Every finding on record at Central Texas Nursing & Rehabilitation

Based on interview and record review, the facility failed to 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 (including nights and weekends) and emergencies and to review and update the assessment, as necessary, and at least annually for 1 of 1 facility reviewed for assessments. The facility failed to conduct and document a facility-wide assessment at least annually. This failure could place residents at risk for inadequate supervision, lack of resources and resident care to competently meet their needs.Findings included: Record review of the Facility Assessment, provided by the Administrator, revealed the assessment was dated 07/21/2025. During an interview on 08/17/2026 at 12:50 p.m., the Administrator said he was aware that the Facility Assessment was required to be updated at least annually. The Administrator said the facility used the Facility Assessment as a means to determine staff ratio when staff resources were available. The Administrator said the facility determined how many staff were needed in the facility based on the level of inequity and census and did not base the final determination exclusively on the Facility Assessment. The Administrator said he was aware the Facility Assessment was required to be completed and utilized and included the facility's census, the residents' needs, and staff competencies. The Administrator said the facility used a multi-disciplinary and multi-dimensional approach to consider and determine facility needs outlined in the Facility Assessment. The Administrator said due to the facility's approach, the fact that the Facility Assessment was not updated annually would not cause negative affects for the residents who resided in the facility. Record review of the facility's policy, Facility Assessment, dated revised 08/08/2024, revealed the facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for the residents competently during day-to-day operations and emergencies. The facility will review and update the assessment, as necessary, and at least annually.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen that prepares meals for 58 of 58 residents, reviewed for food and nutrition services.The facility failed to ensure stored foods were properly stored, labeled, and dated.The facility failed to ensure rotten food was disposed of.The facility failed to ensure Dietary Aide A used hair restraints properly.The facility failed to ensure Dietary Aide A did not wear excessive jewelry as required by facility policy.The facility failed to ensure Dietary Aide A, the Dietary Manager, [NAME] D, and [NAME] B performed handwashing appropriately. The facility failed to ensure clean utensils, dishes, and carry-out containers were stored properly. These failures could place residents at risk for food borne illnesses.Findings included:An observation of the kitchen on 07/13/2026 starting at 9:20 AM revealed the following:-Baking pans and metal lids faced up and were not covered on the bottom shelf of the microwave table.-Styrofoam plates faced up and were not covered on the prep table.-Styrofoam to-go boxes faced up and were not covered on the 2nd shelf of the steam table.-Knives were stored in a metal can and were not covered. -Refrigerator #1:1.The refrigerator had a foul odor. 2.1 zippered bag of fresh broccoli had an unspecified date of 07/02/26 and no other dates. 3.1 zippered bag of lettuce was not dated.4.A plastic bin contained 3 cucumbers with mold.5.A bag of carrots, best by date 06/30/26, contained mold. 6.1 zippered bag of burritos had an unspecified date of 07/09/26 and no other dates.7.1 plastic storage container of grape jelly had an unspecified date of 07/08/26 and no other dates. 8.1 plastic storage container of grape jelly had an unspecified date of 07/12/26 and no other dates. 9.1 plastic storage container of raspberry preserves had an unspecified date of 07/02/26 and no other dates. 10.1 open container of 1000 Island Dressing had an unspecified date of 03/12/26 and no other dates.11.A plastic bin of tomato sauce had an unspecified date of 6/11/26 and no other dates.12.1 open container of Poppy Seed Dressing had an unspecified date of 05/27/26 and no other dates.13.1 open container of [NAME] Goddess Dressing had an unspecified date of 04/23/26 and no other dates.14.1 plastic container contained a red product and was not labeled with item name or any dates.15.1 zippered bag of disposable condiment cups containing sour cream and hot sauce had an unspecified date of 05/04/26 and no other dates.16.1 zippered bag of disposable condiment cups contained red and yellow products and was not labeled with item name and had an unspecified date of 07/03/26 and no other dates.17.A metal bin of chicken and dumplings had an unspecified date of 07/04/26 and no other dates.18.5 bowls of an unknown item was not labeled with item name or any dates.-Refrigerator #2:1.1 cup of an unknown white item was not labeled with item name or any dates.2.1 tray contained bowls of super pudding with an unspecified date of 07/12/26 and no other dates.3.1 storage container of super pudding had an unspecified date of 07/08/26 and no other dates.4.1 tray of sandwiches had an unspecified date of 07/09/26 and an expired date of 07/11/26.5.1 tray of disposable condiment cups of grape jelly had an unspecified date of 06/27/26 and no other dates.6.1 bag of unknown white product was not sealed, was not labeled with item name, had an unspecified date of 07/09/26, and no other dates.7.1 bag of unknown white product was not sealed, was not labeled with item name, had an unspecified date of 07/10/26, and no other dates.8.1 tray of disposable condiment cups of mayonnaise had an unspecified date of 06/25/26 and no other dates.9.1 bag of whipped topping had an expiration date of 07/12/26.10.1 storage container of cheddar cheese had an unspecified date of 06/16/26 and no other dates. -Spice Rack:1.Salt and pepper shakers, filled and empty, were not covered.2.A box of corn starch was open, not sealed, and had an unspecified date of 12/04/25 and no other dates.3.A mixture of cinnamon and sugar, out of the original packages, did not have a lid, had an unspecified date of 04/28/26 and no other dates.4.An open bottle of imitation banana extract did not have any dates.5.An open bottle of imitation coconut extract did not have any dates.6.An open bottle of imitation lemon extract had 1 date only, a best by date of 05/11/26.7.An open bottle of Everything Bagel Seasoning did not have any dates. 8.An open bottle of ground cumin did not have any dates.9.A zippered bag of brown sugar had an unspecified date of 07/08/26 and no other dates.10.A plastic container, with a lid, contained powdered milk out of the original package, had an unspecified date of 01/08/26 and no other dates.Dining Room:1.A cereal dispensing container held toasted oats, out of the original package, and did not have any dates.2.A cereal dispensing container held cinnamon toasters, out of the original package, and did not have any dates.3.A cereal dispensing container held raisin bran, out of the original package, and did not have any dates.4.A cereal dispensing container held crispy rice, out of the original package, and did not have any dates.An observation of the kitchen on 07/14/2026 starting at 11:20 AM revealed the following:-Dietary Aide (DA) A wore 2 rings (not bands) on 2 fingers of each hand and had a bracelet on his right wrist.-DA A wore a hat that did not restrain his hair at his ears and in the back.-DA A, while making desserts for lunch, used bare hands to reach in the bag of vanilla wafers, grabbed a handful, and placed them in dessert bowls. DA A used bare hands to slice bananas, while holding each banana in his bare hand, and dropped the sliced pieces in the dessert bowls. DA A laid peeled banana on top of the pile of banana peels when he finished cutting the banana for the desserts he was working on. DA A touched the food area of the dessert bowls when he picked up each one. During the time DA A prepared the desserts, he did not wash his hands. He wiped them on a rag and on his t-shirt.An observation of the kitchen on 07/14/2026 at 11:45 AM revealed the Dietary Manager (DM) entered the kitchen and did not perform handwashing before touching the prep table and other items in the kitchen.An observation of the kitchen on 07/14/2026 starting at 4:10 PM revealed the following:-A metal bin of strainers was not covered.-A metal whisk and a metal potato masher was on the side of the bread shelf and was not covered.-Skillets were faced up and not covered on the bottom shelf of the microwave table.-Food temperatures were not measured before serving.-Prep Table:1.An opened bag of powdered sugar was not sealed and did not have any dates.2.An opened bag of fruit punch powdered drink mix was not sealed and did not have any dates.-While [NAME] D was placing silverware and napkins on trays, he wiped his face with his right hand, wiped the same hand on his shirt, and continued placing silverware and napkins on trays.-Cook D re-entered the kitchen, placed a hair net on, and washed hands. After washing hands, [NAME] D turned the faucet off with his wet left hand before he dried his hands.-Cook B re-entered the kitchen, did not perform handwashing, and continued cooking.-The bottom of 2 cooking/serving utensil drawers contained debris at the bottom of the drawers. -Cook B touched the food area of built-up plates when picking them up. During an interview on 07/14/2026 at 11:37 AM, the DM was asked to observe DA A and share any concerns observed. The DM listed the following: DA A touched the vanilla wafers with bare hands, and his hat did not restrain his hair. The DM said the failures could cause all kinds of cross-contamination. After informing the DM of observations, the DM excused himself from the interview and said he had to put a stop to what DA A was doing. He said he would have to remake all the desserts for that meal, lunch. During an interview on 07/15/2026 at 2:17 PM, DA A said he took the Food Handler's Course on 11/11/25. This was verified with his certificate. DA A said he was not aware of the policy prohibiting staff from wearing rings and bracelets. DA A said he knew he messed up by not wearing gloves, not performing handwashing, and cross contaminating the foods. He said that it was not an excuse, but he was very busy that day. He said he had to make 6 pots of coffee and stop a resident from entering the kitchen. So, he said he was behind. Said he has worked in the food service industry for 10 years and knows that cross-contamination can cause illnesses and loss of confidence in the kitchen. He said he has not received any training regarding the facility's policies.During an interview on 07/16/2026 at 9:09 AM, the DM revealed the following:-Expectations for labeling refrigerated items are item name, date opened or date prepped. -Refrigerated items should be discarded after being open for 3 days.-Expectations for labeling dry food items are item name, received date, and opened date.-Dry food items should be disposed of typically after being open 6 months.-Labeling was the responsibility of every dietary staff member.-Cleaning the refrigerator weekly was his responsibility.-Cleaning the refrigerator as needed for smells was the responsibility of all dietary staff.-All items should be used on a first in, first out basis.-More than 1 package/container of the same item should not be opened. -Hair nets must always be worn in the kitchen and cover all the hair.-Hats are allowed, with a hair net.- The only jewelry allowed is a plain band ring and a plain watch.-Handwashing is required when entering the kitchen and between tasks. Using a rag to wipe hands is not acceptable. Using a piece of clothing to wipe hands on is not acceptable.-After performing handwashing, the faucet should be turned off using a paper towel.-Food temperatures should be taken after cooking items and before serving items.-Open items must be in a sealed container or sealed bag.-Said cooking/serving utensil drawers should be emptied and cleaned every week by Dietary Staff.-Said he is constantly training/reminding staff of his expectations/requirements. Does not keep a record of training's he has performed.-Said the failures in the kitchen could cause cross-contamination and maybe transfer bacteria to the residents, causing them to be sick.Cook B and [NAME] D were not available for interviews. During an interview on 07/16/2026 at 1:21 PM, the DON said they do not have any residents with feeding tubes or residents that are ordered to have nothing by mouth.Record review of facility's policy titled, Dietary Food Service Personnel Policy and Procedures dated 2012, revealed: - Jewelry, except for a watch and a plain ring, is prohibited.- Hair nets or hats covering the hairline are worn at all times.- Handle all utensils and dishes so the food or customer contact surfaces are not touched.- All unused food must be securely covered. All items are to be dated and labeled as to their content.- All paper goods and other disposables must be kept covered to prevent contamination.Record Review of the facility's policy titled, Cleaning the Refrigerator dated 2012, revealed, Refrigerators are maintained in a clean/sanitary condition free of offensive odors.Record Review of the facility's policy titled, Dry Storage and Supplies dated 2012, revealed:- Dry bulk foods (e.g., flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled.- Open packages of food are stored in closed containers with tight covers and dated as to when opened.Record Review of the facility's policy titled, Food Safety dated 2012, revealed, Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly.Record Review of the facility's policy titled, Meal Temperature Record, dated 2012, revealed, Temperatures should be taken prior to each meal served and should be recorded in the proper column.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and stored in locked compartments under proper temperature controls for and 1 of 3 medication carts (Hall 5 nurse medication cart) and 2 of 6 residents reviewed (Resident #15 and #36) reviewed for medication storage. The facility failed to ensure the nurses cart #1 for hall 4 did not contain medication that was supposed to be stored in the refrigerator, and had no open date. The facility failed to ensure medications were passed correctly. Resident #15's medication was left at bedside. The facility failed to have physician orders for all medications given to residents. Resident #15 was given Guaifenesin (a medication used to loosen mucus in the throat and chest) with no physician's order. The facility failed to ensure staff stored resident medication in locked compartments while not in use. Resident #15 had Guaifenesin and Oxybutynin (medication used to treat an overactive bladder) in her room. Resident #36 had a bottle of Nystatin Powder (medication used to treat skin yeast infections or damage caused by too much exposure to moisture) in her room.These failures could place residents at risk of adverse medication reactions.Findings included: Observation on 07/13/2026 at 10:00am revealed the nurse's medication cart #1 for 400 hall had the following medications:1.Lorazepam Intensol, filled by pharmacy on 10/31/2025, with a yellow sticker placed by pharmacy that read Keep in Refrigerator, Do Not Freeze. 2.Lorazepam Intensol, filled by pharmacy on 6/9/2026, with a yellow sticker placed by pharmacy that read Keep in Refrigerator, Do Not Freeze. Interview on 07/13/26 at 10:00 AM with RN C, she stated that lorazepam intensol is supposed to be stored in the refrigerator. They have a lock box attached to the refrigerator for these items and she was unsure why they were in the cart. She said it was the responsibility for all nurses to check carts for proper storage, but she did not check the whole cart that morning because she normally only does treatments. She stated they don't write the open date and just used the expiration date from the pharmacy on when to discard. Interview on 07/16/26 at 1:36 PM with the DON she stated lorazepam intensol should be stored in the refrigerator. She stated it was the responsibility of nursing management to check and audit the carts after the nurses. The DON said the nurses were responsible for dating the medication when opened. She the risk of not storing the medication properly was decreased efficacy. The DON stated no negative outcomes have resulted due to improper storage. Interview on 7/16/2026 at 1:45pm with the Administrator he stated it is his expectation for the nurses and nursing management to monitor medication carts. The Administrator stated not storing medications properly could cause slight decreased efficacy. He stated no negative outcomes have resulted due to improper storage. Record review of the Recommended Medication Storage policy, dated 7/2012, reflected the following:1.Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened. Lorazepam Intensol (refrigerated)-expires 90 days after initial use. Resident #15Review of Resident #15's admission Record, dated 7/14/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), borderline intellectual functioning (brain function leading to difficulty learning and/or processing information), and history of brain cancer.Review of Resident #15's Quarterly MDS Assessment, dated 4/2/26, revealed:She scored an 11 of 15 (indicating moderate cognitive impairment) on her BIMS and showed no signs of delirium. She rejected care 7 of 7 days (daily).Review of Resident #15's Care Plan last updated 1/26/26, revealed no care plan for self-medication. Reveal of Resident #15's Order Summary Report, dated 7/14/26, revealed orders:Oxybutynin Chloride ER 10 mg dated 6/27/26There was no order that allowed the resident to keep medications at bedside. There was no order for the Guaifenesin.Observation and interview on 7/13/26 at 12:12 p.m. showed a medication cup with two (2) pills in the cup at bedside with no staff present. RN E was shown the pills. RN E said, those shouldn't be there and took the medication cup to the DON. The DON identified the pills as Resident #15's Oxybutynin and Guaifenesin. The DON explained Resident #15 was difficult and usually took her medication if it was left at her bedside. The DON said she did not know if there was an order allowing medication to be left at bedside, but she would check. Review of the facility's Self Medication Program Assessment of Skills, dated 7/13/26 provided at 3:27 p.m. revealed:Resident #15 was fully capable of demonstrating: correct route of administration, knowledge of strength of medication, recognition of medication, and basic knowledge of medication.Resident #15 needed assistance to: have the correct frequency, knowledge of common side effects of his/her medication, and keep medication secured in a designated area. Interview on 7/14/26 at 3:09 PM the DON said the staff should be watching residents take oral medications and they just needed to slow down and watch. The DON said she started an in-service with nurses and staff that residents had to have a may take at bedside order. The DON said Resident # 15 did not have an order for the Guaifenesin because if the resident did not take the medication it was discontinued. The DON said the staff knew leaving medication out on the counter was not good because there was a risk of residents going into the resident's room and taking it causing medication reactions. The Regional RN was present and said residents had the right to have medications if they were safe. The Regional RN stated if a resident did not take the medication, they (Medication Aide) were to keep the medication and come back. The Regional RN said Resident #15 was assessed to keep the medication and it was care planned on 7/13/26 - after surveyor entrance). Interview on 7/14/26 at 4:58 p.m. the DON stated Resident #15's Guaifenesin was discontinued 6/1/26 for non-use. The DON said all the nurses needed to do to get the order reinstated was to call the doctor. Resident #36Review of Resident #36's Quarterly MDS Assessment, dated 6/16/26, revealed she was an [AGE] year-old female admitted to the facility 9/1/17 with diagnoses which included heart disease and diabetes (the body's difficulty in processing glucose). Her BIMS score was 15 of 15 with no signs of delirium (indicating she was cognitively intact). Observation on 7/13/26 at 10:47 a.m. showed a bottle of unsecured Nystatin Powder on Resident #36's bathroom shelf in plain sight. Observation and interview on 7/14/26 at 3:09 PM the DON said Nystatin powder was a prescription medication that needed to applied by a nurse and kept in the treatment cart. When shown, the DON said Resident # 36's Nystatin Powder was not stored safely. DON said the management staff did champion rounds (a practice where a department head talked with residents about how things were going and checked resident room condition) and she did not know how it was missed. The DON said she in-serviced staff about this prior because she found pills in a resident's room. The DON reviewed her history of in-services and said 4/17/26 was the last time medications were in-serviced on. The DON said staff needed to be re-educated. The DON said staff got in a hurry and were not paying attention to what they were doing. The DON stated there was a clinical manager on the night shift who was able to assist with monitoring for staff not passing medications correctly. The DON stated the nurses were just not paying attention. The DON left to go do 100% rounds for other medications. Review of the facility's policy and procedure on Medication Administration Procedures, dated 2003, revealed: Medications are to be poured, administered, and charged by the same licensed person.All current medications and dosage schedules are to be listed on the resident's current medication administration record. Review of the facility's policy and procedures on Medication orders, dated 2025, revealed:Medications are administered only upon clear, complete, and signed orders of a person lawfully authorized to prescribe. Complete Medication orders specify the following components:Clients Full NameName of MedicationDosage and Administration informationRouteAs-Needed medications must specify the condition for which they are being administered, e.g. as needed for pain, as needed for pain, as needed for sleep, and include specific dosing allowed in a 24-hour period. Review of the undated Champion Round sheet documented staff were to look for: any items labeled keep out of reach out in open and medications in room. Review of the 4/17/26 In-service to nurses by the DON documented: Medication administration is an important task when caring for residents. They need such medications for specific disease processes, behaviors, and sleep. When administering medications, it is the nurses responsibility to ensure that the resident receives medication safely. This means that nurses must maintain visual contact with the resident when administering medications and that the medications have been taken. Medications are not to be placed on top of nurses station where it is easy access for another resident to easily pick it up or left in residents' room. 10 nurses signed the in-service.

Based on observations, interviews, and record review, the facility failed to adequately equip residents with the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, for 9 of 59 dually certified resident rooms (rooms #5, #13, #37, #50, #51, #53, #58, #59, and #61) reviewed for resident call systems.The facility failed to ensure dually occupied resident rooms a pull string attached to the call light switch making the call light button inaccessible. The pull string was either too short to be reached or missing. This failure could place residents at risk of harm by not being able to call for help when needed and at risk of not receiving the care and services to maintain their highest level of well-being.Findings included:Observation and interview on 07/15/2026 at 11:53 AM the Administrator said the call light strings for room [ROOM NUMBER] was too short for one of the bed; room [ROOM NUMBER]'s call light string for one bed was too short; room [ROOM NUMBER] had one string that was too short; room [ROOM NUMBER] had no strings for the call light; room [ROOM NUMBER] only had 1 string; room [ROOM NUMBER] had no call light strings at all; room [ROOM NUMBER] only had one string; room [ROOM NUMBER] only had 1 call light string; and room [ROOM NUMBER] only had one call light string. The Administrator stated going forward it would be on the champion rounds (facility practice where one management staff takes responsibility for a hallway and the residents on it) and housekeeping. The Administrator stated he thought if there was only one resident in the room there only needed to be one string. Review of the Champion Rounds Check Off form, undated revealed the first item to be checked was call light within reach.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests throughout the facility.The facility failed to maintain an effective pest control program for roaches in the kitchen.The facility failed to maintain an effective pest control program for resident use areas including the dining room and hallway. This failure could affect all residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illnesses, and decreased quality of life.Findings included:Observation of the kitchen on 07/13/2026 at 9:20 AM revealed, a cock roach crawling on the kitchen floor.Interview during the confidential group interview at an undisclosed date and time revealed nine alert, lucid residents said they see bugs every day. Several residents stated it was the big roaches. One resident joked we should put leashes on them. The residents said the facility sometimes sprayed for bugs and had put little boxes everywhere. Residents said they had reported the insects to staff. Observation on 7/14/26 at 10:17 a.m. revealed a cricket jumping through the dining room.Observation on 7/14/26 at 11:17 a.m. showed a pill bug walking down the '3' hall. Interview on 07/14/2026 at 4:18 PM [NAME] D said he did see cock roaches sometimes, but the problem was way better than it used to be.Interview and record review on 07/14/2026 at 5:42 PM the Administrator showed electronic receipts of pest control visits. The Administrator said the facility was treated on 7/6/26 and they treated the kitchen, public areas, and the medication room. The Administrator stated on 7/6/26 they moved a resident out of their room to treat the entire room. The Administrator showed the receipt for 6/4/26 where the halls, exit points, break room, and some resident rooms were spot treated for roaches and spiders; the company also inspected fly boards in kitchen, inspected bait stations outside. The Administrator showed the receipt dated 5/4/26 that revealed the enter/exit doors, 10 or 15 rooms were treated, washing machine and counters were treated for gnats; the pest control company also checked the fly glue board and replaced four. The Administrator said they treated for ants, gnats, spiders routinely and there was a room with bed bugs and the company came out immediately. The facility said there were sticky traps and rapidly responded to as many reports for pests as they could. The Administrator stated when it rained water roaches did come out of the pipes; he said the facility treated for them, but they came in anyways. The Administrator said the facility bought totes for residents to keep snacks in and they were non-compliant. The Administrator stated he did not know how the facility could be any more aggressive with pest control. Interview on 07/16/2026 at 9:09 AM revealed, the DM said he is aware the facility, including the kitchen, has a problem with cock roaches, but the problem has improved a lot in the last 3 months due to treating heavily. Review of the facility's policy and procedures on Insect and Rodent Control, dated 2012, revealed:The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents.Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places etc. for insects or rodents. Review of Resident Council Minutes, dated 4/16/26, revealed one resident complained of ants in their room.

Based on observation, interviews and record review, the facility failed to ensure sufficient staff to meet the needs necessary to care for residents' behavioral health needs safely and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being for 1 of 2 (Resident #32) reviewed for behaviorally competent nursing staff. Resident #32 had orders for one-on-one monitoring and did not receive it. This failure could place other residents at risk of injury or harm from other residents' actions. The findings included:Review of Resident #32's admission Record, dated 7/15/26, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including frontotemporal neurocognitive disorder (front temporal region of the brain causing behaviors similar to dementia), dementia with other behavioral disorder (a type of dementia where the person does not remember routine behaviors and may act out physically or vocally when triggered), chronic pain, agitation, anxiety, and psychotic disorder with delusions (The person believes things that are not true). Review of Resident #32's Significant Change MDS, dated [DATE] revealed:She had long and short- term memory problems with severely impaired daily decision-making ability. (she was not interviewable)She showed signs of delirium including inattention and disorganized thinking. Her mood assessment showed she had trouble concentrating and being short tempered or easily annoyed nearly every day. She showed physical, verbal, and other behaviors not directed at other people daily. She rejected care and wandered daily.Review of Resident #32's Care Plan last updated, 12/2/25, revealed:Focus: The resident has impaired cognitive function/dementia or impaired thought processes. Goal: The resident will maintain current level of cognitive function through the review date. Interventions included: administer medications as needed; engage the resident in simple, structured activities that avoid over demanding tasks. Review of Resident #32's Care Plan, updated 12/30/25, revealed:Focus: The resident has a communication problem related to dementia. Goal: Staff to anticipate needs when not communicated. Interventions included: be conscious of resident position when in groups, activities, dining room to promote proper communication with others; Use effective strategies touch, facial expression, time to communicate, one on one, quiet setting for communicating with resident. Review of the facility's care plan revised 7/2/26, revealed:Focus: The resident has potential to demonstrate physical behaviors.Goal: The resident will demonstrate effective coping skills through the review date and the resident will not harm self or others through the review date.Interventions included: Analyze of key times places, circumstances, triggers, and what de-escalates behavior and document; if the resident has physical behaviors towards another resident, immediately intervene to protect the residents involved and call for assistance. When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. If response is aggressive staff to walk calmly away and approach later. An observation on 07/15/2026 at 3:36 PM staff were heard reporting Resident #32 threw water on a nurse, then scratched the nurse. Then another resident scolded Resident #32 and was hit for telling Resident #32 not to throw water on staff (The other resident was unharmed physically or psychologically). Observation on 07/15/2026 at 3:42PM revealed Resident #32 was on one-on-one supervision with RRN F in the DON's office. Interview on 07/15/2026 at 3:50 PM RNC-E said At the moment Resident #32 was on one-on-one supervision. RNC-E stated the interdisciplinary team would have to meet and do something differently. Interview on 7/15/2026 at 4:36 PM RNC-F said Resident #32 was cooperative through the day and then she wasn't. Interview on 7/15/2026 at 4:41 PM DON said Resident #32 was good and had calmed down on the secured unit. The DON said Resident #32 was on one-on-one supervision. Interview on 07/16/2026 at 9:41 AM the Administrator stated the facility did a Social Services Assessment on Resident #32 and she had a BIMS score of 0 (indicating severe cognitive impairment). The Administrator said the facility placed Resident #32 back on their secured unit. The Administrator stated there was a lot more stimulation in the non-secured portion of the facility like call lights.Observation on 07/16/2026 at 10:39 AM revealed Resident #32 in the secured unit, lying in bed. Resident #32 was awake and looking around with no staff member within line-of-sight of Resident #32. Observation on 07/16/2026 at 11:27 showed Resident #32 still lying in bed. Resident #32 appeared asleep with no staff member within line-of-sight of Resident #32. Observation and interview on 07/16/26 at 12:07 PM showed Resident #32 on the secured unit roaming up and down the hallways. Resident #32 was observed not on one-on-one supervision. TA- G was the only aide observed on the floor and had Resident #32 on line-of-sight supervision. TA G stated she was the Transportation Aide and she (TA G) was not providing one-on-one supervision. TA G said this was because she (TA G) had to keep an eye on two other residents. TA G stated there were not enough staff because the other aide was at lunch. Interview on 07/16/26 at 12:32 p.m. LVN H stated the secured unit was not adequately staffed based off all the behaviors on the unit. LVN H said she would need two aides for the residents to be safe due to all the behaviors and fall risks. LVN H said there was one aide that would help until 2 p.m. LVN H stated, It gets to be too much. LVN H stated she felt if there were two aides the behaviors would be much better managed and the residents would be easier to redirect because things always happen all at once. Interview on 07/16/26 at 1:09 PM Resident #32's MD said Resident #32 got physically better when she was on the non-secured portion of the facility and she had a history of wandering. The MD stated to his knowledge redirection was not successful. The MD said Resident #32 was placed on the secured unit and the staffing pattern was one nurse and one or two aides depending on how bad the behaviors were. Interview on 07/16/2026 at 1:15 PM the ADO stated in the morning Resident #32 was on on-on-one but at lunch the aide assigned went on break and TA- G did not know Resident #32 was one-on-one and kept Resident #32 in line-of-sight.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans: The facility failed to ensure Residents #1's Care Plan reflected he was a DNR. This failure could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:Record review of Resident #1's admission record, dated 7.7.26, revealed a [AGE] year-old male resident was admitted to the facility on 6.15.26. He had diagnoses including Parkinson disease, hypertension, and hypothyroidism. Record review of Resident #1's quarterly MDS assessment, dated 6.17.26, revealed Resident #1's cognition was 6, indicating sever impaired cognitive status. Record review of Resident #1's Care Plan revealed Resident was a Full Code. Date Initiated: [DATE]. Request for CPR to be initiated Initiate CPR if the resident is without a heartbeat or not breathing. During an interview on 7.2.26 at 10:15 am Family member A stated that Resident #1 was supposed to be DNR. She stated she was the one that came in and made sure the proper documentation was filled out for DNR. She stated he was not full code. Record review of Resident #1s DNR documentation signed by family member A dated 6.17.26. During an interview on 7.7.26 at 1:25 pm MDS A stated Resident #1 was DNR. She stated she must have missed changing that status after Resident #1 was admitted to the facility. She stated when Resident #1 was admitted to the facility he was full code. She stated the change must have happened and she missed it. She stated she would change this immedicably because it would go against Resident #1 rights if anything were to happen to him and the facility started CPR or anything on him. During an interview on 7.7.26 at 1:45 pm the DON stated she did not know that Resident #1's care plan was not updated. She stated that it should have been discussed in morning meeting for MDS A to make the change in the care plan. She stated that without full code being changed to DNR, if anything happened to the residents and they did start CPR it would have gone against the rights of the residents. During an interview on 7.7.26 at 2:25 pm the administrator stated he did not know there was a change in code status and this should have been completed. He stated that negative outcome could have been the residents' rights would not have been followed. Record review of the facility's policy, titled comprehensive care plan, not dated, indicated: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents medical, physical, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 2 of 4 (Resident #1 and #2) residents reviewed for dietary needs. Resident #1 and Resident #2 did not receive food to meet their needs as reported by staff and family since there is no order for special textures or are textures specifically identified. This failure could place residents who received improper diets at risk of difficulty swallowing, possibly resulting in choking. Findings Included:Record review of Resident #1's admission record, dated 7.7.26, revealed a [AGE] year-old male resident was admitted to the facility on 6.15.26. He had diagnoses including Parkinson disease, hypertension, and hypothyroidism. Record review of Resident #1's quarterly MDS assessment, dated 6.17.26, revealed Resident #1's cognition was 6, indicating sever impaired cognitive status. Record review of Resident #1's orders dated 7.2.26 indicated regular diet, regular texture. Record review of Resident #2's admission record, dated 7.7.26, revealed a [AGE] year-old female resident was admitted to the facility on 10.31.25. She had diagnoses including Dementia, anxiety, and type 2 diabetes. Record review of Resident #2's quarterly MDS assessment, dated 5.13.26, revealed Resident #2's cognition was 3. indicating sever impaired cognitive status. Record review of Resident #2's orders dated 7.2.26 indicated regular diet. During an observation on 7.2.26 at 12:45 pm both Resident #1 and Resident #2 had regular/regular trays of food. No mechanical or puree. During an interview on 7.2.26 at 10:15 am Family member A stated that Resident #1 has problems swallowing and was not sure why he did not receive mechanical or even puree food. She stated he should have been on something other than regular food because that was discussed with staff. During an interview on 7.7.26 at 1:45 pm the DON stated she did not know that Resident #1's was receiving regular food. She stated he should be on at least mechanical if not puree. She stated that there really should be a 2-step process to make sure the residents get the correct food. She stated that step one was the correct dietary needs were given to dietary manager and he would put them into their system if the resident was regular, mechanical or puree. She stated that beyond that all staff, nurses included, pass out the trays. She stated that the nurses were there to check the tickets and make sure the residents get the correct diet. She stated this 2-step process was missing and needs to be fixed. She stated that the adverse effects of this mistake could cause choking or other issues for the residents. During an interview on 7.7.26 at 2:25 pm the administrator stated he did not know Resident #1 and Resident #2 were not receiving the correct diets. He stated that would be covered by the nursing staff and the dietary manager. He stated the adverse effects of this mistake could cause choking or other issues for the residents. Record review of a facility policy titled Diet Orders/Diet Manual undated, indicated: To ensure correct understanding and interpretation of therapeutic diets, all diets are ordered as stated in the diet manual. The physician will prescribe diets in accordance with the approved diet manual. A writing order must appear on the medical record before the resident may be served. A diet manual is providing whereby the rationale and use of each diet is explain. This manual is used as the basis of planning modified diets, resident education, and reference on nutrition.

Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1 was provided with timely incontinent care by facility staff. This failure could place residents at risk for discomfort, skin breakdown, and urinary tract infections.Findings include: Record review of Resident #1 face sheet, dated 1/16/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified dementia (significant memory and thinking problems), unspecified convulsions (experiencing sudden, involuntary muscle spasms or full body shaking), chronic obstructive pulmonary disease (progressive lung disease). Resident #1 expired in the facility on 1/3/2026. Record review of Resident #1's Significant Change in Status MDS, dated [DATE], revealed a BIMS score of 00, which indicated severe cognitive impairment. Resident #1 required substantial to maximum assistance of one staff person to move and/or turn and position in bed and extensive assistance of two staff persons to toilet. Section H of MDS revealed resident was always incontinent of bowel and bladder. Record review of Resident #1's Care Plan, initiated on 11/20/2025 and last revised on 12/30/2026, revealed the resident had a terminal prognosis and was receiving hospice services for adult failure to thrive (unexplained decline in physical and functional health) and senile degeneration of the brain (cognitive decline). The Care Plan also revealed the resident had an ADL self-care performance deficit and required staff assist for bathing, bed mobility, dressing and toilet use. The Care Plan revealed an intervention that stated resident had incontinence and to provide incontinent care every 2 hours. Record review of a witness statement, written by RN Treatment nurse, dated 12/26/2025, revealed at approximately 11:15 AM, she was alerted to go to Resident #1's room due to skin concerns. The RN Treatment nurse wrote in the witness statement, Resident #1 had several raised blister-like areas to the right hip, buttock, and redness to coccyx. Resident #1 had soiled sheets, dried BM to the bilateral buttocks, shirt had dried yellow urine smell, and large area of dried food to the back of shirt. The RN Treatment Nurse wrote she notified the DON immediately. Record review of witness statement, written by CNA D, dated 12/26/2025, with no time revealed her and CNA E went to get Resident #1 up for lunch and observed BM dried to his bottom that was difficult to clean. Resident #1's sheets were stained with BM and food. His shirt had dried food on the back. CNA D and CNA E also observed wounds that were not present on 12/24/2025 when he had his last shower. Record review of witness statement, written by CNA E, dated 12/26/2025, with no time, revealed CNA E and CNA D went to get Resident #1 up and ready for the day. Resident #1 had dried feces on his bottom, sheets were stained with feces and food, shirt had dried food that was stuck. While getting him up they also noticed the wounds. Record review of witness statement, written by DON, dated 12/26/2025, with no time, revealed she was asked to go to Resident #1's room and she noticed dried BM on the sheets and dried food the on residents clothing and bed sheets. During an interview on 1/15/2026 at 12:00PM, The RN Treatment Nurse stated the Hospice CNA notified her on 12/26/2025 at approximately 11:30 stated Resident #1 was wearing a shirt and a flannel jacket. He was lying on his right side. His clothing had dried food, dried BM on his buttocks and his back, the sheets had dried BM and yellow urine stains. She stated CNA D and CNA E were working and assigned to Resident #1's hall that morning. The RN Treatment Nurse asked CNA D and CNA E why Resident #1 had not been turned or repositioned, and they stated he was sleeping, and they did not want to wake him up. She reported this to the Administrator. The RN Treatment Nurse stated the risk of residents not being changed was skin breakdown. During an interview on 1/15/2026 at 4:00 PM, Resident #1's physician stated the risk of not changing and turning residents was skin breakdown but in this case the wounds were unavoidable. The Physician stated he did not notice a negative outcome directly from this incident. During an interview on 1/15/2026 at 4:15PM, LVN B stated she was the Nurse in charge of Resident #1 on 12/26/2025. LVN B stated she saw the wounds when the Hospice Aide did. LVN B stated Resident #1 was observed with dried BM on the bedding and his bottom. She stated the risk of not changing a resident at routine intervals could lead to skin breakdown. During an interview on 1/15/2025 at 4:20 PM, RN C stated she was on duty the night of 12/25/2025 and 12/26/2025, and Resident #1 was restless throughout the shift. CNA F was terminated due to this incident and was on shift with RN C that night. RN C stated the risk of not changing residents could be skin breakdown. During an interview on 1/15/2024 at 4:30 PM, CNA D stated she was on shift that day on12/26/2025 beginning at 6:00 AM. She stated it was just her and CNA E working the floor that morning. CNA D stated she looked in on Resident #1 that morning but did not change him. CNA D stated at approximately 11:00 AM her and CNA E went to get him up for the day. She stated Resident #1 had dried food and dried urine on the back of his clothing, dried BM on his bottom and back. CNA D stated this was the first time she had been in Resident #1's room to change him during her shift. CNA D stated she received training on incontinent care. She stated the risk of not changing residents was skin breakdown. During an interview on 1/15/2026 at 4:45 PM, CNA E stated her shift started at 6:00 AM on 12/26/2025. CNA E stated she looked in on Resident #1 but did not disturb him because he was asleep. CNA E stated during report she was told he was changed right before 6:00 AM. At 11:00AM, CNA E and CNA D went to get Resident #1 ready for lunch. The Hospice Aide came to give him his shower at this time as well. Resident #1 had dried food on his clothing, yellow stains on his sheets, dried BM on him, and dried BM on the sheets. CNA E stated this was the first time they went to change Resident #1 on this shift. CNA E stated the Hospice Aide noticed the wounds that were not present on his previous shower day. CNA E stated the risk of this not being done was skin breakdown and infection. During an interview on 1/16/2026 at 11:17 AM, the Hospice Aide stated she arrived at the facility at approximately 11:00 AM on 12/26/2025 to give Resident #1 a shower. The Hospice Aide stated when she arrived in the room CNA D and CNA E were already getting Resident #1 out of bed. The Hospice Aide noticed Resident #1 was wearing the same shirt that she put on him when he had a shower on 12/24/2025. It was dirty with dried food, dried BM, and yellow stains. The Hospice Aide stated CNA D and CNA E were mad about the condition Resident #1 was in. During an interview on 1/16/2026 at 12:47 PM, the DON stated she was called to Resident #1's room on 12/26/2025 to assess his condition. CNA D showed her Resident #1's dirty sheets with urine and dried BM The DON stated they were having trouble with CNA F on the night shift completing her rounds and changing residents. The DON stated she did several in-services and write ups with CNA F. After the incident on 12/26/2025 with Resident #1, CNA F was terminated prior to her next scheduled shift for failure to provide adequate care. The DON stated she also saw an issue with CNA D and CNA E not changing Resident #1 on 12/26/2025 from 6:00 AM to 11:00 AM. The DON started an in-service on incontinent care. The DON stated the risk of not doing incontinent care and turning could be skin breakdown. The DON stated Resident #1 did not have a negative outcome related to this incident. During an interview on 1/16/2026 at 3:05 PM, the Administrator stated he did not watch the cameras or do any further investigation of this incident. He stated CNA F was fired for not doing her job over time. He stated if they had not terminated CNA F he would have considered it neglect. Record review of the facility's in-service on 1/16/2025 at 3:30 PM, dated 12/26/2025, revealed:It is essential that residents be checked and changed as needed and on a schedule. Record review of facility in-service on 1/16/2025 at 4:00PM, dated 12/29/2025, revealed:When rounding on residents, it is to be done on ALL residents every 2 hours at a minimum. Record review on 1/16/2025 of CNA F termination letter, signed by CNA F, DON, and ADON dated 12/29/2025, revealed CNA F was terminated for failing to meet their job duty/responsibility expectations. Termination letter revealed on 12/26/2025 it was found that CNA F failed to provide adequate care and rounding on a resident.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or no later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 3 residents (Resident #1) reviewed for neglect. The facility failed to report an allegation of neglect involving Resident #1 to the State Reporting Agency (HHSC) within 24 hours of CNA D not providing adequate care. This failure could place residents at risk of injury.The findings include: Record review of Resident #1's face sheet, dated 1/16/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified dementia (significant memory and thinking problems), unspecified convulsions (experiencing sudden, involuntary muscle spasms or full body shaking), chronic obstructive pulmonary disease (progressive lung disease). Resident #1 expired in the facility on 1/3/2026 unrelated to the intake. Record review of Resident #1's Significant Change in Status MDS, dated [DATE], revealed a BIMS score of 00, which indicated severe cognitive impairment. Resident #1 required substantial to maximum assistance of one staff person to move and/or turn and position in bed and extensive assistance of two staff persons to toilet. Section H of MDS revealed resident was always incontinent with bowel and bladder. Record review of Resident #1's Care Plan, initiated on 11/20/2025 and last revised on 12/30/2026, revealed the resident had a terminal prognosis and received hospice services for adult failure to thrive (unexplained decline in physical and functional health) and senile degeneration of the brain (cognitive decline). Resident #1 had an ADL self-care performance deficit and required staff assist for bathing, bed mobility, dressing, and toilet use. An intervention was documented that stated the resident had incontinence and to provide incontinent care every 2 hours. Record review of a witness statement, written by RN Treatment nurse, dated 12/26/2025, revealed at approximately 11:15 AM she was alerted to go to Resident #1's room due to skin concerns. RN Treatment nurse wrote in the witness statement Resident #1 had several raised blister-like areas to right hip, buttock, and redness to coccyx. Resident #1 had soiled sheets, dried BM to bilateral buttocks, shirt with dried yellow urine smell, and large area of dried food to the back of his shirt. RN Treatment Nurse wrote she notified the DON immediately. Record review of a witness statement, written by CNA D, dated 12/26/2025, with no time revealed her and CNA E went to get Resident #1 up for lunch and observed BM dried to his bottom that was difficult to clean. Resident #1's sheets were stained with BM and food. His shirt had dried food on the back. CNA D and CNA E also observed wounds that were not present on 12/24/2025 when he had his last shower. Witness statement was provided to Administrator. Record review of witness statement, written by CNA E, dated 12/26/2025, with no time, revealed CNA E and CNA D went to get Resident #1 up and ready for the day. Resident #1 had dried feces on his bottom, sheets were stained with feces and food, shirt had dried food that was stuck. While getting him up they also noticed the wounds. Witness statement was provided to Administrator. Record review of witness statement written by the DON, dated 12/26/2025 with no time, revealed she was asked to go to Resident #1's room and she noticed dried BM on the sheets and dried food on the residents clothing and bed sheets. Witness statement was provided to Administrator.During an interview on 1/15/2026 at 12:00PM, RN Treatment Nurse stated the Hospice CNA notified her on 12/26/2025 at approximately 11:30 AM, that Resident #1 was lying on his right side. His clothing had dried food, dried BM on his buttocks and his back, sheets had dried BM and yellow urine stains. She stated CNA D and CNA E were working and assigned to Resident #1's hall that morning. The RN treatment nurse asked CNA D and CNA E why Resident #1 had not been turned or repositioned and they stated he was sleeping, and they did not want to wake him up. The RN Treatment Nurse reported these findings to the Administrator on 12/26/2025 and the Administrator was given a copy of her witness statement. The RN Treatment Nurse stated the risk of residents not being changed was skin breakdown. The RN Treatment Nurse stated the risk of not following the reporting guidelines was residents experiencing abuse or neglect would not be investigated. During an interview on 1/15/2026 at 4:00 PM, Resident #1's physician stated Resident #1's wounds were unavoidable due to his terminal condition. The risk of not changing was skin breakdown. The Physician stated he did not notice a negative outcome directly from this incident. The risk of not following the facility policy on reporting abuse and neglect allegations could lead to adequate care not being provided. During an interview on 1/15/2024 at 4:30 PM, CNA D stated she was on shift on 12/26/2025 beginning at 6:00AM. She stated it was just her and CNA E who worked the floor that morning. CNA D stated she looked in on Resident #1 that morning but did not change or turn and reposition him. CNA D stated that resident #1 did not like to be woken up in the morning. CNA D stated at approximately 11:00 AM her and CNA E went to get him up for the day. The Hospice Aide was present to shower Resident #1 and that was when the Hospice Aide noticed the wounds. CNA D went to notify the RN Treatment Nurse. She stated Resident #1 had dried food and dried urine on the back of his clothing, dried BM on his bottom and back. CNA D stated this was the first time she had been in Resident #1's room to change him during her shift. She stated the risk of not changing or repositioning residents was skin breakdown. CNA D stated her witness statement was given to the DON and the Administrator. During an interview on 1/15/2026 at 4:45 PM, CNA E stated her shift started at 6:00 AM on 12/26/2025. CNA E stated she looked in on Resident #1 but did not disturb him because he was asleep. CNA E stated during report she was told he was changed right before 6:00 AM. At 11:00 AM, CNA E and CNA D went to get Resident #1 ready for lunch. The Hospice Aide came to give him his shower at this time as well. Resident #1 had dried food on his clothing, yellow stains on his sheets, dried BM on him, and dried BM on the sheets. CNA E stated this was the first time they went to change Resident #1 on this shift. CNA E stated she received education on incontinent care. CNA E stated the risk of this not being done was skin breakdown and infection. CNA E stated her witness statement was provided to the Administrator. During an interview on 1/16/2026 at 11:17AM, the Hospice Aide stated she arrived at the facility at approximately 11:00 AM on 12/26/2025 to give Resident #1 a shower. The Hospice Aide stated when she arrived in the room CNA D and CNA E were already getting Resident #1 out of bed. The Hospice Aide noticed Resident #1 was wearing the same shirt she put on him when he had a shower on 12/24/2025. It was dirty with dried food, dried BM, and yellow stains. The Hospice Aide stated CNA D and CNA E were mad about the condition Resident #1 was in. During an interview on 1/16/2026 at 12:47 PM, the DON stated she was called to Resident #1's room on 12/26/2025 to assess his condition. CNA D showed her Resident #1's dirty sheets with urine and dried BM. The DON stated they had been having trouble with CNA F on the night shift completing her rounds and changing residents. The DON stated she did several in-services and write ups with CNA F. After the incident on 12/26/2025 with Resident #1, CNA F was terminated prior to her next scheduled shift for failure to provide adequate care. The DON stated she also saw an issue with CNA D and CNA E not changing Resident #1 on 12/26/2025 from 6:00 AM to 11:00 AM. The DON started an in-service on incontinent care. The DON stated the risk of not doing incontinent care and turning could be skin breakdown. The DON stated Resident #1 did not have a negative outcome related to this incident. The DON stated she reported this to the Administrator on 12/26/2025. The DON stated the risk of not following facility policy on reporting neglect allegations could lead to decreased quality of care. During an interview on 1/16/2026 at 3:05 PM, the Administrator stated he did not watch the cameras or do any further investigation of this incident. The Administrator stated neglect was the failure to provide goods or services to a resident. He stated when he received the witness statements of Resident #1's condition, he was observed, and he did not see it as neglect. He stated CNA F was fired for not doing her job over time. He stated if they had not terminated CNA F, he would have considered it neglect. The Administrator stated their policy on reporting was the same as the HHSC guidelines. The Administrator stated he only reported the incident because someone called the corporate hotline and said multiple residents were having skin issues, but Resident #1 was the only one specifically named in the corporate report. The Administrator stated the failure in reporting neglect allegations could lead to inadequate care. Record review, on 1/16/2025, of Provider Investigation report to HHSC with allegation of neglect involving Resident #1 and the systemic skin concerns in the facility was reported on 12/29/2025. Record review, on 1/16/2025, of CNA F termination letter signed by CNA F, DON and ADON, dated 12/29/2025, revealed CNA F was terminated for failing to meet their job duty/responsibility expectations. It also revealed, on 12/26/2025 it was found that CNA F failed to provide adequate care and rounding on a resident. Record review, on 1/16/2025, of the facility's, undated, policy titled Abuse/Neglect, revealed: .E. Reporting.3. The Facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/24.b. If the allegation does not involve serious bodily injury, the report must be made within 24 hours of the allegation.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #52, Resident #161) reviewed for incontinent care. CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #52 and Resident #161. CNA A failed to follow Enhanced Barrier Precautions (EBP) while performing incontinent care for Resident #161. These failures could place residents at risk for cross contamination and the spread of infection. Finding included: Resident #52 Record review of Resident #52's facility face sheet, dated May 29th, 2025, revealed Resident #52 was a [AGE] year-old female admitted to the facility on [DATE]. Medical diagnoses included Huntington's Disease (disease affects a person's movements, thinking ability and mental health) lack of coordination, and unsteadiness on feet. Record review of Resident #52's admission MDS (Minimum Data Set) assessment, dated March 14th, 2025, revealed resident needed Partial/moderate assistance. Record review of Resident #52's care plan, dated 3/19/2025, revealed a focus that Resident #52 had an Activities of Daily living/Self Care/Performance Deficit that required x1 staff assistance. Resident #161 Record review of Resident #161's facility face sheet, dated May 29th, 2025, revealed Resident #161 was a [AGE] year-old male admitted to the facility on [DATE]. Medical diagnoses included dementia, type II diabetes and hypertension (high blood pressure ). Record review of Resident #161's care plan, dated 05/22/2025, revealed in part areas of focus that included: Resident #161 had a surgical site to left foot, Resident #161 has an ADL Self Care Performance Deficit, Resident #161 has Indwelling Catheter, Resident #161 resides in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Record review of Resident #161's physician order summary report dated May 29, 2025 revealed several orders related to wound care. Observation on 5/28/25 at 4:09 PM of in-continent care for Resident #52 revealed CNA A failed to sanitize their hands between glove changes. Observation on 5/28/25 at 5:45 PM of in-continent care for Resident #161revealed CNA A failed to don a gown for enhanced barrier precautions and failed to sanitize their hands between glove changes. During an interview on 5/28/2025 at approximately 6:10 PM CNA A stated that she did know that she should be sanitizing between glove changes, but she was not provided with hand sanitizer. CNA A stated that she did not know she needed to have a gown on for incontinent care for Resident #161. CNA A stated she thought that only the wound care needed the gown since the wounds would be uncovered. During an interview on 05/29/25 at 1:45 PM with the DON, the DON stated that she expected her staff to sanitize their hands before care, between glove changes, and wash their hands after caring for a resident. DON stated that the staff should wear gowns and gloves to follow enhanced barrier precautions. The DON stated that residents with wounds, foley catheters, feeding tubes should be on enhanced barrier precautions. The DON stated that staff should wear gowns and gloves while performing high contact activities with the resident's such as incontinent care, toileting, and transfers. Record review of the facility's undated policy titled Fundamentals of Infection Control Precautions reads in part Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. after removing gloves or aprons. Record review of the facility's policy titled Enhanced Barrier Precautions date 4/1/24 reads in part EBP are indicated for residents with any of the following: . wounds and/or indwelling medical devises even if the resident is not known to be infected or colonized with a multidrug-resistant organism, and personal protective equipment for enhanced barrier precautions is only necessary when performing high-contact care activities.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 1 of 3 medication carts (Hall 400 nurse medication cart) reviewed for medication storage. The facility failed to ensure the nurses cart #1 for the 400 Hall did not contain nebulizers and inhalers that were opened and not labeled with the open date. This failure could place residents at risk of adverse medication reactions. Findings included: Observation on 05/28/25 at 11:30 AM revealed the nurse's medication cart #1 for the 400 Hall had the following opened medications with no open date labeled: 1. Advair diskus inhaler 2. Advair HFA 3. Albuterol Sulfate HFA 4. 2 boxes Ipratropium Bromide and albuterol sulfate inhalation solution Interview on 05/28/25 at 11:31 AM with RN B, she said once inhalers, nasal spray, and nebulizers are opened they need to be dated with open dates. She said it was the responsibility for all nurses to check carts for labelling and dating every shift, but she did not check the whole cart that morning. She stated insulins are good for 28 days and inhalers are also good for 30 days. She stated the risk of not having an opening date was they would not be able to know when they expire, and they will not be effective. Interview on 05/28/25 at 1:36 PM with the DON revealed she said inhalers, insulin, and nasal spray when opened should be dated. She stated it was the responsibility of nursing management to check and audit the carts after the nurses. The DON said the nurses were responsible for dating the medication when opened. She stated insulin was good for 28 days, and the inhalers and nebulizer should be dated once the box was opened. Record review of the Recommended Medication Storage policy, dated 7/2012, reflected the following: 1. Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened.

