed non-injury fall, on 03/04/2024, was not noted on this report. Review of a Fall Checklist, provided by the facility and dated 02/25/2025 at 4:02 AM, revealed an intervention to initiate an exercise program for gait training was documented; however, the CCP was not revised with this intervention. Review of a Fall Checklist, provided by the facility and dated 03/04/2025 at 6:10 PM, revealed the CCP was not revised with a new intervention after R13 experienced a non-injury fall. Further review of R13's EMR, revealed no documented evidence the facility's Interdisciplinary Team (IDT) reviewed the above six falls or verified that previous care planned interventions were in place at the time of the resident's falls. Furthermore, there was no documented evidence the facility revised the CCP in an attempt to prevent recurrence. Review of R13's Health Status Note, dated 06/06/2024 at 10:27 PM, located in the resident's EMR, revealed LPN6 reported she found R13 on the side of the bed in a sitting position and blood was streaming down her face. According to the note, R13 was unable to explain how the fall occurred or what she was attempting to do at the time of the incident. Additional review revealed LPN6 notified the House Supervisor, Provider, Resident Representative (RR), and Emergency Medical Services (EMS). R13 was transferred to the local hospital for assessment. Review of R13's Emergency Department (ED) Provider Notes, dated 06/07/2024 at 1:12 AM, located in R13's EMR, revealed the resident presented to the local ED due to a head injury sustained from a fall. According to the ED notes, the examination revealed three lacerations on the right side of the resident's forehead, accompanied by an underlying hematoma. Per the ED note, R13 received a total of seven sutures to close the lacerations, and a CT scan of the head was conducted, which showed no intracranial processes. Further review revealed the resident was alert and neurologically intact at the time of discharge. Review of R13's Health Status Note, dated 06/07/2024 at 12:00 AM, located in the resident's EMR, revealed Nurse Practitioner (NP)1 reported R13 returned from the hospital with 6-9 sutures in head per nursing and complained of right lower rib pain. A chest radiograph (x-ray) was ordered. Review of R13's X-ray Rib Right Chest, dated 06/07/2024 at 11:49 AM, located in the resident's EMR, revealed no definite rib fracture. Although R13's EMR revealed the resident suffered injury related to the 06/06/2025 fall, there was no documented evidence the facility's Interdisciplinary Team (IDT) reviewed R13's falls or verified previous care planned interventions were in place at the time of the resident's falls. Nor did the facility revise the CCP in an attempt to prevent recurrence. Review of R13's quarterly MDS, with an ARD of 02/16/2025, located in R13's EMR, revealed the facility assessed R13 to have a BIMS score of five out of 15, which indicated severe cognitive impairment. Further review revealed the resident was not assessed for having falls during the look back period. Continued review revealed the facility assessed the resident as requiring substantial/maximum assist (helpers did more than half the effort) for transfers and once seated was able to wheel self short distances in a wheelchair. During an interview with LPN1, on 03/15/2025 at 10:22 AM, she stated she was familiar with R13 and due to the resident's diagnosis of Alzheimer's, R13 was forgetful and attempted to self-transfer without staff assistance. LPN1 stated R13 was care planned as a fall risk. She stated staff provided increased checks on the resident and provided activities if she was restless. During additional interview with the MDS Nurse, on 03/11/2025 at 3:55 PM, she stated the CCP should address the resident's needs based on diagnoses and assessments. The MDS Nurse further stated, every resident is at risk for falls, and residents with a history of falls required careful monitoring. She stated the care plan should be revised with new interventions to be implemented after a fall in an attempt to prevent further falls. The MDS Nurse further stated she was unsure why no new interventions were implemented after R13's fall on 06/06/2024. During an interview, on 03/13/2025 at 11:30 AM, with the Director of Nursing (DON), she stated staff was to follow the facility's fall protocol which included completing the Fall Checklist, which listed each step to complete when a fall occurred. She stated the checklist was to be completed by the nurse on duty and given to the DON for review at the Interdisciplinary Team (IDT) meeting. She further stated the IDT would then review the incident and add/revise interventions to prevent future falls. In further interview, she stated she could not find a Fall Checklist for R13's 06/06/2024 fall. The DON stated she currently kept IDT notes in a binder as they were not part of the EMR. During an interview with the Interim Administrator, on 03/15/2025 at 11:46 AM, she stated it was her expectation that staff would follow the facility's policies related to falls, and development/revision of care plans for the safety of the residents.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident received proper care and/or services to ensure he/she was free from accidents and hazards for two (2) of twenty-three (23) sampled residents (Resident #41 and Resident #22). The facility assessed Resident #41 to be an extensive assist of two (2) staff for transfers with a mechanical lift: However, State Registered Nurse Aide (SRNA) #10 used a stand and pivot, one (1) person transfer on 01/05/2022 which resulted in a laceration to Resident #41's left lower leg. Resident #41 was sent to the Emergency Department and received twelve (12) sutures. Resident #22 sustained a non-injury fall on 02/14/2022. Resident #22 had orders for his/her wheelchair to have a dycem cushion to prevent falls. After the fall, it was discovered Resident #22 had not been in his/her wheelchair which had the dycem cushion/pad. Resident #22 had been sitting in a wheelchair without a dycem cushion/pad and slid out of the wheelchair onto the floor. The findings include: Review of the facility's policy titled, Safe Resident Handling/Transfers, undated, revealed it was the policy of the facility to ensure residents were handled and transferred safely to prevent or minimize risks of injury and provide and promote a safe, secure, and comfortable experience. The policy also revealed two (2) staff members were required when a mechanical lift was used to transfer residents. Additionally, the policy noted, each staff member was expected to maintain compliance with safe transfer practices as well as complete this task as described in each resident's personalized care plan. Failure to follow these guidelines would result in disciplinary action up to termination of the staff members. Review of the facility's policy titled, Fall Prevention Program, implemented on 01/31/2022, revealed each resident's risk factors and environmental hazards would be evaluated when the Comprehensive Care Plan was developed, interventions would be monitored for effectiveness, and the care plan would be revised as needed. Review of the facility's policy titled, Falls and Fall Risk Management, revised March 2018, revealed the staff, with intervention of the attending physician, would implement a resident-centered fall prevention plan to reduce the risk factors of falls for each resident at risk or with a history of falls. Review of the facility's policy titled, Resident Rights, dated 04/01/2021, revealed residents had the right to reside in a safe, clean, comfortable, and functional environment and support with activities of daily living. The facility did not provide the State Survey Agency (SSA) with their Accidents and Hazards policy as requested by the Surveyor. 1. Review of Resident #41's medical records revealed the facility admitted the resident, on 05/03/2017, with diagnoses that included: Unspecified Dementia without Behaviors, Moderate Protein-Calorie Malnutrition, Muscle Weakness, [CONDITION(S)], Anxiety Disorder, and Age-Related [CONDITION(S)]. Review of Resident #41's Comprehensive Care Plan, last reviewed on 01/15/2022, revealed an intervention was initiated, on 05/18/2017, that extra care was to be taken when the resident was transferred to prevent arm, legs, and hands from contact with sharp objects. Another intervention initiated on 07/31/2019, was that the resident required a mechanical lift for all transfers. Review of Resident #41's Annual Minimum Data Set (MDS) Assessment, dated 12/30/2021, revealed the facility assessed Resident #41 with a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15), which indicated the resident had a severe cognitive impairment. Continued review of Resident #41's MDS Assessment also revealed the facility assessed the resident as totally dependent on physical assistance of two (2) staff for transfers between surfaces: bed, chair and wheelchair. The facility assessed the resident to have total upper body impairment and was not assessed for use of any mobility devices. Observation of Resident #41, on 03/14/2022 at 3:45 PM, in the common area, revealed the resident was dressed in personal clothes, and when asked, the resident said he/she was doing okay. Staff informed the SSA Surveyor that the resident was non-verbal. Additional observation revealed Resident #41 was in a high back wheelchair, with padding around his/her head and on the footrest. The padding did not have any cuts or cracks in it. Review of Resident #41's Electronic Medical Record (EMR) Progress Notes (PN), dated 01/05/2022, revealed at approximately 8:20 AM, the resident sustained a laceration to the lower left leg. The Wound Care Nurse Practitioner (NP) was on site and recommended the resident be sent to the hospital. Emergency Medical Services (EMS) was called, and the resident was transported to the hospital. Review of the Emergency Department (ED) provider's notes, dated 01/05/2022, no time, revealed the facility sent Resident #41 to the ED due to an injury sustained when staff transferred the resident and caught the resident's leg on an unknown object. The note stated the resident had a four and one-half (4.5) cm (centimeter) laceration to the left distal lateral lower leg and surrounding skin tears. There was a minor gaping defect to the most distal portion and bleeding was controlled at presentation. The ED note stated Resident #41 received two (2) inner sutures and ten (10) outer sutures to the laceration. Also, the note stated Resident #41 was sent back to the nursing home and would be followed by wound care. Review of Progress Notes for Resident #41, dated 01/05/2022, not timed, revealed he/she returned to the facility with ten (10) stitches on the surface of the laceration and two (2) stitches under the skin. Upon the resident's return to the facility, it was noted the wound was dressed and secure; the resident was placed back in bed without concern. Observation of Resident #41's wound, on 03/17/2022 at 11:10 AM, revealed the left lower leg had an intact wound which measured approximately three (3) centimeters (cm) by one (1) cm. The wound area was reddish pink and approximated with well-defined edges. The wound had no discharge or odor. There were no signs or symptoms of infection. Review of the facility's initial report to the State Survey Agency (SSA), dated 01/05/2022, revealed Resident #41 was transferred by State Registered Nurse Aide (SRNA) #1 via a stand and pivot transfer. Resident #41's leg bumped on the wheelchair and resulted in a skin tear. The initial report revealed the resident was care planned for a mechanical lift for transfers. The report also revealed the resident received immediate care for a skin tear and the staff member was reeducated on accessing and following the care plan. The facility unsubstantiated this complaint. Interview with SRNA #10, on 03/17/2022 at 4:04 PM, revealed she was unable to find a mechanical lift, nor could she find any staff member to help her move Resident #41 to his/her wheelchair from the bed. SRNA #10 stated she had only worked at the facility three (3) or four (4) times when this incident happened. She stated other aides had informed her Resident #41 had to be up in his/her chair for all meals no matter what. SRNA #10 revealed when she asked other staff for help, none would help her. She said, on 01/05/2022, she did a regular transfer on Resident #41 and was not aware that his/her leg got caught on anything until she fixed the resident's legs. At that point, she went to get a nurse because she observed the resident was bleeding badly. She stated she had to go back out and call for the nurse again because the nurse did not come directly to help. She was unable to identify the nurse on duty. Interview with SRNA #2, on 03/17/2022 at 9:31 AM, revealed she was an agency staff member, on contract for eight (8) weeks, and she was on her third week. She stated a resident's lift status could be found on the Kardex under lifts. SRNA #2 stated a two (2) person lift should never be done by one (1) person. She also stated mechanical lifts required two (2) staff members to use it. However, she was not able to get the help she needed when she had to transfer the resident. SRNA #2 explained if lifts were done incorrectly, the resident or staff member could be injured. Interview with Licensed Practical Nurse (LPN) #2, on 03/17/2022 at 9:58 AM, revealed if the proper lift techniques were not followed, residents could be hurt. He stated a mechanical lift required two (2) staff members to complete the transfer. He stated it was sometimes difficult to complete a two person lift because staff was not always present to help. LPN #2 reported if this was the case, he would let the resident know he was trying to find another staff member and would get them taken care of as soon as possible. LPN #2 also stated it was important to follow the proper technique with a mechanical lift to prevent injury to the resident or staff member. Interview with the Director of Nursing (DON), on 03/17/2022 at 7:11 PM, revealed she expected staff to transfer residents in a safe manner and that she expected staff to follow the facility's policy and the resident's care plan. She stated staff could complete a mechanical lift with one (1) staff member only in an emergent situation such as a fall or a fire. She stated she was not present on 01/05/2022 and was not a part of the investigation regarding Resident #41's leg injury. 2. Review of Resident #22's medical record revealed the facility admitted the resident, on 08/19/2021, with diagnoses that included: [CONDITION(S)], [CONDITION(S)] (TIA), Dementia, Malnutrition, Manic Depressive Disorder and Chronic Obstructive Pulmonary Disease ([CONDITION(S)]). Review of Resident #22's Comprehensive Care Plan, revealed a fall's intervention, dated 08/20/2021, for the resident to have a dycem pad (a non-slip pad used to prevent falling or sliding out of a wheelchair) attached to his/her wheelchair. Review of Resident #22's Quarterly MDS Assessment, dated 11/25/2021, revealed the facility assessed the resident to mobilize with the use of a wheelchair and/or walker. The assessment stated Resident #22 was generally able to move about the facility with the limited assistance of one (1) staff member. Further review revealed the Brief Interview for Mental Status (BIMS) could not be completed due to the resident's memory problems. Review of the facility's Fall Evaluation document, created on 02/14/2022 at 11:10 AM, and the Progress Notes, dated 02/14/2022, revealed Resident #22 was in the common area, in a wheelchair and participated in a volleyball activity. The document stated Resident #22 leaned forward too far to hit the balloon and slid out of the wheelchair. It was noted the resident was not in his/her own wheelchair at the time. Resident #22 was switched to the correct wheelchair, which had a dycem pad and rollbacks in place. Continued review revealed, on 02/20/2022 at 7:23 PM, the DON concluded Resident #22 was in the wrong wheelchair; however, resident's own wheelchair had anti-rollbacks, which would not have changed the situation. Observation of Resident #22, on 03/14/2022 at 3:55 PM, revealed the resident was in the common area seated in his/her wheelchair. Resident #22 had his/her legs outstretched and his/her back leaned slouched in the chair. Resident #22 did not make any attempts to lean forward or get out of the wheelchair. Observation of Resident #22, on 03/14/2022 at 4:25 PM, revealed the resident was seated in his/her wheelchair in the common area, slouched in the chair, with his/her legs outstretched. Resident #22 had the dycem cushion/pad in place on his/her wheelchair. The resident was able to self-propel around the common area. Interview with the Activity Director (AD), on 03/17/2022 at 3:30 PM, revealed she was present on 02/14/2022 when Resident #22 fell out of his/her wheelchair. She revealed the resident just slipped right out of the wheelchair. She also revealed the resident was not in his/her correct wheelchair. The AD stated Resident #22 had a big letter B for the resident's first name on his/her wheelchair, and it could not be missed. She stated the nurses knew it was not the resident's correct wheelchair, and they went to find the proper wheelchair and placed the resident in it. The AD also explained it was not uncommon for Resident #22 to move around on his/her own, and it was very possible the resident put him/herself in the wrong wheelchair. Interview with Physical Therapy Program Manager (PTPM) #1, on 03/17/2022 at 6:00 PM, revealed Physical Therapy (PT) was only involved with wheelchair assessments in some cases. She revealed Resident #22 was reassessed in April 2021 because the resident appeared to be too twisted up in his/her current wheelchair. She stated Resident #22 was placed in a Broda chair (a multi-position wheelchair to promote skin integrity) at that time. The PTPM revealed Resident #22 was not reassessed by PT for a new cushion or dycem pad, and that would usually be done by nursing staff. Continued interview with the DON, on 03/17/2022 at 7:11 PM, revealed Resident #22 had two (2) different wheelchairs in his/her room. Resident #22 had one (1) with anti-rollbacks, but that would not have prevented Resident #22's fall. She stated the dycem pad was put in place after the incident on 02/14/2022. However, Resident #22's care plan revealed dycem was care planned on 08/20/2021. Interview with the Administrator, on 03/17/2022 at 7:48 PM, revealed he expected all staff members to follow the policies and procedures of the facility. He stated he also expected staff to follow each resident's care plan to ensure they got the best practicable care available to them.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive, person-centered care plan to meet each of the medical, nursing, mental and psychosocial needs identified on the resident's comprehensive assessment. The facility also failed to ensure the care/services were furnished so that residents attained or maintained their highest practicable physical, mental and psychosocial well-being, for three (3) of twenty-three (23) sampled residents (Residents #41, #22 and #14). Resident #41's care plan instructed staff to use a mechanical lift for transfers, however a State Registered Nurse Assistant (SRNA) stated she transferred the resident with a stand and pivot transfer, instead of using a mechanical lift. Resident #41 received a laceration to the left lower extremity which required twelve (12) sutures to repair. Resident #22's care plan instructed staff to have a dycem pad (a non-slip pad used to prevent falling or sliding out of a wheelchair) on his/her wheelchair to prevent falling. However, the resident was in the wrong wheelchair during activity. Resident #22 had a fall from the wheelchair. Review of Resident #14's care plan revealed no documentation for the need for the resident to have a specialized Kick Pad, which served as his/her call light. Nor was there documentation that the Kick Pad was to velcroed to the foot board of the bed to ensure it did not fall off. Resident #14 was left for several hours without the ability to call for help. The findings include: Review of the facility's policy titled, Interdisciplinary Comprehensive Care Plan, effective 01/31/2022, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident. The care plan would include measurable objectives and timeframes to meet the resident's medical, nursing, as well as mental and psychosocial needs that were identified in the resident's comprehensive assessment. 1. Review of Resident #41's medical record revealed the facility admitted the resident, on 05/03/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41's Annual Minimum Data Set (MDS) Assessment, dated 12/30/2021, revealed the facility assessed Resident #41 with a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15), which indicated the resident had severe cognitive impairment. Continued review of Resident #41's MDS Assessment revealed the facility assessed the resident as totally dependent on the physical assistance of two (2) staff for transfers between surfaces: bed, chair, and wheelchair. The facility assessed the resident to have total upper body impairment and was not assessed for use of any mobility device. Review of Resident #41's Comprehensive Care Plan, last reviewed on 01/15/2022, revealed the resident had a deficit of self-care related to Dementia, impaired balance, and history of left [CONDITION(S)]. An intervention was initiated, on 05/18/2017, that extra care was to be taken when the resident was transferred to prevent arm, legs, and hands from contacting sharp objects. Further review revealed an intervention was initiated, on 07/31/2019, that the resident required a mechanical lift for all transfers. The care plan also documented the resident was dependent on staff to turn and reposition in bed every two (2) hours, which was last revised on 10/08/2020. Review of Resident #41's Electronic Medical Record (EMR) Progress Notes (PN), dated 01/05/2022, revealed, on 01/05/2022 at approximately 8:20 AM, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was sent to the hospital Emergency Department (ED and required twelve (12) stitches to repair the wound. Review of the facility's initial report to the State Survey Agency (SSA) dated 01/05/2022, revealed State Registered Nurse Aide (SRNA) #1 transferred Resident #41 via a stand and pivot transfer. Resident #41's leg bumped on the wheelchair and resulted in a skin tear. The initial report revealed the resident was care planned for a mechanical lift for transfers. Interview with SRNA #1, on 03/17/2022 at 4:04 PM, revealed she was unable to follow Resident's #41's care plan because she could not find a mechanical lift, nor could she find any staff member to help her move Resident #41 to his/her wheelchair from the bed. She revealed she had only worked at the facility three (3) or four (4) times when this incident happened. She stated other aides had informed her Resident #41 had to be up in his/her chair for all meals no matter what. SRNA #1 stated when she asked other staff for help, no one would help her. Further interview revealed on 01/05/2022 she did a regular transfer on Resident #41 and was not aware that his/her leg got caught, until she moved the resident's legs. 2. Review of Resident #22's medical record revealed the facility admitted the resident, on 08/19/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's Quarterly MDS Assessment, dated 11/25/2021, revealed the facility assessed the resident to mobilize with the use of a wheelchair and/or walker. The assessment stated Resident #22 was generally able to move about the facility with the limited assistance of one (1) staff member. Further review revealed the Brief Interview for Mental Status (BIMS) was not done because the interview could not be completed due to the resident's memory problems. Review of Resident #22's Care Plan, last revised 01/18/2022, revealed the resident had Activities of Daily Living (ADL) self-care deficits related to impaired mobility, incontinence and Dementia. It stated the resident required limited to extensive assistance by staff for bed mobility, to get dressed, to use the bathroom, and for transfers. Resident #22 was to have dycem (non-stick material) on his/her wheelchair. These interventions were initiated on 08/20/2021. The facility assessed Resident #22 to be a fall risk due to impaired mobility and Dementia. In addition, it stated the resident could not be responsible for getting into the wrong wheelchair due to cognitive impairment. Interview with the Activity Director (AD), on 03/17/2022 at 3:30 PM, revealed she witnessed Resident #22 slip out of the wheelchair. She also revealed the resident was not in his/her assigned wheelchair. She stated Resident #22 had a big letter B on his/her wheelchair cushion, and it stood out. 3. Review of Resident #14's medical record revealed the facility admitted the resident, on 10/16/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Admission MDS Assessment, dated 11/02/2021, revealed the facility assessed the resident to have a BIMS score of thirteen (13) of fifteen (15), which indicated the resident was cognitively intact. The MDS Assessment also revealed the facility assessed the resident to require one (1) person extensive assistance for bed mobility and transfers. Further review revealed the facility assessed Resident #14 to be totally dependent for eating, toileting, and personal hygiene, with extensive assistance of one (1) staff member. Continued review of Resident #14's MDS Assessment revealed the resident was always continent of his/her bowels, had no history of falls prior to entrance to the facility, and was triggered as high risk for pressure ulcers. Review of Resident #14's Care Plan, last reviewed 01/2022, revealed the resident had Activities of Daily Living (ADL) self-care deficits related to impaired mobility and limited range of motion (ROM) to bilateral upper extremities. One (1) intervention listed was to ensure the resident's soft touch call light was within reach of his/her feet and to encourage the resident to use it for assistance. The care plan was updated, on 01/17/2022, for the soft touch call light to be attached with Velcro to the foot of the bed. Interview with Resident #14, on 03/14/2022 at 4:20 PM, revealed the resident did not have use of his/her arms or hands because of ALS. Resident #14 stated that on 01/17/2022 his/her foot call light fell off the bed, and he/she was unable to call for help, from about 11:00 PM until the morning shift arrived and did rounds. Resident #14 revealed he/she did not have a blanket all night, and he/she was very cold. Interview with Registered Nurse (RN) #1 on 03/16/2022 at 2:47 PM, revealed on 01/18/2022 when she arrived for shift and completed her rounds, she found Resident #14, and the resident told her that he/she was so cold and he/she endured the cold all night because the call light fell to the floor and there was no way to get help. She stated she contacted maintenance to fix the call light that day. Interview with the Maintenance Director, on 03/17/2022 at 4:20 PM, revealed he had been contacted by the DON about fixing the kick pad call light for Resident #14. He stated he believed he had been contacted the same day the incident took place. However, he provided a copy of the email he received from the DON, and it was dated 01/19/2022. The kick pad was velcroed to the bed on 01/19/2022. Interview with SRNA #8, on 03/17/2022 at 2:47 PM, revealed she looked at the care plan to determine the appropriate care for each resident. She stated the care plan should always be followed to ensure resident safety was being maintained. She also stated if the care plan was not followed, the resident could get hurt. Interview with Licensed Practical Nurse (LPN) #2, on 03/17/2022 at 9:58 AM, revealed it was important for staff to follow the care plan because that was the guide to what residents needed for their care. LPN #2 revealed the care plan was used to ensure each resident attained their best possible life. He stated when the care plan was followed, residents were more likely to be safe and get proper care. Interview with RN #1, on 03/16/2022 at 2:47 PM, revealed she used the care plan and Kardex to know how to care for each resident. She also revealed it was important to follow the care plan to better prevent accident or injuries and to ensure the right care was provided to the resident. RN #1 also stated, for example, if the resident was care planned for a mechanical lift, but the staff provided a different lift for the resident, the resident could sustain a cut or break a bone. Interview with the DON, on 03/17/2022 at 7:11 PM, revealed the care plan directed staff in the needs and preferences of each resident. She also revealed it was important to follow the care plan to ensure residents got the assistance they needed. She stated she, along with the MDS Coordinator and Night Shift Supervisor, updated care plans. She stated all nurses were able to update care plans, but she was not sure if they did. She explained she and the MDS Coordinator read all orders and updated the care plans accordingly. Continued interview with the DON, on 03/17/2022 at 7:11 PM, revealed the care plans should be updated when there were any changes for a resident. She stated she expected staff to follow the care plan, and if something was incorrect, she expected staff to notify her or the MDS Coordinator to ensure changes would be made. The DON stated SRNA's used the Kardex, which reflected interventions mandated by the care plan, and were expected to follow what the Kardex showed for resident care. Interview with the Administrator, on 03/17/2022 at 7:48 PM, revealed he expected all of his staff to follow the policies and procedures of the facility and the residents' care plans.