Based on interviews and record reviews the facility failed to ensure the residents had the right to participate in his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 5 residents (Resident #14) reviewed. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #14 prior to administering increased dose of Seroquel, a psychotropic medication, (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. Findings included: Record review of Resident #14's face sheet, dated 01/22/2025, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include psychotic disorders with delusions due to known physiological condition (a mental disorder characterized by a significant cognitive departure from reality), psychotic disorder with hallucinations due to a known physiological condition (refers to hallucinations and perceptual disturbances), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, Alzheimer's (a chronic neurodegenerative condition that primarily affects memory, thinking, and behavior), dysuria (painful or difficult urination), and atrial fibrillation (irregular heart rhythm). Record review of quarterly MDS assessment (Minimum Data Set) dated 5/6/2024 revealed Resident #14 was understood and understands others. The MDS revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the resident's cognition was severely impaired. Record Review of Section N0415 indicated Resident #14 was taking antidepressants, antipsychotics, and anticonvulsant medications. Record review of a care plan for Resident #14 dated 3/26/2025 revealed a focus area of Psychotropic Drug Use: Resident requires use of antipsychotic. Goal section of care plan revealed that Resident #14 will be free of drug related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation cognitive behavioral impairment. Approach section of care plan stated observe target behaviors, notify physician of adverse reactions, educate resident/family/caregivers about risks, benefits, and side effects. Review of Resident #14's Medication Administration Record revealed resident was receiving increased dosage of Seroquel 75mg beginning on 05/18/2025-05/29/2025. Prior to this date the order was 50mg. Record review of Resident #14's order summary report dated 5/29/2025 revealed the following orders: Seroquel 50 mg give 1 tablet by mouth twice a day related to psychotic disorder with delusions. Seroquel 25mg give 1 tablet by mouth twice daily related to psychotic disorder with delusions beginning on 5/17/2025. Record review of Resident #14's electronic medical record revealed no consent for Seroquel at this dosage. A gradual dose reduction was completed on 4/7/2025 to Seroquel 50 mg twice daily. On 5/17/2025 Seroquel 25mg twice daily was added to 50mg dosage with no new consent obtained. No record of HHS (Health and Human Services) form 3713 for increased dosage was found. During an interview on 05/29/2025 at 1:00 PM, the DON (Director of Nursing) stated that the facility did not have a signed consent form for Resident #14's Seroquel dosage change. She stated that the primary physician must have added the order without her knowledge. The DON stated that a possible negative outcome for not having a consent for psychotropic medications could be that a wrong medication could be given. Also stated a potential negative outcome to the resident was the resident could have side effects, there could be behaviors and the family would not know. She stated the consent should have been obtained prior to increase in dosage. Record review of facility policy titled Psychotropic Medications - dated 2/12/2025 revealed in part . 1. A psychotropic drug is any drug that affects brain activities associate with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: a. Anti-psychotic b. Anti-depressant c. Anti-anxiety and d. Hypnotic 2. Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative will be informed of the benefits, risks, and alternatives for the medication, including and black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident/resident's representative has the right to accept or decline the initiation or increase of a psychotropic medication. The resident's medical record will include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident's consent to psychotropic medications.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that could be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for hospice services for Resident #1. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Record review of Resident #1's electronic face sheet 05/29/2025 revealed [AGE] year-old female admitted [DATE] and diagnoses included Congestive heart failure (CHF), (condition where the heart is unable to pump blood effectively), Dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily life), Atrial fibrillation (irregular heartbeat), Depression (mood disorder). Record review of Resident #1's Physician Orders dated 01/30/24 revealed: admit to hospice with diagnosis of senile degeneration of the brain (mental deterioration associated with old age), adult failure to thrive (substantial decline in overall health and functional abilities), CHF. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Patterns, Resident #1's BIMS (Brief Interview of Mental status) score 14 (intact cognitive response), Special Treatments, Procedures, and Programs-Hospice care. Record review of Resident #1's Care Plan dated 04/1/2025 revealed no documented Focus, Goal, or Interventions for hospice care for Resident #1. During an interview on 05/29/2025 at 01:26 PM with MDS Coordinator stated she was responsible for participating in care plan development. The MDS Coordinator stated she did not know how the failure occurred for resident to not have complete comprehensive care plans because Resident #1 has been on hospice over a year. The MDS coordinator stated she usually updates changes on the care plan to reflect residents' condition within 3 days. The MDS Coordinator stated this failure could impact the resident's quality of life by staff not recognizing that Resident #1 was on hospice services. During an interview on 05/29/2025 at 2:00 PM the DON stated the MDS coordinator updates all care plans including acute and comprehensive. The DON stated MDS Coordinator was responsible for initiating care plans. The DON stated she was responsible for checking care plans quarterly and when a resident had a change in condition that required additional interventions on care plan. Record review of facility's policy titled Comprehensive Care Planning (not dated) revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following--- The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and addresses the resident's medical, physical, mental and psychosocial needs. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment. The facility will ensure that services provided or arranged are delivered by individuals who have the skills, experience, and knowledge to do a particular task or activity. This includes proper licensure or certification if required.

Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 15 residents (Resident #22 and Resident #31) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #22 prior to administering Buspirone, an anxiolytic (antianxiety medication) used to treat anxiety. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #31 prior to administering Aripiprazole, an antipsychotic medication used to treat psychosis. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. The findings included: Resident #22 Review of Resident #22's Admission Record dated 4/18/24 revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admitted [DATE]. She diagnoses which included psychotic disorder with hallucinations, dementia, and anxiety disorder. Review of Resident #22's Annual MDS assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 8 indicating moderate cognitive impairment, she had no reported behaviors during the look back period, she used a wheelchair for mobility in the facility and required maximum assistance for all ADLs, she was receiving an antipsychotic and an antianxiety medication, and the CAA for psychotropic drug use was triggered and checked for care planning decision. Review of Resident #22's care plan, most recent revision date 3/18/24, revealed no care plan in place for the use of antipsychotic medication or antianxiety medication. Review of Resident #22's Order Summary Report dated 4/18/24 revealed the following: Buspirone HCl Oral Tablet 5 MG (Buspirone HCl) - Give 2.5 mg by mouth three times a day related to unspecified dementia and anxiety disorder (Order Date: 2/15/24) Zyprexa Oral Tablet 5 MG (Olanzapine) - Give 2.5 mg by mouth one time a day for Agitation related to psychotic disorder with delusions (Order Date: 2/26/24) Review of Resident #22's chart revealed no consent for the use of buspirone. Resident #31 Review of Resident #31's Admission Record dated 4/18/24 revealed he was an [AGE] year-old male originally admitted to the facility on [DATE] with a most recent admitted [DATE]. He had diagnoses which included dementia, psychosis, major depressive disorder, Alzheimer's disease, visual hallucinations, psychotic disorder with delusions, and mood disorder. Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 7 indicating severe cognitive impairment, he had no reported behaviors during the look back period, he required moderate to maximum assistance for all ADLs and used a wheelchair for mobility in the facility, and he was receiving an antipsychotic and antianxiety medication. Review of Resident #31's care plan last review date of 3/12/24 revealed: Focus: Resident requires antipsychotic medication for diagnosis of psychotic disorder with delusions - resident's medication aides with his history of hallucinations. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. The resident will reduce the use of psychoactive medication through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Discuss with MD, family regarding ongoing need for use of medication. Educate the resident/family/caregivers about risks, benefits, and side effects. Monitor/document occurrence of target behavior symptoms. Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications. Focus: Resident requires antidepressant medication for diagnosis of major depressive disorder. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The resident will show decreased episodes of signs and symptoms of depression through the review date. Interventions: Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. Give antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor/document/report to MD prn ongoing signs and symptoms of depression unaltered by antidepressant medications. Review of Resident #31's Order Summary Report dated 4/18/24 revealed the following: Aripiprazole Oral Tablet 15 MG - Give 15 mg by mouth one time a day for hallucinations (Order Date: 8/11/23) Escitalopram Oxalate Oral Tablet 5 MG - Give 2 tablet by mouth one time a day related to major depressive disorder (Can change to 10 mg tabs, once daily) (Order Date: 1/26/24) Review of Resident #31's chart revealed no consent for the use of aripiprazole. In an interview on 4/18/24 at 3:02 PM with the DON, she stated that consents for psychotropic medications were her responsibility. She stated the DON was responsible for making sure they were obtained and placed in the chart and the failure was her fault. She stated that on admission, psychotropic medications were flagged in the system as needing consents and ultimately it was up to her to finalize the admission process which included the consents. She stated the psych doctors email consents to her when they are signed outside of the facility. The DON stated that any staff nurse can get a consent signed but that she should be the one ensuring that the consent was part of the medical record. Review of facility policy titled Resident Rights and Consent to Receive Psychotropic Medications revision date February 1, 2007, revealed, in part: Psychoactive medications may not be administered without the consent of residents or their legal representative, except in an emergency .Consent must be obtained before the medication may be started. If a resident is being admitted and is currently receiving a psychoactive medication, the facility will have one week (7 days) to obtain consent. The attempt to obtain this consent must be documented. The facility staff will start a tracking form for monitoring behaviors for antipsychotics and antianxiety medication and side effects for all psychotropic medications.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 15 residents (Residents #22 and Resident #56) reviewed for care plans. The facility failed to ensure that Resident #22 had a care plan in place for the use of psychotropic medications. The facility failed to ensure that Resident #56 had a care plan in place for his orthotic flexion gloves (therapy gloves used to help the resident curl his fingers into a fist) or his PEG tube (percutaneous endoscopic gastrostomy - tube inserted into the stomach used for nutrition due to swallowing difficulties). These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #22 Review of Resident #22's Admission Record dated 4/18/24 revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admitted [DATE]. She diagnoses which included psychotic disorder with hallucinations, dementia, and anxiety disorder. Review of Resident #22's Annual MDS assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 8 indicating moderate cognitive impairment, she had no reported behaviors during the look back period, she used a wheelchair for mobility in the facility and required maximum assistance for all ADLs, she was receiving an antipsychotic and an antianxiety medication, and the CAA for psychotropic drug use was triggered and checked for care planning decision. Review of Resident #22's care plan, most recent revision date 3/18/24, revealed no care plan in place for the use of antipsychotic medication or antianxiety medication. Review of Resident #22's Order Summary Report dated 4/18/24 revealed the following: Buspirone HCl Oral Tablet 5 MG (Buspirone HCl) - Give 2.5 mg by mouth three times a day related to unspecified dementia and anxiety disorder (Order Date: 2/15/24) Resident #56 Review of Resident #56's Admission Record dated 4/17/24 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with a most recent admitted [DATE]. He had diagnoses which included injury at C1 level of cervical spinal cord, stroke, cervical spondylosis with myelopathy (neurologic degenerative changes of the spine at the neck resulting in compression of the spinal cord and nearby structures), and dysphagia (difficulty swallowing. Review of Resident #56's Annual MDS assessment dated [DATE] revealed he had a BIMS score of 3 indicating severe cognitive impairment, he had no reported behaviors, he required maximum to total assistance for all ADLs and used a wheelchair for mobility in the facility, he received enteral feeding via PEG tube, and the CAA for feeding tube was triggered and checked for care planning decision. Review of Resident #56's Order Summary Report dated 4/17/24 revealed the following: Gloves to be worn as tolerated for hand training/movement (making a fist) per therapy q shift - two times a day for hand movement (Order Date: 2/21/24) Enteral Feed - every shift Head of bed up at least 30 degrees during administration of enteral formula or water (Order Date: 7/14/23) Enteral Feed - two times a day for Hold Feeding if residual is over 100ml Check residual before medications and feedings; return contents after each check (Order Date: 7/14/23) Enteral Feed - one time a day Cleanse g-tube site (Order Date: 7/14/23) Enteral Feed - every shift Check placement prior to feeding and medication administration (Order Date: 7/14/23) Enteral Feed - every night shift Change syringe Q 24 hours (Order Date: 7/14/23) Enteral Feed - as needed Change tubing with each enteral feeding set-up (Order Date: 7/15/23) Enteral Feed - every shift Flush with at least 5mls of water between each medication (Order Date: 7/14/23) Enteral Feed - five times a day for via peg tube Isosource 1.5; Tube feeding Bolus: 237ml; Flush Water 30ml before and after feeding (Order Date: 7/18/23, Revision Date: 8/31/23) Enteral Feed - every shift Flush with 50 cc of water before and after feedings (Order Date: 7/25/23) Enteral Feed - every shift Flush with 250 cc of water twice a day (Order Date: 7/25/23) Review of Resident #56's care plan, most recent review date 4/16/24, revealed no care plan in place for his PEG tube or his orthotic flexion gloves. In an interview on 04/18/24 at 10:10 AM with the DOR (Director of Rehab), she stated she did not put anything in the care plan. She stated she attended the care plan meetings and nursing staff, either the DON, ADON or MDS nurse, documented while they were meeting about what needed to be on each resident's care plan regarding the therapy department. The DOR stated without a care plan for the gloves, she stated there was no way the nursing staff would know, and she would have to in-service them. In an interview on 4/18/24 at 2:30 PM with the MDS nurse, she stated that a care plan should be person centered - it should outline what level of care needs to be provided regarding ADLs, the resident's likes and dislikes, potential behaviors and how to resolve them, diet, all medications and why the resident was taking the medication, any special treatments like physical therapy/occupational therapy/speech therapy/dialysis, any skin concerns or wound care so that all staff would know about potential or existing issues. She stated that the entire IDT team was able to contribute to what was added to the care plan, including the family. Regarding whom was able to access and put items into the care plan in the computer, she stated that she (MDS nurse), the social worker, the DON, the ADON, the Dietary Manager, the Activity Director, and the DOR all had the ability to add information to the care plan. She stated she thought the floor nurses could add information, but she was not certain how much access they had. The MDS nurse stated she did not know why Resident #22's care plan did not include her psychotropic medication use and that it was just an oversight and would be corrected immediately. She stated that she thought that Resident #56 had a care plan for his orthotic gloves and when she opened his care plan it showed that after being interviewed by this surveyor, the DOR put a care plan in detailing the glove use. The MDS nurse also stated that she thought that because Resident #56 had a care plan in place for his NPO status that mentioned his PEG tube that was sufficient. In an interview on 4/18/24 at 3:02 PM with the DON, she stated that a care plan should reflect everything a person would need to know to take care of a resident in the sense of all the medical diagnoses and related medications, ADLs, diet, activity preferences, and behaviors. She stated that she (the DON), the ADON, the MDS nurse, the social worker, the Dietary Manager, the Activity Director, and the DOR could enter care plans into the chart. She stated she did do care plan audits as needed, but she did not have a formal process for the audits. The DON stated that Resident #22's psychotropic medications should have been care planned as well as Resident #56's PEG tube and orthotic gloves. Review of undated facility policy titled Comprehensive Care Planning revealed, in part: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 1 resident (Resident #2) reviewed for restraints. The facility failed to ensure Resident #2 had documented, ongoing monitoring of her lap belt use and that she used her lap belt for the least amount of time possible. This failure could place the resident at risk of unnecessarily inhibiting the resident's freedom of movement, and the possibility of skin breakdown if not released from the lap belt at regular intervals. The findings included: Review of Resident #2's Admission Record dated 4/17/24 revealed she was [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admitted [DATE]. She had diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture), generalized muscle weakness, muscle wasting and atrophy (decrease in size), dementia, intellectual disabilities, and convulsions. Review of Resident #2's EHR revealed a letter dated 7/10/24 which stated, It is my medical opinion that 'Resident #2' may utilize a wheelchair self-release, restraint free soft belt for patient safety to prevent sliding/falling out of wheelchair. The letter was signed by a Nurse Practitioner who provided care for Resident #2 as proof of medical necessity for the lap belt used by the resident. Review of Resident #2's Annual MDS assessment dated [DATE] revealed she was unable to complete the BIMS interview process due to sever cognitive impairment, she had short and long term memory problems, she was able to recall staff faces, she had some behaviors not directed at others reported during the look back period, she had limited range of motion in her upper and lower extremities, she used a wheelchair for mobility in the facility, she required maximum assistance or was totally dependent on staff for all ADLs, she was always incontinent of bowel and bladder, she had a PEG (percutaneous endoscopic gastrostomy) tube for nutrition, and she used a trunk restraint daily. Review of Resident #2's care plan, most recent review date 3/12/24, revealed the following: Focus: Resident #2 uses soft belt related to seizure disorder and spastic movements. She was unable to stand, so the belt does not prevent rising. She has spastic upper body movements related to cerebral palsy and was at risk for throwing herself out of the chair and injuring herself. She liked her teddy bear tucked into her soft belt. Date Initiated: 12/19/12 Goals: Resident #2 will remain free of complications related to soft belt use, including contractures, skin breakdown, mental status, isolation, or withdrawal through review date. Target Date: 6/10/24 Interventions: Ensure Resident #2was positioned correctly with proper body alignment while soft belt was in use. Resident needs to have soft belt applied while in chair and removed while in bed. Resident needs to have the belt released and to be checked for incontinent episodes, repositioned every 2 hours and PRN. Revision Date: 6/14/17 Review of Resident #2's Order Summary Report, dated 4/17/24, revealed the following: Soft Belt while in wheelchair; two times a day (Order Date: 4/25/2023) Observation on 4/17/24 at 1:30 PM revealed Resident #2 in her wheelchair with lap belt on. Resident #2 was sitting in lobby/dayroom with group of residents and Activity Director. Resident #2 appeared to be watching television while the other residents participated in the activity that was happening. She did not appear to be in any distress or uncomfortable during this observation. In an interview on 4/18/24 at 3:02 PM with the DON, she stated that Resident #2 was up in her chair for 3-4 hours at a time in her wheelchair using the lap belt. She stated the resident was always under direct supervision when she was in her chair wearing the lap belt. She stated that staff did release the belt more often than every 2 hours for transfers to perform care, but it was not documented as a restraint release. She stated they should be able to add restraint release to the task list for staff in the charting system. The DON stated the nursing staff perform the restraint assessments as per the facility policy, but that since the facility had the letter of medical necessity from the provider, they believed they were not required to do the same monitoring. In an interview on 4/18/24 at 4:08 PM with the Administrator, he stated that Resident #2 did spend several hours a day in her wheelchair wearing the lap belt. He stated he knew that staff stayed with her at all times while she was in her chair, and she was frequently repositioned and removed from the chair to be checked for incontinent episodes. He acknowledged the absence of documentation of restraint monitoring and release times and stated that the issue would be fixed immediately. Review of facility policy titled Restraints revision date February 1, 2017, revealed, in part: Restraint usage shall be limited to circumstances in which the resident has medical symptoms that warrant the use of restraints .Restraints will only be applied after it has been determined that a medical symptom requiring restraint usage exist, and only after other alternatives have been tried unsuccessfully. A physician's order shall be necessary to begin a restraint assessment/evaluation for the resident. The restraint committee shall meet to assess the necessity of restraints for a resident by completing a APre-Restraining Assessment worksheet. Facility staff will develop a care plan for the alternate method identified and/or the restraint usage. Restraints will only be used with informed consent from the resident and/or the resident's representative or responsible party and physician. Restrained residents must be repositioned at least every two hours and each shift. The policy did not address the need for documentation of restraint release or repositioning of the resident in restraints

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (medication cart in secure unit) of 3 medication carts reviewed for pharmacy services, in that: The medication cart used for the secure unit had an insulin pen that had expired as indicated by the manufacturers recommendations. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation and interview on 04/16/24 at 11:44 AM the medication cart in the secure unit was inspected with LVN A present. In the top drawer of the medication cart was one insulin pen that was dated 03/06/24. LVN A said the insulin pen was good for 28 days once they were opened. LVN A said she believed it was the night shift staff that were supposed to monitor the medication cart and inspect for expired or undated medications. LVN A said if a resident received an expired insulin, it might not be as effective or produce the desired effect. LVN A said she would dispose of the expired insulin and had not noticed that the insulin had expired. During an interview on 04/18/24 at 10:30 AM the DON said it was her expectation for staff to label and date the insulin pens with the expiration dates when first opened and dispose of the expired ones. The DON said she encouraged nurses to monitor the medication carts and disposed of expired medications. The DON said the ADON was delegated to check the medication carts to see if there were any expired medications and also that they were labeled and dated. The DON said if a resident received an expired medication it could lead to an adverse reaction or not receive the desired effect. During an interview on 04/18/24 at 10:52 AM the Administrator said his expectation was for staff to date medications when opened and discard them when expired. The Administrator said the ADON was delegated to check the carts for expired medications and also their pharmacist would conduct medication checks when they came by the facility. The Administrator said if a resident received expired medication, it could not be as effective. During an interview on 04/18/24 at 10:58 AM the ADON said he would check the medication carts every two weeks. He said he would check for expired medications and that he must have missed that one insulin that was expired. He said if a resident received an expired medication, they might not receive the desired effect. Record review of the facility's policy dated 2003 and titled Medications that must be dated when opened or storage conditions changed indicated in part: All the medications below should have the date opened written on the medication and/or container it arrived in. Insulins (Vials, cartridge, Pens) Keep refrigerated until needed for use. Expiration is based on manufactures recommendations after opening and/or stored at room temperature. Record review of the facility's in-service dated 04/16/24 and titled Medication expiration dates indicated in part: When insulin or new meds are opened nursing must document an expiration date of 28 days from open date. Any medications that are expired must be removed from the med cart and discarded per policy.

Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for the facilities only medication room reviewed for labeling/storage of drugs and biologicals. The facility failed to provide separately locked, permanently affixed compartments for the storage of controlled drugs. These failures could place the facility at risk of drug diversion and access to medications. Findings included: Observation of the facility medication room with LVN B on 04/16/2024 at 03:32 pm revealed a narcotic lock box in the locked medication refrigerator. The Narcotic lock box was not secured to the fridge. The box contained four boxes of lorazepam 2mg/ml. An interview with LVN B on 04/16/2024 at 03:34 pm, stated the lock box was normally glued to the bottom of the fridge but it had gotten dislodged at some point. LVN B was unsure how long the box had been loose in the fridge. LVN B states she was off for a week and when she last worked the box was affixed to the fridge. An interview with the DON and Administrator on 04/16/24 at 10:32 am the DON stated that the narcotic box should be permanently affixed and locked to prevent controlled drug diversion. The DON had no reason the lock box would not be properly locked or affixed. The DON was unaware the box was not affixed. The administrator stated he was informed by maintenance they are trying to obtain a chain for the lock box but needs approval from the pharmacy company to be able to alter the lock box. Unable to provide any documentation of conversation. A review of the facility policy titled Storage and Documentation of Schedule II Controlled Medications, provided by the DON, reads, in part, All Schedule II controlled medications will be stored under double lock and checked for accountability at each change of shift . With a date of 2003.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #3) of 7 residents who were reviewed for accidents and supervision in that: The facility failed to ensure Resident #3 did not elope after she was identified to be of high risk for elopement based on pre-admission documentation received from Resident #3's previous nursing home placement that was submitted prior to Resident #3's admission on 11/28/2023. Resident #3 eloped on 12/23/2023 around 12:33 p.m., and was found on 12/23/2023 around 2:00 p.m. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 12/18/2023 and ended 01/10/2024. The facility had corrected the noncompliance before the survey began. The deficient practice could place residents at risk and could result in harm and serious injury. The findings included: Record review of Resident #3's Face Sheet, dated 01/23/2024, revealed Resident #3 was a [AGE] year-old female who was admitted into the nursing facility on 11/28/2023. Resident #3's diagnoses included Huntington's Disease (an inherited condition that stops parts of the brain from working properly over time), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Anxiety Disorder, unspecified (a type of mental disorder where you may respond to certain things or situations with fear or dread and may experience physical signs of heart pounding and sweating, but does not meet the exact criteria for any other anxiety disorder but significant enough to be distressing and disruptive), and Dysphagia (swallowing difficulties), unspecified. Record review of Resident #3's Admission MDS assessment, dated 12/10/2023, revealed a BIMS score of 10, which indicated moderate impairment. Section B0100 revealed Resident #3 had adequate hearing with no difficulty in normal conversation. Section B0600 revealed Resident #3 had clear speech and was usually understood. B1000 revealed adequate vision without corrective lenses. Section E0900 of the assessment revealed Resident #3 did not exhibit the behavior of wandering. Record review of Resident #3's Admission Nurse Note, dated 11/28/2023, revealed RN B completed the admission process with Resident #3 and completed the physical assessment on 11/28/2023 at 4:26 p.m., when Resident #3 arrived. Resident #3 arrived at the nursing facility by the facility's van and was transported in via wheelchair. The document revealed RN B recorded Resident #3 was oriented to person and time, was able to walk independently without the use of aides and had a history of wandering. The Admission Nurse Note revealed Resident #3 would require a secure unit. Record review of Resident #3's Elopement Risk Assessment, dated 11/28/2023, completed by LVN D, revealed Resident #3 was an elopement risk. Further review revealed Resident #3 could ambulate independently, recognized stop lights and signs, knew precautions when crossing streets, could recognize her own physical needs, and knew her name. The assessment revealed Resident #3 had made statements to leave her previous facility within the last month. Record review of Resident #3's SecureCare Environment Screening Tool, dated 11/28/2023, revealed Resident #3 did not continue to display exit seeking behaviors, was dependent on staff for mobility, and had a history of exit seeking. Record review of Resident #3's electronic Care Plan clinical records on 01/24/2024 revealed Resident #3 did not have a Baseline Care Plan. Record review of Resident #3's Care Plan, dated 12/26/2023, revealed Resident #3's plan was updated to identify Resident #3 was a risk for Elopement and a history of elopement by climbing out her window, to include interventions on 12/26/2023. The plan identified interventions to include, - distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #3 was reevaluated and found to be appropriate for the secured unit, was moved to the secured unit where the windows do not open all the way to prevent exiting the facility that way. Family to be notified of attempts to leave the facility. Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. If the resident is exit-seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Monitor for fatigue and weight loss. PCP was notified when Resident #3 was feeling sad and wanted to go see her family member, antidepressants added to help her. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Record review of Resident #3's Progress Notes, dated 11/30/2023 at 9:08 a.m., revealed Resident #3 went into the front unsecure unit of the facility to attend church services and returned to the secure memory care unit at 9:50 a.m., with no exit seeking behavior observed. Record review of Resident #3's Progress Notes, dated 12/05/2023 at 10:03 a.m., revealed Resident #3 went into the front unsecure unit of the facility to attend bible study, with no exit seeking behavior observed. Record review of Resident #3's Progress Notes, dated 12/08/2023 at 1:26 p.m., revealed Resident #3 went into the front unsecure unit of the facility to watch a movie and have popcorn, with no exit seeking behavior observed. Record review of Resident #3's Progress Notes, dated 12/18/2023 at 10:41 a.m., revealed DON C document Resident #3 was being transferred to the front unsecure unit of the facility for a trial period and permission was received by Resident #3's family member. Record review of the Nursing 24-hour Report, dated 12/18/2023, revealed Resident #3 would participate in a trial transfer to front from back, continue medication with move, can ambulate, and monitor for exit behaviors. Record review of Resident #3's Care Plan Risk for Elopement, dated 12/18/2023, revealed staff would monitor Resident #3 to ensure she would not elope from the facility every hour for 24-hours and every 4-hours for 72 hours (3 days). Record review of the document revealed there was no other interventions documented or put in place to prevent Resident #3 from leaving the facility unattended other than monitoring. Record review of a documentation sent by cell phone text, dated 12/18/2023 at 4:47 p.m., revealed DON C sent a text to all employees of the facility and confirmed that 37 employees read the text that stated, Reminder: Please keep an eye on Resident #3. She eloped at her previous facility, but she was on COVID isolation and was physically attacked by another resident. Record review of Resident #3's monitoring documentation, dated 12/18/2023, revealed staff documented Resident #3 from 11:00 a.m. through 7:00 p.m. with hourly documented location; 8:00 p.m. through 5:00 a.m. with a line marked, which indicated Resident #3 was in her room; and 6:00 a.m. through 11:00 a.m. with hourly documented location. Review of the 4-hour monitoring documentation revealed staff documented Resident #3 from 12/19/2023 at 11:00 a.m. through 12/21/23 at 11:00 a.m. with documented location noted every 4-hours. Record review of Resident #3's Event Nurses' Note, dated 12/23/2023 at 5:07 p.m., completed by DON C, revealed Resident #3 was found walking down the road by another resident's family who called the facility, and the nurse on duty went to pick her up. Resident #3's window was found open, and footprints were outside on the ground. DON C documented the facility camera did not show evidence Resident #3 went out the front door. During an interview on 01/24/2024 at 9:40 a.m., Resident #3 said she left the facility by herself because it was Christmas time and she wanted to see her family. Resident #3 said she would not try to escape out of her window again and knew she was wrong for leaving the facility. Resident #3 said her family member moved her to be closer to where she lived, and Resident #3 said she wished her family member would come to visit her more often. Resident #3 said she should not have left the facility alone without telling anyone but Resident #3 said she was frustrated and wanted to see her family. Resident #3 said she was mad at her family member for not picking her up. During an interview on 01/24/2024 at 10:20 a.m., LVN A said Resident #3 had not attempted to leave the facility by herself during the period she was admitted to the nursing home on 11/28/2023 and moved to the front, unsecured section the facility on 12/18/2023, for a trial period to live in a least restrictive environment. LVN A said Resident #3 returned to the memory care secure unit on 12/23/2023. LVN A said Resident #3 had not displayed exit-seeking or negative behaviors when she resided on the secure memory care unit. LVN A said Resident #3 acted content and happy by her facial expressions and interactions with other residents and nursing staff. LVN A said when he heard that Resident #3 had left the facility, he was shocked, as Resident #3 had never demonstrated exit-seeking behavior while on the secure unit. During an interview on 01/24/2024 at 12:16 p.m., Resident #3's Family Member said she was contacted by the nursing facility when Resident #3 left the facility unaccompanied on 12/23/2023. Resident #3's Family Member said Resident #3 told her the reason she left the nursing home by herself was she wanted to come see her for Christmas and was frustrated. Resident #3's Family Member said she told Resident #3 that she could not leave by herself, and Resident #3 was apologetic and told her she would not leave the facility again. Resident #3's Family Member said she was contacted by the facility and had agreed for Resident #3 to move to the front, unsecured area of the facility for a trial period. Resident #3's Family Member said Resident #3 had told her she felt safe at the new facility and did not complain like she did when she was residing at the previous facility. Resident #3's Family Member said she was surprised that Resident #3 left unaccompanied. During an interview on 01/24/2024 at 12:37 p.m., Resident #5's Family Member said she had departed the facility on 12/23/2023, but could not remember the time, and drove approximately a half mile from the facility when she saw Resident #3 as she walked on the side of the road. Resident #5's Family Member said Resident #3 carried a paper bag with the same name of the convenience store that was located approximately 0.6 miles from the facility and Resident #3 was walking in the direction away from the store. Resident #5's Family Member said Resident #3 walked in a safe manner and looked like she was fine, but Resident #5's Family Member said she was startled to see Resident #3 by herself. Resident #5's Family Member said she stopped her car to check on Resident #3 and called the facility to notify the nurse that Resident #3 was away from the facility. Resident #5's Family Member said when she rolled down her window and asked Resident #3 if she remembered her and Resident #3 responded yes. Resident #5's Family Member said Resident #3 told her she wanted to see her family in San [NAME]. Resident #5's Family Member said Resident #3 said she knew San [NAME] was too far to walk but she was mad at her family and went to the store to get a coke and a snack. Resident #5's Family Member said the nurse from the facility and police arrived and talked to Resident #3 in a respectful manner. Resident #5's Family Member said Resident #3 was transported back to the facility. During an interview on 01/24/2024 at 1:50 p.m., DON C said Resident #3 was new to the facility and she was placed in the memory care secure unit due to her history of leaving the facility without notifying staff at the previous facility Resident #3 resided in. DON C said Resident #3 was admitted on [DATE] and then moved to the unsecure part of the nursing facility for a trial period 12/18/2023 because Resident #3 had not attempted to leave the facility since she was admitted . DON C said the decision to transfer Resident #3 was discussed in the administration stand-up morning meeting and documented in the facility 24-hour report. DON C said the nursing staff would have been notified by reading the 24-hour report that Resident #3 had a history of elopement, and the information would be shared with the nursing staff verbally. During an interview on 01/24/2024 at 3:06 p.m., LVN D said she had been at the facility since 2019 and was familiar with Resident #3. LVN D said she worked on the floor when Resident #3 moved to the front, unsecure part of the nursing facility for a trial period and Resident #3 did well. LVN D said Resident #3 would sit in the same chair in the front common area. LVN D said she was aware Resident #3 was at risk for elopement and monitored Resident #3 during the first three to four days of her trial period. LVN D said Resident #3 would walk to her room and then back to the common area and sit in the same chair. LVN D said Resident #3 never left the area unless she went to activities, such as bingo or listened to live music. LVN D said she never witnessed Resident #3 demonstrate exit seeking behaviors and when LVN D heard Resident #3 had left the facility, LVN D said she was shocked. During an interview on 01/24/2024 at 3:59 p.m., LVN E said she received a phone call from Resident #5's Family Member who reported she had witnessed Resident #3 outside the facility on the side of the road near a convenience store. LVN E said she left the facility and went to pick up Resident #3. LVN E said Resident #3 told her she wanted to go see her family and was frustrated that she was not with her family for Christmas. LVN E said when she arrived, Resident #3 did not want to return to the facility, so LVN E called the police. LVN E said when the police arrived, Resident #3 calmly complied and returned to the facility. LVN E said she attended the in-service on 12/27/2023 that covered elopements and how to respond when a resident eloped. During an interview on 01/24/2024 at 4:16 p.m., CNA F said she had worked at the facility for 14 months and was familiar with Resident #3. CNA F said she was on duty in the memory care secure unit the day Resident #3 left the facility by herself. CNA F said when the staff became aware Resident #3 was not at the facility, an all-staff alert was made, and all staff began searching the facility and surrounding area outside (this was at the same time that LVN E received the phone call from Resident #5's family member). CNA F said staff became aware Resident #3 was not in the building at the same time LVN E had received the phone call from Resident #5's Family Member and had left the facility to pick up Resident #3. CNA F said LVN E had not reported Resident #3 had eloped to all employees on duty in the facility, so an all-staff alert went out and everyone began searching for Resident #3 in the facility and outside grounds. CNA F said LVN E reported to the other nurse on duty Resident #3 had been seen away from the facility and left the building without notification to all staff. During an interview on 01/29/2024 at 10:59 a.m., MDS Case Manager G said she had been at the facility for three (3) years. MDS Case Manager G said she knew in advance if a new residence was going to be admitted and the DON would print out the preadmission paperwork. MDS Case Manager G said the charge nurse on duty would pass the information to the nursing staff coming on duty by use of the 24-hour report and verbally. MDS Case Manager G said the information that Resident #3 was elopement risk on 01/18/2023, when she was moved to the front, unsecure part of the nursing facility for a trial period would have been provided by verbal report from the nurse on duty to the on-coming staff and by use of the 24-hour report. MDS Case Manager G said when Resident #3 transferred into the unsecure part of the facility, interventions should have been in her care plan. During an interview on 01/29/2024 at 1:48 p.m., the Administrator said he had agreed to move Resident #3 to the front, unsecured area of the facility on 12/18/2023 for a trial period to determine the least restrictive environment. The Administrator said Resident #3 had not demonstrated or voiced any intentions of leaving the facility by herself and he felt a trial period was appropriate. The Administrator said the staff monitored Resident #3 appropriately during the early time period of the move and Resident #3 made no attempts to leave the facility. The Administrator said when Resident #3 eloped, the facility immediately put measures in place to ensure her safety. The Administrator said the facility held an ad hoc IDT meeting and contacted the physician and transferred Resident #3 to the secure memory care unit of the facility where the windows would not open wide enough to allow Resident #3 to crawl through. The Administrator said an elopement risk assessment was completed for Resident #3 and 15-minute monitor was initiated and completed for Resident #3 on 12/23/2023 through 12/26/2023. During an observation on 02/12/2024 at 1:15 p.m., observed the window in a resident room on Hall 1. Observed the large window had a screen and observed approximately six to eight inches above the top windowpane, a small silver metal box was attached to the window frame. Observed the box was approximately 1 inch by 1 inch in size and located on the left side of the window frame. Opened the window and observed the window only opened about six inches and did not provide enough space for a person to crawl through. During an interview on 02/12/2024 at 2:15 p.m., DON C said she informed staff that Resident #3 would be transferred to the front, unsecured part of the nursing facility on 12/18/2023 and provided the information that Resident #3 had a history of elopement. DON C said she informed staff verbally and through the facility's messaging system. DON C said the facility used a cellular application that communicated with all staff who had the application on their phone. DON C said she had the text message and the documentation of 37 employees who read the text message that informed staff Resident #3 must be monitored for elopement due to leaving the facility she previously resided in. During an interview on 02/12/2024 at 1:40 p.m., Maintenance Supervisor I said the facility had installed window limiters and placed them in all the windows within the facility. Maintenance Supervisor I said the facility completed the task based on a precaution after a resident eloped from the facility by kicking out her screen and exiting out the window. Maintenance Supervisor I said on 12/27/2023, he went to the local hardware store and bought all the window limiter locks that was in stock and ordered the number the facility would need to install in all windows. Maintenance Supervisor I said the supply was shipped and arrived approximately one week later. Maintenance Supervisor I said he placed the locks on the resident rooms, lobby, offices, kitchen/dining room, and every window in the facility within a few days after the locks arrived. Maintenance Supervisor I said when he looked at the receipt, the window limiters arrived on 01/05/2024, so he had all the devices installed by 01/10/2024. Maintenance Supervisor I said prior to the installation of the window limiter locks, the memory care unit had a screw like barrier to prevent the window from opening no further 6 to 8 inches. Maintenance Supervisor I said the facility changed the code on the keypad every month as a precaution as well. Maintenance Supervisor I said he had been in-serviced on elopements and how to respond when a resident eloped on 12/27/2023. During a phone interview on 02/12/2024 at 3:28 p.m., CNA J said she was on duty when Resident #3 eloped on 12/23/2023 and was assigned to Hall 1. CNA J said she had walked with Resident #3 to her room from the dining room after lunch at approximately 12:00 p.m., or 12:05 p.m. CNA J said she remembered Resident #3 had said she wanted to take a nap. CNA J said she walked into Resident #3's room and observed as she laid down on her bed. CNA J said she knew Resident #3 had a history of leaving the facility unaccompanied. CNA J said she had been in-serviced on elopements and how to respond when a resident eloped or was not located in the facility on 12/27/2023. CNA J said she had been trained on the elopement policy and what action she should take if a resident was missing from the facility. CNA J said she attended the in-service on how to prevent elopement episodes and elopement response on 12/27/2024. During an interview on 02/12/2024 at 3:54 p.m., the Administrator said he had reviewed [NAME] footage on 12/23/2023 from Hall 1 and had observed Resident #3 enter her room at 12:33 p.m. and did not observe Resident #3 exit during the time up to 2:20 p.m., when the facility was notified she was observed away from the facility. During an interview on 02/13/2024 at 11:00 a.m., DON C said the Care Plan Risk Assessment for Elopement was completed for Resident #3 on 12/18/2023. DON C said when Resident #3 moved to the unsecure, front unit of the facility, the move was considered a transfer and the policy was implemented. DON C said the policy gave specific details on how the transfer would be made based on case-by-case basis according to the need of the resident. DON C said Resident #3 could independently ambulate and walk without assistance. During an interview on 02/14/2024 at 10:46 a.m., the Administrator said he arrived at the facility on 12/23/2023 immediately after he was informed Resident #3 had eloped. The Administrator said an Ad Hoc QA Meeting with the IDT team was held and the Elopement Risk Assessments were discussed. The Administrator said the physician, family, and staff were involved in the meeting and agreed Resident #3 would be safer in the secure memory care unit. The Administrator said Resident #3 was moved after the physician gave orders and the Care Plan was updated with interventions to prevent further elopement. The Administrator said the Maintenance Director had gone to the local hardware store on 12/27/2023 and purchased all the window limiters in stock and installed them in the windows in the front unsecure part of the facility. The Administrator said an Ad Hoc QAPI meeting was held on 12/27/2023 to further address incident of elopement. The Administrator said all staff were in-serviced on elopements and what actions to take if a resident was missing. During an interview on 02/14/2024 at 4:31 p.m., Physician K said he was familiar with Resident #3 and was aware Resident #3 left the faciity on [DATE]. Physician K said Resident #3 was in no danger when she left the facility unsupervised. Physician K said Resident #3 had no history of falls, was alert and had a steady gait. Physician K said Resident #3 had mild symptoms of her diagnosis and was in no physical or mental danger when Resident #3 left the faciity on [DATE]. Record review of receipts for the local hardware store revealed window limiters were purchased on 12/27/2023 and additional locks were ordered. Review revealed the window limiters were delivered to the facility on [DATE]. Record review of the Ad Hoc QAPI, dated 12/27/2023, revealed the content of the meeting resulted in the need for elopement risk assessments to be completed before moving out of the Memory Care Unit. Additionally, the Secure Care Unit Decision Tree would be utilized before a resident was transferred out of the Memory Care Unit. Record review of the Provider Investigation Report, dated 12/29/2023, revealed the Administrator reviewed [NAME] footage during the investigation after Resident #3 had eloped and observed Resident #3 had entered her room at 12:33 p.m., on 12/23/2023 and was not observed to come out during the timeframe when she was found missing. At 2:20pm, LVN E had received a call from Resident #5's Family Member had observed Resident #3 approximately half a mile from the facility. On 02/15/2024 at 10:05 a.m., extended the sample and randomly reviewed records for completion of elopement assessments. Record review of Resident #6's Elopement Assessment, dated 12/23/2023 revealed the facility completed the action of completing assessments on all residents. Record review of Resident #7's Elopement Assessment, dated 12/24/2023 revealed the facility completed the action of completing assessments on all residents. Record review of Resident #8's Elopement Assessment, dated 12/23/2023 revealed the facility completed the action of completing assessments on all residents. Record review of Resident #9's Elopement Assessment, dated 12/23/2023 revealed the facility completed the action of completing assessments on all residents. The Administrator was notified of an Immediate Jeopardy (IJ) on 02/15/2024 at 12:14 p.m. and was given a copy of the IJ Template. Explained a plan of removal would not be required due to the fact that all interventions were corrected prior to on-site entrance date of 01/23/2024. It was determined these failures placed Resident #3 in an Immediate Jeopardy (IJ) situation from 12/18/2023 through 12/23/2023. The facility took the following actions to correct the non-compliance and to prevent elopements from the facility, following the incident, to include: 1. QAPI completed 12/27/2023 - IDT Team - Regarding Elopement Incident. 2. Resident #3's care plans were revised on 12/24/23 to include goals and interventions, related to Elopement. 3. Resident #3 was placed on the secured unit on 12/23/23 with documented monitoring. 4. 12/23/23 - 12/26/23: Elopement Risk Assessments were completed for all residents in the facility. Care Plans were reviewed and updated, if needed, for all individuals that met the criteria for high risk. 5. All staff were trained on elopement on 12/27/2023. 6. The facility ordered window restrictors on 12/27/2023 and placed them on every window in the facility, approximately 1 week later once they were received. Record review of the facility's policy, Elopement Prevention, dated 10/07/2010, revealed every effort would be made to prevent elopement episodes while maintaining the least restrictive environment for residents who were at risk for elopement. During an observation on 02/15/2024 at 1:03 p.m., to complete random window observations, observed the front window located by the front entrance door and observed a small silver metal box was attached to the window frame. Observed the box was approximately 1 inch by 1 inch in size and located on the left side of the window frame. Observed the window limiter lock prevented the window from opening more than 6 inches. During an observation on 02/15/2024 at 1:05 p.m., observed the window in the office of the Administrator and observed a small silver metal box was attached to the window frame. Observed the box was approximately 1 inch by 1 inch in size and located on the left side of the window frame. Observed the window limiter lock prevented the window from opening more than 6 inches.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for two (Resident #1 and Resident #2) of five residents reviewed for infection control. The facility failed to: A. Test Resident # 1 for COVID-19 at the time she displayed symptoms of a scratchy throat and runny nose on the evening of 01/19/22 and subsequently was observed the morning of 01/20/22 less than the recommended social distance of 6 ft around five other residents that were negative for COVID-19, at the time. Resident #1 tested positive for COVID-19 on 01/20/22. B. Ensure Resident #2 did not cross over into the warm zone from the hot zone and ensure sanitization efforts were made when Resident #2 had bodily fluids dripping from his nares onto the floor in the warm zone. C. Ensure the appropriate signage, personal protective equipment (PPE) was donned and doffed appropriately and education to staff was provided when Hall 700 was considered to be a warm zone on 01/18/22 . An Immediate Jeopardy (IJ) was identified on 01/20/22. While the IJ was removed on 01/21/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems These failures placed residents at risk for exposure to COVID-19 which could result in serious illness, hospitalization , and/or death. Findings Included: A. Record review of Resident #1's electronic face sheet dated 01/21/22 revealed she was an [AGE] year-old female admitted to the facility on [DATE] to the Secure Unit Hall 7, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated severe cognitive impairment. Section E revealed she had behaviors of rejection of care and was known to wander. Section G revealed Resident #1 required Supervision by one staff and setup help and/or assistance from one staff member for assistance with all ADLs. Record review of Resident #1's immunization Report dated 01/21/22 revealed that Resident #1 was unvaccinated for Covid-19. Record review of Resident #1's care plan revealed the following: Problem: Resident is at Risk for s/x of COVID-19; Date Initiated: 1/5/22 .Goal: Resident will not exhibit s/s of COVID-19, through next review .Target Date: 3/3/2022 .Interventions: Educate staff, resident, family, and visitors of COVID-19 signs and symptoms and precautions. Following Facility Protocol for COVID-19 Screening/Precautions .Observe for s/sx of COVID-19 document and promptly report s/sx : fever, coughing, sneezing, sore throat, respiratory issues . Problem: Acute Care plan: COVID-19 Infection Date initiated: 1/20/22 .I require care and isolation precautions specifically related to active COVID-19 infection .Goal: I will not experience any signs and symptoms of the COVID-19 infection .Interventions: Please allow me to get plenty of rest, Please encourage me to consume extra amounts of fluids daily, i.e. hot tea with lemon, water, juice, etc. to stay hydrated. Please encourage me to cover my mouth and nose when coughing or sneezing .Please ensure I stay in my room, away from other people as much as possible . Observation on 1/20/22 at 9:40 am revealed Resident #1 in the dining area, sitting less than six feet away from five other residents that resided on the secure unit and at the time the entire secure unit was considered to be a warm zone. All the residents in the dining area were unmasked. Record review on 01/20/22 at 9:42am of the 24-hour report dated 1/20/22 revealed the following entry .[Resident #1] .10pm-6am .scratchy throat, runny nose . unsigned. In an observation on 01/20/22 at 9:45 am, LVN A was performing routine outbreak testing for COVID-19 for all residents that were on the secure unit, Hall 700 that were in the warm zone. Observation of the rapid [MEDICATION(S)] tests in the medication room revealed three positive rapid [MEDICATION(S)] tests, which included Resident #1. In an interview on 01/20/22 at 9:50 am, LVN A said she received in shift change report from LVN B this morning that Resident #1 displayed symptoms of a scratchy throat and runny nose. LVN A said that Resident #1 was not tested last night by LVN B and that the rapid [MEDICATION(S)] tests for COVID-19 were available and located in the medication room. In an interview on 01/20/22 at 12:33pm, LVN A said I don't remember if Resident #1 ate breakfast in the dining room this morning, she usually eats breakfast in her room; but I did ask night nurse if she tested Resident #1 and [LVN B] said she wasn't sure if she could perform the test; I should have tested [Resident #1] right away; [Resident #1] was in the dining room less than six feet from other residents unmasked after breakfast; [Resident #1] should have been isolated and tested right away this morning. I just didn't do it, I was busy. LVN A said that the purpose of testing residents promptly when they show symptoms of COVID-19 was to be able to identify and prevent the spread of the COVID-19 virus to other residents in the facility. LVN A said that Resident #1 should have been tested immediately when she was symptomatic so that the facility could have prevented Resident #1 from exposure to other residents residing on the secure unit from the COVID-19 virus. In a Telephone interview on 01/20/22 at 10:22pm, LVN B said she recalled the 24-hour report that she filled out the evening prior and dated 1/20/22. LVN B said that she indicated on her evening shift of 1/19/22 that Resident #1 had a scratchy throat and runny nose. LVN B verified that the 24-hour report that she filled out for her shift that began on 01/19/22 beginning at 6:00pm and ended on 01/20/22 at 6:00am was dated with a date of 1/20/22. LVN B indicated that signs of the COVID-19 virus were sore throat, congestion, fever, runny nose, fatigue, loss of taste or smell, cough. LVN B said she was not aware there were rapid COVID tests in the medication room and was not aware she was supposed to test a resident if they were symptomatic; LVN B said that she reported to the oncoming nurse on the morning of 01/20/22 and felt that she would either test her or notify the DON that she needed to be tested . B. Record review of Resident #2's electronic face sheet dated 01/21/22 revealed he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's annual MDS assessment dated [DATE] revealed a BIMS score of 02, which indicated severe cognitive impairment. Section E revealed he had behaviors of wandering. Section G revealed Resident #2 required Supervision by one staff and setup help and/or assistance from one staff member for assistance with locomotion on and off unit, walking in room, walking in corridor, eating, extensive assistance by two staff with bed mobility, toilet use, extensive assistance with one staff for personal hygiene and bathing. Resident #2 used a walker for mobility. Record review of Resident #2's immunization Report dated 01/21/22 revealed that Resident #2 was fully vaccinated including the booster for COVID-19 virus. Record review of Resident #2's care plan revealed the following: Problem: [Resident #2] is at risk for wandering .Date Initiated 06/12/2020, Revised on 01/20/22, Goal: The resident's safety will be maintained through the review date .Intervention: .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Assess for fall risk Identify pattern of wandering .Problem: Acute Care plan: COVID-19 Infection I require care and isolation precautions specifically related to active COVID-19 infection Date Initiated 01/19/22 Goal: I will not experience any signs and symptoms of the COVID-19 infection following completion of . Intervention: Please allow me to get plenty of rest .Please encourage me to cover my mouth and nose when coughing or sneezing. Ensure that good infection control measures and personal protective equipment is used when working with me. Please ensure I stay in my room, away from other people as much as possible (Contact and Droplet Precautions) .Resident is at Risk for s/x of COVID-19; Date Initiated: 1/5/22 .Goal: Resident will not exhibit s/s of COVID-19, through next review .Target Date: 3/3/2022 .Interventions: Educate staff, resident, family, and visitors of COVID-19 signs and symptoms and precautions. Following Facility Protocol for COVID-19 Screening/Precautions .Observe for s/sx of COVID-19 document and promptly report s/sx : fever, coughing, sneezing, sore throat, respiratory issues . Problem: Acute Care plan: COVID-19 Infection Date initiated: 1/20/22 .I require care and isolation precautions specifically related to active COVID-19 infection .Goal: I will not experience any signs and symptoms of the COVID-19 infection .Interventions: Please allow me to get plenty of rest, Please encourage me to consume extra amounts of fluids daily, i.e. hot tea with lemon, water, juice, etc. to stay hydrated. Please encourage me to cover my mouth and nose when coughing or sneezing .Please ensure I stay in my room, away from other people as much as possible . Record review of Resident #2's electronic progress notes revealed the following entry: .01/19/2022 at 8:34am 'SW called [family member] to let her know that [Resident #2] has tested positive and will be moved to the memory unit temporarily as he is refusing to stay in his room. [Family Member] reported that she understood and would be calling to check in on him. SW added COVID+ to care plan. No other concerns at this time .' Author: [SW] e-signed . '01/19/2022 at 19:00 (7:00 pm) .resident continuously ambulates in hallway without walker, redirected to room by staff several times. Resident assisted to room by staff, only to come back out shortly afterwards .Author: [LVN B] e-signed' . Record review of COVID-19 testing logs revealed Resident #2 tested positive for COVID-19 on 01/19/22. In an interview on 01/19/22 at 1:03pm, LVN A said there were three COVID positive residents at the end of the hall; LVN A said that the Hot Zone was identified by red tape on the floor. LVN A said that Resident #2 had recently been admitted on to the secure unit and has been wandering out of his room off of the hot zone multiple times already and has to be constantly redirected. LVN A said that the reason for the red tape was to identify the hot zone and that residents that were COVID positive needed to stay behind the red tape. If COVID positive residents crossed over the red tape it could potentially expose a resident that was negative to the COVID-19 virus. Observations on 01/19/22 revealed the following: 1:08 PM-Resident #2, unmasked, walked halfway down the hallway(off of the hot zone), without his walker, touching handrails. CNA A redirected resident back to room. Resident #2 voiced I don't want to go back to my room. No sanitization of handrails after Resident #2 was redirected back to the Hot zone. 1:14 PM- Resident #2 walking out of his room, crossing over the red tape, redirection from staff provided, Resident #2 voiced, I may as well die. 1:17 PM- Resident #2 walking out of his room, CNA A and LVN A down the hall, out of sight; OTA redirected Resident #2 back to his room; Resident #2 refused to go back to his room, Resident #2 observed to have clear drainage coming from his nose, dripping onto floor. No sanitization effort made where nasal drainage dripped onto floor was performed. 1:23PM- Resident #2 out of his room, without walker, crossed over red tape and walked down the hallway of secure unit, clear drainage still continued to drip periodically from his nose; CNA A unable to be seen, LVN A at nurses' desk at the other end of the hallway. Redirection provided by OTA for Resident #2 to return to his room. No sanitization effort made where nasal drainage dripped onto floor was performed. 1:28 PM- Resident #2 observed to walk halfway down hallway without walker, CNA A at kiosk with back turned, LVN A continued to remain at nurse's desk. OTA provided redirection again for Resident #2 to return back to his room. 1:29 PM- Resident #2 from the warm zone observed wandering onto the hot zone into Resident #2's room for approximately three minutes, staff unaware. 1:31 PM- Resident #2 observed to walk halfway down hallway, touching handrails, nasal drainage dripping from his nose onto floor, Resident #2 remained off of the hot zone and in the warm zone for three minutes before CNA A provided redirection back to his room. No sanitization effort made where nasal drainage dripped onto floor, or cleaning of handrails was performed. 1:37 PM- Resident #2 observed out of his room, walking without a walker, more than halfway down the hall onto the warm zone Hospice Aid A walked out from the shower room on the secure unit, without PPE other than her facemask, Hospice Aid A, reached out to steady Resident #2 by touching his left forearm, Resident #2 walked back to room by himself without any redirection from CNA A or LVN A; both of which were observed at the nurses station and assisting a resident in the dining area. 1:45 PM- Resident #2 observed back out of his room, without his walker and off of the hot unit, standing amongst a group of five unmasked residents that resided on the warm zone. The OTA that was assisting another resident, came out of room and voiced to Resident #2 to go back to his room. Resident #2 was observed to have an unsteady gait and the OTA grabbed Resident #2 and held him up. Observation of Resident #2's nose dripping clear drainage onto the floor. Observation of the OTA calling out in a loud voice twice for LVN A or CNA A to assist Resident #2. No sanitization effort made where nasal drainage dripped onto floor was performed. 2:05 PM- Observation of CNA A placing bedside tray table in front of doorway of Resident #2's room. 2:43 PM-Observation of Resident #2 pushing bedside tray table out of the doorway, walking out of room without walker. Resident #2 walked off of hot zone and halfway down hallway of warm zone and was observed having clear drainage from nose dripping onto floor; the Activity Assistant assisted Resident #2 back to his room, observation during this redirection revealed the Activity Assistant was touching Resident #2's left upper arm when assisting him back to his room on the hot zone. Observation of the Activity Assistant walked back into warm zone without doffing contaminated PPE from touching Resident #2's left forearm, nor was there sanitization from nasal drainage dripping onto the floor performed. 2:47 PM- Observation of Resident #2 walking back out of his room crossing over the red tape of the hot zone, observation of Resident #2's nose having clear drainage dripping onto the floor; Activity Assistant continuously making attempts to verbally redirect Resident #2; Resident #2 offered a roll of toilet paper by Activity Assistant. Activity Assistant observed assisting Resident #2 back to his room on the hot zone and walking back onto the warm zone without doffing PPE. No sanitization efforts made to sanitize the floor from the nasal drainage from Resident #2's nose. 7:14 PM- Resident #2 was observed lying in bed in room [ROOM NUMBER]; Resident #2 got up from the bed and walked out onto the secure unit; Resident #2's nose was observed dripping a clear substance onto the floor; Resident #2 asked LVN B for a Kleenex; LVN B provided Resident #2 with toilet tissue and redirected Resident #2 back to his room on the COVID unit. In an interview on 01/19/22 at 1:40 PM, Hospice Aid A said she was not aware there were COVID positive residents on the secure unit, specifically, she was not aware Resident #2 was COVID positive. In an interview on 01/19/22 at 1:55 PM, LVN A said that Resident #2 had been on the secure unit, hot zone for about two hours and that it was hard to see when he walked off of the unit if she was at her nurse's desk charting. LVN A said that it is very difficult to constantly be redirecting him and perform her tasks assigned with the other residents she was caring for. LVN A said that she was not sure how many times he had been off of the hot zone but knew it was a lot. LVN A was not sure who brought him down onto the secure unit but that she was not given any specific instructions about keeping him on the hot zone but knew he was not supposed to cross the red line. In an interview on 01/19/22 at 2:15 PM, CNA A said, I did move bedside table in front of doorway of Resident #2's room, I was going to empty the lunch tray but had to get a new trash bag and forgot to move it back. CNA A stated that she was the only staff member on the secure unit at the moment and that she needed to go check on a resident and proceeded to walk away from the interview. In an interview on 01/19/22 at 5:00 PM, the DON said that she was aware of how often Resident #2 was wandering out of his room, off the COVID unit and onto the warm zone. The DON said that staff have been told to redirect him as an intervention for the wandering, the DON said that she was not aware of any other options at this time to prevent Resident #2 from wandering off the COVID unit. The DON also said that it was necessary for him to stay on the COVID unit because he tested positive for COVID-19 earlier in the day (1/19/22) and he would further expose other residents to the virus if he wandered. The DON said that she was not aware Resident #2's nose was running and dripping onto the floor. In an interview on 01/19/22 at 7:25 PM, LVN B said that she was not aware Resident #2 had been lying in another room off of the COVID unit; LVN B said that she was also unaware that Resident #2's drainage from his nose had dripped onto the floor. C. Observation on 01/19/22 at 12:57 PM revealed the entrance onto the secure unit, Hall 700 did not identify any signage to indicate a warm zone, PPE required or to see a nurse prior to entrance. Observation on 01/19/22 at 1:35 PM Hospice Nurse A and Hospice Aid A on secure unit wearing only a face mask, Hospice Aid A was providing a shower for a resident that resided on the secure unit. In an interview on 01/19/22 at 1:40PM, Hospice Aid A said she was not instructed to don any PPE prior to entering secure unit on Hall 700; not aware the secure unit was considered a warm zone; did not know there were positive COVID residents residing on secure unit. Observation on 01/19/22 at 2:17 PM revealed the Activity Assistant entering the secure unit/Hall 700 with only a KN95 mask donned. No other PPE observed on staff member. Observation on 01/19/22 at 2:21 PM revealed the DON entering onto the secure unit/Hall 700. Observed the DON instructing the Activity Assistant to don full PPE. In an interview on 01/19/22 at 2:23 PM, the DON said that there was not PPE available at the entrance of the secure unit for staff to know to don PPE prior to entering the unit, nor was there a sign on door indicating the need for full PPE or that it was a warm zone. In an interview on 01/19/22 at 3:10 PM, Hospice Nurse A said that her and the Hospice Aid A had just come from the secure unit/Hall 700 and provided a shower and assessment on a resident that resided on the secure unit/Hall 700. Hospice Nurse A said that her and the Hospice Aid A was not aware the secure unit on Hall 700 was considered to be a warm zone and there was not any signage on the door, therefore they did not don any PPE other than the mask they were already wearing. The Hospice Nurse A said that she was told by the DON, as she and Hospice Aid A were leaving the secure unit on Hall 700 that the unit was considered to be a warm zone and full PPE was necessary. In an interview on 01/19/22 at 3:15 PM, the DON said a face shield should be worn on hot zone when entering a resident room and providing care. In an interview on 01/19/22 at 5:00 PM, the DON said the entire secure unit on Hall 700 had close contact and unmasked exposure on 01/18/22, when a resident that resided on the secure unit tested positive for COVID-19, therefore the entire secure unit/Hall 700 was considered a warm zone except for the last two rooms on the end of the hall, which was a hot zone that had three COVID positive residents. The DON said that the way staff knew that the secure unit was a warm zone on 01/18/22 was verbally. The DON said that there should have been a sign up to alert staff and visitors going into the secure unit that a gown, gloves, an N-95 mask, and eye protection was required. The DON said that there was not a reason why a sign was not up, other than she had been very busy trying to test and do room changes in other halls and it just was overlooked. In an interview on 1/19/22 at 6:39 PM, LVN B said that she received in shift change report that there were three COVID positive residents residing at the end of the hall on the secure unit. LVN B said that she had not been told by anyone that the secure unit was considered a warm zone and stated that the reason she was in full PPE was due to the fact there were COVID positive residents on the secure unit. In an interview on 01/19/22 at 6:42 PM, CNA B said that she was told during shift change that full PPE was required due to having COVID positive residents on the secure unit. According to the Centers for Disease Control (CDC), COVID-19 is a respiratory disease caused by [CONDITION(S)]-CoV-2, a coronavirus discovered in 2019. The virus spreads mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks. Some people who are infected may not have symptoms. For people who have symptoms, illness can range from mild to severe. Adults [AGE] years and older and people of any age with underlying medical conditions are at higher risk for severe illness .People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, new loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea . https://www.cdc.gov/dotw/covid-19/index.html and https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html Accessed on 01/27/22 Record review of the COVID-19 Response for Nursing Facilities, Version 4.1 updated 12/31/21, revealed the following: .page 19 'the NF must have a response plan that includes cohorting plans with designated spaces for residents of each COVID-19 status (positive, negative and unknown).' .page 46 .'cold zone- area with no COVID-19 infection present, warm zone- area used to monitor residents probable of COVID-19 infection, hot zone- area where COVID-19 infection is present' . page 70 .2. Identify infections early: a. Actively screen all residents for fever and symptoms of COVID-19 at least once a day. b. If symptomatic, immediately isolate and implement appropriate Transmission-Based Precautions . Record review of the facility's policy entitled Section: Infection Prevention and Control, Title: COVID-19 Response Plan, dated 06/08/21, updated 06/21; revealed the following: Residents of nursing facilities (NFs) are more susceptible to COVID-19 infection and the detrimental impact of the virus than the general population .The Purpose of this document is to provide NFs with response guidance in the event of a positive COVID 19 case associated with the facility .Core Principles of COVID-19 Infection Prevention Surveillance /Monitoring .Individuals with COVID-19 have a wide range of symptoms- ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus .cough .sore throat .congestion or runny nose .If a resident is exhibiting symptoms of COVID-19 and/or fever, they should be isolated immediately and placed under transmission-based precautions. Test for COVID-19 .Isolation Once a case of COVID-19 is identified in the facility, immediate action must be taken to isolate the resident who is positive for COVID-19 away from other residents- cold zone Zoning .Cold Zone- negative and recovered residents .warm zone- presumptive (known exposure) and/or symptomatic Do not cohort, initiate transmission-based precautions, consider serial testing, PPE changed between residents. Hot Zone-confirmed positive .Safe to cohort, dedicated health care professional, Optimize PPE supply, Dedicated equipment. Barriers .Temporary walls, barriers, plastic sheeting and/or floor markings must be used to distinguish zones .9. Determine how probable and positive residents are isolated in the facility a. use separate HCP teams for the hot zone .b. designate separate facilities or units within a facility to separate residents into three categories: i. COVID 19-negative- cold zone, ii COVID-19 positive- hot zone; iii Unknown COVID-19 status- warm zone .10. Quarantine residents with prolonged close exposure, or symptoms, regardless of vaccination status a. Quarantine residents with potential or Confirmed Exposure . Record review of the facility's policy entitled, Infection Control Plan: Overview dated 2019, revealed the following: Infection Control The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection .Preventing Spread of Infection (1) when the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility will isolate the resident .Intent .Perform surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection .5. Gowns and protective apparel .2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment. 6. Resident care equipment and articles .3. Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with an approved disinfectant by the nursing assistant. A documentation system will be maintained of the cleaning. The Administrator was notified on 01/20/22 at 2:15 PM an IJ situation was identified due to the above failures and an IJ template was provided. The plan of removal was accepted on 01/21/2022 at 1:25 PM and reflected: [Facility Name] 01/20/2022 Plan of Removal Allegation: Infection Control Staff did not test nor initiate transmission-based precautions symptomatic Resident. Warm zone was not properly identified Staff did not complete appropriate Donning/Doffing PPE on the warm and hot zones Interventions: Facility isolated positive resident on 1/20/2022 Warm and Hot zones were properly identified on 1/19/2022 Respiratory screens will be completed in the Electronic Medical Record on all residents with unknown Covid-19 status daily. Wandering residents redirected back to appropriate zones Routine resident Covid testing is being conducted twice weekly and PRN if resident becomes symptomatic per outbreak protocol to identify and isolate positive cases. Residents in designated warm/hot zones not in clear view of nurse's station are monitored by direct care staff by line-of-sight observation. Sanitizing of high touch areas completed every two hours. The following in-services were initiated by the DON, ADON and Regional Nurse on 1/20/2022: Any staff member not present or in-serviced on 1/20/2022, will not be allowed to assume their duties until in-serviced. o In-services: Infection Control Overview to include initiating transmission-based precautions and testing symptomatic residents on 1/20/22. (in-service attached) Proper PPE use on residents COVID-19 positive and residents potentially exposed to COVID-19 on 1/20/22 (in-service attached) Respiratory screens will be completed in the Electronic Medical Record on all residents with unknown Covid-19 status daily. Wandering residents redirected back to appropriate zones Routine resident Covid testing is being conducted twice weekly and PRN if resident becomes symptomatic per outbreak protocol to identify and isolate positive cases. Residents in designated warm/hot zones not in clear view of nurse's station are to be monitored by direct care staff by line-of-sight observation. Sanitizing of high touch areas is to be completed every two hours. The medical director was notified of the immediate jeopardy situation on 1/20/2022 @ 1435 Monitoring: The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts The DON/Designee will make routine daily rounds on the warm and Hot zones to ensure infection control measures are being followed. The DON/designee will review the 24-hour report twice daily in the morning prior to the stand-up meeting and again in the evening prior to leaving the facility on weekdays to ensure that any resident that has displayed symptoms of Covid-19 has been tested and TBP have been initiated. The weekend supervisor will perform this task on the weekends. The Housekeeping Supervisor/designee will monitor sanitizing of high touch areas daily to ensure compliance The QA committee will review findings in the facilities monthly meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring of the plan of removal revealed: Verification In an observation on 01/20/22 at 9:30 AM, there was appropriate signage outside the door of the secure unit on Hall 700, which indicated it was a warm zone and PPE was required. Observation just inside the door, revealed an ample amount of PPE to include gowns, gloves, N95 face masks, and eye protection was available; in addition, there were appropriate bins to place doffed PPE in with access to a hand washing sink or alcohol-based hand rub was accessible prior to exit from the warm zone on the secure unit, Hall 700. In an observation on 01/21/22 at 9:45 AM, Resident #2 had dedicated staff within line of sight to redirect him to ensure he remained on the COVID unit; at 10:15 AM, Resident #2 was moved to Hall 500 (a larger designated COVID unit), where he would have a larger area to walk the hallways; dedicated staff was observed to have line of sight with Resident #2 and provide redirection as needed. Observation on 1/21/22 at 12:30 of the secure unit revealed residents were socially distanced and there were dedicated staff to redirect on hot zone. Observations on 01/21/22 during multiple times throughout the day between 9:00AM - 4:00 PM, there was designated staff present on the hot zone providing redirection w [TRUNCATED]

Based on observation, interview, and record review, the facility failed to notify the physician when there was a significant change of condition for one (Resident #1) of five residents reviewed for notification of changes. The facility did not notify Resident #1's physician when there was an open area to the resident's foot. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Closed record review of Resident #1's Face sheet dated 12/5/19 indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Closed record review of Resident #1's Admission MDS dated [DATE] indicated a BIMS of 3 or severely impaired cognition. Resident #1 required extensive assist of one to two persons. Resident #1 had no skin conditions. Closed record review of Resident #1's Care Plan with a last review date of 11/18/19 indicated the following: Focus: Resident #1 has a pressure ulcer or potential for pressure ulcer development. Goal: The resident will have intact skin, free of redness, blisters or discoloration . Interventions/Tasks: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Closed record review of Resident #1's Weekly Skin assessment dated [DATE] indicated discoloration of bilateral upper extremities and an open area to buttocks. No wounds to feet were identified. There was no weekly assessment after 11/20/19. Closed record review of Resident #1's nurse's note dated 11/29/19 indicated an open area to top of left foot. The note was written by LVN B. Closed record review of Resident #1's Consolidated orders dated 12/5/19 indicated no orders for the open area to Resident #1's foot. Record review of the hospital records for Resident #1 for admission on 12/2/19 that was signed by the Hospital doctor on 12/3/19 indicated the following: History of Present Illness: Altered Consciousness (reason admitted ) Integumentary: Ulcer on the left foot . Skin: 2x3 cm ulcer top of left foot with some surrounding redness and tenderness . Red at tip of the big toes. Onychomycosis of big toenails. During an interview and observation at the hospital with the Hospital Nurse who wished to remain anonymous on 12/3/19 at 10:50 am, showed Resident #1's bilateral extremities which had redness to both big toes and the left ankle was wrapped with a dressing. She said there was a wound to the top of the ankle that had green drainage yesterday (12/2/19) upon admission. Patient had no signs or symptoms of pain and was pleasant; however, patient was a poor historian. During an interview with LVN A on 12/3/19 at 2:22 pm, she said she was the nurse that had worked the night before the resident had been transferred to the hospital and she said she was not aware of Resident #1 having wounds to his feet. During an interview with the DON on 12/3/19 at 3:21 pm, she said that Resident #1 had a wound to the top of his foot but was unsure what side the wound was on. She said she told the nurse that assessed the new wound to call the doctor for orders for the wound on 11/29/19. During an interview with the DON on 12/3/19 at 3:31 pm, she said she could not locate orders for the wound on top of the foot for Resident #1 for the entry in the nurse's notes on 11/29/19. She said the wound had been dressed with a dry dressing according to nursing. During an interview with LVN B (nurse who wrote entry on 11/29/19 related to foot wound for Resident #1) on 12/3/19 at 3:55 pm, she said that the aides had told her that Resident #1 had a wound to the top of his foot. She said she believed the order for the wound was to cleanse and cover the wound with a dressing. She said she was not sure if anything was put in the computer related to description of the wound or orders. She said she was unsure if the physician was contacted about the foot wound. Closed record review of the Weekly Skin Assessment indicated the following: Weekly Skin Assessment overdue 11/27/19 During an interview with the DON on 12/3/19 at 4:10 pm, she said her expectations were that skin assessments be done weekly. She said she was not aware that Resident #1 had a past due Weekly Skin Assessment prior to transfer to the hospital. During an interview with Doctor C the resident's physician on 12/3/19 at 8:20 pm, he said that the facility had reported bilateral extremity swelling and he had ordered treatment for [REDACTED]. He said he was not aware of a wound to the top of Resident #1's foot. During an interview with LVN [NAME] on 12/5/19 at 7:20 am, she said she was the nurse who transferred Resident #1 to the hospital on [DATE]. She said the resident had socks on when he was transferred, and she was not aware of any wounds to his feet. During an interview with LVN D on 12/5/19 at 1:09 pm, she said that expectations are that the physician be notified of wounds. She said wounds should be documented along with orders obtained from the doctor. She said wound assessments should be completed weekly on residents. During an interview with the DON on 12/5/19 at 1:42 pm, she said her expectations were that nurses report wounds to the doctor and obtain orders for treatment. She said skin assessments should be done weekly and upon identification of new wounds. She said she expected policies of the facility to be followed. Record review of the facility's Notifying the Physician of Change of Status dated (MONTH) 11, 2013 indicated the following: 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, interventions that were implemented in the resident's clinical record. Record review of the facility's Skin Integrity Management dated (MONTH) 5, (YEAR) indicated the following: 1. If wound is noted, perform an assessment and initiate a treatment plan as soon as possible. Document in resident's chart area of change, who you notified, and treatment applied. 3. Wound care should be performed as ordered by physician.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #1) of five residents reviewed for wounds. The facility failed to ensure complete, timely and accurate assessments were completed regarding Resident #1's foot wound. Resident #1's physician was not notified when the wound was identified (11/29/19), and there was no order for treatment. The failure placed residents at risk for a deterioration in condition and delay in appropriate treatment. Findings included: Closed record review of Resident #1's Face sheet dated 12/5/19 indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Closed record review of Resident #1's Admission MDS dated [DATE] indicated a BIMS of 3 or severely impaired cognition. Resident #1 required extensive assist of one to two persons. Resident #1 had no skin conditions. Closed record review of Resident #1's Care Plan with a last review date of 11/18/19 indicated the following: Focus: Resident #1 has a pressure ulcer or potential for pressure ulcer development. Goal: The resident will have intact skin, free of redness, blisters or discoloration . Interventions/Tasks: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Closed record review of Resident #1's Weekly Skin assessment dated [DATE] indicated discoloration of bilateral upper extremities and an open area to buttocks. No wounds to feet were identified. There was no weekly assessment after 11/20/19. Closed record review of Resident #1's nurse's note dated 11/29/19 indicated an open area to top of left foot. The note was written by LVN B. Closed record review of Resident #1's Consolidated orders dated 12/5/19 indicated no orders for the open area to Resident #1's foot. Record review of the hospital records for Resident #1 for admission on 12/2/19 that was signed by the Hospital doctor on 12/3/19 indicated the following: History of Present Illness: Altered Consciousness (reason admitted ) Integumentary: Ulcer on the left foot . Skin: 2x3 cm ulcer top of left foot with some surrounding redness and tenderness . Red at tip of the big toes. Onychomycosis of big toenails. During an interview and observation at the hospital with the Hospital Nurse who wished to remain anonymous on 12/3/19 at 10:50 am, showed Resident #1's bilateral extremities which had redness to both big toes and the left ankle was wrapped with a dressing. She said there was a wound to the top of the ankle that had green drainage yesterday (12/2/19) upon admission. Patient had no signs or symptoms of pain and was pleasant; however, patient was a poor historian. During an interview with LVN A on 12/3/19 at 2:22 pm, she said she was the nurse that had worked the night before the resident had been transferred to the hospital and she said she was not aware of Resident #1 having wounds to his feet. During an interview with the DON on 12/3/19 at 3:21 pm, she said that Resident #1 had a wound to the top of his foot but was unsure what side the wound was on. She said she told the nurse that assessed the new wound to call the doctor for orders for the wound on 11/29/19. During an interview with the DON on 12/3/19 at 3:31 pm, she said she could not locate orders for the wound on top of the foot for Resident #1 for the entry in the nurse's notes on 11/29/19. She said the wound had been dressed with a dry dressing according to nursing. During an interview with LVN B (nurse who wrote entry on 11/29/19 related to foot wound for Resident #1) on 12/3/19 at 3:55 pm, she said that the aides had told her that Resident #1 had a wound to the top of his foot. She said she believed the order for the wound was to cleanse and cover the wound with a dressing. She said she was not sure if anything was put in the computer related to description of the wound or orders. She said she was unsure if the physician was contacted about the foot wound. Closed record review of the Weekly Skin Assessment indicated the following: Weekly Skin Assessment overdue 11/27/19 During an interview with the DON on 12/3/19 at 4:10 pm, she said her expectations were that skin assessments be done weekly. She said she was not aware that Resident #1 had a past due Weekly Skin Assessment prior to transfer to the hospital. During an interview with Doctor C the resident's physician on 12/3/19 at 8:20 pm, he said that the facility had reported bilateral extremity swelling and he had ordered treatment for [REDACTED]. He said he was not aware of a wound to the top of Resident #1's foot. During an interview with LVN [NAME] on 12/5/19 at 7:20 am, she said she was the nurse who transferred Resident #1 to the hospital on [DATE]. She said the resident had socks on when he was transferred, and she was not aware of any wounds to his feet. During an interview with LVN D on 12/5/19 at 1:09 pm, she said that expectations are that the physician be notified of wounds. She said wounds should be documented along with orders obtained from the doctor. She said wound assessments should be completed weekly on residents. During an interview with the DON on 12/5/19 at 1:42 pm, she said her expectations were that nurses report wounds to the doctor and obtain orders for treatment. She said skin assessments should be done weekly and upon identification of new wounds. She said she expected policies of the facility to be followed. Record review of the facility's Notifying the Physician of Change of Status dated (MONTH) 11, 2013 indicated the following: 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, interventions that were implemented in the resident's clinical record. Record review of the facility's Skin Integrity Management dated (MONTH) 5, (YEAR) indicated the following: 1. If wound is noted, perform an assessment and initiate a treatment plan as soon as possible. Document in resident's chart area of change, who you notified and treatment applied. 3. Wound care should be performed as ordered by physician.

Based on record review and interview the facility failed to ensure 1 resident (Resident #1) of 5 residents reviewed received adequate supervision on 10/3/11 to prevent an accident which resulted in a serious injury. The facility failed to ensure: 1. on 10/3/11 Resident #1 was transferred by 2 staff as was required by the resident's care plan. 2. on 10/3/11 Resident #1 was assessed for injury by a licensed nurse. The resident fell to the floor during a transfer from a wheelchair at about 2:00 p.m. on that day. Unlicensed staff assessed the resident and determined the resident was not injured by the fall. At about 2:30 p.m. the charge nurse was told by an aide Resident #1 was complaining of leg pain; it was subsequently determined the resident had sustained a fracture of the right leg. These facility failures resulted in harm and an injury, and a delay in treatment for [REDACTED]. Findings include: Review of Resident #1's record of admission revealed she was admitted to the facility on [DATE]. The resident was [AGE] years old at the time of this investigation. At the time of this investigation, Resident #1 was in the hospital for reasons unrelated to the fractured leg bone. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's quarterly minimum data set assessment dated [DATE] revealed the resident was usually able to understand others, and was able to make herself understood, however the resident had short-term and long-term memory deficits. The resident required extensive physical help from 2 or more staff members for transfers. Review of Resident #1's Plan of Care dated 4/1/11 revealed the resident required the assistance of 2 staff for transfers. Review of Resident #1's hospital history and physical report dated 10/3/11 revealed the resident was admitted to the hospital following a fall which occurred in the nursing home that same day. According to this report, the resident had a fracture of the right upper leg bone. The physician documented the resident reported her pain was severe, and seemed to be worse with movement. The report documented a plan of surgical repair of the leg bone fracture. Review of a Provider Investigation Report dated 10/4/11 revealed on 10/3/11 at 2:30 p.m. hospitality aide (HA) 'A' attempted to transfer Resident #1 but was unable to prevent the resident from falling to the floor. According to this report, certified nurse aide (CNA) 'A' and CNA 'B' assisted Resident #1 from the floor to a commode chair, and then to a recliner after the fall. The report documented Resident #1 later told a nurse the staff had dropped her to the floor, and she was experiencing severe pain in the right leg. The report documented the resident's right foot was externally rotated (a indicator of a possible fracture). In a written statement included with this report, HA 'A' wrote she attempted to transfer Resident #1 because a nurse directed her to do so. In a separate written statement included in this report, CNA 'A' wrote at the time of the incident HA 'A' told her a nurse instructed her (HA 'A') to assist the resident to the commode chair. Review of HA 'A's written statement dated 10/4/11 revealed HA 'A' wrote on 10/3/11 at about 1:50 p.m. the charged nurse asked her to help Resident #1 to the bathroom. HA 'A' wrote she first clocked in, then did as the charge nurse instructed. HA 'A' wrote when she attempted to assist Resident #1 to the toilet, the resident was unable to bear her weight, so she assisted the resident to the floor. HA 'A' wrote CNA 'A' and CNA 'B' came into the resident's room at that time, and all three staff members (CNA 'A', CNA 'B' and HA 'A') lifted the resident from the floor. HA 'A' wrote the two CNA's told her to "say nothing" about the incident. Review of CNA 'A's written statement dated 10/3/11 at 8:51 p.m. revealed she entered Resident #1's room (earlier in the shift) and saw the resident was on the floor. CNA 'A' wrote HA 'A' was in the room at that time, and told her a nurse had instructed her (HA 'A') to assist Resident #1 to the toilet. In an interview on 10/11/11 at 3:08 p.m. CNA 'A' said on 10/3/11 at about 2:30 p.m. she was working on the hall where Resident #1 lived. She said earlier that day she had weighed the resident in the resident's wheelchair, and she needed to weigh the wheelchair by itself to obtain an accurate weight for the resident. CNA 'A' said she went to the resident's room and saw the resident on the floor in a sitting position. CNA 'A' said HA 'A' was in the resident's room at that time. CNA 'A' said HA 'A' told her she had tried to transfer Resident #1 from her wheelchair to the commode chair but was unable to keep the resident from falling to the floor. CNA 'A' said she knew CNA 'B' was in the hall at that time, so she called CNA 'B' to the resident's room to help get the resident off the floor. CNA 'A' said she did not notify the charge nurse that Resident #1 was on the floor, but assessed the resident herself and determined the resident had not been injured by the fall. CNA 'A' said she had no training to assess a resident for bone fracture. She said she and CNA 'B' picked up the resident from the floor and put her on the commode chair. CNA 'A' said she instructed HA 'A' to remain with the resident, then she (CNA 'A') and CNA 'B' left the room. CNA 'A' said after several minutes she and CNA 'B' returned to Resident #1's room and transferred the resident to her recliner. CNA 'A' said at that time the resident began to complain of pain in her right leg. CNA 'A' said at that time she thought Resident #1 could have been injured by her fall, however she did not report to the charge nurse the resident's fall and subsequent complaint of leg pain. CNA 'A' said she later reported this to the DON, at about 4:00 p.m. on that same day. In an interview on 10/11/11 at 3:50 p.m. HA 'A' said from the first day of her employment at the facility (about 7/30/11) she wheeled residents in wheelchairs without supervision by licensed or certified staff. She said in the last week of September 2011 she began transferring residents from a wheelchair to a bed without help from other staff. She said none of the other staff stopped her from doing this so she thought it was appropriate for her to do so. She said on 10/3/11 at about 2:00 p.m. the charge nurse instructed her to help Resident #1 to the bathroom. HA 'A' said she tried to transfer Resident #1 from her wheelchair to the commode chair, however the resident was unable to bear her own weight. HA 'A' said she did not drop Resident #1, but lowered her to the floor. In an interview on 10/12/11 at 9:00 a.m. the administrator said HA 'A' was hired on the condition she attend a state approve CNA training program and pass the state CNA certification exam. The administrator said HA 'A' did complete the CNA training program but failed the certification exam. The administrator said HA 'A' had not been certified as competent to work as a nurse aide, however could work in the facility as a hospitality aide with the expectation HA 'A' would re-take the state exam in the future. In an interview on 10/12/11 at 9:07 a.m. the ADON said after HA 'A' failed the state CNA certification exam, the facility kept her (HA 'A') and permitted her to continue to work as an uncertified staff member, performing tasks such as transferring residents and toileting residents, although HA 'A' was not to do this independently. The ADON said she told HA 'A' she could continue to work until she re-took and passed the state exam. In an interview on 10/12/11 at 1:55 p.m. CNA 'B' said on 10/3/11 at about 2:00 p.m. she was on the hall where Resident #1 resided. CNA 'B' said CNA 'A' called her to come to Resident 1's room. CNA 'B' said when she entered Resident #1's room she saw the resident was on the floor in a sitting position. CNA 'B' said she did not know why the resident was on the floor. She said there was a hospitality aide in the room at that time, but she did not know the hospitality aide's name. CNA 'B' said she did not hear the hospitality aide say anything. CNA 'B' said she assisted CNA 'A' pick up the resident off the floor and put her on a commode chair. CNA 'B' said she and CNA 'A' remained in the room until the resident was finished with the commode chair, then she and CNA 'A' transferred the resident to a recliner. CNA 'B' said at that time the resident began to complain of pain in her upper right thigh. In an interview on 10/12/11 at 2:25 p.m. RN 'A' said she reported to work on 10/3/11 at 2:00 p.m. She said on that day she was the charge nurse for the hall where Resident #1 resided. RN 'A' said at about 2:30 that day a nurse aide came to her and reported Resident #1 was complaining of pain in her right leg. RN 'A' said she did not recall which aide reported this. RN 'A' said she went to the resident's room and saw the resident sitting in her recliner. RN 'A' said the resident told her the staff dropped her to the floor. RN 'A' said none of the staff had reported this to her. RN 'A' said she reported this to the administrator and director of nurses who went to the resident's room to assess the resident for injury. RN 'A' said she then contacted the resident's physician who instructed her to transfer the resident to a hospital emergency room for evaluation. According to a list provided by the facility, there were 26 residents who required extensive staff assistance for transfers.