Based on observation, interview, record review and review of facility policies, it was determined the facility failed have an effective system to prepare, and serve food under sanitary conditions in accordance with professional standards for food service safety to prevent the spread of Gastrointestinal (GI) illness. On 12/19/19, the facility contacted the Health Department related to an outbreak of GI illness and on that date the Health Department visited and made dietary sanitation recommendations in an attempt to prevent the transmission of [MEDICAL CONDITION] to include sanitizing solution using bleach with chlorine levels one hundred-fifty (150) to two hundred (200) Parts per Million (PPM). However, observation of the kitchen on 01/13/2020, revealed two (2) sanitation buckets tested at seventy-five (75) to one hundred (100) PPM per the test strip. In addition, observation on 01/14/2020 of the two (2) sanitation buckets containing bleach solution in the kitchen revealed test results of ten (10) PPM and twenty-five (25) PPM, and dietary staff was observed using a dishcloth from the sanitation bucket tested at ten (10) PPM to clean the kitchen food preparation table. Additionally, observation on 01/14/2020 on the Memory Care/St. Francis Unit, revealed the sanitation bucket containing bleach solution was observed with zero (0) PPM on the test strip. Staff interviews revealed the facility did not have a policy or system in place to monitor the sanitation buckets to ensure each one had bleach sanitizing solution at the proper PPM, or to monitor how often the solution was changed. Furthermore, facility policies were not implemented related to ensuring dish machines were reaching proper temperature and silverware was washed three (3) times in the correct manner. Observation on 01/14/2020, revealed the Temp Thermo Label applied to a dish to test the internal kitchen dish machine water temperature did not reach one hundred sixty (160) degrees Fahrenheit. In addition, observation on 01/14/2020 of the dish machine on the Memory Care/St. Francis Unit, revealed the Temp Thermo Label did not reach one hundred sixty (160) degrees Fahrenheit with two (2) different tests, and brown flecks were observed in a bowl after the dishwashing process was complete. Moreover, review of the Dishwasher Temperature Logs dated December 2019 and January 2020, revealed multiple meals/dates with either low temperatures documented or no documentation of the dish machine temperatures on the logs. In addition, interviews with Dietary Staff revealed silverware was not washed/sanitized three (3) times, as per policy. Additionally, there was no documented evidence the facility trained all dietary employees on the use of the new dishwashers when they were installed in October, 2019 and no documented evidence the facility policy was revised related to the proper use of the equipment. These failures resulted in the inability to contain the organism as there were forty-seven (47) residents with signs and symptoms of GI illness. The facility's failure to have an effective system in place to ensure dietary sanitation has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/17/2020, and determined to exist on 12/19/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 01/29/2020 alleging removal of the Immediate Jeopardy on 01/30/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 02/01/2020, prior to exit on 02/01/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Infection Control/Exposure Control Department: Dietary Policy, effective 05/30/13, revealed the Dietary Department recognizes the importance of implementing safe food handling practices and the elements of standard precautions to limit cross-contamination/exposure. Further review revealed the Dietary Manager is responsible for the supervision and training of all dietary staff in the practices of sanitation; housekeeping; safety in storage, preparation and service of food within the state and federal guidelines; infection control and exposure; personal protective equipment, and work practice controls. Continued review revealed employees are educated on the necessity of reporting any fever, coughing, sneezing, infections, open wounds, rashes or any other issues to the Dietary Supervisor for evaluation in relation to the ability to safely perform their tasks. Per Policy, training regarding hand hygiene supplies and cleaning products is the responsibility of the department manager and staff education will be recorded and maintained by the department head. Review of the Cleaning/Sanitation/Care of Dietary Equipment Department:Dietary Infection Control Policy, effective 05/30/13, revealed a properly scheduled and carefully monitored program of equipment care and cleaning ensures adequate sanitation and maintenance of the dietary department. Further review revealed the Dietary Director and Supervisors are responsible for supervising all sanitation and housekeeping procedures within the dietary department. The Dietary Director develops a cleaning schedule and is responsible for seeing that it is followed. Checklists and quality assurance monitors provide an efficient method for doing this. The Dietary Director is responsible for supervising and training all personnel in proper cleaning and sanitation procedures for all dietary equipment. The procedures for washing and sanitizing all silverware, china, pitchers and glasses are developed and posted in the kitchen. Temperatures for the dish machine are recorded daily. Review of the facility Cleaning Dishes/Dish Machine Policy, undated, revealed dishes and cookware will be washed and sanitized after each use/meal. Allow dishwasher to run a full cycle, making sure the temperature for washing is one hundred fifty (150) degrees Fahrenheit, and the rinse temperature is at one hundred eighty (180) degrees Fahrenheit, and if not, run the dishes a second time. After the second time, if the dishwasher doesn't reach the appropriate temperature, immediately notify the Supervisor or Director. Continued review of the Policy, revealed silverware should be presoaked prior to washing. First wash silverware on flat rack. Then place silverware into cylinders with mouth pieces exposed and wash the silverware in cylinders. Turn silverware over exposing the handles into the cylinder and wash for the third washing. Review of the facility Proper Sanitation of Food-Contact Surfaces Policy, effective 11/17/10, revealed the dietary department is to wash and sanitize all food contact surfaces with an appropriate sanitizing agent to prevent contamination and/or illness. Per Policy, all food-contact surfaces must be washed and sanitized with appropriate sanitizing agents after each use; when an employee begins working with another type of food; any time there is an interruption during a task and the tools or items being used may have become contaminated, and at four (4) hour intervals if the items are in constant use. Review of the Health Department Time Line for the facility GI Outbreak, events as of 01/16/2020, revealed an environmental site visit was completed on 12/19/19 and facility staff was advised on sanitizing and proper disinfection using bleach, including the appropriate chlorine levels of 150-200 PPM. Review of the email dated 12/19/19 at 5:27 PM, sent from the Dietitian to the Dietary Manager, Kitchen Supervisor, Administrator, Director of Nursing (DON), Infection Control Nurse, Nurse Manager, Environmental Services Director and Administrator, revealed the Health Department (HD) visited the facility on 12/19/19. Further, the Dietician needed to talk with everyone in the entire department on 12/20/19 about the HD mandate on cleaning with bleach until further notice due to the potential Norovirus outbreak. There was an exact process and bleach concentration that had to be achieved and followed. Continued review revealed chlorine based bleach must be used as it was the only chemical that will kill the Norovirus. On 01/15/2020 at 4:15 PM, the Surveyor requested the minutes of the staff meeting held 12/20/19, and was advised by the Director of Nursing (DON) the facility did not retain written minutes of the meeting. Interview with the Registered Dietitian (RD), on 01/14/2020 at 10:57 AM, on 01/16/2020 at 4:51 PM, and post survey phone interview on 02/06/2020 at 3:59 PM, revealed on 12/19/19, the HD Staff visited the facility late in the evening regarding the potential GI outbreak and made verbal recommendations for bleach sanitizing solution due to suspicion of Norovirus, as the quad sanitizer the facility typically used was not effective against [MEDICAL CONDITION]. Per interview, HD staff recommended filling one (1) of the compartments of the three (3) compartment sink with water and then adding one (1) capful of bleach to make the proper concentration and provided strips to test the solution. Further interview revealed the RD arranged for bleach to be purchased that evening and the following day, on 01/20/2020, per the HD instruction she filled the sink with water and added one (1) capful of bleach and the solution tested two hundred (200) PPM. Additional interview revealed the HD staff recommended to clean kitchen/food prep surfaces with the bleach solution and then go back over the surfaces with just water. Per interview, staff was to fill sanitation buckets with the bleach solution from the three (3) compartment sink. Additional interview with the RD, revealed after she received the HD recommendations, she did provide a quick inservice to all dietary staff on 12/20/19, regarding how to fill one (1) of the compartments on the sink with water and add one (1) capful of bleach to make the proper concentration, and also demonstrated how to test the solution with the test strips to ensure the solution was 200 PPM. She further stated she also included in her inservice the need to change the solution every four (4) hours as per the HD recommendations. The RD stated this was not a formal inservice and there was no documentation related to the inservice to submit for review. She stated, starting 12/20/19, dietary staff was to check the sanitizing solution at each shift/meal and she also randomly checked the solution; however, there was no documented evidence of the monitoring as staff did not log these checks. Further interview with the RD, revealed she was unaware of any written policy change related to using the bleach sanitizer, or related to how often the solution in the sanitization buckets were to be changed out after the HD made the verbal recommendations on 12/19/19. Continued interview with the RD, revealed she attended the IDT meeting on 12/20/19 and reiterated the HD recommendations from 12/19/19. She stated the outbreak of the GI illness was discussed in general at the meeting, but she could not recall anything specific. Further interview with the RD, revealed the Health Department made another visit to the facility on [DATE] and found concerns related to the HD recommendations not being followed, and further education was completed by the Dietary Manager. Review of the Department for Public Health Food Establishment Inspection Report, dated 01/02/2020, revealed there were spray bottles of chlorine bleach based sanitizer less than fifty (50) PPM and should be one hundred (100) to two hundred (200) PPM. Further review revealed the Francis dish machine was at 146 155-degrees Fahrenheit. Continued review revealed the dish machines for the Francis Unit and Therese Unit thermometer digital readout was plus thirty (30) degrees Fahrenheit more than the actual temperature observed internally. The Report noted employees lacking test kit (papers, tape, ect.) to verify rinse temperatures. Further review of the Report, revealed the Francis Unit dish machine was lacking dish detergent and the Therese dish machine was lacking rinse aid. Per the Report, there was an investigation due to ongoing confirmed Norovirus outbreak among residents and staff was advised to cease communal dining until outbreak had ceased. Staff advised of proper concentration of chlorine based sanitizer for all food prep surfaces. Review of the Inservice topics education, provided by the Dietary Manager, revealed training was provided to dietary staff from 01/05/2020 through 01/13/2020, which covered the areas of proper use and storage of personal beverage containers; proper use of chlorine sanitizer versus Quaternary ammonia; proper setup and breakdown of dish machines; proper handwashing and soap replacement policy; use only chlorine-based sanitizer on all food contact surface areas at 100-200 PPM and air dry only; use temperature test strips for the dish machine; finding and replacing dish machine chemicals; and cups should have straws and lids and if stored in a food service area should only be stored below food prep surfaces. Dietary staff signed as inserviced on the above topics. Interview with the Dietary Manager, on 01/13/2020 at 1:47 PM, revealed he provided additional training to dietary staff from 01/05/2020 through 01/13/2020, after it was identified by the HD on 01/02/2020, there was ongoing issues related to dietary sanitation. Further interview revealed the Kitchen Sanitation Company Regional Technician installed bleach solution system pumps set at 200 PPM in the kitchen and the Housekeeping area towards the beginning of January 2020. He stated these pumps automatically dispensed the correct bleach sanitation solution and staff no longer had to mix the bleach and water in the three (3) compartment sink for the sanitizing buckets. Review of the Kitchen Company Accounts Service document, dated 01/03/2020, revealed two (2) Hydro Streamline sanitation dispensers were installed. 1. Observation on 01/13/2020 at 1:47 PM, revealed the Dietary Manager tested the sanitizing buckets in the kitchen using the test strips. One (1) of the sanitation buckets tested at seventy-five (75) PPM and another sanitation bucket tested at one hundred (100) PPM. The buckets did not have a time and date to indicate when the water was last changed. Interview with the Dietary Manager, revealed the facility was using a chlorine bleach sanitizer solution which was to be at one hundred fifty (150) to two hundred (200) PPM, and the bleach solution in the sanitation buckets was to be changed every two (2) hours in order for the sanitizing solution to be effective. Further interview revealed he did not know when these buckets had last been tested for PPM or when the water had last been changed out as this information was not documented. He stated when the water in the sanitation bucket was used more than an hour, it usually looked like it needed changed. Further observation revealed the Dietary Manager then checked a sanitation bucket that he had just obtained from the bleach solution system pump and the solution tested at 150 PPM. The Dietary Manager stated the solution from the pump should have tested at 200 PPM and he would need to notify the Kitchen Sanitation Company Regional Technician. Interview with the Kitchen Sanitation Company Regional Technician, on 01/14/2020 at 11:40 AM, revealed he checked the kitchen bleach solution system pump on arrival this date and the reading was seventy-five (75) to one hundred (100) PPM. He further stated he had placed a cap on the bleach with a hole in the center to allow for the tubing to enter the container, and this was gone and he thought this was allowing the chlorine to gas off which caused the chlorine to become at a lower level. He stated he was replacing the cap on the pump. 2. Observation on 01/14/2020 at 12:00 PM, revealed the Kitchen Supervisor was wiping a kitchen table surface with a dish cloth from a sanitation bucket in the main kitchen. The facility Kitchen Sanitation Company Regional Technician tested the sanitation bucket with the Dietary Supervisor present and the test strip was ten (10) PPM. An additional sanitation bucket in the main kitchen was tested at twenty-five (25) PPM. Interview with the Kitchen Supervisor revealed she did not fill up the sanitation buckets and thought the staff who arrived at 9:00 AM, prior to her, filled the buckets. There was no date or time observed on the sanitation buckets. Further interview revealed dietary staff was to change the sanitizer in the sanitizing buckets every two (2) to four (4) hours depending on use. Continued interview with the Kitchen Supervisor, revealed she should have checked the sanitation bucket for PPM before she started wiping, and cleaning with the water from the bucket. She stated it was her responsibility to make sure the kitchen was properly sanitized. 3. Observation of the Saint Francis Memory Care Unit kitchenette, on 01/14/2020 at 12:40 PM, revealed a sanitation bucket with no date, but there was a sticker on the bucket noting the water was changed at 11:04 AM. The sanitation bucket was tested by the Kitchen Sanitation Company Regional Technician and the test strip revealed zero (0) PPM. Interview with Dietary Aide #1, who was working on the unit at the time of this observation, revealed she was supposed to check the sanitizer solution that morning, but she could not find the strips. She then went to a kitchenette cabinet and found the strips in the bottom of the cabinet. Interview with the Dietary Manager, on 01/14/2020 at 9:00 AM and 01/16/2020 at 4:04 PM, revealed bleach concentration of zero (0), ten (10) or twenty-five (25) PPM would not be effective at reducing harmful pathogens to a safe level, specifically killing the Norovirus, which was the reason the facility was using the bleach sanitizer. Per interview, the bleach sanitizer should have been at one hundred fifty (150) PPM to two hundred (200) PPM which was higher than the normal concentration related to the Norovirus. Further interview revealed staff had not been labeling and dating the sanitation buckets when the water was changed out, nor was there a policy related to how often the water in the buckets was to be changed. In addition, he stated staff had not been documenting testing of the sanitation solution. Continued interview revealed the facility did not have a written policy regarding sanitation buckets or documented evidence of monitoring to ensure the sanitizer was at the appropriate level, and therefore there was no way to verify the system was working as far as using the sanitizer correctly. Interview with the Infection Control Nurse, on 01/16/2020 at 9:45 AM, revealed the sanitation buckets that tested at zero (0) to twenty-five (25) PPM would not be effective to kill the organism and there should have been a system in place to monitor the sanitation buckets solution to ensure the solution was at appropriate chlorine levels of 150-200 PPM, as per the HD recommendations. 4. Review of the Dishwasher Temperature Logs dated December 2019 and January 2020, revealed instructions for the wash temperature to be one hundred fifty (150) degrees Fahrenheit and rinse temperature to be at one hundred eighty (180) degrees Fahrenheit. The dishwasher temperature must be checked after each meal by the Dining Room Aide. Record the wash and final rinse temperature on the above chart. If temperature is not reaching the appropriate range, please notify the Supervisor. Continued review of the Dishwasher Temperature Logs dated December 2019, revealed multiple meals/dates with no documentation of the dish machine temperatures on the logs. Review of the logs for the St. Joseph Unit, revealed the rinse temperatures were below one hundred eighty (180) degrees Fahrenheit on 12/12/19, 12/13/19, 12/17/19 and 12/19/19. Per the documentation, dish machine temperatures were only documented for twenty-five (25) of the ninety three (93) meals served for 12/2019. Review of the logs for T2/Saint Therese Unit, revealed dish machine temperatures were only documented for nine (9) of the ninety three (93) meals served for 12/2019. Review of the logs for Saint Frances/Memory Care Unit, revealed dish machine temperatures were only documented for fifty (50) of the ninety three (93) meals served for 12/2019. Review of the logs for T1/Marian Unit, revealed temperatures were only documented for sixty-nine (69) of the ninety three (93) meals served for 12/2019 and the wash temperature was recorded below one hundred fifty (150) degrees Fahrenheit on eight (8) days, 12/03/19, 12/04/19, 12/09/19, 12/12/19, 12/14/19, 12/15/19, 12/18/19, and 12/21/19. Review of the Dishwasher Temperature Logs for January, 2019, from 01/01/2020 through 01/12/2020 (total of thirty six (36) meals served for these dates), revealed multiple meals/dates with no documentation of the dish machine temperatures on the logs. Review of the logs for the St. Joseph Unit, revealed dish machine temperatures were only documented nineteen (19) of the thirty-six (36) meals served through 01/12/2020. Interview with Dietary Aide #2, on 01/14/2020 at 1:15 PM, who worked on the St. Joseph Unit, verified dietary staff was supposed to log the wash and rinse cycle temperatures of the dish machine on the Dishwasher Temperature Logs book at each meal. Review of the logs for T2/St. Therese Unit, revealed dish machine temperatures were only documented seven (7) of the thirty-six (36) meals served through 01/12/2020. Review of the logs for St. Frances/Memory Care Unit, revealed dish machine temperatures were only documented for three (3) of the thirty-six (36) meals served through 01/12/2020. Review of the logs for T1/Marian Unit, revealed temperatures were only documented for fifteen (15) of the thirty six (36) meals through 01/12/2020, and broken or not in use was documented for eleven (11) of the thirty-six (36) meals through 01/12/2020. Interview with the Dietary Manager, on 01/16/2020 at 4:04 PM, revealed all the facility dish machines used heat sanitation, detergent and rinse aide and did not use chemical sanitizers. Per interview, the temperature for washing should be one hundred fifty (150) degrees Fahrenheit, and the rinse temperature should be one hundred eighty (180) degrees Fahrenheit. Further interview revealed in the past, the readings on the dish machines were consistently logged; however, the logged temperatures for 12/2019 and 01/2020 were hit and miss and he thought staff was out of the habit of logging the temperatures. He further stated some of the dish machines were not used some of the time in January 2020, but he was unable to provide specific dates. He further stated without documenting the temperatures, there was no way of knowing if the machines reached the proper temperature to ensure sanitation. 5. Observation on 01/14/20 at 11:40 AM, of the dish machine in the kitchen, revealed the Temp Thermo Label applied to a dish to test the water temperature inside the machine, did not indicate the dish reached the one hundred sixty (160) degrees Fahrenheit. Interview with the facility Kitchen Sanitation Company Regional Technician, during the observation, revealed it may be due to the tray/rack containing small openings and he would let the Dietary Manager know he recommended using racks with larger openings. Interview with the Dietary Manager, on 01/14/2020 at 1:20 PM, revealed the racks with smaller openings were used for silverware. 6. Observation of the under counter dish machine, on the Memory Care/St. Francis Unit, on 01/14/2020 at 12:20 PM, with the Kitchen Sanitation Company Regional Technician, revealed the dish machine wash temperature was one hundred fifty-two (152) degrees Fahrenheit and the rinse temperature was one hundred ninety four (194) degrees Fahrenheit per the digital readings. However, the Kitchen Sanitation Company Regional Technician stated the Temp Thermo Label on the dish used to test the water temperature inside the machine did not indicate water reached one hundred sixty (160) degrees Fahrenheit with two (2) tests of the machine. Per interview, this meant the water temperatures inside the machine was not reflected in the digital temperature. Further, brown flecks were observed in a bowl after the dishwashing process was complete. He stated this may have been due to the dish machine needing to be emptied and refilled. Per interview, it was recommended the dish machine water was emptied and refilled between each meal for the under counter machines, but this was not required for the other dish machines. Further interview with the Kitchen Sanitation Company Regional Technician revealed this under the counter dish machine was installed in October 2019, before he started working at the facility, and he could not find documented evidence all dietary staff was trained on this type of dish machine. Interview with Dietary Aide #1 on 01/14/2020 at 12:40 PM, revealed she usually emptied the water in the dish machine between breakfast and lunch, but she did not do it today. Interview with the Dietary Manager, on 01/14/2020 at 1:20 PM, revealed the Health Department identified during their visit on 01/02/2020, there was a difference in the temperature of the water inside the dish machine during wash and rinse cycles as compared with the digital reading on the outside of the dish machines for the dish machines on the nursing units. Further interview revealed the Kitchen Sanitation Company Regional Technician who serviced the machines had to raise the pressure of the machines related to the discrepancy in water temperatures on more than one (1) occasion. He stated the Temp Thermo Label was applied to a dish prior to the dish cycle and the heat sanitizing should cause the Temp Thermo Label test tapes to reach one hundred sixty (160) degrees Fahrenheit to verify the machines were working properly on the inside and to ensure sanitizing at one hundred sixty (160) degrees Fahrenheit or above for all dish machines. Further interview revealed he had been testing the dish machines since the Health Department visit on 01/02/2020 with the Temp Thermo Label test tapes and had been getting one hundred percent (100%) compliance; however, the Dietary Manager stated he had no documented evidence of testing the dish machine water temperatures using the Temp Thermo Label test tapes. Further interview revealed the facility had been using disposable silverware, plates, and trays since 01/03/2020; however, weighted utensils and special eating devices could not be replaced with disposable items. Further interview with the Dietary Manager, on 01/16/2020 at 4:04 PM, revealed the under the counter dish machines were installed prior to his working at the facility, and he was unable to find a policy related to these dish machines, which were installed in October, 2019. Continued interview revealed he could find no documented evidence dietary staff were trained on the use of the new dish machines. Review of the Kitchen Company Accounts Service document, dated 10/30/19, revealed the prior Dietary Manager reported issues of needing training on new machines and low water levels in new machines and others. However, there was no documented evidence all dietary staff were trained on how to properly operate the new machines. Review of the Kitchen Company Accounts Service document, dated 01/09/2020, revealed concerns related to machine temperatures on floors were too low and under counter dishwasher was not getting up to plate temperature and the machine pressures were adjusted. However, there was no documented evidence staff was trained on monitoring the temperatures of the dishwasher. 7. Interview with Dietary Aide #2, on 01/14/2020 at 1:15 PM, revealed when washing silverware, she was taught to place the silverware on a tray and push button number two (2) for extended cycle on the dish machines, but she was not trained regarding any other specifics related to washing silverware. Interview with the Dietary Supervisor, on 01/14/2020 11:40 AM, revealed she did not typically wash silverware, but silverware was washed on each unit at the individual stations, as long as all dishwashers were operational. Further interview revealed he did not know the policy, but stated the silverware was placed on a flat tray, placed in the sink under water and detergent and then run through dish machine. When asked if silverware was washed in the dish machine more than once, she stated not to her knowledge. Interview with the Dietary Manager, on 01/16/2020 at 4:04 PM, revealed the protocol for washing silverware was to spray it off and run it through the dish machine one (1) time. The facility policy was provided for his review and he stated according to the written policy, silverware was supposed to be soaked and washed three (3) times, flat, in a cylinder, and then flipped and in the cylinder again for the third time. Continued interview revealed he had only been employed at the facility since 12/04/19, and had not yet reviewed the facility dietary policies. Continued interview revealed the reason for washing the silverware three (3) times was to ensure it was washed and sanitized thoroughly. Per interview, if silverware was not washed as per policy, there was a higher probability the silverware hadn't been effectively sanitized and could cause the spread of harmful pathogens. Per the Dietary Manager, the facility did not begin using disposable items to serve food facility wide until 01/03/2020. Interview with the Director of Nursing (DON), on 01/17/2020 at 4:00 PM, revealed the sanitation bucket solution should be at the appropriate PPM as recommended by the Health Department in order for the solution to be effective at sanitizing and preventing the spread of illness. Further interview revealed dietary staff should have been testing and monitoring the sanitizing solution in the sanitizing buckets and documenting the test results. She further stated staff should have been changing out the sanitation buckets as necessary. Further interview revealed she was unsure of kitchen policies regarding the dish machines, but it was her expectation dietary staff follow the facility's dietary policies and procedures in order to prevent foodborne illness and to prevent the spread of the Norovirus/GI illness to residents. Interview with the Administrator, on 01/15/2020 at 3:30 PM and 01/17/2020 at 6:26 PM, revealed it was her expectation staff follow the recommendations of the Health Department regarding ensuring the correct bleach sanitizing solution was used in the sanitation buckets in order to prevent the transmission of disease and infection. However, she stated she was unaware of any monitoring system in regards to ensuring the sanitizing bleach solution in sanitation buckets was at the correct sanitation level or ensuring the sanitation bucket solution was changed out at certain intervals. She stated this should have been monitored with results documented in order to ensure the sanitizer was effective in killing germs [MEDICAL CONDITION]. She further stated she was unaware until this week that staff was not using the correct bleach sanitizing solution in the sanitation buckets. Continued interview with the Administrator, revealed it was her expectation staff follow facility polices regarding dish machine temperatures and washing of silverware. Per interview, staff should be logging dish machine temperatures after each meal and there should have been monitoring to ensure dish machine temperatures were high enough to be effective to sanitize dishware. Further, she was not sure if mechanically the new under counter dish machines ran differently than the other dish machines. Per interview, when the new dish machines were installed in October, 2019, the Kitchen Sanitation Company Regional Technician spoke with the previous Dietary Manager about the machines, but she was unsure if anyone educated the Dietary Aides related to use of the dish machines. She stated she was unable to submit any formal training for review related to the ne (TRUNCATED)

Based on observation, interview, record review, review of the Director of Nursing and Administrator's Job Descriptions, and review of the facility's Policies and Procedures, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident during the Gastrointestinal (GI) outbreak at the facility during the months of [DATE] and [DATE]. There was no documented evidence the facility's Administration ensured the facility Hydration Policy, was implemented during the Gastrointestinal Outbreak at the facility. Further, there was no documented evidence the Comprehensive Care Plans were revised to promote sufficient fluid intake, and to reflect the GI illness, nor was there documented evidence Acute Care Plans were initiated for a change in condition related to the GI illness, as per facility policy. Furthermore, there was no documented evidence the Physician was notified when there was a change in status related to the GI illness and no documented evidence the Physician was notified when residents did not meet their estimated fluid requirements due to GI illness during the GI outbreak. This affected Residents #2, #3, #4, #5, #10, #11, #12. (Refer to F-580, F-697, and F-692) In addition, there was no documented evidence the facility's Administration ensured the facility Infection Control Policies and Health Departments recommendations were implemented during the Gastrointestinal Outbreak at the facility. (Refer to F-880) Moreover, the facility's Administration failed to ensure the facility policies and procedures and Health Department recommendations were followed related to kitchen sanitation during the Gastrointestinal outbreak. (Refer to F-812) These failures by Administration resulted in multiple residents being hospitalized related to [DIAGNOSES REDACTED].#2, Resident #3 and Resident #11 expired following complications from the illness. In addition, at least forty-seven (47) residents were being placed in isolation due to signs or symptoms of GI illness. The facility's failure to have an effective system in place to ensure it was 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 has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Administration Policy, undated, revealed it is the policy of the facility that the facility 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. Continued review revealed the facility will conduct and document a facility wide assessment to determine what resources are necessary to care for its residents competently during both day to day operations and emergencies. The facility's resource includes, but is not limited to all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers. Review of the facility's Job Description for Administrator, undated, revealed under the general direction of the Governing Board, the Administrator of Carmel Manor is Chief Executive Officer of the Home and directs all its operations. The Administrator establishes and maintains policies and practices to insure the best care possible for the residents within federal, state, and local law and standards, reflecting the mission and philosophy of the Carmelite Sisters for the Aged and Infirm. Continued review revealed duties and responsibilities include establishing policies and setting standards pertaining to total resident care, personnel, medical staff, financial staff, public relations and maintenance and communicating such policies to staff and other concerned parties. Further review revealed the Administrator reviews performance by personnel and medical staff, and periodically reviews policies and makes changes as necessary. Additional review revealed duties and responsibilities of the Administrator includes ensuring compliance of institution with federal, state, and local standards. Review of the Job Description for Director of Nursing (DON), undated, revealed the DON reports to the Administrator and supervises all nursing staff. Further review revealed the DON for Carmel Manor, being directly responsible to the Administrator and in a collaborative relationship with the Medical Director and Ancillary Services, develops and implements the objectives, policies and standards for nursing care of residents which reflects the mission and philosophy of the Carmelite Sisters of the Aged and Infirm and the purpose of the home, and assures compliance with State and Federal guidelines. Continued review revealed the DON's duties and responsibilities include implementing the philosophy, objectives, policies and standards for nursing care of residents which reflects the purpose of the Home and idealism of the Carmelite Sisters for the Aged and Infirm. The DON assures orientation and on the job training of nurses and nurse aides and establishes, monitors and enhances the quality of nursing care given. Additional review revealed the DON formulates, defines and interprets nursing policies to personnel and maintains a current manual of nursing policies and procedures; and plans, organizes and directs effective administration of each nursing unit to assure residents have a comfortable, clean, orderly and safe environment. Review of the Job Description for Infection Control Specialist (ICS), undated, revealed the ICS reports to the DON and does not supervise any staff. Further review revealed under the supervision of the DON, the ICS coordinates the Infection Control Program and develops and maintains Quality Assurance Audits related to Infection Control as part of the Infection Control Program. Continued review revealed duties and responsibilities include conducting surveillance of infections with follow up as needed; directing other departments in maintaining infection control; instructing all residents, families, and staff in infection control policies and procedures; monitoring any isolation procedures and precautions initiated within the facility; monitoring all specimens sent for culture and infection identification; reviewing nursing documentation and reporting discrepancies to the DON; and reviewing and maintaining the Infection Control Policy and Procedure manual. 1. Review of the facility's Hydration Policy, undated, revealed it is the policy of Carmel Manor to identify residents exhibiting risk factors which lead to dehydration. For these residents the facility shall develop interventions to provide sufficient fluid intake to maintain proper hydration and health. Further review revealed residents are assessed to identify risk factors for dehydration. Based on the risk factors and clinical condition, interventions shall be developed and implemented to avoid dehydration. Carmel Manor will assess residents with Minimum Data Set (MDS) Assessment changes or significant change of condition to identify newly emerging risk factors for dehydration. Appropriate interventions will be provided as indicated. Additional review revealed the facility will monitor the effectiveness of individual resident's hydration interventions to evaluate effectiveness of plan. Residents will be monitored for signs and symptoms of dehydration on the weekly skin round assessments. The facility will maintain a method of communicating residents recommended fluid needs. The resident's response to interventions will be evaluated and the plan will be revised as indicated. Residents #2, #3, #4, #5, #10, #11 and #12 exhibited signs and symptoms of Gastrointestinal (GI) illness during the months of [DATE] and/or [DATE], including diarrhea and/or vomiting as there was a GI illness outbreak in the facility. However, there was no documented evidence the facility identified the residents' risk for dehydration and implemented interventions to promote fluid intake and ensure sufficient fluid intake to maintain proper hydration. There was no documented evidence the Comprehensive Plan of Care (CCP) was revised related to the GI illness and related to the potential for dehydration to include individualized interventions to promote hydration. Further, there was no documented evidence an Acute Care Plan was initiated for a change in condition related to the GI illness, as per facility policy. Although these residents did not meet their estimated fluid requirements during their illness, there was no documented evidence of monitoring fluid intakes, performing hydration assessments or notification to the Physician or Registered Dietician (RD) related to low fluid intakes, and/or the GI illness symptoms. This resulted in residents being hospitalized with [DIAGNOSES REDACTED]. Interview with the DON, on [DATE] at 3:27 PM, [DATE] at 4:15 PM, [DATE] at 11:35 AM, and [DATE] at 4:00 PM, revealed as DON she should have ensured nursing staff was aware of the residents' estimated fluid requirements and ensured nurses were notifying the Physician and Registered Dietician (RD) for orders if the residents were unable to orally consume adequate fluids due to the GI Illness. Continued interview revealed it was her expectation the nurses notify the Physician of changes in condition and decreased fluid intake. Further, the Comprehensive Care Plans (CCPs) should have been revised to include interventions to promote fluid intake, and the Acute Care Plans should have been initiated related to the acute GI illness. Additional interview revealed it was her responsibility to monitor the meal consumption and fluid sheets, and she normally reviewed them weekly; however, she had not been reviewing these records during the GI outbreak. Further, the facility typically held a monthly nutritional at risk meeting to discuss residents who had been identified to have nutrition/hydration concerns; however, the last meeting was held on [DATE], prior to the GI illness outbreak and therefore residents who had the GI illness were not discussed in the meeting. Additional interview with the DON, revealed the facility did not have a system in place to monitor the residents' hydration status and if a system had been in place, this could have potentially prevented hospitalization and death of the residents. Interview with the Physician/Medical Director, on [DATE] at 5:10 PM, revealed he had only been notified of two (2) or three (3) residents exhibiting signs and symptoms of the illness, and had not been notified half of the total resident census in the building had symptoms of GI illness. Additional interview revealed it was his expectation for staff to monitor the hydration status of the residents and to notify the Physician if fluid intakes were low, if the residents were exhibiting signs and symptoms of dehydration, or if there was a change in a resident's condition, in order for a decision to be made related to treatment. Additional interview revealed staff should have monitored the residents who showed symptoms of the [MEDICAL CONDITION] closely, as it was better to be hypervigilant than no measures be taken. Furthermore, he stated the facility should have followed all the HD recommendations as well as facility policies related to infection control in an attempt to prevent the transmission of the disease. 2. Review of the facility General Policy Department: Infection Control Policy, undated, revealed the infection control program is ongoing to provide a safe and sanitary environment for all residents, personnel, visitors, volunteers, vendors and other guests. The infection prevention/control program is created through education, prevention, surveillance, investigation, identification, control and reporting of organisms, and is based on standard and transmission-based precautions as well as hand hygiene. Continued review revealed it shall be the responsibility of each Department Head, or designee, to assure that all infection control policies and procedures are implemented and followed as necessary. Further review revealed the Director of Nursing (DON), or designee, shall notify all necessary personnel of any extended precautions and enforce these implementations as needed. Per Policy, the education program and policies/procedures shall reflect updated information and guidelines of the Center for Disease Control, the local health department and state and federal regulations, including but not limited to standard precautions, transmission-based precautions, and hand hygiene. Further review of the Policy, revealed there are guidelines for admissions, staff employment, education and investigation of infections/diseases within the facility, as well as a committee that provides guidance for the program. On [DATE], the facility identified three (3) residents with Gastrointestinal (GI) signs and symptoms (S/S), and on [DATE], the Health Department (HD) was notified related to additional residents identified with GI S/S. Although the HD visited the facility on [DATE] and made recommendations to contain the spread of the disease, observation, staff interview, and record review revealed facility failed to consistently implement the HD recommendations in order to ensure the disease was contained and not transmitted to other residents. The HD recommendations were not consistently followed related to closing the facility to new admissions until seven (7) days after the last onset of illness; ensuring ill employees stayed home for three (3) days after the symptoms of their illness had resolved; stopping communal activities; avoiding sharing staff members between units with symptomatic patients; placing STOP signs at every entrance; limiting visitors from coming in and warning them of the outbreak; implementing environmental disinfecting/sanitizing with a bleach solution as outlined in the Norovirus Outbreak Guide; placing contact Personal Protective Equipment (PPE) outside every symptomatic resident's room; and collecting stool samples to be tested as soon as possible. Furthermore, the facility failed to ensure necessary personnel were notified of any extended precautions and ensure these precautions were enforced, as per facility policy. Interview with the Infection Control Nurse (ICN), on [DATE] at 11:20 AM and 3:27 PM, [DATE] at 10:11 AM, [DATE] at 9:45 AM, 10:10 AM, and 5:45 PM, and [DATE] at 8:27 AM, revealed on [DATE], she learned of three (3) cases of excessive diarrhea. She stated she met with the DON to discuss how to proceed related to the concern and the DON told her to figure it out as she was the Infection Preventionist. Further interview revealed the facility did not have an infection control committee and she contacted the Health Department (HD) on [DATE] (per the HD, the initial contact was [DATE]) and the HD staff sent her a packet on what to do and advised her there had been Norovirus in the area. Continued interview revealed she sent the HD Recommendations per email on [DATE] at 6:13 PM, to the Department Heads, Administrator, Assistant Administrator, DON, Nurse Manager, Dietitian, Dietary Manager, Dietary Supervisor, and Environmental Services Director, as each department head was responsible for their own staff. The ICN stated she was informed by the facility management that she should not have contacted the HD after the outbreak of the GI symptoms. However, she further stated reporting was required per regulation and she needed guidance from the HD. Further interview with the ICN, revealed she acknowledged the facility did not consistently follow all the [DATE] HD recommendations. She stated as ICN, she should have been directing the nursing department as well as all other departments in maintaining infection control measures in order to prevent the transmission of infection. However, she stated she was just one (1) person, and did not receive the support needed from administrative staff nor did she have authority over all departments to ensure all HD recommendations were followed. Per interview, approximately forty-seven (47) residents were placed on isolation precautions due to GI signs/symptoms from [DATE] through [DATE]. Interview with the DON on [DATE] at 3:27 PM, [DATE] at 4:15 PM, [DATE] at 11:35 AM, and [DATE] at 4:00 PM, revealed on [DATE] the HD made recommendations to prevent the spread of infection related to the GI outbreak. The DON stated, although she received an email on [DATE] related to the recommendations, she did not ensure the nursing department consistently followed the recommendations related to collecting stool samples to be tested ; ensuring there were no new admissions until seven (7) days after the last onset of illness; ensuring ill employees stayed home for three (3) days after the symptoms of their illness had resolved; stopping communal activities as well as communal dining; avoiding sharing staff members between units; placing STOP signs at every entrance; limiting visitors from coming in and warning them of the outbreak; ensuring Personal Protective Equipment (PPE) and isolation carts were outside every symptomatic resident's room; educating staff on PPE; and ensuring nursing staff was cleaning surfaces contaminated with vomitus or stool with the appropriate cleaning kit. However, she stated as DON, she should have ensured oversight related to infection control measures and ensured all HD recommendations were followed in an attempt to prevent the spread of infection. Further interview revealed failure to ensure facility infection control policies and HD recommendations were followed may have contributed to the transmission of infection during the GI outbreak. Observation of the bleach solution system pump, in the Housekeeping area, on [DATE] at 12:15 PM, revealed the Kitchen Sanitation Company Regional Technician tested the solution from the pump at 100 PPM; therefore, the Table 1: Bleach Dilutions included in the Kentucky Public Health Norovirus Outbreak Response Guide was not followed. Interview with the Kitchen Sanitation Company Regional Technician during the observation revealed the facility wanted the solution at ,[DATE] PPM, and the pump was set for 100 to 200 PPM. He further stated he was unaware of the HD recommendations for the bleach solution to be at higher PPM. Per interview, this pump was installed in the Housekeeping area toward the beginning of [DATE]. Interview with the Environmental Services Director, on [DATE] at 3:25 PM, revealed she was never advised on the bleach concentration levels. She stated she did not receive any documentation regarding bleach concentrations, nor did she receive the Norovirus Outbreak Guide. Additional interview revealed a bleach solution system pump was installed in the housekeeping area towards the beginning of [DATE]. However, she stated she was not told anything about testing the solution when the pump was installed, nor had she been told anything about testing the solution to this date. Continued interview revealed there was no system in place to ensure environmental services were cleaning the environment per HD recommendations in order to prevent the spread of infections. Per interview, all information regarding cleaning and bleach concentration recommendations should have been shared with all departments from the beginning. 3. Review of the Cleaning/Sanitation/Care of Dietary Equipment Department: Dietary Infection Control Policy, effective [DATE], revealed a properly scheduled and carefully monitored program of equipment care and cleaning ensures adequate sanitation and maintenance of the dietary department. Further review revealed the Dietary Director and Supervisors are responsible for supervising all sanitation and housekeeping procedures within the dietary department. The Dietary Director develops a cleaning schedule and is responsible for seeing that it is followed. Checklists and quality assurance monitors provide an efficient method for doing this. The Dietary Director is responsible for supervising and training all personnel in proper cleaning and sanitation procedures for all dietary equipment. The procedures for washing and sanitizing all silverware, china, pitchers and glasses are developed and posted in the kitchen. Temperatures for the dish machine are recorded daily. On [DATE], the HD made dietary sanitation recommendations to prevent the transmission of the GI outbreak which included sanitizing solution using bleach with chlorine levels one hundred-fifty (150) to two hundred (200) Parts per Million (PPM). However, observation of the kitchen on [DATE], revealed two (2) sanitation buckets tested at seventy-five (75) to one hundred (100) PPM. In addition, observation on [DATE] of the two (2) sanitation buckets containing bleach solution in the kitchen revealed test results of ten (10) PPM and twenty-five (25) PPM. Furthermore, observation on [DATE] on the Memory Care/St. Francis Unit, revealed the sanitation bucket bleach solution was observed with zero (0) PPM on the test strip. Moreover, facility policies were not implemented related to ensuring dish machines were reaching proper temperature and silverware was washed three (3) times in the correct manner. Observation on [DATE], revealed the Temp Thermo Label applied to a dish to test the internal kitchen dish machine water temperature did not reach one hundred sixty (160) degrees Fahrenheit. Additionally, observation on [DATE] of the dish machine on the Memory Care/St. Francis Unit, revealed the Temp Thermo Label did not reach one hundred sixty (160) degrees Fahrenheit with two (2) different tests, and brown flecks were observed in a bowl after the dishwashing process was complete. Furthermore, review of the Dishwasher Temperature Logs dated [DATE] and [DATE], revealed multiple meals/dates with either low temperatures documented or no documentation of the dish machine temperatures on the logs. In addition, interviews with Dietary Staff revealed silverware was not washed/sanitized three (3) times, as per policy. Additionally, there was no documented evidence the facility trained all dietary employees on the use of the new dishwashers when they were installed in October, 2019 and no documented evidence the facility policy was revised related to the proper use of the equipment. Interview with the Registered Dietitian (RD), on [DATE] at 10:57 AM, on [DATE] at 4:51 PM, and post survey phone interview on [DATE] at 3:59 PM, revealed on [DATE], the HD Staff visited the facility regarding the GI outbreak and made verbal recommendations for bleach sanitizing solution due to suspicion of Norovirus, as the quad sanitizer the facility typically used was not effective against this virus. The RD further stated after she received the HD recommendations, she provided a quick inservice to all dietary staff on [DATE], regarding how to fill one (1) of the compartments on the sink with water and add one (1) capful of bleach to make the proper concentration, and also demonstrated how to test the solution with the test strips to ensure the solution was 200 PPM. She further stated her inservice included the need to change the sanitizer solution every four (4) hours and the need to check the sanitizing solution at each shift/meal. However, the RD stated this was not a formal inservice and there was no documentation related to the inservice. Further, there was no documented evidence of monitoring dietary staff to ensure the HD recommendations were followed related to using the correct bleach sanitizer, testing the sanitizing solution and ensuring the sanitation buckets were changed out every four (4) hours. Per interview, on [DATE] the HD visited and identified concerns related to the HD recommendations for dietary sanitation not being followed, and further education was completed with Dietary Staff by the Dietary Manager. Interview with the Dietary Manager, on [DATE] at 1:47 PM, [DATE] at 9:00 AM and 4:20 PM, [DATE] at 4:04 PM, revealed he provided additional training to dietary staff from [DATE] through [DATE], after it was identified by the HD on [DATE], there was ongoing issues related to dietary sanitation. He stated bleach solution system pumps set at 200 PPM were installed in the kitchen towards the beginning of [DATE], and these pumps automatically dispensed the correct bleach sanitation solution and staff no longer had to mix the bleach and water in the three (3) compartment sink for the sanitizing buckets. Additional interview revealed staff had not been labeling and dating the sanitation buckets when the water was changed out, nor was there a policy related to how often the water in the buckets was to be changed. In addition, he stated staff had not been documenting testing of the sanitation solution. Continued interview revealed the facility did not have a written policy regarding sanitation buckets or documented evidence of monitoring to ensure the sanitizer was at the appropriate level, and therefore there was no way to verify the system was working as far as using the sanitizer correctly. Continued interview with the Dietary Manager, revealed all the facility dish machines used heat sanitation, detergent and rinse aide for washing. Per interview, the dish machine temperature should be one hundred fifty (150) degrees Fahrenheit, and the rinse temperature should be one hundred eighty (180) degrees Fahrenheit. Further interview revealed the logged temperatures for ,[DATE] and ,[DATE] were hit and miss and without documenting the temperatures, there was no way of knowing if the machines reached the proper temperature to ensure sanitation. Further interview with the Dietary Manager, revealed the HD identified during their visit on [DATE], there was a difference in the temperature of the water inside the dish machine during wash and rinse cycles as compared with the digital reading on the outside of the dish machines for the dish machines on the nursing units. He stated the machines were then serviced to raise the pressure of the machines related to the discrepancy in water temperatures. Per interview, the Temp Thermo Label was applied to a dish prior to the dish cycle and the heat sanitizing should cause the Temp Thermo Label test tapes to reach one hundred sixty (160) degrees Fahrenheit to verify the machines were working properly on the inside and to ensure sanitizing at one hundred sixty (160) degrees Fahrenheit or above for all dish machines. He stated he had been testing the dish machines since the HD visit on [DATE] with the Temp Thermo Label test tapes and had been getting one hundred percent (100%) compliance; however, there was no documented evidence of testing the dish machine water temperatures using the Temp Thermo Label test tapes. Additional interview with the Dietary Manager, revealed the under the counter dish machines were installed prior to his working at the facility, and he was unable to find a policy related to these dish machines, which were installed in October, 2019. Continued interview revealed he could find no documented evidence dietary staff were trained on the use of the new dish machines. Further interview revealed he had only been employed at the facility since [DATE], and had not yet reviewed the facility dietary policies and was unaware silverware was not washed as per policy. Interview with the Administrator, on [DATE] at 1:15 PM, [DATE] at 8:30 AM and [DATE] at 6:26 PM, revealed it was her expectation the facility Hydration Policy was followed. She stated residents who were ill with the GI illness should have been closely assessed, and monitored in an attempt to prevent dehydration. She further stated there should have been care plan revisions to include interventions to promote fluid intake for residents related to the GI illness symptoms. However, she stated documentation revealed residents were not assessed and monitored for signs and symptoms of dehydration, nor were interventions implemented to ensure residents received sufficient fluid intake during the GI outbreak. Further, the Physician was not notified of all residents who were ill with the GI symptoms in order for necessary treatment to be provided, nor was the Physician notified when residents were not receiving sufficient fluid intake. She acknowledged there were several hospitalization s and also residents declined related to dehydration. The Administrator stated she was not aware of any system in place to monitor the hydration status of the residents who became ill with the GI illness. Further interview revealed there were gaps in the care provided and in documentation and there should have been oversight by Administrative Staff to ensure residents received necessary care related to the GI outbreak. Additional interview with the Administrator, revealed when the HD visited on [DATE], after the GI illness outbreak, the HD gave the facility staff a sheet on how to mix the water and bleach solution for sanitizing in the kitchen/dietary and for environmental cleaning in order to kill the Norovirus. She stated at the beginning of [DATE], the facility bleach solution system pumps were installed, one (1) in the kitchen and one (1) in the Housekeeping area, which was to register the correct amount of sanitizer in order to kill the Norovirus. She further stated she was unaware the bleach solution system pump in the Housekeeping area was not at the correct sanitizing level. Further interview revealed Administrative Staff should have ensured the Nursing Units and Environmental Services staff was informed of all HD recommendations related to cleaning in order to ensure cleaning agents were effective against organisms including the Norovirus. Further interview with the Administrator, revealed it was her expectation HD recommendations were implemented related to ensuring the correct bleach sanitizing solution was used in the sanitation buckets in order to prevent the transmission of disease and infection. However, she stated she was unaware of any monitoring system in regards to ensuring the sanitizing bleach solution in sanitation buckets was at the correct sanitation level or ensuring the sanitation bucket solution was changed out at certain intervals. Additional interview revealed it was her expectation staff follow facility polices regarding dish machine temperatures and washing of silverware. Per interview, staff should be logging dish machine temperatures after each meal and there should have been monitoring to ensure dish machine temperatures were high enough to be effective to sanitize dishware. Further, she was unsure if anyone educated the Dietary Aides related to use of the new dish machines installed in [DATE] and unable to submit any formal training for review related to the new dish machines. She further stated she was unaware until this week that dietary staff was not following facility policies related to the dish machines and washing of silverware. Additional interview with the Administrator, revealed it was her responsibility to ensure oversight of the facility. She stated she should have ensured necessary personnel were notified of any extended precautions related to the GI outbreak and ensured these precautions were enfor (TRUNCATED)

Based on observation, interview, record review, review of facility policy, and review of Health Department recommendations, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections. On 12/17/19, the facility identified three (3) residents with Gastrointestinal (GI) signs and symptoms (S/S). On 12/19/19, additional residents were identified with GI S/S and the Health Department (HD) was notified. On 12/19/19, the HD entered the facility and made recommendations to contain the spread of the disease including closing the facility to new admissions until seven (7) days after the last onset of illness; ensuring ill employees stayed home for three (3) days after the symptoms of their illness had resolved; stopping communal activities; avoiding sharing staff members between units with symptomatic patients; placing STOP signs at every entrance; limiting visitors from coming in and warning them of the outbreak; implementing environmental disinfecting/sanitizing with a bleach solution as outlined in the Norovirus Outbreak Guide; and placing contact Personal Protective Equipment (PPE) outside every symptomatic resident's room. In addition, the HD recommended stool samples to be collected and tested as soon as possible as this would help determine more agent related recommendations. However, the facility failed to consistently implement these Health Department recommendations in order to ensure the disease was contained and not transmitted to other residents. Furthermore, the facility failed to ensure necessary personnel were notified of any extended precautions and ensure these precautions were enforced, as per facility policy. Approximately forty-seven (47) residents were placed on isolation precautions due to GI signs/symptoms from 12/19/19 through 01/16/2020, per the documentation provided by the Infection Control Nurse on 01/17/2020 at 8:27 AM. The facility's failure to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/17/2020, and determined to exist on 12/19/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 01/29/2020 alleging removal of the Immediate Jeopardy on 01/30/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 02/01/2020, prior to exit on 02/01/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F-812 F-692 and F-835) The findings include: Review of the facility General Policy Department: Infection Control Policy, undated, revealed the infection control program is ongoing to provide a safe and sanitary environment for all residents, personnel, visitors, volunteers, vendors and other guests. The infection prevention/control program is created through education, prevention, surveillance, investigation, identification, control and reporting of organisms, and is based on standard and transmission-based precautions as well as hand hygiene. Continued review revealed it shall be the responsibility of each Department Head, or designee, to assure that all infection control policies and procedures are implemented and followed as necessary. Further review revealed the Director of Nursing (DON), or designee, shall notify all necessary personnel of any extended precautions and enforce these implementations as needed. Per Policy, the education program and policies/procedures shall reflect updated information and guidelines of the Center for Disease Control, the local health department and state and federal regulations, including but not limited to standard precautions, transmission-based precautions, and hand hygiene. Further review of the Policy, revealed there are guidelines for admissions, staff employment, education and investigation of infections/diseases within the facility, as well as a committee that provides guidance for the program. Review of the facility Transmission Based Isolation/Operational Procedures Department: Infection Control, undated, revealed the facility has established Transmission Based Isolation Procedures for the prevention and transmission of infectious/communicable diseases found within our facility. Further review revealed Transmission Based Isolation Procedures shall be used to maintain a safe, sanitary environment, and to prevent spread of infection and disease to other residents, personnel, volunteers, visitors and the general public. The Director of Nursing, or designee, shall be responsible for organizing and directing the functions of the Transmission Based infection Control Policies and Procedures when transmission based isolation becomes necessary. Continued review revealed the Charge Nurse of each unit shall be responsible for carrying out all functions of the transmission procedures as directed, including supervision of personnel and assuring all personnel and visitors follow transmission based procedures as established by this facility as well as any special instructions that may be issued. If the charge nurse has reason to believe that a resident has an infection or communicable disease, the Director of Nursing or Shift Supervisor shall be consulted, and if there is sufficient reason, the Attending Physician shall be contacted and informed of the condition. The physician's orders [REDACTED]. The resident shall be moved to the designated isolation room if needed and isolation procedures implemented if warranted by facility protocol. Review of the facility Housekeeping Services Department Environmental Services Housekeeping Policy, undated, revealed it is the policy of the Housekeeping Department to maintain a clean, safe and sanitary environment at all times following the Infection Control Committee Guidelines. Further review revealed the Director of Environmental Services and Housekeeping staff meet regularly to in-service on the policies and procedures regarding the facility. Continued review of the Policy, revealed with housekeeping methods, materials and machines changing at an ever-accelerating pace, the people using them must keep current in their specialties. This is accomplished through in-service and on-the-job instruction. Interview with the Infection Control Nurse (ICN), on 01/14/2020 at 10:26 AM and 01/15/2020 at 9:45 AM, revealed she received a call from the Nurse Manager, who was over all the units on 12/17/19, stating there were three (3) cases of excessive diarrhea, and was advised the physician had ordered [MEDICAL CONDITIONS] testing ([MEDICAL CONDITION] is a bacterium that causes diarrhea). Further interview revealed she attempted to discuss how to proceed related to the concern with the DON, who told her to figure it out as she was the Infection Preventionist. Continued interview revealed the facility did not have an infection control committee and each department head was responsible for their own staff. She stated she contacted the Health Department (HD) on 12/18/19 (per the HD, the initial contact was 12/19/19) and the HD staff sent her a packet on what to do and advised her there had been Norovirus in the area. Continued interview revealed she sent the HD Recommendations per email on 12/19/19 at 6:13 PM, to the Department Heads, Administrator, Assistant Administrator, DON, Nurse Manager, Dietitian, Dietary Manager, Dietary Supervisor, and Environmental Services Director. The ICN stated she was told by the facility management that she should not have contacted the HD after the outbreak of the GI symptoms. However, she stated reporting was required per regulation and she needed guidance from the HD. Review of the Health Department (HD) Time Line, revealed a site visit from the HD occurred on 12/19/19 and the ICN was given a copy of the Kentucky Public Health Norovirus Outbreak Response Guide. All outbreak precaution measures were discussed verbally with the ICN, stressing emphasis on having ill employees stay home for seventy (72) hours after the resolution of symptoms. The ICN expressed three (3) major concerns to the HD staff including: 1) Environmental services only cleaned the facility once daily and did not clean more frequently during times of increased illness; 2) the facility did not stock enough isolation supplies (gowns, gloves, masks, etc) and was refusing to let her order more, and 3) the facility did not keep good records of employee call offs as an employee could call in sick, but did not have to explain their symptoms. The ICN was advised Environmental Services should be cleaning more and using a bleach solution as outlined in the Norovirus Outbreak Response Guide. The HD recommended testing ill patients by sending a sample to the Kentucky Department of Laboratory Services (DLS); and re-educating employees related to hand washing. HD staff also explained to the ICN, the importance of keeping good records of employee call offs, and the ICN responded the facility would call all employees who were listed sick on the call log to see what symptoms they had. Review of the Health Department Recommendations, sent via email to the Infection Control Nurse, titled GI Illness Outbreak, dated 12/19/19 at 2:11 PM, revealed the following: *The facility will need to close to new admissions until seven (7) days after the last onset of illness *Ill employees need to stay home for three (3) days after the symptoms of their illness have resolved *Communal activities need to be stopped including, but not limited to physical therapy and dining. If physical therapy is warranted, it must be done in the patient's room or conducted in a common space, one (1) patient at a time, with a thorough cleaning between patients *Avoid sharing staff members between units with symptomatic patients with units that are absent of illness *Place STOP signs, masks, and hand sanitizer at every entrance *Prohibit any symptomatic visitors or children twelve (12) years of age or under from entering the facility *Limit other visitors from coming in and if they persist, warn them of the outbreak *Implement extra environmental disinfecting/sanitizing *Place contact Personal Protective Equipment (PPE) outside every symptomatic patient's room Continue review of the Health Department Recommendations, revealed the HD wanted stool samples to be collected and tested as soon as possible as this would help determine more agent related recommendations. Per the HD, the facility was to send an updated line list daily or whenever there was a new case until the outbreak was deemed over (a line list is the list of residents with GI symptoms). Review of the email titled Training/Inservices/Health Department Mandate dated 12/19/19 at 6:13 PM, sent from the Infection Control Nurse (ICN) to Department Heads, to include Administrator, Assistant Administrator, Director of Nursing (DON), Nurse Manager, Dietitian, Dietary Manager, Dietary Supervisor, and Environmental Services Director, revealed it contained the same HD recommendations sent via email to the ICN; however, it excluded the following measures: Implement extra environmental disinfecting/sanitizing and Place contact PPE (Personal Protective Equipment) outside every symptomatic patient's room, and stool samples to be collected and tested as soon as possible. Further review revealed the recommended plan above was to be put into effect immediately and there would be more discussion at the Friday Morning Meeting (12/20/19). On 01/15/2020 at 4:15 PM, the Surveyor requested the minutes of the staff meeting held 12/20/19, and was advised by the DON, the facility did not retain written minutes of the meeting. Review of the Health Department (HD) Time Line, revealed on 01/02/2020, the facility Infection Control Nurse called the HD and reported an increase of GI illness circulating around the building with five (5) residents ill on one (1) unit and two (2) residents ill on another unit as well as about five (5) employees were ill. Further review revealed the HD emailed a list of Outbreak control measures with attachments of STOP signs, a Norovirus Fact Sheet, and a letter regarding GI illness outbreaks in Long Term Care Facilities and line lists for residents and employees. 1. The facility failed to implement the 12/19/19 HD recommendations related to collecting stool samples as soon as possible in order to help determine more agent related recommendations. Interview with the ICN, on 01/14/2020 at 10:26 AM and 11:20 AM and 01/15/2020 at 9:45 AM, revealed she spoke with the facility Physician/Medical Director (date unknown), and requested intermittent testing for residents in order to find out if the facility did in fact have Norovirus as per the HD staff's request on 12/19/19. Per interview, up to that point only a few residents with diarrhea had been tested for [MEDICAL CONDITION] and they were reported negative. The ICN stated she received approval to send random stool samples for Norovirus testing, and she verbally told nurses on the units to collect the samples, and also placed the information on the Communication Board in the Electronic Health Record (EHR) system (date unknown). However, further interview revealed there was no documented evidence of a stool sample sent to test for Norovirus until ten (10) days after the recommendation when a stool sample was collected for Resident #2 on 12/29/19, which indicated positive results for Norovirus on 01/01/2020. Record review revealed as of 01/02/2020, there was a total of only six (6) residents who had stool samples tested after Resident #2 was tested . Resident #4 tested positive for Norovirus on 1/10/2020; Resident #10 tested positive for Norovirus on 01/17/2020; Resident #12 tested positive for Norovirus and [MEDICATION NAME] e-coli on 01/23/2020; and two (2) unsampled residents tested negative for Norovirus on 01/09/2020. Review of the EHR Communication Board, revealed no documented evidence of instructions to collect stool samples for Norovirus testing entered until 12/24/19 at 11:17 AM, when there was communication from the ICN to collect stool samples for residents with sign and symptoms of nausea, vomiting, and diarrhea and test for Norovirus, as this had been approved by the Physician on 12/19/19. Further review of the EHR Communication Board, revealed documentation dated 01/08/2020 by Licensed Practical Nurse (LPN) #6, stating any resident that had loose stool needed a specimen collected. Please label the specimen with the following: Name, Date of Birth, Date collected and time collected. These samples will be collected by the Health Department. Do not send to our lab. Once collected please place in refrigerator and let the DON, ICN, or Nurse Manager know it was collected and the HD will be called for pick up. This same message was entered in the EHR Communication Board on 01/12/2020, by another nurse. Interview with Registered Nurse (RN) #3, on 01/17/2020 at 12:22 PM, revealed she typically worked the St. Joseph Unit. Further interview revealed in the beginning there were not many stool samples collected. She further stated she did not remember seeing a message on the EHR Communication Board around the date of 12/19/19, regarding obtaining stool samples. Per interview, she was recently told to obtain stool samples and was given names of the residents by the Infection Control Nurse and Nurse Manager. Interview with the Physician/Medical Director, on 01/17/2020 at 5:10 PM, revealed he was aware there were GI issues in the facility and stool samples tested for [MEDICAL CONDITION] were negative. Further interview revealed the ICN informed him (date unknown) the HD required testing and he told her if the HD required it, the testing would need to be done. Interview with the DON, on 01/17/2020 at 4:00 PM, revealed the HD asked for the stool sample testing as per their recommendations on 12/19/19. However, she stated she was unaware if the message was entered on the EHR Communication Board, and thought the request for stool samples was communicated verbally by the ICN to the nurses on the units. Per interview, stool samples should have been collected as per the HD recommendations and there should have been follow up to ensure this recommendation was followed. Interview with the Administrator on 01/13/2020 at 1:15 PM, and 01/14/2020 at 8:30 AM and 01/17/2020 at 6:26 PM, revealed she was aware of the HD recommendations for stool samples to be collected due to the GI illness in the building; however, was unaware they were not collected timely. Continued interview revealed it was important for nursing staff to follow the HD recommendations and she was unsure why there was a delay in collecting the samples. 2. The facility failed to implement the HD recommendations from the Kentucky Public Health Norovirus Outbreak Response Guide, related to instructions for the the amount of bleach and water to combine for the approximate Parts per Million (PPM), for cleaning surfaces. Review of the Kentucky Public Health Norovirus Outbreak Response Guide, under Table 1: Bleach Dilutions, provided to the facility by the HD on 12/19/19, revealed instructions for the the amount of bleach and water to combine for the approximate Parts per Million (PPM), the application/type of surface to be cleaned, and the suggested cleaning method. The suggested cleaning method for non porous surfaces such as handrails, tile floors, countertops, sinks, toilets, doorknobs and other commonly handled items that were visibly soiled with vomitus or feces (surfaces not likely to have food or mouth contact) was to clean surfaces with soap and water, rinse with clean water and dry towel, then spray with bleach solution with 1/4 (one fourth) cup bleach to one (1) gallon water for approximately 800 PPM or 1/3 (one third) cup bleach per one (1) gallon water for approximately 1000 PPM and allow to air dry. Additional review revealed for food/mouth contact items, stainless steel, and toys mouthed by children, clean surfaces with soap and water, rinse with clean water and dry towel, then spray with bleach solution with two (2) teaspoons bleach per one (1) gallon water for approximately 200 PPM or one (1) tablespoon bleach per one (1) gallon water for approximately 200 PPM and allow to air dry. Review of the Health Department (HD) Time Line, revealed observation on 01/02/2020, during the HD site visit at the facility, the HD staff spoke briefly with the Director of Environmental Services about outbreak cleaning procedures to which she couldn't respond off the top of her head, but provided HD staff with the cleaning product information sheets. HD staff observed the facility staff using a basic cleaner that was not able to kill Norovirus in the facility outside the kitchen. Staff was again instructed to use the appropriate bleach solution to clean and disinfect the entire facility. Further review revealed the HD sent another email on 01/03/2020 to the DON and ICN which included all outbreak prevention measures. Review of an email sent by the HD to the facility DON and ICN, on 01/09/2020 at 2:23 PM, revealed the facility needed to ensure extra environmental cleaning was being done using a bleach solution. Per review, the facility had advised the HD that a new cleaning/disinfecting product had been ordered, but a bleach solution needed to be used in the interim. Continued review revealed all of these practices need to be conducted in conjunction with the prevention and control measures that were provided to the facility on [DATE] and 01/02/2020. Observation of the bleach solution system pump, in the Housekeeping area, on 01/14/2020 at 12:15 PM, revealed the Kitchen Sanitation Company Regional Technician tested the solution from the pump at 100 PPM, thus the Table 1: Bleach Dilutions included in the Kentucky Public Health Norovirus Outbreak Response Guide was not followed. The Kitchen Sanitation Company Regional Technician stated the facility wanted the solution at 100-200 PPM, and the pump was set for 100 to 200 PPM. He stated he was unaware of the HD recommendations for the bleach solution to be at higher PPM. Per interview, one (1) bleach solution system pump was installed in the kitchen and one (1) was installed in the Housekeeping area toward the beginning of January 2020. Further interview revealed he was unsure if the sanitizer in the pumps was monitored for the correct PPM. Review of the Kitchen Company Accounts Service document, dated 01/03/2020, revealed two (2) Hydro Streamline sanitation dispensers were installed. Interview with Housekeeping Aide #1, on 01/16/2020 at 8:21 AM, revealed she typically worked on St. Therese Unit, but today was working on on the St. Joseph Unit. Further interview revealed she was to sanitize her cart and wash her hands prior to moving from one unit to another. She stated she used a bleach solution for cleaning and disinfecting which she obtained from the bleach solution system pump in the Housekeeping area. She further stated she changed the solution each morning, midday, and at the end of the day. Per interview, prior to the facility obtaining the solution from the bleach solution system pump in the Housekeeping area, she used a yellow colored peroxide multi surface cleaner. Interview with Certified Nursing Assistant (CNA) #2, on 01/16/2020 at 8:33 AM, revealed she had not received specific instructions on how to clean up vomitus, other than to clean up as much as possible and then contact housekeeping to sanitize. Observation on 01/16/2020 at 10:50 AM, revealed MicroKill wipes in the isolation cart on the St. Joseph Unit; however, the label on the container did not indicate the product was effective against Norovirus. Interview with CNA #2 during the observation, revealed staff used the wipes to clean bowel movement and then asked housekeeping to further sanitize the area. Interview with the ICN, on 01/16/2020 at 9:45 AM and 10:54 AM, revealed she reviewed the container of MicroKill wipes and stated the documentation on the label did not indicate it would kill Norovirus. The ICN stated the facility was supposed to be using bleach solution. Per interview, the facility was advised from the HD staff to use bleach solution or an Environmental Protection Agency (EPA) approved cleaner and there were specified lengths for solutions to remain on the surface being cleaned. Continued interview revealed even though there were recommendations on 12/19/19 from the HD for cleaning with a dilution of bleach, she was aware housekeeping had been using a peroxide cleaner to spray and wipe, prior to 01/02/2020, which would not be appropriate to kill [MEDICAL CONDITION]. Interview with the DON, on 01/14/2020 at 4:45 PM and 01/17/2020 at 4:00 PM, revealed the HD was at the facility on 12/19/19, and recommended cleaning with bleach and provided instructions on how the bleach water was to be mixed. Per interview, the HD visited again on 01/09/2020, and provided a document on how to clean and mix bleach. Further interview revealed she and the ICN received an email from the HD on 01/09/2020 to reiterate the need for environmental cleaning to be done with a bleach solution and to ensure the prevention and control measures that were provided to the facility on [DATE] and 01/02/2020 were followed. Further interview revealed there should have been a system in place for the Environmental staff to monitor the bleach solution to ensure the solution was at the appropriate PPM in order to prevent transmission of organisms. Continued interview revealed there were special kits to clean up vomit/diarrhea and she did update the EHR Communication Board for nursing staff on 01/09/2020 related to instructions for cleaning. Review of the EHR Communication Board, revealed the DON left instructions on 01/09/2020 for the nursing staff to use the vomit/diarrhea clean up kits which had been placed in every medication room. Interview with the Environmental Services Director, on 01/16/2020 at 3:25 PM, revealed she received the email from the Infection Control Nurse, on 12/19/19, and had environmental services do extra cleaning to include door knobs, door handles, call lights, public restrooms and toilets, and residents in isolation had their rooms cleaned twice a day. However, she stated prior to 01/03/2020, the Housekeepers were cleaning with a peroxide based cleaner instead of the recommended bleach and water concentration. Further, she stated she was never advised on the bleach concentration levels, as she did not receive any documentation regarding bleach concentrations, nor did she receive the Norovirus Outbreak Guide. Further interview revealed a bleach solution system pump was installed in the housekeeping area towards the beginning of January 2020. However, she stated she was not told anything about testing the solution when the pump was installed, nor had she been told anything about testing the solution to this date. Further interview revealed there was no system in place to ensure environmental services were cleaning the environment per HD recommendations in order to prevent spread of infections. Additional interview revealed all information regarding cleaning and bleach concentration recommendations should have been shared with all departments from the beginning. Review of the Spot Inservice Record, dated 01/06/2020 at 3:00 PM, provided by the Infection Control Nurse, revealed the subject of the inservice was cleaning products. Per the inservice, staff was to clean with bleach 1/3 (one third) cup bleach to one (1) gallon water. However, only six (6) nursing staff signed as receiving the education; and there was no documented evidence of further education with other nursing staff. In addition, there was no documented evidence of education related to environmental cleaning using a bleach sanitizer with Environmental housekeeping staff. Interview with the Administrator, on 01/14/2020 at 8:30 AM and 01/17/2020 at 6:26 PM, revealed when the HD came on the first visit (12/19/19), after the GI illness outbreak, the HD gave the facility staff a sheet on how to mix the water and bleach solution for sanitizing in the kitchen/dietary and for environmental cleaning in order to kill the Norovirus. Per interview, at the beginning of January 2020, the facility had the Kitchen Sanitation Company Regional Technician install bleach solution system pumps, one (1) in the kitchen and one (1) in the Housekeeping area, which was to register the correct amount of sanitizer in order to kill the Norovirus. She stated she was unaware the bleach solution system pump in the Housekeeping area was not at the correct sanitizing level, and was unaware nursing staff was using MicroKill wipes to clean surfaces which was not effective against the Noravirus. Further interview revealed the Nursing Units and Environmental Services should have been fully informed of all HD recommendations related to cleaning and should have implemented these recommendations in order to ensure cleaning agents were effective against organisms including the Norovirus. 3. The facility failed to implement the 12/19/19 HD recommendations related to closing the facility to new admissions until seven (7) days after the last onset of illness. Review of Resident #6's medical record revealed the facility admitted the resident on 12/20/19 to the Saint Frances Unit, after the HD recommendation was made to close the facility to new admissions, thus exposing Resident #6 to the GI illness. Review of the line list of residents documenting signs or symptoms of GI illness provided by the facility, revealed Resident #6 was placed on the line list on 01/05/2020, related to having diarrhea for two (2) days. Interview with the ICN, on 01/15/2020 at 10:11 AM, revealed she did not think the facility had any new admissions after 12/19/19. When shown the Roster Matrix provided by the facility indicating Resident #6 was newly admitted to the facility on [DATE], she stated she wasn't aware. Subsequent interview on 01/16/2020 at 10:10 AM, with the ICN, revealed the facility should not have taken any new admissions after 12/19/19 as per the HD recommendations. Interview with the DON, on 01/17/2020 at 4:00 PM, revealed she was aware Resident #6 was admitted after the HD recommended closing the facility to new admissions; however, she thought because the resident was being admitted to the St. Francis Unit, and not being admitted to St. Therese unit where [MEDICAL CONDITION] started, that it would be okay. However, further review of the line list with the DON, revealed two (2) residents were documented on the line lists for having GI symptoms on the St. Francis Unit on 12/19/19, prior to Resident #6 being admitted on [DATE] to that unit. The DON stated the HD recommendations should have been followed related to closing the facility to new admission. Interview with the Administrator, on 01/17/2020 at 6:26 PM, revealed she was aware of the HD recommendations received by the facility on 12/19/19 related to closing the facility to new admissions due to the GI illness in the building. However, she stated the facility did admit Resident #6 on 12/20/19, which was an oversight. She stated some of the interdisciplinary staff did not review the email which included the HD recommendations sent by the ICN on 12/19/19, until the morning of 12/20/19, after Resident #6 was accepted as a new admission. In addition, the facility failed to ensure residents were not moved from one (1) unit to the other during the GI outbreak. Resident #4's closed medical record revealed a Progress Note, dated 12/23/19 at 1:02 PM, revealing it was reported by staff the resident was having loose stools and complaints of nausea and temperature was 97.9 degrees Fahrenheit. Review of the Progress Note, dated 12/28/19 at 10:58 AM, revealed Resident #4 was transferred from the Marian Unit to the St. Joseph Unit on 12/26/19. Interview with the ICN, on 01/16/2020 at 9:45 AM, revealed Resident #4 resided on Marion Unit (Rehab unit) and then moved to St. Joseph Unit on 12/26/19. Per interview, Resident #4 had diarrhea symptoms of GI illness prior to the resident's transfer from Marian Unit to St. Joseph Unit, but it was unknown at that time if the resident had Norovirus. Review of the Laboratory Services Report, date 01/10/2020, revealed Resident #4 tested positive for Norovirus. Further interview with the ICN, revealed the resident moving from one unit to another unit could have been a source of cross contamination. 4. The facility failed to implement HD recommendations from 12/19/19, related to stopping communal activities. Review of the Health Department (HD) Time Line, revealed observation on 01/02/2020, during the HD site visit at the facility, revealed residents were freely roaming around the halls, and there was a group activity of balloon volleyball in one of the activity rooms. One (1) unit of the facility (St Joseph) had been quarantined and the doors to the unit were closed, but the other two (2) units (St.Therese and St Francis) were unrestricted. Further review revealed the HD staff met with the ICN and the DON and went through all outbreak prevention measures and expressed why these measures were important; Observation on 01/16/2020 at 8:10 AM, on the Marian Unit, revealed three (3) residents were in the dining room for breakfast. Interview with Licensed Practical Nurse (LPN) #2, during the observation, revealed the Marion Unit had a census of four (4) residents on the unit. She stated residents on the Marion Unit were allowed to eat in the dining room, but the other units were on quarantine and could not participate in communal activities or eat (TRUNCATED)