Based on interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively to attain the highest practicable well being for 1 resident (Resident #1) of 5 reviewed residents. 1. From 9/23/11 to 10/3/11 the administrator failed to ensure the facility direct care staff were competent to perform tasks assigned to them. The administrator used hospitality aides to perform nurse aide tasks. When a hospitality aide dropped a resident during a transfer from a wheelchair, certified nurse aides assessed Resident #1 for injury on 10/3/11; the aides incorrectly determined Resident #1 was not injured by a fall, but it was later determined the resident sustained [REDACTED]. 2. The human resources coordinator failed to provide to newly hired employees a detailed, written job description for the hospitality aide position as was required by facility policy. This failure resulted in an unclear understanding of the job duties of the hospitality aides. On 10/3/11 a hospitality aide attempted to transfer Resident #1; the resident fell and sustained a leg fracture. 3. The assistant director of nurses failed to supervise hospitality aides to ensure they were used for tasks not involving nurse aide duties. Hospitality aides were assigned nursing aide tasks. On 10/3/11 a hospitality aide attempted to transfer Resident #1; the resident fell and sustained a leg fracture. These administration failures resulted in harm to Resident #1, but could have affected all 26 residents who required extensive physical help for transfers. Findings include: Resident #1 Review of Resident #1's record of admission revealed she was admitted to the facility on [DATE]. The resident was [AGE] years old at the time of this investigation. At the time of this investigation, Resident #1 was in the hospital for reasons unrelated to the injury being investigated. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's quarterly minimum data set assessment dated [DATE] revealed the resident was usually able to understand others, and was able to make herself understood, however the resident had short-term and long-term memory deficits. The resident required extensive physical help from 2 or more staff members for transfers. Review of Resident #1's Plan of Care dated 4/1/11 revealed the resident required the assistance of 2 staff for transfers. Review of a Provider Investigation Report dated 10/4/11 revealed on 10/3/11 at 2:30 p.m. hospitality aide (HA) 'A' attempted (without other staff assistance) to transfer Resident #1 but was unable to prevent the resident from falling to the floor. According to this report, certified nurse aide (CNA) 'A' and CNA 'B' subsequently assisted Resident #1 from the floor to a commode chair, and then to a recliner. The report documented Resident #1 later told a nurse the staff had dropped her to the floor, and she was experiencing severe pain in the right leg. The report documented the resident's right foot was externally rotated (an indicator of a possible bone fracture). In a written statement included with this report, HA 'A' wrote she attempted to transfer Resident #1 because a nurse directed her to do so. In a separate written statement included in this report, CNA 'A' wrote at the time of the incident HA 'A' told her a nurse instructed her (HA 'A') to assist the resident to the commode chair. The report did not contain any documentation the facility interviewed nurses to ascertain whether a nurse did instruct HA 'A' to assist Resident #1 to a toilet or commode chair. Review of Resident #1's hospital history and physical report dated 10/3/11 revealed the resident was admitted to the hospital following a fall which occurred in the nursing home that same day. According to this report, the resident had a [MEDICAL CONDITION] upper leg bone. The physician documented the resident reported her pain was severe, and seemed to be worse with movement. The report documented a plan of surgical repair of the leg bone fracture. Review of HA 'A's written statement dated 10/4/11 revealed HA 'A' wrote on 10/3/11 at about 1:50 p.m. the charged nurse asked her to help Resident #1 to the bathroom. HA 'A' wrote she first clocked in, then did as the charge nurse instructed. HA 'A' wrote when she attempted to assist Resident #1 to the toilet, the resident was unable to bear her weight, so she assisted the resident to the floor. HA 'A' wrote CNA 'A' and CNA 'B' came into the resident's room at that time, and all three staff members (CNA 'A', CNA 'B' and HA 'A') lifted the resident from the floor. HA 'A' wrote the two CNA's told her to "say nothing" about the incident. Review of CNA 'A's written statement dated 10/3/11 at 8:51 p.m. revealed she entered Resident #1's room (earlier in the shift) and saw the resident was on the floor. CNA 'A' wrote HA 'A' was in the room at that time, and told her a nurse had instructed her (HA 'A') to assist Resident #1 to the toilet. In an interview on 10/11/11 at 3:08 p.m. CNA 'A' said on 10/3/11 at about 2:30 p.m. she was working on the hall where Resident #1 lived. She said earlier that day she had weighed the resident in the resident's wheelchair, and she needed to weigh the wheelchair by itself to obtain an accurate weight for the resident. CNA 'A' said she went to the resident's room and saw the resident on the floor in a sitting position. CNA 'A' said HA 'A' was in the resident's room at that time. CNA 'A' said HA 'A' told her she had tried to transfer Resident #1 from her wheelchair to the commode chair but was unable to keep the resident from falling to the floor. CNA 'A' said she knew CNA 'B' was in the hall at that time, so she called CNA 'B' to the resident's room to help get the resident off the floor. CNA 'A' said she did not notify the charge nurse that Resident #1 was on the floor, but assessed the resident herself and determined the resident had not been injured by the fall. CNA 'A' said she had no training to assess a resident for bone fracture. She said she and CNA 'B' picked up the resident from the floor and put her on the commode chair. CNA 'A' said she instructed HA 'A' to remain with the resident, then she (CNA 'A') and CNA 'B' left the room. CNA 'A' said after several minutes she and CNA 'B' returned to Resident #1's room and transferred the resident to her recliner. CNA 'A' said at that time the resident began to complain of pain in her right leg. CNA 'A' said at that time she thought Resident #1 could have been injured by her fall, however she did not report to the charge nurse the resident's fall and subsequent complaint of leg pain. CNA 'A' said she later reported this to the DON, at about 4:00 p.m. on that same day. Using unqualified staff to perform direct care tasks. Review of a written statement by the human resources coordinator (HR) dated 10/4/11 revealed HA 'A' was hired on 7/28/11 as a hospitality aide under the condition HA 'A' complete a state approved nurse aide training course. According to this statement, HA 'A' did complete the course but failed the state nurse aide certification exam on 9/23/11. The HR documented the facility continued to employ HA 'A' as a hospitality aide. In a telephone interview on 10/11/11 at 3:50 p.m. HA 'A' said when she was hired she was not provided a written or verbal job description. She said from the first day of her employment at the facility (about 7/30/11) she wheeled residents in wheelchairs without supervision by licensed or certified staff. She said in the last week of September 2011 she began transferring residents from a wheelchair to a bed without help from other staff. She said the other staff knew she was doing this but did not stopped her from doing this so she thought it was appropriate for her to do so. In interviews on 10/11/11 at 3:08 p.m. and on 10/12/11 at 9:00 a.m. the administrator said in late July 2011 the facility hired a number of employees who were given the job title "hospitality aide". She said at that time the facility had no written job description for the hospitality aide position. She said these new employees were hired on the condition they attend a state approved nurse aide training program and pass the state nurse aide certification exam. The administrator said when the state exam was administered on 9/22/11, three of these hospitality aides failed. The administrator said, however, these 3 employees were kept in the hospitality aide position with the understanding they re-take and pass the state exam in October, 2011. At a later time during this investigation, the administrator provided the surveyor the corporation's written job description for the hospitality aide position. Review of a corporate document entitled Job Description -- Unit Helper/Nursing Assistant Trainee/Hospitality Aide, dated 2003, revealed the general duties of these staff positions included: -- respond to resident requests for assistance and attend to those needs which do not require direct care. -- relay resident needs to nursing staff. -- no physical contact with the residents. This written job description included a section entitled Applicant Declaration, in which the employee was to attest "I have read the qualifications and requirements of the position of Unit Helper/Nursing Assistant Trainee/Hospitality Aide. To the best of my knowledge, I believe I can perform these duties." This job description form included a signature line for the employee. In an interview on 10/12/11 at 9:58 a.m. the HR said it was the corporation's policy to provide each new employee a written job description which the employee was to sign. The HR said it was her responsibility to provide the employee this written job description and it was her responsibility to obtain the employee's signature. She said, however, none of the hospitality aides hired in July were provided a job description. She said she left it to the director of nurses and assistant director of nurses (ADON) to determine the scope of practice for the hospitality aides. The ADON failed to appropriately supervise hospitality aides. In a telephone interview on 10/12/11 at 1:40 p.m. HA 'B' said she was employed at the facility while she was enrolled in the nurse aide training program. She said she took the state nurse aide certification test in September 2011, but failed the exam. She said after she failed the state test, the facility allowed her to continue to work as a hospitality aide, although the facility did not provide her a job description for that position. She said she had to rely on the nurse aides and the ADON to tell her what she should be doing. She said as a hospitality aide she was providing direct resident care such as incontinent care. She said she voluntarily terminated her employment at the facility because she was scheduled to work only 2 days a week. In interviews on 10/12/11 at 9:07 a.m. and at 3:40 p.m. the ADON said the facility had a policy to provide a minimum number of direct care staff per shift, which the ADON explained included nurse aides and hospitality aides. She reviewed the written staffing record for 10/3/11 and said HA 'A' was scheduled and worked as one of the 4 required direct care staff on the 2:00 p.m. to 10:00 p.m. shift that day. The ADON said even though HA 'A' had failed the state CNA certification exam, she (HA 'A') continued to work in the facility under her (the ADON) supervision as an uncertified staff member, performing tasks such as transferring residents and toileting residents, although HA 'A' was not to do this independently. The ADON said she told HA 'A' she could continue to work until she re-took and passed the state exam. In an interview on 10/12/11 at 3:50 p.m. the administrator said it was the facility's policy to provide 4 nurse aides for the 2:00 p.m. to 10:00 p.m. shift. She said she did not know whether or not this was a written policy. Review of facility documents entitled 24 Hour Work Report dated 9/23/11 through 10/3/11 revealed HA 'A' was scheduled and worked on 9/30/11 (2-10 shift), 10/1/11(2-10 shift), 10/2/11(10-6 shift), and 10/3/11 (2-10 shift). These documents revealed HA 'B' was scheduled and worked on 9/26/11 (10-6 shift), and 9/27/11 (10-6 shift). HA 'B' was also scheduled but failed to report for work on 10/1/11 (10-6 shift) and 10/2/11 (10-6 shift). These work reports had signatures of the employees who reported for work, and remarks such as "called in" for employees who did not report for work as scheduled. According to a list provided by the facility, there were 26 residents who required extensive physical help with transfers.

Based on interview and record review the facility failed to ensure 3 hospitality aides (HA) who had worked less than 4 months as a nurse aide had demonstrated competence through the satisfactory participation in a State approved nurse aide training program. HA 'A', 'B', and 'C' were hired on or about 7/28/11 as hospitality aides. These employees completed a state approved nurse aide training program in late September 2011, however failed the state nurse aide competency exam on or about 9/23/11. After this date the facility continued to use HA 'A' and HA 'B' as nurse aides. This failure affected 1 resident (Resident #1) of 5 residents reviewed. On 10/3/11 HA 'A', who was used as a nurse aide, attempted to transfer Resident #1; during this transfer the resident fell to the floor and sustained a leg fracture. This failure caused harm to Resident #1, but could have affected all 26 residents who required extensive physical assistance for transfers. Findings include: Review of Resident #1's record of admission revealed she was admitted to the facility on [DATE]. The resident was [AGE] years old at the time of this investigation. At the time of this investigation, Resident #1 was in the hospital for reasons unrelated to the fractured leg bone. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's quarterly minimum data set assessment dated [DATE] revealed the resident was usually able to understand others, and was able to make herself understood, however the resident had short-term and long-term memory deficits. The resident required extensive physical help from 2 or more staff members for transfers. Review of Resident #1's Plan of Care dated 4/1/11 revealed the resident required the assistance of 2 staff for transfers. Review of Resident #1's hospital history and physical report dated 10/3/11 revealed the resident was admitted to the hospital following a fall which occurred in the nursing home that same day. According to this report, the resident had a [MEDICAL CONDITION] upper leg bone. The physician documented the resident reported her pain was severe, and seemed to be worse with movement. The report documented a plan of surgical repair of the leg bone fracture. Review of a Provider Investigation Report dated 10/4/11 revealed on 10/3/11 at 2:30 p.m. hospitality aide (HA) 'A' attempted to transfer Resident #1 but was unable to prevent the resident from falling to the floor. According to this report, certified nurse aide (CNA) 'A' and CNA 'B' assisted Resident #1 from the floor to a commode chair, and then to a recliner. The report documented Resident #1 later told a nurse the staff had dropped her to the floor, and she was experiencing severe pain in the right leg. The report documented the resident's right foot was externally rotated. In a written statement included with this report, HA 'A' wrote she attempted to transfer Resident #1 because a nurse directed her to do so. In a separate written statement included in this report, CNA 'A' wrote at the time of the incident HA 'A' told her a nurse instructed her (HA 'A') to assist the resident to the commode chair. The report did not contain any indication the facility interviewed nurses to ascertain whether a nurse did instruct HA 'A' to assist Resident #1 to a toilet or commode chair. Review of a written statement by the human resources coordinator (HR) dated 10/4/11 revealed HA 'A' was hired on 7/28/11 as a hospitality aide under the condition HA 'A' complete a state approved nurse aide training course. According to this statement, HA 'A' did complete the course but failed the state nurse aide certification exam on 9/23/11. The HR documented the facility continued to employ HA 'A' as a hospitality aide. Review of a corporate document entitled Job Description -- Unit Helper/Nursing Assistant Trainee/Hospitality Aide, dated 2003, revealed the general duties of these staff positions included: -- respond to resident requests for assistance and attend to those needs which do not require direct care. -- relay resident needs to nursing staff. -- no physical contact with the residents. In a telephone interview on 10/11/11 at 3:50 p.m. HA 'A' said when she was hired she was not provided a written or verbal job description. She said from the first day of her employment at the facility (about 7/30/11) she wheeled residents in wheelchairs without supervision by licensed or certified staff. She said in the last week of September 2011 she began transferring residents from a wheelchair to a bed without help from other staff. She said the other staff knew she was doing this but did not stopped her from doing this so she thought it was appropriate for her to do so. In interviews on 10/11/11 at 3:08 p.m. and on 10/12/11 at 9:00 a.m. the administrator said in late July 2011 the facility hired a number of employees who were given the job title "hospitality aide". She said at that time the facility had no written job description for the hospitality aide position. She said these new employees were hired on the condition they attend a state approved nurse aide training program and pass the state nurse aide certification exam. The administrator said when the state exam was administered on 9/22/11, three of these hospitality aides failed (HA 'A', 'B', and 'C'). The administrator said, however, these 3 employees were kept in the hospitality aide position with the understanding they re-take and pass the state exam in October, 2011. At a later time during this investigation, the administrator provided the surveyor the corporation's written job description for the hospitality aide position. In a telephone interview on 10/11/11 at 4:45 p.m. HA 'C' said she was hired by the facility in late July 2011. She said she was enrolled in the nurse aide training program however failed the state nurse aide competency exam in September 2011. She said after she failed the exam, the facility retained her as a hospitality aide, however she not worked since she failed the state exam. In an interview on 10/12/11 at 9:58 a.m. the HR said it was the corporation's policy to provide each new employee a written job description which the employee was to sign. The HR said it was her responsibility to provide the employee this written job description and it was her responsibility to obtain the employee's signature. She said, however, none of the hospitality aides hired in July were provided a job description. She said she left it to the director of nurses (DON) and assistant director of nurses (ADON) to determine the scope of practice for the hospitality aides. In a telephone interview on 10/12/11 at 1:40 p.m. HA 'B' said she was hired at the end of July 2011 and employed at the facility while she was enrolled in the nurse aide training program. She said she took the state nurse aide certification test in September 2011, but failed the exam. She said after she failed the state test, the facility allowed her to continue to work as a hospitality aide, although the facility did not provide her a job description for that position. She said she had to rely on the nurse aides and the ADON to tell her what she should be doing. She said as a hospitality aide she was providing direct resident care such as incontinent care. She said she voluntarily terminated her employment at the facility because she was scheduled to work only 2 days a week. In interviews on 10/12/11 at 9:07 a.m. and at 3:40 p.m. the ADON said the facility had a policy to provide a minimum number of direct care staff, which the ADON explained included nurse aides and hospitality aides. She reviewed the written staffing record for 10/3/11 and said HA 'A' was scheduled and worked as one of the 4 required direct care staff on the 2:00 p.m. to 10:00 p.m. shift that day. The ADON said even though HA 'A' had failed the state CNA certification exam, she (HA 'A') continued to work in the facility under her (the ADON) supervision as an uncertified staff member, performing tasks such as transferring residents and toileting residents, although HA 'A' was not to do this independently. The ADON said she told HA 'A' she could continue to work until she re-took and passed the state exam. In an interview on 10/12/11 at 3:50 p.m. the administrator said it was the facility's policy to provide 4 nurse aides for the 2:00 p.m. to 10:00 p.m. shift. She said she did not know whether or not this was a written policy. Review of facility documents entitled 24 Hour Work Report dated 9/23/11 through 10/3/11 revealed HA 'A' was scheduled and worked on 9/30/11 (2-10 shift), 10/1/11(2-10 shift), 10/2/11(10-6 shift), and 10/3/11 (2-10 shift). These documents revealed HA 'B' was scheduled and worked on 9/26/11 (10-6 shift), and 9/27/11 (10-6 shift). HA 'B' was also scheduled but failed to report for work on 10/1/11 (10-6 shift) and 10/2/11 (10-6 shift). These work reports had signatures of the employees who reported for work, and remarks such as "called in" for employees who did not report for work as scheduled. According to a list provided by the facility, there were 26 residents who required extensive physical help with transfers.

Based on interview and record review the facility failed to ensure 3 direct care staff members (certified nurse aides (CNA) 'A' and 'B', and hospitality aide (HA) 'A') were able to demonstrate competency in tasks they performed. The facility failed to: 1. ensure on 10/3/11 only staff who were competent to transfer residents transferred Resident #1. On that day HA 'A', who was used by the facility as a nurse aide, attempted to transfer Resident #1 without assistance of a second staff member as was required by the resident's care plan. During this transfer the resident fell and sustained a fracture of her right leg. 2. ensure on 10/3/11 only staff who were competent to assess a resident for injury assessed Resident #1 following a fall. Following this fall, CNA 'A' assessed the resident for injury and incorrectly determined the resident was not injured by the fall, however it was later determined the resident had a [MEDICAL CONDITION] leg. 3. ensure on 10/3/11 CNAs 'A' and 'B' were competent in skills and technique when they transferred Resident #1 from the floor to a commode chair and then to a recliner even though the resident had fallen and could have been, and was, injured, having sustained a right leg fracture. 4. ensure on 10/3/11 HA 'A', CNA 'A', and CNA 'B' were competent to report to the charge nurse when Resident #1 had fallen during a transfer and could have been (was) injured. These facility failures resulted in harm to Resident #1 but could have affected all 26 residents who required extensive physical help with transfers. Findings include: Review of Resident #1's record of admission revealed she was admitted to the facility on [DATE]. The resident was [AGE] years old at the time of this investigation. At the time of this investigation, Resident #1 was in the hospital for reasons unrelated to the fractured leg bone. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's quarterly minimum data set assessment dated [DATE] revealed the resident was usually able to understand others, and was able to make herself understood, however the resident had short-term and long-term memory deficits. The resident required extensive physical help from 2 or more staff members for transfers. Review of Resident #1's Plan of Care dated 4/1/11 revealed the resident required the assistance of 2 staff for transfers. Review of Resident #1's hospital history and physical report dated 10/3/11 revealed the resident was admitted to the hospital following a fall which occurred in the nursing home that same day. According to this report, the resident had a [MEDICAL CONDITION] upper leg bone. The physician documented the resident reported her pain was severe, and seemed to be worse with movement. The report documented a plan of surgical repair of the leg bone fracture. Review of a Provider Investigation Report dated 10/4/11 revealed on 10/3/11 at 2:30 p.m. hospitality aide (HA) 'A' attempted to transfer Resident #1 but was unable to prevent the resident from falling to the floor. According to this report, certified nurse aide (CNA) 'A' and CNA 'B' assisted Resident #1 from the floor to a commode chair, and then to a recliner. The report documented Resident #1 later told a nurse the staff had dropped her to the floor, and she was experiencing severe pain in the right leg. The report documented the resident's right foot was externally rotated (an indicator of a possible fracture). In a written statement included with this report, HA 'A' wrote she attempted to transfer Resident #1 because a nurse directed her to do so. In a separate written statement included in this report, CNA 'A' wrote at the time of the incident HA 'A' told her a nurse instructed her (HA 'A') to assist the resident to the commode chair. The report did not contain any indication the facility interviewed nurses to ascertain whether a nurse did instruct HA 'A' to assist Resident #1 to a toilet or commode chair. Review of HA 'A's written statement dated 10/4/11 revealed HA 'A' wrote on 10/3/11 at about 1:50 p.m. the charged nurse asked her to help Resident #1 to the bathroom. HA 'A' wrote she first clocked in, then did as the charge nurse instructed. HA 'A' wrote when she attempted to assist Resident #1 to the toilet, the resident was unable to bear her weight, so she assisted the resident to the floor. HA 'A' wrote CNA 'A' and CNA 'B' came into the resident's room at that time, and all three staff members (CNA 'A', CNA 'B' and HA 'A') lifted the resident from the floor. HA 'A' wrote the two CNA's told her to "say nothing" about the incident. Review of CNA 'A's written statement dated 10/3/11 at 8:51 p.m. revealed she entered Resident #1's room (earlier in the shift) and saw the resident was on the floor. CNA 'A' wrote HA 'A' was in the room at that time, and told her a nurse had instructed her (HA 'A') to assist Resident #1 to the toilet. In an interview on 10/11/11 at 3:08 p.m. CNA 'A' said on 10/3/11 at about 2:30 p.m. she was working on the hall where Resident #1 lived. She said earlier that day she had weighed the resident in the resident's wheelchair, and she needed to weigh the wheelchair by itself to obtain an accurate weight for the resident. CNA 'A' said she went to the resident's room and saw the resident on the floor in a sitting position. CNA 'A' said HA 'A' was in the resident's room at that time. CNA 'A' said HA 'A' told her she had tried to transfer Resident #1 from her wheelchair to the commode chair but was unable to keep the resident from falling to the floor. CNA 'A' said she knew CNA 'B' was in the hall at that time, so she called CNA 'B' to the resident's room to help get the resident off the floor. CNA 'A' said she did not notify the charge nurse that Resident #1 was on the floor, but assessed the resident herself and determined the resident had not been injured by the fall. CNA 'A' said she had no training to assess a resident for bone fracture. She said she and CNA 'B' picked up the resident from the floor and put her on the commode chair. CNA 'A' said she instructed HA 'A' to remain with the resident, then she (CNA 'A') and CNA 'B' left the room. CNA 'A' said after several minutes she and CNA 'B' returned to Resident #1's room and transferred the resident to her recliner. CNA 'A' said at that time the resident began to complain of pain in her right leg. CNA 'A' said at that time she thought Resident #1 could have been injured by her fall, however she did not report to the charge nurse the resident's fall and subsequent complaint of leg pain. CNA 'A' said she later reported this to the DON, at about 4:00 p.m. on that same day. In a telephone interview on 10/11/11 at 3:50 p.m. HA 'A' said from the first day of her employment at the facility (about 7/30/11) she wheeled residents in wheelchairs without supervision by licensed or certified staff. She said in the last week of September 2011 she began transferring residents from a wheelchair to a bed without help from other staff. She other staff knew she was doing this but did not stop her so she thought it was appropriate for her to do so. She said on 10/3/11 at about 2:00 p.m. she tried to transfer Resident #1 from her wheelchair to the commode chair, however the resident was unable to bear her own weight. HA 'A' said she did not drop Resident #1, but lowered her to the floor. In an interview on 10/12/11 at 9:00 a.m. the administrator said HA 'A' was hired on the condition she attend a state approve CNA training program and pass the state CNA certification exam. The administrator said HA 'A' did complete the CNA training program but failed the certification exam. The administrator said HA 'A' had not been certified as competent to work as a nurse aide, however could work in the facility as a hospitality aide with the expectation HA 'A' would re-take the state exam in the future. In an interview on 10/12/11 at 9:07 a.m. the ADON said after HA 'A' failed the state CNA certification exam, she (HA 'A') continued to work in the facility as an uncertified staff member, performing tasks such as transferring residents and toileting residents, although HA 'A' was not to do this independently. The ADON said she told HA 'A' she could continue to work until she re-took and passed the state exam. In an interview on 10/12/11 at 1:55 p.m. CNA 'B' said on 10/3/11 at about 2:00 p.m. she was on the hall where Resident #1 resided. CNA 'B' said CNA 'A' called her to come to Resident 1's room. CNA 'B' said when she entered Resident #1's room she saw the resident was on the floor in a sitting position. CNA 'B' said she did not know why the resident was on the floor. She said there was a hospitality aide in the room at that time, but she did not know the hospitality aide's name. CNA 'B' said she did not hear the hospitality aide say anything. CNA 'B' said she assisted CNA 'A' pick up the resident off the floor and put her on a commode chair. CNA 'B' said she and CNA 'A' remained in the room until the resident was finished with the commode chair, then she and CNA 'A' transferred the resident to a recliner. CNA 'B' said at that time the resident began to complain of pain in her upper right thigh. In an interview on 10/12/11 at 2:25 p.m. RN 'A' said she reported to work on 10/3/11 at 2:00 p.m. She said on that day she was the charge nurse for the hall where Resident #1 resided. RN 'A' said at about 2:30 that day a nurse aide came to her and reported Resident #1 was complaining of pain in her right leg. RN 'A' said she did not recall which aide reported this. RN 'A' said she went to the resident's room and saw the resident sitting in her recliner. RN 'A' said the resident told her the staff dropped her to the floor. RN 'A' said none of the staff had reported this to her. RN 'A' said she reported this to the administrator and DON who went to the resident's room to assess the resident for injury. RN 'A' said she then contacted the resident's physician who instructed her to transfer the resident to a hospital emergency room for evaluation. According to a list provided by the facility, there were 26 residents who required extensive staff assistance for transfers.

Based on observations, record review and interviews the facility failed to provide residents on the Certified Alzheimer's secured unit adequate supervision to prevent elopement and possible injury. This failure affected 2 of 6 (Resident # 1 and 2 ) residents sampled for wandering, risk of elopement and supervision on the secured unit. The facility failures were evidenced by the following: 1). The facility failed to ensure the gate that exited from the secured unit's patio to an outside parking lot was kept closed and locked properly at all times for the safety of the wandering residents. Resident # 1 eloped from the facility through the patio gate and walked to some apartments that were about 1 and 1/2 blocks from the facility and asked a stranger to take her home. The stranger took the resident to her home. The facility was unaware the resident had eloped the facility until she was brought back to the facility by her husband and the stranger. 2). The facility failed to ensure the alarm on the door that exited from the secured unit on to the patio was on and functioning to alert staff when wandering residents who required supervision were going out on the patio. 3). The facility failed to ensure that residents on the secured Alzheimer's unit were supervised while outside on the patio. Resident # 2 was observed unsupervised out on the patio. 4). The facility failed to keep the Alzheimer's unit secure. The facility allowed families/staff free access to the secured Alzheimer's unit through a locked patio gate from a parking lot. These failures resulted in an Immediate Jeopardy which was identified on 04/19/11. While the Immediate Jeopardy was removed on 04/19/11 the facility remained out of compliance with a potential for more than minimal harm at a pattern. Failure to provide adequate supervision and safety to residents with dementia and wandering behaviors who reside on a secured unit could lead to elopement and possible injuries. This failure could affect any of the 16 residents who resided on the facility's secured Alzheimer's unit. Findings include: RESIDENT # 1 Review of Resident # 1's admission record revealed the resident was [AGE] years old at the time of this investigation and was admitted on [DATE] to the Certified Alzheimer's secured unit. Admitting [DIAGNOSES REDACTED]. Review of a facility form titled "Elopement Risk Assessment" dated 02/09/10 revealed Resident # 1 was at HIGH RISK due to resident is occasionally or always disoriented, ambulates self, wanders and has intentionally or unintentionally attempted to leave facility. Needs wander alarm bracelet on Alzheimer's unit. Review of Resident # 1's prior care plan dated 02/14/10 revealed: PROBLEMS: Behavior; wanders in hallways and into other resident's room uninvited. GOALS: Wanders within specified boundaries during waking hours and is maintained in a safe environment. APPROACHES/INTERVENTIONS: Supervise closely to prevent elopement, Keep resident close to area that is supervised. Staff interventions to redirect when wandering is observed. Ensure that alarmed exits are functional at all times. Review of a Quarterly Social Worker Review dated 05/04/10 revealed : Cognitive Patterns: Resident currently lives on the Certified Alzheimer's unit and is under care for severe dementia and psychosocial difficulties. Prior to her admission in to the facility the resident was at high risk to wander into the community and become lost or in danger. At the time the resident has successfully acclimated to the living environment and has marginally improved in terms of verbal and non-verbal communication. The resident does experience "Sun Down" syndrome and may have distinct changes in cognitive functioning in the latter hours of the day. Identified Needs/Resolved Issues: The resident requires frequent, if not constant monitoring for basic safety and support needs. Social Services recommendations/interventions: Monitor for safety and support as needed. Quarterly Social Worker Review dated 07/27/10 revealed: Resident demonstrates severe cognitive impairment and currently resides on Certified Alzheimer's unit. This resident has great difficulty identifying person, place or time and frequently places herself at risk for injury or lack of safety due to her cognitive impairment and lack of personal judgement. Identified Needs: Resident requires monitoring and supervision to enhance safety and well being. Social Service recommendations/intervention: Monitor for basic safety and comfort Review of Resident #1's most current MDS dated [DATE] revealed. According to the MDS Resident # 1 had no problems with her hearing, she did have unclear speech at times. However she was able to make her self understood and usually understood others. Resident # 1 had both long and short term memory problems. According to the MDS the resident was moderately cognitively impaired. The resident had feelings of appearing down, depressed, or hopeless, as well as feeling tired with little energy. Resident # 1 had trouble concentrating on things almost daily. Resident # 1 had wandering behaviors, however according to the MDS the resident had not displayed wandering behaviors that placed her at risk. Resident # 1 was independent with all ADL's except for locomotion off the unit and bathing. These activities required supervision of one staff member. Review of Resident # 1's current care plan dated 01/23/11 and updated on 03/31/11 revealed: PROBLEMS: secured unit, resident wanders, would be lost and anxious outside controlled environment. GOALS: Resident resides on secured unit related to wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries daily X's 90 days. APPROACHES/INTERVENTIONS: monitor for episodes of wandering. Redirect resident if wandering. Monitor resident whereabouts frequently. Reorient throughout day. Review of a hospital Discharge Summary dated 03/21/11 revealed the resident had undergone a left modified radical [PROCEDURE] due to multifocal invasive [DIAGNOSES REDACTED] of the left breast. INCIDENT REPORT: Review of an incident report dated 04/10/11 at 7:02 p.m. revealed LVN "A" and LVN "C" (ADON) were discussing Resident # 1's care at the nursing station. Resident # 1 became upset when she overheard them and saw her name on her chart. According to the incident report Resident # 1 gets upset when she hears anyone discuss her. LVN 'C' and LVN 'A' explained to the resident they were talking about her care. Resident # 1 walked away upset. LVN 'C' and LVN 'A' left the nurse's station to assist the CNA's with another resident. According to the incident report as LVN 'A' came out of the other resident's room. Resident # 1, was with her husband and an unknown visitor standing at the nurse's station. Resident # 1's husband asked LVN 'A' why Resident # 1 was so upset. LVN 'A' explained to the resident's husband what had happened. It was at this time Resident # 1's husband informed LVN 'A' that Resident # 1 had been found at some apartments approximately a block and a half from the facility and that he and the visitor had brought her back to the facility. The resident said at this time she just wanted to go home. According to the incident report the resident was gone from the facility for approximately 15 minutes. The resident was assessed at this time and there were no injuries. Review of a nurse's note written by LVN 'A ' dated 04/10/11 at 7:50 p.m. Resident # 1 was sitting on a chair beside the couch in the living room, watching TV. LVN 'A ' documented she went to assist another resident, came back up to the nurse's desk as Resident #1, her husband and a visitor walked up to her. Resident # 1's husband asked what happened? Resident #1 was crying and upset. LVN 'A' documented 15 minutes prior she and LVN 'C' (ADON) were doing medication checks and Resident # 1 heard her name and became very upset as she does whenever anyone references her name. Resident # 1's husband stated at this time that the visitor had picked his wife up at some apartments that were approximately a block and a half from the facility. LVN 'A' documented the time was 6:02 p.m. According to the nurse's note Resident # 1 was assessed to have no injuries. LVN 'A' directed other staff at this time to check and make sure all other residents in the secured unit were accounted for. LVN 'A' documented she checked the door leading from the main part of the facility into the secured unit and it was locked, then she went out on the patio and checked the gate, that is when she found the gate was about 1/4 opened. LVN 'A' documented she pulled the gate hard until it was completely closed and locked. LVN 'A' documented she reported what she found to LVN 'C'. The administrator was notified at this time as well as the DON. LVN 'A' documented she was instructed to do 15 minute checks and head counts on the residents until the gate could be repaired by maintenance. Review of a witness statement from Resident # 1's husband dated 04/11/11 at 11:53 a.m. revealed Resident # 1 was brought to his house on 04/10/11 by a woman (Visitor Z). According to Resident # 1's husband the woman told him his wife (Resident # 1) had knocked on her apartment door and said her car had broken down and could the woman take her home. He said when his wife came home she was happy and laughing when she saw him. Review of a witness statement from Visitor 'Z' given to LVN 'C' on 04/11/11 at 1:10 p.m. revealed on 04/10/11 at about 7:00 p.m. she was sitting in her car at an apartment complex when Resident # 1 knocked on her car window and asked her for help. According to Visitor 'Z ' the resident told her that her car had run out of gas and that she had been walking for a long time. Visitor 'Z' said Resident # 1 could not give her address, but was able to give directions back to house. Visitor 'Z' said when she and the resident drove up to the house Resident # 1 said she was supposed to be at the nursing home. Visitor 'Z' said she and the resident's husband brought Resident # 1 back up to the nursing home. Visitor 'Z ' said they entered through the back gate. Visitor 'Z' said Resident # 1's husband put in the code. Visitor 'Z' said she was not sure if the gate was locked when Resident # 1's husband put in the code. Visitor 'Z' said when they brought Resident # 1 back into the unit the staff were not even aware the resident had left. Review of a witness statement written by LVN 'C' on 04/11/11 (no time) revealed she was notified by LVN 'A' on 04/10/11 that Resident # 1 was brought back into the facility by her husband and Visitor 'Z". According to the statement she was told Resident # 1 was found by some apartments. LVN 'C ' documented she asked LVN 'A' how did she get out? LVN 'A' answered she must have followed someone out. LVN 'C' documented she checked the doors and the patio gate and found that the gate was not closing. The gate required being pulled shut so that the magnet would catch. DON and Administrator were notified at 7:02 p.m. According to the statement she left the secured unit at 6:45 p.m. and Resident # 1 was in the unit and still asking the nurse why we were taking about her. Fifteen (15) minute checks started on residents and patio gate at this time. Interview and observation on 04/19/11 at 1:40 p.m. with LVN 'C' (ADON) revealed the door from the secured unit out onto the patio was unsecured. LVN 'C' said residents are free to come and go out onto the patio. She said the residents can go out onto the patio unsupervised. Observation at this time revealed a high wood fence with a tall wooden gate. LVN 'C' said Resident # 1 eloped from the secured unit on 04/10/11 and was gone about 15 minutes. LVN 'C' said staff did not know Resident # 1 was gone from the unit. LVN 'C' said at about 7:00 p.m. LVN 'A' came to the front of the facility and told LVN 'C' Resident # 1 had evidently gotten out of the secured unit because her husband brought the resident back to the unit and was asking how Resident # 1 got out. LVN 'C' said she examined the patio gate on 04/10/11 and discovered that a board on the gate was broken and the latch was not working properly due to the broken board. LVN 'C' said no one knew the board was broken or that there was any problems with the gate not closing. LVN 'C' said the maintenance man came that evening and worked on the gate. He put a new board on the gate and a tighter spring so that the gate would close and the magnet would lock the gate properly. She said also 15 minute checks were started checking the where abouts of the residents and checking the gate. Observation on 04/19/11 at 1:50 p.m. revealed when exiting the secured unit door onto the patio the alarm did not sound. LVN 'C' opened the gate using the gate punch code. LVN 'C' demonstrated how the gate would close by itself and latch. However when the gate closed by itself it did not latch. The gate was observed to still be open 2 to 3 inches. LVN 'C' said the gate had been closing, however maybe due to the high winds it would not close properly. Observation on 04/19/11 at 2:25 p.m. revealed when exiting the secured unit door onto the patio the alarm did not sound. Resident # 2 was out on the patio alone and unsupervised sitting in her wheelchair. The patio gate was shut and locked at this time. Interview with LVN 'A' on 04/19/11 at 2:55 p.m. revealed Resident # 1 became upset when LVN 'A' and LVN 'C ' were discussing her care at the nurse's station. After explaining to the resident that they were only discussing her care LVN 'A' said she and LVN 'C' left the nurse's station. LVN 'A' said she went to help with resident care. When she returned to the nurse's station about 15 minutes later Resident # 1, her husband and a female visitor entered the secured unit through the door from the patio. Resident # 1's husband said the resident was found by the female visitor at some apartments. Resident # 1 had asked the female visitor to take her home. On 04/19/11 at 3:50 p.m. DON was notified of Immediate Jeopardy. The Administrator was not in the building at this time. On 04/19/11 at 5:05 p.m. the DON stated the door from secured unit onto patio is not kept locked. She said the door has an alarm, however it is very loud and shrill and upsets the residents so the staff turn it off. The DON said at this time she will have staff activate the alarm on the door that goes to the patio so that staff will know anytime a resident goes out onto the patio. Review of a facility document titled "Frequent Observation Log" dated 04/19/11 revealed the repairs were completed to the secured unit patio gate at 5:11 p.m. The form was signed by the maintenance staff as well as LVN 'C ' (ADON). During an interview with LVN 'H' on 04/21/11 at 11:30 a.m. he said the gate on the patio had been broken and was not secure as it should have been. He said he thought the wind had been so strong that it had broken the gate. LVN 'H' said families also use the gate to come and go from the secured unit. He said one of them may not have shut the gate good. He said Resident # 1 may have gotten out then. LVN 'H' said now we are checking the gate every shift. During an interview with LVN 'H ' on 04/21/11 at 5:50 p.m. he said facility did not have a policy to have the alarm activated on the secured unit door that exited onto the patio. LVN 'C' said after the incident with Resident # 1 we are required to have it on. During an interview with the Administrator on 04/21/11 at 12:05 p.m. he said families had been allowed to come and go through the patio gate into the secured unit. However now that will no longer be allowed. During an interview with the Administrator on 04/21/11 at 1:00 p.m. he said staff had been turning off the alarm on the patio door because it was to loud and upset the residents. Review of the facility's policy on Elopement Prevention dated 10/27/10 revealed: Environmental Modification: # 6 Use door alarms or monitoring devices to notify staff when residents try to leave the facility. If applicable, consider the resident for a secured unit. Physical Plant: # 1 All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Keypad exit magnetic locks, keyed alarms, secured unit or a combination of the above. RESIDENT # 2 Review of Resident # 2's current MDS dated [DATE] revealed the resident was [AGE] years old at the time of this investigation and had been re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Under other health conditions was listed Shortness of Breath. According to the MDS the resident had no communication problems, but did wear glasses. The mental status of the resident was assessed as a (2). Mental status scores ranged from 1 (lowest) to 15 (highest function), The resident's mood interview revealed the resident felt tired with little energy and had a poor appetite on many days. According to the MDS the resident had delusions and exhibited verbal behavioral symptoms directed at others, such as threatening, screaming and cursing at others. She also had other behaviors with physical symptoms that occurred almost daily such as hitting, scratching self, pacing, rummaging, and verbal/vocal acts symptoms like screaming and disruptive sounds. The resident was assessed to wander daily. According to the MDS the resident was independent in bed mobility, transfers, walking in room or corridor, locomotion on and off unit, and dressing. The resident required limited assistance with toilet use, bathing and personal hygiene. The resident was frequently incontinent of bowel and bladder. Review of a facility form titled "Elopement Risk Assessment" dated 11/05/10 and updated on 02/01/11 revealed the resident was on a secured unit and was an "IMMINENT RISK" for elopement due to the resident being occasionally or always disoriented and will attempt to leave facility at any opportunity. Review of a facility form titled "Fall Risk Assessment" dated 11/05/10 and updated on 02/01/11 revealed the resident had a score of 20. According to the form a score of over 10 represented HIGH RISK for falls. Review of a facility form titled "Continued Stay Review" dated 08/01/07, updated 11/05/10 and updated again (no date documented/ note all other assessments were dated 02/01/11) revealed Resident # 2 "habitually wanders, or would wander, and not be able to find way back." Review of Quarterly Social Services Review dated 11/16/10 revealed the resident required structure and safety on the secured unit. Resident # 2 was at risk for wandering and possibly falling due to her dementia and compromised gait/balance and stamina. Social Services Recommendations were: Monitor for safety and comfort as needed. Review of Resident # 2's care plan dated 11/09/10 and updated on 02/07/11 revealed the following: PROBLEM: Secure unit--resident wanders without regard to safety. GOALS: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries daily X 90 days. APPROACHES/INTERVENTIONS: Monitor for episodes of wandering, redirect resident if wandering, monitor resident's whereabouts frequently, reorient throughout the day, administer medications as ordered and notify MD and family of any changes. ***** The care plan did not address the resident's safety when out on the patio and the need for supervision given the facility's determination on the elopement risk assessment (02/01/11) that the resident was a IMMINENT RISK for elopement. PROBLEM: potential of falls related to shuffling gait and impaired balance. Use wheelchair due to pelvic fracture and HIGH RISK for falls. APPROACHES/INTERVENTIONS: keep resident's room free from clutter, provide appropriate footwear, refer to therapy as needed, deep living area well lit, appropriate amount of staff for transfers, gait belt as needed, call light within reach, fall risk assessment on admission, quarterly and after each fall, notify MD and family after each fall. GOALS: resident will be free from falls the next 90 days. ***** The care plan did not address the resident's need for supervision to protect her from falls especially out on the patio despite the facility's determination the resident had impaired balance and that the resident was at HIGH RISK for falls. PROBLEM: resident is forgetful/impaired cognition and disoriented related to dementia/Alzheimer's Disease. GOALS: resident will remain safe and protected in environment for next 90 days. APPROACHES/INTERVENTIONS: approach resident in an open, friendly and relaxed manner and expression, encourage family to bring in familiar items, provide a stable/supportive environment through consistency in daily routine, pace activities, minimize distractions, provide orientation to decrease confusion, encourage participation in divisional activities, give short simple explanations to attempt to avoid confusion, visit with to provide reassurance and notify MD an family of any mental changes. ***** Despite a goal of keeping the resident in a safe and protected environment due to impaired cognition due to her disease process there were no interventions in this care plan that addressed supervision especially while on the patio despite the resident's documented confusion, high risk for falls and being an imminent elopement risk. Review of a facility document titled " 48 Hour Behavior Observation Report " dated 04/02/11 revealed the resident characteristics were documented as wandering in facility, history of falls and unintentional injuries to self. According to this form the resident had been placed in a wheelchair due to unsteady ambulation. Documentation on this form revealed the resident was able to get around in the wheelchair independently and was adjusting to the use of the wheelchair for mobility. Observation on 04/19/11 at 2:25 p.m. revealed when exiting the secured unit door onto the patio the alarm did not sound. Resident # 2 was out on the patio alone and unsupervised sitting in her wheelchair. The patio gate was shut and locked at this time. During an interview with RN 'T' on 04/21/11 at 2:45 p.m. he said Resident # 2 was able to propel herself in her wheelchair and go out onto the patio unassisted. RN 'T' said the resident loves it outside. According to the Administrator on 04/21/11 at 3:30 p.m. there were 16 resident's on the secured Certified Alzheimer's unit. Plan to remove Immediate Jeopardy was submitted on 04/19/11. The plan consisted of the following: 1. The facility maintenance staff will add springs to the gate door on the secured unit to ensure proper closer by 6:00 p.m. on 04/18/11 2. Staff on the secured unit initiated and began documenting every 15 minute checks at 3:45 p.m. on 04/19/11 on all residents until gate door is repaired. 3. a staff member (starting at 3:45 p.m.) will monitor the gate continuously until the door/gate is repaired. 4. Staff will monitor and document proper closure of the gate every shift for 1 month after repairs are made and will notify maintenance immediately if repairs are needed. Form will be located at the nurse's station in the maintenance log book. 5. In the event that repairs are needed on the gate in the future the staff will initiate all of the above monitoring. 6. Alarm to patio door will be on at all times starting at 5:05 p.m. to alert staff of any persons entering or exiting the unit from the patio. 7. When a resident exits the unit onto the patio a 15 minute monitoring log will be initiated to ensure the residents safety. 8. All staff will be in-serviced on monitoring and documentation of the alarm and the gate as noted above within 48 hours and before the start of their shift and job duties. Verification of Plan: 04/19/11 Review of frequent observation log revealed patio gate was being visually monitored until gate is repaired. Observation revealed at 5:00 p.m. staff member sitting in front of patio gate. At 5:05 p.m. DON stated alarm on patio will be turned on immediately to alert staff when residents go out on patio. 5:10 p.m. Maintenance supervision and Housekeeping supervisor completed work on gate. Gate now has two springs that will close gate when it is opened. If someone opens gate it must be held open or it will automatically close quickly due to springs. Gate will not open until code used on code key panel. 5:12 p.m. DON demonstrated door from secured unit onto patio alarm is not activated. Must turn off alarm with a key. The alarm will not turn off by itself. 5:15 p.m. DON said inservice will be provided to staff concerning alarms, 15 minute checks for supervision and patio gate. All staff will be inserviced within 48 hours and before they come on duty. 5:45 p.m. Observed LVN 'C' (ADON) inservicing 2 staff members on patio alarms and gate security. On 04/21/11 at 12:05 p.m. the Administrator stated the code on the gate leading to the secured unit patio had been changed. He said family members and visitors will no longer be allowed to use the gated entrance to enter the secured unit. The Administrator said a letter had been sent out to all the families notifying them of the change. He said the facility policy had been amended to reflect that change. According to the Administrator there were 16 residents that lived on the secured unit.