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective system to ensure each resident was provided sufficient fluid intake to maintain proper hydration for seven (7) of nineteen (19) sampled residents (Residents #2, #3, #4, #5, #10, #11, #12) during a Gastrointestinal (GI) illness outbreak. Resident #2 exhibited signs and symptoms of a Gastrointestinal (GI) illness including diarrhea starting [DATE], and lab results received on [DATE], revealed positive results for the Norovirus. However, there was no documented evidence interventions were implemented to prevent dehydration. Staff interview and record review revealed the resident's fluid intake was not monitored, nor were hydration assessments completed in order to check for signs and symptoms of dehydration. Furthermore, there was no documented evidence the Physician or Registered Dietician (RD) was notified the resident was not meeting his/her fluid intake from [DATE] through [DATE], with the exception of [DATE], or that the resident had no documented fluid intake from [DATE] through [DATE]. Hospice Care was ordered on [DATE], and the resident expired on [DATE]. Resident #3 did not meet his/her estimated fluid requirement for twenty-four (24) consecutive days from [DATE] through [DATE], had a substantial decrease in fluid intake starting [DATE], and exhibited GI illness signs and symptoms on [DATE], with no documented evidence the Physician was notified. Further, there was no documented evidence the resident's fluid intake was monitored, nor hydration assessments completed in order to check for signs and symptoms of dehydration. In addition, there was no documented evidence the Physician was notified of the resident's decreased fluid intake until [DATE]. On [DATE] orders were received for a Chest X-Ray, labs, antibiotics and a diet change; however, the resident continued to decline and was transferred to the Hospital and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was transferred back to the facility on [DATE], Hospice Care was ordered, and the resident expired on [DATE]. Resident #11 began exhibiting GI illness signs and symptoms on [DATE] including watery diarrhea; however, there was no documented evidence the Physician was notified and no documented evidence interventions were implemented to prevent dehydration. Furthermore, there was no documented evidence the Physician and RD was notified of the resident not meeting his/her estimated fluid requirement from [DATE] through [DATE], and no documented evidence the resident was assessed for signs and symptoms of dehydration, even though the resident was having loose stools and was lethargic. On [DATE], the resident was sent to the Hospital Emergency Department (ED) related to congested cough, sluggish skin turgor and dry mucous membranes. The Hospital Discharge Summary, dated [DATE], revealed the resident was treated for [REDACTED]. The resident returned to the facility on [DATE] and expired on [DATE] Resident #4 started having GI illness symptoms including loose stools and complaining of nausea on [DATE], and record review revealed the resident did not meet his/her fluid requirements from [DATE] through [DATE]. However, there was no documented evidence the resident's fluid intake was monitored, or the resident was assessed for signs and symptoms of dehydration. Furthermore, there was no documented evidence the Physician was notified of the symptoms of GI illness or the Physician and RD was notified of the resident's low fluid intake from [DATE] through [DATE]. On [DATE], the resident was assessed as having increased weakness, increased bilateral lower extremity [MEDICAL CONDITION] and respiratory distress and complained of having diarrhea and feeling miserable. Resident #4 was transferred to the Hospital ED on [DATE], and was admitted and treated for [REDACTED]. Resident #4 was discharged home with orders for Hospice Care on [DATE]. Resident #5 was noted to have a liquid watery stool on [DATE], and on [DATE] had emesis and diarrhea. Record review revealed the resident did not meet his/her fluid requirement from [DATE] through [DATE]. However, there was no documented evidence the resident's fluid intake was monitored, or that the resident was assessed for signs and symptoms of dehydration. In addition, there was no documented evidence the Physician was notified of the loose stools or the Physician or Registered Dietician (RD) was notified of the resident's low fluid intake. On [DATE] the resident was admitted to the Hospital and treated for [REDACTED]. Resident #12 was symptomatic with GI illness, and was having large amounts of watery liquid stools on [DATE]. Record review revealed the resident did not meet his/her fluid requirement for seventeen (17) consecutive days from [DATE] through [DATE]. In addition, a stool specimen collected on [DATE], revealed positive results for Norovirus. However, there was no documented evidence the resident's fluid intake was monitored or the resident was assessed for signs and symptoms of dehydration. In addition, there was no documented evidence the Physician or RD were notified of the resident's low fluid intake, or the Physician was notified of the resident's GI symptoms. On [DATE], the resident was noted to have altered mental status, low oxygen saturation level, low blood pressure, and was assessed as cold, clammy, sweating, and wheezing. On [DATE], the resident was admitted to the Hospital Intensive Care Unit with [DIAGNOSES REDACTED]. Resident #10 was having active symptoms of vomiting and diarrhea beginning on [DATE] and continuing through [DATE], according to the Health Department Surveillance Form, completed by the Infection Control Nurse. The resident did not meet his/her fluid requirement from [DATE] through [DATE], and tested positive for Norovirus on [DATE]. However, there was no documented evidence Resident #10 was placed on Intake and Output in order to closely monitor the resident's fluid intake, and no documented evidence of a hydration assessment completed. Furthermore, there was no documented evidence the Physician was notified of the resident's GI symptoms until [DATE], and no documented evidence the Physician and RD were notified of the resident's low fluid intake until [DATE]. (Refer to F-580, F-657, F-880, and F-835) The facility's failure to have an effective system in place to ensure residents receive sufficient fluid intake to maintain proper hydration caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on [DATE], and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Hydration Policy, undated, revealed it is the policy of Carmel Manor to identify residents exhibiting risk factors which lead to dehydration. For these residents the facility shall develop interventions to provide sufficient fluid intake to maintain proper hydration and health. Further review revealed residents are assessed to identify risk factors for dehydration. Based on the risk factors and clinical condition, interventions shall be developed and implemented to avoid dehydration. Carmel Manor will assess residents with Minimum Data Set (MDS) Assessment changes or significant change of condition to identify newly emerging risk factors for dehydration. Appropriate interventions will be provided as indicated. Additional review revealed the facility will monitor the effectiveness of individual resident's hydration interventions to evaluate effectiveness of plan. Residents will be monitored for signs and symptoms of dehydration on the weekly skin round assessments. The facility will maintain a method of communicating residents recommended fluid needs. The resident's response to interventions will be evaluated and the plan will be revised as indicated. 1. Review of Resident #2's closed medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. During the resident's stay at the facility, he/she resided on St Joseph Terrace unit while a resident at the facility. Review of the Resident #2's Comprehensive Care Plan (CCP), initiated [DATE], revealed a focus of nutritional problem related to [DIAGNOSES REDACTED]. Comfort measures ordered on [DATE]. The goal stated the resident would consume sufficient food/fluids to satisfy thirst and hunger sensations through review date of [DATE]. Interventions initiated on [DATE] included: monthly weights; administer medications as ordered; monitor/document/report as needed any signs and symptoms of chewing problems and dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and spitting foods out; monitor/record report to Physician as needed related to malnutrition; obtain lab work as needed and report to Physician; provide and serve supplements as ordered; Registered Dietician (RD) to evaluate and make diet change recommendation as needed; and extensive to total assistance with feeding. On [DATE] an intervention was initiated for No Concentrated Sweets Health Shakes with lunch and supper. Review of the Nutritional Comprehensive Assessment, dated [DATE], revealed Resident #2 was on Blenderized Nectar Consistency Diet. Further, the resident's estimated fluid requirement was 2,250 milliliters per day. Review of Resident #2's Significant Change Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Review of Section G, revealed the resident was assessed as requiring extensive assistant of one (1) staff for eating and drinking. Review of Section K, revealed the resident was on a mechanically altered diet. Review of Resident #2's Monthly [DATE] and [DATE] physician's orders [REDACTED]. Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirements from [DATE] through [DATE]. On [DATE], the resident consumed 960 milliliters (mls) of fluid; [DATE], the resident consumed 480 mls of fluid; [DATE], the resident consumed 360 mls of fluid; [DATE], the resident consumed 1,120 mls of fluid; [DATE], the resident consumed 1,020 mls of fluid; [DATE], the resident consumed 840 mls of fluid; [DATE], the resident consumed 1,560 mls of fluid; [DATE], the resident consumed 360 mls of fluid; and [DATE], the resident consumed 2,860 mls of fluid. Review of the Progress Note, dated [DATE], completed by the Dietary Technician, revealed the resident would usually drink better than eat solid foods, and appetite was poor depending on level of alertness. Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirements from [DATE] through [DATE]. On [DATE], the resident consumed 600 mls of fluid; [DATE], the resident consumed 960 mls of fluid; [DATE], the resident consumed 780 mls of fluid; [DATE], the resident consumed 960 mls of fluid; and [DATE], the resident consumed 920 mls of fluid. Review of Resident #2's Progress Notes, dated [DATE] at 12:07 PM, completed by Licensed Practical Nurse (LPN) #5, revealed the resident was incontinent of a large amount of projectile yellowish diarrhea. The Infection Control Nurse was notified and a standing order was obtained from the Physician to send a stool culture out for Norovirus Testing. Further, the nurse would continue to monitor for diarrhea and encourage fluids. Additional review revealed there was no documented evidence the Physician was notified the resident was not meeting his/her estimated fluid requirement, even though the resident was having projectile diarrhea. Review of the Resident #2's Progress Note, dated [DATE] at 5:36 PM, completed by the Director of Nursing (DON), revealed the resident was noted to have a liquid watery bowel movement, [MEDICAL CONDITION] symptoms. Interview with the DON, on [DATE] at 4:00 PM, revealed she did not review the resident's fluid intake and therefore did not notify the Physician of the resident's decreased fluid intake when Resident #2 was noted to have continued loose stools on [DATE]. Review of the Resident Meal Consumption and Fluid Intake Record, revealed Resident #2 did not meet his/her fluid requirements from [DATE] through [DATE]. On [DATE], the resident consumed 720 mls of fluid; [DATE], the resident consumed 720 mls of fluid; [DATE], the resident consumed 1,320 mls of fluid; [DATE], the resident consumed 0 mls of fluid; [DATE], the resident consumed 0 mls of fluid; [DATE], the resident consumed 0 mls of fluid; [DATE], the resident consumed 0 mls of fluid; [DATE], the resident consumed 0 mls of fluid; and [DATE], the resident consumed 0 mls of fluid. Review of Resident #2's Laboratory Report, revealed a stool specimen collected [DATE], indicated positive results for Norovirus on [DATE]. Review of the Resident #2's Progress Notes, dated [DATE] at 5:06 PM, completed by Registered Nurse (RN) #3, revealed stool cultures came back positive for Norovirus GI and Norovirus GII. The Physician was notified with no new orders received. Further, the nurse would continue to keep the resident in his/her room and the resident's Power of Attorney (POA) was notified. Review of Resident #2's Progress Notes, dated [DATE] at 2:21 AM, completed by LPN #9, revealed the resident was noted to have Norovirus, and was on the Physician's List to be seen in the morning. Further review revealed the resident was having nausea and stomach pain. Continued review revealed the nurse would try to keep him/her away from other residents while symptoms persist. Review of the Resident #2's Progress Notes, dated [DATE] at 8:51 AM, completed by RN #1, revealed the resident was declining, and per night shift, the resident might have aspirated. Resident #2 was pale in color with Temperature 98.7, Pulse 88, Respirations 24, Blood Pressure (B/P) ,[DATE] and Oxygen Saturation 98% (percent) on two (2) liters of oxygen per nasal cannula. Further review revealed the resident had no mottling to lower extremities, the family was at the bedside, and the Physician would be in to see the resident on rounds. Review of the Physician's Progress Notes, dated [DATE], revealed there was discussion with Resident #2's POA with regards to the resident's condition and the POA wanted comfort care only for the resident. Further review revealed there was a new order to add PRN (as needed) [MEDICATION NAME] Medication ([MEDICATION NAME] is a narcotic pain medication). Review of physician's orders [REDACTED]. Review of the Nutrition Comprehensive Assessment, dated [DATE], completed by the Dietary Technician, revealed the meal consumption record indicated the resident did not meet his/her estimated fluid requirement for eight (08) consecutive days from [DATE] through [DATE]. Further, the resident did not meet the estimated fluid requirement for fourteen (14) consecutive days from [DATE] through [DATE]. Additional review revealed the dietary recommendations included two (2) health shakes with all meals. Further review of the medical record revealed there was no documented evidence the facility revised the Comprehensive Plan of Care in an attempt to promote fluid intake, even though the resident did not meet his/her fluid requirement, had decreased fluid intake from [DATE] and was exhibiting signs and symptoms of GI illness including diarrhea, and tested positive for Norovirus. In addition, there was no documented evidence the resident was placed on Intake and Output in order to closely monitor the resident's fluid intake, and no documented evidence of a hydration assessment completed. Although the Physician was notified of signs and symptoms of GI illness, there was no documented evidence the Physician or Registered Dietician (RD) was notified the resident was not meeting his/her fluid intake from [DATE] through [DATE], with the exception of [DATE], or that the resident had no documented fluid intake from [DATE] through [DATE]. Review of Resident #2's Progress Note, dated [DATE] at 3:57 AM, completed by LPN #8, revealed the nurse was called to the resident's bedside and there was no signs of life. The resident's son was at the bedside and an order was received to release the body to the funeral home of choice. Review of the Discharge MDS Assessment, dated [DATE], revealed the resident was discharged related to death on [DATE]. Interview with Certified Nursing Assistant (CNA) #2, on [DATE] at 8:33 AM, revealed she had been frequently assigned to Resident #2 and the resident was on a slow decline prior to contracting the [MEDICAL CONDITION]. She further stated once the resident became ill with [MEDICAL CONDITION] he/she became bedridden quickly. Interview with RN #1, on [DATE] at 8:59 AM, revealed she had been assigned to Resident #2 on a regular basis and was aware the resident was ill with GI symptoms including loose stools toward the end of [DATE] and beginning of [DATE]. She stated there was [MEDICAL CONDITION] going around the facility and several residents were ill. Per interview, she did not have documented evidence she performed hydration assessments on the resident to include checking skin turgor and mucous membranes, nor did she ensure the resident was monitored closely for fluid intake as the resident was not placed on intake and output. She further stated she recalled the resident being on a slow decline with dementia; however, once the resident tested positive for the Norovirus, the resident declined quickly and became bed ridden. She further stated the Physician visited with Resident #2 and met with his/her family on [DATE]. Per interview, the family decided they did not want aggressive treatment and Resident #2 went under Hospice Care. Interview with LPN #5, on [DATE] at 3:00 PM, revealed she typically worked on St Joseph Terrace Unit. She stated she remembered Resident #2 having projectile loose stools and wrote the Progress Note dated [DATE]; however, she stated there was no documented evidence she assessed the resident for signs and symptoms of dehydration, reviewed the resident's fluid intake while the resident was ill with GI symptoms, or notified the Physician of the resident's decreased fluid intake. She further stated she depended on the CNAs to inform her if residents were not eating or drinking, and she did not recall anyone informing her Resident #2 was eating or drinking less than usual. She further stated it was important to monitor a resident's hydration status if the resident was showing signs and symptoms of a GI illness, such as loose stools and implement interventions to prevent dehydration. However, she stated she was unaware of who was responsible for reviewing the Meal Consumption and Fluid Intake Records. Interview with Director of Nursing (DON) on [DATE] at 3:27 PM, revealed Resident #2 did test positive for Norovirus, and nursing staff should have been monitoring the resident's fluid intake closely, and performing hydration assessments. Further, the Physician should have been notified of the resident not meeting his/her fluid requirements in an attempt to prevent dehydration, especially with the resident having loose stools. 2. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the St. Joseph Terrace unit. Review of the Nutrition Comprehensive Assessment, dated [DATE], written by the Dietary Technician, revealed the resident's estimated fluid requirement was 1,715 mls per day. Further review revealed the resident was receiving a regular diet with thin liquids, continued to self feed with encouragement, and occasionally needed to be fed by staff. Review of Resident #3's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of seven (07) out of fifteen (15) indicating severe cognitive impairment. Review of Section G, revealed the resident was assessed as requiring limited assistance with eating or drinking. Review of physician's orders [REDACTED]. Review of the Physician's Progress Note, dated [DATE], revealed the resident had increased shortness of breath, increased [MEDICAL CONDITION] and was receiving [MEDICATION NAME] (diuretic medication). Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirement from [DATE] through [DATE], twenty-four (24) consecutive days. On [DATE], the resident consumed 665 milliliters (mls) of fluid; [DATE], the resident consumed 900 mls of fluid; [DATE], the resident consumed 360 mls of fluid; [DATE], the resident consumed 1,020 mls of fluid; [DATE], the resident consumed 960 mls of fluid; [DATE], the resident consumed 300 mls of fluid; [DATE], the resident consumed 960 mls of fluid; [DATE], the resident consumed 240 mls of fluid; [DATE], the resident consumed 1,700 mls of fluid; [DATE], the resident consumed 720 mls of fluid; [DATE], the resident consumed 600 mls of fluid; [DATE], the resident consumed 960 mls of fluid; [DATE], the resident consumed 940 mls of fluid; [DATE], the resident consumed 880 mls of fluid. [DATE], the resident consumed 720 mls of fluid; [DATE], the resident consumed 960 mls of fluid; [DATE], the resident consumed 1,080 mls of fluid; [DATE], the resident consumed 0 mls of fluid; [DATE], the resident consumed 515 mls of fluid; [DATE], the resident consumed 240 mls of fluid; [DATE], the resident consumed 120 mls of fluid; [DATE], the resident consumed 240 mls of fluid; [DATE], the resident consumed 35 mls of fluid; and [DATE], the resident consumed 360 mls of fluid. Review of Resident #3's Progress Note, dated [DATE] at 7:03 PM, written by RN #3, revealed the resident had a small amount of emesis noted this evening, and was afebrile with temperature of 98.8. However, there was no documented evidence the resident's fluid intake was reviewed. Further, there was no documented evidence the Physician was notified related to symptoms of GI illness. Review of the Progress Note, dated [DATE] at 11:33 AM, written by RN #1, revealed the resident was having difficulty eating. B/P ,[DATE], Pulse 64, Respirations 20, Temperature 98.8 and refused oxygen. Further, the resident's POA was notified. Review of the Progress Note, dated [DATE] at 11:44 AM, written by RN #1, revealed the nurse spoke with Resident #3's POA and if the resident should decline further, the POA wanted the resident to be sent out to the hospital. Further, Resident #3 was full code status. Although the resident did not meet his/her fluid requirement from [DATE] through [DATE], had a substantial decrease in fluid intake starting [DATE], and was receiving [MEDICATION NAME] medication, there was no documented evidence the Physician was notified of the resident's decreased fluid intake until [DATE]. Review of Resident #3's Change of Condition Note, dated [DATE] at 1:38 PM, written by RN #9, revealed the resident seemed different than usual, food/fluid intake was decreased, and the resident was unable to eat/drink adequate amounts. Per the Note, the Physician was notified. Review of Resident #3's Progress Note, dated [DATE] at 5:27 PM, written by LPN #3, revealed the resident was seen by the Physician on rounds today. New orders were received for [MEDICATION NAME] (antibiotic) daily, Chest X-Ray, Complete Blood Count (blood test to measure red blood cells, white blood cells and platelets), and Comprehensive Metabolic Panel (a blood test to check status of kidneys, liver, electrolytes, blood sugar, and blood proteins). Further, the resident's diet was changed to puree and the Physician did not want the resident fed if lethargic related to this being a choking hazard. Further, the resident's POA was made aware of the new orders. Review of Resident #3's Physician Orders, dated [DATE], revealed a diet change for Pureed Diet with Honey Thick Liquids, Chest X-Ray, CBC, CMP, and [MEDICATION NAME] 500 milligrams by mouth for seven (7) days for aspiration pneumonia. Further review of the medical record revealed there was no documented evidence the facility had identified this resident's risk for dehydration and revised the Comprehensive Plan of Care in an attempt to promote fluid intake even though the resident did not meet his/her fluid requirement [DATE] through [DATE], and was exhibiting signs and symptoms of GI illness including emesis on [DATE]. In addition, there was no documented evidence the resident was placed on Intake and Output in order to closely monitor the resident's fluid intake, and no documented evidence of a hydration assessment completed. In addition, there was no documented evidence the Registered Dietician (RD) was notified the resident was not meeting his/her fluid requirement [DATE] through [DATE], or notified of the substantial decrease in fluid intake [DATE] through [DATE]. Review of Resident #3's Progress Note, dated [DATE] at 8:05 AM, written by LPN #5, revealed report was received from night shift that the resident was declining. Upon assessment, the resident's eyes were closed and he/she was not responding to verbal stimuli. Vital signs were documented as Temperature 97.8, Pulse 84, Respirations 16, Blood Pressure ,[DATE]. Oxygen saturation was documented as 90% (percent) on two (2) liters of oxygen per nasal cannula. Further review revealed the resident's color was flushed, lung sounds were diminished to anterior fields, and abdomen was soft and non-distended with positive bowel sounds x four (4) quadrants. Per the Note, a call was placed to the POA concerning the resident's condition, and the POA wanted the resident to be transferred to the Emergency Department (ED) for further evaluation. Review of the Hospital Emergency Department (ED) Note, dated [DATE], revealed Resident #3 presented from the nursing home for evaluation of [MEDICAL CONDITION] and altered mental status. Workup revealed Acute Kidney Injury and Dehydration. ED clinical Impression: Dehydration and Stupor. Further review revealed the patient would be admitted in Serious Condition and received intravenous fluids. Further review revealed the patient's POA wanted the resident to be treated for [REDACTED]. Review of Laboratory values collected on [DATE] revealed BUN 58 High (BUN is a test to measure the amount of urea nitrogen in the blood in order to check kidney function) (reference range ,[DATE] milligrams/deciliter (mg/dl) and Creatinine value 3.01 High (Creatinine is a test to measure kidney function) (reference range 0XXX,[DATE].30 mg/dl). Review of the Hospital Discharge Summary, dated [DATE], revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further, the patient improved with rehydration with intravenous (IV) fluids with gradual return to baseline and Acute Kidney Injury resolved. Per the Summary, due to the patient's ongoing chronic issues, he/she was a candidate for Hospice Care and was discharged back to the facility on [DATE] with Hospice. Review of the Progress Note, dated [DATE] at 7:43 PM, written by RN #4, revealed the resident arrived back to the facility via ambulance. Per the Note, the resident only mumbled when spoken to, lungs were clear on auscultation, heart tones were normal, and bowel sounds were present x four (4) quadrants, skin warm and dry and no signs or symptoms of breakdown. Review of the Hospice Care Long Term Care Status Form, dated [DATE], revealed the resident was being admitted to hospice with terminal [DIAGNOSES REDACTED]. Observation of Resident #3 on [DATE] at 11:30 AM, revealed the resident was lying in bed with eyes closed. Review of the Progress Note, dated [DATE] at 2:30 PM, written by RN #3, revealed the resident was sleepy most of the time, and would awaken when his/her name was called. Further, the resident was pocketing food for breakfast, and food was removed from his/her mouth with care rendered. Temperature 98.1 Pulse 72, Respirations 19, Blood Pressure ,[DATE] and Oxygen saturation ,[DATE]% on room air. Per the Note, oxygen was started on two (2) liters via nasal cannula. After a recheck of oxygen saturation after thirty minutes, oxygen saturation was up to 93%. Interview with LPN #5, on [DATE] at 3:00 PM, revealed she was assigned to Resident #3 on [DATE], when the resident was sent to the hospital ER for evaluation. She stated she received report from night shift that the resident had been declining and started showing signs of low blood pressure. She further stated the resident was lethargic, not responding to her and the resident was a full code. Per interview, she notified the resident's POA of the resident's condition and the POA requested the resident be sent to the hospital ER. Further interview revealed the resident's admitting [DIAGNOSES REDACTED]. However, she stated since return from the hospital, the resident was not alert and was bedridden. She further stated they were trying to encourage fluids which was a challenge as the resident was not very alert. Review of the Nutrition Comprehensive Assessment, dated [DATE], completed by the RD, revealed the resident's estimated fluid requirement was 2,050 mls per day. Further review revealed the resident did not meet the estimated fluid requirement for twenty-five (25) consecutive days from [DATE] through [DATE]. Further review revealed the resident was at high nutritional risk related to decline i (TR

Based on interview, record review, review of facility policy, and review of the Centers for the Medicare and Medicaid Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure the Comprehensive Care Plans were reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for eight (8) of nineteen (19) sampled residents (Resident #1, #2, #3, #4, #5, #10, #11 and #12). Residents #2, #3, #4, #5, #10, #11 and #12 exhibited signs and symptoms of Gastrointestinal (GI) illness during the months of [DATE] and/or [DATE] as there was a GI illness outbreak in the facility. However, there was no documented evidence the facility identified the residents' risk for dehydration and revised the Comprehensive Plan of Care (CCP) in an attempt to promote fluid intake and ensure sufficient fluid intake to maintain proper hydration. Although these residents did not meet their estimated fluid requirements during their illness, there was no documented evidence of monitoring fluid intakes, performing hydration assessments or notification to the Physician or Registered Dietician (RD) related to low fluid intakes. Furthermore, there was no documented evidence the CCPs were revised to reflect the GI illness and no documented evidence an Acute Care Plan was initiated for a change in condition as per facility policy. In addition, Resident #1's CCP included an intervention to monitor/document for signs or symptoms of Urinary Tract Infection [MEDICAL CONDITION]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. However, there was no documented evidence the CCP was revised to include notification of the physician for signs/symptoms of UTI. In addition, there was no documented evidence the CCP was revised or the Acute Care Plan was initiated as per facility policy when the resident complained of burning on urination on [DATE]. Review of the Laboratory Reports, revealed the urine specimens collected on [DATE] and [DATE], indicated the urinalysis results met criteria to perform urine culture for Staphylococcus Aureus and sensitivity completed; however, no treatment was ordered. Furthermore, there was no documented evidence of Physician notification or Care Plan revision when the resident exhibited increased confusion on [DATE], and experienced disorientation and altered cognition, on [DATE]. On [DATE], the resident had a further change in condition including tongue was slightly swollen, difficulty with speech, increased sinus drainage, coughing with all intake of liquids and solids, and headache and a call was placed to the Physician at 1:05 PM, with no return call. According to the Progress Note, dated [DATE], at 6:15 PM, the resident further declined and became unresponsive, and hypotensive, and was transferred to the Hospital ED. Resident #1 was admitted to the hospital [DATE] with Acute Altered Mental Status; Urinary Tract Infection; [MEDICAL CONDITION]; Hypothermia, Secondary to UTI [MEDICAL CONDITION]; Dehydration; and [MEDICAL CONDITION], secondary to UTI. (Refer to F-580, F-684, and F-692) The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan was revised caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Interdisciplinary Comprehensive Care Plan Policy, undated, revealed it is the policy of Carmel Manor 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 resident's medical, nursing, as well as mental and psychosocial needs that are identified in the resident's comprehensive assessment. In addition, the resident care plan will focus on Person-Centered care, meaning to focus on the resident as the locus of control and support the resident in making their own choices and having control over his/her daily life. The comprehensive care plan must describe the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's Acute Care Plan Documentation Policy, undated, revealed it is the policy of Carmel Manor to document all pertinent information regarding resident conditions to ensure proper tracking and follow up. This policy reflects the mission and philosophy of the Carmelite Sisters for the Aged and Infirmed. In addition, licensed nurses will document in the nurses notes on any resident who is listed on the Twenty-four (24) Hour Report every shift and on any active acute care plan. Licensed nurses will initiate an acute care plan, place residents on the Twenty-four (24) Hour Report sheet and begin every shift charting when conditions meet the charting guidelines. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #2's closed clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. During the resident's stay at the facility, he/she resided on St Joseph Terrace unit. Review of the Resident #2's Comprehensive Care Plan (CCP), initiated [DATE], revealed a focus of nutritional problem related to [DIAGNOSES REDACTED]. The goal revealed the resident would consume sufficient food/fluids to satisfy thirst and hunger sensations through review date of [DATE]. Interventions initiated on [DATE] included: monthly weights; administer medications as ordered; monitor/document/report as needed any signs and symptoms of chewing problems and dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and spitting foods out; monitor/record report to Physician as needed related to malnutrition; obtain lab work as needed and report to Physician; provide and serve supplements as ordered; Registered Dietician (RD) to evaluate and make diet change recommendation as needed; and extensive to total assistance with feeding. On [DATE] an intervention was initiated for No Concentrated Sweets Health Shakes with lunch and supper. Review of the Nutritional Comprehensive Assessment, dated [DATE], revealed Resident #2 was on Blenderized Nectar Consistency Diet, and the resident's estimated fluid requirement was 2,250 milliliters per day. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #2 as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Review of Section G, revealed the resident was assessed as requiring extensive assistant of one (1) staff for eating and drinking, and review of Section K, revealed the resident was on a mechanically altered diet. Review of Resident #2's Monthly [DATE] and [DATE] physician's orders [REDACTED]. Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirements of 2,250 milliliters per day from [DATE] through [DATE]. Total fluid intake was recorded on [DATE], 960 milliliters (mls); [DATE], 480 mls of fluid; [DATE], 360 mls of fluid; [DATE], 1,120 mls of fluid; [DATE], 1,020 mls of fluid; [DATE], 840 mls of fluid; [DATE], 1,560 mls of fluid; [DATE], 360 mls of fluid. (On [DATE], the resident consumed 2,860 mls of fluid and did meet his/her fluid requirement). Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirements from [DATE] through [DATE]. Total fluid intake was recorded on [DATE], 600 mls of fluid;[DATE], 960 mls of fluid;[DATE], 780 mls of fluid; [DATE], 960 mls of fluid; and [DATE], 920 mls of fluid. Review of Resident #2's Progress Note, dated [DATE] at 12:07 PM, completed by Licensed Practical Nurse (LPN) #5, revealed the resident was incontinent of a large amount of projectile yellowish diarrhea. Per the Note, the Infection Control Nurse was notified and a standing order was obtained from the Physician to send a stool culture for Norovirus Testing. Further review revealed the nurse would continue to monitor for diarrhea and encourage fluids. Review of the Resident #2's Progress Note, dated [DATE] at 5:36 PM, completed by the Director of Nursing (DON), revealed the resident was noted to have a liquid watery bowel movement, [MEDICAL CONDITION] symptoms. Review of the Resident Meal Consumption and Fluid Intake Record, revealed Resident #2 did not meet his/her fluid requirements from [DATE] through [DATE]. Total fluid intake was recorded on [DATE], 720 mls of fluid; [DATE], 720 mls of fluid; [DATE], 1,320 mls of fluid; and [DATE] through [DATE], there was zero (0) mls of fluid documented. Review of the Laboratory Report, revealed a stool specimen collected [DATE], indicated positive results for Norovirus on [DATE]. Review of the Resident #2's Progress Notes, dated [DATE] at 5:06 PM, completed by Registered Nurse (RN) #3, revealed stool culture results were positive for Norovirus GI and Norovirus GII, and the Physician was notified with no new orders received. Further review revealed the nurse would continue to keep the resident in his/her room and the resident's Power of Attorney (POA) was notified. Review of Resident #2's Progress Notes, dated [DATE] at 2:21 AM, completed by LPN #9, revealed the resident was noted to have the Norovirus, and was on the Physician's List to be seen in the morning. Additional review revealed the resident was having nausea and stomach pain, and the nurse would try to keep him/her away from other residents while symptoms persist. Review of the Resident #2's Progress Note, dated [DATE] at 8:51 AM, completed by RN #1, revealed the resident was declining, and per night shift staff, the resident might have aspirated. Per the Note, Resident #2 was pale in color with Temperature 98.7, Pulse 88, Respirations 24, Blood Pressure (B/P) ,[DATE] and Oxygen Saturation 98% (percent) on two (2) liters of oxygen per nasal cannula. Continued review revealed the resident had no mottling to lower extremities, the family was at the bedside, and the Physician would be in to see the resident on rounds. Review of the Physician's Progress Notes, dated [DATE], revealed there was discussion with Resident #2's Power of Attorney (POA) related to the resident's condition and the POA wanted comfort care only for the resident. Additional review revealed there was a new order to add PRN (as needed) [MEDICATION NAME] Medication ([MEDICATION NAME] is a narcotic pain medication). New physician's orders [REDACTED]. Review of Resident #2's Nutrition Comprehensive Assessment, dated [DATE], completed by the Dietary Technician, revealed the meal consumption record indicated the resident did not meet his/her estimated fluid requirement for eight (08) consecutive days from [DATE] through [DATE]. Further, the resident did not meet the estimated fluid requirement for an additional fourteen (14) consecutive days from [DATE] through [DATE]. Continued review revealed the dietary recommendations included two (2) health shakes with all meals. There was no documented evidence the resident's fluid intake was closely monitored and no documented evidence of a hydration assessment completed. Although the Physician was notified of signs and symptoms of GI illness, there was no documented evidence the Physician or Registered Dietician (RD) was notified the resident was not meeting his/her estimated fluid intake from [DATE] through [DATE], with the exception of [DATE], or that the resident was not consuming any fluids from [DATE] through [DATE]. Review of the CCP, revealed no revisions in an attempt to promote fluid intake even though the resident did not meet his/her fluid requirement, had decreased fluid intake from [DATE], was exhibiting signs and symptoms of GI illness including diarrhea, and tested positive for Norovirus. The CCP did not include interventions related to monitoring fluid intake, performing hydration assessments or notification to the Physician related to decreased fluid intake. Further, there no revision related to the GI illness. Additional review of the Resident #2's medical record revealed no documented evidence of an initiation of Acute Care Plan as per facility policy, even though the resident had a change in condition on [DATE], and tested positive for the Norovirus. Review of the Discharge MDS Assessment, dated [DATE], revealed the resident was discharged related to death on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 4:00 PM, revealed she wrote the Note related to the resident's loose stools on [DATE]. She stated she should have reviewed and revised Resident #2's CCP with interventions related to monitoring and promoting fluid intake, monitoring for signs and symptoms of dehydration, and notification to the Physician related to decreased fluid intake. Further, she should have ensured there was an Acute Care Plan in place related to the GI illness. Interview with RN #1, on [DATE] at 8:59 AM, revealed she had been assigned to Resident #2 on a consistent basis and was aware the resident was ill with GI symptoms including loose stools toward the end of [DATE] and beginning of [DATE]. Per interview, there was [MEDICAL CONDITION] going around the facility and several residents were ill. She stated she did not have documented evidence she performed hydration assessments nor did she ensure the resident was monitored closely for fluid intake as the resident was not placed on intake and output. She further stated once the resident tested positive for the Norovirus, he/she declined quickly and became bed ridden. She further stated she should have ensured the resident's CCP was revised with interventions for strict intake and output and hydration assessments in order to promote sufficient fluid intake and try to prevent dehydration. Further, she should have initiated an Acute Care Plan related to the GI illness as the resident was on contact precautions. Interview with LPN #5, on [DATE] at 3:00 PM, revealed she typically worked on St Joseph Terrace Unit and remembered Resident #2 having projectile loose stools and completed the Progress Note dated [DATE]. However, she did not revise the resident's CCP related to [MEDICAL CONDITION], nor did she ensure interventions were in place to promote hydration. Per interview, she did not remember any residents' CCPs being revised nor was there Acute Care Plans initiated during the GI outbreak; however, she stated the nurses should have ensured there were care plan interventions to address Resident #2's GI illness and to prevent dehydration. 2. Review of Resident #3's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Per record review the resident resided on the St. Joseph Terrace unit. Review of the Nutrition Comprehensive Assessment, dated [DATE], completed by the Dietary Technician, revealed Resident #3's estimated fluid requirement was 1,715 mls per day. Additional review revealed the resident was receiving a regular diet with thin liquids, continued to self feed with encouragement, and occasionally needed to be fed by staff. Review of Resident #3's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of seven (07) out of fifteen (15) which indicated severe cognitive impairment. Section G, revealed the resident was assessed as requiring limited assistance with eating and drinking. Review of physician's orders [REDACTED]. Review of Resident #3's Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirement of 1,715 from [DATE] through [DATE], twenty-four (24) consecutive days. The following intakes were recorded for the twenty-four (24) hour period: [DATE], 665 milliliters (mls) of fluid; [DATE], 900 mls of fluid; [DATE], 360 mls of fluid; [DATE], 1,020 mls of fluid; [DATE], 960 mls of fluid; [DATE], 300 mls of fluid; [DATE], 960 mls of fluid; [DATE], 240 mls of fluid; [DATE], 1,700 mls of fluid; [DATE], 720 mls of fluid; [DATE], 600 mls of fluid; [DATE], 960 mls of fluid; [DATE], 940 mls of fluid; [DATE], 880 mls of fluid; [DATE], 720 mls of fluid; [DATE], 960 mls of fluid; [DATE], 1,080 mls of fluid; [DATE], zero (0) mls of fluid; [DATE], 515 mls of fluid; [DATE], 240 mls of fluid; [DATE], 120 mls of fluid; [DATE], 240 mls of fluid; [DATE], 35 mls of fluid; and [DATE], 360 mls of fluid. Review of the Progress Note, dated [DATE] at 7:03 PM, written by RN #3, revealed the resident had a small amount of emesis noted this evening, and was afebrile with temperature of 98.8. Interview with RN #3 on [DATE] at 11:35 AM, revealed it was the responsibility of the nurse assigned to update the care plan for any change in condition. She stated she should have revised Resident #3's CCP related to the potential for dehydration on [DATE] when the resident was having GI illness symptoms. She further stated she was unaware of the policy related to Acute Care Plans until last week. Review of the Progress Note, dated [DATE] at 11:33 AM, completed by RN #1, revealed the resident was having difficulty eating. Blood Pressure (B/P) ,[DATE], Pulse 64, Respirations 20, Temperature 98.8 and refused oxygen. The resident's POA was notified. Review of the subsequent Progress Note dated [DATE] at 11:44 AM, completed by RN #1, revealed the nurse spoke with the resident's Power of Attorney (POA) and if the resident should decline further he/she should be sent out. Resident #3 did not meet his/her fluid requirement from [DATE] through [DATE], and had a substantial decrease in fluid intake starting [DATE]; however, there was no documented evidence the Physician was notified of the resident's decreased fluid intake until [DATE]. Review of Resident #3's Change of Condition Note, dated [DATE] at 1:38 PM, completed by RN #9, revealed the resident seemed different than usual, food/fluid intake was decreased, and the resident was unable to eat/drink adequate amounts. According to the Note, the Physician was notified. Review of the Progress Note, dated [DATE] at 5:27 PM, written by LPN #3, revealed the resident was seen by the Physician on rounds today and new orders were received for [MEDICATION NAME] (antibiotic) daily, Chest X-Ray, Complete Blood Count (blood test to measure red blood cells, white blood cells and platelets), and Comprehensive Metabolic Panel (a blood test to check status of kidneys, liver, electrolytes, blood sugar, and blood proteins). Further review revealed the resident's diet was changed to puree and the Physician did not want the resident fed if lethargic related to this being a choking hazard. The resident's POA was made aware of the new orders. Review of Resident #3's Physician Orders, dated [DATE], revealed a diet change for Pureed Diet with Honey Thick Liquids, Chest X-Ray, CBC, CMP, and [MEDICATION NAME] 500 milligrams by mouth for seven (7) days for aspiration pneumonia. There was no documented evidence Resident #3 was placed on Intake and Output in order to closely monitor the resident's fluid intake, and no documented evidence of a hydration assessment completed. In addition, there was no documented evidence the Registered Dietician (RD) was notified the resident was not meeting his/her fluid requirement [DATE] through [DATE], or notified of the substantial decrease in fluid intake [DATE] through [DATE]. Review of Resident #3's CCP, revealed no documented evidence the facility had identified this resident's risk for dehydration and revised the CCP in an attempt to promote fluid intake even though the resident did not meet his/her fluid requirement [DATE] through [DATE], and was exhibiting signs and symptoms of GI illness including emesis on [DATE], and was receiving a diuretic. Further, there no revision related to the GI illness. Additional review of the Resident #3's medical record revealed no documented evidence of an initiation of Acute Care Plan as per facility policy even though the resident had a change in condition related to the GI illness. Review of Resident #3's Progress Note, dated [DATE] at 8:05 AM, written by LPN #5, revealed upon assessment the resident's eyes were closed and he/she was not responding to verbal stimuli. Vital signs were recorded as Temperature 97.8, Pulse 84, Respirations 16, Blood Pressure ,[DATE]. Oxygen saturation was documented as 90% (percent) on two (2) liters of oxygen via nasal cannula. Continued review revealed the resident's color was flushed, lung sounds were diminished to anterior fields, and abdomen was soft and non-distended with positive bowel sounds x four (4) quadrants. According to the Note, a call was placed to the POA concerning the resident's condition, and the POA wanted the resident to be transferred to the Emergency Department (ED) for further evaluation. Review of the Hospital Discharge Summary, dated [DATE], revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the patient improved with rehydration with intravenous (IV) fluids with gradual return to baseline and Acute Kidney Injury resolved. Per the Discharge Summary, due to the patient's ongoing chronic issues, he/she was a candidate for hospice and was discharged back to the facility on [DATE] with hospice. Review of Resident #3's Progress Note, dated [DATE] at 7:43 PM, completed by RN #4, revealed the resident arrived back to the facility via ambulance. Review of the Hospice Care Long Term Care Status Form, dated [DATE], revealed Resident #3 was being admitted to hospice with terminal [DIAGNOSES REDACTED]. Review of the Discharge MDS Assessment, dated [DATE], revealed the resident was discharged related to death on [DATE]. 3. Review of Resident #11's closed clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Per record review, Resident #11 resided on the St. Joseph Terrace Unit. Review of the Nutrition Comprehensive Assessment, dated [DATE], completed by the Dietary Technician, revealed Resident #11's estimated fluid requirement was 2,160 mls per day, and the resident received a regular diet with no nutritional supplements. Continued review revealed the resident was at moderate nutritional risk related to Diabetes Mellitus Type 2, and did not follow a diabetic diet due to preferring a regular diet. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of six (6) out of fifteen (15), revealing severe cognitive impairment. Review of Section G, revealed the facility assessed the resident as requiring supervision for eating and drinking with setup help only. Review of Resident #11's physician's orders [REDACTED]. Review of the Progress Notes, dated [DATE] at 5:35 PM, completed by the DON, revealed Resident #11 was having liquid/watery bowel movements, and symptoms of virus. Review of Resident #11's Progress Note, dated [DATE] at 5:25 PM, completed by RN #9, revealed the resident had no emesis or diarrhea at this time. Review of Resident #11's subsequent Progress Note, dated [DATE] at 1:31 AM, completed by LPN #9, revealed the resident was lethargic and not trying to assist while care was being provided. However, there was no documented evidence of an hydration assessment completed. Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirements from [DATE] through [DATE], nineteen (19) consecutive days. The following intakes were recorded for the twenty-four (24) hour period: [DATE], 360 milliliters (mls) of fluid; [DATE], 480 mls of fluid; [DATE], 1,200 mls of fluid; [DATE], 600 mls of fluid; [DATE], 170 mls of fluid; [DATE], 1,080 mls of fluid; [DATE], 1,260 mls of fluid; [DATE], 780 mls of fluid; [DATE], 960 mls of fluid; [DATE], 480 mls of fluid; [DATE], 480 mls of fluid; [DATE], 360 mls of fluid; [DATE], 360 mls of fluid; [DATE], 840 mls of fluid; [DATE], 1,620 mls of fluid; [DATE], 840 mls of fluid; [DATE], 960 mls of fluid; [DATE], 600 mls of fluid; and [DATE], 600 mls of fluid. Additional review of the medical record revealed there was no documented evidence the resident was placed on Intake and Output in order to closely monitor fluid intake, and no documented evidence of a hydration assessment completed [DATE] through [DATE], even though the resident was having loose stools and was lethargic. Further, there was no documented evidence the Physician or Registered Dietician (RD) was notified of the resident not meeting his/her estimated fluid requirement from [DATE] through [DATE]. Review of Resident #11's CCP, revealed there was no documented evidence the facility had identified this resident's risk for dehydration and revised the Plan of Care in an attempt to promote fluid intake even though the resident did not meet his/her fluid requirement from [DATE] through [DATE], and was exhibiting signs and symptoms of GI illness including diarrhea. Further, there no revision related to the GI illness. Additional review of the Resident #11's medical record revealed no documented evidence of an initiation of Acute Care Plan per facility policy even though the resident had a change in condition related to the GI illness. Review of the Progress Note, dated [DATE] at 7:58 AM, completed by RN #8, revealed the resident was assessed as having a congested cough, sluggish skin turgor and dry mucous membranes, and the nurse was awaiting call back from the Physician. Review of the subsequent Progress Note, dated [DATE] at 9:44 AM, completed by RN #8, revealed the Physician returned the call and was informed Resident #11 was refusing to eat or drink anything, was very lethargic and may need fluids. Orders were obtained to send the resident to the Hospital ED for further evaluation if the resident's POA was in agreement. Review of the Hospital Discharge Summary, dated [DATE], revealed the facility had transferred Resident #11 to the ED with concerns related to course cough, decreased oral intake, and the possibility the resident had become dehydrated over recent days, as the resident had diarrhea for nearly two (2) weeks. Further, the patient was a Do Not Resuscitate code status, and the family decided overnight they wanted NO treatment except comfort care and wanted the patient to return to the facility for end of life care. Further, the patient was treated for [REDACTED]. Active Hospital Problems [MEDICAL CONDITION], and End of Life Care. Review of Resident #11's Progress Note, dated [DATE], written by RN #8, revealed the Physician called and alerted the facility that the resident would be returning under hospice care and prescriptions were being sent. Review of Resident #11's Progress Note, dated [DATE] at 11:55 AM, revealed at 11:37 AM the resident was noted to be without pulse, B/P and respirations, and the family and Hospice Chaplin was at bedside. Per the Note, the Physician was notified by phone at 11:45 AM. Review of the Discharge MDS Assessment, dated [DATE], revealed the resident died at the facility on [DATE]. Interview with RN #3, on [DATE], revealed she was frequently assigned to Resident #11 during the time he/she had symptoms of the GI illness. She stated the resident had been in isolation related to the GI illness and was having diarrhea off and on prior to being hospitalized related to dehydration. Per interview, she had not revised the resident's CCP in an attempt to monitor and promote fluid intake, nor revised the CCP related to the GI illness. Further, there had been no Acute Care Plan initiated related to the resident illness to her knowledge. 4. Review of Resident #4's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Per record review, Resident #4 resided on St. Joseph Terrace unit. Review of Resident #4's Nutrition Comprehensive Assessment, dated [DATE], completed by the Dietary Technician, revealed the resident's estimated fluid requirement was 2,450 mls per day. Further review revealed the resident had no known food allergies [REDACTED]. Additional review revealed the resident received vanilla health shakes with breakfast and lunch, had stable weight, and skin was intact. Continued review revealed the resident had adequate nutritional status; adequate intake; and diet tolerance. Review of Resident #4's Admission MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) which indicated intact cognition. Section G, revealed the facility assessed the resident as requiring sup (TRUNCATED)

Based on interview, record review and review of facility policy it was determined the facility failed to have an effective system to ensure the Physician was notified when there was a significant change in condition and a need to alter treatment for [REDACTED].#1, #2, #3, #4, #5, #10, #11 and #12). Although residents exhibited signs and symptoms of Gastrointestinal (GI) illness during the months of [DATE] and/or [DATE] due to the GI illness outbreak in the building, there was no documented evidence the Physician was notified related to change in condition due to GI illness/signs/symptoms including nausea, vomiting, and diarrhea. In addition, although the residents did not meet their estimated fluid requirements during their illness, there was no documented evidence of monitoring fluid intakes, performing hydration assessments or notification to the Physician or Registered Dietician (RD) related to low fluid intakes. This affected Residents #2, #3, #4, #5, #10, #11 and #12. On [DATE], after Resident #1 complained of dysuria (painful urination), a urinalysis, culture and sensitivity (UA/C&S) was ordered. The Laboratory Report, revealed the urine specimen collected on [DATE] and reported on [DATE], indicated the urinalysis results met criteria to perform urine culture for Staphylococcus Aureus and sensitivity completed. However, there was no documented evidence the Physician was notified of the results of the UA/C&S reported to the facility on [DATE], until [DATE], six (6) days later. There were no new orders received on [DATE] related to the UA/C&S results; however, physician's orders [REDACTED]. On [DATE], the resident exhibited increased confusion; however, there was no documented evidence the Physician or Power of Attorney (POA) was notified of the change in condition. The Laboratory Report, for the urine specimen collected on [DATE] and reported on [DATE], indicated the urinalysis results met criteria to perform urine culture for Staphylococcus Aureus and sensitivity completed. However, there was no documented evidence the Physician was notified of the UA/C&S results, with the exception of the undated Physician's initials on the Laboratory Report. On [DATE] the resident was observed to have periods of disorientation and altered cognition, was lethargic and was noted to fall asleep during meal times. However, there was no documented evidence the Physician or POA was notified of the resident's change in condition. On [DATE], the resident had further change in condition, including runny nose, coughing with any oral intake, and hallucinations, and a call was placed to the Physician at 1:05 PM. Prior to the Physician returning the call, the resident continued to decline until he/she was unresponsive, and hypotensive. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and admitted with Acute Altered Mental Status; Urinary Tract Infection [MEDICAL CONDITION]; [MEDICAL CONDITION]; Hypothermia Secondary to UTI [MEDICAL CONDITION]; Dehydration; and [MEDICAL CONDITION], secondary to UTI. (Refer to F-657, F-684, F-692 and F-880) The facility's failure to have an effective system in place to ensure the Physician was notified when there was a significant change in condition and need to alter treatment caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Nursing Service: Notification of Changes Policy, undated, revealed the facility shall promptly notify the resident and/or resident representative and his or her Physician or delegate of changes in the resident's condition or status, in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. Continued review revealed the nurse will immediately attempt to notify the resident, resident representative and resident Physician if there is a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complications; a need to alter treatment significantly; a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. Continued review of the Policy, revealed the nurse will notify the resident, resident's Physician and the resident representative for non-immediate changes of condition on the shift the change occurs, unless otherwise directed by the Physician. Per Policy, the nurse will document the notification and record any new orders on the resident's medical record and will educate the resident and/or resident representative about the proposed plan to treat, manage, or monitor the resident's change in condition. Further review revealed the nurse will educate the resident and/or resident representative about the proposed treatment change and provide an opportunity for the resident to make an informed choice of the treatment or alternate that they prefer. 1. Review of Resident #2's closed medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #2 resided on the St. Joseph Terrace during his/her stay at the facility. Review of the Nutritional Comprehensive Assessment, dated [DATE], revealed Resident #2 was on Blenderized Nectar Consistency Diet, and the resident's estimated fluid requirement was 2,250 milliliters per day. Resident #2's Monthly [DATE] and [DATE] physician's orders [REDACTED]. Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirements of 2,250 milliliters per day from [DATE] through [DATE], with the exception of meeting his/her fluid requirement on [DATE]. Furthermore, there was no documented fluid intake from [DATE] through [DATE]. Review of Resident #2's Progress Note, dated [DATE] at 12:07 PM, signed by Licensed Practical Nurse (LPN) #5, revealed the resident was incontinent of a large amount of projectile yellowish diarrhea. Per the Note, the Infection Control Nurse was notified and a standing order was obtained from the Physician to send a stool culture for Norovirus Testing. Interview with LPN #5, on [DATE] at 3:00 PM, revealed she typically worked on St Joseph Terrace Unit and remembered Resident #2 having projectile loose stools as per her Progress Note dated [DATE]. However, she stated she did not recall reviewing the resident's fluid intake while the resident was ill with GI symptoms, or notifying the Physician of the resident's decreased fluid intake. Review of the Resident #2's Progress Note, dated [DATE] at 5:36 PM, completed by the Director of Nursing (DON), revealed the resident was noted to have a liquid watery bowel movement, and [MEDICAL CONDITION] symptoms. Interview with the DON, on [DATE] at 3:27 PM, revealed she wrote the Note on [DATE] related to Resident #2 having virus symptoms, and she should have reviewed the resident's fluid intake and ensured the Physician was notified the resident was not meeting his/her fluid requirement. Review of the Resident Meal Consumption and Fluid Intake Record, revealed Resident #2 did not meet his/her fluid requirements from [DATE] through [DATE]. Review of the Laboratory Report, revealed the stool specimen collected [DATE], indicated positive results for Norovirus, on [DATE]. Review of the Resident #2's Progress Notes, dated [DATE] at 5:06 PM, signed by Registered Nurse (RN) #3, revealed stool culture results were positive for Norovirus GI and Norovirus GII, and the Physician was notified with no new orders received. Further review revealed the resident's Power of Attorney (POA) was notified. Review of Resident #2's Progress Notes, dated [DATE] at 2:21 AM, signed by LPN #9, revealed the resident was noted to have the Norovirus, and was on the Physician's List to be seen in the morning. Additional review revealed the resident was having nausea and stomach pain, and the nurse would try to keep him/her away from other residents while symptoms persist. Review of the Resident #2's Progress Note, dated [DATE] at 8:51 AM, signed by RN #1, revealed the resident was declining, and per night shift staff, the resident might have aspirated. Per the Note, Resident #2 was pale in color with Temperature 98.7, Pulse 88, Respirations 24, Blood Pressure (B/P) ,[DATE] and Oxygen Saturation 98% (percent) on two (2) liters of oxygen per nasal cannula. Continued review revealed the family was at the bedside, and the Physician would be in to see the resident on rounds. Review of the Physician's Progress Notes, dated [DATE], revealed there was discussion with Resident #2's Power of Attorney (POA) related to the resident's condition and the POA wanted only comfort care for the resident. Further, there was a new order to add PRN (as needed) [MEDICATION NAME] Medication ([MEDICATION NAME] is a narcotic pain medication). physician's orders [REDACTED]. Review of Resident #2's Nutrition Comprehensive Assessment, dated [DATE], signed by the Dietary Technician, revealed the resident did not meet his/her estimated fluid requirement for eight (08) consecutive days from [DATE] through [DATE]; and did not meet the estimated fluid requirement for an additional fourteen (14) consecutive days from [DATE] through [DATE]. Although the Physician was notified of signs and symptoms of the GI illness, there was no documented evidence the Physician or Registered Dietician (RD) was notified Resident #2 was not meeting his/her estimated fluid intake from [DATE] through [DATE], with the exception of [DATE], or that the resident was not consuming any fluids from [DATE] through [DATE]. Review of Resident #2's Progress Note, dated [DATE] at 3:57 AM, signed by LPN #8, revealed the nurse was called to the resident's bedside and there was no signs of life. The resident's son was at the bedside and an order was received to release the body to the funeral home of choice. Interview with RN #1, on [DATE] at 8:59 AM, revealed she had been assigned to Resident #2 on a consistent basis and was aware the resident was ill with GI symptoms including loose stools toward the end of [DATE] and beginning of [DATE]. Per interview, several residents were ill with the [MEDICAL CONDITION] that was going around the facility. She further stated once Resident #2 tested positive for the Norovirus, he/she declined quickly and became bed ridden. She stated she did not have documented evidence she reviewed the resident/s fluid intake or notified the Physician and RD of decreased fluid intake during the resident's illness. 2. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #3 resided on the St. Joseph Terrace unit. Review of the Nutrition Comprehensive Assessment, dated [DATE], signed by the Dietary Technician, revealed Resident #3's estimated fluid requirement was 1,715 mls per day. Additional review revealed the resident received a regular diet with thin liquids. Resident #3's physician's orders [REDACTED]. Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirement of 1,715 mls from [DATE] through [DATE], twenty-four (24) consecutive days. Review of Resident #3's Progress Note, dated [DATE] at 7:03 PM, signed by RN #3, revealed the resident had a small amount of emesis this evening, and was afebrile with temperature of 98.8. However, there was no documented evidence the the Physician was notified of the resident's low fluid intake or GI illness symptoms. Interview with RN #3 on [DATE] at 11:35 AM, revealed when she wrote the Note dated [DATE], she should have reviewed Resident #3's resident's fluid intake and notified the Physician the resident was not meeting his/her fluid requirement. Further, she should have notified the Physician of the resident's symptoms of GI illness when she noted the resident vomiting. She stated it was the responsibility of the nurse to notify the physician of a change in condition. However, she stated there were several residents ill with the [MEDICAL CONDITION], and she did not recall notifying the physician of any resident not meeting their estimated fluid requirement, or notifying the Physician when the residents were noted to have loose stools or vomiting. Review of the Progress Note, dated [DATE] at 11:33 AM, signed by RN #1, revealed the resident was having difficulty eating. Vital signs: Blood Pressure (B/P) ,[DATE], Pulse 64, Respirations 20, Temperature 98.8 and refused oxygen. POA notified of the above. Review of the subsequent Progress Note dated [DATE] at 11:44 AM, signed by RN #1, revealed the nurse spoke with the resident's POA and if the resident should decline further he/she should be sent out. Resident #3 was receiving [MEDICATION NAME] medication, and did not meet his/her fluid requirement from [DATE] through [DATE]. In addition, the resident had substantially decreased fluid intake starting [DATE]. The following fluid intake was documented. On [DATE], zero (0) mls of fluid; [DATE], 515 mls of fluid; [DATE], 240 mls of fluid; [DATE], 120 mls of fluid; [DATE], 240 mls of fluid; [DATE], 35 mls of fluid; and [DATE], 360 mls of fluid. However, there was no documented evidence the Physician was notified of the resident's low fluid intake until [DATE]. Resident #3's Change of Condition Note, dated [DATE] at 1:38 PM, signed by RN #9, revealed the resident seemed different than usual, food/fluid intake was decreased, and the resident was unable to eat/drink adequate amounts and the Physician was notified. Review of the Progress Note, dated [DATE] at 5:27 PM, signed by LPN #3, revealed the resident was seen by the Physician on rounds today and new orders were received. Additional review revealed the resident's diet was changed to puree and the Physician did not want the resident fed if lethargic related to this being a choking hazard. Resident #3's POA was made aware of the new orders. Review of the Physician Orders, dated [DATE], revealed orders for a diet change to Pureed Diet with Honey Thick Liquids, Chest X-Ray, CBC (Complete Blood Count- (blood test to measure red blood cells, white blood cells and platelets), CMP (Comprehensive Metabolic Panel-a blood test to check status of kidneys, liver, electrolytes, blood sugar, and blood proteins) and [MEDICATION NAME] 500 milligrams (antibiotic medication) by mouth for seven (7) days for aspiration pneumonia. There was no documented evidence the Registered Dietician (RD) was notified the resident was not meeting his/her fluid requirement [DATE] through [DATE], or notified of the substantial decrease in fluid intake [DATE] through [DATE]. Review of Resident #3's Progress Note, dated [DATE] at 8:05 AM, signed by LPN #5, revealed the resident's eyes were closed and he/she was not responding to verbal stimuli. Vital signs: Temperature 97.8, Pulse 84, Respirations 16, Blood Pressure ,[DATE]. Oxygen saturation 90% (percent) on two (2) liters of oxygen via nasal cannula. Per the Note, the resident was flushed, lung sounds were diminished to anterior fields, and abdomen was soft and non-distended with positive bowel sounds x four (4) quadrants. A call was placed to the POA concerning the resident's condition, and the POA wanted the resident to be transferred to the Emergency Department (ED) for further evaluation. The Hospital Discharge Summary, dated [DATE], revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The patient improved with rehydration with intravenous (IV) fluids with gradual return to baseline and Acute Kidney Injury resolved. Further review of the Discharge Summary, revealed due to the patient's ongoing chronic issues, he/she was a candidate for hospice and was discharged back to the facility on [DATE] with hospice. Review of Resident #3's Progress Note, dated [DATE] at 7:43 PM, signed by RN #4, revealed the resident arrived back to the facility via ambulance. Review of the Hospice Care Long Term Care Status Form, dated [DATE], revealed Resident #3 was being admitted to hospice with terminal [DIAGNOSES REDACTED]. Review of the Nutrition Comprehensive Assessment, dated [DATE], completed by the RD, revealed the resident's estimated fluid requirement was 2,050 mls per day, and the resident did not meet the requirement for twenty-four (24) consecutive days from [DATE] through [DATE]. Further review revealed Resident #3 was at high nutritional risk related to decline in condition which had impacted ability to chew, swallowing, appetite, and weight status. According to the Note, the resident had been refusing oral intake, had been combative with staff, and the family opted for Hospice Care while the resident was hospitalized . Additionally, the RD spoke to the resident's POA, who stated she wanted no aggressive measures pursued including no labs, no feeding tube and no IV fluids, and the POA's wishes were communicated to the interdisciplinary team. Review of the Discharge MDS Assessment, dated [DATE], revealed the resident was discharged related to death on [DATE]. 3. Review of Resident #11's closed medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #11 resided on the St. Joseph Terrace Unit while a resident at the facility. Review of the Nutrition Comprehensive Assessment, dated [DATE], signed by the Dietary Technician, revealed Resident #11's estimated fluid requirement was 2,160 mls per day, and the resident received a regular diet with no nutritional supplements. Additional review revealed the resident was at moderate nutritional risk related to Diabetes Mellitus Type 2, and did not follow a diabetic diet due to preferring a regular diet. Resident #11's physician's orders [REDACTED]. Review of the Progress Notes, dated [DATE] at 5:35 PM, signed by the DON, revealed Resident #11 was having liquid/watery bowel movements, and symptoms of virus. However, there was no documented evidence the Physician was notified of the change in condition. Interview with the DON, on [DATE] at 3:37 PM, revealed she should have notified the Physician of Resident #11's GI symptoms when she wrote the Note on [DATE]. Review of Resident #11's Progress Note, dated [DATE] at 5:25 PM, signed by RN #9, revealed the resident had no emesis or diarrhea at this time. Review of the Progress Note, dated [DATE] at 1:31 AM, signed by LPN #9, revealed the resident was lethargic and not trying to assist while care was being provided. Review of the Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirements from [DATE] through [DATE], nineteen (19) consecutive days. Further review revealed there was no documented evidence the Physician or Registered Dietician (RD) was notified of the resident not meeting his/her estimated fluid requirement from [DATE] through [DATE], even though the resident was having loose stools and was lethargic. Resident #11's Progress Note, dated [DATE] at 7:58 AM, signed by RN #8, revealed the resident was assessed as having a congested cough, sluggish skin turgor and dry mucous membranes, and the nurse was awaiting call back from the Physician. Review of the subsequent Progress Note, dated [DATE] at 9:44 AM, signed by RN #8, revealed the Physician returned the call and was informed Resident #11 was refusing to eat or drink anything, was very lethargic and may need fluids. Orders were obtained to send the resident to the Hospital ED for further evaluation if the resident's POA was in agreement. Review of the Hospital Discharge Summary, dated [DATE], revealed the facility transferred Resident #11 to the ED related to concerns of course cough, decreased oral intake, and the possibility the resident had become dehydrated over recent days, as the resident had diarrhea for nearly two (2) weeks. The patient was a Do Not Resuscitate code status, and the family decided overnight they wanted NO treatment except comfort care and wanted the patient to return to the facility for end of life care. Additional review revealed the patient was treated for [REDACTED]. Per the Summary, Active Hospital Problems [MEDICAL CONDITION], and End of Life Care. The Discharge MDS Assessment, dated [DATE], revealed the resident died at the facility on [DATE]. Interview with RN #3, on [DATE], revealed she was frequently assigned to Resident #11 during the time he/she was ill with the GI illness. She further stated the resident had been in isolation related to the GI illness and was having diarrhea off and on prior to being hospitalized related to dehydration. Per interview, there should have been documented evidence of a hydration assessment, fluid intake review and notification to the Physician and RD related to GI symptoms, and decreased fluid intake. 4. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #4 resided on the St. Joseph Terrace. Review of the Nutrition Comprehensive Assessment, dated [DATE], signed by the Dietary Technician, revealed the resident's estimated fluid requirement was 2,450 mls per day. Review of the Progress Note, dated [DATE] at 1:00 PM, written by Certified Nurse Aide (CNA) #5 revealed the resident was having loose stools and complaining of nausea which was reported to the nurse. However there was no documented evidence the Physician was notified of the loose stools and nausea. Review of Resident #4's Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her estimated fluid requirements of 2,450 ml's per day from [DATE] through [DATE]. Review of the Progress Notes, dated [DATE] at 4:39 AM, signed by LPN #9, revealed the resident was noted to have three (3) loose stools and complained of nausea. However there was no documented evidence the Physician was notified of the loose stools or of the resident not meeting the estimated fluid requirements. Review of the Progress Notes dated [DATE] at 10:28 AM, signed by RN #1, revealed the resident was up in the recliner with loose stool noted, and fluids were encouraged. Interview with RN #1 on [DATE] at 8:59 AM, revealed she had been assigned to Resident #4 and had written the Note dated [DATE] at 10:28 AM, related to the resident having loose stools. She stated she should have performed a hydration assessment, reviewed the resident's fluid intake, and notified the Physician of the resident having loose stools and decreased fluid intake. Review of the Laboratory Report, revealed the stool sample collected on [DATE], revealed positive results for Norovirus on [DATE]. There was no documented evidence the Physician was notified of the resident's signs and symptoms of GI illness, and no documented evidence the Physician and RD were notified of the resident's low fluid intake from [DATE] through [DATE]. Review of the Progress Note, dated [DATE] at 2:11 PM, signed by RN #8, revealed the resident was noted to have increased weakness, increased bilateral lower extremity [MEDICAL CONDITION] and respiratory distress. The resident's oxygen saturation was at eighty-four percent (84%) on two (2) liters of oxygen via nasal cannula. Continued review revealed the head of the bed was elevated, and the resident was educated to take deep breaths. Per the Note, Resident #4 stated he/she had been having diarrhea for a while now and felt miserable. Further, the resident's POA was notified of the change in condition and wanted the resident to be sent out to the hospital to be evaluated, and the Physician was notified. Interview with RN #8, on [DATE] at 3:20 PM, revealed on [DATE], she assessed Resident #4 and determined he/she needed to be transferred to the hospital ED for further evaluation. She stated she was familiar with the resident and was often assigned to him/her; however, she did not recall reviewing the resident's fluid intake, or performing a hydration assessment of the resident during [DATE] and [DATE] when the resident was having GI illness. Further, she did not recall notifying the physician of the resident's symptoms of GI illness until [DATE]. Review of Resident #4's Hospital Discharge Summary, dated [DATE], revealed the patient was admitted on [DATE]. Per the Discharge Summary, the patient was hospitalized related to Shortness of Breath, Acute Kidney Injury, Respiratory Distress, [MEDICATION NAME], Diarrhea Infectious Origin, Acute [MEDICAL CONDITIONS] and Acute [MEDICAL CONDITION]. [MEDICAL CONDITION] or Pneumonia could not be ruled out considering the patient had been sick for a week, and the resident was started on [MEDICATION NAME] (antibiotic medication) and [MEDICATION NAME] (antibiotic medication) empirically. According to the Discharge Summary, blood culture results on [DATE] were negative. Continued review revealed the diarrhea had stopped, and suspicion for Norovirus resolved, but the patient's prognosis was poor as the patient appeared to have some air hunger. According to the Discharge Summary, the patient was discharged to hospice care at home with daughter on [DATE]. Interview with RN #3, on [DATE] at 12:22 PM, revealed she was assigned to Resident #4 after the resident was transferred from the Mariam unit to the St Joseph Terrace unit on [DATE]. She stated several residents had been experiencing GI symptoms and when a resident exhibited these symptoms they were to be quarantined in their rooms with isolation precautions and the DON was to be notified. Continued interview with RN #3, revealed she had not been completing hydration assessments on Resident #4 and other residents who were ill and she was not aware of who was reviewing the meal/fluid consumption sheets. However, she stated any resident experiencing GI symptoms was at risk for dehydration and therefore it would be important to monitor fluid intake closely and assess for signs and symptoms of dehydration. Further, the Physician should be notified of any resident with a change in condition such as a GI illness in order for the Physician to make a decision related to treatment including hydration interventions. 5. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Nutrition Comprehensive Assessment, dated [DATE], signed by the Dietary Technician, revealed the resident had an estimated fluid requirement of 1,720 ml daily. physician's orders [REDACTED]. Review of the Progress Notes, dated [DATE] at 2:28 PM, signed by RN #3, revealed the resident was noted to have a liquid watery stool. However, there was no documented evidence of Physician notification. Review of Resident #5's Progress Notes dated [DATE] at 12:09 PM, signed by RN #8, revealed the resident had emesis and diarrhea this AM (morning), and the POA was notified. However, there was no documented evidence of Physician notification. Review of the Progress Note, dated [DATE] at 1:07 PM, signed by RN #1, revealed the resident continued to have large loose watery stools throughout the day and fluids were offered. However, there was no documented evidence of Physician notification. Review of Resident #5's Resident Meal Consumption and Fluid Intake Record, revealed the resident did not meet his/her fluid requirement from [DATE], through [DATE], fifteen (15) consecutive days. There was no documented evidence the Physician was notified of the loose stools starting [DATE], nor was there documented evidence the Physician or Registered Dietician (RD) was notified of the resident's low fluid intake. Review of the Progress Note, dated [DATE] at 1:22 PM, signed by RN #8, revealed the CNA alerted the nurse the resident looked ill and had a high heart rate, The Physician was notified and orders were received to transfer the resident to the hospital ED for further evaluation. Interview with RN #8, on [DATE] at 3:20 PM, revealed she was assigned to Resident #5 on [DATE], when the resident was transferred to the Hospital ED. Per interview, she had not been informed of the resident not eating or drinking prior to [DATE], but stated she was aware the resident was having signs and symptoms of the [MEDICAL CONDITION] on [DATE], according to the Note she wrote on that date. Further interview revealed on [DATE] when the resident was noted to have signs and symptoms of GI illness, she should have performed a hydration assessment, reviewed the resident's fluid intakes, and notified the Physician of her findings. Review of the Hospital Discharge Summary, dated [DATE], revealed the resident was admitted on [DATE] and discharged back to the facility on [DATE]. Reason for hospitalization listed as Acute [MEDICAL CONDITION], Urinary Tract Infectious Disease, Chronic [MEDICAL CONDITION], Depression, Anxiety, [MEDICAL CONDITION], Hypercholesteremia, [MEDICAL CONDITION], Primary [MEDICAL CONDITION] involving multiple joints and Hypertension. Hospital Course/Significant Findings:[MEDICAL CONDITION] with Urinary Tract Infection improved with treatment. Discharge Diagnosis: [REDACTED]. Condition at Discharge: Good. Review of the facility Progress Note, dated [DATE] on 5:41 PM, revealed the resident returned to the facility via ambulance at approximately 5:00 PM. 6. Review of Resident #12's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's Nutrition Comprehensive assessment dated [DATE], signed by the Dietary Technician, revealed the resident's estimated (TRUNCATED)