Based on observation, record review, and interview the facility failed to provide 1 resident (Resident #1) of 13 sampled residents the necessary care and services to attain and maintain the highest practicable well being. The facility failed to: 1. provide Resident #1 1800 cc of daily fluids as the physician ordered. On 10/27/10 the resident was admitted to a hospital for treatment of [REDACTED]. 2. provide Resident #1 more than 1200 cc of daily fluids as the physician ordered after the resident was readmitted from the hospital to the nursing home on 11/5/10. 2. provide or obtain for Resident #1 a physician ordered glucose tolerance test on 10/1/10 and on 10/15/10. On 10/27/10 the resident was admitted to a hospital with severe [MEDICAL CONDITION]. 3. administer to Resident #1 the ordered evening dose of regular insulin. From 11/5/10 to 12/8/10 the facility failed to give the resident the required insulin on 28 days. These facility failures resulted in actual serious harm to Resident #1 who was admitted to the hospital on [DATE] for severe [MEDICAL CONDITION] and dehydration. According to Resident #1's physician, the uncontrolled [MEDICAL CONDITION] and the dehydration worsened the effects of a stroke. These failures also created for Resident #1 the continued risk for serious harm from uncontrolled [MEDICAL CONDITION] (such as kidney damage and [MEDICAL CONDITION]) and serious harm from dehydration (such as hypovolemic shock) after she returned from the hospital to the facility on [DATE]. These failures resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a level of a pattern of actual harm. Although this facility failure affected Resident #1, all 19 residents who lived on the Alzheimer's unit could have been affected. Findings include: Review of Resident #1's record of admission revealed this female resident was admitted to the facility on [DATE]. She was [AGE] years old at the time of this investigation. Review of Resident #1's consolidated physician orders [REDACTED]. According to these orders, the resident was to be given 1800 cc of fluids per day; this order was dated 6/15/09. Review of Resident #1's annual MDS dated [DATE] revealed at that time the resident had both short-term and long-term memory loss. Her cognitive ability for daily decision making was severely impaired. She rarely or never was able to understand others, and rarely or never able to make herself understood. Her speech was unclear, mumbled words. The resident required extensive physical help from 2 staff members for most activities of daily living, but needed total care for some. Review of Resident #1's physician progress notes [REDACTED]. The resident lived at a different nursing home at that time, but this progress note documented the resident had a history of [REDACTED]. Review of Resident #1's medical record revealed documentation of fluid intake from 2/2/10 to 11/11/10. According to the resident's consolidated physician orders, the facility was to provide the resident 1800 cc of fluids each day, beginning 6/15/09. For February through May 2010 the intake records documented Resident #1 drank at least 1800 cc of fluid only on 10 days during this 4 month period, and drank less than 1000 cc on 29 days. For June through September 2010 there was documentation of intake on only 17 days. Of these 17 days, staff documented an intake of 1800 cc or more on only 1 day. Review of Resident #1's lab report dated 9/30/10 revealed the resident's blood glucose level was 136 milligrams per deciliter. According to the lab report, the normal range for blood glucose was 70 to 110. Review of the 24-hour Report dated 10/15/10 revealed RN 'A' documented Resident #1's physician office called and stated they had ordered for Resident #1 a glucose tolerance test but had not received a report on the result of the ordered test. Review of Resident #1's hospital medical record history and physical and discharge summary, dated 10/27/10 and 11/5/10 respectively, revealed the resident was admitted to the acute care unit of the hospital on [DATE] for altered mental status with a decreased alertness for several days, and was barely responsive at the time of the hospital admission. The reports documented the resident was severely hyperglycemic (very high blood glucose level) with an initial blood glucose level of 697 (normal levels are 70 to 110). The reports documented the resident, prior to this hospital admission, had not been diagnosed with [REDACTED]. The reports documented the resident also had new right-sided [MEDICAL CONDITION] (weakness) and decreased right side mobility which suggested a stroke had occurred. The reports documented the resident was treated in the hospital with IV insulin and fluids for 3 days. Review of an undated web article entitled [MEDICAL CONDITION] in Diabetes (Mayo Clinic website) revealed blood glucose levels greater than 600 mg/dL can lead to coma and cause life-threatening dehydration. Review of undated web articles entitled Dehydration (Mayo Clinic website) revealed a serious potential complication of dehydration is hypovolemic shock, which is a drop in blood pressure with a corresponding reduction in the amount of oxygen reaching tissues. If untreated, hypovolemic shock can cause death in a matter of minutes. Review of Resident #1's physician orders [REDACTED]. These orders instructed the facility to check the resident's blood glucose level twice a day and give the resident regular insulin according to a sliding scale (the amount of insulin was to adjusted according to the residents blood glucose level). Attached to these orders was a copy of the hospital Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to these orders, the facility was to ensure the resident was to drink more than 1200 cc daily. Review of Resident #1's nursing home nursing notes for 11/5/10 revealed the resident was readmitted from the hospital to the facility at 2:35 p.m. on that day. Review of Resident #1's nursing home diabetic treatment record for November 2010 (11/5/10 to 11/30/10) revealed the resident's blood glucose levels were checked each evening at 8:00 p.m. The resident's blood glucose level on 7 days was more than 150 but less than 201, so according to the sliding scale the resident should have been given 2 units of regular insulin at 8:00 p.m. on each of those days. On 9 days, the resident's evening blood glucose level was greater than 200 but less than 251, so the resident should have been given 4 units of regular insulin on those days. On 4 days the resident's evening glucose level was greater than 250 but less than 301, so the resident should have been given 6 units of regular insulin on those days. According to the resident's diabetic treatment record, the resident was not given any regular insulin at 8:00 p.m. on the 20 days when her evening blood glucose level was high. Review of Resident #1's diabetic treatment record for December 2010 (12/1/10 though 12/8/10) revealed the resident's evening blood glucose level was more than 150 but less than 201 on 6 days. The resident should have been given 2 units of regular insulin at 8:00 p.m. on those days. On 2 days the resident's evening blood glucose level was more than 201 or higher but less than 251. The resident should have been given 4 units of regular insulin on those days. According to this record, the resident did not receive any regular insulin at 8:00 p.m. on any day even though she should have. Review of Resident #1's fluid intake records for 11/5/20 to 11/11/10 revealed: -- on 11/5/10 there was no documentation of fluid intake, even though the resident was readmitted to the nursing home on that day at 2:35 p.m. -- on 11/6/10 the staff documented the resident drank 480 cc. -- on 11/7/10 the staff documented the resident drank 1050 cc. -- on 11/8/10 the staff documented the resident drank only 400 cc. -- on 11/9/10 the staff documented the resident drank only 524 cc. -- on 11/10/10 the staff documented the resident drank 880 cc. -- on 11/11/10 the staff documented the resident drank only 740 cc. Observation on 12/8/10 at 10:43 a.m. revealed CNA 'A' and CNA 'B' used a mechanical lift to transfer Resident #1 from a wheelchair to the resident's bed. The aides provided the resident incontinent care then transferred the resident back to the wheelchair and took her back to the lobby area of the dementia unit. Observation on 12/8/10 at 1:10 p.m. revealed Resident #1 was up in a wheelchair in the dining room for lunch. The resident made no effort to feed herself, so staff fed the resident. The resident drank tea, water, juice, and a health shake, about 480 cc in all. Observation on 12/8/10 at 4:20 p.m. revealed Resident #1 drank about 180 cc of water. Observation on 12/8/10 at 5:40 p.m. revealed Resident #1 was in the dining room for supper. She drank about 480 cc. In an interview on 12/9/10 at 10:30 a.m. Resident #1's physician said on 10/1/10 she instructed the facility to obtain for the resident a glucose tolerance test. (A glucose tolerance test is a medical test in which glucose was to be given to the resident and blood samples were to be taken afterward to determine how quickly the glucose was cleared from the blood. This test is usually used to check for diabetes). The physician said when she next saw the resident during an office visit on 10/27/10, the resident was very obtunded (mentally dull), so she had the resident immediately admitted to the hospital. The physician said hospital lab tests showed the resident was severely hyperglycemic (very high blood glucose level) as well as very significantly dehydrated. The physician said although the resident's family refused to have a CT of the resident's head (a medical imaging method), she thought the resident had a stroke because the resident was showing new [MEDICAL CONDITION] (weakness on one side of the body). The physician said the resident's severe [MEDICAL CONDITION] would have significantly worsened the resident's dehydration which in turn would have worsened the stroke. The physician said had the facility obtained a glucose tolerance test as was ordered on [DATE], the resident would have started treatment to control her blood glucose levels, and the effects of the stroke would have been lessened. In an interview on 12/9/10 at 1:40 p.m. LVN 'A' said she was the nurse that transcribed Resident #1's hospital discharge orders for the use of regular insulin. She reviewed the hospital discharge orders and her transcription of the orders to the facility's medication administration records. She said it was clear at the time of this interview the resident should have been getting regular insulin in the evenings, but she did not transcribe that to the facility MAR. The LVN said she did not know what she was thinking at the time she transcribed the orders, but she should have contacted the physician for clarification of the order. The LVN said it was clear to her that she transcribed the order in error and should have called the physician for clarification. In an interview on 12/9/10 at 2:10 p.m. CNA 'A' said she had worked in facility about 1 year. She said until about 1 week or so before Resident #1 was admitted to the hospital on [DATE] the resident was able to walk when 2 staff held onto the resident's gait belt. CNA 'A' said the resident was able to speak at that time, although she was not able to carry on a conversation, and what the resident said made little sense. The CNA said the resident then began to show signs of weakness, and the staff started using a wheelchair for her. The CNA said after the resident returned to the nursing home after her hospital stay (10/27/10 to 11/5/10) the resident was significantly declined, was then unable to stand and required a mechanical lift for transfers, and the resident did not speak at all any longer. In an interview on 12/9/10 at 2:25 p.m. the DON said prior to 11/12/10 the facility was doing nothing to ensure Resident #1 received the amount of daily fluids ordered by her physician. On 12/9/10 at 4:04 p.m. the office nurse for Resident #1's physician sent to the surveyor by fax the resident's lab report dated 9/30/10 and a list of the dates and times she communicated with the physician and the nursing home about the resident's glucose tolerance test. In a telephone interview on 12/9/10 at 4:10 p.m. the office nurse for Resident #1's physician said on 10/1/10 the physician told her to instruct the nursing home to obtain a glucose tolerance test for the resident. The office nurse said she phoned the facility that day and gave the order to 1 of the facility nurses. The office nurse said on 10/15/10, when Resident #1's physician had not received a report from the facility regarding the glucose tolerance test, she called the facility again and reminded them of the order to get that test. In a telephone interview on 12/10/10 at 9:45 a.m. the office nurse for Resident #1's physician said the facility should have been giving Resident #1 regular insulin both in the morning and in the evening since the resident was readmitted to the facility on [DATE]. In an interview on 12/12/10 at 2:00 p.m. CNA 'C' said Resident #1 always needed assistance with eating and drinking, but did drink well when she was offered a drink, even before the resident was admitted to the hospital on [DATE]. In an interview on 12/13/10 at 2:34 p.m. RN 'A' said on 10/15/10 at about 2:00 p.m. she received a telephone call from the office nurse of Resident #1's physician. RN 'A' said the office nurse asked why the physician had not received a report on the results of the ordered blood glucose tolerance test. RN 'A' said she reviewed the resident's medical record and found there had not been an order written [REDACTED]. RN 'A' did not explain why she did not write the order herself, or why she did not ask the office nurse for clarification at the time of her telephone conversation. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Coordinator. According to this plan, the facility determined on 11/12/10 (after the surveyor entered the facility to investigate an allegation of dehydration) it had not been correctly monitoring Resident #1's hydration. The plan documented all residents were assessed for dehydration on 12/12/10. The facility determined it's hydration policy had been inadequate to ensure residents remained well hydrated, so a new policy was written and put into effect. Staff inservice on the new hydration policy began on 12/12/10 and was completed on 12/14/10. The plan documented all newly admitted residents were to be monitored for 72 hours to determine whether they were at risk for dehydration and a plan of care for hydration was to be established within 72 hours following the determination of a resident's risk of dehydration. Review of the inservice records revealed on 11/20/10 40 staff members, licensed and unlicensed, received training on resident hydration and on intake documentation. Review of the facility's newly written hydration policy revealed residents were to be offered 360 cc to 480 cc of fluids at each meal as determined by each resident's dietician evaluation of fluid needs. Fluid intake for at risk residents was to be documented each shift, reviewed by charge nurses, and monitored by the DON and ADON. Review of the Plan of Removal of Immediate Jeopardy revealed the following documentation tools were to be used in the facility: a dehydration risk appraisal checklist, a new fluid intake/output worksheet, a new weekly intake/output monitoring form, and a new checklist to evaluate for the signs and symptoms of dehydration. Review of an inservice training record dated 12/12/10 revealed licensed and unlicensed staff were trained on the use of the new hydration policy and procedures. According to this plan, on 12/10/10 the facility inserviced all nursing staff on the correct manner to clarify physician's orders [REDACTED]. According to the plan, the DON and the ADON will monitor all new physician orders [REDACTED]. Also, according to the plan, the facility administration created a new policy regarding the receiving and transcribing of physician orders. According to this plan, on 11/5/10 a nurse failed to clarify Resident #1's physician order [REDACTED]. This inservice was completed on 12/10/10. Review of the inservice attendance record revealed 12 nurses received this training. According to the plan, the DON and the ADON will monitor all new physician orders [REDACTED]. Also, according to the plan, the facility administration created a new policy regarding the receiving and transcribing of physician orders. Plan of Removal Verification Facility staff were interviewed on 12/14/10 concerning the inservice training related to resident hydration. All staff interviewed confirmed they received the inservice and communicated knowledge of the facility's policy on resident hydration Observations revealed staff were providing fluids from a hydration cart and at meals. Facility nurses were interviewed on 12/14/10 concerning the inservice training related to physician orders. All nurses interviewed confirmed they received the inservice and communicated knowledge of the facility's policy on receiving, clarifying, and transcribing physician orders. The Immediate Jeopardy was lowered to actual harm prior to the exit on 12/14/10 at 2:45 p.m. According to the Administrator during the entrance conference on 11/12/10 at 9:50 a.m. the census was 59. According to a resident worksheet compiled and printed on 12/12/10, there were 14 residents who had a [DIAGNOSES REDACTED]. According to a list provided by the facility there were 2 residents with a physician order [REDACTED].

Based on observation, interview and record review the facility failed to provide or obtain a physician ordered laboratory test for 1 resident (Resident #1) of 8 residents sampled for laboratory services. The facility failed to provide or obtain for Resident #1 a physician ordered glucose tolerance test on 10/1/10 and on 10/15/10. This facility failure resulted in actual harm to Resident #1 who was admitted to the hospital on [DATE] for severe [MEDICAL CONDITION] and dehydration. According to Resident #1's physician, the uncontrolled [MEDICAL CONDITION] worsened the effects of a stroke. This failure resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a pattern level of actual harm. Although this facility failure affected only Resident #1, all 59 residents could have been affected. Findings include: Review of Resident #1's record of admission revealed this female resident was admitted to the facility on [DATE]. She was [AGE] years old at the time of this investigation. Review of Resident #1's consolidated physician orders [REDACTED]. According to these orders the resident was to have routine lab work every 6 months, to be done each March and September. These labs were to include a metabolic panel which included a test for blood glucose level. Review of Resident #1's annual MDS dated [DATE] revealed at that time the resident had both short-term and long-term memory loss. Her cognitive ability for daily decision making was severely impaired. She rarely or never was able to understand others, and rarely or never able to make herself understood. Her speech was unclear, mumbled words. The resident required extensive physical help from 2 staff members for most activities of daily living, but needed total care for some. Observation on 12/8/10 at 10:43 a.m. revealed CNA 'A' and CNA 'B' used a mechanical lift to transfer Resident #1 from a wheelchair to the resident's bed. The aides provided the resident incontinent care then transferred the resident back to the wheelchair and took her back to the lobby area of the dementia unit. Review of Resident #1's lab report dated 9/30/10 revealed the resident's blood glucose level was 136 milligrams per deciliter. According to the lab report, the normal range for blood glucose was 70 to 110. Review of Resident #1's hospital medical record history and physical and discharge summary, dated 10/27/10 and 11/5/10 respectively, revealed the resident was admitted to the acute care unit of the hospital on [DATE] for altered mental status with a decreased alertness for several days, and was barely responsive at the time of the hospital admission. The reports documented the resident was severely hyperglycemic (very high blood glucose level) with an initial blood glucose level of 697 (normal levels are 70 to 110). The reports documented the resident, prior to this hospital admission, had not been diagnosed with [REDACTED]. The reports documented the resident also had new right-sided [MEDICAL CONDITION] (weakness) and decreased right side mobility which suggested a stroke had occurred. The reports documented the resident was treated in the hospital with IV insulin and fluids for 3 days. Review of an undated web article entitled [MEDICAL CONDITION] in Diabetes (Mayo Clinic website) revealed blood glucose levels greater than 600 mg/dL can lead to coma and cause life-threatening dehydration. In an interview on 12/9/10 at 10:30 a.m. Resident #1's physician said on 10/1/10 she instructed the facility to obtain for the resident a glucose tolerance test. (A glucose tolerance test is a medical test in which glucose was to be given to the resident and blood samples were to be taken afterward to determine how quickly the glucose was cleared from the blood. This test is usually used to check for diabetes). The physician said when she next saw the resident during an office visit on 10/27/10, the resident was very obtunded (mentally dull), so she had the resident immediately admitted to the hospital. The physician said hospital lab tests showed the resident was severely hyperglycemic (very high blood glucose level) as well as very significantly dehydrated. The physician said although the resident's family refused to have a CT of the resident's head (a medical imaging method), she thought the resident had a stroke because the resident was showing new [MEDICAL CONDITION] (weakness on one side of the body). The physician said the resident's severe [MEDICAL CONDITION] would have significantly worsened the resident's dehydration which in turn would have worsened the stroke. The physician said had the facility obtained a glucose tolerance test as was ordered on [DATE], the resident would have started treatment to control her blood glucose levels, and the effects of the stroke would have been lessened. In an interview on 12/9/10 at 2:10 p.m. CNA 'A' said she had worked in facility about 1 year. She said until about 1 week or so before Resident #1 was admitted to the hospital on [DATE] the resident was able to walk when 2 staff held onto the resident's gait belt. CNA 'A' said the resident was able to speak at that time, although she was not able to carry on a conversation, and what the resident said made little sense. The CNA said the resident then began to show signs of weakness, and the staff started using a wheelchair for her. The CNA said after the resident returned to the nursing home after her hospital stay (10/27/10 to 11/5/10) the resident was significantly declined in that she was then unable to stand and required a mechanical lift for transfers, and the resident did not speak at all any longer. On 12/9/10 at 4:04 p.m. the office nurse for Resident #1's physician sent to the surveyor by fax the resident's lab report dated 9/30/10 and a list of the dates and times she communicated with the physician and the nursing home about the resident's glucose tolerance test. In a telephone interview on 12/9/10 at 4:10 p.m. the office nurse for Resident #1's physician said on 10/1/10 the physician told her to instruct the nursing home to obtain a glucose tolerance test for the resident. The office nurse said she phoned the facility that day and gave the order to 1 of the facility nurses. The office nurse said on 10/15/10, when Resident #1's physician had not received a report from the facility regarding the glucose tolerance test, she called the facility again and reminded them of the order to get that test. In an interview on 12/13/10 at 2:34 p.m. RN 'A' said on 10/15/10 at about 2:00 p.m. she received a telephone call from the office nurse of Resident #1's physician. RN 'A' said the office nurse asked why the physician had not received a report on the results of the ordered blood glucose tolerance test. RN 'A' said she reviewed the resident's medical record and found there had not been an order written [REDACTED]. RN 'A' did not explain why she did not write the order herself, or why she did not ask the office nurse for clarification at the time of her telephone conversation with the physician's office nurse. Review of the 24-hour Report dated 10/15/10 revealed RN 'A' documented Resident #1's physician office called and stated they had ordered for Resident #1 a glucose tolerance test but had not received a report on the result of the ordered test. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Officer. According to this plan, on 12/10/10 the facility inserviced all nursing staff on the correct manner to clarify physician's orders [REDACTED]. According to the plan, the DON and the ADON will monitor all new physician orders [REDACTED]. Also, according to the plan, the facility administration created a new policy regarding the receiving and transcribing of physician orders. Plan of Removal Verification Facility nurses were interviewed on 12/14/10 concerning the inservice training related to physician orders. All nurses interviewed confirmed they received the inservice and communicated knowledge of the facility's policy on receiving, clarifying, and transcribing physician orders. The Immediate Jeopardy was lowered to actual harm prior to the exit on 12/14/10 at 2:45 p.m. According to the Administrator during the entrance conference on 11/12/10 at 9:50 a.m. the census was 59.

Based on observation, record review, and interview the facility failed to implement its written policy and procedures that prohibit neglect. This failure affected 2 residents (Residents #1 and #2) of 13 sampled residents. The facility failed to: 1. obtain for Resident #1 a physician ordered glucose tolerance test on 10/1/10 and on 10/15/10. As a result of this failure, the resident was hosptalized on [DATE] with severe hyerglycemia (high blood glucose level) that worsened the effects of a stroke. A glucose tolerance test is a medical test in which glucose was to be given to the resident and blood samples were to be taken afterward to determine how quickly the glucose was cleared from the blood. This test is usually used to check for diabetes. 2. provide Resident # cc of daily fluids as the physician ordered, from 2/2/10 to 10/27/10. On that day the resident was admitted to a hospital for treatment of [REDACTED]. 3. provide Resident #1 more than 1200 cc of daily fluids as the physician ordered after the resident was readmitted from the hospital to the nursing home on 11/5/10. 4. identify and provide Resident #2 the necessary services by neglecting to provide for Resident #2 a psychiatric evaluation. The facility failed to consult with the resident's attending physician to obtain an order for [REDACTED]. These facility failures resulted for Resident #1 of actual harm related to severe [MEDICAL CONDITION] and dehydration, and created for Resident #1 the continued risk for serious harm from uncontrolled [MEDICAL CONDITION] (such as kidney damage and [MEDICAL CONDITION]) and serious harm from dehydration (such as hypovolemic shock). These failures resulted in a delay of treatment for [REDACTED].#2's inappropriate sexual behaviors. This failure resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a level of a pattern of actual harm. Although these facility failures affected Residents #1 and #2, all 19 residents who lived on the Alzheimer's unit could have been affected. Findings include: Review of Resident #1's record of admission revealed this female resident was admitted to the facility on [DATE]. She was [AGE] years old at the time of this investigation. Review of Resident #1's physician progress notes [REDACTED]. The resident had lived at a different nursing home at that time, but this progress note documented the resident had a history of [REDACTED]. Review of Resident #1's consolidated physician orders [REDACTED]. According to these orders, the resident was to be given 1800 cc of fluids per day; this order was dated 6/15/09. According to these orders the resident was to have routine lab work every 6 months, to be done each March and September. These labs were to include a metabolic panel which included a test for blood glucose level. Review of Resident #1's annual MDS dated [DATE] revealed at that time the resident had both short-term and long-term memory loss. Her cognitive ability for daily decision making was severely impaired. She rarely or never was able to understand others, and rarely or never able to make herself understood. Her speech was unclear, mumbled words. The resident required extensive physical help from 2 staff members for most activities of daily living, but needed total care for some. Observation on 12/8/10 at 10:43 a.m. revealed CNA 'A' and CNA 'B' used a mechanical lift to transfer Resident #1 from a wheelchair to the resident's bed. The aides provided the resident incontinent care then transferred the resident back to the wheelchair and took her back to the lobby area of the dementia unit. Review of Resident #1's lab report dated 9/30/10 revealed the resident's blood glucose level was 136 milligrams per deciliter. According to the lab report, the normal range for blood glucose was 70 to 110. Review of Resident #1's hospital medical record history and physical and discharge summary, dated 10/27/10 and 11/5/10 respectively, revealed the resident was admitted to the acute care unit of the hospital on [DATE] for altered mental status with a decreased alertness for several days, and was barely responsive at the time of the hospital admission. The reports documented the resident was severely hyperglycemic (very high blood glucose level) with an initial blood glucose level of 697 (normal levels are 70 to 110). The reports documented the resident, prior to this hospital admission, had not been diagnosed with [REDACTED]. The reports documented the resident also had new right-sided [MEDICAL CONDITION] (weakness) and decreased right side mobility which suggested a stroke had occurred. The reports documented the resident was treated in the hospital with IV insulin and fluids for 3 days. Review of Resident #1's physician orders [REDACTED]. According to these orders, the facility was to ensure the resident was to drink more than 1200 cc daily. Review of Resident #1's nursing home nursing notes for 11/5/10 revealed the resident was readmitted to the facility at 2:35 p.m. on that day. Review of Resident #1's fluid intake records for 11/5/20 to 11/11/10 revealed: -- on 11/5/10 there was no documentation of fluid intake, even though the resident was readmitted to the nursing home on that day at 2:35 p.m. -- on 11/6/10 the staff documented the resident drank 480 cc. -- on 11/7/10 the staff documented the resident drank 1050 cc. -- on 11/8/10 the staff documented the resident drank only 400 cc. -- on 11/9/10 the staff documented the resident drank only 524 cc. -- on 11/10/10 the staff documented the resident drank 880 cc. -- on 11/11/10 the staff documented the resident drank only 740 cc. In an interview on 12/9/10 at 10:30 a.m. Resident #1's physician said on 10/1/10 she instructed the facility to obtain for the resident a glucose tolerance test. (A glucose tolerance test is a medical test in which glucose was to be given to the resident and blood samples were to be taken afterward to determine how quickly the glucose was cleared from the blood. This test is usually used to check for diabetes). The physician said when she next saw the resident during an office visit on 10/27/10, the resident was very obtunded (mentally dull), so she had the resident immediately admitted to the hospital. The physician said hospital lab tests showed the resident was severely hyperglycemic (very high blood glucose level) as well as very significantly dehydrated. The physician said although the resident's family refused to have a CT of the resident's head (a medical imaging method), she thought the resident had a stroke because the resident was showing new [MEDICAL CONDITION] (weakness on one side of the body). The physician said the resident's severe [MEDICAL CONDITION] would have significantly worsened the resident's dehydration which in turn would have worsened the stroke. The physician said had the facility obtained a glucose tolerance test as was ordered on [DATE], the resident would have started treatment to control her blood glucose levels, and the effects of the stroke would have been lessened. In an interview on 12/9/10 at 2:10 p.m. CNA 'A' said she had worked in facility about 1 year. She said until about 1 week or so before Resident #1 was admitted to the hospital on [DATE] the resident was able to walk when 2 staff held onto the resident's gait belt. CNA 'A' said the resident was able to speak at that time, although she was not able to carry on a conversation, and what the resident said made little sense. The CNA said the resident then began to show signs of weakness, and the staff started using a wheelchair for her. The CNA said after the resident returned to the nursing home after her hospital stay (10/27/10 to 11/5/10) the resident was significantly declined in that she was then unable to stand and required a mechanical lift for transfers, and the resident did not speak at all any longer. On 12/9/10 at 4:04 p.m. the office nurse for Resident #1's physician sent to the surveyor by fax the resident's lab report dated 9/30/10 and a list of the dates and times she communicated with the physician and the nursing home about the resident's glucose tolerance test. In a telephone interview on 12/9/10 at 4:10 p.m. the office nurse for Resident #1's physician said on 10/1/10 the physician told her to instruct the nursing home to obtain a glucose tolerance test for the resident. The office nurse said she phoned the facility that day and gave the order to 1 of the facility nurses. The office nurse said on 10/15/10, when Resident #1's physician had not received a report from the facility regarding the glucose tolerance test, she called the facility again and reminded them of the order to get that test. In an interview on 12/13/10 at 2:34 p.m. RN 'A' said on 10/15/10 at about 2:00 p.m. she received a telephone call from the office nurse of Resident #1's physician. RN 'A' said the office nurse asked why the physician had not received a report on the results of the ordered blood glucose tolerance test. RN 'A' said she reviewed the resident's medical record and found there had not been an order written [REDACTED]. RN 'A' did not explain why she did not write the order herself, or why she did not ask the office nurse for clarification at the time of her telephone conversation with the physician's office nurse. Review of the 24-hour Report dated 10/15/10 revealed RN 'A' documented Resident #1's physician office called and stated they had ordered for Resident #1 a glucose tolerance test but had not received a report on the result of the ordered test. Review of Resident #1's medical record revealed documentation of fluid intake from 2/2/10 to 11/11/10. According to the resident's consolidated physician orders, the facility was to provide the resident 1800 cc of fluids each day, beginning 6/15/09. For February through May 2010 the intake records documented Resident #1 drank at least 1800 cc of fluid only on 10 days during this 4 month period, and drank less than 1000 cc on 29 days. For June through September 2010 there was documentation of intake on only 17 days. Of these 17 days, staff documented an intake of 1800 cc or more on only 1 day. Review of undated web articles entitled Dehydration and [MEDICAL CONDITION] in Diabetes (Mayo Clinic website) revealed blood glucose levels greater than 600 mg/dL can lead to coma and cause life-threatening dehydration. A serious potential complication of dehydration is hypovolemic shock, which is a drop in blood pressure with a corresponding reduction in the amount of oxygen reaching tissues. If untreated, hypovolemic shock can cause death in a matter of minutes. Observation on 12/8/10 at 1:10 p.m. revealed Resident #1 was up in a wheelchair in the dining room for lunch. The resident made no effort to feed herself, so staff fed the resident. The resident drank tea, water, juice, and a health shake, about 480 cc in all. Observation on 12/8/10 at 4:20 p.m. revealed Resident #1 drank about 180 cc of water. Observation on 12/8/10 at 5:40 p.m. revealed Resident #1 was in the dining room for supper. She drank about 480 cc. In an interview on 12/9/10 at 2:10 p.m. CNA 'A' said she had worked in facility about 1 year. She said until about 1 week or so before Resident #1 was admitted to the hospital on [DATE] the resident was able to walk when 2 staff held onto the resident's gait belt. CNA 'A' said the resident was able to speak at that time, although she was not able to carry on a conversation, and what the resident said made little sense. The CNA said the resident then began to show signs of weakness, and the staff started using a wheelchair for her. The CNA said after the resident returned to the nursing home after her hospital stay (10/27/10 to 11/5/10) the resident was significantly declined in that she was then unable to stand and required a mechanical lift for transfers, and the resident did not speak at all any longer. In an interview on 12/9/10 at 2:25 p.m. the DON said prior to 11/12/10 the facility was doing nothing to ensure Resident #1 residents received the amount of daily fluids ordered by her physician. In an interview on 12/12/10 at 2:00 p.m. CNA 'C' said Resident #1 always needed assistance with eating and drinking, but did drink well when she was offered a drink, even before the resident was admitted to the hospital on [DATE]. Resident #2 Review of Resident #2's admission face sheet dated 11/25/09 revealed this male resident was admitted to the facility on [DATE]. Resident #2 was [AGE] years old at the time of this investigation. Review of Resident #2's consolidated physician orders [REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. The resident's cognitive skills for daily decision making were moderately impaired. Resident #2 experienced periods of inattention and disorganized thinking. The resident experienced trouble concentrating on things such as reading the newspaper or watching television. The resident's wandering behaviors occurred daily. For most activities of daily living Resident #2 required only minimal help. He was, however frequently incontinent of bladder and always continent of bowel. Review of Resident #2's Plan of Care dated 7/20/10 and continued on 10/25/10 revealed the facility had identified the problem of socially inappropriate sexual advances. Goals set for Resident #2 were for him to refrain from this behavior for 90 days. Approaches and interventions included redirection of the resident at each episode, assisting the resident with redressing when needed, providing privacy to maintain dignity, providing diversion activities when needed to redirect behaviors, notifying the resident's family of inappropriate behaviors, and notifying the social worker when needed. Review of Resident #2's Social Progress Notes dated 8/07/09 at 10:00 a.m. revealed the social worker (SW) documented he received a note from a nurse working on the Alzheimer's unit stating the resident had made a comment to another resident in regards to "killing himself ". The SW stated information related to Resident #2's comment was reported to the DON and the ADON. The SW documented he directly asked Resident #2 if he was thinking about killing himself and Resident #2 responded stating he thinks about death, further stating that he's [AGE] years old and feels his family has abandoned him. The SW documented he communicated openly with the nursing staff on duty, and offered input for attention to the resident's need for safety. Review of Resident #2's Social Service Progress Notes dated 8/07/09 revealed the SW had discussed Resident #2's suicidal statement with the resident's family. The SW stated he discussed with Resident #2's family the possibility of Resident #2 needing a psychiatric evaluation "at the next possible time when the psychiatrist was in the building." The SW stated the family was "accommodating and agreeable to having psychiatric intervention as needed." The SW documented his recommendation for a psychiatric consult with psychiatrist as soon as possible to assess for mood and/or thought disorder. The SW worker documented his recommendation that prudent care should be taken with Resident #2 due to at least one prior incident of suicidal ideation, in combination with the age of Resident #2, and cognitive impairment associated with [MEDICAL CONDITION]. Review of Resident #2's Quarterly/Annual Review-Progress Note dated 1/ 26/10 revealed Resident #2 did not directly pose any threat for self harm, however it was prudent to monitor his daily activities as his personal judgment and orientation could have become altered at any given time due to the disease process. Review of Resident #2's Quarterly/Annual Review- Progress Note dated 4/27/10 revealed Resident #2 was compliant and passive in nature, but had at least one experience in which he walked into a female residents room. The facility documented Resident #2 comprehended that his judgment and decision making ability were poor and often caused him frustration. Review of Resident #2's physician progress notes [REDACTED]. The physician documented after reviewing the nurse's notes, "Resident #2 has engaged in inappropriate behavior. He has wandered into a female resident's room and touched her groin area." Review of Resident #2's Quarterly/Annual Review-Progress Note dated 7/20/10 revealed, "On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents." Review of Resident #2's Social Service Progress Notes dated 10/11/10 revealed, "SW is informed by nurse on duty that Resident #2 had 'touched' the breast of a female resident. At that time the nurse stated he had already confronted the resident, however felt the SW should provide confrontation since this type of behavior has been a problem with Resident #2 prior to today. SW met with Resident #2 privately in his room and verbalized the necessity for Resident #2 to cease touching the other residents, and unwanted sexual advances are not tolerated in the facility. Resident #2 had a dejected or sad affect when he was confronted about the behavior." Review of Resident #2's Abnormal Behavior Pattern Monitoring (ABPM) from 5/26/10 through 12/08/10 revealed: -- on 5/26/10 Resident #2 had behaviors identified as "sexually acting out". Interventions: 15 minute checks and frequent monitoring. -- on 6/23/10 Resident #2 had behaviors identified as "promiscuity with female residents". Interventions: Frequent checks and close monitoring of where Resident #2 is on the unit. -- on 6/30/10 Resident #2 had behaviors identified as "promiscuity with female residents". Interventions: SW confrontation of behaviors. -- on 8/11/10 revealed Resident #2 had behaviors identified as "Enticing female resident into room (possible sexual intent)". Interventions: SW notified, discussed intervention with ADON, heightened monitoring, Confrontation's 2 times weekly or when needed. -- on 10/06/10 Resident #2 had behaviors identified as "Attempting to engage other resident in sex". Intervention: ADON/ SW meeting with unit nurse and resident. -- on 10/13/10 revealed Resident #2 had behaviors identified as "Inappropriate touching with female resident". Intervention: None listed. -- on 12/08/10 revealed Resident #2 had behaviors identified as "Inappropriate touching with female CNA". Intervention: SW conference with Resident #2's son, confrontation of Resident #2. There was no documentation of any psychiatric evaluation despite multiple episodes of inappropriate sexual behavior. Review of Resident #2's nursing notes revealed: -- on 9/29/10 at 4:30 p.m. the nurse documented "Another female resident came to the nurse's station crying almost hysterically. When the unidentified female resident was asked what was wrong, the female resident stated, 'That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back' The female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the female's room." The nurse's note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other residents rooms. The nursing note did not identify the female resident. -- on 9/30/10 at 8:00 p.m. the nurse documented while a CNA was assisting a unidentified female resident with preparing for bed, Resident #2 walked into the female resident's room. The female resident became "teary-eyed and frightened". Resident #2 was asked to leave the room. -- on 10/4/10 the nurse documented "Resident #2 was seen outside in the patio area interacting inappropriately with a female resident. ADON saw him." (Female resident was later identified to be Resident #11). -- 10/20/10 on (2-10 shift) the nurse documented "Going into other resident's rooms constantly, Redirection not effective " -- on 11/04/10 at 3:45 p.m. the nurse documented an unidentified female resident complained Resident #2 grabbed her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12). -- on 11/15/10 at 7:00 p.m. the nurse documented an unidentified female resident complained Resident #2 attempted to force her hands down his pants. (Female resident later identified as Resident #11). In an interview on 11/18/10 at 11:15 a.m. the administrator and the DON said they had no knowledge of sexual allegation or physical contact between Resident #2 and Resident #12. They both said the staff had not reported anything to them about the incident. In an interview on 11/18/10 at 11:35 a.m. the DON said Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse's station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In an interview on 11/18/10 at 2:30 p.m. the ADON said the facility had not been doing incident reports on Resident #2's sexually inappropriate behaviors. The ADON said she was not aware Resident #2 had more episodes of inappropriate behaviors with females after the incident with Resident #13. In an interview on 11/18/10 at 3:00 p.m. the DON said the facility had not contacted Resident #2's physician or family regarding each incident of social/sexual inappropriate behaviors. However the physician was aware Resident #2 had inappropriate behaviors. She stated she had not wanted to contact Resident #2's wife due to her being sick, and not wanting to upset her. Review of a Facility Incident/Accident Report dated 12/05/10 at 10:15 a.m. revealed Resident #2 was being assisted to shave by a female CNA. While the CNA was assisting Resident #2 with shaving, Resident #2 attempted to touch the female staff member between her legs. The CNA asked Resident #2 to keep his hands to himself and Resident #2 attempted to touch the female staff between her legs again. In an interview on 12/09/10 at 2:50 p.m. LVN 'B' said she felt Resident #2's Care Plan was effective approximately 50 to 75% of the time. LVN 'B' was asked how the staff was managing Resident #2's care for the 25 to 50% of the time his Care Plan was not effective. She stated, " Resident #2 is very random. We try to redirect his behaviors when they occur. She stated she felt Resident #2 was 'very predatory' and seems to 'seek out' the female residents that are smaller and weaker than he is. She stated she felt it was more important to redirect the female residents away from Resident #2 in order to keep them safe from his sexual behaviors. In an interview on 12/10 /10 at 10:00 a.m. the administrator said the problems with Resident #2 were due to Resident #2 thinking the female residents on the unit were his wife. When asked if the physicians and families of the female residents( Resident # 11, #12, #13) who had been accosted by Resident #2 had been notified of the incidents, the administrator said, "It's not like he penetrated one of them. They forgot about the entire incident within 30 minutes." In an interview on 12/10/10 at 10: 45 a.m. the social worker said he was aware of Resident #2 having social/sexual inappropriate behaviors. He was asked if he felt Resident #2's care plan was effective regarding social/sexual inappropriate behaviors. He said he felt the care plan needed to be updated to reflect the interventions the facility had put in place for Resident #2. The social worker was asked if the facility preformed Mini-Mental State Examinations (MMSE) or had any evaluation tools to determine the severity of the resident's cognitive impairment. He stated he preformed MMSE when the nursing staff requested one done on a resident. He was asked if it was social services responsibility to assist with residents receiving psychiatric consults. He said if he felt one of the residents required a psychiatric consult he passed the information on to the nursing department and they in turn requested the physician orders [REDACTED].#2's chart were he had noted recommending Resident #2 be evaluated by a psychiatrist and if so was he aware if Resident #2 had been evaluated by a psychiatrist. He stated he remembered making the recommendation for a psychiatric consult to LVN 'C' , and he wasn't aware if LVN 'C' had requested the physician order [REDACTED]. In a telephone interview on 1213/10 at 10:35 a.m. Resident #2's physician said up to the time of her recent visit to the facility on [DATE] she had the impression the staff had been successfully redirecting Resident #2 when staff observed him attempt inappropriate behavior. The physician said when she recently reviewed the resident's nursing notes she became aware the resident was continuing to have inappropriate behaviors, and she increased the resident's psychoactive medication. She said she did not recall the facility consulting her about a psychiatric evaluation for Resident #2, but would have approved the request if she had known about it. Review of the undated facility written policy entitled Abuse Prohibition Program revealed: -- neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. -- the facility was required to identify and correct situations in which neglect was more likely to occur. Such situations included residents who required extensive or total nursing care. -- physical neglect involves failure to provide goods and services necessary for health and well-being of the elder. It may include withholding meals or hydration. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Coordinator. According to this plan, the facility determined on 11/12/10 (after the surveyor entered the facility to investigate an allegation of dehydration) it had not been correctly monitoring Resident #1's hydration. The plan documented all residents were assessed for dehydration on 12/12/10. The facility determined it's hydration policy had been inadequate to ensure residents remained well hydrated, so a new policy was written and put into effect. Staff inservice on the new hydration policy began on 12/12/10 and was completed on 12/14/10. The plan documented all newly admitted residents were to be monitored for 72 hours to determine whether they were at risk for dehydration and a plan of care for hydration was to be established within 72 hours following the determination of a resident's risk of dehydration. Review of the inservice records revealed on 11/20/10 40 staff members, licensed and unlicensed, received training on resident hydration and on intake documentation. Review of the facility's newly written hydration policy revealed residents were to be offered 360 cc to 480 cc of fluids at each meal as determined by each resident's dietician evaluation of fluid needs. Fluid intake for at risk residents was to be documented each shift, reviewed by charge nurses, and monitored by the DON and ADON. Review of the Plan of Removal of Immediate Jeopardy revealed the following documentation tools were to be used in the facility: a dehydration risk appraisal checklist, a new fluid intake/output worksheet, a new weekly intake/output monitoring form, and a new checklist to evaluate for the signs and symptoms of dehydration. Review of an inservice training record dated 12/12/10 revealed licensed and unlicensed staff were trained on the use of the new hydration policy and procedures. According to the Plan of Removal of Immediate Jeopardy, the DON consulted with Resident #2's physician on 12/9/10 regarding the resident's inappropriate sexual behaviors. The plan documented the physician ordered an increase with 1 of the resident's psychoactive medications ([MEDICATION NAME]). On 12/11/10 the facility started 1-on-1 supervision of Resident #2. This supervision was to be continuous, round the clock, 24 hours a day, 7 days a week. On 12/12/10 the resident's physician ordered the facility to administer to the resident the drug Depo-[MEDICATION NAME] to treat his sexual behaviors. The initial dose was administered on 12/12/10 at 12:50 a.m. The ADON was to review Resident #2's chart daily for further incidents of inappropriate behaviors. According to the Plan of Removal of Immediate Jeopardy, the DON conducted inservice training for administrative nurses on the subject of sexual misconduct. Review of the Plan of Removal of Immediate Jeopardy revealed the facility adopted a new or revised policy entitled Residents with Sexually Aggressive Behaviors. According to this policy, the facility nurses were to complete an incident report and an administrative nurse will conduct an investigation when sexual conduct occurred between resident who were of diminished mental capacity. A review of this inservice attendance record revealed 6 administrative nurses received this training. Plan of Removal Verification Facility staff were interviewed on 12/14/10 concerning the inservice training related to resident hydration. All staff interviewed confirmed they received the inservice and communicated knowledge of the facility's policy on resident hydration Observations revealed staff were providing fluids from a hydration cart and at meals. The Immediate Jeopardy was lowered to actual harm prior to the exit on 12/14/10 at 2:45 p.m. According to a list provided by the facility there were 2 residents with a physician order [REDACTED]. In an observation on 12/14/10 at 10:00 a.m. Resident #2 was observed to be resting in his room. The facility had provided a personal sitter who was seated in a chair outside Resident #2's room with Resident #2 in his line of site. Resident #2's sitter was observed to document Resident #2's whereabouts on a 15 minute basis. In an interview on 12/14/10 at 10:15 a.m. Resident#2's personal sitter said he was to have Resident #2 in his line of site at all times. Resident #2's sitter stated he was to report all care needs to the LVN or CNA, his duty was to watch Resident #2 and alert the staff of any abnormal behaviors. In an interview on 12/14/10 at 10:20 a.m. with LVN 'D" revealed the staff had been inserviced on how to monitor resident's hydration, hydration issues the CNA's needed to report to nursing staff, and any abnormal incidents regarding the residents should be documented on an Incident and Accident Report and given to the ADON or DON for rev