Based on interview, record review, and review of facility Policies, it was determined the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one (1) of nineteen (19) sampled residents (Resident #1). According to Resident #1's Progress Note, dated 09/05/19, the resident complained of dysuria (painful urination) and the resident's Power of Attorney (POA) left a note for staff stating the Physician should be notified in order for a urinalysis to be ordered. A urinalysis, culture and sensitivity (UA/C&S) was ordered on [DATE]; however, the specimen was not collected and sent to the lab timely. Review of the Laboratory Report, revealed the urine specimen collected on 09/08/19 and reported on 09/12/19, indicated the urinalysis results met criteria to perform urine culture for Staphylococcus Aureus and sensitivity completed. However, there was no documented evidence the Physician was notified of the results of the UA/C&S reported to the facility on [DATE], until 09/18/19, six (6) days later, and there were no new orders obtained on 09/18/19 related to the UA/C&S results. physician's orders [REDACTED]. On 09/19/19, the resident exhibited increased confusion; however, there was no documented evidence the Physician or POA was notified of the change in condition. Review of the Laboratory Report, for the urine specimen collected on 09/18/19 and reported on 09/21/19, indicated the urinalysis results met criteria to perform urine culture for Staphylococcus Aureus and sensitivity completed. However, there was no documented evidence the Physician was notified of the UA/C&S results with the exception of the Physician's initials on the report which was undated. On 10/02/19 the resident was noted to have periods of disorientation and altered cognition, was lethargic and was noted to fall asleep during meal times. However, there was no documented evidence the Physician or POA was notified of the change in condition. On 10/06/19, the resident had further change in condition, including runny nose, coughing with any oral intake, and hallucinations, and later became unresponsive, with B/P (blood pressure) documented as low 98/58, and 106/51. On 10/06/19, the resident was transferred to the Hospital Emergency Department (ED) for evaluation and admitted with Acute Altered Mental Status; Urinary Tract Infection; [MEDICAL CONDITION]; Hypothermia Secondary to UTI [MEDICAL CONDITION]; Dehydration; and [MEDICAL CONDITION], secondary to UTI. (Refer to F-580 and F-657) The findings include: Review of the facility Nursing Service: Notification of Changes Policy, undated, revealed the facility shall promptly notify the resident and/or resident representative and his or her physician or delegate of changes in the resident's condition or status, in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. Review of the facility Resident Bill of Rights document, undated, revealed residents have the right to be informed of their condition and treatment and receive adequate and appropriate health care and support services. Review of Resident #1's closed medical record revealed the facility admitted the resident on 09/16/15 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, initiated 12/27/16, revealed a focus of frequently incontinent of bladder. The goal stated the resident would be clean, dry, and odor free daily; and the resident would remain free from skin breakdown due to incontinence, pressure, and brief use with a target date of 06/13/19. Interventions included: use disposable briefs, change every two (2) hours and as needed; check for incontinence every two (2) hours, with toileting and as required for incontinence; wash, rinse and dry perineum and change clothing as needed after incontinence episodes; and monitor/document for signs or symptoms of Urinary Tract Infection [MEDICAL CONDITION] including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. However, the Care Plan did not include interventions for notification to the Physician if signs and symptoms of UTI. (Refer to F-657) Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/10/19, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for bed mobility, transfer and toileting. Continued review revealed the facility assessed the resident as requiring extensive assistance of one (1) person for personal hygiene, and locomotion on and off the unit. Per the MDS Assessment, the resident was assessed as frequently incontinent of urine and always continent of bowel. Review of the Progress Note, dated 09/05/19 at 6:19 AM, revealed the resident complained of dysuria (pain when urinating). Further, the Power of Attorney (POA) was concerned pain may indicate UTI. The POA left a note stating the resident had been complaining of pain upon urination and the POA wanted the Physician notified in the morning in order for a urinalysis to be ordered. Continued review revealed fluids were encouraged and will continue to monitor. Review of Resident #1's Progress Note, dated 09/05/19 at 8:41 AM, revealed the resident was assessed for complaints of dysuria due to the note left by the POA last night stating the resident was complaining of burning when urinating. Resident states, I did yesterday. Further review revealed fluids were encouraged and will monitor. Review of physician's orders [REDACTED]. Review of the Progress Note, dated 09/05/19 at 10:27 AM, revealed new physician's orders [REDACTED]. Review of Resident #1's Progress Note, dated 09/10/19 at 10:32 PM, revealed the resident was resting comfortably in bed with no complaints of dysuria or signs and symptoms of hematuria (blood in urine) noted. Urine culture pending. No signs and symptoms of discomfort or distress noted at this time. Review of the Progress Note, dated 09/07/19 at 11:53 AM, revealed night shift collected a urine specimen for UA/C&S. Further, no hematuria or dysuria noted at this time. Review of Resident #1's Progress Note, dated 09/08/19 at 12:22 AM, revealed the resident's urine was obtained on 09/06/19, but the specimen was not picked up by the lab related to no order entered for lab to pick up the urine on 09/07/19. A new order was entered for the lab to pick up the resident's urine on 09/09/19. No signs or symptoms of dysuria or hematuria noted. Review of the Progress Note, dated 09/08/19 at 7:46 AM, revealed urine was collected via clean catch and ready to be picked up by lab. Urine light amber and cloudy with no odor noted. No complaints of dysuria and no hematuria noted. Review of the Laboratory Report results, revealed the urine specimen was collected 09/08/19 and reported 09/12/19 at 2:54 PM. Results- cloudy, three (3) plus blood, two (2) plus protein, three (3) plus leukocytes, six (6) to twenty (20) RBC (red blood cells) (reference range less than six (6), WBC (white blood cells) greater than fifty (50) (reference range less than six (6), few bacteria (reference range negative). Continued review revealed the urinalysis results met criteria to perform urine culture. Less than 10,000 CFU/ml Proteus sp, no sensitivity to be done. Per the urine culture 40-50,000 CFU/ml (forty to fifty thousand colony forming units per milliliter) Staphylococcus Aureus and sensitivity completed for Staphylococcus Aureus. New physician's orders [REDACTED]. There was no documented evidence the resident's Physician was notified of the results of the UA/C&S reported on 09/12/19 until 09/18/19, six (6) days later. A Progress Note, dated 09/18/19 at 3:11 PM, written by Licensed Practical Nurse (LPN) #1, revealed the Laboratory Report was reviewed by the Physician at this time. Review of the Progress Note, dated 09/17/19 at 4:13 PM, written by RN #2, revealed a urine specimen was collected and placed in the refrigerator for the lab to collect tonight. Review of the Progress Note, dated 09/19/19 at 3:58 PM, written by LPN #1, revealed the resident had increased confusion this shift. After meal service, the resident stated, Do I wear oxygen all the time? I had it on yesterday and I'm not sure where I'm supposed to be, what am I doing? Have I eaten at all today? There was no documented evidence the Physician or POA was notified of the resident's increased confusion. Review of the Progress Note, dated 09/20/19 at 1:00 AM, revealed a urinalysis culture was still pending at this time. No increased behaviors noted this shift. Per the Note, the resident was resting quietly in bed, and PO (by mouth) fluids encouraged during awake hours. No acute signs of distress noted. Temperature 97.8 degrees Fahrenheit. Review of the subsequent Progress Note, dated 09/20/19 at 1:50 PM, revealed the urine culture was pending, and the resident was afebrile with no increased confusion noted. Will continue to monitor and encourage fluids. Review of the Laboratory Report, revealed a urine specimen was collected 09/18/19, for UA with culture if indicated, and reported 09/21/19 at 5:52 PM. Results-urine cloudy, one (1) plus blood, two (2) plus protein, three (3) plus leukocytes, twenty one (21) to fifty (50) RBCs (reference range less than six (6), WBCs greater than fifty (50) ( reference range less than six (6) and few bacteria (reference range-negative). Continued review revealed the urinalysis results met criteria to perform urine culture. Less than 10,000 CFU/ml Proteus sp, no sensitivity to be done, and less than 10,000 CFU/ml mixed skin flora, no sensitivity done. Further review revealed per the urine culture 10-50,000 CFU/ml (ten to fifty thousand colony forming units per milliliter) Staphylococcus Aureus, and sensitivity was completed for Staphylococcus Aureus. Review of the Progress Note, dated 09/21/19 at 3:56 PM, written by RN #2, revealed the urine culture indicated 10-50,000 CFU/ml (ten to fifty thousand colony forming units per milliliter) Staphylococcus Aureus, less than 10,000 CFU/ml Proteus sp, no sensitivity to be done, and less than 10,000 CFU/ml mixed skin flora, no sensitivity done. Review of the record revealed no documented evidence the Physician was notified of the results with the exception of the Physician's initials on the report which was undated. Interview with RN #2, on 01/17/2020 at 10:59 AM, revealed she could not recall if she notified the Physician of Resident #1's UA/C &S lab results on 09/21/19. Per interview, after laboratory results were received, the Laboratory Report was to be faxed to the Physician unless it was urgent and then the nurses should call the Physician with the results. Further interview revealed the Physician was responsible to make the determination whether or not medication would be prescribed. Review of the Progress Note, dated 10/02/2019 at 2:09 PM, written by LPN #1, revealed Resident #1 was noted to have periods of disorientation and altered cognition. Further, the resident was lethargic and falls asleep during meal times. Upon verbalizing needs, Resident #1 stutters and there is a delay in communication. He/she will make statements saying, I haven't eaten today after having finished a meal, and state, I don't know what to do. Will continue to monitor. Further review of the Progress Note, revealed no documented evidence the Physician or POA was notified of the resident's change in status. Interview with LPN #1, on 01/28/2020 at 4:10 PM, revealed when a resident had a change of condition, an assessment should be completed and the Physician should be notified. Further, the Nurse Manager, Director of Nursing (DON), and Administrator should be notified. She stated at the time she wrote the Progress Note dated 09/19/19 at 3:58 PM, she did not consider increased confusion a change in condition for Resident #1 as he/she was ninety-nine (99) years old and was going to have some level of confusion. Per interview, she thought the issue of whether Resident #1 had a UTI had been addressed with the urine cultures. However, she stated in hindsight, she probably should have notified the Physician of the resident's increased confusion on 09/19/19 because this could be a sign of a UTI in the elderly. Further interview with LPN #1, revealed Resident #1 was having increased confusion when she wrote the Progress Note dated 10/02/19. She stated the resident would fall asleep, but he/she was ready to die, and the POA wanted him/her to live to be one hundred (100) years old. LPN #1, further stated she was aware Resident #1 had a history of [REDACTED]. However, she stated she should have notified the Physician of the resident's change in condition on 10/02/19. She stated the Physician came to the facility twice a week and there was always a Physician on call. Review of the Progress Note, dated 10/06/19 at 11:50 AM, written by RN #1, revealed Resident #1's tongue was slightly swollen, and she could not make sense of some of his/her speech. Per the Note, she placed a call to ST (Speech Therapy) for evaluation. Review of the subsequent Progress Note, dated 10/06/19 at 12:55 PM, written by RN #2, revealed the resident had increased sinus drainage and was coughing with all intake of liquids and solids. Per the Note, the resident complained of a headache, and clear nose and eye drainage was noted. Tylenol (pain medication) was administered. Additional review of the Progress Note, revealed RN #2 placed a call to the on call physician, on 10/06/19 at 1:05 PM. Review of the Progress Note, dated 10/06/19 at 6:15 PM, written by RN #2, revealed the resident was unresponsive, and unable to speak to the nurse or other staff members. B/P (blood pressure) very low 98/58, and 106/51. Per the Note, the resident had a runny nose, and had been coughing on all intake today, hallucinations. Call made to Physician this afternoon, with no return call. Per the note, the resident was transferred to the POA's preferred Hospital emergency room (ER) for evaluation, and the Physician, POA, and Administrator were notified. Interview with RN #2, on 01/17/2020 at 10:59 AM, revealed she contacted speech therapy regarding the resident's swollen tongue on 10/06/19. She stated she was the nurse that sent the resident to the hospital due to the resident was not himself/herself and vital signs were abnormal for the resident. Per interview, the resident was admitted to the hospital with [REDACTED]. Review of the Progress Note, dated 10/06/19 at 11:59 PM, revealed Resident #1 had been admitted to the hospital with [REDACTED]. Review of the Hospital Emergency Department (ED) Provider Notes, dated 10/06/19, revealed the patient meets criteria for [MEDICAL CONDITION] with presumed infection based on [MEDICAL CONDITION] Campaign guidelines. Further review revealed final impression as follows: 1. Acute altered mental status 2. Urinary Tract Infection 3. [MEDICAL CONDITION] 4. Hypothermia secondary to Urinary Tract Infection and [MEDICAL CONDITION] 5. [MEDICAL CONDITION] without active bleeding 6. [MEDICAL CONDITION], chronic and stable 7. Acute on chronic [MEDICAL CONDITION] 8. Dehydration 9. [MEDICAL CONDITION] secondary to UTI Review of the Hospital History and Physical Note, dated 10/06/19, revealed routine urine culture obtained per straight catheter, collection time 10/06/19 at 7:31 PM. Culture result greater than 100,000 CFU/ml Staph Aureus. Review of the Hospital Discharge Summary, dated 10/13/19, revealed discharge Diagnosis: [REDACTED]. Further review revealed according to the daughter, over the past two (2) weeks, the patient had been more lethargic and not acting his/her usual self. Continued review of the Hospital Discharge Summary, revealed the patient's daughter had been concerned he/she might have a UTI given previous incidences with similar onset; however, the nursing home told her they checked the patient's urine twice without signs of infection. EMS reported the resident was hypotensive and was given bolus of intravenous (IV) fluids. Further review revealed in the ED, the patient was found to be hypothermic, with a rectal temperature of 93.2 and was placed on a bair hugger. A work up in the ED included a Computed Tomography (CT) Scan of the head that showed no acute findings, and CT of the chest showed mild interstitial [MEDICAL CONDITION] and small bilateral effusions. [MEDICATION NAME] 0.75 (test to detect high levels of [MEDICATION NAME] in the blood that may be an indication of lack of oxygen), BUN 28 High (Blood Urea Nitrogen is a test to check kidney function), Creatinine 1.73 (test to check kidney function), BNP 142 (Brain Natriuretic Peptide is a test to check for heart failure). UA showed small leukocytes, positive [MEDICATION NAME], and greater than 100 WBCs. The patient received IV fluids [MEDICAL CONDITION] protocol and two (2) grams [MEDICATION NAME] (antibiotic medication), and was admitted for further workup and management. Additional review of the Hospital Discharge Summary, revealed the patient's AMS (Altered Mental Status) due to acute toxic and metabolic [MEDICAL CONDITION], was back to baseline; EEG (electroencephalogram) indicated generalized slowing; UTI [MEDICAL CONDITION], Urine culture growing staph. Will continue IV antibiotics [MEDICATION NAME](antibiotic medication) and switch to oral antibiotics at discharge; ARF (Acute [MEDICAL CONDITION]), has stage 3 CKD ([MEDICAL CONDITION]); and [MEDICAL CONDITION], may be drug induced or due [MEDICAL CONDITION]. Further review revealed discussed with family aggressive versus palliative approach at this time and they chose to enroll in palliative care. Hospice referral to be made. Phone interview with Resident #1's POA, on 01/24/2020 at 4:32 PM, revealed Resident #1 had been complaining of burning on urination and the POA reported this to the facility nurses around the first part of September 2019. Continued interview revealed the resident was clearly deteriorating and the symptoms were classic symptoms of a UTI for this resident. Per interview, at the POA's request the facility completed urine testing (UA) and informed her (POA) the urine testing was normal. Per interview, she actually saw the documentation of the urine testing and there had been culture and sensitivity completed. The POA further stated when the resident was in the hospital, the NP (Nurse Practitioner) asked why the facility didn't treat the resident and informed her the resident's urine was not clear and had pus. The POA stated she repeatedly told the facility nurses she felt the resident had an infection, but the resident was not treated and the facility did not have an Infection Control Nurse at the time. Further interview revealed after the resident was hospitalized , she had a meeting with the facility and was advised by the Administrator it could be illegal for the facility to have treated the resident with antibiotics due to antibiotic stewardship, but the POA stated Resident #1 did have presenting symptoms of a UTI and the culture and sensitivity did show Staph Aureus. Further interview revealed Resident #1 was discharged from the hospital on hospice. Interview with the Director of Nursing (DON), on 01/17/2020 at 4:00 PM, revealed the Physician made the determination regarding treating UTIs. However, she stated when Resident #1 had the change of condition including lethargy, disorientation, altered cognition, and falling asleep during meals, the Physician should have been notified. Per interview, the Physician should be notified of any changes in condition, and the nursing staff should have recognized this resident could have had a UTI due to presenting symptoms given the resident's history of UTIs. Further interview revealed after Resident #1's discharge from the facility, a family meeting was held, and the family questioned the Physician regarding treatment related to the UA/C&S results. The DON stated the Physician was at the meeting and reported he did not feel the UA/C&S results for Resident #1 met the criteria for treatment; however, she did not know if the nurses made the Physician aware of the resident's lethargy, and increased confusion because there was no notification to the Physician documented until 10/06/19, the day the resident was transferred to the hospital. Interview with the Physician/Medical Director, on 01/17/2020 at 5:10 PM and 01/31/2020 at 9:18 AM, revealed he told Resident #1's family the resident's urinalysis/C &S did not meet criteria for treatment. However, he stated at the time, he spoke with the family, he was unaware the resident had symptoms including disorientation, altered cognition, and lethargy during the timeframe of the urine results reported. Further interview revealed staff should have notified him when Resident #1 had the change in condition and he did not recall being notified. He stated if the nursing staff had notified him about the resident's signs and symptoms of a UTI, and changes in mental status, he would have ensured further treatment was ordered. Interview with the Interim Administrator, on 02/01/2020 at 5:14 PM, revealed the previous Administrator no longer worked at the facility. Further, the Administrator stated he did not work at the facility during the time Resident #1 resided at the facility. However, he stated as Interim Administrator, it was his expectation staff notify the Physician for any change in a resident's condition in order for the Physician to be able to to make an informed decision related to necessary care and treatment, as failure to do so could be detrimental to the residents.

Based on interview, record review and review of the facility's policy and Incident/Accident Report, it was determined the facility failed to ensure services were provided in accordance with each resident's written Comprehensive Care Plan for three (3) of fifteen (15) sampled residents (Residents #2, #3 and #11). Resident #2's Comprehensive Care Plan dated 04/17/14, revealed the resident was to be transferred with a Hoyer lift for all transfers. However, on 11/12/14, Resident #2's care plan intervention was not implemented for the Hoyer lift, and staff transferred the resident using a stand and pivot transfer with two (2) staff's assistance. Resident #2's left leg got caught during the transfer on the button which raised the side rails up and down, resulting in the resident sustaining a large deep laceration to his/her left leg, and also causing a skin tear to the left shin. Resident #2 was transferred to the hospital emergency room (ER) where he/she received eighteen (18) staples to the laceration. (Refer to F-323) Additionally, Resident #2's care plan was not followed regarding notification of the Physician for a change in the resident's skin condition. On 05/19/15, an open area was noted to Resident #2's second finger on the left hand per documentation; however, there was no documented evidence the Physician was notified of this information until 05/21/15 (two {2} days later), after Surveyor intervention. (Refer to F-314) In addition, Resident #3's care plan was not implemented related to notification of the Physician for changes in the resident's skin condition. Resident #3 was noted to have an open area to the sacrum on 03/30/15; however, there was no documented evidence the Physician was notified of the area until 04/06/15, (seven {7} days later) when the area was then identified to be a partial thickness wound (Stage II Pressure Ulcer). Also, Resident #3's care plan was not followed regarding monitoring the resident's skin condition during care. As evidenced by, staff being unaware of the resident having a Stage I Pressure Ulcer to the right heel, until a skin assessment conducted with the Surveyor on 05/20/15. (refer to F-314) Review of Resident #11's Comprehensive Care Plans revealed a behavior care plan with interventions which included one (1) on one (1) time as necessary, encourage activities, redirection/reorientation, reassurance as needed. Continued review of the Comprehensive Care Plan revealed Resident #11 was care planned for incontinence of bowel and bladder and to wear adult briefs with goals including the resident would be clean and dry. However, observation and interview revealed Resident #11's Comprehensive Care Plans were not implemented when the resident was repeatedly yelling for help and yelling he/she needed to pee on 05/20/15, during his/her roommate's skin assessment/dressing change which was performed by two (2) nurses. Neither nurse attempted to assist Resident #11 or attempted to obtain assistance for Resident #11 by ringing the call light to request help for the resident. In addition, the nurses failed to attempt to re-assure Resident #11 or provide the toileting assistance needed. (Refer to F-246) The findings include: Review of the facility's policy titled, Care Planning, undated, revealed a resident's personalized care plan was to reflect all services provided to the resident to attain or maintain the individual resident's highest practicable physical, mental and psychological well-being. Continued review revealed the care plan would address the interventions required to assist the resident to meet their goals. Interview with the Director of Nursing (DON) on 05/22/15 at 6:00 PM, revealed the facility's expectation was for residents' care plans to be followed. 1. Record review revealed the facility admitted Resident #2's on 04/10/12, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #2 to have short term and long term memory loss, not to have ambulated and to require total assistance of two (2) staff with bed mobility. Review of the resident's Comprehensive Care Plan, dated 04/17/14, revealed the facility had care planned Resident #2 as at risk for falls related to the resident having contractures, being unable to sit or stand unsupported, receiving an antidepressant medication, not being able to make his/her needs known and requiring total care. Continued review of the risk for falls care plan revealed the goal stated Resident #2 would be free of serious injury related to falls, with interventions which included use of a geri-chair when up and out of bed for proper positioning, repositioning the resident as needed and use of a Hoyer lift for all transfers. Review of the facility's Incident/Accident Report, dated 11/12/14, revealed on 11/12/14 at 7:30 PM, an incident/accident occurred when two (2) staff transferred Resident #2 without using the Hoyer lift. Continued review revealed during the transfer Resident #2 sustained a large deep skin tear to his/her lower left leg calf muscle and a small skin tear to the left shin. Further review revealed a section labeled additional comments which noted the Certified Nursing Assistants (CNAs) needed to use the Hoyer lift per the resident's care plan. Review of Resident #2's Clinical Notes Report dated 11/13/14 at 1:59 AM, revealed it was regarding the incident which occurred on 11/12/14 at 7:30 PM, and was documented by Registered Nurse (RN) #1. Per the Report, two (2) nurse aides were attempting to transfer Resident #2 from the geri-chair to bed, for which the resident was care planned to have a Hoyer lift used for all transfer. Continued review revealed the nurse aides did not use the Hoyer Lift for the transfer, and during the transfer Resident #2's lower leg got caught on the button which lowered the bed's side rail and the resident sustained [REDACTED]. Interview was attempted on 05/20/15 at 11:30 AM with Resident #2 without success. Interview, on 05/22/15 at 10:30 AM and 2:30 PM, with Licensed Practical Nurse (LPN) #1, revealed on 11/12/14, she had still been a CNA and had been assigned to Resident #2's care that night. Per interview, there was a book at the nurse's station which the CNAs referred to for residents' CNAs Care Plan which specified how the resident was to be transferred. She stated the CNAs also had a sheet which they carried in their pocket which specified the transfer technique to be used for a resident. According to LPN #1, she had been trained to follow residents' care plans prior to the incident on 11/12/14, and was aware Resident #2 was to be transferred with a Hoyer lift. Per the LPN, she and another CNAs, who was no longer working at the facility, were attempting to transfer Resident #2 from the geri-chair to the bed; however, the Hoyer lift pad under the resident was not positioned correctly. LPN #1 revealed they tried adjusting the lift pad under the resident, but Resident #2 fit too snugly in the geri-chair and they were not able to get the lift pad repositioned or the resident repositioned to be able to use the Hoyer lift. Continued interview they pushed the Hoyer lift out of the way, and decided to attempt a two (2) person transfer using a gait belt with their arms under Resident #2's arms. LPN #1 revealed Resident #2 was able to bear some weight as he/she used to use the Sara Lift (a standing and raising aid). According to LPN #1, however, they had never attempted to transfer Resident #2 using a stand and pivot of two (2) staff before. She stated they assisted Resident #2 to stand first to see how the resident would do, which he/she did with no problem. LPN #1 revealed as they started pivoting Resident #2 his/her leg got caught on the bed's push button (used to raise and lower the side rails), and the resident sustained [REDACTED]. Further interview revealed she was counseled by RN #1, as well as, the DON and had received education related to following the care plan after the incident. Phone interview with RN #1 on 05/22/15 at 11:30 AM, revealed Resident #2 was care planned for transfer with a Hoyer lift; however, on 11/12/14, the CNAs had tried to do a two (2) person transfer instead of using the Hoyer lift when they were transferring the resident. According to RN #1, Resident #2's leg got caught during the improper transfer and as a result the resident sustained [REDACTED]. He stated if the CNAs were unable to get the lift pad under the resident properly in order to use the Hoyer lift, they should have informed him for instructions before proceeding with a transfer. Continued interview revealed the facility's process was for the CNAs to check the CNA Care Plans for residents' transfer technique and also to read the communication board at the nurse's station for any updates to residents' care at the beginning of each shift. RN #1 stated he wrote the CNAs, involved in Resident #2's improper transfer, up for not following the resident's care plan related to the transfer technique. Further interview revealed RN #1 performed rounds to check to ensure residents were receiving care as per their care plans including the transfer technique to be used. Phone interview was attempted with CNA #1 on 05/22/15 at 2:30 PM, who was no longer employed by the facility; however, contact with CNA #1 was unsuccessful. Interview with the Unit Coordinator (UC) and the DON on 05/22/15 at 2:50 PM, revealed per the DON, all staff when hired were inserviced regarding following residents' care plans and on transfer techniques. According to the DON, interview with the Staff Development Nurse (SDN) who inserviced new hires, was not possible at the time as he/she was off on leave and was unable to be reached for telephone interview regarding the inservicing related to following the care plans or transfer techniques. The DON revealed when the CNAs determined they would not be able to utilized the Hoyer lift for Resident #2 on 11/12/14, they should have obtained assistance from the nurse in order for him to assess the situation and find the best way to transfer the resident. Per interview, this incident would not have happened had the CNAs transferred Resident #2 with the Hoyer Lift as per his/her care plan. Further interview revealed it was his expectation for nurses to do rounds during the shift to ensure residents' care plans were being followed and for CNAs follow residents' care plans interventions. Interview with the Administrator on 05/22/15 at 12:00 PM, revealed staff had used an improper transfer technique which resulted in Resident #2 sustaining a laceration because the CNAs had not followed the resident's care plan. Further interview revealed the facility's expectation was for staff to follow residents' care plans. Continued review of Resident #2's medical record revealed a Significant Change MDS assessment dated [DATE], which noted the facility continued to assess the resident as having both short term and long term memory loss. Continued review of the Significant Change MDS revealed the facility assessed Resident #2 to require total assistance of two (2) staff for bed mobility, transfers and bathing and to require extensive assistance of one (1) person for hygiene. Further review of the 04/15/15, MDS Assessment revealed the facility assessed Resident #2 as having one (1) Stage II Pressure Ulcer (P.U.). Review of Resident #2's Comprehensive Care Plan dated 04/16/15, revealed the facility had care planned the resident as at risk for skin breakdown related to [MEDICAL CONDITION], contractures and being dependent on staff for his/her Activities of Daily Living (ADL's). Continued review of the at risk for skin breakdown care plan revealed the goal stated Resident #2 would be free of skin breakdown related to incontinence and pressure. Further review of the care plan revealed interventions which included monitoring the resident's skin during care for signs and symptoms of skin breakdown, such as, warmth, redness, non-blanchable skin; and notifying the Physician if signs and symptoms were observed for further evaluation. Review of Resident #2's physician's orders [REDACTED]. Review of the May 2015 Monthly physician's orders [REDACTED]. Observation during a skin assessment for Resident #2 on 05/21/15, from 10:00 AM through 11:00 AM, performed by LPN #2/Wound Nurse and RN #2/Wound Nurse, revealed the resident had contractures of the left and right hand. Observation revealed a soft glove on the left hand and the fingers of the gloves were between each finger, and the right hand had a palm protector in place. Continued observation revealed, during the skin assessment, a Stage II P.U. was identified by the nurses on Resident #2's left hand on the second finger at the first joint, between the second and third fingers which measured 1.3 centimeters (cm) in length by (x) 1.3 cm in width with a red wound bed and redness in the surrounding area. Interview during the skin assessment with LPN #2/Wound Nurse and RN #2/Wound Nurse revealed they were both unaware of the area on Resident #2's left hand, and both agreed it was a Stage II Pressure Ulcer. Continued interview, on 05/21/15 at 11:00 AM, at the time of the skin assessment and at 5:20 PM, with LPN #2/Wound Nurse revealed she had completed a [MEDICATION NAME] treatment to Resident #2's left hand yesterday and the P.U. area was not there at that time. Per interview, she placed wash cloths or gauze between the resident's fingers and in his/her contracted hands, as well as, placed palm protectors. LPN #2/Wound Nurse revealed she checked Resident #2's hands and fingers once or twice a day on the days she worked. Review of the Clinical Notes Report, dated 05/19/15 at 11:47 AM, completed by LPN #1, revealed Resident #2 had a small circular open area noted on the left hand between the second and third digit (finger) with a yeast odor noted. Continued review of the Clinical Notes Report revealed LPN #1 documented the area on Resident #2's finger was cleansed with Normal Saline (N/S), dried, and [MEDICATION NAME] Powder was applied per the treatment plan. Interview with LPN #1 on 05/22/15 at 9:00 AM, revealed she had last completed the treatment of [REDACTED].#2's left hand on 05/19/15. She stated at the time she did the treatment on 05/19/15, Resident #2 had palm protectors between both hands, but she was unsure if the resident had anything between his/her fingers. Continued interview revealed she did not realize there was a new area and had not checked the Nurse's Notes because she thought the treatment for [REDACTED]. Further interview revealed on 05/19/15, between Resident #2's fingers on the left hand there appeared to be an open area; however, she did not measure or stage the open area/wound. According to LPN #1, per Resident #2's care plan she was to notify the MD if there was a new area of skin breakdown but, she had not realized the open area was a new area. Interview, on 05/21/15 at 5:15 PM, with RN #4 revealed she was the nurse assigned to Resident #2 on 05/20/15, and she was notified yesterday, 05/20/15, of the resident having an open area on the finger of his/her left hand by LPN #1, who did not mention whether she (LPN #1) had notified the Physician or not. Further interview revealed she thought LPN #2/Wound Nurse was notified of the open area yesterday, 05/20/15 and it was the facility's protocol to notify the Wound Nurse of any areas of skin breakdown. Further review of Resident #2's Clinical Notes Reports and physician's orders [REDACTED].#2's open area on the finger of the left hand for signs and symptoms of further skin breakdown, such as, warmth, redness, non-blanchable skin; and Physician notification if signs and symptoms were observed. Review of the physician's orders [REDACTED]. Phone interview on 05/22/15 at 3:40 PM, with Resident #2's Attending Physician revealed Resident #2 had contracted hands. Per interview, even though Resident #2 had an order in place for [MEDICATION NAME] Powder when the Stage II Ulcer to his/her finger was identified, he (the Physician) would need to be notified for additional treatment orders because the [MEDICATION NAME] would just be an adjunctive (used with a primary treatment) treatment for [REDACTED]. 2. Observation of a skin assessment conducted on 05/20/15 at 2:45 PM until 4:00 PM, by LPN #2/Wound Nurse, revealed Resident #3 had a sacral wound which was a Stage III P.U., that measured 3.1 cm in length x 2 cm in width and the Wound Nurse stated there was not a depth to measure. Per LPN #2/Wound Nurse, the area was twenty-five percent (25%) slough with pink granulating (the newly formed vascular tissue normally produced in healing of wounds of soft tissue) tissue and a red beefy center. Record review revealed Resident #3's [DIAGNOSES REDACTED].U., [MEDICAL CONDITIONS] with [MEDICAL CONDITION] (paralysis), Dementia with Behavioral Disturbance and [MEDICAL CONDITION]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #3 as having a Brief Interview for Mental Status (BIMS) score of a fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed Resident #3 as requiring extensive assist of two (2) for bed mobility, transfers, and toilet use, as not ambulating, as frequently incontinent of bowel and bladder and as having a healed Stage II Pressure Ulcer. Review of Resident #3's Comprehensive Care Plan dated 10/03/14, revealed the facility care planned the resident as at risk for skin breakdown related to Diabetes Mellitus, decreased mobility, [MEDICAL CONDITIONS], Pain, history [MEDICAL CONDITIONS] and fragile skin. Continued review of the at risk for skin breakdown care plan revealed the goal stated Resident #3 would be free of skin breakdown related to incontinence and pressure. Further review of the MDS revealed interventions which included monitoring Resident 3's skin during care for signs and symptoms of breakdown, such as, redness, warmth, nonblanchable skin and notifying the Physician for further treatment. Review of the Clinical Notes Report dated 03/30/15, completed by RN #1, revealed Resident #3 had two (2) open areas on the buttocks, and the nurse had visualized the left buttock area as approximately a fourth (1/4) inch round open area, and the area above the rectum between the buttocks as approximately an eighth (1/8th) of an inch wide and approximately a 1/4 to three eighths (3/8th) inch long slit. Continued review revealed the areas were creamed with a protective paste; however, there was no documented evidence the Physician was notified of the areas, as per the care plan. Interview with RN #1 on 05/21/15 at 5:00 PM, revealed he did not inform the Physician of the areas of skin breakdown on Resident #3's buttocks areas, and was not sure why he did not inform the Physician right away. RN #1 stated Resident #3 already had [MEDICATION NAME] Ointment (an [MEDICATION NAME],skin protectant cream) ordered which had been used. Review of Resident #3's March and April 2015 Medication Administration Record [REDACTED]. Also, RN #1 reviewed Resident #3's Comprehensive Care Plan with the Surveyor, and stated he had not followed the resident's care plan related to notification to the Physician for new areas of skin breakdown for further treatment; however, should have. Record review revealed documentation of a Skin Assessment performed by LPN #2/Wound Nurse on 04/05/15, which noted there was an open area to Resident #3's center buttock which was a partial thickness wound that measured 2.0 cm in length x 0.6 cm in width x 0.2 cm in depth. Continued review of the Skin Assessment documentation noted by LPN #2/Wound Nurse revealed the open area had pink tissue, clear yellow drainage and [MEDICATION NAME] Ointment was applied. However, further review of the Skin Assessment revealed no documented evidence the Physician was notified of the wound on 04/05/15, by LPN #2/Wound Nurse, as per the care plan. Further observation of the skin assessment for Resident #3 on 05/20/15 at 2:45 PM, performed by LPN #2/Wound Nurse revealed the resident's right heel was red and the Surveyor asked the nurse to describe the area. LPN #2/Wound Nurse pushed on Resident #3's right heel and reported it was soft and boggy, but blanchable (turning lighter and then returning to normal skin color) and was not a Stage I Pressure Ulcer. However, observation by the Surveyor revealed there was no blanching observed when the nurse pushed on the heel. The Surveyor asked LPN #2/Wound Nurse to have Resident #3's heels off loaded (removal of pressure by elevation off of a surface) so the right heel area could be re-checked in approximately thirty (30) minutes to see if the heel was still red. The Surveyor also requested LPN #2/Wound Nurse bring another nurse in with her at that time, for a second opinion related to the resident's heel. Resident #3's heel was off loaded at 4:00 PM. Additional observation by the Surveyor on 05/20/15 at 4:50 PM, with LPN #2/Wound Nurse and RN #2/Wound Nurse revealed Resident #3's right heel area was palpated and remained red (nonblanchable) even though the heel had been off loaded for fifty (50) minutes. RN #2/Wound Nurse assessed the right heel area and described it as a Stage I P.U., which measured 3.8 cm in length x 4.2 cm in width. Further review of Resident #3's record revealed no documented evidence staff had identified the area on the resident's right heel prior to the skin assessment conducted with the Surveyor on 05/20/15. Review also revealed no documented evidence Resident #3's skin including the right heel had been monitored during care, as per care plan. Interview, on 05/22/15 at 9:00 AM, with LPN #1 revealed she was the nurse assigned to Resident #3 on 05/19/15, on the day shift,and she did the treatment to the resident's left foot that day. LPN #1 revealed however, an entire skin assessment was not completed by her, and she did not notice any redness to Resident #3's right heel. Per interview, she had not been notified by staff of the the area to Resident #3's right heel. Interview, on 05/21/15 at 7:10 PM, with LPN #3 who was assigned to Resident #3 on 05/19/15 from 11:00 PM until 7:00 AM on 05/20/15, revealed she was not really familiar with the resident as she was hardly ever assigned to him/her. However, LPN #3 did remember Resident #3 having redness to the right heel while he/she was in bed. Continued interview revealed she did not realize the area was new however, and did not check to see if there was a treatment ordered or check the Nurse's Notes to see if the area had been previously identified. LPN #3 revealed she did not inform anyone of the red area to Resident #3's right heel, and the resident already had orders for protective boots. Phone interview on 05/22/15 at 3:40 PM, with Resident #3's Attending Physician revealed his expectation was for either him or one (1) of the providers to be notified of any new areas of skin breakdown, and the Physician or other provider would assess the new areas, triage them, and send the resident to the hospital Wound Clinic. Continued interview revealed the Physician would need to see any new open wound, even if there was an order in place for treatment to the area. The Physician revealed this was needed in order to decide if there was a need for an additional treatment for [REDACTED].#3 who had an order for [REDACTED]. Continued interview on 05/22/15 at 6:00 PM with the DON and the UC revealed the UC explained the facility had recognized communication was a concern when staff found a P.U. or other types of skin breakdown. The UC revealed when new skin breakdown was observed all the nurses on all shifts, as well as, the Physician should be notified, as per the care plan; however, the facility had recognized this was not occurring. Continued interview with the UC revealed the facility's protocol for when a new area of skin breakdown was found, was for the nurse to put the information regarding the area on the 24 Hour Report and the next day one (1) of the facility's two (2) Wound Nurses was to measure and stage the wound; however, the follow through did not always occur. Further interview revealed the UC felt residents' skin was to be monitored during care by both the CNAs and the nurses. Per interview, it was all the nurses' responsibility to ensure this occurred during care, as per the resident's care plan. The DON revealed the care plan should be followed related to skin issues and if new skin breakdown was noted the Physician should be notified as per the Care Plan. The DON revealed the facility was in the middle of a Performance Improvement Plan (PIP) which was started about three (3) weeks ago and was headed by RN #2/Wound Nurse. According to the DON, the PIP was put in place because the facility had recognized there were problems with P.U., Physician notification and documentation. However, he stated there had been no recent inservicing or education performed for the facility's nursing staff. 3. Review of Resident #11's medical record revealed [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS of a five (5) out of fifteen (15) indicating severe cognitive impairment. Continued review of the MDS Assessment revealed the facility assessed Resident #11 as having verbal, physical and other behaviors. Further review revealed the facility assessed Resident #11 as requiring extensive assistance of two (2) staff for bed mobility and transfer, and total assistance of two (2) staff for toilet use and as always being incontinent of bowel and bladder. Review of Resident #11's Comprehensive Care Plan dated 11/19/14, revealed the facility care planned the resident for an alteration in behavior related to Anxiety, Dementia and Delusional Disorder as evidenced by repeatedly calling out help me, please help me, also got verbal with staff and swatted at staff. Continued review of the alteration in behavior care plan revealed the goal stated Resident #11's behaviors would be easily altered and occur less often with interventions which included one (1) on one (1) time as necessary, encourage activities, redirection/reorientation, and reassurance as needed. Additionally, review of the Comprehensive Care Plan dated 05/15/15, revealed the facility had care planned Resident #11 to be incontinent of bowel and bladder and to wear adult briefs. Continued review of the incontinence care plan revealed the goals stated Resident #11 would be clean and dry, with interventions which included to check the resident every two (2) hours and as needed for episodes of incontinence, and to have the call light in reach when he/she was in his/her room and answer the call light in a timely manner. During observation of a dressing change/skin assessment for Resident #3, who was Resident #11's roommate, on 05/20/15 from 2:45 PM until 4:00 PM, it was observed Resident #11 yelled help me, help me intermittently throughout the dressing change/skin assessment. LPN #2/Wound Nurse and RN #6, an orientee, were conducting the skin assessment and dressing changes for Resident #3; however, neither LPN #2/Wound Nurse nor, RN #6 attempted to determine what Resident #11 needed or required, and did not leave Resident #3's bedside to find out. In addition, the nurses did not ring the call bell for someone to come and help Resident #11. Continued observation revealed at 3:55 PM, Resident #11 yelled, I have to pee, and then intermittently continued to call out I have to pee, until finally Resident #11 yelled I peed. Further observation revealed however, LPN #2/Wound Nurse and RN #6/Orientee neither one (1) responded to Resident #11 yelling he/she needed to pee, and they continued performance of the dressing change/skin assessment of Resident #3 at his/her bedside. Neither nurse rang the call light for assistance for Resident #11. Observation revealed at 4:00 PM, another staff member from the hallway responded to Resident #11's yelling and came to assist Resident #11. Interview, on 05/20/15 at 4:10 PM, with LPN #2/Wound Nurse and with RN #6/Orientee, both nurses revealed they had not rang the call bell to get assistance for Resident #11, or attempted to assist Resident #11 themselves when the resident was yelling for help and yelling he/she needed to pee. LPN #2/Wound Nurse stated she did hear Resident #11 yelling for help and saying he/she needed to pee; however, the nurses had not attempted to assist the resident because they were busy with Resident #3. Further interview revealed one (1) of them should have washed their hands and gotten help for Resident #11. Further interview, on 05/22/15 at 6:00 PM, with the UC and the DON revealed all nurses were responsible for ensuring resident's care plans were followed. The UC stated the nurses should have rang the call bell and attempted to assist or get assistance for Resident #11, when the resident was yelling for help and needing to go to the bathroom. She stated Resident #11 normally yelled and might have confusion; however, the nurses should have attempted to help the resident.