Based on observation, interview and record review the facility failed to ensure that 7 alleged incidents of mistreatment, neglect, or abuse involving 4 residents (Resident's #2, #11, #12, #13) of 13 sampled residents were thoroughly investigated and reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility further failed to have evidence of interventions to prevent further potential abuse while the investigation was in progress. 1. The facility Abnormal Behavior Pattern Monitoring Sheets identified 7 incidents when Resident #2 had social/sexual inappropriate behaviors involving female resident's (#11, #12, and #13). These failures could affect any of the 19 residents residing at the facility's Alzheimer's unit by placing them at risk for continued physical and psychological harm. These failures resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a level of potential for serious harm. The findings included: Resident #2 A review of Resident #2's Admission Face Sheet dated 11/25/09 at 2:24 p.m. revealed this male resident was admitted to the facility on [DATE] at 12:00 p.m. Resident #2 was [AGE] years old at the time of this investigation. A review of Resident #2's Consolidated Physician order [REDACTED]. A review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 was usually able to make himself understood and was usually able to understand others. Resident #2's cognitive skills for daily decision making were identified to be moderately impaired. Resident #2 ' s signs and symptoms of [MEDICAL CONDITION] were listed as: Behavior present, fluctuates in areas of Inattention, Disorganized thinking, and was listed as: Behavior not present in areas of Altered Consciousness, and Psychomotor [MEDICAL CONDITION]. Assessment of Resident #2 's mood indicated symptoms; Feeling or appearing down, depressed, or hopeless with a symptom frequency: Never or 1 day, Indications that he felt bad about himself, was a failure, or has let himself or his family down with a symptom frequency: Never or 1 day, and Trouble concentrating on things such as reading the newspaper or watching television with a symptom frequency of 2-6 days. The facility had identified Resident #2 as having [MEDICAL CONDITION] with behavior symptoms not directed towards others occurring 1-3 days. The facility had identified Resident #2 ' s wandering behaviors occurring daily. Resident #2 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, Locomotion on/off the unit and Toilet use. Resident #2 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #2 was frequently incontinent of bladder and always continent of bowel. A review of Resident #2 's Social Progress Notes dated 8/07/09 at 10:00 a.m. revealed the social worker (SW) had received a note from a nurse working on the Alzheimer ' s unit stating the resident had made a comment to another resident in regards to " killing himself ". The SW stated information related to Resident #2 's comment was reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The SW stated he directly asked Resident #2 if he was thinking about killing himself and Resident #2 responded stating he thinks about death, further stating that he's " [AGE] years old " and feels his family has abandoned him. The SW ' s Comments revealed: Communicated openly with the nursing staff on duty, offered input for attention to the resident ' s need for safety. Plan to meet with the family as they arrive at the facility this morning. A review of Resident #2 's Social Service Progress Notes dated 8/07/09 at 10:40 a.m. revealed the SW had discussed Resident #2 's suicidal statement with Resident #2 's family. The SW stated he discussed with Resident #2 's family, the possibility of Resident #2 needing a psychiatric evaluation, "at the next possible time when the psychiatrist was in the building." The SW stated the family was " accommodating and agreeable to having a psychiatric intervention as needed. " The SW Comments revealed: " Recommend psychiatric consult with psychiatrist as soon as possible to assess for mood and/or thought disorder. Communicated prudent care should be taken with Resident #2 due to at least one prior incident of suicidal ideation, in combination with the age of Resident #2, and cognitive impairment associated with Alzheimer 's disease. Family consented to having a psychiatrist see Resident #2 and agree that this is an appropriate time. " A review of Resident #2 's Quarterly/Annual Review- Progress Note dated 1/ 26/10 revealed, " Resident #2 does not directly pose any threat for self harm, however it is prudent to monitor his daily activities as his personal judgment and orientation may become altered at any given time due to the disease process. " A review of Resident #2 's Quarterly/Annual Review- Progress Note dated 4/27/10 revealed, " Behaviorally, Resident #2 is complaint and passive in nature, but has at least one experience in which he walked into a female residents room. Resident #2 comprehends that his judgment and decision making ability are poor, often causing frustration. " A review of Resident #2 ' s physician progress notes [REDACTED]. The physician had commented after reviewing the nurse ' s notes, " Resident #2 has engaged in inappropriate behavior. He has wandered into a female resident ' s room and touched her groin area. " Review of Resident #2's Abnormal Behavior Pattern Monitoring (ABPM) on 5/26/10 revealed Resident #2 had behaviors identified as " sexually acting out " . Interventions: 15 minute checks and frequent monitoring. Review of Resident #2's ABPM on 6/23/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: Frequent checks and close monitoring of where Resident #2 is on the unit. Review of Resident #2's ABPM on 6/30/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: SW confrontation of behaviors. A review of Resident #2's Quarterly/Annual Review- Progress Note dated 7/20/10 revealed, " On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents. " A review of Resident #2 's Plan of Care dated 7/20/10 and continued on 10/25/10 revealed the facility had identified the problem of: Socially Inappropriate Sexual Advances. Goals set for Resident #2 were for him to: Refrain from this Behavior for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. Review of Resident #2's ABPM on 8/11/10 revealed Resident #2 had behaviors identified as " Enticing female resident into room (possible sexual intent) " . Interventions: SW notified, discussed intervention with ADON, heightened monitoring, Confrontation 's 2 times weekly or when needed. Review of Resident #2's Nurse's Notes dated 9/29/10 at 4:30 p.m. revealed an entry stating, " Another female resident came to the nurse ' s station crying almost hysterically. When the unidentified female resident was asked what was wrong, the unidentified female resident stated, ' That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back. ' The unidentified female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the unidentified female's room. " The nurse's note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other residents rooms. In an interview on 12/10/10 at 10:10 a.m. with LVN ' C ' revealed the unidentified female noted in the 9/29/10 Nurses Note was identified to be Resident #13. Review of Resident #2's Nurse's Notes dated 9/30/10 at 8:00 p.m. revealed while a CNA was assisting a unidentified female resident with preparing for bed, Resident #2 walked into the unidentified female residents room. The unidentified female became " teary-eyed and frightened. Resident #2 was asked to leave the room. Review of Resident #2's Nurse's Notes dated 10/4/10 revealed an entry stating, " Resident #2 was seen outside in the patio area interacting inappropriately with a female resident. ADON saw him." (Female resident was later identified to be Resident #11) In an interview on 12/10/10 at 10:10 a.m. with LVN ' C ' revealed the unidentified female noted in the 11/15/10 Nurses Note was identified to be Resident #11. Review of Resident #2's ABPM on 10/06/10 revealed Resident #2 had behaviors identified as " Attempting to engage other resident in sex ". Intervention: ADON/ SW meeting with unit nurse and resident. A review of Resident #2's Social Service Progress Notes dated 10/11/10 revealed, " SW is informed by nurse on duty that Resident #2 had ' touched ' the breast of a female resident. At that time the nurse stated he had already confronted the resident, however felt the SW should provide confrontation since this type of behavior has been a problem with Resident #2 prior to today. SW met with Resident #2 privately in his room and verbalized the necessity for Resident #2 to cease touching the other residents, and unwanted sexual advances are not tolerated in the facility. Resident #2 had a dejected or sad affect when he was confronted about the behavior. Review of Resident #2's ABPM on 10/13/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female resident ". Intervention: None listed. Review of Resident #2 ' s Nurse ' s Notes dated 10/20/10 on (2-10 shift) revealed an entry stating, " Going into other resident's rooms constantly, Redirection not effective." Review of Resident #2's Nurse's Notes dated 11/03/10 at 7:00 p.m. revealed," Resident was punched with fists by another resident. He was not injured as staff intervened in time. " The ADON and Resident #2 's wife were notified of the incident. Review of Resident #2's Nurse's Notes dated 11/04/10 at 1:00 a.m. revealed Resident #2 was resting quietly without distress and had no red or bruised areas noted from previous altercation with his roommate. Review of Resident #2's Nurse's Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12) Review of Resident #2 ' s Nurse ' s Notes dated 11/15/10 at 7:00 p.m. revealed an unidentified female resident had complaints of Resident #2 attempting to force her hands down his pants. (Female resident later identified as Resident #11) In an interview on 12/10/10 at 10:10 a.m. with LVN ' C ' revealed the unidentified female noted in the 11/15/10 Nurses Note was identified to be Resident #11. In an interview on 11/18/10 at 11:15 am with Administrator (ADM) and Director of Nursing (DON) revealed they had no knowledge of sexual allegation or physical contact between Resident #2 and Resident #12. Further stating the staff had not reported anything. In an interview on 11/18/10 at 11:35 a.m. with DON revealed Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse ' s station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In an interview on 11/18/10 at 2:30 p.m. with ADON revealed the facility had not been doing incident reports on Resident #2's sexually inappropriate behaviors. ADON stated she was not aware Resident #2 had more episodes of inappropriate behaviors with females after the incident with Resident #13. Review of a Facility Incident/Accident Report dated 12/05/10 at 10:15 a.m. revealed Resident #2 was being assisted to shave by a female CNA. While the CNA was assisting Resident #2 with shaving, Resident #2 attempted to touch the female staff member between her legs. The CNA asked Resident #2 to keep his hands to himself and Resident #2 attempted to touch the female staff between her legs again. Review of Resident #2's ABPM on 12/08/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female CNA " . Intervention: SW conference with Resident #2 's son, confrontation of Resident #2. In an interview on 12/10 /10 at 10:00 a.m. with ADM revealed, " The problems with Resident #2 are due to Resident #2 thinking the female residents on the unit are his wife. When asked if the physicians and families of the female residents( Resident # 11, #12, #13) who had been accosted by Resident #2 had been notified of the incident's, ADM stated, "It 's not like he penetrated one of them, they forgot about the entire incident within 30 minutes. " In an interview on 12/10/10 at 10: 45 a.m. with SW revealed he was aware of Resident #2 having social/sexual inappropriate behaviors. SW was asked if he felt Resident #2 ' s care plan was effective regarding social/sexual inappropriate behaviors. He stated he felt the care plan needed to be updated to reflect the interventions the facility had put in place for Resident #2. SW was asked if the facility preformed Mini-Mental State Examinations (MMSE) or had any evaluation tools to determine the severity of the resident ' s cognitive impairment. He stated he preformed MMSE when the nursing staff requested one is done on a resident. SW was asked if it was social services responsibility to assist with residents receiving psychiatric consults. He stated if he felt one of the resident required a psychiatric consult he passed the information on to the nursing department and they in turn requested the physician orders [REDACTED].#2 ' s chart were he had noted recommending Resident #2 be evaluated by a psychiatrist and if so was he aware if Resident #2 had been evaluated by a psychiatrist. He stated he remembered making the recommendation for a psychiatric consult to LVN ' C ' , and he wasn't ' aware if LVN ' C ' had requested the physician order [REDACTED]. In an interview on 12/10/10 at 11:35 a.m. with ADM revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. ADM stated since the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. In an interview on 12/10/10 at 11:35 a.m. with DON revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. DON verified the ADM statement of the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. Furthermore the DON stated there were no formal assessments done on the residents involved in the incidents of Resident #2 ' s social/sexual inappropriate behaviors. In an interview on 12/10/10 at 1:15 p.m. with the ADON revealed the facility had not notified Resident #2 ' s family about his social/sexual inappropriate behaviors after each incident due to Resident #2 ' s wife being very ill and having to undergo surgery. She stated Resident #2 ' s son was aware of Resident #2 ' s social/sexual inappropriate behaviors " as a whole " , but was not informed following each incident. ADON was asked if the physicians and families of the female residents that had been affected by Resident #2 ' s social/sexual inappropriate behaviors had been notified following each incident. She stated the physicians and families of the female residents had not been notified of any of the incidents due to the facility not identifying the situations as " incidents " . Resident #11 Review of Resident #11's Admission Face Sheet dated 11/25/09 at 2:34 p.m. revealed Resident #11 had been admitted to the facility on [DATE] at 12:00 p.m. Resident #11 was [AGE] years old at the time of this investigation. Review of Resident #11's Consolidated Physician order [REDACTED]. Review of Resident #11's quarterly Minimum (MDS) data set [DATE] revealed Resident #11 had the ability to make herself understood and understands others. Resident #11 had short and long term memory problems. Resident #11 ' s cognitive skills for daily decision making were identified as severely impaired. Resident #11's signs and symptoms of [MEDICAL CONDITION] were listed as: Behavior present, fluctuates in areas of Inattention, Disorganized thinking and was listed as: Behavior continuously present. Assessment of Resident #11's mood indicated symptoms; Trouble concentrating on things, such as reading the newspaper or watching television. The facility had identified Resident #11 as having no [MEDICAL CONDITION] or behavior symptoms. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #11 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #11 was frequently incontinent of bladder and bowel. Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 3/2/10 revealed Resident #11continued to require accommodations on the Alzheimer's Unit due to exhibiting classic symptoms of moderate dementia, memory and perceptual deficits, inappropriate social skills /behaviors, tendency to wander without regard to personal safety. Social Service recommendations/interventions: Maintain effective working relationship with resident and family. Monitor for basic safety. Monitor for inappropriate social interaction i.e. conflict, sexual enticement, etc. Review of Resident #11's Plan of Care dated 5/31/10 revealed the facility had identified the problems of: 1. Resident is confused. Goals set for Resident #11: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident wanders without regard to safety. Goals set for Resident #11: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently.Reorient throughout the day. Notify physician and family of any changes. 3. Resident has socially inappropriate behaviors. Goals set for Resident #11: Refrain from the behavior of toileting in inappropriate places for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 6/1/10 revealed Resident #11 memory was poor and basic judgment was highly impaired. Behaviorally, Resident #11 required " frequent and repetitious redirection when placing herself in socially compromising situations without awareness of doing so " . Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 8/17/10 revealed Resident #11 was unable to maintain any consistent thought tracking, had poor mental focus and often became distracted. Resident #11 had diminished capabilities of abstract thinking, could only perform simple tasks and did not retain much if any judgment in terms of personal safety. Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 11/19/10 revealed Resident #11had severe impairment of general judgment and perception. Resident #11's cognitive decline presented a high degree of social vulnerability and self neglect. Resident #12 Review of Resident #12 's Admission Face Sheet revealed Resident #12 was admitted to the facility on [DATE] with no documented time. Resident #12 was [AGE] years old at the time of this investigation. Review of Resident #12's Consolidated Physician order [REDACTED]. [MEDICAL CONDITION], Convulsions, Muscular Wasting and Atrophy, Alzheimer ' s Disease, Diabetes Mellitus, Essential Hypertension, and Abnormality of Gait. Review of Resident #12's Admission Minimum (MDS) data set [DATE] revealed Resident #12 had short and long term memory problems. Resident # 12 was able to make herself understood and sometimes understand others. Resident #12 had behaviors indicated as wandering and resists care. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #12 was listed as extensive assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #12 was continent of bladder and bowel. Review of Resident #12's Plan of Care dated revealed the facility had identified the problems of: 1. Resident wanders without regard to safety. Goals set for Resident #12: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently. Reorient throughout the day. Notify physician and family of any changes. 2. Resident is forgetful and had impaired cognition. Goals set for Resident #12: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. Review of Resident #2's Nurse's Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12) * There was no corresponding nurse's notes found in Resident #12 ' s chart.* Resident #13 Review of Resident #13 ' s Admission Face Sheet revealed Resident #13 was admitted to the facility on [DATE] at 12:00 p.m. Resident #13 was [AGE] years old at the time of this investigation. Review of Resident #13's Consolidated Physician order [REDACTED]. Review of Resident #13 's quarterly Minimum (MDS) data set [DATE] revealed Resident #13 had the ability to make herself understood and to understand others. Resident #13 had short and long term memory problems. Resident #13's cognitive skills for daily decision making were moderately impaired. Resident #13's signs and symptoms of [MEDICAL CONDITION] were listed as: Behavior present fluctuates in areas of Inattention and Disorganized thinking. Resident #13 had no indicators of [MEDICAL CONDITION]. Resident #13's behaviors were listed as verbal behavioral symptoms directed towards others occurring 1-3 days. Resident #13 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #13 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #13 was occasionally incontinent of bladder and always continent of bowel. Review of Resident #13 ' s Plan of Care dated 5/18/10 and continued on 11/20/10 revealed the facility had identified the problems of: 1. Resident #13 was Forgetful and had impaired cognition related to Dementia. Goals set for Resident #13 were: Resident will remain safe and protected in her environment and be oriented to person and place for the next 90 days. Approaches and Interventions: Provide a stable and supportive environment through consistency of daily routine. Pace activities. Minimize distractions. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident #13 was oriented to person only, confused daily, unaware of date time and situation, unable to make decisions and exhibits poor safety awareness. Goals set for Resident #13 were: All of Resident #13 's needs were to be anticipated and met until next review. Approaches and Interventions: Staff to anticipate and provide daily care. Re-orient and redirect as needed. Monitor resident ' s safety. Keep family and physician aware of any changes of condition, needs or wants. 3. Resident #13 is confused related to Alzheimer ' s disease. Goals set for Resident #13: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. A review of Resident #13 's Quarterly/Annual Review- Progress Note dated 8/17/10 revealed Resident #13 was often confused and disoriented. Careful monitoring of behavior and safety is necessary due to resident #13 's cognitive impairment and lack of judgment. A review of Resident #13 ' s Quarterly/Annual Review- Progress Note dated 11/9/10 revealed Resident #13 had moderate impairment in terms of memory and perception. Resident #13 is mobile and at risk to wander causing her to become lost and/or in jeopardy of abuse and exploitation. Resident #13 requires careful monitoring. In an interview on 11/18/10 at 11:35 a.m. with DON revealed Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse ' s station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In a review of the facility's Incident and Accident Process received 12/11/10 at 11:00 a.m. revealed: 1. Immediately assess the condition of the individual involved, and implement measures to prevent the incident from reoccurring. 2. Notify the attending physician/ treating physician, family, responsible party and document the time and name of the physician and responsible party in the medical record. If unable to reach the physician and /or responsible party, make continuous attempts and document all attempts in the medical record. Document the medical facts in the medical record. 3. Complete and Incident and Accident (I/A) Report when an incident or accident occurs. 4. Complete an Incident and Accident report when the accident within 48 hours and do not leave any areas blank. 5. Place on the 24 hour report until the incident is resolved and chart on the incident each shift. 6. The Administrator, Director of Nursing and Interdisciplinary team (IDT) will review all I/A reports within 24-72 hours at the morning Stand up meeting to evaluate the circumstances and probable cause of the event and complete an Investigation report, to come to some reasonable conclusion as to why the I/A occurred or the need for further investigation. 7. The IDT will implement/ modify the Care Plan and treatment approaches to minimize repeat I/A. 8. All I/A will be placed on the I/A Log within 72 hours. 9. The Administrator and Director of Nursing will review the I/A Log at least once a week to identify developing trends/ patterns for possible early interventions. 10. By the 10 th of the following month the DON or designee will complete Monthly I/A Summary. This report will track and trend occurrences in the facility. Results will be analyzed for trends and patterns to use as a basis for implementation of process improvement. 11. Action Plans will be written and implemented to address the trends and patterns. Results will be reported to the QA&A Committee for recommendations. 12. The I/A reports and Investigation reports are to be attached to the reports. 13. The facility staff must call the Administrator at anytime night or day when Abuse/ Neglect are suspected, or there is a complaint of Abuse/ Neglect. The Administrator will determine if the I/A is to be called to the State. In a review of the facility ' s Adverse Incident Reporting Policy received on 12/10/10 at 9:00 a.m. revealed: As part of the administrative functions these protocols have been established as key components of the company ' s risk management functions. The protocols function to provide: Guidelines to respond document and communicate incidents, consistent collection of preliminary data to track and analyze incidents, methods to incorporate preventative measures based on quality data. The protocols purpose revealed: To establish protocols for responding to documenting, communicating and managing incidents that are reportable under state, federal or company guidelines. The facility has an obligation to communicate adverse incidents. The facility Administrator will contact all of the following: Regional VP of Operations and the Regional Nurse Consultant. State Agencies and Ombudsman representatives as required and Public Agencies as deemed necessary (Police, Health, and Fire). Further review of Adverse Incident Reporting revealed a Event Severity Levels, Actions and Reporting Chart with levels indicated from Level 1 ( the least severe)- No adverse effect/outcome to person, through Level 5 (the most severe)- Non- Reversible Outcome in which examples were listed as Abuse/ sexual assault. Immediate Action required for all investigations: Assess the resident, Notify the physician and family, Document incident, Report per State and Federal requirements. In a facility inservice with the title " Abuse & Neglect " received on 12/13/10 at 1:40 p.m. revealed, " Abuse and/or Neglect of the elderly, whatever the cause, is NEVER acceptable!!! " Further revealing, under the following headings: 1. What is Abuse & Neglect? Sexual Abuse incl

Based on observations, interviews and record reviews, the facility failed to implement its written policies and procedures for the prevention, identification, investigation, and reporting of abuse and/or neglect, for 4 (Resident #2, #11,#12, #13) of 13 residents reviewed for abuse/neglect as evidenced by: 1. The facility failed to investigate allegations regarding multiple incidents of Resident #2's social/sexual inappropriate behaviors involving female residents (#11, #12, and #13). These failures resulted in incidents of Resident #2's social/sexual inappropriate behaviors involving Residents #11, #12, and #13 not being fully investigated and resulted in the lack of corrective measures being implemented. These failures could affect any of the 19 residents who reside on the facility 's Alzheimer 's Unit and could result in abuse and neglect occurring undetected in the facility. These failures resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a level of potential for serious harm. The findings included: In a review of the facility's Incident and Accident Process received 12/11/10 at 11:00 a.m. revealed: 1. Immediately assess the condition of the individual involved, and implement measures to prevent the incident from reoccurring. 2. Notify the attending physician/ treating physician, family, responsible party and document the time and name of the physician and responsible party in the medical record. If unable to reach the physician and /or responsible party, make continuous attempts and document all attempts in the medical record. Document the medical facts in the medical record. 3. Complete and Incident and Accident (I/A) Report when an incident or accident occurs. 4. Complete an Incident and Accident report when the accident within 48 hours and do not leave any areas blank. 5. Place on the 24 hour report until the incident is resolved and chart on the incident each shift. 6. The Administrator, Director of Nursing and Interdisciplinary team (IDT) will review all I/A reports within 24-72 hours at the morning Stand up meeting to evaluate the circumstances and probable cause of the event and complete an Investigation report, to come to some reasonable conclusion as to why the I/A occurred or the need for further investigation. 7. The IDT will implement/ modify the Care Plan and treatment approaches to minimize repeat I/A. 8. All I/A will be placed on the I/A Log within 72 hours. 9. The Administrator and Director of Nursing will review the I/A Log at least once a week to identify developing trends/ patterns for possible early interventions. 10. By the 10th of the following month the DON or designee will complete Monthly I/A Summary. This report will track and trend occurrences in the facility. Results will be analyzed for trends and patterns to use as a basis for implementation of process improvement. 11. Action Plans will be written and implemented to address the trends and patterns. Results will be reported to the QA&A Committee for recommendations. 12. The I/A reports and Investigation reports are to be attached to the reports. 13. The facility staff must call the Administrator at anytime night or day when Abuse/ Neglect are suspected, or there is a complaint of Abuse/ Neglect. The Administrator will determine if the I/A is to be called to the State. In a review of the facility's Adverse Incident Reporting Policy received on 12/10/10 at 9:00 a.m. revealed: As part of the administrative functions these protocols have been established as key components of the company ' s risk management functions. The protocols function to provide: Guidelines to respond document and communicate incidents, consistent collection of preliminary data to track and analyze incidents, methods to incorporate preventative measures based on quality data. The protocols purpose revealed: To establish protocols for responding to documenting, communicating and managing incidents that are reportable under state, federal or company guidelines. The facility has an obligation to communicate adverse incidents. The facility Administrator will contact all of the following: Regional VP of Operations and the Regional Nurse Consultant. State Agencies and Ombudsman representatives as required and Public Agencies as deemed necessary (Police, Health, and Fire). Further review of Adverse Incident Reporting revealed a Event Severity Levels, Actions and Reporting Chart with levels indicated from Level 1 ( the least severe)- No adverse effect/outcome to person, through Level 5 (the most severe)- Non- Reversible Outcome in which examples were listed as Abuse/ sexual assault. Immediate Action required for all investigations: Assess the resident, Notify the physician and family, Document incident, Report per State and Federal requirements. In a facility inservice with the title " Abuse & Neglect " received on 12/13/10 at 1:40 p.m. revealed, " Abuse and/or Neglect of the elderly, whatever the cause, is NEVER acceptable!!! " Further revealing, under the following headings: 1. What is Abuse & Neglect? Sexual Abuse includes but is not limited to sexual harassment, sexual; coercion, or sexual assault. Psychological (mental) Abuse inflicts emotional pain or distress on its victims. It may consist of verbal scolding, harassment, or intimidation, threatening to punish or deprivation, treating the victim like a child or infant or isolating the elder from family, friends, or activities. 2. Neglect involves failure to provide goods and services necessary for health and well-being of the elder. 3. Who are abusers inside the facility? Employee to resident, Family to resident, and Resident to resident. 4. Why does abuse and neglect occur? Can arise from misunderstanding or ignorance. Mental illness, alcoholism or drug abuse. Inadequate building grounds security. 5. What should you do if you suspect abuse and/or neglect? Report to your supervisor immediately- it is your ethical and legal responsibility. Your primary concern is to protect the elder adult. 6. What happens when you report abuse and/or neglect to your supervisor? A full investigation must be completed and a report to the State may need to be filed. If a report to the State is called in they will do an onsite investigation. Resident #2 Review of Resident #2's admission face sheet dated 11/25/09 revealed this male resident was admitted to the facility on [DATE]. Resident #2 was [AGE] years old at the time of this investigation. Review of Resident #2's consolidated physician orders [REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. The resident's cognitive skills for daily decision making were moderately impaired. Resident #2 experienced periods of inattention and disorganized thinking. The resident experienced trouble concentrating on things such as reading the newspaper or watching television. The resident's wandering behaviors occurred daily. For most activities of daily living Resident #2 required only minimal help. He was, however frequently incontinent of bladder and always continent of bowel. Review of Resident #2 ' s Abnormal Behavior Pattern Monitoring (ABPM) on 5/26/10 revealed Resident #2 had behaviors identified as " sexually acting out " . Interventions: 15 minute checks and frequent monitoring. Review of Resident #2 ' s ABPM on 6/23/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: Frequent checks and close monitoring of where Resident #2 is on the unit. Review of Resident #2 ' s ABPM on 6/30/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: SW confrontation of behaviors. A review of Resident #2's Quarterly/Annual Review- Progress Note dated 7/20/10 revealed, "On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents." A review of Resident #2 ' s Plan of Care dated 7/20/10 and continued on 10/25/10 revealed the facility had identified the problem of: 1. Socially Inappropriate Sexual Advances. Goals set for Resident #2 were for him to: Refrain from this Behavior for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. A review of Resident #2 ' s Social Progress Notes dated 8/07/09 at 10:00 a.m. revealed the social worker (SW) had received a note from a nurse working on the Alzheimer ' s unit stating the resident had made a comment to another resident in regards to " killing himself " . The SW stated information related to Resident #2 ' s comment was reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The SW stated he directly asked Resident #2 if he was thinking about killing himself and Resident #2 responded stating he thinks about death, further stating that he ' s " [AGE] years old " and feels his family has abandoned him. The SW ' s Comments revealed: Communicated openly with the nursing staff on duty, offered input for attention to the resident ' s need for safety. Plan to meet with the family as they arrive at the facility this morning. A review of Resident #2 ' s Social Service Progress Notes dated 8/07/09 at 10:40 a.m. revealed the SW had discussed Resident #2 ' s suicidal statement with Resident #2 ' s family. The SW stated he discussed with Resident #2 ' s family, the possibility of Resident #2 needing a psychiatric evaluation, " at the next possible time when the psychiatrist was in the building. " The SW stated the family was " accommodating and agreeable to having a psychiatric intervention as needed. " The SW Comments revealed: " Recommend psychiatric consult with psychiatrist as soon as possible to assess for mood and/or thought disorder. Communicated prudent care should be taken with Resident #2 due to at least one prior incident of suicidal ideation, in combination with the age of Resident #2, and cognitive impairment associated with Alzheimer ' s disease. Family consented to having a psychiatrist see Resident #2 and agree that this is an appropriate time. " A review of Resident #2 ' s Quarterly/Annual Review- Progress Note dated 1/ 26/10 revealed, " Resident #2 does not directly pose any threat for self harm, however it is prudent to monitor his daily activities as his personal judgment and orientation may become altered at any given time due to the disease process. " A review of Resident #2 ' s Quarterly/Annual Review- Progress Note dated 4/27/10 revealed, " Behaviorally, Resident #2 is complaint and passive in nature, but has at least one experience in which he walked into a female residents room. Resident #2 comprehends that his judgment and decision making ability are poor, often causing frustration. " A review of Resident #2 ' s physician progress notes [REDACTED]. The physician had commented after reviewing the nurse ' s notes, " Resident #2 has engaged in inappropriate behavior. He has wandered into a female resident ' s room and touched her groin area. " A review of Resident #2 ' s Quarterly/Annual Review- Progress Note dated 7/20/10 revealed, " On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents. " Review of Resident #2's ABPM on 8/11/10 revealed Resident #2 had behaviors identified as " Enticing female resident into room (possible sexual intent) " . Interventions: SW notified, discussed intervention with ADON, heightened monitoring, Confrontation ' s 2 times weekly or when needed. Review of Resident #2's Nurse's Notes dated 9/29/10 at 4:30 p.m. revealed an entry stating, " Another female resident came to the nurse ' s station crying almost hysterically. When the unidentified female resident was asked what was wrong, the unidentified female resident stated, ' That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back. ' The unidentified female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the unidentified female ' s room. " The nurse's note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other residents rooms. Review of Resident #2's Nurse's Notes dated 9/30/10 at 8:00 p.m. revealed while a CNA was assisting a unidentified female resident with preparing for bed, Resident #2 walked into the unidentified female residents room. The unidentified female became " teary-eyed and frightened. Resident #2 was asked to leave the room. Review of Resident #2's ABPM on 10/06/10 revealed Resident #2 had behaviors identified as " Attempting to engage other resident in sex " . Intervention: ADON/ SW meeting with unit nurse and resident. Review of Resident #2's Nurse's Notes dated 10/4/10 revealed an entry stating, " Resident #2 was seen outside in the patio area interacting inappropriately with a female resident. ADON saw him. " (Female resident was later identified to be Resident #11) Review of Resident #2's ABPM on 10/13/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female resident " . Intervention: None listed. A review of Resident #2 ' s Social Service Progress Notes dated 10/11/10 revealed, " SW is informed by nurse on duty that Resident #2 had ' touched ' the breast of a female resident. At that time the nurse stated he had already confronted the resident, however felt the SW should provide confrontation since this type of behavior has been a problem with Resident #2 prior to today. SW met with Resident #2 privately in his room and verbalized the necessity for Resident #2 to cease touching the other residents, and unwanted sexual advances are not tolerated in the facility. Resident #2 had a dejected or sad affect when he was confronted about the behavior. Review of Resident #2 ' s Nurse ' s Notes dated 10/20/10 on (2-10 shift) revealed an entry stating, " Going into other resident ' s rooms constantly, Redirection not effective. " Review of Resident #2 ' s Nurse ' s Notes dated 11/03/10 at 7:00 p.m. revealed, " Resident was punched with fists by another resident. He was not injured as staff intervened in time. " The ADON and Resident #2 ' s wife were notified of the incident. Review of Resident #2 ' s Nurse ' s Notes dated 11/04/10 at 1:00 a.m. revealed Resident #2 was resting quietly without distress and had no red or bruised areas noted from previous altercation with his roommate. Review of Resident #2 ' s Nurse ' s Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12) Review of Resident #2 ' s Nurse ' s Notes dated 11/15/10 at 7:00 p.m. revealed an unidentified female resident had complaints of Resident #2 attempting to force her hands down his pants. (Female resident later identified as Resident #11) In an interview on 11/18/10 at 11:15 am with Administrator (ADM) and Director of Nursing (DON) revealed they had no knowledge of sexual allegation or physical contact between Resident #2 and Resident #12. Further stating the staff had not reported anything. In an observation on 11/18/10 at 11:35 a.m. revealed Resident #2 sleeping in his recliner in Room: 52. In an interview on 11/18/10 at 11:35 a.m. with DON revealed Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse ' s station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In an interview on 11/18/10 at 2:30 p.m. with ADON revealed the facility had not been doing incident reports on Resident #2 ' s sexually inappropriate behaviors. ADON stated she was not aware Resident #2 had more episodes of inappropriate behaviors with females after the incident with Resident #13. In an interview on 11/18/10 at 3:00 p.m. with DON revealed the facility had not contacted Resident #2 ' s physician or family regarding each incident of social/sexual inappropriate behaviors. However the physician was aware Resident #2 had inappropriate behaviors. She stated she had not wanted to contact Resident #2 ' s wife due to her being sick, and not wanting to upset her. Review of a Facility Incident/Accident Report dated 12/05/10 at 10:15 a.m. revealed Resident #2 was being assisted to shave by a female CNA. While the CNA was assisting Resident #2 with shaving, Resident #2 attempted to touch the female staff member between her legs. The CNA asked Resident #2 to keep his hands to himself and Resident #2 attempted to touch the female staff between her legs again. Review of Rseident #2's ABPM on 12/08/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female CNA " . Intervention: SW conference with Resident #2 ' s son, confrontation of Resident #2. In an interview on 12/09/10 at 2:50 p.m. with LVN ' B ' revealed she felt Resident #2 ' s Care Plan was effective approximately " 50 to 75 % " of the time. LVN ' B ' was asked how the staff was managing Resident #2 ' s care for the 25 to 50 % of the time his Care Plan was not effective. She stated, " Resident #2 is very random. We try to redirect his behaviors when they occur. She stated she felt Resident #2 was ' very predatory ' and seems to ' seek out ' the female residents that are smaller and weaker than he is. She stated she felt it was more important to redirect the female residents away from Resident #2 in order to keep them safe from his sexual behaviors. In an interview on 12/10 /10 at 10:00 a.m. with ADM revealed, " The problems with Resident #2 are due to Resident #2 thinking the female residents on the unit are his wife. When asked if the physicians and families of the female residents( Resident # 11, #12, #13) who had been accosted by Resident #2 had been notified of the incident ' s, ADM stated, " It ' s not like he penetrated one of them, they forgot about the entire incident within 30 minutes. " In an interview on 12/10/10 at 10: 45 a.m. with SW revealed he was aware of Resident #2 having social/sexual inappropriate behaviors. SW was asked if he felt Resident #2 ' s care plan was effective regarding social/sexual inappropriate behaviors. He stated he felt the care plan needed to be updated to reflect the interventions the facility had put in place for Resident #2. SW was asked if the facility preformed Mini-Mental State Examinations (MMSE) or had any evaluation tools to determine the severity of the resident ' s cognitive impairment. He stated he preformed MMSE when the nursing staff requested one is done on a resident. SW was asked if it was social services responsibility to assist with residents receiving psychiatric consults. He stated if he felt one of the resident required a psychiatric consult he passed the information on to the nursing department and they in turn requested the physician orders [REDACTED].#2 ' s chart were he had noted recommending Resident #2 be evaluated by a psychiatrist and if so was he aware if Resident #2 had been evaluated by a psychiatrist. He stated he remembered making the recommendation for a psychiatric consult to LVN ' C ' , and he wasn ' t aware if LVN ' C ' had requested the physician order [REDACTED]. In an interview on 12/10/10 at 11:35 a.m. with ADM revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. ADM stated since the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. In an interview on 12/10/10 at 11:35 a.m. with DON revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. DON verified the ADM statement of the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. Furthermore the DON stated there were no formal assessments done on the residents involved in the incidents of Resident #2 ' s social/sexual inappropriate behaviors. In an interview on 12/10/10 at 1:15 p.m. with the ADON revealed the facility had not notified Resident #2 ' s family about his social/sexual inappropriate behaviors after each incident due to Resident #2 ' s wife being very ill and having to undergo surgery. She stated Resident #2 ' s son was aware of Resident #2 ' s social/sexual inappropriate behaviors " as a whole " , but was not informed following each incident. ADON was asked if the physicians and families of the female residents that had been affected by Resident #2 ' s social/sexual inappropriate behaviors had been notified following each incident. She stated the physicians and families of the female residents had not been notified of any of the incidents due to the facility not identifying the situations as " incidents " . Resident #11 Review of Resident #11's Admission Face Sheet dated 11/25/09 at 2:34 p.m. revealed Resident #11 had been admitted to the facility on [DATE] at 12:00 p.m. Resident #11 was [AGE] years old at the time of this investigation. Review of Resident #11's Consolidated Physician order [REDACTED]. Review of Resident #11's quarterly Minimum (MDS) data set [DATE] revealed Resident #11 had the ability to make herself understood and understands others. Resident #11 had short and long term memory problems. Resident #11's cognitive skills for daily decision making were identified as severely impaired. Resident #11 ' s signs and symptoms of [MEDICAL CONDITION] were listed as: Behavior present, fluctuates in areas of Inattention, Disorganized thinking and was listed as: Behavior continuously present. Assessment of Resident #11's mood indicated symptoms; Trouble concentrating on things, such as reading the newspaper or watching television. The facility had identified Resident #11 as having no [MEDICAL CONDITION] or behavior symptoms. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #11 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #11 was frequently incontinent of bladder and bowel. Review of Resident #11's Plan of Care dated 5/31/10 revealed the facility had identified the problems of: 1. Resident is confused. Goals set for Resident #11: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident wanders without regard to safety. Goals set for Resident #11: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently. Reorient throughout the day. Notify physician and family of any changes. 3. Resident has socially inappropriate behaviors. Goals set for Resident #11: Refrain from the behavior of toileting in inappropriate places for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 3/2/10 revealed Resident #11continued to require accommodations on the Alzheimer ' s Unit due to exhibiting classic symptoms of moderate dementia, memory and perceptual deficits, inappropriate social skills /behaviors, tendency to wander without regard to personal safety. Social Service recommendations/interventions: Maintain effective working relationship with resident and family. Monitor for basic safety. Monitor for inappropriate social interaction i.e. conflict, sexual enticement, etc. Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 6/1/10 revealed Resident #11 memory was poor and basic judgment was highly impaired. Behaviorally, Resident #11 required " frequent and repetitious redirection when placing herself in socially compromising situations without awareness of doing so " . Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 8/17/10 revealed Resident #11 was unable to maintain any consistent thought tracking, had poor mental focus and often became distracted. Resident #11 had diminished capabilities of abstract thinking, could only perform simple tasks and did not retain much if any judgment in terms of personal safety. Review of A review of Resident #11's Quarterly/Annual Review- Progress Note dated 11/19/10 revealed Resident #11had severe impairment of general judgment and perception. Resident #11's cognitive decline presented a high degree of social vulnerability and self neglect. Resident #12 Review of Resident #12's Admission Face Sheet revealed Resident #12 was admitted to the facility on [DATE] with no documented time. Resident #12 was [AGE] years old at the time of this investigation. Review of Resident #12's Consolidated Physician order [REDACTED]. [MEDICAL CONDITION], Convulsions, Muscular Wasting and Atrophy, Alzheimer ' s Disease, Diabetes Mellitus, Essential Hypertension, and Abnormality of Gait. Review of Resident #12's Admission Minimum (MDS) data set [DATE] revealed Resident #12 had short and long term memory problems. Resident # 12 was able to make herself understood and sometimes understand others. Resident #12 had behaviors indicated as wandering and resists care. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #12 was listed as extensive assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #12 was continent of bladder and bowel. Review of Resident #12's Plan of Care dated revealed the facility had identified the problems of: 1. Resident wanders without regard to safety. Goals set for Resident #12: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently. Reorient throughout the day. Notify physician and family of any changes. 2. Resident is forgetful and had impaired cogniton. Goals set for Resident #12: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. Review of Resident #2's Nurse's Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12) * There was no corresponding nurse ' s notes found in Resident #12's chart.* Resident #13 Review of Resident #13's Admission Face Sheet revealed Resident #13 was admitted to the facility on [DATE] at 12:00 p.m. Resident #13 was [AGE] years old at the time of this investigation. Review of Resident #13 's Consolidated Physician order [REDACTED]. Review of Resident #13's quarterly Minimum (MDS) data set [DATE] revealed Resident #13 had the ability to make herself understood and to understand others. Resident #13 had short and long term memory problems. Resident #13's cognitive skills for daily decision making were moderately impaired. Resident #13's signs and symptoms of [MEDICAL CONDITION] were listed as: Behavior present fluctuates in areas of Inattention and Disorganized thinking. Resident #13 had no indicators of [MEDICAL CONDITION]. Resident #13's behaviors were listed as verbal behavioral symptoms directed towards others occurring 1-3 days. Resident #13 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #13 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #13 was occasionally incontinent of bladder and always continent of bowel. Review of Resident #13's Plan of Care dated 5/18/10 and continued on 11/20/10 revealed the facility had identified the problems of: 1. Resident #13 was Forgetful and had impaired cognition related to Dementia. Goals set for Resident #13 were: Resident will remain safe and protected in her environment and be oriented to person and place for the next 90 days. Approaches and Interventions: Provide a stable and supportive environment through consistency of daily routine. Pace activities. Minimize distractions. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident #13 was oriented to person only, confused daily, unaware of date time and situation, unable to make decisions and exhibits poor safety awareness. Goals set for Resident #13 were: All of Resident #13's needs were to be anticipated and met until next review. Approaches and Interventions: Staff to anticipate and provide daily care. Re-orient and redirect as needed. Monitor resident ' s safety. Keep family and physician aware of any changes of condition, needs or wants. 3. Resident #13 is confused related to Alzheimer's dis

Based on observation, interview and record review the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident following incidents of Resident #2's inappropriate social/sexual behaviors involving 4 (Resident ' s # 2, #11, #12, #13) of 13 residents sampled for social services. 1.The facility failed to act on the social services recommendation for a psychiatric consult for Resident #2 related to Resident #2's suicidal ideation and multiple incidents of Resident #2's inappropriate social/sexual behaviors towards female residents. 2. The facility failed to ensure the psychosocial needs of each resident were identified and addressed. Resident #11, #12 and #13 were not assessed by the social worker for potential psychological harm as a result of Resident #2's inappropriate social/sexual behavior. This failure to act on the social services recommendation for a psychiatric consult for Resident #2 resulted in a delay in treatment and the lack of social services intervention placed Resident #11, #12, and #13 at risk for continued physical and psychological harm related to Resident #2's inappropriate social/sexual behaviors. The facility's failures could affect any of the 19 residents residing on the Alzheimer's unit, by placing them at risk for psychological harm and a decline in their physical, mental and psychosocial well-being. These failures resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a level of potential for serious harm. The findings included: Resident #2 Review of Resident #2's admission face sheet dated 11/25/09 revealed this male resident was admitted to the facility on [DATE]. Resident #2 was [AGE] years old at the time of this investigation. Review of Resident #2's consolidated physician orders [REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. The resident's cognitive skills for daily decision making were moderately impaired. Resident #2 experienced periods of inattention and disorganized thinking. The resident experienced trouble concentrating on things such as reading the newspaper or watching television. The resident's wandering behaviors occurred daily. For most activities of daily living Resident #2 required only minimal help. He was, however frequently incontinent of bladder and always continent of bowel. A review of Resident #2 ' s Social Progress Notes dated 8/07/09 at 10:00 a.m. revealed the social worker (SW) had received a note from a nurse working on the Alzheimer's unit stating the resident had made a comment to another resident in regards to " killing himself " . The SW stated information related to Resident #2's comment was reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The SW stated he directly asked Resident #2 if he was thinking about killing himself and Resident #2 responded stating he thinks about death, further stating that he's " [AGE] years old " and feels his family has abandoned him. The SW ' s Comments revealed: Communicated openly with the nursing staff on duty, offered input for attention to the resident ' s need for safety. Plan to meet with the family as they arrive at the facility this morning. A review of Resident #2 ' s Social Service Progress Notes dated 8/07/09 at 10:40 a.m. revealed the SW had discussed Resident #2 's suicidal statement with Resident #2 ' s family. The SW stated he discussed with Resident #2 's family, the possibility of Resident #2 needing a psychiatric evaluation, " at the next possible time when the psychiatrist was in the building. " The SW stated the family was " accommodating and agreeable to having a psychiatric intervention as needed. " The SW Comments revealed: " Recommend psychiatric consult with psychiatrist as soon as possible to assess for mood and/or thought disorder. Communicated prudent care should be taken with Resident #2 due to at least one prior incident of suicidal ideation, in combination with the age of Resident #2, and cognitive impairment associated with Alzheimer ' s disease. Family consented to having a psychiatrist see Resident #2 and agree that this is an appropriate time. " A review of Resident #2's Quarterly/Annual Review- Progress Note dated 1/ 26/10 revealed, " Resident #2 does not directly pose any threat for self harm, however it is prudent to monitor his daily activities as his personal judgment and orientation may become altered at any given time due to the disease process. " A review of Resident #2's Quarterly/Annual Review- Progress Note dated 4/27/10 revealed, " Behaviorally, Resident #2 is complaint and passive in nature, but has at least one experience in which he walked into a female residents room. Resident #2 comprehends that his judgment and decision making ability are poor, often causing frustration. " Review of Resident #2 ' s Abnormal Behavior Pattern Monitoring (ABPM) on 5/26/10 revealed Resident #2 had behaviors identified as " sexually acting out " . Interventions: 15 minute checks and frequent monitoring. Review of Resident #2 ' s ABPM on 6/23/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: Frequent checks and close monitoring of where Resident #2 is on the unit. Review of Resident #2 ' s ABPM on 6/30/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: SW confrontation of behaviors. A review of Resident #2 ' s physician progress notes [REDACTED]. The physician had commented after reviewing the nurse ' s notes, " Resident #2 has engaged in inappropriate behavior. He has wandered into a female resident ' s room and touched her groin area. " A review of Resident #2 's Plan of Care dated 7/20/10 and continued on 10/25/10 revealed the facility had identified the problem of: Socially Inappropriate Sexual Advances. Goals set for Resident #2 were for him to: Refrain from this Behavior for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. A review of Resident #2's Quarterly/Annual Review- Progress Note dated 7/20/10 revealed, " On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents. " A review of Resident #2's Social Service Progress Notes dated 10/11/10 revealed, " SW is informed by nurse on duty that Resident #2 had ' touched ' the breast of a female resident. At that time the nurse stated he had already confronted the resident, however felt the SW should provide confrontation since this type of behavior has been a problem with Resident #2 prior to today. SW met with Resident #2 privately in his room and verbalized the necessity for Resident #2 to cease touching the other residents, and unwanted sexual advances are not tolerated in the facility. Resident #2 had a dejected or sad affect when he was confronted about the behavior. . Review of Resident #2 ' s ABPM on 8/11/10 revealed Resident #2 had behaviors identified as " Enticing female resident into room (possible sexual intent) " . Interventions: SW notified, discussed intervention with ADON, heightened monitoring, Confrontation ' s 2 times weekly or when needed. Review of Resident #2 ' s Nurse's Notes dated 9/29/10 at 4:30 p.m. revealed an entry stating, " Another female resident came to the nurse's station crying almost hysterically. When the unidentified female resident was asked what was wrong, the unidentified female resident stated, ' That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back. ' The unidentified female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the unidentified female ' s room. " The nurse ' s note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other residents rooms. Review of Resident #2 ' s Nurse ' s Notes dated 9/30/10 at 8:00 p.m. revealed while a CNA was assisting a unidentified female resident with preparing for bed, Resident #2 walked into the unidentified female residents room. The unidentified female became " teary-eyed and frightened. Resident #2 was asked to leave the room. Review of Resident #2 ' s Nurse's Notes dated 10/4/10 revealed an entry stating, " Resident #2 was seen outside in the patio area interacting inappropriately with a female resident. ADON saw him. " (Female resident was later identified to be Resident #11) Review of Resident #2's ABPM on 10/06/10 revealed Resident #2 had behaviors identified as " Attempting to engage other resident in sex " . Intervention: ADON/ SW meeting with unit nurse and resident. Review of Resident #2's ABPM on 10/13/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female resident " . Intervention: None listed. Review of Resident #2's Nurse's Notes dated 10/20/10 on (2-10 shift) revealed an entry stating, " Going into other resident ' s rooms constantly, Redirection not effective. " Review of Resident #2 ' s Nurse ' s Notes dated 11/03/10 at 7:00 p.m. revealed, " Resident was punched with fists by another resident. He was not injured as staff intervened in time. " The ADON and Resident #2 ' s wife were notified of the incident. Review of Resident #2's Nurse's Notes dated 11/04/10 at 1:00 a.m. revealed Resident #2 was resting quietly without distress and had no red or bruised areas noted from previous altercation with his roommate. Review of Resident #2 ' s Nurse's Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12) Review of Resident #2's Nurse's Notes dated 11/15/10 at 7:00 p.m. revealed an unidentified female resident had complaints of Resident #2 attempting to force her hands down his pants. (Female resident later identified as Resident #11) In an interview on 11/18/10 at 11:15 am with Administrator (ADM) and Director of Nursing (DON) revealed they had no knowledge of sexual allegation or physical contact between Resident #2 and Resident #12. Further stating the staff had not reported anything. In an observation on 11/18/10 at 11:35 a.m. revealed Resident #2 sleeping in his recliner in Room: 52. In an interview on 11/18/10 at 11:35 a.m. with DON revealed Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse ' s station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In an interview on 11/18/10 at 2:30 p.m. with ADON revealed the facility had not been doing incident reports on Resident #2's sexually inappropriate behaviors. ADON stated she was not aware Resident #2 had more episodes of inappropriate behaviors with females after the incident with Resident #13. In an interview on 11/18/10 at 3:00 p.m. with DON revealed the facility had not contacted Resident #2's physician or family regarding each incident of social/sexual inappropriate behaviors. However the physician was aware Resident #2 had inappropriate behaviors. She stated she had not wanted to contact Resident #2 ' s wife due to her being sick, and not wanting to upset her. Review of Resident #2's ABPM on 12/08/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female CNA " . Intervention: SW conference with Resident #2 ' s son, confrontation of Resident #2. Review of a Facility Incident/Accident Report dated 12/05/10 at 10:15 a.m. revealed Resident #2 was being assisted to shave by a female CNA. While the CNA was assisting Resident #2 with shaving, Resident #2 attempted to touch the female staff member between her legs. The CNA asked Resident #2 to keep his hands to himself and Resident #2 attempted to touch the female staff between her legs again. In an interview on 12/09/10 at 2:50 p.m. with LVN ' B ' revealed she felt Resident #2's Care Plan was effective approximately " 50 to 75 % " of the time. LVN ' B ' was asked how the staff was managing Resident #2's care for the 25 to 50 % of the time his Care Plan was not effective. She stated, " Resident #2 is very random. We try to redirect his behaviors when they occur. She stated she felt Resident #2 was ' very predatory ' and seems to ' seek out ' the female residents that are smaller and weaker than he is. She stated she felt it was more important to redirect the female residents away from Resident #2 in order to keep them safe from his sexual behaviors. In an interview on 12/10 /10 at 10:00 a.m. with ADM revealed, " The problems with Resident #2 are due to Resident #2 thinking the female residents on the unit are his wife. When asked if the physicians and families of the female residents( Resident # 11, #12, #13) who had been accosted by Resident #2 had been notified of the incident ' s, ADM stated, " It ' s not like he penetrated one of them, they forgot about the entire incident within 30 minutes. " In an interview on 12/10/10 at 10: 45 a.m. with SW revealed he was aware of Resident #2 having social/sexual inappropriate behaviors. SW was asked if he felt Resident #2 ' s care plan was effective regarding social/sexual inappropriate behaviors. He stated he felt the care plan needed to be updated to reflect the interventions the facility had put in place for Resident #2. SW was asked if the facility preformed Mini-Mental State Examinations (MMSE) or had any evaluation tools to determine the severity of the resident ' s cognitive impairment. He stated he preformed MMSE when the nursing staff requested one is done on a resident. SW was asked if it was social services responsibility to assist with residents receiving psychiatric consults. He stated if he felt one of the resident required a psychiatric consult he passed the information on to the nursing department and they in turn requested the physician orders [REDACTED].#2 ' s chart were he had noted recommending Resident #2 be evaluated by a psychiatrist and if so was he aware if Resident #2 had been evaluated by a psychiatrist. He stated he remembered making the recommendation for a psychiatric consult to LVN ' C ' , and he wasn't ' aware if LVN ' C ' had requested the physician order [REDACTED]. In an interview on 12/10/10 at 11:35 a.m. with ADM revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. ADM stated since the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. In an interview on 12/10/10 at 11:35 a.m. with DON revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. DON verified the ADM statement of the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. Furthermore the DON stated there were no formal assessments done on the residents involved in the incidents of Resident #2 ' s social/sexual inappropriate behaviors. In an interview on 12/10/10 at 1:15 p.m. with the ADON revealed the facility had not notified Resident #2 ' s family about his social/sexual inappropriate behaviors after each incident due to Resident #2 ' s wife being very ill and having to undergo surgery. She stated Resident #2 ' s son was aware of Resident #2 ' s social/sexual inappropriate behaviors " as a whole " , but was not informed following each incident. ADON was asked if the physicians and families of the female residents that had been affected by Resident #2 ' s social/sexual inappropriate behaviors had been notified following each incident. She stated the physicians and families of the female residents had not been notified of any of the incidents due to the facility not identifying the situations as " incidents " . In a telephone interview on 1213/10 at 10:35 a.m. Resident #2's physician said up to the time of her recent visit to the facility on [DATE] she had the impression the staff had been successfully redirecting Resident #2 when staff observed him attempt inappropriate behavior. The physician said when she recently reviewed the resident's nursing notes she became aware the resident was continuing to have inappropriate behaviors, and she increased the resident's psychoactive. She said she did not recall the facility consulting her about a psychiatric evaluation for Resident #2, but would have approved the request if she had known about it. Resident #11 Review of Resident #11 ' s Admission Face Sheet dated 11/25/09 at 2:34 p.m. revealed Resident #11 had been admitted to the facility on [DATE] at 12:00 p.m. Resident #11 was [AGE] years old at the time of this investigation. Review of Resident #11 ' s Consolidated Physician order [REDACTED]. Review of Resident #11 ' s quarterly Minimum (MDS) data set [DATE] revealed Resident #11 had the ability to make herself understood and understands others. Resident #11 had short and long term memory problems. Resident #11 ' s cognitive skills for daily decision making were identified as severely impaired. Resident #11 ' s signs and symptoms of Delirium were listed as: Behavior present, fluctuates in areas of Inattention, Disorganized thinking and was listed as: Behavior continuously present. Assessment of Resident #11 ' s mood indicated symptoms; Trouble concentrating on things, such as reading the newspaper or watching television. The facility had identified Resident #11 as having no psychosis or behavior symptoms. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #11 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #11 was frequently incontinent of bladder and bowel. Review of Resident #11 ' s Plan of Care dated 5/31/10 revealed the facility had identified the problems of: 1. Resident is confused. Goals set for Resident #11: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident wanders without regard to safety. Goals set for Resident #11: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently. Reorient throughout the day. Notify physician and family of any changes. 3. Resident has socially inappropriate behaviors. Goals set for Resident #11: Refrain from the behavior of toileting in inappropriate places for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. Review of A review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 3/2/10 revealed Resident #11continued to require accommodations on the Alzheimer ' s Unit due to exhibiting classic symptoms of moderate dementia, memory and perceptual deficits, inappropriate social skills /behaviors, tendency to wander without regard to personal safety. Social Service recommendations/interventions: Maintain effective working relationship with resident and family. Monitor for basic safety. Monitor for inappropriate social interaction i.e. conflict, sexual enticement, etc. Review of A review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 6/1/10 revealed Resident #11 memory was poor and basic judgment was highly impaired. Behaviorally, Resident #11 required " frequent and repetitious redirection when placing herself in socially compromising situations without awareness of doing so " . Review of A review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 8/17/10 revealed Resident #11 was unable to maintain any consistent thought tracking, had poor mental focus and often became distracted. Resident #11 had diminished capabilities of abstract thinking, could only perform simple tasks and did not retain much if any judgment in terms of personal safety. Review of A review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 11/19/10 revealed Resident #11had severe impairment of general judgment and perception. Resident 311 ' s cognitive decline presented a high degree of social vulnerability and self neglect. Resident #12 Review of Resident #12 ' s Admission Face Sheet revealed Resident #12 was admitted to the facility on [DATE] with no documented time. Resident #12 was [AGE] years old at the time of this investigation. Review of Resident #12 ' s Consolidated Physician order [REDACTED]. Psychosis, Convulsions, Muscular Wasting and Atrophy, Alzheimer ' s Disease, Diabetes Mellitus, Essential Hypertension, and Abnormality of Gait. Review of Resident #12 ' s Admission Minimum (MDS) data set [DATE] revealed Resident #12 had short and long term memory problems. Resident # 12 was able to make her understood and sometimes understand others. Resident #12 had behaviors indicated as wandering and resists care. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #12 was listed as extensive assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #12 was continent of bladder and bowel. Review of Resident #12 ' s Plan of Care dated revealed the facility had identified the problems of: 1. Resident wanders without regard to safety. Goals set for Resident #12: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently. Reorient throughout the day. Notify physician and family of any changes. 2. Resident is forgetful and had impaired cognition. Goals set for Resident #12: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. Resident #13 Review of Resident #13's Admission Face Sheet revealed Resident #13 was admitted to the facility on [DATE] at 12:00 p.m. Resident #13 was [AGE] years old at the time of this investigation. Review of Resident #13 ' s Consolidated Physician order [REDACTED]. Review of Resident #13's quarterly Minimum (MDS) data set [DATE] revealed Resident #13 had the ability to make herself understood and to understand others. Resident #13 had short and long term memory problems. Resident #13 ' s cognitive skills for daily decision making were moderately impaired. Resident #13 ' s signs and symptoms of Delirium were listed as: Behavior present fluctuates in areas of Inattention and Disorganized thinking. Resident #13 had no indicators of psychosis. Resident #13 ' s behaviors were listed as verbal behavioral symptoms directed towards others occurring 1-3 days. Resident #13 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #13 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #13 was occasionally incontinent of bladder and always continent of bowel. Review of Resident #13's Plan of Care dated 5/18/10 and continued on 11/20/10 revealed the facility had identified the problems of: 1. Resident #13 was Forgetful and had impaired cognition related to Dementia. Goals set for Resident #13 were: Resident will remain safe and protected in her environment and be oriented to person and place for the next 90 days. Approaches and Interventions: Provide a stable and supportive environment through consistency of daily routine. Pace activities. Minimize distractions. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident #13 was oriented to person only, confused daily, unaware of date time and situation, unable to make decisions and exhibits poor safety awareness. Goals set for Resident #13 were: All of Resident #13 ' s needs were to be anticipated and met until next review. Approaches and Interventions: Staff to anticipate and provide daily care. Re-orient and redirect as needed. Monitor resident ' s safety. Keep family and physician aware of any changes of condition, needs or wants. 3. Resident #13 is confused related to Alzheimer ' s disease. Goals set for Resident #13: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. A review of Resident #13's Quarterly/Annual Review- Progress Note dated 8/17/10 revealed Resident #13 was often confused and disoriented. Careful monitoring of behavior and safety is necessary due to resident #13 ' s cognitive impairment and lack of judgment. A review of Resident #13's Quarterly/Annual Review- Progress Note dated 11/9/10 revealed Resident #13 had moderate impairment in terms of memory and perception. Resident #13 is mobile and at risk to wander causing her to become lost and/or in jeopardy of abuse and exploitation. Resident #13 requires careful monitoring. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Coordinator. According to the plan, Social Services will play a more prominent role in assisting with the plan of care and implementation of care for residents with behavioral problems. According to the plan the interdisciplinary team will review any problems with residents behaviors during the weekly Abnormal Behavior Pattern Monitoring meeting and the team can be called in for any emergencies. According to the plan it will be the social workers responsibility to arrange for psychiatric consults and coordinate with nursing services by requesting a physicians order be obtained. According to the plan, a new Social Services Referral form will be utilized to have a documented interaction between disciplines and facilitate a more effective way to communicate between Social Services and Nursing Services. Plan of Removal Verification The facility's Social worker was interviewed as to what his expectations were in regards to a more prominent role in assisting with planning and implementation of residents care. He stated he would be requesting all psychiatric consults and be using a Social Services Referral Form for documentation in order to have a more effective way of communication between Social Services and Nursing Services. He stated that he was developing a Social Services Plan of Care to be incorporated with the residents Plan of Care to facilitate a better focus on the resident ' s psychosocial needs. The Immediate Jeopardy was lowered to potential for actual harm prior to the exit on 12/14/10 at 2:45 p.m.

Based on observation, interview and record review the facility failed to consult with the physician and notify the legal representative of 1 resident (Resident #2) of 13 sampled residents of inappropriate social/sexual behaviors. The facility failed to: 1. consult Resident #2's physician after the facility social worker recommended a psychiatric consult following Resident #2's documented suicidal ideation. 2. notify Resident #2's legal representative on multiple occasions following inappropriate social/sexual behaviors towards other residents residing on the Alzheimer's unit and staff. 3. consult the physician and notify the legal representatives of Resident # 11, #12, and #13 after incidents involving Resident #2's inappropriate social/sexual behaviors towards them. These failures resulted in a delay in treatment for [REDACTED].#12, and #13 at risk for continued physical and psychological harm related to Resident #2's inappropriate social/sexual behaviors. The facility's failure could affect any of the 19 residents residing on the Alzheimer's unit. This failure placed them at risk for continued physical and psychological harm related to Resident #2's inappropriate social/sexual behaviors, and possible delayed treatment due to the physician not being notified of the residents' physical and psychological conditions. These failures resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a pattern level of potential harm. The findings included: Resident #2 Review of Resident #2's admission face sheet dated 11/25/09 revealed this male resident was admitted to the facility on [DATE]. Resident #2 was [AGE] years old at the time of this investigation. Review of Resident #2's consolidated physician orders [REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. The resident's cognitive skills for daily decision making were moderately impaired. Resident #2 experienced periods of inattention and disorganized thinking. The resident experienced trouble concentrating on things such as reading the newspaper or watching television. The resident's wandering behaviors occurred daily. For most activities of daily living Resident #2 required only minimal help. He was, however frequently incontinent of bladder and always continent of bowel. A review of Resident #2's Social Progress Notes dated 8/07/09 at 10:00 a.m. revealed the social worker (SW) had received a note from a nurse working on the Alzheimer's unit stating the resident had made a comment to another resident in regards to " killing himself ". The SW documented information related to Resident #2's comment was reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The SW documented he directly asked Resident #2 if he was thinking about killing himself and Resident #2 responded he thinks about death, further stating that he's " [AGE] years old " and feels his family has abandoned him. The SW's documented: Communicated openly with the nursing staff on duty, offered input for attention to the resident's need for safety. Plan to meet with the family as they arrive at the facility this morning. A review of Resident #2's Social Service Progress Notes dated 8/07/09 at 10:40 a.m. revealed the SW had discussed Resident #2's suicidal statement with Resident #2's family. The SW stated he discussed with Resident #2's family, the possibility of Resident #2 needing a psychiatric evaluation, "at the next possible time when the psychiatrist was in the building." The SW stated the family was " accommodating and agreeable to having a psychiatric intervention as needed." The SW documented "Recommend psychiatric consult with psychiatrist as soon as possible to assess for mood and/or thought disorder. Communicated prudent care should be taken with Resident #2 due to at least one prior incident of suicidal ideation, in combination with the age of Resident #2, and cognitive impairment associated with [MEDICAL CONDITION]. Family consented to having a psychiatrist see Resident #2 and agree that this is an appropriate time." Review of Resident #2's Abnormal Behavior Pattern Monitoring (ABPM) on 5/26/10 revealed Resident #2 had behaviors identified as "sexually acting out". Interventions: 15 minute checks and frequent monitoring. Review of Resident #2's ABPM on 6/23/10 revealed Resident #2 had behaviors identified as "promiscuity with female residents". Interventions included frequent checks and close monitoring of where Resident #2 is on the unit. Review of Resident #2's ABPM on 6/30/10 revealed Resident #2 had behaviors identified as "promiscuity with female residents" . Interventions included social worker confrontation of behaviors. A review of Resident #2's Quarterly/Annual Review- Progress Note dated 7/20/10 revealed, "On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents." A review of Resident #2's Plan of Care dated 7/20/10 and continued on 10/25/10 revealed the facility had identified the problem of: Socially Inappropriate Sexual Advances. Goals set for Resident #2 were for him to: Refrain from this Behavior for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. A review of Resident #2's ABPM on 8/11/10 revealed Resident #2 had behaviors identified as "Enticing female resident into room (possible sexual intent)". Interventions: SW notified, discussed intervention with ADON, heightened monitoring, Confrontations 2 times weekly or when needed. Review of Resident #2's Nurse's Notes dated 9/29/10 at 4:30 p.m. revealed an entry stating, " Another female resident came to the nurse's station crying almost hysterically. When the unidentified female resident was asked what was wrong, the unidentified female resident stated, ' That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back. ' The unidentified female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the unidentified female ' s room. " The nurse's note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other resident ' s rooms. (Female resident was later identified to be Resident #13) In an interview on 12/10/10 at 10:10 a.m. with LVN ' C ' revealed the unidentified female noted in the 9/29/10 Nurses Note was identified to be Resident #13. Review of Resident #2's Nurse's Notes dated 9/30/10 at 8:00 p.m. revealed while a CNA was assisting a unidentified female resident with preparing for bed, Resident #2 walked into the unidentified female residents room. The unidentified female became " teary-eyed and frightened. Resident #2 was asked to leave the room. Review of Resident #2's Nurse's Notes dated 10/4/10 revealed an entry stating, " Resident #2 was seen outside in the patio area interacting inappropriately with a female resident. ADON saw him." (Female resident was later identified to be Resident #11) In an interview on 12/10/10 at 11:00 a.m. with ADON revealed the unidentified female noted in the 10/4/10 Nurses Note was identified to be Resident #11. Review of ABPM on 10/06/10 revealed Resident #2 had behaviors identified as " Attempting to engage other resident in sex " . Intervention: ADON/ SW meeting with unit nurse and resident. Review of ABPM on 10/13/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female resident " . Intervention: None listed. Review of Resident #2's Nurse's Notes dated 10/20/10 on (2-10 shift) revealed an entry stating, " Going into other resident's rooms constantly, Redirection not effective." Review of Resident #2's Nurse's Notes dated 11/03/10 at 7:00 p.m. revealed, " Resident was punched with fists by another resident. He was not injured as staff intervened in time. " The ADON and Resident #2's wife were notified of the incident. Review of Resident #2's Nurse's Notes dated 11/04/10 at 1:00 a.m. revealed Resident #2 was resting quietly without distress and had no red or bruised areas noted from previous altercation with his roommate. Review of Resident #2's Nurse's Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12) In an interview on 11/16/10 at 7:00 p.m. with LVN ' B ' revealed the unidentified female noted in the 11/04/10 Nurse ' s Note was identified to be Resident #12. Review of Resident #2's Nurse's Notes dated 11/15/10 at 7:00 p.m. revealed an unidentified female resident had complaints of Resident #2 attempting to force her hands down his pants. (Female resident later identified as Resident #11) In an interview on 12/10/10 at 10:10 a.m. with LVN ' C ' revealed the unidentified female noted in the 11/15/10 Nurses Note was identified to be Resident #11. In an interview on 11/18/10 at 11:15 am with Administrator (ADM) and Director of Nursing (DON) revealed they had no knowledge of sexual allegation or physical contact between Resident #2 and Resident #12. Further stating the staff had not reported anything. In an interview on 11/18/10 at 11:35 a.m. with DON revealed Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse ' s station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In an interview on 11/18/10 at 2:30 p.m. with ADON revealed the facility had not been doing incident reports on Resident #2's sexually inappropriate behaviors. ADON stated she was not aware Resident #2 had more episodes of inappropriate behaviors with females after the incident with Resident #13. In an interview on 11/18/10 at 3:00 p.m. with DON revealed the facility had not contacted Resident #2's physician or family regarding each incident of social/sexual inappropriate behaviors. However the physician was aware Resident #2 had inappropriate behaviors. She stated she had not wanted to contact Resident #2's wife due to her being sick, and not wanting to upset her. Review of a Facility Incident/Accident Report dated 12/05/10 at 10:15 a.m. revealed Resident #2 was being assisted to shave by a female CNA. While the CNA was assisting Resident #2 with shaving, Resident #2 attempted to touch the female staff member between her legs. The CNA asked Resident #2 to keep his hands to himself and Resident #2 attempted to touch the female staff between her legs again. Review of ABPM on 12/08/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female CNA " . Intervention: SW conference with Resident #2's son, confrontation of Resident #2. In an interview on 12/09/10 at 2:50 p.m. with LVN ' B ' revealed she felt Resident #2's Care Plan was effective approximately " 50 to 75 % " of the time. LVN ' B ' was asked how the staff was managing Resident #2's care for the 25 to 50 % of the time his Care Plan was not effective. She stated, " Resident #2 is very random in his behaviors. We try to redirect his behaviors when they occur. She stated she felt Resident #2 was ' very predatory ' and seems to ' seek out ' the female residents that are smaller and weaker than he is. She stated she felt it was more important to redirect the female residents away from Resident #2 in order to keep them safe from his sexual behaviors. In an interview on 12/10 /10 at 10:00 a.m. with ADM revealed, " The problems with Resident #2 are due to Resident #2 thinking the female residents on the unit are his wife. When asked if the physicians and families of the female residents( Resident # 11, #12, #13) who had been accosted by Resident #2 had been notified of the incident's, the ADM stated, " It ' s not like he penetrated one of them, they forgot about the entire incident within 30 minutes. " In an interview on 12/10/10 at 10: 45 a.m. with SW revealed he was aware of Resident #2 having social/sexual inappropriate behaviors. SW was asked if he felt Resident #2 ' s care plan was effective regarding social/sexual inappropriate behaviors. He stated he felt the care plan needed to be updated to reflect the interventions the facility had put in place for Resident #2. SW was asked if the facility preformed Mini-Mental State Examinations (MMSE) or had any evaluation tools to determine the severity of the resident ' s cognitive impairment. He stated he preformed MMSE only when the nursing staff requested one be done on a resident. SW was asked if it was social services responsibility to assist with residents receiving psychiatric consults. He stated if he felt one of the resident required a psychiatric consult he passed the information on to the nursing department and they in turn requested the physician orders [REDACTED].#2 ' s chart were he had noted recommending Resident #2 be evaluated by a psychiatrist and if so was he aware if Resident #2 had been evaluated by a psychiatrist. He stated he remembered making the recommendation for a psychiatric consult to LVN ' C ' , and he wasn't ' aware if LVN ' C ' had requested the physician order [REDACTED]. In an interview on 12/10/10 at 11:35 a.m. with ADM revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. ADM stated since the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. In an interview on 12/10/10 at 11:35 a.m. with DON revealed the facility was unaware of the need to perform Incident/Accident reports on residents who had social/sexual inappropriate behaviors and the other residents who were affected by those behaviors. DON verified the ADM statement of the Incident/Accident reports had not been completed for those incidents and the physician ' s and families were not notified. Furthermore the DON stated there were no formal assessments done on the residents involved in the incidents of Resident #2 ' s social/sexual inappropriate behaviors. In an interview on 12/10/10 at 1:15 p.m. with the ADON revealed the facility had not notified Resident #2 ' s family about his social/sexual inappropriate behaviors after each incident due to Resident #2's wife being very ill and having to undergo surgery. She stated Resident #2 ' s son was aware of Resident #2 ' s social/sexual inappropriate behaviors " as a whole " , but was not informed following each incident. ADON was asked if the physicians and families of the female residents that had been affected by Resident #2 ' s social/sexual inappropriate behaviors had been notified following each incident. She stated the physicians and families of the female residents had not been notified of any of the incidents due to the facility not identifying the situations as " incidents " . Resident #11 Review of Resident #11 ' s Admission Face Sheet dated 11/25/09 at 2:34 p.m. revealed Resident #11 had been admitted to the facility on [DATE] at 12:00 p.m. Resident #11 was [AGE] years old at the time of this investigation. Review of Resident #11 ' s Consolidated Physician order [REDACTED]. Review of Resident #11 ' s quarterly Minimum (MDS) data set [DATE] revealed Resident #11 had the ability to make herself understood and understands others. Resident #11 had short and long term memory problems. Resident #11 ' s cognitive skills for daily decision making were identified as severely impaired. Resident #11 ' s signs and symptoms of [MEDICAL CONDITION] were listed as: Behavior present, fluctuates in areas of Inattention, Disorganized thinking and was listed as: Behavior continuously present. Assessment of Resident #11 ' s mood indicated symptoms; Trouble concentrating on things, such as reading the newspaper or watching television. The facility had identified Resident #11 as having no [MEDICAL CONDITION] or behavior symptoms. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #11 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #11 was frequently incontinent of bladder and bowel. Review of Resident #11 ' s Plan of Care dated 5/31/10 revealed the facility had identified the problems of: 1. Resident is confused. Goals set for Resident #11: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident wanders without regard to safety. Goals set for Resident #11: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently. Reorient throughout the day. Notify physician and family of any changes. 3. Resident has socially inappropriate behaviors. Goals set for Resident #11: Refrain from the behavior of toileting in inappropriate places for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. Review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 3/2/10 revealed Resident #11continued to require accommodations on the Alzheimer ' s Unit due to exhibiting classic symptoms of moderate dementia, memory and perceptual deficits, inappropriate social skills /behaviors, tendency to wander without regard to personal safety. Social Service recommendations/interventions: Maintain effective working relationship with resident and family. Monitor for basic safety. Monitor for inappropriate social interaction i.e. conflict, sexual enticement, etc. Review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 6/1/10 revealed Resident #11 memory was poor and basic judgment was highly impaired. Behaviorally, Resident #11 required " frequent and repetitious redirection when placing herself in socially compromising situations without awareness of doing so " . Review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 8/17/10 revealed Resident #11 was unable to maintain any consistent thought tracking, had poor mental focus and often became distracted. Resident #11 had diminished capabilities of abstract thinking, could only perform simple tasks and did not retain much if any judgment in terms of personal safety. Review of Resident #11 ' s Quarterly/Annual Review- Progress Note dated 11/19/10 revealed Resident #11had severe impairment of general judgment and perception. Resident #11 ' s cognitive decline presented a high degree of social vulnerability and self neglect. Review of Resident #2 ' s Nurse ' s Notes dated 11/15/10 at 7:00 p.m. revealed an unidentified female resident had complaints of Resident #2 attempting to force her hands down his pants. (Female resident later identified as Resident #11, there was no corresponding Nurse's note in Resident #11's chart.) Resident #12 Review of Resident #12 ' s Admission Face Sheet revealed Resident #12 was admitted to the facility on [DATE] with no documented time. Resident #12 was [AGE] years old at the time of this investigation. Review of Resident #12 ' s Consolidated Physician order [REDACTED]. [MEDICAL CONDITION], Convulsions, Muscular Wasting and Atrophy, Alzheimer ' s Disease, Diabetes Mellitus, Essential Hypertension, and Abnormality of Gait. Review of Resident #12 ' s Admission Minimum (MDS) data set [DATE] revealed Resident #12 had short and long term memory problems. Resident # 12 was able to make herself understood and sometimes understand others. Resident #12 had behaviors indicated as wandering and resists care. Resident #11 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #12 was listed as extensive assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #12 was continent of bladder and bowel. Review of Resident #12 ' s Plan of Care dated revealed the facility had identified the problems of: 1. Resident wanders without regard to safety. Goals set for Resident #12: Resides on secure unit related to unsafe wandering. Resident will not have any accidents or injury related to wandering and will wander within appropriate boundaries for the next 90 days. Approaches and Interventions: Monitor for episodes of wandering. Redirect resident if wandering. Monitor resident ' s whereabouts frequently. Reorient throughout the day. Notify physician and family of any changes. 2. Resident is forgetful and had impaired cognition. Goals set for Resident #12: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. Review of Resident #2 ' s Nurse ' s Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12) * There was no corresponding nurse ' s notes found in Resident #12 ' s chart.* Resident #13 Review of Resident #13 ' s Admission Face Sheet revealed Resident #13 was admitted to the facility on [DATE] at 12:00 p.m. Resident #13 was [AGE] years old at the time of this investigation. Review of Resident #13 ' s Consolidated Physician order [REDACTED]. Review of Resident #13 ' s quarterly Minimum (MDS) data set [DATE] revealed Resident #13 had the ability to make herself understood and to understand others. Resident #13 had short and long term memory problems. Resident #13 ' s cognitive skills for daily decision making were moderately impaired. Resident #13 ' s signs and symptoms of [MEDICAL CONDITION] were listed as: Behavior present fluctuates in areas of Inattention and Disorganized thinking. Resident #13 had no indicators of [MEDICAL CONDITION]. Resident #13 ' s behaviors were listed as verbal behavioral symptoms directed towards others occurring 1-3 days. Resident #13 was listed as independent with no set up or physical assistance from staff for: Bed mobility, Transfer, Walk in room, Walk in corridor, and Locomotion on/off the unit. Resident #13 was listed as limited assistance from one staff for: Dressing, Personal hygiene and supervision with assistance from one staff for: Bathing. Resident #13 was occasionally incontinent of bladder and always continent of bowel. Review of Resident #13 ' s Plan of Care dated 5/18/10 and continued on 11/20/10 revealed the facility had identified the problems of: 1. Resident #13 was Forgetful and had impaired cognition related to Dementia. Goals set for Resident #13 were: Resident will remain safe and protected in her environment and be oriented to person and place for the next 90 days. Approaches and Interventions: Provide a stable and supportive environment through consistency of daily routine. Pace activities. Minimize distractions. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. 2. Resident #13 was oriented to person only, confused daily, unaware of date time and situation, unable to make decisions and exhibits poor safety awareness. Goals set for Resident #13 were: All of Resident #13 ' s needs were to be anticipated and met until next review. Approaches and Interventions: Staff to anticipate and provide daily care. Re-orient and redirect as needed. Monitor resident ' s safety. Keep family and physician aware of any changes of condition, needs or wants. 3. Resident #13 is confused related to Alzheimer ' s disease. Goals set for Resident #13: Resident will remain safe and protected in her environment. Approaches and Interventions: Approach the resident in an open, friendly and relaxed manner and expression. Provide a stable/supportive environment through consistency in daily routine. Provide orientation to decrease confusion. Notify physician and family of any mental status changes. A review of Resident #13's Quarterly/Annual Review- Progress Note dated 8/17/10 revealed Resident #13 was often confused and disoriented. Careful monitoring of behavior and safety is necessary due to resident #13 ' s cognitive impairment and lack of judgment. Review of Resident #2 ' s Nurse ' s Notes dated 9/29/10 at 4:30 p.m. revealed an entry stating, " Another female resident came to the nurse ' s station crying almost hysterically. When the unidentified female resident was asked what was wrong, the unidentified female resident stated, ' That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back. ' The unidentified female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the unidentified female ' s room. " The nurse ' s note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other residents rooms. (Female resident was later identified to be Resident #13 however there was not a corresponding Nurse's Note found in Resident #13's chart.) A review of Resident #13's Quarterly/Annual Review- Progress Note dated 11/9/10 revealed Resident #13 had moderate impairment in terms of memory and perception. Resident #13 is mobile and at risk to wander causing her to become lost and/or in jeopardy of abuse and exploitation. Resident #13 requires careful monitoring. In an interview on 11/18/10 at 11:35 a.m. with DON revealed Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse ' s station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In a review of the facility ' s Incident and Accident Process received 12/11/10 at 11:00 a.m. revealed: Immediately assess the condition of the individual involved, and implement measures to prevent the incident from reoccurring. Notify the attending physician/ treating physician, family, responsible party and document the time and name of the physician and responsible party in the medical record. If unable to reach the physician and /or responsible party, make continuous attempts and document all attempts in the medical record. Document the medical facts in the medical record. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Coordinator. According to this plan, the facility determined it had not notified the physician and legal representatives regarding Resident #2's social services recommendation for a psychiatric evaluation, had not notified Resident #2's physician regarding multiple incidents of social/sexual inappropriate behaviors, and had not notified the family's of Resident #11, #12, #13 following incidents when they were involved in Resident #2's social/sexual inappropriate behaviors. According to the plan, the DON had contacted Resident #2's physician regarding a pharmaceutical intervention to help control Resident #2's social/sexual inappropriate behaviors and an order was given for an increase of [MEDICATION NAME] to 500 mg. According to the plan on 12/11/10 at 2:20 p.m. the Administrator placed Resident #2 on one to one (24/7) supervision until he is no longer a danger to other residents. Observed supervision was to be documented in the frequent observation log. According to the plan on 12/12/10 at 12:50 a.m. the DON secured an order for [REDACTED]. According to the plan, the physician of the resident will always be notified of behaviors that would be considered a danger to him/her self or other residents, visitors, and staff. Notification of the physician will be done by the charge nurse. Plan of Removal Verification Facility nurses were interviewed on 12/14/10 concerning notifying the physicians following recommendations from social services regarding psychiatric evaluation. All nurses interviewed confirmed they would notify the physician with all recommendations. The Immediate Jeopardy was lowered to potential for harm prior to the exit on 12/14/10 at 2:45 p.m. In an interview on 12/14/10 at 11:00 a.m. with CNA 'D' revealed any abnormal finding of any kind regarding the residents was to be reported to the charge nurse. In an interview on 12/14/10 at 1:05 p.m. with ADON revealed Resident #2 had received the medication Depo-[MEDICATION NAME] on 12/13/10 to "decrease his libido". Resident #2's physician had been contacted, and orders were received for Resident #2 to have a psychiatric evaluation on 12/16/10. In a review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] In the entrance interview on 11/12/10 at 9:50 a.m. the administrator said the census was 59. Depo [MEDICATION NAME]---released in the early 1990s---is an injectable suspension that contains 150 mg of the synthetic hormone [MEDICATION NAME]. Depo [MEDICATION NAME] must be injected every three months to remain effective. When prescribed to women for birth control or to treat painful symptoms of endometriosis, Depo [MEDICATION NAME]'s slow release of synthetic [MEDICATION NAME] inhibits the secretion of other reproductive hormones, prevents ovulation and thins endometrial tissue (the uterus lining). The active ingredient in Depo [MEDICATION NAME]---[MEDICATION NAME]---was being used decades before Depo [MEDICATION NAME] was created to curb the sexual urges, fantasies and arousal ability of men with pedophil

Based on interviews and record reviews the facility failed to develop, review and revision of care plans for 1 (Residents #2) of 13 sampled residents. The facility failed to: 1. Revise Resident #2's care plan to include appropriate approaches/interventions regarding multiple incidents of continued social/sexual inappropriate behaviors. This failure could affect all 19 residents who reside on the Alzheimer's Unit and place them at risk of receiving inadequate care and services. These failures resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on the 12/14/10, the facility remained out of compliance at a level of potential for harm. The findings included: Review of Resident #2's admission face sheet dated 11/25/09 revealed this male resident was admitted to the facility on [DATE]. Resident #2 was [AGE] years old at the time of this investigation. Review of Resident #2's consolidated physician orders [REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. The resident's cognitive skills for daily decision making were moderately impaired. Resident #2 experienced periods of inattention and disorganized thinking. The resident experienced trouble concentrating on things such as reading the newspaper or watching television. The resident's wandering behaviors occurred daily. For most activities of daily living Resident #2 required only minimal help. He was, however frequently incontinent of bladder and always continent of bowel. A review of Resident #2's Social Progress Notes dated 8/07/09 at 10:00 a.m. revealed the social worker (SW) had received a note from a nurse working on the Alzheimer's unit stating the resident had made a comment to another resident in regards to " killing himself " . The SW documented information related to Resident #2's comment was reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The SW documented he directly asked Resident #2 if he was thinking about killing himself and Resident #2 responded he thinks about death, further stating that he's " [AGE] years old" and feels his family has abandoned him. The SW's documented: Communicated openly with the nursing staff on duty, offered input for attention to the resident's need for safety. Plan to meet with the family as they arrive at the facility this morning. A review of Resident #2 ' s Social Service Progress Notes dated 8/07/09 at 10:40 a.m. revealed the SW had discussed Resident #2 ' s suicidal statement with Resident #2 ' s family. The SW stated he discussed with Resident #2 ' s family, the possibility of Resident #2 needing a psychiatric evaluation, " at the next possible time when the psychiatrist was in the building. " The SW documented the family was " accommodating and agreeable to having a psychiatric intervention as needed. " The SW documented: " Recommend psychiatric consult with psychiatrist as soon as possible to assess for mood and/or thought disorder. Communicated prudent care should be taken with Resident #2 due to at least one prior incident of suicidal ideation, in combination with the age of Resident #2, and cognitive impairment associated with Alzheimer ' s disease. Family consented to having a psychiatrist see Resident #2 and agree that this is an appropriate time. " Review of Resident #2 ' s Abnormal Behavior Pattern Monitoring (ABPM) on 5/26/10 revealed Resident #2 had behaviors identified as " sexually acting out " . Interventions: 15 minute checks and frequent monitoring. Review of Resident #2 ' s ABPM on 6/23/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: Frequent checks and close monitoring of where Resident #2 is on the unit. Review of Resident #2 ' s ABPM on 6/30/10 revealed Resident #2 had behaviors identified as " promiscuity with female residents " . Interventions: SW confrontation of behaviors. A review of Resident #2 ' s Quarterly/Annual Review- Progress Note dated 1/ 26/10 revealed, " Resident #2 does not directly pose any threat for self harm, however it is prudent to monitor his daily activities as his personal judgment and orientation may become altered at any given time due to the disease process. " A review of Resident #2 ' s Quarterly/Annual Review- Progress Note dated 4/27/10 revealed, " Behaviorally, Resident #2 is complaint and passive in nature, but has at least one experience in which he walked into a female residents room. Resident #2 comprehends that his judgment and decision making ability are poor, often causing frustration. " A review of Resident #2 ' s physician progress notes [REDACTED]. The physician had commented after reviewing the nurse ' s notes, " Resident #2 has engaged in inappropriate behavior. He has wandered into a female resident ' s room and touched her groin area. " A review of Resident #2 ' s Quarterly/Annual Review- Progress Note dated 7/20/10 revealed, " On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents. " A review of Resident #2's Plan of Care dated 7/20/10 and continued on 10/25/10 revealed the facility had identified the problem of: Socially Inappropriate Sexual Advances. Goals set for Resident #2 were for him to: Refrain from this Behavior for 90 days. Approaches and Interventions were listed as: Redirect resident at each episode, assist with redressing when needed, pull privacy curtain to maintain dignity, provide diversion activities when needed to redirect behaviors, notify family of inappropriate behaviors, and notify the social worker when needed. Review of Resident #2 ' s ABPM on 8/11/10 revealed Resident #2 had behaviors identified as " Enticing female resident into room (possible sexual intent) "Interventions: SW notified, discussed intervention with ADON, heightened monitoring, Confrontation ' s 2 times weekly or when needed. Review of Resident #2's Nurse's Notes dated 9/29/10 at 4:30 p.m. revealed an entry stating, " Another female resident came to the nurse's station crying almost hysterically. When the unidentified female resident was asked what was wrong, the unidentified female resident stated, ' That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back. ' The unidentified female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the unidentified female ' s room. " The nurse's note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other resident ' s rooms. (Female resident was later identified to be Resident #13) Review of Resident #2 ' s Nurse' s Notes dated 9/30/10 at 8:00 p.m. revealed while a CNA was assisting a unidentified female resident with preparing for bed, Resident #2 walked into the unidentified female residents room. The unidentified female became " teary-eyed and frightened. Resident #2 was asked to leave the room. Review of Resident #2 ' s Nurse ' s Notes dated 10/4/10 revealed an entry stating, " Resident #2 was seen outside in the patio area interacting inappropriately with a female resident. ADON saw him. " Review of Resident #2 ' s ABPM on 10/06/10 revealed Resident #2 had behaviors identified as " Attempting to engage other resident in sex " . Intervention: ADON/ SW meeting with unit nurse and resident. A review of Resident #2 ' s Social Service Progress Notes dated 10/11/10 revealed, " SW is informed by nurse on duty that Resident #2 had ' touched ' the breast of a female resident. At that time the nurse stated he had already confronted the resident, however felt the SW should provide confrontation since this type of behavior has been a problem with Resident #2 prior to today. SW met with Resident #2 privately in his room and verbalized the necessity for Resident #2 to cease touching the other residents, and unwanted sexual advances are not tolerated in the facility. Resident #2 had a dejected or sad affect when he was confronted about the behavior. Review of Resident #2 ' s ABPM on 10/13/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female resident " . Intervention: None listed. Review of Resident #2 ' s Nurse 's Notes dated 10/20/10 on (2-10 shift) revealed an entry stating, " Going into other resident ' s rooms constantly, Redirection not effective. " Review of Resident #2 ' s Nurse's Notes dated 11/03/10 at 7:00 p.m. revealed, " Resident was punched with fists by another resident. He was not injured as staff intervened in time. " The ADON and Resident #2 ' s wife were notified of the incident. Review of Resident #2 ' s Nurse's Notes dated 11/04/10 at 1:00 a.m. revealed Resident #2 was resting quietly without distress and had no red or bruised areas noted from previous altercation with his roommate. Review of Resident #2 ' s Nurse's Notes dated 11/04/10 at 3:45 p.m. revealed an unidentified female resident had complaints of Resident #2 grabbing her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. Review of Resident #2 ' s Nurse's Notes dated 11/15/10 at 7:00 p.m. revealed an unidentified female resident had complaints of Resident #2 attempting to force her hands down his pants. In an observation on 11/18/10 at 11:35 a.m. revealed Resident #2 sleeping in his recliner in Room: 52. In an interview on 11/18/10 at 11:35 a.m. with DON revealed Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse ' s station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure a female resident into his room. In an interview on 11/18/10 at 2:30 p.m. with ADON revealed she was not aware Resident #2 had more episodes of inappropriate behaviors with females after the incident with Resident #13. Review of Resident #2 ' s ABPM on 12/08/10 revealed Resident #2 had behaviors identified as " Inappropriate touching with female CNA " . Intervention: SW conference with Resident #2 ' s son, confrontation of Resident #2. Review of a Facility Incident/Accident Report dated 12/05/10 at 10:15 a.m. revealed Resident #2 was being assisted to shave by a female CNA. While the CNA was assisting Resident #2 with shaving, Resident #2 attempted to touch the female staff member between her legs. The CNA asked Resident #2 to keep his hands to himself and Resident #2 attempted to touch the female staff between her legs again. In an interview on 12/09/10 at 2:50 p.m. with LVN ' B ' revealed she felt Resident #2 ' s Care Plan was effective approximately " 50 to 75 % " of the time. LVN ' B ' was asked how the staff was managing Resident #2 ' s care for the 25 to 50 % of the time his Care Plan was not effective. She stated, " Resident #2 is very random. We try to redirect his behaviors when they occur. She stated she felt Resident #2 was " very predatory " and seems to ' seek out ' the female residents that are smaller and weaker than he is. She stated she felt it was more important to redirect the female residents away from Resident #2 in order to keep them safe from his sexual behaviors. In an interview on 12/10/10 at 10: 45 a.m. with SW revealed he was aware of Resident #2 having social/sexual inappropriate behaviors. SW was asked if he felt Resident #2 ' s care plan was effective regarding social/sexual inappropriate behaviors. He stated he felt the care plan needed to be updated to reflect the interventions the facility had put in place for Resident #2. SW was asked if the facility preformed Mini-Mental State Examinations (MMSE) or had any evaluation tools to determine the severity of the resident ' s cognitive impairment. He stated he preformed MMSE when the nursing staff requested one is done on a resident. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Coordinator. According to this plan, the facility determined it had not developed a more comprehensive plan of dealing with difficult residents. Furthermore the facility determined the lack of communication between Social Services, Nursing Services, and Administration had lead to a lack of a more comprehensive plan for residents care and proper implementation of interventions. Plan of Removal Verification According to the plan, the Administrator will develop a more comprehensive plan on dealing with residents with behavioral difficulties. According to the plan, the ADON will monitor Resident#2's chart daily to insure that all behaviors are being addressed. In her absence the MDS coordinator will review Resident #2's chart. This will be documented in the nurses notes signed and dated by the nurses reviewing for incidents. According to the plan, the administrative staff had a plan to improve the clerical portion of nursing services to insure that residents are receiving nursing care in the manner in which the physician intended. According to the plan, the Social worker will immediately initiate a psychosocial assessment to identify immediate psychiatric and or counseling needs and meet with the facility's Interdisciplinary Team to create a comprehensive plan of safety. The Immediate Jeopardy was lowered to potential for harm prior to the exit on 12/14/10 at 2:45 p.m. In an interview on 11/12/10 at 9:50 a.m. the administrator said the census on the Alzheimer's Unit was 19.

Based on observation, interview, and record review the facility failed to provide 1 resident (Resident #1) of 13 residents sampled with sufficient fluid intake to maintain proper hydration and health. The facility failed to: 1. provide Resident #1 1800 cc of daily fluids as the physician ordered, from 2/2/10 to 10/27/10. On 10/27/10 the resident was admitted to a hospital for treatment of [REDACTED]. 2. provide Resident #1 more than 1200 cc of daily fluids as the physician ordered, from 11/5/10 to 11/12/10, which placed the resident at risk for continued dehydration following her hosptalization. These facility failures resulted in actual harm to Resident #1. Resident #1 was admitted to the hospital on [DATE] for dehydration. In the hospital the resident required IV fluids for 3 days. According to her physician, the resident's dehydration worsened the effects of a stroke. When the Resident #1 returned to the facility from the hospital on [DATE], the facility still failed to provide the resident the amount of daily fluids ordered by the physician, which created the risk of serious harm such as hypovolemic shock. This failure resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a level of a pattern of actual harm. Although only 1 resident was affected by these facility failures, all 5 residents identified by the facility as having a physician order [REDACTED]. Findings include: Review of Resident #1's record of admission revealed this female resident was admitted to the facility on [DATE]. She was [AGE] years old at the time of this investigation. Review of Resident #1's physician progress notes [REDACTED]. The resident lived at a different nursing home at that time, but this progress note documented the resident had a history of [REDACTED]. Review of Resident #1's consolidated physician orders [REDACTED]. According to these orders, the resident was to be given 1800 cc of fluids per day; this order was dated 6/15/09. Review of Resident #1's annual MDS dated [DATE] revealed at that time the resident had both short-term and long-term memory loss. Her cognitive ability for daily decision making was severely impaired. She rarely or never was able to understand others, and rarely or never able to make herself understood. Her speech was unclear, mumbled words. The resident required extensive physical help from 2 staff members for most activities of daily living, but needed total care for some. Review of Resident #1's medical record revealed documentation of fluid intake from 2/2/10 to 11/11/10. According to the resident's consolidated physician orders, the facility was to provide the resident 1800 cc of fluids each day, beginning 6/15/09. For February through May 2010 the intake records documented Resident #1 drank at least 1800 cc of fluid only on 10 days during this 4 month period, and drank less than 1000 cc on 29 days. For June through September 2010 there was documentation of intake on only 17 days. Of these 17 days, staff documented an intake of 1800 cc or more on only 1 day. Review of Resident #1's hospital medical record history and physical and discharge summary, dated 10/27/10 and 11/5/10 respectively, revealed the resident was admitted to the acute care unit of the hospital on [DATE] for altered mental status with a decreased alertness for several days, and was barely responsive at the time of the hospital admission. The reports documented the resident was severely hyperglycemic (very high blood glucose level) with an initial blood glucose level of 697 (normal levels are 70 to 110). The reports documented the resident was also significantly dehydrated. The reports documented the resident also had new right-sided [MEDICAL CONDITION] (weakness) and decreased right side mobility which suggested a stroke had occurred. The reports documented the resident was treated in the hospital with IV fluids and insulin for 3 days. Review of undated web articles entitled Dehydration and [MEDICAL CONDITION] in Diabetes (Mayo Clinic website) revealed blood glucose levels greater than 600 mg/dL can lead to coma and cause life-threatening dehydration. A serious potential complication of dehydration is hypovolemic shock, which is a drop in blood pressure with a corresponding reduction in the amount of oxygen reaching tissues. If untreated, hypovolemic shock can cause death in a matter of minutes. In an interview on 12/9/10 at 10:30 a.m. Resident #1's physician said when she saw the resident during an office visit on 10/27/10, the resident was very obtunded (mentally dull), so she had the resident immediately admitted to the hospital. The physician said hospital lab tests showed the resident was severely hyperglycemic (very high blood glucose level) as well as very significantly dehydrated. The physician said although the resident's family refused to have a CT of the resident's head (a medical imaging method), she thought the resident had a stroke because the resident was showing new [MEDICAL CONDITION] (weakness on one side of the body). The physician said the resident's significant dehydration would have worsened the stroke. Review of Resident #1's physician orders [REDACTED]. According to these orders, the facility was to ensure the resident was to drink more than 1200 cc daily. Review of Resident #1's nursing home nursing notes for 11/5/10 revealed the resident was readmitted to the facility at 2:35 p.m. on that day. Review of Resident #1's fluid intake records for 11/5/20 to 11/11/10 revealed: -- on 11/5/10 there was no documentation of fluid intake, even though the resident was readmitted to the nursing home on that day at 2:35 p.m. -- on 11/6/10 the staff documented the resident drank 480 cc. -- on 11/7/10 the staff documented the resident drank 1050 cc. -- on 11/8/10 the staff documented the resident drank only 400 cc. -- on 11/9/10 the staff documented the resident drank only 524 cc. -- on 11/10/10 the staff documented the resident drank 880 cc. -- on 11/11/10 the staff documented the resident drank only 740 cc. In an interview on 12/9/10 at 2:25 p.m. the DON said prior to 11/12/10 the facility was doing nothing to ensure Resident #1 received the amount of daily fluids ordered by her physician. Observation on 12/8/10 at 1:10 p.m. revealed Resident #1 was up in a wheelchair in the dining room for lunch. The resident made no effort to feed herself, so staff fed the resident. The resident drank tea, water, juice, and a health shake, about 480 cc in all. Observation on 12/8/10 at 4:20 p.m. revealed Resident #1 drank about 180 cc of water. Observation on 12/8/10 at 5:40 p.m. revealed Resident #1 was in the dining room for supper. She drank about 480 cc of tea, juice, and water. In an interview on 12/9/10 at 2:10 p.m. CNA 'A' said she had worked in facility about 1 year. She said until about 1 week or so before Resident #1 was admitted to the hospital on [DATE] the resident was able to walk when 2 staff held onto the resident's gait belt. CNA 'A' said the resident was able to speak at that time, although she was not able to carry on a conversation, and what the resident said made little sense. The CNA said the resident then began to show signs of weakness, and the staff started using a wheelchair for her. The CNA said after the resident returned to the nursing home after her hospital stay (10/27/10 to 11/5/10) the resident had significantly declined, she was then unable to stand and required a mechanical lift for transfers, and the resident did not speak at all any longer. In an interview on 12/12/10 at 2:00 p.m. CNA 'C' said Resident #1 always needed assistance with eating and drinking, but did drink well when she was offered a drink, even before the resident was admitted to the hospital on [DATE]. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Coordinator. According to this plan, the facility determined on 11/12/10 (after the surveyor entered the facility to investigate an allegation of dehydration) it had not been correctly monitoring Resident #1's hydration. The plan documented all residents were assessed for dehydration on 12/12/10. The facility determined it's hydration policy had been inadequate to ensure residents remained well hydrated, so a new policy was written and put into effect. Staff inservice on the new hydration policy began on 12/12/10 and was completed on 12/14/10. The plan documented all newly admitted residents were to be monitored for 72 hours to determine whether they were at risk for dehydration and a plan of care for hydration was to be established within 72 hours following the determination of a resident's risk of dehydration. Review of the inservice records revealed on 11/20/10 40 staff members, licensed and unlicensed, received training on resident hydration and on intake documentation. Review of the facility's newly written hydration policy revealed residents were to be offered 360 cc to 480 cc of fluids at each meal as determined by each resident's dietician evaluation of fluid needs. Fluid intake for at risk residents was to be documented each shift, reviewed by charge nurses, and monitored by the DON and ADON. Review of the Plan of Removal of Immediate Jeopardy revealed the following documentation tools were to be used in the facility: a dehydration risk appraisal checklist, a new fluid intake/output worksheet, a new weekly intake/output monitoring form, and a new checklist to evaluate for the signs and symptoms of dehydration. Review of an inservice training record dated 12/12/10 revealed licensed and unlicensed staff were trained on the use of the new hydration policy and procedures. Plan of Removal Verification Facility staff were interviewed on 12/14/10 concerning the inservice training related to resident hydration. All staff interviewed confirmed they received the inservice and communicated knowledge of the facility's policy on resident hydration Observations revealed staff were providing fluids from a hydration cart and at meals. The Immediate Jeopardy was lowered to actual harm prior to the exit on 12/14/10 at 2:45 p.m. According to a list provided by the facility there were 2 residents with a physician order [REDACTED].

Based on record review and interview the facility failed to provide for 1 resident (Resident #1) of 13 sampled residents pharmaceutical services that met the needs of the resident. The facility failed to: 1. correctly transcribe Resident #1's hospital discharge order which required the resident to be given regular insulin according to a sliding scale each day in the morning and in the evening. 2. administer to Resident #1 the ordered regular insulin. From 11/5/10 to 12/8/10 the facility failed to give the resident the required insulin on 28 days. This failure resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a level a pattern of potential serious harm. These failures created the risk for Resident #1 of serious harm from uncontrolled hyperglycemia, such as kidney damage and blindness. Although 1 resident was identified as affected by these failures, all 14 residents identified as having diabetes could have been affected. Findings include: Review of Resident #1's record of admission revealed this female resident was admitted to the facility on [DATE]. She was [AGE] years old at the time of this investigation. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's annual MDS dated [DATE] revealed at that time the resident had both short-term and long-term memory loss. Her cognitive ability for daily decision making was severely impaired. She rarely or never was able to understand others, and rarely or never able to make herself understood. Her speech was unclear, mumbled words. The resident required extensive physical help from 2 staff members for most activities of daily living, but needed total care for some. Review of Resident #1's lab report dated 9/30/10 revealed the resident's blood glucose level was 136 milligrams per deciliter. According to the lab report, the normal range for blood glucose was 70 to 110. Review of Resident #1's hospital medical record history and physical and discharge summary, dated 10/27/10 and 11/5/10 respectively, revealed the resident was admitted to the acute care unit of the hospital on [DATE] for altered mental status with a decreased alertness for several days, and was barely responsive at the time of the hospital admission. The reports documented the resident was severely hyperglycemic (very high blood glucose level) with an initial blood glucose level of 697 (normal levels are 70 to 110). The reports documented the resident, prior to this hospital admission, had not been diagnosed with [REDACTED]. The reports documented the resident was treated in the hospital with IV insulin and fluids for 3 days. Review of an undated web article entitled Hyperglycemia in Diabetes (Mayo Clinic website) revealed blood glucose levels greater than 600 mg/dL can lead to coma and cause life-threatening dehydration. In an interview on 12/9/10 at 10:30 a.m. Resident #1's physician said when she saw the resident during an office visit on 10/27/10, the resident was very obtunded (mentally dull), so she had the resident immediately admitted to the hospital. The physician said hospital lab tests showed the resident was severely hyperglycemic (very high blood glucose level) as well as very significantly dehydrated. The physician said although the resident's family refused to have a CT of the resident's head (a medical imaging method), she thought the resident had a stroke because the resident was showing new hemiparesis (weakness on one side of the body). The physician said the resident's severe hyperglycemia would have significantly worsened the resident's dehydration which in turn would have worsened the stroke. Review of Resident #1's physician orders [REDACTED]. These orders instructed the facility to check the resident's blood glucose level twice a day and give the resident regular insulin according to a sliding scale. Attached to these orders was a copy of the hospital Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #1's nursing home diabetic treatment record for November 2010 revealed the resident's blood glucose levels were checked each evening at 8:00 p.m. The resident's blood glucose level on 7 days was more than 150 but less than 201, so according to the sliding scale the resident should have been given 2 units of regular insulin on each of those days. On 9 days, the resident's evening blood glucose level was greater than 200 but less than 251, so the resident should have been given 4 units of regular insulin on those days. On 4 days the resident's evening glucose level was greater than 250 but less than 301, so the resident should have been given 6 units of regular insulin on those days. According to the resident's diabetic treatment record, the resident was not given any regular insulin on the 20 days when her evening blood glucose level was high. Review of Resident #1's diabetic treatment record for December 2010 (12/1/10 though 12/8/10) revealed the resident's evening blood glucose level was more than 150 but less than 201 on 6 days. The resident should have been given 2 units of regular insulin on those days. On 2 days the resident's evening blood glucose level was more than 201 or higher but less than 251. The resident should have been given 4 units of regular insulin on those days. According to this record, the resident did not receive any regular insulin on any day even though she should have. In an interview on 12/9/10 at 1:40 p.m. LVN 'A' said she was the nurse that transcribed Resident #1's hospital discharge orders for the use of regular insulin. She reviewed the hospital discharge orders and her transcription of the orders to the facility's medication administration records. She said it was clear at the time of this interview the resident should have been getting regular insulin in the evenings, but she did not transcribe that to the facility MAR. The LVN said she did not know what she was thinking at the time she transcribed the orders, but she should have contacted the physician for clarification of the order. The surveyor asked the LVN if she was saying this because she really believed it or because the surveyor had questioned the accuracy of the order as it was transcribed to the facility MAR. The LVN said it was clear to her that she transcribed the order in error and should have called the physician for clarification. In a telephone interview on 12/10/10 at 9:45 a.m. the office nurse for Resident #1's physician said the facility should have been giving Resident #1 regular insulin both in the morning and in the evening since the resident was readmitted to the facility on [DATE]. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Officer. According to this plan, on 11/5/10 a nurse failed to clarify Resident #1's physician order [REDACTED]. This inservice was completed on 12/10/10. Review of the inservice attendance record revealed 12 nurses received this training. According to the plan, the DON and the ADON will monitor all new physician orders [REDACTED]. Also, according to the plan, the facility administration created a new policy regarding the receiving and transcribing of physician orders. Plan of Removal Verification Facility nurses were interviewed on 12/14/10 concerning the inservice training related to physician orders. All nurses interviewed confirmed they received the inservice and communicated knowledge of the facility's policy on receiving, clarifying, and transcribing physician orders. The Immediate Jeopardy was lowered to potential for serious harm prior to the exit on 12/14/10 at 2:45 p.m. According to a resident worksheet compiled and printed on 12/12/10, there were 14 residents who had a [DIAGNOSES REDACTED].

Based on observations, interview, and record review the facility failed to ensure that it was administered in a manner that enabled it to use resources effectively to attain the highest practicable well-bing for 2 residents (Residents #1 and #2) of 13 residents sampled. The adminstrator failed to administer the facility effectively and efficiently to attain an maintain the highest practicable well-being for 2 residents (Residents #1 and #20 of 13 sampled residents. 1. The administrator failed to develop a hydration policy which directed staff to provide sufficient fluids for Resident #1. 2. The administrator failed to ensure staff implemented the facility abuse prevention policy which required staff to consult Resident #2's physician concerning his continuing inappropriate sexual behavior, investigate and report to the state agency those behaviors. 3. The DON failed to supervise nursing staff to ensure Resident #1 was administered the physician ordered evening dose of regular insulin. 4. RN 'A', a charge nurse, failed to follow-up on a physician order [REDACTED]. 5. The social workder fialed to provide necessary medically related social services for Resident #2. These facility failures resulted in actual harm to Resident #1 who was admitted to the hospital on [DATE] for severe [MEDICAL CONDITION] and dehydration. According to Resident #1's physician, the uncontrolled [MEDICAL CONDITION] and the dehydration worsened the effects of a stroke. These failures also created for Resident #1 the continued risk for serious harm from uncontrolled [MEDICAL CONDITION] (such as kidney damage and [MEDICAL CONDITION]) and serious harm from dehydration (such as hypovolemic shock) after she returned from the hospital to the facility on [DATE]. These failures also resulted in a delay of treatment for [REDACTED].#2's inappropriate sexual behaviors. These failures resulted in an Immediate Jeopardy which was identified on 12/10/10. While the Immediate Jeopardy was removed on 12/14/10, the facility remained out of compliance at a patten level of actual harm. Although these facility failures affected Residents #1 and #2, all 19 residents who lived on the Alzheimer's unit could have been affected. Findings include: Review of the undated facility written policy entitled Abuse Prohibition Program revealed: -- neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. -- the facility was required to identify and correct situations in which neglect was more likely to occur. Such situations included residents who required extensive or total nursing care. -- sexual abuse included but was not limited to sexual harrassment, sexual coercion, or sexual assault. -- mental abuse included but was not limited to humiliation and harrassment. -- physical neglect involves failure to provide goods and services necessary for health and well-being of the elder. It may include withholding meals or hydration. Review of Resident #1's record of admission revealed this female resident was admitted to the facility on [DATE]. She was [AGE] years old at the time of this investigation. Review of Resident #1's physician progress notes [REDACTED]. The resident had lived at a different nursing home at that time, but this progress note documented the resident had a history of [REDACTED]. Review of Resident #1's consolidated physician orders [REDACTED]. According to these orders, the resident was to be given 1800 cc of fluids per day; this order was dated 6/15/09. Review of Resident #1's annual MDS dated [DATE] revealed at that time the resident had both short-term and long-term memory loss. Her cognitive ability for daily decision making was severely impaired. She rarely or never was able to understand others, and rarely or never able to make herself understood. Her speech was unclear, mumbled words. The resident required extensive physical help from 2 staff members for most activities of daily living, but needed total care for some. Observation on 12/8/10 at 10:43 a.m. revealed CNA 'A' and CNA 'B' used a mechanical lift to transfer Resident #1 from a wheelchair to the resident's bed. The aides provided the resident incontinent care then transferred the resident back to the wheelchair and took her back to the lobby area of the dementia unit. Review of Resident #1's lab report dated 9/30/10 revealed the resident's blood glucose level was 136 milligrams per deciliter. According to the lab report, the normal range for blood glucose was 70 to 110. Review of Resident #1's hospital medical record history and physical and discharge summary, dated 10/27/10 and 11/5/10 respectively, revealed the resident was admitted to the acute care unit of the hospital on [DATE] for altered mental status with a decreased alertness for several days, and was barely responsive at the time of the hospital admission. The reports documented the resident was severely hyperglycemic (very high blood glucose level) with an initial blood glucose level of 697 (normal levels are 70 to 110). The reports documented the resident, prior to this hospital admission, had not been diagnosed with [REDACTED]. The reports documented the resident also had new right-sided [MEDICAL CONDITION] (weakness) and decreased right side mobility which suggested a stroke had occurred. The reports documented the resident was treated in the hospital with IV insulin and fluids for 3 days. Review of Resident #1's fluid intake records for 11/5/20 to 11/11/10 revealed: -- on 11/5/10 there was no documentation of fluid intake, even though the resident was readmitted to the nursing home on that day at 2:35 p.m. -- on 11/6/10 the staff documented the resident drank 480 cc. -- on 11/7/10 the staff documented the resident drank 1050 cc. -- on 11/8/10 the staff documented the resident drank only 400 cc. -- on 11/9/10 the staff documented the resident drank only 524 cc. -- on 11/10/10 the staff documented the resident drank 880 cc. -- on 11/11/10 the staff documented the resident drank only 740 cc. Review of undated web articles entitled Dehydration and [MEDICAL CONDITION] in Diabetes (Mayo Clinic website) revealed blood glucose levels greater than 600 mg/dL can lead to coma and cause life-threatening dehydration. A serious potential complication of dehydration is hypovolemic shock, which is a drop in blood pressure with a corresponding reduction in the amount of oxygen reaching tissues. If untreated, hypovolemic shock can cause death in a matter of minutes. In an interview on 12/9/10 at 10:30 a.m. Resident #1's physician said on 10/1/10 she instructed the facility to obtain for the resident a glucose tolerance test. (A glucose tolerance test is a medical test in which glucose was to be given to the resident and blood samples were to be taken afterward to determine how quickly the glucose was cleared from the blood. This test is usually used to check for diabetes). The physician said when she next saw the resident during an office visit on 10/27/10, the resident was very obtunded (mentally dull), so she had the resident immediately admitted to the hospital. The physician said hospital lab tests showed the resident was severely hyperglycemic (very high blood glucose level) as well as very significantly dehydrated. The physician said although the resident's family refused to have a CT of the resident's head (a medical imaging method), she thought the resident had a stroke because the resident was showing new [MEDICAL CONDITION] (weakness on one side of the body). The physician said the resident's severe [MEDICAL CONDITION] would have significantly worsened the resident's dehydration which in turn would have worsened the stroke. The physician said had the facility obtained a glucose tolerance test as was ordered on [DATE], the resident would have started treatment to control her blood glucose levels, and the effects of the stroke would have been lessened. In an interview on 12/9/10 at 2:10 p.m. CNA 'A' said she had worked in facility about 1 year. She said until about 1 week or so before Resident #1 was admitted to the hospital on [DATE] the resident was able to walk when 2 staff held onto the resident's gait belt. CNA 'A' said the resident was able to speak at that time, although she was not able to carry on a conversation, and what the resident said made little sense. The CNA said the resident then began to show signs of weakness, and the staff started using a wheelchair for her. The CNA said after the resident returned to the nursing home after her hospital stay (10/27/10 to 11/5/10) the resident was significantly declined in that she was then unable to stand and required a mechanical lift for transfers, and the resident did not speak at all any longer. On 12/9/10 at 4:04 p.m. the office nurse for Resident #1's physician sent to the surveyor by fax the resident's lab report dated 9/30/10 and a list of the dates and times she communicated with the physician and the nursing home about the resident's glucose tolerance test. In a telephone interview on 12/9/10 at 4:10 p.m. the office nurse for Resident #1's physician said on 10/1/10 the physician told her to instruct the nursing home to obtain a glucose tolerance test for the resident. The office nurse said she phoned the facility that day and gave the order to 1 of the facility nurses. The office nurse said on 10/15/10, when Resident #1's physician had not received a report from the facility regarding the glucose tolerance test, she called the facility again and reminded them of the order to get that test. In an interview on 12/10/10 at 9:08 a.m. the administrator said the facility did not have a writen resident hydration policy or program. In an interview on 12/13/10 at 2:34 p.m. RN 'A' said she was a charge nurse. She said on 10/15/10 at about 2:00 p.m. she received a telephone call from the office nurse of Resident #1's physician. RN 'A' said the office nurse asked why the physician had not received a report on the results of the ordered blood glucose tolerance test. RN 'A' said she reviewed the resident's medical record and found there had not been an order written [REDACTED]. RN 'A' did not explain why she did not write the order herself, or why she did not ask the office nurse for clarification at the time of her telephone conversation with the physician's office nurse. Review of the 24-hour Report dated 10/15/10 revealed RN 'A' documented Resident #1's physician office called and stated they had ordered for Resident #1 a glucose tolerance test but had not received a report on the result of the ordered test. Review of Resident #1's medical record revealed documentation of fluid intake from 2/2/10 to 11/11/10. According to the resident's consolidated physician orders, the facility was to provide the resident 1800 cc of fluids each day, beginning 6/15/09. For February through May 2010 the intake records documented Resident #1 drank at least 1800 cc of fluid only on 10 days during this 4 month period, and drank less than 1000 cc on 29 days. For June through September 2010 there was documentation of intake on only 17 days. Of these 17 days, staff documented an intake of 1800 cc or more on only 1 day. Review of Resident #1's physician orders [REDACTED]. According to these orders, the facility was to ensure the resident was to drink more than 1200 cc daily. Review of Resident #1's nursing home nursing notes for 11/5/10 revealed the resident was readmitted to the facility at 2:35 p.m. on that day. Observation on 12/8/10 at 1:10 p.m. revealed Resident #1 was up in a wheelchair in the dining room for lunch. The resident made no effort to feed herself, so staff fed the resident. The resident drank tea, water, juice, and a health shake, about 480 cc in all. Observation on 12/8/10 at 4:20 p.m. revealed Resident #1 drank about 180 cc of water. Observation on 12/8/10 at 5:40 p.m. revealed Resident #1 was in the dining room for supper. She drank about 480 cc. In an interview on 12/9/10 at 2:10 p.m. CNA 'A' said she had worked in facility about 1 year. She said until about 1 week or so before Resident #1 was admitted to the hospital on [DATE] the resident was able to walk when 2 staff held onto the resident's gait belt. CNA 'A' said the resident was able to speak at that time, although she was not able to carry on a conversation, and what the resident said made little sense. The CNA said the resident then began to show signs of weakness, and the staff started using a wheelchair for her. The CNA said after the resident returned to the nursing home after her hospital stay (10/27/10 to 11/5/10) the resident was significantly declined in that she was then unable to stand and required a mechanical lift for transfers, and the resident did not speak at all any longer. In an interview on 12/9/10 at 2:25 p.m. the DON said prior to 11/12/10 the facility was doing nothing to ensure Resident #1 residents received the amount of daily fluids ordered by her physician. In an interview on 12/12/10 at 2:00 p.m. CNA 'C' said Resident #1 always needed assistance with eating and drinking, but did drink well when she was offered a drink, even before the resident was admitted to the hospital on [DATE]. Resident #2 Review of Resident #2's admission face sheet dated 11/25/09 revealed this male resident was admitted to the facility on [DATE]. Resident #2 was [AGE] years old at the time of this investigation. Review of Resident #2's consolidated physician orders [REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. The resident's cognitive skills for daily decision making were moderately impaired. Resident #2 experienced periods of inattention and disorganized thinking. The resident experienced trouble concentrating on things such as reading the newspaper or watching television. The resident's wandering behaviors occurred daily. For most activities of daily living Resident #2 required only minimal help. He was, however frequently incontinent of bladder and always continent of bowel. Review of Resident #2's Plan of Care dated 7/20/10 and continued on 10/25/10 revealed the facility had identified the problem of socially inappropriate sexual advances. Goals set for Resident #2 were for him to refrain from this behavior for 90 days. Approaches and interventions included redirection of the resident at each episode, assisting the resident with redressing when needed, providing privacy to maintain dignity, providing diversion activities when needed to redirect behaviors, notifying the resident's family of inappropriate behaviors, and notifying the social worker when needed. Review of Resident #2's Social Progress Notes dated 8/07/09 at 10:00 a.m. revealed the social worker (SW) documented he received a note from a nurse working on the Alzheimer's unit stating the resident had made a comment to another resident in regards to "killing himself ". The SW stated information related to Resident #2's comment was reported to the DON and the ADON. The SW documented he directly asked Resident #2 if he was thinking about killing himself and Resident #2 responded stating he thinks about death, further stating that he's [AGE] years old and feels his family has abandoned him. The SW documented he communicated openly with the nursing staff on duty, and offered input for attention to the resident's need for safety. Review of Resident #2's Social Service Progress Notes dated 8/07/09 revealed the SW had discussed Resident #2's suicidal statement with the resident's family. The SW stated he discussed with Resident #2's family the possibility of Resident #2 needing a psychiatric evaluation "at the next possible time when the psychiatrist was in the building." The SW stated the family was "accommodating and agreeable to having psychiatric intervention as needed." The SW documented his recommendation for a psychiatric consult with psychiatrist as soon as possible to assess for mood and/or thought disorder. The SW worker documented his recommendation that prudent care should be taken with Resident #2 due to at least one prior incident of suicidal ideation, in combination with the age of Resident #2, and cognitive impairment associated with [MEDICAL CONDITION]. Review of Resident #2's Quarterly/Annual Review-Progress Note dated 1/ 26/10 revealed Resident #2 did not directly pose any threat for self harm, however it was prudent to monitor his daily activities as his personal judgment and orientation could have become altered at any given time due to the disease process. Review of Resident #2's Quarterly/Annual Review- Progress Note dated 4/27/10 revealed Resident #2 was compliant and passive in nature, but had at least one experience in which he walked into a female residents room. The facility documented Resident #2 comprehended that his judgment and decision making ability were poor and often caused him frustration. Review of Resident #2's physician progress notes [REDACTED]. The physician documented after reviewing the nurse's notes, "Resident #2 has engaged in inappropriate behavior. He has wandered into a female resident's room and touched her groin area." Review of Resident #2's Quarterly/Annual Review-Progress Note dated 7/20/10 revealed, "On at least one occasion Resident #2 has been observed interacting with a female resident in a suspiciously sexual nature, i.e. in her room with his pant unzipped, etc. Resident #2 requires close observation and frequent checks in order to prevent any undue incidents involving the residents and other residents." Review of Resident #2's Social Service Progress Notes dated 10/11/10 revealed, "SW is informed by nurse on duty that Resident #2 had 'touched' the breast of a female resident. At that time the nurse stated he had already confronted the resident, however felt the SW should provide confrontation since this type of behavior has been a problem with Resident #2 prior to today. SW met with Resident #2 privately in his room and verbalized the necessity for Resident #2 to cease touching the other residents, and unwanted sexual advances are not tolerated in the facility. Resident #2 had a dejected or sad affect when he was confronted about the behavior." Review of Resident #2's Abnormal Behavior Pattern Monitoring (ABPM) from 5/26/10 through 12/08/10 revealed: -- on 5/26/10 Resident #2 had behaviors identified as "sexually acting out". Interventions: 15 minute checks and frequent monitoring. -- on 6/23/10 Resident #2 had behaviors identified as "promiscuity with female residents". Interventions: Frequent checks and close monitoring of where Resident #2 is on the unit. -- on 6/30/10 Resident #2 had behaviors identified as "promiscuity with female residents". Interventions: SW confrontation of behaviors. -- on 8/11/10 revealed Resident #2 had behaviors identified as "Enticing female resident into room (possible sexual intent)". Interventions: SW notified, discussed intervention with ADON, heightened monitoring, Confrontation's 2 times weekly or when needed. -- on 10/06/10 Resident #2 had behaviors identified as "Attempting to engage other resident in sex". Intervention: ADON/ SW meeting with unit nurse and resident. -- on 10/13/10 revealed Resident #2 had behaviors identified as "Inappropriate touching with female resident". Intervention: None listed. -- on 12/08/10 revealed Resident #2 had behaviors identified as "Inappropriate touching with female CNA". Intervention: SW conference with Resident #2's son, confrontation of Resident #2. There was no documentation of any psychiatric evaluation despite multiple episodes of inappropriate sexual behavior. Review of Resident #2's nursing notes revealed: -- on 9/29/10 at 4:30 p.m. the nurse documented "Another female resident came to the nurse's station crying almost hysterically. When the unidentified female resident was asked what was wrong, the female resident stated, 'That man came into my room and pushed me into the closet. I kept trying to get away and he kept pushing me back' The female resident was taken out into the hall and asked to point out which male resident it was, and pointed to Resident #2 standing in the hallway close to the female's room." The nurse's note further stated that Resident #2 was observed on two other occasions that evening to attempt to go into other residents rooms. The nursing note did not identify the female resident. -- on 9/30/10 at 8:00 p.m. the nurse documented while a CNA was assisting a unidentified female resident with preparing for bed, Resident #2 walked into the female resident's room. The female resident became "teary-eyed and frightened". Resident #2 was asked to leave the room. -- on 10/4/10 the nurse documented "Resident #2 was seen outside in the patio area interacting inappropriately with a female resident. ADON saw him." (Female resident was later identified to be Resident #11). -- 10/20/10 on (2-10 shift) the nurse documented "Going into other resident's rooms constantly, Redirection not effective " -- on 11/04/10 at 3:45 p.m. the nurse documented an unidentified female resident complained Resident #2 grabbed her breast. Resident #2 was observed at the far end of the hallway, from the area that the unidentified female resident was coming from. The unidentified female resident was noted to be agitated due to the incident. (Female resident later identified as Resident #12). -- on 11/15/10 at 7:00 p.m. the nurse documented an unidentified female resident complained Resident #2 attempted to force her hands down his pants. (Female resident later identified as Resident #11). In an interview on 11/18/10 at 11:15 a.m. the administrator and the DON said they had no knowledge of sexual allegation or physical contact between Resident #2 and Resident #12. They both said the staff had not reported anything to them about the incident. In an interview on 11/18/10 at 11:35 a.m. the DON said Resident #2 had been moved from his room near the end of the hall, to the room next to the nurse's station due to making advances towards female residents. Resident #2 had been found on one occasion in his room with his pants down and attempting to lure Resident #13 into his room. In an interview on 11/18/10 at 2:30 p.m. the ADON said the facility had not been doing incident reports on Resident #2's sexually inappropriate behaviors. The ADON said she was not aware Resident #2 had more episodes of inappropriate behaviors with females after the incident with Resident #13. In an interview on 11/18/10 at 3:00 p.m. the DON said the facility had not contacted Resident #2's physician or family regarding each incident of social/sexual inappropriate behaviors. However the physician was aware Resident #2 had inappropriate behaviors. She stated she had not wanted to contact Resident #2's wife due to her being sick, and not wanting to upset her. Review of a Facility Incident/Accident Report dated 12/05/10 at 10:15 a.m. revealed Resident #2 was being assisted to shave by a female CNA. While the CNA was assisting Resident #2 with shaving, Resident #2 attempted to touch the female staff member between her legs. The CNA asked Resident #2 to keep his hands to himself and Resident #2 attempted to touch the female staff between her legs again. In an interview on 12/09/10 at 2:50 p.m. LVN 'B' said she felt Resident #2's Care Plan was effective approximately 50 to 75% of the time. LVN 'B' was asked how the staff was managing Resident #2's care for the 25 to 50% of the time his Care Plan was not effective. She stated, " Resident #2 is very random. We try to redirect his behaviors when they occur. She stated she felt Resident #2 was 'very predatory' and seems to 'seek out' the female residents that are smaller and weaker than he is. She stated she felt it was more important to redirect the female residents away from Resident #2 in order to keep them safe from his sexual behaviors. In an interview on 12/10 /10 at 10:00 a.m. the administrator said the problems with Resident #2 were due to Resident #2 thinking the female residents on the unit were his wife. When asked if the physicians and families of the female residents( Resident # 11, #12, #13) who had been accosted by Resident #2 had been notified of the incidents, the administrator said, "It's not like he penetrated one of them. They forgot about the entire incident within 30 minutes." In an interview on 12/10/10 at 10: 45 a.m. the social worker said he was aware of Resident #2 having social/sexual inappropriate behaviors. He was asked if he felt Resident #2's care plan was effective regarding social/sexual inappropriate behaviors. He said he felt the care plan needed to be updated to reflect the interventions the facility had put in place for Resident #2. The social worker was asked if the facility preformed Mini-Mental State Examinations (MMSE) or had any evaluation tools to determine the severity of the resident's cognitive impairment. He stated he preformed MMSE when the nursing staff requested one done on a resident. He was asked if it was social services responsibility to assist with residents receiving psychiatric consults. He said if he felt one of the residents required a psychiatric consult he passed the information on to the nursing department and they in turn requested the physician orders [REDACTED].#2's chart were he had noted recommending Resident #2 be evaluated by a psychiatrist and if so was he aware if Resident #2 had been evaluated by a psychiatrist. He stated he remembered making the recommendation for a psychiatric consult to LVN 'C' , and he wasn't aware if LVN 'C' had requested the physician order [REDACTED]. In a telephone interview on 1213/10 at 10:35 a.m. Resident #2's physician said up to the time of her recent visit to the facility on [DATE] she had the impression the staff had been successfully redirecting Resident #2 when staff observed him attempt inappropriate behavior. The physician said when she recently reviewed the resident's nursing notes she became aware the resident was continuing to have inappropriate behaviors, and she increased the resident's psychoactive medication. She said she did not recall the facility consulting her about a psychiatric evaluation for Resident #2, but would have approved the request if she had known about it. Facility Plan of Removal of Immediate Jeopardy On 12/14/10 at 2:45 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Enforcement Coordinator. According to this plan, the facility determined on 11/12/10 (after the surveyor entered the facility to investigate an allegation of dehydration) it had not been correctly monitoring Resident #1's hydration. The plan documented all residents were assessed for dehydration on 12/12/10. The facility determined it's hydration policy had been inadequate to ensure residents remained well hydrated, so a new policy was written and put into effect. Staff inservice on the new hydration policy began on 12/12/10 and was completed on 12/14/10. The plan documented all newly admitted residents were to be monitored for 72 hours to determine whether they were at risk for dehydration and a plan of care for hydration was to be established within 72 hours following the determination of a resident's risk of dehydration. Review of the inservice records revealed on 11/20/10 40 staff members, licensed and unlicensed, received training on resident hydration and on intake documentation. Review of the facility's newly written hydration policy revealed residents were to be offered 360 cc to 480 cc of fluids at each meal as determined by each resident's dietician evaluation of fluid needs. Fluid intake for at risk residents was to be documented each shift, reviewed by charge nurses, and monitored by the DON and ADON. Review of the Plan of Removal of Immediate Jeopardy revealed the following documentation tools were to be used in the facility: a dehydration risk appraisal checklist, a new fluid intake/output worksheet, a new weekly intake/output monitoring form, and a new checklist to evaluate for the signs and symptoms of dehydration. Review of an inservice training record dated 12/12/10 revealed licensed and unlicensed staff were trained on the use of the new hydration policy and procedures. According to the Plan of Removal of Immediate Jeopardy, the DON consulted with Resident #2's physician on 12/9/10 regarding the resident's inappropriate sexual behaviors. The plan documented the physician ordered an increase with 1 of the resident's psychoactive medications ([MEDICATION NAME]). On 12/11/10 the facility started 1-on-1 supervision of Resident #2. This supervision was to be continuous, round the clock, 24 hours a day, 7 days a week. On 12/12/10 the resident's physician ordered the facility to administer to the resident the drug Depo-[MEDICATION NAME] to treat his sexual behaviors. The initial dose was administered on 12/12/10 at 12:50 a.m. The ADON was to review Resident #2's chart daily for further incidents of inappropriate behaviors. According to the Plan of Removal of Immediate Jeopardy, the DON conducted inservice training for administrative nurses on the subject of sexual misconduct. Review of the Plan of Removal of Immediate Jeopardy revealed the facility adopted a new or revised policy entitled Residents with Sexually Aggressive Behaviors. According to this policy, the facility nurses were to complete an incident report and an administrative nurse will conduct an investigation when sexual conduct occurred between resident who were of diminished mental capacity. A review of this inservice attendance record revealed 6 administrative nurses received this training. Plan of Removal Verification Facility staff were interviewed on 12/14/10 concerning the inservice training related to resident hydration. All staff interviewed confirmed they received the inservice and communicated knowledge of the facility's policy on resident hydration Observations revealed staff were providing fluids from a hydration cart and at meals. The Immediate Jeopardy was lowered to actual harm prior to the exit on 12/14/10 at 2:45 p.m. According to a list provided by the facility there were 2 residents with a physician order [REDACTED]. In an observation on 12/14/10 at 10:00 a.m. Resident #2 was observed to be resting in his room. The facility had provided a personal sitter who was seated in a chair outside Resident #2's room with Resident #2 in his line of site. Resident #2's sitter was observed to document Resident #2's whereabouts on a 15 minute basis. In an interview on 12/14/10 at 10:15 a.m. Resident#2's personal sitter said he was to have Resident #2 in his line of site at all times. Resident #2's sitter stated he was to report all care needs to the LVN or CNA, his duty was to watch Resident #2 and alert the staff of any abnormal behaviors. In an interview on 12/14/10 at 10:20 a.m. with LVN 'D" revealed the staff had been inserviced on how to monitor resident's