Based on observation, interview, record review and review of the facility's policy and Incident/Accident Report, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of fifteen (15) sampled residents (Resident #2). Resident #2 was assessed by the facility to require total assistance of two (2) persons for transfers per the Minimum Data Set (MDS) assessment dated [DATE]. According to the Comprehensive Care Plan dated 04/17/14, Resident #2 was to be transferred with a Hoyer lift for all transfers. However, on 11/12/14, Resident #2 was not transferred, as per the care plan, and was transferred with a stand and pivot transfer with two (2) staff and a gait belt. Resident #2's leg got caught during the transfer on the side rail button which raised the side rails up and down and the resident sustained [REDACTED]. Resident #2 had to be sent to the hospital emergency room (ER) as a result and received eighteen (18) staples to the lacerated area. The findings include: Review of the facility's policy titled, Incident/Accident, undated, revealed incidents and accidents were to be reported immediately to the Charge Nurse, and the Physician was to be notified in a timely manner. Per the Policy, the nursing notes should include interventions to prevent re-occurrence. Review of Resident #2's medical record revealed the facility admitted the resident on 04/10/12, with [DIAGNOSES REDACTED]. Review of the Fall Assessment Tool and Guidelines for Use, dated 07/16/14, revealed Resident #2's risk factors for falls included: over the age of eight (80); having confusion at all times; and requiring assistance with elimination. Continued review of the Assessment Tool revealed Resident #2 was not assessed to be at risk for falls as a score of ten (10) or above placed residents at risk for falls, and the resident scored nine (9). Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #2 as having both short term and long term memory loss. Further review revealed the facility assessed the resident as requiring total assistance of two (2) for bed mobility and transfers, and as ambulation not occurring. Review of Resident #2's Comprehensive Care Plan of Care, dated 04/17/14, revealed the resident was at risk for falls related to: requiring total care; having contractures; receiving Celexa (an antidepressant medication); unable to make needs known; and was unable to sit or stand unsupported. Continued review of the risk for falls care plan revealed interventions which included: repositioning the resident as needed; geri-chair when up and out of bed for proper positioning; and Hoyer lift for all transfers. Review of the facility's Incident/Accident Report, dated 11/12/14, revealed on 11/12/14 at 7:30 PM two (2) staff were transferring Resident #2 to bed without the use of the Hoyer lift. The Incident/Accident Report revealed during the transfer Resident #2 sustained a large deep skin tear to the lower left leg calf muscle and a small skin tear to the left shin. Per the Report, the section labeled additional comments revealed the Certified Nursing Assistants (CNAs) needed to use the Hoyer lift as per the Plan of Care. Review of the Clinical Notes Report dated 11/13/14 at 1:59 AM, completed by Registered Nurse (RN) #1, revealed an event occurred on 11/12/14 at 7:30 PM, when two (2) nurse aides went to transfer Resident #2 from the geri-chair to bed. Per the Note, Resident #2 was to have the Hoyer lift used for all transfers per the Plan of Care,but the Hoyer lift was not used for this transfer. Continued review revealed during the transfer Resident #2's lower leg got caught on the button which lowered the bed's side rail and the resident sustained [REDACTED]. The Note revealed the large laceration/deep tissue injury was on Resident #2's lower calf muscle, left leg lateral side ventral surface and measured approximately five (5 ) inches long and one and a half (1.5) inches deep. Further review revealed the wound was packed with Normal Saline (N/S) soaked 4 x 4 sterile gauze, two (2) dry 4 x 4 gauze to cover the wound and then wrapped in roll gauze. In addition, review revealed Resident #2 also received a small skin tear approximately two (2) inches below the other wound on the medial surface of the left shin which was approximately two (2) inches long and steri-strips were applied after cleansing with N/S. Review of the Clinical Note Report dated 11/13/14 at 2:09 AM, revealed the Administrator on duty, the Physician and Resident #2's Power of Attorney (POA) were notified and the resident was transferred to the hospital ER at 8:50 PM. Review of the Hospital ER Notes and Discharge Instructions, dated 11/13/14, revealed Resident #2 arrived in the ER at 9:03 PM, and was diagnosed with [REDACTED]. Per the ER Notes, the laceration was closed with staples and the wound area dressed with a sterile dressing. Continued review of the Notes revealed Resident #2 was given a tetanus immunization prior to discharge. Review of the Discharge Instructions revealed the instructions included: clean wound twice a day and apply Polysporin (an antibiotic ointment); dressing change as needed; keep wound clean and dry; watch for signs and symptoms of infection including redness, swelling or drainage; Tylenol (pain medication) for pain; and return as needed. Further review of Resident #2's medical record Clinical Note Report dated 11/13/14 at 2:15 PM, for the event which occurred on 11/12/14, revealed a nurse from the ER called at 9:55 PM on 11/12/14, and reported Resident #2 had received eighteen (18) staples to the left lower leg and was given a tetanus shot. Further review of the Clinical Note Report revealed Resident #2 arrived back at facility without incident on 11/12/14, at 10:40 PM. Interview was attempted on 05/20/15 at 11:30 AM with Resident #2 without success. Interview, on 05/22/15 at 10:30 AM and 2:30 PM, with Licensed Practical Nurse (LPN) #1, revealed she was still a CNA back on 11/12/14, and was assigned to Resident #2. Continued interview revealed on 11/12/14, she and another CNA, who no longer worked at the facility, were going to transfer Resident #2 from the geri-chair to the bed and were aware the resident's CNA Care Plan stated he/she was to be transferred per the Hoyer Lift. LPN #1 stated however, the Hoyer lift pad under Resident #2 was not positioned correctly in order for them to use the Hoyer lift. She stated they attempted to adjust the lift pad; however, the resident fit too snug in the geri-chair and they were unable to reposition the pad by repositioning the resident and his/her legs. Per interview, they tried to hook up the Hoyer lift to the pad under the resident; however, were unable to do so as it would not reach the way the pad was positioned. LPN #1 stated they then pushed the Hoyer lift out of the way, and attempted to do a two (2) person transfer using a gait belt with their arms under Resident #2's arms. She stated Resident #2 could bear some weight because the resident used to use the Sara Lift (standing and raising aid); however, they had never transferred the resident with a stand and pivot of two (2) staff before. Further interview revealed the two (2) CNAs positioned the geri-chair at the end of the bed facing the head of the bed and stood Resident #2 first to see how he/she would do. LPN #1 revealed Resident #2 stood with no problems so they started pivoting him/her, and the resident's leg got caught on the push button which dropped the side rail. Per LPN #1, Resident #2 sustained a laceration to the leg during the pivot because the push button was sticking out, but there was nothing wrong with the bed or how it functioned. Observation, during the interview, with LPN #1 revealed the type of bed Resident #2 used on 11/14/15, had side rails that when lowered, needed to be pushed in towards the bed in order for the push button (a rectangle shaped device) to recess. LPN #1 revealed she and CNA #1 might not have had the side rail pushed in all the way prior to the transfer causing the push button to stay out. Phone interview with RN #1 on 05/22/15 at 11:30 AM, revealed Resident #2's leg was caught during an improper transfer and the resident sustained [REDACTED]. Continued interview revealed the CNAs had tried to do a two (2) person transfer instead of using the Hoyer lift, as per the care plan, and Resident #2 sustained a laceration to the leg as a result. RN #1 revealed Resident #2 was lying on the bed when he entered the room and assessed the resident and situation, noting the laceration was too deep to treat at the facility. Per interview, he remembered packing the wound and sending Resident #2 to the ER. Further interview revealed if the CNAs were unable to get the lift pad under Resident #2 properly, they should have informed him in order for him to provide additional instructions. Phone interview was attempted with CNA #1 on 05/22/15 at 2:30 PM; however, was unsuccessful and the CNA was never reached. Interview, on 05/22/15 at 2:50 PM, with the Unit Manager (UM) and the DON, revealed on hire all staff was inserviced related to transfer techniques for residents, as well as, following the care plan. He stated the Staff Development Nurse (SDN) was off on leave and unable to be reached for interview at the time. The DON revealed when the CNAs could not reposition the Hoyer lift pad under Resident #2 in order to use the lift, they should have asked for assistance from the nurse, so the nurse could assess the situation and find the best way to transfer the resident. He stated no other resident had ever gotten injured on the beds and Resident #2 would not have been, had the CNAs transferred the resident with the Hoyer lift, as per the care plan. Per the UM, LPN #1 was counseled and educated related to the incident, and CNA #1 was terminated after the incident. Interview with the Administrator on 05/22/15 at 12:00 PM, revealed Resident #2 sustained a laceration due to an improper transfer technique because the resident's care plan was not followed by the CNAs.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for one (1) of fifteen (15) sampled residents (Resident #2). Resident #2 had a history of [REDACTED]. Resident #2 experienced falls while attempting to self ambulate after releasing his/her self releasing alarmed seat belt; however, the facility failed to thoroughly investigate the 05/24/13 fall and failed to revise the plan of care to include effective interventions to prevent further falls. On 06/01/13, Resident #2 fell and was diagnosed with [REDACTED]. The findings include: Review of the facility's policy, "Fall Investigation Committee", undated, revealed the Committee was to share ideas to prevent, reduce and provide safety for the facility's residents. The Committee was to review the circumstances surrounding falls with recommendations made based on the review, the care plan was to be reviewed and new interventions initiated. Review of Resident #2's record revealed the facility admitted the resident on 03/12/12, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 03/05/13, revealed the facility assessed Resident #2 to have a Brief Interview of Mental Status (BIMS) of ninety-nine (99) which indicated the resident was unable to complete the interview. Continued review of the MDS revealed the facility assessed Resident #2 to have short term and long term memory impairment and to be moderately impaired with cognitive skill for daily decision making. The facility assessed the resident to require extensive assistance of one (1) staff for Activities of Daily Living (ADLs) and ambulation; and to be frequently incontinent with bowel and bladder. Review of Resident #2's Comprehensive Care Plan, dated 03/06/13, revealed the facility had determined Resident #2 was at risk for falls related to falls prior to admission to the facility which resulted in a [MEDICAL CONDITION] and repair of the fracture. Review revealed the resident was also at risk for falls related to poor decision making, safety awareness, poor balance and was agitated and restless at times. Interventions on this Care Plan included afternoon rest periods in bed or a recliner from either 2:00 PM or 3:00 PM to 5:00 PM were to be initiated by staff and the resident was to be assisted to a recliner by 7:00 PM or right after dinner. Further review revealed interventions included a quick release alarmed seat belt to his/her wheelchair. Review of the Incident Report and Falls Investigation Report documentation, dated 05/24/13, revealed Resident #2 experienced a fall on 05/24/13 at 5:55 PM, while ambulating independently from his/her wheelchair. Review revealed Resident #2 was found in the common area of the unit on his/her "bottom" with no apparent injury and the chair alarm had not sounded related to dead batteries which were replaced. Further review of the Falls Investigation Report revealed no documented evidence of changes in interventions. Review of the 05/31/13 Physical Restraint Committee Review form revealed Resident #2 had experienced a fall from his/her wheelchair on 05/24/13. Further review of the 05/31/13 Committee form revealed no documented evidence of changes in interventions. Review of Resident #2's Comprehensive Care Plan revealed the care plan had not been revised to address the resident's 05/24/13 fall. Review of the Incident Report, dated 06/01/13 revealed at 11:45 AM, Resident #2 experienced a fall. The Incident Report indicated the resident went into another resident's room, shut the door, and ambulated independently. According to the Incident Report Resident #2 was found on his/her "bottom" and was assessed to have no injuries. Further review of the Incident Report revealed Resident #2 complained of pain "several hours later", an x-ray order was obtained, and results of the x-ray indicated the resident had a right [MEDICAL CONDITION] and was sent to the hospital. Interview, on 07/18/13 at 11:25 AM, with Nursing Assistant (NA) #1 revealed she was not aware of any new interventions added after Resident #2's fall on 05/24/13. Interview, on 07/18/13 at 11:44 AM, with NA #3 revealed she was not aware of any new interventions added after the resident's fall in May 2013. Interview, on 07/19/13 at 3:23 PM, with Licensed Practical Nurse (LPN) #4 revealed she had cared for Resident #2. She stated Resident #2 had a history of [REDACTED]. LPN #4 stated she was not aware of any new interventions being added to the Care Plan after the resident's fall on 05/24/13. Interview, on 07/19/13 at 3:37 PM, with Registered Nurse (RN) #1 revealed he was not aware of any new interventions added to Resident #2's Care Plan to prevent further falls after his/her fall on 05/24/13. He stated when the fall occurred on 05/24/13 the resident's chair alarm didn't sound related to batteries that needed to be replaced. The RN stated the batteries were replaced and the alarm worked after that. RN #1 stated increased supervision of Resident #2 might have helped to prevent further falls from occurring. Interview, on 07/19/13 at 4:20 PM, with RN #5 revealed the resident had a history of [REDACTED]. She stated she was aware Resident #2 had experienced a fall in May 2013. The RN indicated no new interventions were added to the Care Plan to prevent further falls. She stated "we were just following through with our present interventions, nothing changed". According to the RN she thought it would have been good if they could have had increased supervision of the resident and that might have prevented the fall on 06/01/13. Interview, on 06/19/13 at 5:37 PM, with the Minimum Data Set (MDS) Nurse revealed the Care Plan was not revised with new interventions after the 05/24/13 fall. She indicated Resident #2 already had interventions which included a bed alarm, chair alarm, perimeter mattress, and self releasing seat belt with alarm. According to the MDS Nurse, Resident #2 had "pretty much" all interventions available and there was "only so much you can do". Interview, on 06/19/13 at 3:50 PM, with the Unit Manager who was the acting Director of Nursing (DON) revealed all falls were discussed in morning meetings and in the Falls Committee meetings to attempt to determine the root cause of the fall and if new interventions were indicated. She stated the root cause of Resident #2's fall on 05/24/13 was determined to be "dead batteries" in the chair alarm which were replaced. The acting DON stated if the chair alarm batteries had been working, the alarm would have sounded and staff would have been able to get to the resident to prevent the fall on 05/24/13. Per interview, no additional interventions were indicated to Resident #2's Care Plan.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent falls for one (1) of fifteen (15) sampled residents (Resident #2). Resident #2 sustained a fall on 05/24/13 while attempting to self transfer after releasing his/her self-releasing seat belt; however, there was no documented evidence the facility conducted a thorough investigation to determine the root cause of the falls and/or revised fall interventions to prevent further falls. On 06/01/13, Resident #2 sustained another fall while the resident was attempting to ambulate independently and was diagnosed with [REDACTED]. The findings include: . Review of Resident #2's record revealed the facility admitted the resident on 03/12/12, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 03/05/13, revealed the facility assessed Resident #2 to have a Brief Interview of Mental Status (BIMS) of ninety-nine (99) which indicated the resident was unable to complete the interview. Continued review of the MDS revealed the facility assessed Resident #2 to have short term and long term memory impairment and to be moderately impaired with cognitive skill for daily decision making. The facility assessed the resident to require extensive assistance of one (1) staff for Activities of Daily Living (ADLs) and ambulation; and to be frequently incontinent with bowel and bladder. Review of Resident #2's Comprehensive Care Plan, dated 03/06/13, revealed the facility had determined Resident #2 was at risk for falls related to falls prior to admission to the facility which resulted in a hip fracture and repair of the fracture; poor decision making, recall ability, and safety awareness; poor balance; and he/she got agitated and restless at times. Interventions on this Care Plan included staff were to initiate afternoon rest periods in bed or a recliner from 2:00 PM or 3:00 PM to 5:00 PM and assist the resident to recliner by 7:00 PM or right after dinner; and a quick release alarmed seat belt to wheelchair. Review of the Nurse's Note, dated 05/24/13 at 5:55 PM, revealed Resident #2 was "found in common area" on his/her "bottom". The nurse documented the resident had "no injuries" and the alarm on his/her wheelchair did not sound. Further review of the Nurse's Notes revealed no documented evidence the Comprehensive Care Plan was revised to prevent further falls. Review of the Fall Investigation Report dated 05/24/13, revealed at 5:55 PM Resident #2 had been ambulating independently and was found sitting in the "common area" on his/her "bottom" and when asked what happened the resident stated "I don't know". Continued review of the Fall Investigation Report revealed Resident #2 had a chair alarm to his/her wheelchair that did not sound related to the batteries which were replaced. Review of the Physical Restraint Committee Review forms revealed Resident #2 had a quick release "Velcro" alarmed seat belt related to poor safety awareness, unsteady gait, and poor unsupported standing balance since July 2012. Continued review revealed Resident #2 was noted from 07/31/12 to 05/31/13 to "manipulate and release the seatbelt at times". Review of the 05/31/13 Physical Restraint Committee Review form revealed Resident #2 had sustained a fall on 05/24/13 from the wheelchair. Further review of the 05/31/13 form revealed no documented evidence of any changes to the resident's Plan of Care to prevent further falls. Interview, on 07/18/13 at 11:25 AM, with Nursing Assistant (NA) #1 revealed the facility had "sheets" that told NAs what residents care needs were; however, there was not always copies of these "sheets" for NA's to use. She stated she had cared for Resident #2 before she was not aware of any new interventions being put in place after the 05/24/13 fall. Interview, on 07/18/13 at 11:44 AM, with NA #3 revealed she had cared for Resident #2 before. The NA stated she was not aware of any new interventions being put in place after Resident #2's fall in May 2013. Interview, on 07/19/13 at 3:23 PM, with Licensed Practical Nurse (LPN) #4 revealed she had cared for Resident #2. She stated Resident #2 had a history of [REDACTED]. LPN #4 stated Resident #2 tried to stand up on his/her own and would bend over trying to reach for things. According to the LPN, the alarming self-release seat belt "seemed to work" because as soon as he/she took it off the alarm would go off and staff would go to him/her. She stated no new interventions were added that she was aware of after Resident #2's fall on 05/24/13. Interview, on 07/19/13 at 3:37 PM, with Registered Nurse (RN) #1 revealed he was aware of the resident's fall on 05/24/13, however he was unaware of any new interventions being put in place to prevent further falls after that fall. He stated at the time of the 05/24/13 the resident's chair alarm didn't sound related to batteries that needed to be replaced and this was done. The RN stated Resident #2 had an alarming seat belt implemented soon after being admitted to the facility related to him/her attempting to ambulate unassisted. RN #1 indicated Resident #2 had a chair alarm and fall mats in place also. He stated this was related to Resident #2 having several "little" falls prior to the alarming seat belt, chair alarm, and fall mats. The RN stated increased supervision of Resident #2 might have helped to prevent further falls from occurring. Interview, on 07/19/13 at 4:20 PM, with RN #5 revealed she had cared for Resident #2. She stated the resident had a history of [REDACTED]. RN #5 stated Resident #2 had an alarming self-release seat belt which he/she "fooled with a lot" and would get to the edge of the wheelchair seat where he/she would slide out of the chair. According to the RN, she was knew Resident #2 had experienced a fall in May 2013; however, didn't believe any new interventions were added to prevent further falls. She stated "we were just following through with our present interventions, nothing changed". The RN stated staff attempted to keep Resident #2 in the common area for observation; however, no one was assigned to only observe this area, staff had other duties and were busy. Interview, on 06/19/13 at 5:37 PM, with the Minimum Data Set (MDS) Nurse revealed no new interventions were added after the 05/24/13 fall as Resident #2 already had a bed alarm, chair alarm, perimeter mattress, self releasing seat belt with alarm. She stated Resident #2 had "pretty much" all interventions available and there was "only so much you can do". According to the MDS Nurse, the main thing was to try and occupy the resident. Review of the Comprehensive At Risk for Falls Care Plan, dated 03/06/13, revealed no documented evidence of any revisions to prevent further falls after the 05/24/13 fall. Review of the Incident Report, dated 06/01/13 revealed at 11:45 AM, Resident #2 experienced a fall when he/she went into another resident's room, shut the door, and ambulated independently. Review revealed the resident was found on his/her "bottom". Continued review revealed Resident #2 was assessed to have no injuries. Review revealed no documented evidence the resident's alarming seat belt had been on and was functioning properly and no indication if a chair alarm was in place and sounding. Further review of the Incident Report revealed a note which stated, "several hours later resident c/o (complained of) pain, order for x-ray, has right hip fx (fracture), sent to hospital". Review of the Nurse's Note, dated 06/01/13 at 12:57 PM, revealed Resident #2 was "found" on the floor of another's resident's room with the door closed. The nurse documented she assessed Resident #2 before staff assisted him/her back into the chair. Continued review revealed Resident #2's range of motion was within normal limits "for all extremities" and the resident had "no pain". Review revealed the nurse documented "no apparent injuries"; the Power of Attorney (POA) was notified; and a "non-urgent" fax was sent to the Primary Care Physician's (PCP) office. Review of a Nurse's Note, dated 06/01/13 at 3:09 PM, recorded by Registered Nurse (RN) #5, revealed Resident #2's daughter/POA came to visit and reported the resident was "expressing pain" in the right hip. The nurse documented Resident #2 was assessed by herself and another nurse and the resident expressed pain by "yelping out" when his/her leg was raised and lowered. RN #5 documented the resident had facial grimacing with the movement and an x-ray order was obtained. Review of a Nurse's Note, dated 06/01/13 at 3:48 PM, recorded by RN #1 revealed the PCP ordered the x-ray STAT (as soon as possible), the portable x-ray company was called and informed of the order. Review of the physician's orders [REDACTED]. Review of a Nurse's Note recorded by RN #1, at 11:03 PM on 06/01/13, revealed the STAT x-ray had been obtained and revealed "an acute complete femoral neck fracture with complete displacement". The RN documented he contacted the PCP for orders regarding the x-ray results. RN #1 documented at 11:07 PM that Resident #2 was grimacing when his/her right leg was touched and he/she was having pain. RN #1 documented he informed the medication nurse of Resident #2's pain and the resident was to receive Percocet (a pain medication). Review of a Nurse's Note dated 06/01/13 at 11:11 PM revealed the PCP had ordered Resident #2 to be sent to the emergency room (ER) for evaluation. Review revealed the ambulance service was notified and Resident #2 was transported at 8:20 PM. Review of the physician's orders [REDACTED].#2 to the ER for evaluation. Further record review revealed a hospital Discharge Summary dated 06/05/13, that indicated Resident #2 was admitted to the hospital on [DATE] where surgery was performed to repair the resident's fractured hip. Further review revealed Resident #2 was to be discharged from the hospital that day and back to the facility. Interview, on 07/18/13 at 11:25 AM, with Nursing Assistant (NA) #1 revealed on 06/01/13 she came to work at 6:00 PM and Resident #2 was in bed and "looked like" he/she was "sick or something". She indicated the resident was not talking or responding to her questions which was a change for Resident #2. According to NA #1 the resident was to wear an alarming seat belt which was in place on 06/01/13. Interview, on 07/18/13 at 11:44 AM, with NA #3 revealed she had cared for Resident #2 on 06/01/13. She stated she had been on break and came back to the unit between 11:00 AM and 12:00 PM. NA #3 stated she was told Resident #2 had been found in another resident's room on the floor. The NA indicated when she went to the room where Resident #2 was on the floor, she could hear the "alarm going off". She stated the resident wasn't having pain when the nurse was moving his/her arms and legs and inquiring of Resident #2 if she had pain. NA #3 reported she and other staff "got" the resident back up and into his/her wheelchair and took Resident #2 to lunch. She stated she didn't think Resident #2 "ate much". According to NA #3, Resident #2 had probably been wandering up and down the hall as he/she always did. She stated Resident #2 had periods of "antsiness" and was always moving around in his/her wheelchair. The NA stated staff "tried" to keep him/her up by the nurse's station. Interview, on 07/18/13 at 4:16 PM, with RN #1 revealed he had cared for Resident #2 before. He stated he usually came to work at 3:00 PM. The RN indicated when he came to work on 06/01/13 he came into a "mess". He stated he thought he was told by the nurses on duty that Resident #2 had fallen about 12:30 PM that day and the Charge Nurse had assessed him/her and "it didn't look like anything was broken". According to the RN, two (2) other nurses (RN #5 and the wound nurse) told him they thought Resident #2's hip was broken and the Charge Nurse "refused to get an x-ray". RN #1 stated he immediately notified the PCP and obtained an order for [REDACTED]. Interview, on 07/19/13 at 4:20 PM, with RN #5 revealed she had worked on 06/01/13 passing medications; however, was not made aware Resident #2 had fallen until approximately 2:15 PM when Resident #2's daughter/POA came to her and asked her to "check" the resident's right leg. She stated the daughter/POA stated she knew Resident #2 had fallen as someone had called her and informed her of this. The RN stated the daughter/POA told her Resident #2 was in pain and so she obtained pain medication for the resident and administered it. RN #5 stated when she assessed Resident #2's right leg the resident stated "oh, oh" as if in pain. The RN indicated she informed RN #1 as soon as he came in at 3:00 PM and he got an order for [REDACTED]. The RN stated she was sure "everyone had a reason they weren't watching" the resident at the time of the fall. She stated Resident #2 was constantly taking the self release alarming seat belt off and it would sound. RN #5 stated staff just got "used to it going off, like with the little boy who cried wolf" and didn't respond as promptly as they should have she guessed. /1The RN stated she thought it would have been good if they could have had increased supervision of the resident and that might have prevented the fall on 06/013. Interview, on 06/19/13 at 3:50 PM, with the Unit Manager who was the acting Director of Nursing (DON) revealed falls were reviewed daily Monday through Friday in a morning meeting and a meeting was also held every Tuesday to discuss any falls that had occurred. She stated if a resident experienced two (2) falls they were added to the Falls Committee for follow up; however, all falls were discussed at the Falls Committee meetings weekly to attempt to determine the root cause of the fall. She stated Resident #2's fall on 05/24/13 occurred on a Friday and it was discussed in the Monday morning meeting and in the Tuesday Falls Committee meeting. She stated the root cause of Resident #2's fall on 05/24/13 was "dead batteries" in the chair alarm which were replaced. According to the acting DON, had the chair alarm batteries been working, the alarm would have sounded and staff would have been able to get to the resident to prevent the fall. Additional interview, on 07/19/13 at 5:08 PM, with the acting DON revealed Resident #2 was taken out of the Falls Committee in February or March 2013 by the DON as he/she had been free of falls for a while.

Based on observation, interview, record review, review of the facility's policy and review of the acceptable Plan of Correction (POC), it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for residents by providing an environment free from accidental hazards. The Administration failed to ensure the acceptable POC with a compliance date of 09/23/11 was implemented to ensure compliance with F323. Rounds made by maintenance, housekeeping or nursing staff failed to identify that flammable and chemical hazards were stored improperly and not in accordance with the facility's Maintenance Department's policy and procedure, "Toxic and Flammable Liquids". The facility failed to ensure staff was knowledgeable regarding appropriate storage of flammable products. The facility stored flammable products in resident rooms #129A, #129B, #130B and #141B. Refer to F323 The findings include: Review of the acceptable Plan of Correction, from the 09/15/11 survey, with a compliance date of 09/23/11 revealed the Maintenance Director was to perform monthly rounds that incuded a variety of different physical plant issues including environmental safety. Review of the facility's policy, "Toxic and Flammable Liquids" (Storage of), undated, stated "under no circumstances are flammables to be stored in patient areas". 1. Observation, on 11/21/11 at 6:20 PM, revealed an aerosol cannister of hairspray located on the bathroom counter in room [ROOM NUMBER]B. The cannister was labeled with a resident's name. The cannister label noted "Warning: FLAMMABLE, contents under pressure". 2. Observation, on 11/22/11 at 9:30 AM, 1:00 PM and 5:30 PM, revealed an aerosol cannister of Lamar Vitae Hairspray on the bathroom counter in resident room [ROOM NUMBER]B. The manufacturer's instructions noted on the cannister included, "Warning: FLAMMABLE, Contents under pressure. Do not puncture". 3. Observation on 11/22/11 at 9:30 AM, 1:00 PM and 5:30 PM, revealed a aerosol cannister of Lysol Neutra Air on the bathroom counter in resident room [ROOM NUMBER]A. Instructions noted on the label included, "Precautionary statements: hazards To human And domestic animals. Caution: do not spray directly in eyes... Call a poison control center or doctor for treatment advice. Physical hazards: contents under pressure. Do not use or store near heat or open flame. Do not puncture or incinerate container. Exposure to temperature above 130 Farenheit may cause bursting". 4. Observation, on 11/22/11 at 9:30 AM, 1:00 PM and 5:30 PM, revealed a cannister of Airwick Aerosol on the bathroom counter in resident room [ROOM NUMBER]B. The manufacturer's instructions on the label included CAUTION: CONTENTS UNDER PRESSURE CONTAINER MAY EXPLODE IF HEATED. MAY IRRITATE EYES. DO NOT get in eyes, on skin or clothing...FIRST AID TREATMENT; ...If on skin, wash area with soap and water...". Interview with the Maintenance Director, on 11/22/11 at 3:00 PM, revealed he utilized an audit form when making rounds. However, he stated he did not focus his rounds to include the residents' bathrooms. Review of the audit forms revealed no documented evidence the facility had identified the flammable cannisters in resident care areas. Interview with the Director of Nursing (DON), on 11/22/11 at 6:05 PM, revealed most of the nursing staff was probably not aware that aerosol containers of hairspray should not be left in residents' rooms. Interview with the Education Director, on 11/23/11 at 2:00 PM, revealed during new employee orientation it was covered that aerosols must be kept under lock and key. However, further interview revealed a lot of information was shared during the general orientation and that the specific information related to storage of aerosols had not been a focus of in-service education following general orientation. Interview with the Administrator, on 11/23/11 at 3:45 PM, revealed the facility staff was responsible for ensuring the resident areas were free of hazards. Continued interview revealed the random monthly checks performed by maintenance to identify potential hazards focused on the physical environment. Further interview revealed the plan of action developed by the Quality Assurance Committee was focused on facility compliance related to the incident of a resident fall and not all potential environmental hazards.

Based on observation, interviews, and record reviews, it was determined the facility failed to have an effective system in place to ensure an environment free from accident hazards and failed to provide adequate supervision and monitoring for one (1) of twelve (12) sampled residents, (Resident #1). The facility failed to identify the causal factors of a fall, which prevented the facility from implementing effective interventions to prevent the recurrence of accidents. On 09/03/11, Resident #1, while being unsupervised by staff and without staff knowledge, self propelled his/her wheelchair through the unsecured and unalarmed exit door at stairway #3. At approximately 3:45 PM, facility utility staff heard a voice calling for help through an elevator shaft. The utility staff went into stairwell #3 and found Resident #1 lying at the bottom of a flight of six (6) stairs. Resident #1's wheelchair was at the top of the flight of six (6) stairs. Resident #1 sustained bruising to both palms and a skin tear to his/her left elbow. There was no evidence the facility identified the resident as having access to an unsupervised exit door as a causal factor resulting in the facilities failure to implement corrective action to prevent incident recurrence. The facility had assessed and identified five (5) residents, which included Resident #1, as being demented and ambulatory with assistive devices. After review of the facility's Roster Matrix, there were twenty four (24) residents assessed as being independently ambulatory or mobile non-ambulatory with assistive devices who had access to stairwell #3 and who attended activities in the area without being supervised by staff. The facility failed to provide an environment free from accidental hazards and failed to thoroughly investigate the accident to determine causal factors, and implement effective action plans in response. The failure and the facility's non-compliance caused or was likely to cause Resident #1 and other residents, identified as having the potential to access the unsecured exit door, serious injury, harm, impairment, or death to a resident. An acceptable Allegation of Compliance was received on 09/14/11, which alleged removal of Immediate Jeopardy on 09/14/11. On 09/15/11 the State Agency verified the Immediate Jeopardy was removed on 09/14/11, prior to exit. The findings include: Record review revealed the facility admitted Resident #1 on 09/12/07, with [DIAGNOSES REDACTED]. Review of Resident #1's Wandering Assessment, dated 05/24/11, revealed the facility assessed him/her as not being a wander risk. Review of Resident #1's Fall Assessment, dated 05/24/11, revealed the facility had assessed Resident #1 as a risk for falls. Review of Resident #1's Plan of Care, dated 06/24/11, revealed the facility had Resident #1 care planned as a fall risk, cognitive loss related to Dementia, and Glaucoma. The facility placed the intervention to monitor for, anticipate, and intervene for factors causing prior falls, also to orient to facility and environment on admit, reorient confused resident as needed. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 08/22/11, revealed the facility had assessed Resident #1 as having short term and long term memory problems and his/her cognitive skills for daily decision making were moderately impaired. Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS revealed the facility assessed Resident #1 as having one (1) fall for that review period. Interview with Utilities Staff, on 09/10/11 at 6:30 PM, revealed he last saw Resident #1 in the activity room at approximately 3:10 PM when he was gathering the trash. He further stated he looked at the clock before he went to another unit to start gathering trash and it was around 3:40 PM and that was when he went to get on the elevator outside of stairwell #3. He stated he heard a voice calling for help and he preceded to try and locate the person calling for help. Further interview with Utilities Staff revealed when he entered stairwell #3 he saw a wheelchair sitting at the top of a flight of six (6) stairs and when he turned the corner he saw Resident #1 lying at the bottom of the flight of six (6) stairs. Review of the Incident Report, dated 09/03/11, revealed Resident #1 sustained bruising to both palms and a laceration to the left elbow. Review of the Falls Investigation Report, dated 09/03/11, revealed Resident #1 pushed open the stairwell door after leaving the Activity Room, fell and sustained injury to both palms and left elbow. Further review revealed Resident #1 complained of pain was sent to the hospital via Emergency Medical Services (EMS) for evaluation. Observation, on 09/09/11 at 5:00 PM, revealed the door leading to stairwell #3 was able to be accessed by pushing on the door's push bar. There was no locking or securing mechanism in place to prevent the door from being opened by a resident. There was no Wander Guard alarming system in place on the door. Further observation revealed a plastic strip securing the carpet to the first stair was lose and sticking out approximately two (2) inches. Observation, on 09/12/11 at 1:50 PM, revealed the door leading to stairwell #3 remained unsecured and able to be opened by pushing on the push bar. Further observation revealed no staff in the area observing or supervising the unsecured door. Interviews on 09/12/11 at times ranging from 2:00 PM, revealed with License Practical Nurse (LPN) #1 at 3:00 PM, #4 at 3:15 PM , and #3 at 3:20 PM, Certified Nursing Assistant (CNA) #3 at 4:05 PM, #4 at 3:30 PM, and #7 4:30 PM, revealed at no time had Administrative Staff or Supervisors instructed them to increase observation and supervision of the unsecured door leading to stairwell #3. Interview with Maintenance Assistant, on 09/10/11 at 2:15 PM, revealed he had not been told about the incident until sometime later in the week by the Utilities staff who had found Resident #1. He further stated no staff from Administration notified him of the incident nor had they address what to do to secure the door to prevent further accidents with another resident. He further stated he felt with the door left unsecured another resident could have gained access to the area and sustain injury. Interview with the Maintenance Director, on 09/10/11 at 2:00 PM, revealed after the incident occurred the unsecured door should have been addressed to prevent another resident from sustaining a injury. Interview with Registered Nurse (RN) #2, on 09/10/11 at 3:20 PM, revealed she was the nursing supervisor the day the incident involving Resident #1 occurred. She stated no administrative staff addressed increased supervision or observation of the unsecured/unlocked door leading to stairwell #3. She stated the door being unsecured/unlocked had never been addressed with her in anyway related to this incident involving Resident #1. Interview with RN #1, on 09/10/11 at 4:00 PM, revealed she updated Resident #1's Care Plan with the intervention of placing the wander guard on the resident's wheelchair; however, no other interventions were discussed on the date of the incident or during Administrative staff meeting on 09/06/11 when the incident was discussed. Further interview with RN #1 revealed at no time was the unsecured door to stairwell #3 discussed or interventions placed to prevent another resident from entering the area through the unsecured door. Interview with Assistant Administrator, on 09/10/11 at 3:40 PM, revealed the incident had been discussed in the meeting on the following Tuesday, 09/06/11. She further stated the cause of the incident had not been discussed in that meeting and at no time was the unsupervised door to stairwell #3 identified as the cause of the incident. Further interview revealed at no time was the unsecured door addressed as needing to have extra supervision or observation to prevent further accidents with residents who would had access to the area. She further stated by leaving the door unsecured another resident could enter the area leading to another accident in the stairwell. Record review and interview with the Director of Nursing (DON), on 09/10/11 at 2:00 PM, revealed the facility had assessed and identified five (5) residents, which included Resident #1, as being demented and ambulatory with assistive devices. After review of the facility's Roster Matrix, there were twenty four (24) residents assessed as being independently ambulatory or mobile non-ambulatory with assistive devices who had access to stairwell #3 and who attended activities in the area without being supervised by staff. Interview with Director of Nursing (DON) and Administrator, on 09/10/11 at 4:30 PM, revealed the Administrator stated during the meeting with Administrative Staff, the unsecured door was never brought up and no interventions were discussed to be put into place to prevent another accident. Observation, on 09/12/11 at 3:00 PM, revealed an elastic band stretched across the door leading to stairwell #3 with a red stop sign in the middle of the band. The door leading to stairwell #3 was still unsecured and no staff was observed in the area for increased observation or supervision of the unsecured door. Record review and interview with the Director of Nursing (DON) , on 09/10/11 at 2:00 PM, revealed the facility had accessed and identified five (5) residents, which included Resident #1, as being demented and ambulatory with assistive devices. After review of the facility's Roster Matrix, there were twenty four (24) residents assessed as being independently ambulatory or mobile non-ambulatory with assistive devices who had access to stairwell #3 and who attended activities in the area without being supervised by staff. Interview with the DON and Administrator, on 09/12/11 at 6:10 PM, revealed the cause of the incident with Resident #1, on 09/03/11, was the unsecured door leading to stairwell #3. The DON further stated the unsecured door should have been addressed the day of the incident, with staff being in-serviced on and being placed one (1) on one (1) in front of the unsecured door until the Maintenance Director was able to set up an electrician to code and secure/lock the door. Further interview with the Administrator revealed the intervention of placing the stop sign across the unsecured door was not an appropriate intervention to prevent residents from accessing the stairwell and potentially causing another accident. The facility did not to identify the unsecured door as the cause for the incident on 09/03/11, and further failed to place appropriate interventions to prevent further injury to other residents who had access to the unsecured door, placing the residents with access to this door in danger. An acceptable AOC was received on 09/14/11 and the Immediate Jeopardy was found to be corrected prior to exit on 09/15/11. A review of the AOC revealed the following: Immediately on 09/12/11, the facility initiated staff supervision of Terrace level, stairway door #3 by placing staff person, twenty four (24) hours per day, at the door to stairway #3, the root cause of problem, to prevent egress of residents. Staff remained continually until the keypad access was installed and functioning properly. The facility recognizes that the lack of supervision of the door, and the door being unlocked, lead to the "Immediate Jeopardy" of residents. Security personnel and maintenance were responsible for maintaining coverage of staff at Terrace level, stairway door #3, twenty four (24) hours daily until the key pad was installed and functioning properly. All security and maintenance staff have been in serviced one (1) on one (1) by Assistant Administrator, DON, or Maintenance Director on procedures to monitor the door and residents coming to the area to promote safety of all residents. Prior to being stationed at stairway #3 door, staff was instructed to observe resident activity in the area and prevent egress through stairwell door. To prevent further incidents of this nature, the facility will "lock and alarm" the Terrace level, stairway door #3, work to be performed immediately. Staff members will continue to monitor door until keypad is installed and functioning properly. Electrician installing hardware 09/13/11. All staff will be in-serviced on the need of supervision for this and all doors to prevent egress of residents. In-services have been conducted by the Education Director beginning 09/13/11. Staff not in-serviced will not be permitted to work until attending in-service program. A "Quality Assurance Monitor" which monitors all doors being locked and alarmed to ensure resident safety has been developed by the Maintenance Director, and conducted by the Maintenance Director, Maintenance Staff, or Security personnel, three (3) times per day at the beginning/end of each shift, for seven (7) days, once daily for seven (7) days at the beginning/end of day shift, weekly for four (4) weeks on day shift, then monthly on day shift to monitor door being locked and alarmed. Maintenance Director to immediately conduct "Quality Assurance Monitor" on 09/13/11 of all doors checking for security of locks and/or alarms and accessibility to assure all doors being locked and alarmed. Maintenance Director to immediately initiate on 09/13/11 a policy and procedure for securing all entrances/exits for residents safety. In-service for all staff regarding new policy and procedure included in in-services conducted on 09/13/11 by Education Director. Administration has coordinated installation of the keypad on 09/13/11 and any other repairs and enhancements of the door security/alarm system. Administration has participated in any policy and procedure creations or revisions and had final approval for all such creations or revisions and assured staff was knowledgeable on any new or revised policies. The following corrective measures taken by the facility were validated as completed prior to the survey exit on 09/15/11: Observations made on 09/13/11 and 09/14/11 revealed staff were sitting at the door leading to stairwell #3. Interviews with those staff on 09/14/11 and 09/15/11 revealed the Maintenance Director and DON had in-serviced them on the reason for the one (1) on one (1) observation of the door. Record review of the one (1) on one (1) sign on/off sheet revealed staff was to sign, name, date, and time when they started the observation of the door and time they were relieved. Further review of the sign on/off sheet revealed instructions for staff to observe for residents in the area and to prevent egress through stairwell door. Record review, on 09/13/11, revealed staff were in-serviced addressing the reason for the one (1) on one (1) observation of the door leading to stairwell #3. Further review revealed signatures of staff on the form indicating they had been instructed to observe the area for residents and to prevent egress through the stairwell #3 door. Interview with the Maintenance Director, on 09/13/11 at 4:40 PM, revealed he had instructed all staff who were to do the one (1) on one (1) observation of the door, to sign in and out on the sheet, to use the radio to call for help if a resident was trying to egress or they needed a break, and to never leave the door until another staff whom had also been in-serviced could take over the post. Observation and interviews, on 09/13/11, revealed the electrician for a contracted company was installing a lock/alarm mechanism for the door leading to stairwell #3. Interview with the electrician, on 09/13/11 at 3:00 PM, revealed the lock would be functioning by the end of the day; however, the parts for the alarm would not be in until the following day. He further stated the door would be a lock/alarm door, if the bar to open the door was pushed without the code being entered the alarm would sound to alert staff someone was trying to bypass the code. Observation of the door, on 9/13/11 at 5:00 PM, revealed the locking mechanism was functioning, the door was secured and a code had to be entered for the door to be opened. Interview with the Maintenance Director, on 09/14/11 at 3:00 PM, revealed the electrician was still working on the wiring for the alarm; therefore, staff continued with the one (1) on one (1) observation of the door until the electrician was done and the door was secured. Interview with the Education Director, on 09/14/11 at 2:00 PM, revealed she had began the in-services with staff on 09/13/11. Review of the in-service,"Resident safety-Doorway access and supervision" revealed the facility had in-serviced staff on door safety and awareness for resident safety, instructions for responding to a door alarm going off, and review of the new policy and procedure titled, "Maintenance" dated 09/13/11. Further interviews conducted with staff from 09/13/11 at 2:00 PM, to 09/14/11 at 4:00 PM, revealed staff was knowledgeable of the policy regarding doorway access and supervision and material covered in the in-service provided by the Education Director. Further interview with the Education Director revealed any staff not at work will be mandated to attend the in-service before returning to work. She stated she had made a list of all staff who had not attended the in-service and had forwarded a copy to their supervisor to ensure they were not permitted to work the floor until they attended the in-service. A review of the monitoring tool the Maintenance Director created revealed daily monitoring of the doors which were locked and/or alarmed was conducted on 09/13/11, and was on going. Interview with the Maintenance Director, on 09/14/11 at 3:30 PM, revealed he planned to continue to perform the monitors per the AOC. He further stated he had in-serviced the Maintenance Assistant and security staff to perform the monitors when he was not in the facility. The monitors will be reviewed weekly by the Administrative Staff in the weekly meetings to address if the monitors were effective and to ensure interventions placed were effective. On 09/14/11 at 3:30 PM, an environmental tour with the Maintenance Director revealed all doors were secured and functioning properly on Terrace level. When the door to stairwell #3 was tested and the alarm sounded, staff responded to the area in under one minute. Observation of door to stairwell #3 revealed the electrician had finished installing the alarm and it was secured and functioning at this time. Interviews with the Maintenance Director, DON, and Assistant Administrator, conducted on 09/14/11, revealed the monitors would be reviewed daily in Administrative Staff meetings and when determined appropriate would then be reviewed weekly in the Quality Assurance meetings. Interview with the DON, on 09/15/11 at 11:00 AM, revealed the Administrative Staff held a meeting and discussed the coordination of placing staff on continuous observation of the door leading to stairway #3 until the electrician could secure and alarm the door. He stated the Administrator, Assistant Administrator, and himself have been and will continue to work directly with the Maintenance Director and Education Director to continue to monitor and address issues, on a daily basis. He further stated that once the Maintenance Director and Administrator had finalized the new policy and procedure "Maintenance" they had a meeting and reviewed the final draft and then it was given to the Education Director to incorporate into the in-service. The State Agency determined the Immediate Jeopardy was removed on 09/14/11, prior to exit, which lowered the scope and severity to an "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities.

Based on observation, interview, record review, facility policy review, facility audit review, and 09/15/11 Facility Plan of Correction review, it was determined the facility failed to ensure the environment was free from accidental hazards in four (4) residents' rooms. The facility failed to follow their toxic Flammable Liquids policy and procedure. The facility failed to ensure flammable aerosol cannisters were stored in non resident areas and that staff was knowledgeable of the policy and storage requirements. Flammable aerosol cannisters were observed stored in resident rooms #129A, #129B, #141B, and #130B. Additionally, the facility failed to ensure compliance through implementation of their plan of correction related to the 09/15/11 survey which identified deficient practice at this tag. The findings include: Review of the facility's policy, "Toxic and Flammable Liquids" (Storage of), undated, revealed under no circumstances are flammables to be stored in patient areas. 1. Observation, on 11/21/11 at 6:20 PM, revealed an aerosol cannister of hairspray located on the counter in the bathroom of room #129A. The cannister was noted to have the resident's name printed with a marker pen on the cannister. The manufacturer's instructions noted on the cannister included, "Warning: FLAMMABLE, Contents under pressure. Do not puncture. Do not use if spray button is missing or defective. Do not expose to heat or store at temperatures above 120 degrees as can may burst". Interview with Licensed Practical Nurse (LPN) #1, on 11/21/11 at 6:40 PM, revealed there should not be a cannister of hairspray in the bathroom because it is combustible. Aerosols should be labeled and kept in a safe location. Further interview revealed it appeared to be a partially used cannister and labeled indicating the cannister was previously stored out of the resident's bathroom after use. She stated she did not notice the cannister in the resident's room but had not been in the resident's bathroom during her shift. However, she indicated that she had not retrieved the cannister from storage during her shift so she assumed it had been in the bathroom since the morning when staff assisted the resident with grooming. 2. Observation, on 11/22/11 at 9:30 AM, 1:00 PM and 5:30 PM, revealed an aerosol cannister of Lamar Vitae Hairspray on the bathroom counter located in resident room #141. The manufacturer's instructions noted on the cannister included, "Warning: FLAMMABLE, Contents under pressure. Do not puncture. Do not use if spray button is missing or defective. Do not expose to heat or store at temperatures above 120 degrees as can may burst". 3. Observation, on 11/22/11 at 9:30 AM, 1:00 PM and 5:30 PM, revealed an aerosol cannister of Lysol Neutra Air on the bathroom counter in resident room #129B. Instructions noted on the label included, "Precautionary statements: hazards to human and domestic animals. Caution: do not spray directly in eyes. First aid if in eyes hold eye open and rinse slowly and gently for 15-20 minutes. Remove contact lenses if present, after the first 5 minutes, then continue rinsing eyes. Call a poison control center or doctor for treatment advice. Physical hazards: contents under pressure. Do not use or store near heat or open flame. Do not puncture or incinerate container. Exposure to temperature above 130 Farenheit may cause bursting." 4. Observation, on 11/22/11 at 9:30 AM, 1:00 PM and 5:30 PM, revealed a cannister of Airwick Aerosol on the bathroom counter in resident room #130B. The manufacturer's instructions on the printed label included CAUTION: CONTENTS UNDER PRESSURE CONTAINER MAY EXPLODE IF HEATED. MAY IRRITATE EYES. DO NOT get in eyes, on skin or clothing...Prolonged or frequent skin contact may cause an allergic reaction...FIRST AID TREATMENT; ...If on skin, wash area with soap and water..." Interview with Certified Nursing Assistant (CNA) #2, on 11/22/11 at 5:35 PM, revealed she was unaware that storage for the aerosol cannisters needed to be in a secured location. Interview with the Education Director, on 11/23/11 at 2:00 PM, revealed during new employee orientation it was covered that aerosols must be kept under lock and key. However, further interview revealed a lot of information was shared during the general orientation and the specific information related to storage of aerosols had not been a focus of in-service education following general orientation. Interview with the Director of Nursing, on 11/22/11 at 6:05 PM, revealed most of the nursing staff was probably not aware that aerosol containers should not be left in residents' rooms. He was also unable to confirm if residents had been given information regarding bringing aerosol cannisters into the facility. Review of the acceptable Plan of Correction for the 09/15/11 survey, which detailed the facility alleged compliance with the regulation as of 09/23/11 revealed the Maintenance Director would perform monthly rounds that incuded a variety of different physical plant issues including environmental safety. However, interview with the Maintenance Director, on 11/22/11 at 3:00 PM, revealed he utilized an audit form when making rounds but did not focus his rounds to include the residents' bathrooms. Audit form review completed as part of the plan of correction for the 09/12/11 revealed no documented evidence the facility had identified the flammable cannisters in resident care areas. Interview with the Administrator, on 11/23/11 at 3:45 PM, revealed the facility staff was responsible for ensuring the resident areas were free of hazards, random monthly checks performed by maintenance were to identify potential hazards focused on the physical environment. However, the interview further revealed the plan of action developed by the Quality Assurance Committee was focused on facility compliance related to the incident of a resident fall and not all potential environmental hazards.

Based on observation, interview, record review, and review of hospital records it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental psychosocial well-being for residents in providing an environment free from accidental hazards and regarding adequate supervision to prevent accidents for one (1) of twelve (12) sampled residents, Resident #1. The facility administration failed to identify the root cause of Resident #1's accident on 09/03/11 as being the unsecured/unsupervised door leading to stairwell #3, failed to ensure residents received adequate supervision to prevent accidents, and failed to provide an environment as free from accident hazards as possible. Record review and interview with the Director of Nursing (DON), on 09/10/11 at 2:00 PM, revealed the facility had assessed and identified five (5) residents, which included Resident #1, as being demented and ambulatory with assistive devices. After review of the facility's Roster Matrix, there were twenty four (24) residents assessed as being independently ambulatory or mobile non-ambulatory with assistive devices who had access to stairwell #3 and who attended activities in the area without being supervised by staff. On 09/03/11, Resident #1, a cognitively impaired resident, was found at the bottom of a flight of six (6) stairs by a Utilities Staff. The facility failed to recognize the unsecured/unsupervised door leading to stairwell #3 as the root cause of this incident on the day the incident occurred and again on 09/06/11, in their weekly administrative meeting. The door leading to stairwell #3 was left unsecured and unsupervised from 09/03/11 until 09/12/11 when the facility failed to identify the root cause of the incident as being the unsecured/unsupervised door. The unsecured door leading to stairwell #3 was located in the same hallway as the activity room. The facility had assessed and identified five (5) residents, which included Resident #1, as being demented and ambulatory with assistive devices. After review of the facility's Roster Matrix, there were twenty four (24) residents assessed as being independently ambulatory or mobile non-ambulatory with assistive devices who had access to stairwell #3 and who attended activities in the area without being supervised by staff. Based on the above findings, it was determined the facility failures to identify the unsecured/unsupervised door as the root cause, placed other residents with access to the unsecured door at risk for serious injury, hard, impairment, or death. The facility was informed of the Immediate Jeopardy and Substandard Quality of Care on 09/12/11 at F323 at a S/S of a "K" and F490 at a S/S of a "K". The facility provided an acceptable Allegation of Compliance (AOC) on 09/14/11. Immediate Jeopardy was verified to be removed prior to exit on 09/15/11 with remaining non-compliance at 42 CFR 483.25 Quality of Care (F323) and 42 CFR 483.75 (F490) Administration, at a scope and severity (S/S) of an "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: Review of Resident #1's Clinical Notes Report revealed, on 09/03/11, Resident #1 was found by Utilities Staff at the bottom of a flight of six (6) stairs of stairwell #3. It further revealed Resident #1 was alert with confusion, and combative with staff. It was further documented the fall was unobserved, and Resident #1 had bruising to both palms and a laceration to the left elbow. Review of hospital records from the emergency room revealed Resident #1 was seen in their facility on 09/03/11, with [DIAGNOSES REDACTED]. Record review and interview with the Director of Nursing (DON), on 09/10/11 at 2:00 PM, revealed the facility had assessed and identified five (5) residents, which included Resident #1, as being demented and ambulatory with assistive devices. After review of the facility's Roster Matrix, there were twenty four (24) residents assessed as being independently ambulatory or mobile non-ambulatory with assistive devices who had access to stairwell #3 and who attended activities in the area without being supervised by staff. Interview with RN #2, on 09/10/11 at 3:20 PM, revealed she was the nursing supervisor the day the incident occurred with Resident #1. She stated interventions were put into place when Resident #1 returned to the facility from the hospital; however, at no time was it addressed by the Administrator on call to address any interventions regarding the unsecured door where the incident occurred to ensure safety to other residents who had access to the unsecured door. Interview with RN #1, on 09/09/11 at 4:00 PM, revealed she was the Administrative Staff on call the weekend the incident with Resident #1 occurred. She stated at no time was the unsecured door identified as the cause of the incident. Interview with the Assistant Administrator, on 09/10/11 at 4:30 PM, revealed at no time had the administrative staff identified the root cause of the incident involving Resident #1. She further stated the Administrative Staff had a meeting on 09/06/11, and the incident involving Resident #1 was discussed in the meeting, but no staff identified or brought up the cause of the incident therefore no interventions were put into place regarding the unlocked door at stairwell #3. Interview with the DON, on 09/12/11 at 6:10 PM, revealed the administrative Staff met every week to address any problems or issues which had occurred the week prior to the meetings. Further interview revealed the root cause of the incident involving Resident #1 was the unsecured door leading to stairwell #3 and the interventions placed by the facility were not adequate to prevent another resident from entering the stairwell and becoming injured. He further stated the only way to ensure the other residents safety would have been to place a staff member in constant observation of the door until the Maintenance Director could contract with a electrician to place a code/alarm on the door. Interview with the Administrator, on 09/12/11 at 6:20 PM, revealed at no time was the cause of the incident involving Resident #1 addressed by Administrative Staff. She stated, to her knowledge, there had never been a resident fall or get injured in the stairwell so the need to secure the door was not brought up or discussed. She further stated the Administrative Staff had a meeting on 09/06/11 and had addressed the incident involving Resident #1; however, the unsecured door was never brought up and there was no interventions implemented to prevent further accidents. Further interview revealed the only interventions the facility implemented to prevent another resident from accessing the unsecured door was a Velcro strip across the door with a stop sign in the middle of the Velcro strip. When the Administrator was asked how she felt this would keep other residents from entering the stairwell, she stated, "Because it says to stop, so they will stop and turn around." When the Administrator was asked if she felt the stop sign alone would keep all residents whom had access to the unsecured door from entering, she stated, "Maybe not all of them, but most of them would see the sign and stop." Further interview revealed the Administrative Staff should have identified the cause of the incident as the unsecured door and placed more appropriate interventions to keep all residents with access to the door safe from accidents and injury. There was no documented evidence the Administrative Staff had attempted to identify the root cause of the incident or place appropriate interventions to prevent other residents from sustaining an injury. An acceptable AOC was received on 09/14/11 and the Immediate Jeopardy was found to be corrected prior to exit on 09/15/11. The following corrective measures taken by the facility were validated as completed prior to the survey exit on 09/15/11: Immediately on 09/12/11, the facility initiated staff supervision of Terrace level, stairway door #3 by placing staff person, twenty four (24) hours per day, at the door to stairway #3, the root cause of problem, to prevent egress of residents. Staff remained continually until keypad access installed and functioning properly. The facility recognizes that the lack of supervision of the door, and the door being unlocked, lead to the "Immediate Jeopardy" of residents. Security personal and maintenance were responsible for maintaining coverage of staff at Terrace level, stairway door #3, twenty four (24) hours daily until key pad installed and functioning properly. All security and maintenance staff have been in serviced one (1) on one (1) by Assistant Administrator, DON, or Maintenance Director on procedures to monitor the door and residents coming to the area to promote safety of all residents. Prior to being stationed at stairway #3 door, staff were instructed to observe resident activity in the area and prevent egress through stairwell door. To prevent further incidents of this nature, the facility will "lock and alarm" Terrace level, stairway door #3, work to be performed immediately. Staff members continue to monitor door until keypad is installed and functioning properly. Electrician installing hardware 09/13/11. All staff will be in-serviced on the need of supervision for this and all doors to prevent egress of residents. In-services have been conducted by the Education Director beginning 09/13/11. Staff not in-serviced will not be permitted to work until attending in-service program. A "Quality Assurance Monitor" which monitors all doors being locked and alarmed to ensure resident safety has been developed by the Maintenance Director, and conducted by the Maintenance Director, Maintenance Staff, or Security personnel, three (3) times per day at the beginning/end of each shift, for seven (7) days, once daily for seven (7) days at the beginning/end of day shift, weekly for four (4) weeks on day shift, then monthly on day shift to monitor door being locked and alarmed. Maintenance Detector to immediately conduct "Quality Assurance Monitor" on 09/13/11 of all doors checking for security of locks and/or alarms and accessibility to assure all doors being locked and alarmed. Maintenance Director to immediately initiate on 09/13/11 a policy and procedure for securing all entrances/exits for residents safety. In-service for all staff regarding new policy and procedure included in in-services conducted on 09/13/11 by Education Director. Administration has coordinated installation of the keypad on 09/13/11 and any other repairs and enhancements of the door security/alarm system. Administration has participated in any policy and procedure creations or revisions and had final approval for all such creations or revisions and assured staff were knowledgeable on any new or revised policies. The surveyor validated the corrective action taken by the facility as follows: Observations made on 09/13/11 and 09/14/11 revealed staff sitting at the door leading to stairwell #3. Interviews with those staff revealed the Maintenance Director and DON had in-serviced them on the reason for the one (1) on one (1) observation of the door. Record review of the one (1) on one (1) sign on/off sheet revealed staff were to sign name, date, and time they started the observation of the door and time they were relieved. Further review of the sign on/off sheet revealed instructions for staff to observe for residents in the area and to prevent egress through stairwell door. Record review, on 09/13/11, revealed in-service addressing the reason for the one (1) on one (1) observation of the door leading to stairwell #3. Further review revealed signatures of staff on the form indicating they had been instructed to observe the area for residents and to prevent egress through the stairwell door. Interview with the Maintenance Director, on 09/13/11 at 4:40 PM, revealed he had instructed all staff who were to do the one (1) on one (1) observation of the door, to sign in and out on the sheet, to use the radio to call for help if a resident was trying to egress or they needed a break, and to never leave the door until another staff whom had also been in-serviced could take over the post. Observation and interviews, on 09/13/11, revealed the electrician for a contracted company installing a lock/alarm mechanism for the door leading to stairwell #3. Interview with the electrician, on 09/13/11 at 3:00 PM, revealed the lock would be functioning by the end of the day; however, the parts for the alarm would not be in until the following day. He further stated the door would be a lock/alarm door, if the bar to open the door was pushed without the code being entered the alarm would sound to alert staff someone was trying to bypass the code. Observation of the door, on 9/13/11 at 5:00 PM, revealed the locking mechanism was functioning and the door was secured and a code had to be entered for the door to be opened. Interview with the Maintenance Director, on 09/14/11 at 3:00 PM, revealed the electrician was still working on the wiring for the alarm; therefore, staff continued with the one (1) on one (1) observation of the door until the electrician was done and the door was secured. Interview with the Education Director, on 09/14/11 at 2:00 PM, revealed she had began the in-services with staff on 09/13/11. A review of the roster for staff attending the in-service. Review of the in-service,"Resident safety- Doorway access and supervision" revealed the facility had in-serviced staff on door safety and awareness for resident safety, instructions for responding to a door alarm going off, and review of the new policy and procedure titled, "Maintenance" dated 09/13/11. Further interviews conducted with staff from 09/13/11 at 2:00 PM, to 09/14/11 at 4:00 PM, revealed staff were knowledgeable of the policy regarding doorway access and supervision and material covered in the in-service provided by the Education Director. Further interview with the Education Director revealed any staff not at work will be mandated to attend the in-service before returning to work. She stated she had made a list of all staff who had not attended the in-service and had forwarded a copy to their supervisor to ensure they were not permitted to work the floor until they attended the in-service. A review of the monitoring tool the Maintenance Director created revealed daily monitoring of the doors which were locked and/or alarmed was conducted on 09/13/11, and was on going. Interview with the Maintenance Director, on 09/14/11 at 3:30 PM, revealed he planned to continue to perform the monitors per the AOC. He further stated he had in-serviced the Maintenance Assistant and security staff to perform the monitors when he is not in the facility. The monitors will be reviewed weekly by the administrative staff in the weekly meetings to address if the monitors are effective and to ensure interventions placed are effective. On 09/14/11 at 3:30 PM, an environmental tour with the Maintenance Director revealed all doors were secured and functioning properly on Terrace level. When the door to stairwell #3 was tested and the alarm sounded, staff responded to the area in under one minute. Observation of door to stairwell #3 revealed the electrician had finished installing the alarm and it was secured and functioning at this time. Interviews with the Maintenance Director, DON, and Assistant Administrator, conducted on 09/14/11, revealed the monitors will be reviewed daily in administrative staff meetings and when determined appropriate will then be reviewed weekly in the Quality Assurance meetings. Interview with the DON, on 09/15/11 at 11:00 AM, revealed the administrative staff held a meeting and discussed the coordination of placing staff on continuous observation of the door leading to stairway #3 until the electrician could secure and alarm the door. He stated the Administrator, Assistant Administrator, and himself have been and will continue to work directly with the Maintenance Director and Education Director to continue to monitor and address issues, on a daily basis. He further stated that once the Maintenance Director and Administrator had finalized the new policy and procedure "Maintenance" they had a meeting and reviewed the final draft and then it was given to the Education Director to incorporate into the in-service. The Immediate Jeopardy was verified removed on 09/14/11, prior to exit, with remaining non-compliance at 42 CFR 483.75 Administration, S/S of an "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities.