Every finding on record at Chateau Terrebonne Health Care Center

Based on interviews and record reviews, the facility failed to ensure a resident's medication administration was accurately documented for 3 (Resident #9, Resident #88, Resident #98) of 3 sampled residents investigated for accurate medication administration documentation. Findings:Review of the facility's Charting and Documentation policy and procedure, revised on 07/2017, revealed, in part, documentation in the medical record would be complete and accurate. Review of the facility's Administrating Medications policy and procedure, revised on 04/2019, revealed, in part, the individual that administered medication should sign on the resident's Electronic Medical Administration Record (eMAR) after giving each medication and before administering the next ones. On 05/06/2026 at 11:00AM, S2Director of Nursing (DON) was presented with a request for all February 2026 and March 2026 medication administration records for Resident #9, Resident #88, and Resident #98. Resident #9Review of Resident #9's medical record revealed, in part, Resident #9 was admitted to the facility on [DATE] with diagnoses which included hyperlipidemia (an excess of fat in the blood), allergic rhinitis (inflammation of the nasal mucosa related to allergies), gastro esophageal reflux disease (GERD) (excess stomach acid in the throat), psychosis, insomnia, type 2 diabetes, deep vein thrombosis (DVT) (blood clot), overactive bladder, and chronic obstructive pulmonary disease. Review of Resident #9's May 2026 physician's orders revealed, in part, an order for the following:- Atorvastatin (a medication used to treat excess fat in the blood) oral tablet 40 milligram (mg) one tablet by mouth at bedtime;- Cetirizine Hydrochloride (HCl) (a medication used to treat allergic rhinitis) oral tablet 10 mg one tablet by mouth at bedtime;- Famotidine (a medication used to treat GERD) oral tablet 20 mg one tablet by mouth at bedtime;- Olanzapine (a medication used to treat psychosis) oral tablet 5 mg one tablet by mouth at bedtime;- Trazodone HCl (a medication used to treat insomnia) oral tablet 150 mg one tablet by mouth at bedtime;- Rivaroxaban (a mediation used to treat DVT) oral tablet 20 mg one tablet by mouth in the evening;- Metformin HCl (a medication used to lower blood glucose levels) oral tablet 500 mg one tablet by mouth two times a day;- Oxybutynin Chloride (Cl) (a medication used to treat overactive bladder) oral tablet 5 mg one tablet by mouth two times a day;- Budesonide-formoterol fumarate dihydrate (a medication used to treat COPD) inhalation aerosol 80-4.5 micrograms (mcg)/actuation two inhalations orally two times a day; and,- Insulin aspart (a medication used to lower blood glucose levels) 100 units/milliliters (ml) inject on a sliding scale (amount of medication to be administered determined after resident's capillary blood glucose level was obtained). Review of Resident #9's February 2026 through March 2026 eMAR revealed, in part, no documented evidence Resident #9 was administered rivaroxaban one 20 mg oral tablet on 02/18/2026 and 02/24/2026 at 5:00PM as ordered.Further review revealed no documented evidence Resident #9 was administered the following medications on 02/18/2026, 02/24/2026, and 03/12/2026 at 8:00PM as ordered:- Atorvastatin Calcium one 40 mg oral tablet;- Cetirizine Hydrochloride one 10 mg oral tablet;- Famotidine one 20 mg oral tablet;- Olanzapine one 5 mg oral tablet;- Trazodone HCl one 150 mg oral tablet;- Metformin HCl one 500 mg oral tablet;- Oxybutynin Cl one 5 mg oral tablet; and,- Budesonide-formoterol fumarate dihydrate inhalation aerosol 80-4.5 mcg/act 2 inhalations orally.Further review revealed no documented evidence Resident #9's capillary blood glucose was checked on 02/18/2026 at 4:00PM and/or 8:00PM, and/or on 02/24/2026 and 03/12/2026 at 8:00PM as ordered. Resident #88Review of Resident #88's medical record revealed, in part, Resident #88 was admitted to the facility on [DATE] with diagnoses which included hyperlipidemia, type 2 diabetes mellitus, heart attack, and hypercholesterolemia (an excess of cholesterol in the blood). Review of Resident #88's May 2026 physician's orders revealed, in part, an order for the following:- Atorvastatin calcium oral tablet 80 mg one tablet by mouth at bedtime;- Insulin degludec (a medication used to lower blood glucose levels) 200 units/ml inject 10 units subcutaneously at bedtime; - Insulin aspart 100 units/ml inject on a sliding scale;- Apixaban (a medication used to treat blood clots) oral tablet 5 mg by mouth two times a day;- Omega-3 fatty acid (a medication used to treat excess cholesterol in the blood) oral capsule 1000 mg one capsule by mouth two times a day; - Carvedilol (a medication used to treat high blood pressure) oral tablet 25 mg one tablet by mouth two times a day; and,- Metformin HCl oral tablet 1000 mg one tablet by mouth two times a day. Review of Resident #88's February 2026 through March 2026 eMAR revealed, in part, no documented evidence Resident #88 was administered carvedilol oral tablet 25 mg by mouth on 02/14/2026 and 02/18/2026 at 4:00PM as ordered. Further review revealed no documented evidence Resident #88 was administered metformin HCl on 02/17/2026 and 02/18/2026 at 5:00PM as ordered. Further review revealed no documented evidence the following medications were administered to Resident #88 on 02/18/2026, 02/24/2026, and/or 03/12/2026 at 8:00PM as ordered:- Atorvastatin calcium oral tablet 80 mg one tablet by mouth;- Insulin deglu[DATE] units/ml inject 10 units subcutaneously; - Apixaban oral tablet 5 mg by mouth; and,- Omega-3 fatty acid oral capsule 1000 mg one capsule by mouth.Further review revealed no documented evidence Resident #88's capillary blood glucose level was obtained at 4:00PM on 02/17/2026 and 02/18/2026 as ordered. Resident #98Review of Resident #98's medical record revealed, in part, Resident #98 was admitted to the facility on [DATE] with a diagnosis which included major depressive disorder with psychotic symptoms. Review of Resident #98's May 2026 physician's orders revealed, in part, an order for the following:- Donepezil HCl (a medication used to treat dementia/cognitive impairment) oral tablet 5 mg one tablet by mouth at bedtime; and,- Olanzapine (a medication used to treat psychotic symptoms) oral tablet 15 mg one tablet by mouth at bedtime. Review of Resident #98's February 2026 through March 2026 eMAR revealed, in part, no documented evidence the following medications were administered to Resident #98 on 02/18/2026, 02/24/2026, and/or 03/12/2026 at 8:00PM as ordered:- Donepezil HCl oral tablet 5 mg one tablet by mouth; and,- Olanzapine oral tablet 15 mg one tablet by mouth. In an interview on 05/06/2026 at 11:30AM, S2DON confirmed the above mentioned resident's February 2026 and March 2026 eMARs were not accurate and complete, and should have been. In an interview on 05/06/2026 at 1:00PM, S1Administrator indicated the facility could not provide any documented evidence to dispute the above mentioned deficient practice.

Based on observations, interview, and record review, the facility failed to ensure the resident's environment was clean and sanitary for 1 (Resident #95) of 32 sampled residents reviewed for environmental concerns during initial pool observations. Findings:Review of the facility's Quality of Life Homelike Environment Policy, with a revision date of May 2017, revealed, in part, the facility would ensure a homelike environment which would include a clean, sanitary and orderly environment. Observation on 05/03/2026 at 10:51AM revealed, in part, the base of Resident #95's tube feeding pole was covered with an unidentified dry white and tan substance. Observation on 05/04/2026 at 10:30AM revealed, in part, ten to fifteen spots of an unidentified dried sticky tan substance to the base of Resident #95's tube feeding pole varying in size. Observation on 05/05/2026 at 2:32PM revealed, in part, ten to fifteen spots of an unidentified dried sticky tan substance to the base of Resident #95's tube feeding pole varying in size. In an interview on 05/05/2026 at 3:03PM, S2Director of Nursing (DON) confirmed Resident #95's tube feeding pole base had a dried sticky substance and was not maintained in a sanitary manner as required. S2DON further indicated resident equipment should be maintained in a clean and sanitary manner at all times.

Based on interviews and record review, the facility failed to ensure unnecessary medications were reduced and failed to ensure physician-accepted gradual dose reduction (GDR) recommendations made by the consultant pharmacist were implemented for 1 (Resident #7) of 5 sampled residents reviewed for unnecessary medications. Findings:Review of the facility's Administering Medications policy and procedure, revised 04/2019, revealed medications are to be administered in accordance with physician orders. Review of the Pharmaceutical Consultant Report - Psychoactive GDR form dated 01/07/2026 revealed the consultant pharmacist recommended a dose reduction for duloxetine (medication used to treat major depressive disorder) 30 milligrams (mg) at bedtime. Review of Resident #7's physician orders revealed a physician's order dated 01/19/2026 to discontinue duloxetine 30mg at bedtime. Review of Resident #7's active physician orders dated 05/01/2026 revealed duloxetine 30mg at bedtime remained an active order. Review of Resident #7's Medication Administration Record (MAR) dated 05/01/2026 through 05/31/2026 revealed duloxetine 30mg continued to be administered on 05/01/2026, 05/02/2026, 05/03/2026, and 05/04/2026. Review of survey documentation and records provided by the facility failed to reveal evidence the consultant pharmacist identified, reported, or followed up regarding the continued administration of duloxetine after the physician accepted the GDR recommendation and ordered the medication discontinued on 01/19/2026. In an interview on 05/05/2026 at 12:37PM, S2Director of Nursing confirmed the physician accepted the consultant pharmacist's recommendation to discontinue duloxetine 30mg at bedtime; however, the medication continued to be administered and remained active in the resident's orders. S2Director of Nursing further confirmed no additional documentation was available showing the consultant pharmacist identified or followed-up on the continued administration of the medication after the discontinuation order was written.

Based on interviews and record reviews, the facility failed to complete a care plan conference for 1 (Resident #119) of 1 (Resident #119) sampled residents investigated for care planning. Findings: Review of the facility's Resident Participation in Assessment and Care Plan policy, revised December 2016, revealed, in part, a comprehensive care plan was developed within 7 days of completion of the resident assessment and a 7 day advance notice of the care planning conference was provided to the resident and his or her representative. Review of Resident #119's record revealed no documented evidence, and the facility did not present any documented evidence, evidence a care plan conference had been completed after the completion of the MDS on 04/04/2025. In an interview on 05/18/2025 at 11:59AM, Resident #119 indicated he had not participated in a care plan conference. In an interview on 05/19/2025 at 11:29AM, S8Minimum Data Set Nurse (MDS Nurse) indicated Resident #119 had a MDS assessment completed on 04/04/2025 and should have had a care plan conference. S8MDS nurse indicated Resident #119's last scheduled care plan conference was on 10/03/2025. In an interview on 05/20/2025 at 12:19AM, S2Quality Improvement (QI) Nurse indicated Resident #119 should have had a care plan conference after the Minimum Data Set (MDS) Assessment on 04/04/2025. S2QI Nurse confirmed Resident #119 did not have a scheduled care plan conference in April 2025

Based on observation, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #143) of 1 (Resident #143) sampled residents reviewed for accident hazards. Findings: Review of the facility's Self-Administration of Medications policy and procedure revised on 12/2016 revealed, in part, the interdisciplinary team would assess each resident's cognitive and physical abilities to determine whether self-administration of medications was safe and clinically appropriate for the resident. Further review revealed any medications found at the bedside that were not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party. Review of Resident #143's clinical record revealed Resident #143 was admitted to the facility on [DATE]. Review of Resident #143's Quarterly Minimum Data Set with an Assessment Reference Date of 03/18/2025 revealed, in part, Resident #143 had a Brief Interview of Mental Status score of 6, which indicated Resident #143 had severe cognitive impairment. Review of Resident #143's May 2025 Physician's Orders revealed, in part, no documented evidence of an order for Resident #143 to self-administer medications. Observation on 05/18/2025 at 10:25AM revealed a bottle of Polyvinyl Alcohol 1.4% Lubricating Eye Drops and Systane Lubricant Eye Drops (medicated eye drops used to relieve dry eyes) were on Resident #143's bedside table. Further observation revealed the bottle of Polyvinyl Alcohol 1.4% Lubricating Eye Drops had an expiration date of 07/2024. In an interview on 05/18/2025 at 10:25AM, Resident #143 indicated she self-administered the above mentioned eye drops once or twice a day. Review of Resident #143's clinical record revealed no documented evidence, and the facility did not present any documented evidence Resident #143 was assessed and/or authorized to self-administer medications. In an interview on 05/19/2025 at 10:12AM, S6Licensed Practical Nurse (LPN) indicated the above mentioned medications should not have been at Resident #143's bedside and available for self-administration. In a telephone interview on 05/19/2025 at 10:42AM, Resident #143's son indicated his mother had eye drops at her bedside since she was admitted to the facility. In an interview 05/20/2025 at 2:10PM, S1Assistant Administrator indicated Resident #143 should not have had the above mentioned medications at her bedsides and available for self-administration.

Based on interviews and record reviews, the facility failed to provide the resident or responsible party (RP) with written notice which specified the duration of the bed-hold policy at the time of transfer to the hospital for 2 (Resident #16, Resident #86) of 2 (Resident #16, Resident #86) sampled residents investigated for hospitalizations. Findings: Review of the facility's Bed Hold and Returns policy, revised on 04/16/2024, revealed, in part, when a resident was transferred to the hospital, or goes out on therapeutic leave, a copy of this form (Notice of Hospital Transfer/Therapeutic Leave) was sent with the resident, and the resident representative will be notified specifying the duration of the bed-hold according to state plan, and the facilities policy regarding bed-hold periods. In cases of emergency transfer, notice at the time of transfer means that the family or resident representative are provided with written notification within 24 hours of the transfer. Resident #16 Review of Resident #16's record revealed no documented evidence, and the facility was unable to present any documentation showing that Resident #16 and Resident #16's responsible party had received written notification of the bed hold policy when admitted to the hospital on [DATE]. In an interview on 05/20/2025 at 9:45AM, S1Assistant Administrator indicated the facility did not provide residents with the Notice of Hospital Transfer/Therapeutic Leave policy upon hospital admissions. S1Assistant Administrator confirmed Resident #16 was not provided a copy of the Notice of Hospital Transfer/Therapeutic Leave when Resident #16 was admitted to the hospital on [DATE]. Resident #86 Review of Resident #86's record revealed no documented evidence, and the facility was unable to present any documentation showing that Resident #86 and Resident #86's responsible party had received written notification of the bed hold policy when admitted to the hospital on [DATE]. In an interview on 05/20/2025 at 2:05PM, S1Assistant Administrator indicated Resident #86 was not provided a copy of the Notice of Hospital Transfer/Therapeutic Leave when Resident #86 was admitted to the hospital on [DATE].

Based on interviews, and record reviews, the facility failed to complete quarterly safe smoking assessments for 1 (Resident #11) of 1 (Resident #11) sampled residents investigated for smoking. Findings: Review of the facility's policy and procedure titled, Smoking Policy-Resident, dated 2001 and revised on 03/08/2023, revealed once the resident was determined to be a smoker, his/her ability to smoke safely would be evaluated upon admission, with subsequent Minimum Data Set (MDS) assessment and as needed. Review of Resident #11's annual MDS with an assessment reference date (ARD) of 09/16/2024 revealed Resident #11 used tobacco. Review of the facility's list of smoker's documentation revealed, in part, Resident #11 was determined to be a smoker. Review of Resident #11's medical record revealed the last Safe Smoking Assessment document was completed on 09/16/2024 with Resident #11's Annual MDS. Further review revealed a Quarterly MDS with an ARD of 12/15/2024 and a Quarterly MDS with an ARD of 03/13/2025 was completed. In an interview on 05/19/2025 at 10:36AM, S7 MDS Coordinator indicated the Safe Smoking Assessment document was completed on admit, quarterly with MDS assessment, and as needed. S7MDS Coordinator confirmed the last Safe Smoking Assessment completed in Resident #11's medical record was on 09/16/2024, and Resident #11 should have had a Safe Smoking Assessment completed with the 12/15/2024 MDS and the 03/13/2025 MDS. In an interview on 05/19/2025 at 11:05AM, S3Director of Nursing (DON) indicated Safe Smoking Assessments were completed quarterly with MDS assessments. S3DON further indicated Resident #11 should have had quarterly Safe Smoking Assessments completed since 09/16/2025. There was no documented evidence and the facility failed to present documented evidence a Safe Smoking Assessment document was completed for Resident #11 for December 2024 and March 2025.

Based on record reviews, observations, and interviews, the facility failed to assess residents for self-administration of drugs for 2 (Resident #9 and Resident #61) of 29 (Resident #2, Resident #9, Resident #22, Resident #25, Resident #26, Resident #29, Resident #30, Resident #36, Resident #43, Resident #54, Resident #55, Resident #61, Resident #73, Resident #77, Resident #84, Resident #90, Resident #96, Resident #109, Resident #113, Resident #121, Resident #122, Resident #127, Resident #135, Resident #138, Resident #139, Resident #140, Resident #197, Resident #297, and Resident #397) sampled residents. Findings: Review of the facility's Self-Administration of Medications policy, revised December 2016, revealed, in part, residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. Resident #9 Review of Resident #9's record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of, in part, Osteoarthritis, Dysphagia and Hypertension. Review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/2024 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #9 had moderately impaired cognition. Observation on 05/06/2024 at 10:55 a.m. revealed a disposable medicine cup which contained 7 pills was on Resident #9's overbed table. In an interview on 05/06/2024 at 10:55 a.m., Resident #9's family member stated Resident #9's medications are often left at the bedside. Observation on 05/07/2024 at 9:56 a.m. revealed a disposable medicine cup which contained 8 pills was on Resident #9's overbed table. Observation on 05/07/2024 at 12:02 p.m. revealed a disposable medicine cup which contained 8 pills was on Resident #9's overbed table. Observation on 05/07/2024 at 12:21 p.m. revealed Resident #9 self-administered 6 of the 8 medicines in the disposable medicine cup. In an interview on 05/07/2024 at 12:21 p.m., Resident #9 stated she did not take 2 of the medicines because they give her heartache. In an interview on 05/07/2024 at 12:29 p.m., S5Certified Nursing Assistant (CNA) stated he had observed medications in Resident #9's room, and Resident #9 chose the medications she wanted to take. In an interview on 05/07/2024 at 12:51 p.m., S6Licensed Practical Nurse (LPN) confirmed there were 2 pills in Resident #9's room in a disposable medicine cup. S6LPN identified the pills as a garlic pill and Zoloft 25milligram (a medication used for depression). S6LPN stated Resident #9's medications should not be left at the bedside. In an interview on 05/08/2024 at 12:01 p.m., S1Director of Nursing (DON) stated Resident #9's medications should not have been left at the bedside. Resident #61 Resident #61 was admitted to the facility on [DATE] with diagnoses of, in part, Diabetes, End Stage Renal Disease, Chronic Kidney Disease, and Hypertension. Review of Resident #61's May 2024 electronic Medication Administration Record (eMAR) revealed an order for 4 Sevelamer (a phosphate binder) 800mg tablet to be administered at 5:00 a.m., 1:00 p.m., and 5:00 p.m. Review of Resident #61's MDS with an ARD of 04/13/2023 revealed, in part, a BIMS score of 15, which indicated Resident #61 had intact cognition. Observation on 05/07/2024 at 12:06 p.m. revealed a disposable medicine cup which contained 2 pills was on Resident #61's overbed table. In an interview on 05/07/2024 at 12:06 p.m., Resident #61 stated the pills in the disposable medicine cup were phosphate binders (a medicine used to lower high blood phosphorus levels in patients who are on dialysis due to severe kidney disease). Resident #61 stated the nurse left the phosphate binders at his bedside for Resident #61 to self-administer the medications with his lunch. In an interview on 05/07/2024 at 1:06 p.m., S6LPN stated Resident #61 had a physician's order for 4 tablets of Sevelamer 800mg. S6LPN indicated she had administered 2 of the 4 tablets to Resident #61 and left the remaining 2 tablets with Resident #61 to self-administer with his lunch. In an interview on 05/08/2024 at 12:01 p.m., S1DON indicated medications should not be left at the bedside for Resident #61. In an interview on 05/08/2024 at 12:47 p.m., S2Quality Improvement Nurse indicated Resident #9 and Resident #61 were not assessed for self-administration of medications.

Based on record reviews, observation, and interviews, the facility failed to ensure a resident's tracheostomy care was completed in a sanitary manner for 1 (Resident #90) of 1 (Resident #90) sampled residents investigated for mechanical ventilation and tracheostomy care. Findings: Review of Resident #90's Minimum Data Set with an Assessment Reference Date of 04/21/2024 revealed, in part, Resident #90 had diagnoses of cardiorespiratory conditions and chronic respiratory failure with hypoxia. Further review revealed Resident #90 received tracheostomy care and invasive mechanical ventilation. Review of Resident #90's May 2024 physician's orders revealed, in part, an order for Resident #90 to receive tracheostomy care twice per day. Further review revealed an order to change Resident #90's disposable inner cannula once per day. Review of Resident #90's care plan for ventilator dependence revealed, in part, interventions for Resident #90 to receive tracheostomy care twice in a 24-hour period and Resident #90's inner cannula to be changed once in a 24-hour period or more as necessary. Observation of Resident #90's tracheostomy care on 05/08/2024 at 9:04 a.m. revealed S3RespiratoryTherapist (RT) opened the inner cannula package, and the inner cannula fell out of the package onto Resident #90's bed linen. S3RT then removed Resident #90's existing disposable inner cannula. Further observation revealed S3RT picked up the new inner cannula off Resident #90's bed linen and inserted the inner cannula into Resident #90's tracheostomy stoma. In an interview on 05/08/2024 at 9:51 a.m., S3RT confirmed Resident #90's inner cannula had fallen out of the package prior to the insertion of the inner cannula into Resident #90's tracheostomy stoma. S3RT confirmed she should have obtained a new inner cannula to insert into Resident #90's tracheostomy stoma. In an interview on 05/08/2024 at 9:53 a.m., S4RespiratoryDirector confirmed S3RT should not have placed Resident #90's inner cannula into her tracheostomy stoma after it had fallen on Resident #90's bed. S4Respiratory Director confirmed S3RT should have obtained a new inner cannula.

Based on observation, record review, and interview the facility failed to ensure the menu prescribed by the registered dietician was followed for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for dietary services. Findings: Review of the facility's Menu revealed, in part, Monday's supper was to consist of tomato soup, hot ham and cheese sandwich; cucumber/onion salad; melon cubes, beverage, and grapes and orange slices. In an interview on 07/25/2023 at 4:40 p.m., Resident #2 stated the CNA last night told him the kitchen had ran out of the sandwiches so he would not be receiving one. Resident #2 further stated S4Licensed Practical Nurse (LPN) asked what was wrong when she came to check on me and she was able to get me a peanut butter and jelly sandwich. Resident #2 stated they post our menus every day and quite often what is on the menu the facility runs out of. Review of the facility's Menu revealed, in part, Tuesday's supper was to consist of shrimp etouffee, fluffy rice; breaded zucchini sticks; tossed salad, dressing of choice; dulce de leche brownie; and assorted beverage. Observation on 07/25/2023 at 5:27 p.m. revealed Resident #2's meal tray had shrimp stew, salad, dulce de leche brownie, and beverages. Further observation revealed no zucchini was present on Resident #2's meal tray. In an interview on 07/25/2023 at 5:27 p.m., Resident #2 stated he was not brought or offered zucchini. Resident #2 stated he would like zucchini. Review of Resident #2's Meal Ticket dated 07/25/2023 revealed no documented evidence for the reason as to why Resident #2 did not receive zucchini with his supper meal tray. In an interview on 07/25/2023 at 5:30 p.m., S5Certified Nursing Assistant stated the facility does not run out of food too often. S5CNA stated the kitchen they did run out of zucchini tonight and the alternate was mashed potatoes which did not go with the shrimp stew, therefore the zucchini did not have an alternative on Resident #2's plate. S5CNA stated when the facility runs out of something we were to offer the alternative, and she did not offer Resident #2 the alternative and should have. In an interview on 07/25/2023 at 5:49 p.m., S3Dietary Manager stated the kitchen should not be running out of things at all because we order so much. S3Dietary Manager stated the dietary workers did not let me know they ran out of zucchini tonight. S3Dietary Manager further stated the dietary workers should have called the main kitchen to have more of the zucchini sent over. In an interview on 07/25/2023 at 6:12 p.m., S6Dietary Worker stated the facility rarely run out of a food while serving, and when the facility does it was usually only a part of the meal and the facility staff will offer the alternative. S6Dietary Worker stated the facility ran out of ham and turkey last night and residents were offered the grilled cheese sandwich or peanut butter and jelly. S6Dietary Worker stated tonight the facility had the zucchini as a side, but the zucchini was a bit watery, so we gave salads instead. In an interview on 07/26/2023 at 9:18 a.m., Resident #R2 stated about once to twice a month a side item or something will run out and they will give us an alternative item. In an interview on 07/26/2023 at 2:26 p.m., Resident #2 stated he never received the zucchini on 07/25/2023 for supper, was brought cooked greens last night instead.

Based on observations, record reviews, and interviews, the facility failed to provide supervision to keep a resident free from elopement for 1 (Resident #96) of 10 residents (Resident #29, Resident #49, Resident #71, Resident #75, Resident #96, Resident #98 Resident #133, Resident #147, Resident #158, and Resident #159) identified at risk for elopement in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #96 with a BIMS (Brief Interview Mental Status) score of 3, which indicated Resident #96 had severely impaired cognition on 02/09/2023 when Resident #96 eloped from the facility at approximately 5:00 p.m. Staff were notified by phone at approximately 5:00 p.m. by S18Licensed Practical Nurse (LPN), that Resident #96 was in the front parking lot of the facility approximately 25 feet from the main highway. Resident #96 was assisted back into the facility immediately after receiving the phone call and no injuries identified upon assessment. S1Administrator was notified of the Immediate Jeopardy on 06/13/2023 at 12:27 p.m. The Immediate Jeopardy was removed on 06/13/2023 at 6:22 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Resident #96 was assessed on 02/09/2023 at 5:00 p.m. with no injuries noted from wandering. No additional wandering behaviors were noted at that time. Resident #96 was reassessed on 06/13/2023 at 4:44 p.m., with no additional existing behaviors noted. Resident has had a room assignment change, to be located in a high traffic area directly across from the nurse's station, for increased direct supervision from staff. Staff were in-serviced to redirect Resident #96 to an area of high traffic to be monitored by direct supervision from staff when he exhibited wandering behaviors. 2. Safe Survey Elopement Checks were conducted and completed on 06/13/2023 approximately between 9:00 a.m. and 10:30 a.m. on residents identified at risk for elopement. There were 10 total residents presently at risk for elopement that were all present and accounted for by 10:00 a.m. on 06/13/2023. 3. Staff were in-service, including contracted staff, on identifying residents at risk for elopement, the elopement prevention protocol, the elopement reporting policy and procedures, and on the wanderguard system, this was initiated on 06/13/2023 at 11:30 a.m., and would be completed by 06/16/2023 by 6:00 p.m. Staff that were not in-serviced would not be permitted to work until in-serviced. On 06/13/2023, the social worker composed a letter to residents and their responsible parties regarding the use of facility doors that required codes as of 06/14/2023. It addressed not letting other residents exit with them and to notify staff of any incidents of the alarm sounding or other residents trying to exit with them. On 06/13/2023 as of 5:30 p.m., facility door codes were changed and only designated staff would have access to facility door codes. The facility's main entrance would be designated as an entrance/exit for residents and family member. As of 06/13/2023, a staff member would be designated to supervise this entrance with shifts of 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. In-serviced staff were not to share code. Designated staff would allow entrance and exit to the facility. Monitored use of code by observation 15 minutes a day, 3 days a week for 4 weeks ending on 07/11/2023. Every two hours monitoring of resident's that were at risk for elopement. Assessed residents at risk for elopement would determine if increased supervision was needed, on a resident by resident basis, completed on 06/13/2023 by 5:00 p.m. After assessments completed, if determined the need of increased supervision for resident, it would be initiated on the residents that demonstrated increased wandering behaviors at the time. At the time the resident displayed the behaviors, the resident would be moved to an area of high traffic for monitoring by direct supervision from staff. When residents started to wander, education would be initiated on redirecting resident and would provide direct supervision of resident. High Risk residents would be reassessed weekly for 4 weeks. 4. NFA or designee would perform safe survey elopement checks of residents identified at risk for elopement three times a week times for four weeks, and then weekly thereafter indefinitely. 5. The Facility Administrator would put in place an Elopement Prevention Program initiated by Administration. The Administrator would provide opportunities for staff to express concerns related to elopement risk by open door practice starting on 06/13/2023. a. The S2Director of Nursing and Administrator in-serviced all scheduled staff starting on 06/13/2023 on elopement prevention program, including contracted staff. b. All remaining employees would be in-serviced on elopement prevention program prior to the shift start, by Administrator or designee by 06/13/2023. c. Elopement Prevention Program open door practice included in orientation process for new hire and contract staff. d. Regional [NAME] President or Quality Assurance Nurse would ensure the Administrator/Designee was conducting random observation of elopement risk assessment and monitoring tool completion weekly times 30 days. e. Any negative findings from the Safe Survey Checks would be acted on by the Administrator and immediately report findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. This deficient practice had the likelihood to cause serious harm to the remaining 9 residents identified as elopement risks by the facility. Findings: Review of the facility's Wandering and Elopement Policy revealed, in part, the elopement risk tool will determine if the resident is at risk for wandering/elopement and will be completed on admission/readmission, quarterly during observation period of MDS, annual, significant changes and as needed. Review revealed, staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Review revealed, if an employee observes a resident leaving the premises he/she should: attempt to prevent the departure, get help from other staff members, instruct a staff member to inform the charge nurse or Director of Nursing that a resident has left the premises. When the resident returns to the facility, the director of nursing or charge nurse shall: notify regulatory agencies per state guidelines as indicated. Review of Resident #96's medical record revealed, in part, Resident #96 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances and major depressive disorder. Review of Resident #96's MDS (Minimum Data Sheet) with an ARD(Assessment Reference Date) of 05/17/2023 revealed, in part, Resident #96 had a BIMS (Brief Interview Mental Status) score of 3, which indicated Resident #96 had severely impaired cognition. Further review revealed, Resident #96 used a wander/elopement alarm daily. Review of Resident #96's Comprehensive Care Plan revealed, in part, Resident #96 was at risk for elopement. Further review revealed Resident #96's interventions included: should have a wanderguard applied as ordered. Resident #96's wanderguard should be monitored for proper functioning, staff should be aware of their surroundings daily, staff should redirect Resident #96 as needed, and Resident #96 should be on the wander list located at the nurse's station. Further review of Resident #96's care plan revealed no additional interventions implemented after elopement on 02/09/2023. Review of Resident #96's nurses' notes revealed, in part, a nurse's note with a date of 02/09/2023 written by S5LPN which stated Resident #96 was found outside by staff. Further review revealed, in part, Resident #96 left out of the door behind a resident who goes outside regularly and alarm was not censored at the time. Review of Resident #96's medical record revealed, in part, Resident #96 did not have an elopement risk assessment completed prior to the incident of elopement on 02/09/2023. Review of Resident #96's elopement risk assessment dated [DATE] revealed, in part, Resident #96 had a history of leaving the facility without needed supervision. Further review revealed, Resident #96 is at risk for elopement. Review of the facility's Incident Report for Resident #96 dated 02/09/2023 revealed, in part, Resident #96 was found outside of the facility by staff. Observation on 06/11/2023 at 10:00 a.m., revealed Resident #96 in his wheelchair rolling near Door A with no direct staff supervision. Observation on 06/11/2023 at 11:28 a.m., revealed Resident #96 in his wheelchair rolling on Hall 3 asking a staff member about getting out of the facility to go home. In an interview on 06/12/2023 at 9:06 a.m., S8CNA (Certified Nursing Assistant) stated Resident #96 wanders frequently. S8CNA further stated Resident #96 frequently tries to get out of the facility so he can go home to his mother. In an interview on 06/12/2023 at 9:10 a.m., S9MDS LPN (Licensed Practical Nurse) stated Resident #96 was found in the parking lot a few months ago while wearing a wanderguard. In an interview on 06/12/2023 at 10:25 a.m., S9MDS LPN stated elopement risk assessments are completed quarterly. S9MDS LPN confirmed Resident #96's elopement risk assessment was not completed quarterly and should have been completed quarterly. In an interview on 06/12/2023 at 10:34 a.m., S11Maintenance Supervisor stated wander guards were checked weekly. Observation on 06/12/2023 at 10:27 a.m., revealed Resident #96 sitting in wheelchair in dining area with staff present at the nurses station. Resident #96 talking with administrator stating, I am hoping to get out of here. In an interview on 06/12/2023 at 11:00 a.m., S10MDS RN (Registered Nurse) stated Resident #96 did not have any elopement risk assessments completed in 2021 or 2022. In an interview on 06/12/2023 at 12:15 p.m., S5LPN stated she was alerted by another staff member that Resident #96 was found outside of the facility. S5LPN further stated she was not aware Resident #96 had exited the facility and would not have known if she had not been notified by another staff member. In an interview on 06/12/2023 at 12:25 p.m., S12TreatmentNurse (TN) stated she answered the phone when someone called to report Resident #96 was outside in the grass area near the road. S12TN stated she and other staff assisted Resident #96 back inside and notified the nurse. S12TN stated she was not aware Resident #96 had exited the building and does not recall whether the alarm sounded when Resident #96 exited the building. In an interview on 06/12/12023 at 12:35 p.m., S5LPN stated she was on the hall and did not recall hearing the alarm on 02/09/2023 when she was notified Resident #96 was found outside of the building. In an interview on 06/12/2023 at 12:53 p.m., S14CNA stated she is only aware of residents who wander by their wanderguard. In an interview on 06/12/2023 at 2:36 p.m., S16CNA stated Resident #96 wanders around the building and thinks Resident #96 has a wanderguard on. In an interview on 06/12/2023 at 3:15 p.m., S2DON stated elopement risk assessments are completed on admission, readmission, status changes, and quarterly. S2DON stated she was told Resident #96 was found outside. S2DON further stated Resident #96 got outside when another resident had the door open, and unsure how long Resident #96 was outside. S2DON stated when Resident #96 was assisted back inside the facility, the nurse ensured Resident #96's wanderguard was on. S2DON stated some cognitive residents have the door code. S2DON stated all staff are expected to provide increased supervision and be aware of residents who are identified as an elopement risk, location in the facility at all times. In an interview on 06/12/2023 at 3:25 p.m., S1Administrator stated he was present in the facility when Resident #96 went out of Door A when the door was propped open by Resident #13 who was smoking in the front of the building. S1Administrator stated he did not complete a SIMS (Statewide Incident Management System) report since he did not consider Resident #96 exiting the facility a reportable event because Resident #96 was still on facility grounds. S1Administrator stated cognitive residents who are capable of going in and out of the facility are allowed to have the door code to access any of the entrances in the facility. S1Administrator stated he does not have a documented investigation related to the incident. In an interview on 06/12/2023 at 4:25 p.m., S26Administrator stated Hall 4 does not have an elopement risk binder because that is the vent unit and the majority of those residents are bedbound. S26Administrator stated all of the facility doors lock at 7:00 p.m., and an alarm will go off if the door is held open. S26Administrator further stated the box located at Station 1 and Station 2 will indicate which door is alarming. At this time, S26Administrator held the door open and it took approximately 1 minute for the alarm to sound. In an interview on 06/12/2023 at 5:55 p.m., S17Assistant Administrator stated S18LPN witnessed Resident #96 going out of Door A down the driveway near the ambulance entrance when she was getting in her car after her shift. In an interview on 06/12/2023 at 6:18 p.m., S18LPN stated on 02/09/2023 she left the facility when her shift ended at 3:00 p.m., to run an errand and did not see Resident #96 in the parking lot when she left the facility. S18LPN further stated when she passed back in front of the facility after her errand she noticed Resident #96 outside in the front parking lot heading toward the ambulance entrance. S18LPN stated she called the facility to let staff know Resident #96 was outside because she knew Resident #96 was confused. S18LPN stated she turned into the parking lot and prior to exiting her car the other staff were coming out the door to assist Resident #96 back in the facility. In an interview on 06/13/2023 at 8:45 a.m., S17Assistant Administrator stated the facility did not have any documented evidence that the incident on 02/09/2023 for Resident #96 was reviewed in the Quarterly Quality Assurance (QA) meeting held on 04/25/2023. Observation on 06/13/2023 at 9:40 a.m. S18LPN escorted surveyor from Resident #96's previous room, which was located across the building, to the front of the facility and displayed the area where Resident #96 was found on 02/09/2023. Observation further revealed the area Resident #96 was found in was the front parking lot of the facility approximately 25 feet from the main highway, which was unable to be supervised by staff assigned to Resident #96. In an interview on 06/13/2023 at 9:40 a.m., S24CNA stated she had been working at the facility for approximately 4 months. S24CNA further stated residents who wander are identified by their wander guard bracelets. In an interview on 06/13/2023 at 9:46 a.m., S25CNA stated she has been working at the facility for approximately 1 year. S25CNA further stated residents who wander are identified by their wander guard bracelets. S25CNA stated if the alarm goes off the staff know a wander resident is at the door. S25CNA further stated without a wander guard in place, the staff do not have any way of knowing if a resident is an elopement risk. In an interview on 06/13/2023 at 11:35 a.m., S20CNA stated Resident #96 is allowed to move throughout the facility in his wheelchair without direct staff supervision. In an interview on 06/13/2023 at 11:36 a.m., S21CNA stated monitoring a resident that is at risk for wandering, every 2 hours is not sufficient. In an interview on 06/13/2023 at 11:37 a.m., S22CNA stated monitoring a resident that is at risk for wandering, every 2 hours is not sufficient. S22CNA further stated Resident #96 moves around freely in the wheelchair and likes to sit by the door. In an interview on 06/13/2023 at 11:39 a.m., S23CNA stated monitoring a resident that is at risk for wandering, every 2 hours is not sufficient. In an interview on 06/13/2023 at 4:40 p.m., S13QI Nurse stated if Resident #96 did not have direct supervision while in the parking lot then the facility should have notified herself or the regional vice president to review the situation and determine whether a SIMS (state incident reporting system) report should have been completed. S13QINurse also stated she was not notified by the facility of the elopement incident on 02/09/2023. S13QI Nurse stated residents who are elopement risk should have increased supervision. S13QI Nurse stated the regional vice president or herself will oversee the administrator with weekly site visits for 4 weeks, at the end of the 4 weeks they will evaluate whether weekly site visits should be extended. In an interview on 06/13/2023 at 5:30 p.m., S13QI Nurse stated an investigation should be completed when residents are outside of the facility unsupervised. In an interview on 06/13/2023 at 5:35 p.m., S1Administrator stated the family members are allowed to have the code to enter the facility at any of the entrances because his facility is too big for him to control who comes in and out of it through one entrance. S1Adminstrator stated any resident in the facility who is cognitive or a safe smoker can have the code to the facility doors. S1Adminstrator stated his facility was not a 1 on 1 facility and they could not provide 24 hour continuous supervision for Resident #96. S1Administrator stated an incident of an elopement could occur at any point in his facility and there would be nothing he could do about it.

The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to provide supervision to keep a resident free from elopement for 1 (Resident #96) of 10 residents (Resident #29, Resident #49, Resident #71, Resident #75, Resident #96, Resident #98 Resident #133, Resident #147, Resident #158, and Resident #159) identified at risk for elopement in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #96 with a BIMS (Brief Interview Mental Status) score of 3, which indicated Resident #96 had severely impaired cognition on 02/09/2023 when Resident #96 eloped from the facility at approximately 5:00 p.m. Staff were notified by phone at approximately 5:00 p.m. by S18Licensed Practical Nurse (LPN), that Resident #96 was in the front parking lot of the facility approximately 25 feet from the main highway. Resident #96 was assisted back into the facility immediately after receiving the phone call and no injuries identified upon assessment. S1Administrator was notified of the Immediate Jeopardy on 06/13/2023 at 12:27 p.m. The Immediate Jeopardy was removed on 06/13/2023 at 6:22 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Administrator was in-serviced by S13QI Nurse on Elopement on 06/13/2023 at 12:00 p.m. Resident #96 was assessed on 02/09/23 at 5:00 p.m. with no injuries noted from wandering. No additional wandering behaviors were noted at that time. Resident #96 was reassessed on 06/13/2023 at 4:44 p.m., with no additional existing behaviors noted. Resident has had a room assignment change, to be located in a high traffic area directly across from the nurse's station, for increased direct supervision from staff. Staff were in-serviced to redirect Resident #96 to an area of high traffic to be monitored by direct supervision from staff when he exhibited wandering behaviors. 2. Administrator was in-serviced by S13QI Nurse on reporting of elopement on 06/13/2023. a. Regional [NAME] President or Quality Assurance Nurse would ensure Administrator/Designee is conducting random observation of elopement audit with residents' weekly times 30 days with completion date of 07/11/2023. 3. The S11Maintenance Supervisor conducted and completed a safe survey elopement checks on 06/13/2023 to ensure that any further potential elopement was prevented. Safe Survey Elopement Checks would be conducted by Administrative designees on random residents weekly for 30 days, then monthly thereafter indefinitely. Any negative finding will be reported to the Administrator and acted on immediately. Staff in-serviced, including contracted staff, on identifying residents at risk for elopement, the elopement prevention protocol, the elopement reporting policy and procedures, and on the wanderguard system was initiated on 06/13/2023 at 11:30 a.m. and to be completed by 06/16/2023 by 6:00 p.m. Staff not in-serviced would not be permitted to work until in-serviced. On 06/13/2023 Social Worker, composed a letter to residents and their responsible parties regarding the use of facility doors that required codes as of 06/14/2023. It would address not letting other residents exit with them and to notify staff of any incidents of the alarm sounding or other residents trying to exit with them. On 06/13/2023 as of 5:30 p.m., facility door codes would have been changed, and only designated staff would have access to the facility's door codes. The facility's main entrance would be designated as an entrance/exit for residents and family members. As of 06/13/2023, a staff member would be designated to supervise this entrance with shifts of 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. In-serviced staff not to share code. Designate staff would allow entrance and exit to the facility. Monitored use of code by observation 15 minutes a day 3 days a week x 4 weeks ending on 07/11/2023. Every two hours monitoring of resident's at risk for elopement. Assessed resident's at risk for elopement would determine if increased supervision is needed, on a resident by resident basis, completed on 06/13/2023 by 5:00 p.m. After assessments completed, if determined the need of increase supervision for resident, it would be initiated on the residents that demonstrated increased wandering behaviors at the time. At the time the resident displayed the behaviors, the resident would be moved to an area of high traffic for monitoring by direct supervision from staff. When residents started to wander, education would be initiated on redirecting resident and to provide direct supervision of resident. High Risk residents will be reassessed weekly for 4 weeks. 4. The Administrator reviewed the completed the safe survey checks on 06/13/2023 to determine if any abuse, neglect or mistreatment had occurred. a. Safe Survey Elopement Checks would be reviewed by Administrator weekly for 30 days, then monthly thereafter. Any negative finding would be acted upon immediately. 5. After elopement investigation is completed by facility, it would be reviewed by Regional [NAME] President or Quality Improvement Nurse prior to closing the SIMS report. 6. Any negative findings from the Safe Survey Elopement Checks would be acted on by the Administrator immediately, then reported findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. This deficient practice had the likelihood to cause serious harm to the remaining 9 residents identified as elopement risks by the facility. Findings: Cross Reference F689 In an interview on 06/12/2023 at 3:15 p.m., S2DON stated elopement risk assessments are completed on admission, readmission, status changes, and quarterly. S2DON stated she was told Resident #96 was found outside. S2DON further stated Resident #96 got outside when another resident had the door open, and unsure how long Resident #96 was outside. S2DON stated when Resident #96 was assisted back inside the facility, the nurse ensured Resident #96's wanderguard was on. S2DON stated some cognitive residents have the door code. S2DON stated all staff are expected to provide increased supervision and be aware of residents who are identified as an elopement risk, location in the facility at all times. In an interview on 06/13/2023 at 8:45 a.m., S17Assistant Administrator stated the facility did not have any documented evidence that the incident on 02/09/2023 for Resident #96 was reviewed in the Quarterly Quality Assurance (QA) meeting held on 04/25/2023. In an interview on 06/13/2023 at 4:40 p.m., S13QI Nurse stated if Resident #96 did not have direct supervision while in the parking lot then the facility should have notified herself or the regional vice president to review the situation and determine whether a SIMS (state incident reporting system) report should have been completed. S13QINurse also stated she was not notified by the facility of the elopement incident on 02/09/2023. S13QI Nurse stated residents who are elopement risk should have increased supervision. S13QI Nurse stated the regional vice president or herself will oversee the administrator with weekly site visits for 4 weeks, at the end of the 4 weeks they will evaluate whether weekly site visits should be extended. In an interview on 06/13/2023 at 5:30 p.m., S13QI Nurse confirmed she in-serviced S1Adminstrator, S17Assistant Administrator, and S26Administrator on reporting reportable events. In an interview on 06/13/2023 at 5:35 p.m., S1Administrator stated the family members are allowed to have the code to enter the facility at any of the entrances because his facility is too big for him to control who comes in and out of it through one entrance. S1Adminstrator stated any resident in the facility who is cognitive or a safe smoker can have the code to the facility doors. S1Adminstrator stated his facility was not a 1 on 1 facility and they could not provide 24 hour continuous supervision for Resident #96. S1Administrator stated an incident of an elopement could occur at any point in his facility and there would be nothing he could do about it.

Based on record review and interviews, the facility failed to report an incident of neglect, which resulted in elopement, to the State Survey Agency for 1 (Resident #96) of 1 (Resident #96) sampled residents who was identified as having eloped from the facility in a total sample of 10 residents (Resident #29, Resident #49, Resident #71, Resident #75, Resident #96, Resident #98 Resident #133, Resident #147, Resident #158, and Resident #159) identified as being at risk for elopement. Findings: Review of the facility's Wandering and Elopement Policy revealed, in part, when the resident returns to the facility, the director of nursing or charge nurse shall notify regulatory agencies per state guidelines as indicated. Review of the facility's Incident Report for Resident #96 dated 02/09/2023 at 5:00 p.m. revealed, in part, Resident #96 was found outside of the facility by staff. In an interview on 06/12/2023 at 3:25 p.m., S1Administrator stated he was present in the facility when Resident #96 went out of Door A when the door was propped open by Resident #13 who was smoking in the front of the building. S1Administrator stated he did not complete a SIMS (Statewide Incident Management System) report since he did not consider Resident #96 exiting the facility a reportable event because Resident #96 was still on facility grounds. S1Administrator stated he did not have any documented evidence to dispute that the above mentioned incident was not considered an elopement. In an interview on 06/12/2023 at 6:18 p.m., S18LPN stated on 02/09/2023 she left the facility when her shift ended at 3:00 p.m., to run an errand and did not see Resident #96 in the parking lot when she left the facility. S18LPN further stated when she passed back in front of the facility after her errand she noticed Resident #96 outside in the front parking lot heading toward the ambulance entrance. S18LPN stated she called the facility to let staff know Resident #96 was outside because she knew Resident #96 was confused. S18LPN stated she turned into the parking lot and prior to exiting her car the other staff were coming out the door to assist Resident #96 back in the facility. Observation on 06/13/2023 at 9:40 a.m. S18LPN escorted surveyor from Resident #96's previous room, which was located across the building, to the front of the facility and displayed the area where Resident #96 was found on 02/09/2023. Observation further revealed the area Resident #96 was found in was the front parking lot of the facility approximately 25 feet from the main highway, which was unable to be supervised by staff assigned to Resident #96. In an interview on 06/13/2023 at 4:40 p.m., S13QI Nurse stated if Resident #96 did not have direct supervision while in the parking lot then the facility should have notified herself or the regional vice president to review the situation and determine whether a SIMS (state incident reporting system) report should have been completed. S13QINurse also stated she was not notified by the facility of the elopement incident on 02/09/2023. In an interview on 06/13/2023 at 5:30 p.m., S13QI Nurse stated an investigation should be completed when residents are outside of the facility unsupervised.

Based on record reviews and interviews, the facility failed to: 1.) maintain ongoing communication with the dialysis center, and 2.) to act upon the Registered Dietician's recommendations for 1 (Resident #65) of 1 sampled resident investigated for dialysis services . Findings : Review of Resident #65's record revealed, in part, diagnoses of Chronic Kidney Disease, Diabetes, and End Stage Renal Disease. Review of Resident #65's June 2023 Physician's Orders revealed, in part, dialysis every Monday, Wednesday, and Friday. Review of Resident #65's Care Plan dated 10/13/2023 revealed, in part, assess vital signs upon return from dialysis, review communication form and address any new recommendations or orders. Further review revealed ongoing communication will continue between dialysis and facility to coordinate care. In an Interview on 06/12/2023 at 08:57 a.m., S5Licensed Practical Nurse (LPN) stated Resident #65 goes to dialysis on Monday, Wednesday, and Fridays. S5LPN stated she used the Nursing Facility/Dialysis Communication Sheet to document vital signs and any significant information prior to Resident #65 going to dialysis and sends the form with him. S5LPN further stated the dialysis clinic faxed the form back to nursing home daily. Review of Resident #65's record revealed the facility did not have Resident #65's Nursing Facility/Dialysis Communication Sheets for the following dates: 04/03/2023, 04/10/2023, 04/14/2023, 04/17/2023, 04/19/2023, 04/21/2023, 04/24/2023, 05/05/2023, 05/08/2023, 05/12/2023, 05/19/2023, 05/26/2023, 05/29/2023, 05/31/2023, 06/07/2023 and 06/09/2023. In an interview on 06/12/2023 at 12:05 p.m., S4Medical Records Supervisor confirmed the facility did not have Resident #65's Nursing Facility/Dialysis Communication Sheets for the above listed dates. Review of Resident #65's June 2023 Physician Orders revealed, in part, liquid protein by mouth three times a day and nepro supplement one carton by mouth twice daily. Review of Resident #65's Registered Dietician(RD) note dated 05/09/2023 at 10:51 a.m. revealed a recommendation to decrease liquid protein to twice a day due to protein needs can be met via by mouth intake and twice daily protein supplementation. Further review revealed a recommendation to decrease Nepro to once a day. In an interview on 06/12/2023 at 3:30 p.m., S3Dietary Manager(DM) stated the RD emailed a list of all recommendations to the Assistant Administrator, Director of Nursing, Assistant Director of Nursing, and herself. S3DM stated S2DON then had someone contact the physician to determine if they want to change the orders as recommended by the RD. In an interview on 06/12/2023 at 3:31 p.m., S2DON stated S6Assistant Director of Nursing(ADON) was responsible to contact the physician to determine if they want to change orders as recommended by the RD. In an interview on 06/12/2023 at 3:35pm, S6ADON stated she contacted Resident #65's physician at the end of May and left a message; however, the message had not been returned. S6ADON stated she had not attempted to re-contact the physician. In an interview on 06/12/2023 at 3:38 p.m., S2DON stated S6ADON should have contacted the physician to discuss the recommendation but failed to do so.

Based on record review, interview, and observation, the facility failed to: 1. Assess a resident with a [MEDICATION(S)] (an opening in the abdominal wall that drains urine) for signs and symptoms of a urinary tract infection (Resident #70); and, 2. Assess for and act upon complications related to a resident's indwelling urinary catheter (Resident #37). This deficient practice was identified for 2 of 3 sampled residents investigated for urinary tract infections in a total investigative sample of 34, but had the potential to affect any of the 18 residents with indwelling or external urinary devices as documented on the facility's Resident Census and Conditions of Residents, CMS Form-672. Findings: Resident #70 Review of Resident #70's face sheet revealed, in part, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #70's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/2022, revealed, in part, Resident #70 had a [MEDICATION(S)]. Review of Resident #70's [MEDICATION(S)] Care Plan revealed, in part, a goal for Resident #70 to experience no urinary tract infections by 11/04/2022. Further review of Resident #70's care plan revealed interventions for facility staff to complete an ongoing assessment of color, clarity and character of urine and assess Resident #70 for symptoms of a urinary tract infection, with no frequency noted for either intervention. There was no documented evidence and the facility was unable to provide any documented evidence of an ongoing assessment of Resident #70's urine for color, clarity and character or assessments of Resident #70 for symptoms of a urinary tract infection. Review of Resident #70's urinalysis results (a laboratory test to detect abnormalities in the urine), collected on 06/13/2022, revealed, in part, abnormal results of red blood cells, white blood cells and many bacteria present in Resident #70's urine. Review of Resident #70's urine culture results, collected on 06/13/2022, revealed, in part, an abnormal result of [CONDITION(S)] pneumonia (a type of bacteria). Review of Resident #70's June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #70's June 2022 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 08/05/2022 at 9:54am, S12Registered Nurse (RN) stated she should assess the Resident #70 for signs and symptoms of infection and urine characteristics every shift due to Resident #70 having a [MEDICATION(S)], which put her at a high risk for urinary tract infections. S12RN stated urine characteristic charting or charting of signs and symptoms monitoring was typically completed on the eMAR. S12RN confirmed an assessment for urine characteristics and assessment of symptoms of urinary tract infection was part of Resident #70's care plan, but S12RN stated she could not find documentation every shift for the assessment. In an interview on 08/05/2022 at 10:22am, S6MDS Registered Nurse stated nurses typically chart urine characteristics assessments either in the nurse's notes or on the resident's eMAR. S6MDS Registered Nurse further stated Resident #70's [MEDICATION(S)] care plan intervention for assessment of urine characteristics and signs of a urinary tract infection did not need a frequency to indicate how often those assessments needed to be completed. S6MDS Registered Nurse confirmed there was no ongoing documentation of Resident #70's urine characteristics or assessment of Resident #70 for symptoms of a urinary tract infection. In an interview on 08/05/2022 at 1:21pm, S1Director of Nursing (DON) stated if she were caring for a resident with a [MEDICATION(S)], she would document urine characteristics and an assessment for signs and symptoms of urinary tract infections every shift, even if the results of the assessment were within normal limits. S1DON confirmed that a resident with a [MEDICATION(S)] would be at a high risk for urinary tract infections. Resident #37 Review of Resident #37's medical record revealed, in part, that Resident #37 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #37's Quarterly MDS (Minimum Data Sheet) with an ARD of 07/19/2022 revealed, in part, Resident #37 had a BIMS (Brief Interview for Mental Status) score of 13, indicating mild cognitive impairment. Further review revealed Resident #37 had an indwelling catheter and had rare pain at a level of 4 out of 10. Review of Resident #37's Care Plan revealed, in part, Resident #37 was care planned for the potential for pain, with the goal to minimize risk for pain daily and interventions for the nurse to assess for pain, administer pain medications as ordered, and notify the physician as needed. Further review revealed Resident #37 had a foley catheter due to urinary retention and [CONDITION(S)], with the goal to remain free from infection and interventions to observe foley catheter tubing placement to avoid pressure to the skin and/or avoid pressure to skin or kinking/coiling of tubing. Review of Resident #37's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/01/2022 at 3:19pm Resident #37 acknowledged he has pain from his catheter only when moving. Observation on 08/03/2022 at 1:10pm, revealed S14Certified Nursing Assistant (CNA) entered Resident #37's room to complete incontinence care. Further observation revealed Resident #37's foley catheter tubing was not secured to his leg with the leg strap. Observation also revealed Resident #37 complained of pain when S14CNA opened his diaper and cleaned his scrotum and buttocks with a wash cloth. In an interview on 08/03/2022 at 3:20 pm, S11LPN indicated yesterday (08/02/2022) Resident #37 complained of pain to his penis from his catheter being pulled. S11LPN acknowledged the physician was notified of Resident #37's complaints of catheter pain. In an interview 08/05/22 at 10:55am S4Nurse Auditor indicated it is protocol for a resident to have catheter tubing secured to the leg. In an interview08/05/22 1:35pm S1Director of Nursing (DON) indicated resident #37 should have had a leg strap secured to his catheter tubing, and the nurse should have documented when the physician about complaints of catheter/penis pain.

Based on record review, observation, and interview, the facility failed to: 1. Ensure a ventilator (a machine or device used medically to support or replace breathing) dependent resident's respiratory care and services was accurately reflected on a resident's plan of care (Resident #39); 2. Ensure staff maintained a resident's nasal cannula in a sanitary condition per their policy and procedure (Resident #85); and 3. Ensure staff maintained a resident's nebulizer mask in a sanitary condition per their policy and procedure (Resident #108). This deficient practice was identified for 3 of 3 sampled residents investigated for respiratory care in a total sample of 34 residents, but had the potential to affect any of the 50 residents who received respiratory services as documented on the facility's Resident Census and Conditions of Residents, CMS Form-672. Findings: Resident #39 Review of Resident #39's medical record revealed hospital documentation that Resident #39 was admitted to the hospital on 04/23/2022 in respiratory distress. Further review revealed Resident #39 had a [CONDITION(S)] (small surgical opening that is made through the front of the neck into the windpipe) surgically placed while hospitalized and was discharged back to the facility requiring continuous ventilator support through the [CONDITION(S)] on 05/09/2022. Review of Resident #39's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/2022 revealed, in part, Resident #39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's current Care Plan revealed, in part, Resident #39 was care planned for oxygen delivered per nasal cannula at 2 liters per minute with an onset date of 12/18/2019. Further review of Resident #39's Care Plan revealed no care plan which reflected Resident #39's [CONDITION(S)] or ventilator dependence. Observation on 08/03/2022 at 12:18pm revealed Resident #39 lying in bed with a ventilator attached to his [CONDITION(S)] site. In an interview on 08/04/2022 at 12:40pm, S16Licensed Practical Nurse (LPN) stated Resident #39 had been receiving oxygen via his [CONDITION(S)] and ventilator since his readmission after a hospitalization in May 2022. LPN stated Resident #39 had not used oxygen via nasal cannula since prior to his hospitalization . In an interview on 08/04/2022 at 12:50pm, S7Respiratory Director stated Resident #39 was ventilator dependent with a [CONDITION(S)]. S7Respiratory Director also stated Resident #39 did not use a nasal cannula. S7Respiratory Director further stated the staff did not realize that Resident #39's care plan did not reflect his current [CONDITION(S)] and ventilator status until the surveyor had brought it to their attention. In an interview on 08/04/2022 at 3:09pm, S6MDS Registered Nurse stated Resident #39 did not have a care plan related to his [CONDITION(S)] and ventilator until the morning of 08/04/2022. S6MDS Registered Nurse stated Resident #39's oxygen therapy per nasal cannula care plan was not updated after Resident #39 returned from the hospital in May 2022. Resident #85 Record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #85's medical record revealed an MDS with an ARD of 06/09/2022 that indicated, in part, Resident #85 had a diagnosis, in part of [CONDITION(S)] received oxygen therapy. Review of the facility's Policy and Procedure on Oxygen/Respiratory equipment revealed in part oxygen tubing is changed every 7 days and to replace tubing weekly or as needed. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/02/2022 at 10:22am revealed Resident #85's cannula end of the oxygen tubing was on the floor beside her bed. Observation on 08/03/2022 at 12:20pm revealed Resident #85's oxygen tubing was laying across her bedside table with the cannula end lying on the floor. Observation on 08/04/2022 at 11:15am revealed Resident #85's nasal cannula end of oxygen tubing was touching the floor. In an interview on 08/03/2022 at 12:22pm, Resident #85 stated she used oxygen daily. In an interview on 08/04/2022 at 2:29pm, S13LPN observed Resident #85's oxygen tubing observed on the floor and indicated should be changed. In an interview on 08/04/2022 at 2:47pm S1DON indicated that the tubing should not have been on the floor. Resident #108 Review of the facility's Nursing Services Policy and Procedure entitled Administering Medications through a Small Volume (handheld) Nebulizer revealed, in part: Step #29 when equipment is completely dry, store in a plastic bag with the resident's name and the date on it; and, Step #30 change equipment and tubing every seven days. Review of Resident #108's MDS with an ARD of 06/09/2022 revealed, in part: Resident #108 had a Brief Interview of Mental Status (BIMS) score of 03 which indicated Resident #108 had severe cognitive impairment; Section I revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #108's EHR (electronic health record) revealed, in part: a care plan was developed for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #108's Nurses Notes, dated 08/04/2022, revealed, in part, Resident #108's nurse notified the physician on 08/03/2022 at 8:00pm that Resident #108 had bilateral crackles with a cough that produced yellow sputum. Further review revealed a new order for a one time dose of [MEDICATION(S)] (medication used to treat breathing problems) 8mg by intramuscular injection, [MEDICATION(S)] (antibiotic used to treat infections) 500mg by mouth once daily for one week, and a chest x-ray. Review of Resident #108's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order with a start date of 08/04/2022 for [MEDICATION(S)] 4mg/ml vial, give one 8mg injection intramuscularly, an order with a start date of 08/04/2022 for chest x-ray, and an order with a start date of 08/04/2022 for [MEDICATION(S)] 500mg tablet give one tablet daily for one week. Review of Resident #108's August 2022 eMAR (Electronic Medication Administration Record) revealed, in part, [MEDICATION(S)]/[MEDICATION(S)] 0.5-3(2.5) mg/3mL was administered via nebulizer on 08/04/2022 at 5:31am. Observation on 08/01/2022 at 1:12pm revealed Resident #108 received 2 liters of oxygen via nasal cannula and was short of breath while sitting on the side of her bed. Resident #108 had a nebulizer machine on her bedside table and the nebulizer tubing, canister, mask, and mouth piece was not dated; however, the above mentioned respiratory equipment was inside a plastic bag dated 07/10/2022. Observation on 08/02/2022 at 12:17pm revealed, in part: Resident #108's nebulizer mask, mouth piece, canister, and tubing remained inside a plastic bag dated 07/10/2022. Resident #108 was unable to verify if she used the nebulizer machine and equipment. Observation on 08/03/2022 at11:03am revealed Resident #108's nebulizer mask, mouthpiece, canister, and tubing remained inside a plastic bag labeled 07/10/2022. In an interview on 08/03/2022 at 3:20pm, S11Liscensed Practical Nurse (LPN) acknowledged Resident #108 got short of breath with exertion and required nebulizer treatments occasionally. S11LPN further acknowledged the last time she was administered a nebulizer treatment to Resident #108 was yesterday (08/02/2022). S11LPN was not aware if Resident #108 had any recent respiratory infections or if the physician had been notified of increased congestion and wet cough. In an interview on 08/04/2022 at 4:40pm, S1Director of Nursing acknowledged that the nebulizer equipment for Resident #108 should have been changed weekly per policy and physician order.

Based on record review, observation, and interview the facility failed to ensure medications were not left unattended on a resident's bedside table. This deficient practice was identified for 1 of 2 sampled residents (Resident #78) observed during the medication administration facility task observation, but had the potential to affect any of the 172 residents who may receive medications as documented on the facility's Resident Census and Conditions of Residents form, CMS-672. Findings: Review of the facility's Storage of Medications Policy and Procedure revealed, in part, all drugs and biologicals used in the facility are to be stored in a locked compartment, and that nursing staff were responsible for maintaining medication storage. Observation on 08/01/2022 at 10:46am revealed a bottle of tablets labeled as [MEDICATION(S)] Sublingual Tablets, 0.4 milligrams (mg) per tablet (medication used to treat and prevent chest pain), a tube labeled [MEDICATION(S)] Sodium Topical Gel, 1% (medication used to treat pain), and a bottle of Nasocort nasal spray (medication used to treat allergies) on Resident #78's bedside table. In an interview on 08/01/2022 at 10:47am, Resident #78 explained she kept [MEDICATION(S)] and [MEDICATION(S)] cream on her rolling bedside table, but Resident #78 stated was unaware she had Nasocort. Resident #78 stated she had self-administered the [MEDICATION(S)] once after her admission to the facility, and she had self-administered the [MEDICATION(S)] cream as needed on her shoulders and feet. Resident #78 further stated she had self-administered the [MEDICATION(S)] cream about a week ago. Resident #78 also stated she had self-administered Nasocort when she had a nose bleed. Observation on 08/02/2022 at 3:30pm, revealed a bottle of tablets labeled as [MEDICATION(S)] Sublingual Tablets, 0.4mg per tablet, a tube labeled [MEDICATION(S)] Sodium Topical Gel, 1%, and a bottle of Nasocort nasal spray on Resident #78's bedside table. Observation on 08/03/2022 at 8:40am revealed a bottle of tablets labeled as [MEDICATION(S)] Sublingual Tablets, 0.4mg per tablet, a tube labeled [MEDICATION(S)] Sodium Topical Gel, 1%, and a bottle of Nasocort nasal spray on Resident #78's bedside table. There was no documented evidence and the facility was unable to provide any documented evidence that Resident #78 was assessed, care planned, and approved to have medications at the bedside to self-administer. In interview on 08/03/2022 at 8:45am, S11Licensed Practical Nurse (LPN) acknowledged she removed a bottle of [MEDICATION(S)], a tube of [MEDICATION(S)] cream, and a bottle of Nasocort nasal spray from Resident #78's bedside table. S11LPN stated facility nursing staff was not administering [MEDICATION(S)], [MEDICATION(S)] cream or Nasocort nasal spray to Resident #78. In an interview on 08/04/22 at 2:20pm, S1Director of Nursing (DON) stated the medications should not have been left at Resident #78's bedside to self-administer without an order or a care plan to self-administer medications. S1DON further stated the facility should have obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, and interview the facility failed to ensure a dependent resident's fingernails were clean and trimmed for 1 (Resident #109) of 3 dependent sampled residents who required assistance with ADL's (Activities of Daily Living) in a total investigative sample of 34 residents. Findings: Resident #109 Review of Resident #109's the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/09/2022 revealed, in part, Resident #109 had a BIMS (Brief Interview of Mental Status) score of 12, which indicated moderate cognitive impairment, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #109's care plan revealed, in part, assistance was required with activities of daily living. Further review revealed one approach was to assist Resident #109 with hygiene and grooming tasks. Observation on 08/01/2022 at 1:35pm revealed Resident #109 had long fingernails that extended past her fingertips with a dark brown unknown substance also observed underneath her fingernails on both hands. Observation on 08/02/2022 at 10:22am revealed Resident #109 had long fingernails that extended past her fingertips with a dark brown unknown substance also observed underneath her fingernails on both hands. Observation on 08/03/2022 at 12:22pm revealed Resident #109 had long fingernails that extended past her fingertips with a dark brown substance also observed underneath her fingernails on both hands. Observation on 08/04/2022 at 11:12am revealed Resident #109 had long fingernails that extended past her fingertips with a dark brown substance also observed underneath her fingernails on both hands. In an interview on 08/03/2022 at 12:23pm, Resident #109 indicated she would like her fingernails trimmed and cleaned. In an interview on 08/04/2022 at 11:22am, S8Certified Nursing Assistant (CNA) Supervisor acknowledged that Resident # 109's fingernails should have been cleaned and trimmed. S8CNA Supervisor also indicated nurses and/or treatment nurses are responsible for trimming the fingernails of diabetic residents. In an interview on 08/05/2022 at 1:24pm, S1Director of Nursing (DON) indicated when a resident receives a bath or shower, the CNA was responsible for nail care unless the resident was a diabetic. S1DON further indicated, if a CNA observes a resident's nails were in need of being trimmed and was a diabetic, the CNA should inform the floor nurse or treatment nurse. In an interview on 08/05/2022 at 1:38pm, S17Treatment Nurse stated CNAs trim the nails of residents who are not diabetic. S17 Treatment Nurse also indicated that nurses and/or treatment nurses are responsible for trimming fingernails and toenails of diabetic residents. S17Treatment Nurse further indicated if she observed a residents' fingernails are in need of trimming while performing wound care she would trim as needed.

Based on observation, interview, and record review the facility failed to ensure Certified Nursing Assistant (CNA) staff demonstrated competency while handling soiled linens per facility policy. This deficient practice was identified for 2 of 3 sampled residents reviewed for incontinence care (Resident #89 and Resident #102) and observed receiving assistance from staff with personal hygiene in a total investigative sample of 34, but had the potential to affect any of the 172 residents who reside at the facility and may have soiled linens handled by staff as documented on the facility's Resident Census and Conditions of Residents CMS Form-672. Findings: Review of the facility's policy and procedures related to soiled laundry and bedding revealed the following, in part: Handling: 1. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. a. Soiled Laundry and bedding contaminated with blood or other potentially infectious materials is handled as little as possible and with a minimum of agitation. b. Laundry that is contaminated with blood and/or body substances is placed in leak-proof bags or containers. c. Contaminated laundry is placed in a bag or container at the location where it is used and not sorted or rinsed at the location of use. Review of the facility's Infection Control Policy and Procedures revealed, in part, that staff should remove soiled gloves after providing personal care and/or handling soiled linens and perform hand hygiene. Resident #102: Observation on 08/03/2022 at 1:00pm, revealed S9CNA performed incontinence care on Resident #102 and placed the towels, which were soiled with urine and fecal matter, on the floor. Further observation revealed S9CNA then touched Resident 102's oxygen nasal cannula, call light, television remote, and bed controls with the same gloves he had used to provide personal care on Resident #102. In interview on 08/03/2022 at 1:45pm, S9CNA indicated he should have placed the soiled linen in the appropriate container instead of placing the soiled linens on the floor. S9CNA further acknowledged that the above mentioned objects were contaminated after touching the above mentioned objects with the soiled gloves and needed to be cleaned. In interview on 08/05/2022 at 9:50am, S18CNA indicated she was the one who trained and oriented S9CNA for 3 days on the floor before he worked independently. In 08/05/2022 at 10:35am, S18CNA Supervisor was informed of the above findings and indicated S9CNA was not trained to perform the above mentioned tasks like that. Resident #89 Observation on 08/04/2022 at 10:10am, revealed Resident #89's Hospice CNA, was observed providing a bed bath to Resident #89. Further observation revealed Resident #89's Hospice CNA then picked up the soiled linens which was rolled up and placed at the foot of Resident 89's bed with gloved hands and proceeded down the hallway with the soiled linen, but was re-directed back to Resident #89's room to dispose of the soiled linens. Resident #89's Hospice CNA disposed of the soiled linens, Resident #89's Hospice CNA then touched Resident #89's coloring books, IPad, IPhone, television remote, call bell, bed controls, and privacy curtain with the same gloves used to bathe Resident #89 and transport the soiled linens. In interview on 08/04/2022 at 10:16am, Resident #89's Hospice CNA indicated she should have washed her hands before going back to Resident #89 bedside and touching Resident #89's personal belongings. On 08/04/2022 at 10:20am, S1Director of Nursing (DON) became aware of the above and then declared the importance of following the above mentioned protocols/procedures by Resident #89's Hospice CNA.

Based on record review and interview the facility failed to ensure residents received adequate supervision and assistive devices to ensure a resident was transferred appropriately to prevent injury for 1 of 3 residents reviewed for accidents (Resident #82). This deficient practice resulted in an Actual Harm on 8-16-2019 for Resident #82 when the resident was assisted with transferring from the wheelchair to the bed by one CNA (S9CNA). The resident, who required extensive assistance of two persons with the use of a Hoyer lift, sustained an acute distal fibula and tibia [MEDICAL CONDITION] leg when S9CNA pivoted the resident to the bed. The resident was hospitalized from [DATE] through 8/21/2019 and treated for [REDACTED]. This failed practice had the potential to affect any of the 151 residents requiring assistance with transfers as documented on the facility's Resident Census and Conditions of Residents form (CMS-672). Findings: Review of Resident #82's record revealed [DIAGNOSES REDACTED]. Review of Resident #82's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) dated 07/21/19 revealed the resident required extensive assistance of two persons for transfers. Review of Resident #82's MDS ARD 11/01/19 revealed a BIMS (Brief Interview for Mental Status) score of 10 (score of 08-12 indicating moderate cognitive impairment). Review of Resident #82's Care Plan with a goal date of 12/12/19 revealed a problem of, in part: the resident required assistance with ADLs (Activities of Daily Living) exhibited by the resident required extensive assistance of two persons with transfers. Review of Resident #82's Lift/Transfer assessment dated [DATE] revealed, in part: Resident #82's lift/transfer plan dated 07/15/19 was red, total lift with two person assist. Further review revealed the resident required a multipurpose with head support sling, with comments of Hoyer lift. Review of Resident #82's Investigative Report dated 08/17/19 at 3:30pm revealed S12LPN (License Practical Nurse) was called to Resident #82's room due to the resident's complaint of pain to the right ankle area. Review revealed upon assessment resident was noted with mild swelling to the inner ankle. Review revealed the resident stated the pain began on 08/16/19 around 6-7pm after the staff transferred her to bed. Resident #82's Physician was notified and an x-ray to right ankle and leg was performed. Review of S9CNA's (Certified Nursing Assistant) undated Incident Witness Statement revealed S9CNA documented earlier on the date of the incident (no date given) the Hoyer lift had stopped working when placing Resident #82 in the wheelchair. Review revealed when S9CNA was asked to place Resident #82 back into the bed S9CNA did not want to use the Hoyer lift and had asked another staff member for assistance. Further review revealed S9CNA did not wait for the other CNA to come back, and decided to pivot the resident into the bed alone. Review revealed the resident had complained about her foot hurting. Observations during the survey process on 11/04/19 thru 11/07/19 revealed no evidence of any of the Hoyer lifts not operating properly. In an interview on 11/07/19 at 1:54pm, Resident #82 stated she still was not able to put weight on her right ankle and it made her feel terrible. Resident #82 stated she still had pain in that foot. In an interview on 11/07/19 at 3:10pm, Resident #82's nighttime sitter stated S9CNA and another aide came to put the resident back to bed after therapy, and S9CNA stated she was not using the lifter she was doing this her way. S9CNA told the resident to put her arms around her neck and the resident's leg was turned to the side. Resident #82's sitter stated the resident stated you hurt my leg, you hurt my leg. Resident #82's nighttime sitter stated she then put her to bed and took the resident's sock off and did not see any issues and the resident did not complain of any further issues until the next day when the other sitter told me about the resident's foot. The sitter then informed the nurse. In an interview on 11/07/19 at 3:35pm, S12LPN stated one of the aides came and notified me Resident #82 was having pain. S12LPN stated she went to the room and the sitter told me she was transferred without a lift and was hurt. S12LPN stated she thinks she was first notified of the issues of Resident #82's leg pain on 08/17/19. S12LPN stated she called the family and the resident's physician. Review of Resident #82's (MONTH) 2019 EMAR (Electronic Medication Administration Record) revealed Resident #82 was assessed as having pain of a 5 (on a scale of 0-10 with 0 being no pain and 10 being the worst pain) on 08/17/19 at 8:21am and a 8 on 08/17/19 at 3:24pm. Review of (MONTH) 2019 EMAR from 08/01/19 to 08/16/19 Resident #82 was only assessed as having pain once on 08/04/19 at a 7/10. Review of Resident #82's x-ray results dated 08/18/19 revealed, in part: acute distal tibia fracture and acute distal fibula fracture. Review of Resident #82's Physician Telephone Orders dated 08/18/19 revealed an order to send Resident #82 to the emergency room for evaluation of tibia and fibula fracture. Review of Resident #82's Hospital Discharge Summary dated 08/21/19 revealed Resident #82 was treated for [REDACTED]. Review of S9CNA's Personnel File revealed no documented evidence of competency evaluations for S9CNA's skills having been conducted from hire to the date of last date worked of 08/18/19. Review of S9CNA's employee warning report dated 08/18/19 revealed S9CNA had transferred (moved the resident from one surface to another) a resident x 1 (without assistance of another staff) which resulted in an injury. In an interview 11/06/19 at 4:07pm, S4Corporate Nurse stated the facility had not completed S9CNA's competency evaluation. In an interview on 11/07/19 at 4:02pm, S3DON (Director of Nursing) stated Resident #82 was improperly transferred by S9CN[NAME]

Based on record review and interview the facility failed to ensure a resident's right to be free from mental or emotional abuse for 1 (Resident #3) of 5 sampled residents (Residents #1, 2#, #3, #4, and #5). A cognitively intact resident (Resident #3) reported that on 03/23/12 at 6:00pm S12 CNA raised her hand and attempted to hit her. Resident #3 was in Immediate Jeopardy after this allegation was reported and the Registered Nurse (RN) Weekend Supervisor (S8 RN) failed to immediately remove remove Certified Nursing Assistant (CNA) (S12 CNA) from resident care. The facility failed to: 1. follow facility policy and procedure and ensure the allegation was reported immediately to the administrator or his designee; 2. follow facility policy and procedure and immediately begin investigation; take all necessary steps to prevent further abuse while the investigation was in progress by not suspending the alleged perpetrator (S 12 CNA) pending the completion of the investigation. The facility allowed the alleged perpetrator (S12 CNA) to continue to work in the facility from 03/23/12 through 03 25/12 in a unit near Resident #3 after an allegation of potential physical abuse was reported to the Night Unit Nurse (S8 RN) and the Registered Nurse Weekend Supervisor (S7 RN); 3. ensure Resident #3 was observed at all times by an assigned staff member until another directive was given per policy. The Immediate Jeopardy was removed for Resident #3 on 03/25/12 at 9:53pm when S12 CNA clocked/punched out on the time clock and left the facility. The deficient practice remains for all residents as a system has not been put into place to correct the deficient practice. The administrator was notified of the Immediate Jeopardy situation on 4/3/12 at 11:36 a.m. Findings: Review of the clinical record Resident #3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3 is Vent Dependent, Tube Feed, able to Communicate with a Valve and cognitively intact. During an interview on 4/2/12 at 1:15 pm with Resident #3 she stated last week on Friday night the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed CNA arm and told her that she better not ever try to hit her again. Resident #3 stated the CNA had come in to change her. She had headphones on with plugs in her ear. She stated the CNA never talked to or greeted her, even with previous care. She stated she is usually rough and mean; but never tried to hurt her before. Resident #3 stated she waited until after 10:00pm to report this to the nurse because of fear of retaliation and wanted to make sure she was off the shift. She stated she was still afraid until she heard the CNA had been let go the following Monday. She acknowledged that S12 CNA did not work with her and she did not see her after Friday night. She states she understands the CNA was still working, but not allowed to work with her. Review of the facility Resident Grievance & Complaint Form dated 3/24/12 documents in part: Person making complaint ____ (named Resident 3). Explanation/Nature of Complaint: Stated that the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed CNA arm and told her that she better not ever try to hit her again. She does not want this CNA in her room. She is very afraid of her. The form was signed by S8 RN, S9 LPN and S7 RN Weekend Supervisor. The area for date was blank. Further review of the form in another type of ink pen, the following was written in the areas: Action Taken: Terminated, Resolved: Yes was circled, Further Action Necessary: No was circled and Follow-up: Employee was terminated. This section was signed by S2 DON. There was no documented evidence that an incident report was completed. There was no documented evidence the incident details were noted in Resident #3 ' s nurse ' s notes or communicated between shifts for follow-up. Review of the OTIS (Online Tracking Incident/Investigation System) Report # documented an incident occurred and revealed in part: Events: Occurred on 3/23/12 at 6:00 pm, discovered 3/23/12 at 10:30 pm, Findings & determination 3/26/12 at 9:00 am and entered 3/26/12 at 12:56 pm. Contact/Reporter: _____ (named S2 DON) Accused/Allegation: ____(named S12 CNA) Abuse: Emotional Substantiated Victims: ____ (named Resident #3) Case Notes: Description: It was reported to me, the DON this morning at 8:30 a.m. that this client ____ (named Resident #3) was emotionally abused on Friday night by the aide ____ (named S12 CNA). The resident stated that she had put on her call light saying she needed to be changed. She stated the aid came into the room, wearing ear phones and began changing her. She said all of a sudden the aide raised her hand to strike her. She stated she grabbed the aides hand and told her, " You better not! " She stated she was fearful of the aide and did not want her back in her room anymore. Summary: " The resident stated this happened about 6pm; however she did not report it to any staff member until 10:30 pm. At that time she reported it to ____ (named S8 RN) when she came into the room on her rounds. The aide was not allowed to go back into the room for the remainder of the shift. I learned the aide asked other aides who would be off Saturday and Sunday evening to take her weekend shifts. Someone did take her Saturday shift; but she worked on Sunday evening. She was not allowed to render care to the resident. The aide refused to write a statement. She just denied the allegation. The resident is on a ventilator, but can speak by using a Passemuer Valve. Her roommate is semi-comatose and cannot communicate. There were no witnesses to this incident and only a few residents on this unit can communicate. The employee is a recent graduate of a CNA program and a recent hire. Prior to this I never got any complaints from other residents. This resident however, has resided at this facility for years and has never lodged a complaint about any other aide. She is cognitively intact. She repeated the same event and details to three nurses besides myself. Even though there were no witnesses and I cannot substantiate the allegation, I believe this resident and cannot have her remain on the schedule for fear she might abuse a resident who is high risk for abuse due to poor cognition and/or the inability to speak." During an interview on 4/2/12 at 3:00 pm with S2 DON she stated she was first made aware of the incident on 3/26/12 during the review of the weekend QA (Quality Assurance) report. She stated she began investigation and submitted an OTIS report. She stated both RN ' s know they should have notified her. During an interview on 4/3/12 at 10:00 am with S2 DON she stated she had a miss call from the facility. She stated she called back and _____ (named S17 LPN) the LPN from unit IV checked all the units and stated no one needed her. She acknowledged she never asked for the weekend supervisor to see if she had called for her. She stated she learned later that it was _____ (named S9 LPN) that had placed a call to her. During an interview on 4/2/12 at 3:10 pm with S9 LPN she stated the first she learned of the incident was on Saturday evening. She acknowledged signing the grievance/complaint form completed by S8RN. She stated the weekend supervisor was made aware. She stated S12 CNA did not work on Saturday; but she did come to work on Sunday at 2:00 pm; however she and one of the other aides traded patients in this area. She acknowledged being familiar with Abuse protocol, policy and procedures. She offered no explanation as to why she did not notify the Administrator or DON. During a telephone interview on 4/2/12 at 3:50 pm with S8 RN she stated she did talk with Resident #3 on Friday night about 10:30 pm. She stated the CNA was gone already and not scheduled to come back until middle of next week. She supposedly had gotten someone to work for her. She stated she completed a grievance/complaint form and gave to the weekend supervisor. She stated she was surprised when she came on duty Sunday at 7:00pm and saw _____ (named S12 CNA). She stated the weekend supervisor was gone already. She stated she asked the other nurse "why is she working?" She stated she was told the CNA came on at 2;00 pm and was allowed to work on the other end of unit and not the area or with Resident #3. She acknowledged awareness of facility policy & procedure for allegations of abuse. She stated she used to be a supervisor here at the facility. She offered no explanation as to why she did not call the administrator or DON. During a telephone interview on 4/2/12 at 4:00 pm with S7 RN Weekend Supervisor she stated when she came in on Saturday morning she was told to go check on _____ (named Resident 3) by ____ (named S8 RN). She stated the resident was still asleep so she went back to S8RN and ask for specifics of what happened. She stated she told S8 RN to write it up and she would have ___ (named S9 LPN) sign also. She stated she made rounds. She stated later when she went to ask Resident #3 what happened the resident stated she didn't want to talk about it, or cause trouble for anyone. She stated she did not want retaliation. S7 RN stated she assured the resident their job is to care for her. She received permission to pull up a chair and sit down. She stated Resident #3 said the CNA takes care of her, but never talks to her, she is rough with her, she raised her hand like going to hit her, but nothing happened because she was looking right at her and caught her hand, grabbed it and told her she better not ever hit her. S7 RN acknowledged she allowed S12 CNA to return to work on Sunday 3/25/12 at 2:00 pm. She stated the CNA she had swapped with couldn't fulfill the commitment so she had to come in. She stated she worked on the other end of hall/unit. She stated she was not aware she couldn't at all. She thought it just had to be in another area. She stated neither one of the nurses told her that needed to be done. She stated she was familiar with facility policy & procedures on abuse. She stated she called the DON on Saturday, but did not get a response. She stated she placed a copy of the grievance/complaint form under the door of the DON and Administrator so they would see it on Monday morning and follow up. She acknowledged that at no time did she question S12 CNA or do a formal investigation. She stated she did not try to call the Administrator or retry the DON because she had put info under their door. Review of the facility Abuse/Neglect Reporting-Resident policy and procedure with an original date of 04/06 and latest revision date of 6/23/09 revealed in part: Page 2 of 3: 3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, an occurrence will be reported immediately to the administrator or his or her designee of the facility who will immediately notify the Regional and the appropriate state officials. 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until complete. 5. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. Review of the facility Signature Sheet & Department Head In-Service for Possible Abuse and/or Neglect on March 9, 2012 revealed in part: 1. Anytime you are the department head supervisor on the weekend and a resident or family member alleges that they have been abused in any manner, you must immediately notify the administrator and the DON. You will be given further directives from that point. 2. Alleged abuse includes physical, verbal, emotional, sexual. 3. If allegations are made, you must immediately get any witness statements from staff who saw or heard anything. These are to be given to the Administrator or DON as soon as possible. 4. Do not discuss the matter with any one not directly involved in the situation. 5. Do not call the responsible party nor MD until directed to do so by the administrator or DON. 7. If the weekend RN Supervisor is in the building, summon her to assist with the situation, but make sure you or her contact the DON or administrator immediately. During an interview on 4/3/12 at 11:36 am with S1 Administrator, S3 RN Corporate Nurse and S2 DON they all stated and agreed the policy and procedure dated 4/06 and revised 6/23/09 were the most current. They also stated, the facility is in the plan of correction mode for other outstanding concerns and the staff just had in-services covering the same issues. During an interview on 4/3/12 at 3:00 pm with S2 DON she stated she has formal 1.5 hour detailed and informal highlighted/abbreviated in-services all the time. She stated the staff sign off acknowledging understanding. She stated the only person that does not attend in-services regularly is ___ (named S8RN), because she has two jobs. She stated but she knows all the rules, regulations and protocol she used to be a supervisor here. She stated she does not understand why they did not call her; but she has done a warning write-up statement on both Nurses. During an interview on 4/3/12 at 2:10 pm with S2 DON she acknowledged there was no documented evidence that an incident report was completed, there were no details in the nurse ' s notes from 3/23/12 through 3/26/12 and there was no notification to the family or physician.

Based on record review and interview the facility failed to implement their policy and procedures that prohibit abuse regarding protection of residents for 1 (Resident #3) of 5 sampled residents (Residents #1, 2#, #3, #4, and #5). A cognitively intact resident reported that on 03/23/12 at 6:00pm S12 CNA raised her hand and attempted to hit her. Resident #3 was in Immediate Jeopardy after this allegation was reported and the Registered Nurse (RN) Weekend Supervisor (S8 RN) failed to immediately remove Certified Nursing Assistant (CNA) (S12 CNA) from resident care. The facility failed to: 1. follow facility policy and procedure and ensure the allegation was reported immediately to the administrator or his designee; 2. follow policy and procedure and immediately begin investigation; take all necessary steps to prevent further abuse while the investigation was in progress by not suspending the alleged perpetrator (S 12 CNA) pending the completion of the investigation. The facility allowed the alleged perpetrator (S12 CNA) to continue to work in the facility from 03 23/12 through 03/25/12 in a unit near Resident #3 after an allegation of potential physical abuse was reported to the Registered Nurse Weekend Supervisor (S8 RN); 3. ensure Resident #3 was observed at all times by an assigned staff member until another directive was given per policy. The Immediate Jeopardy was removed for Resident #3 on 03/25/12 at 9:53pm when S12 CNA clocked/punched out on the time clock and left the facility. The deficient practice remains for all residents as a system has not been put into place to correct the deficient practice. The administrator was notified of the Immediate Jeopardy situation on 4/3/12 at 11:36 a.m. Findings: Review of the facility's Abuse/Neglect Reporting-Resident policy and procedure with an original date of 04/06 and latest revision date of 06/23/09 revealed in part: Page 2 of 3: 3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, an occurrence will be reported immediately to the administrator or his or her designee of the facility who will immediately notify the Regional and the appropriate state officials. 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until complete. 5. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. Further review of the Abuse and Neglect Procedure revealed: If you witness any type of abuse, you must do the following: 1. Do not leave the victim alone with the predator. Put the light on and call for the nurse. 2. Call the DON and the Administrator as soon as possible. 3. You as a nurse will be given a directive if law enforcement is to be notified. 4. The MD (doctor/physician), RP (Responsible Party) must be notified immediately. 5. The predator must be observed at all times by an assigned staff member till another directive is given. 6. Any and all witnesses must give a written statement shortly after the incident which is thorough and factual. 7. The nurse is to thoroughly document all data and the entire incident in the nurses notes as soon as possible while the details are fresh in your mind. During an interview on 4/3/12 at 11:36 am with S1 Administrator, S3 RN Corporate Nurse and S2 DON they all stated and agreed the policy and procedure dated 4/06 and revised 6/23/09 were the most current. Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3 is Vent Dependent, Tube Feed, able to Communicate with a Valve and cognitively intact. During an interview on 04/02/12 at 1:15 pm Resident #3 stated last week on Friday night the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed the CNA ' s arm and told her that she better not ever try to hit her again. She stated the CNA had come in to change her. Resident #3 further stated the CNA had headphones on with plugs in her ear. She stated the CNA never talked to or greeted her, even with previous care. She sated she is usually rough and mean; but never tried to hurt her before. Resident #3 stated she waited until after 10:00pm to report to the nurse because of fear of retaliation and wanted to make sure the CNA was off the shift. She stated she was still afraid until she heard she had been let go the following Monday. She acknowledged that S12 CNA did not work with her and she did not see her after Friday night. She states she understands the CNA was still working, but not allowed to work with her. Review of the facility Time Card Alternative Report date range 3/16/12 to 3/31/12 revealed S12 CNA worked on the TDC (Technically Dependent Care) Unit. The computerized documented punches included in part: Friday 03/23/12 1:53 pm to 9:53 pm total hours = 8 Saturday 03/24/12 Blank Sunday 03/25/12 1:52 pm to 9:53 pm total hours = 8.25 Personnel record review for S12 CNA revealed in part: A date of hire 02/07/12, job description dated 02/07/12, In-services training totaling 8 hours dated 02/07/12, Criminal Background Check dated 02/07/12 with results as of 02/08/12 no record located nationwide, Sex offender Registry Search with results as of 2/8/12 no results located. Review of S12 CNA's Constitute Reasons for Immediate Termination revealed the form was signed on 02/07/12 (Verbal and physical abuse of a resident was listed first on the list of 12 areas). A Personnel Action Form dated 3/23/12 indicated the following: Warning/Separation (with separation circled) was issued today, named S12 CNA and department. The areas checked were 9. Improper Conduct and 11. Violation of company rules. Under remarks: Employee allegedly raised her hand to physically strike a resident ___ (initials of Resident #3). See attached statement and grievance. She is terminated for mental abuse. Resident is fearful of employee. The form was signed and dated 03/26/12 by S2 DON, S12 CNA and S1 Administrator. There was a separation notice dated 04/04/12 with last day of work 03/25/12 and reason for separation was stated as employee raised her hand to allegedly strike a resident. This is subsequently voiced fear of this employee. Employee refused to suplly statement during investigation.. Review of the facility In-Service Training & Signature Sheet revealed in part on March 5, 2012 at 10:00 am S12 CNA had additional abuse & neglect training on reporting to immediate supervisor. Review of the facility In-Service Training & Signature Sheet revealed on March 20, 2012 at 10:00 am S12 CNA had additional abuse & neglect procedure and reporting in-services. Review of the facility Signature Sheet & Department Head In-Service for Possible Abuse and/or Neglect on March 9, 2012 revealed in part: 1. Anytime you are the department head supervisor on the weekend and a resident or family member alleges that they have been abused in any manner, you must immediately notify the administrator and the DON. You will be given further directives from that point. 2. Alleged abuse includes physical, verbal, emotional, sexual. 3. If allegations are made, you must immediately get any witness statements from staff who saw or heard anything. These are to be given to the Administrator or DON as soon as possible. 4. Do not discuss the matter with any one not directly involved in the situation. 5. Do not call the responsible party nor MD until directed to do so by the administrator or DON. 7. If the weekend RN Supervisor is in the building, summon her to assist with the situation, but make sure you or her contact the DON or administrator immediately. Review of the facility's Resident Grievance & Complaint Form dated 03/24/12 documents in part: Person making complaint ____ (named Resident #3). Explanation/Nature of Complaint: Stated that the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed CNA arm and told her that she better not ever try to hit her again. She does not want this CNA in her room. She is very afraid of her. The form was signed by S8 RN, S9 LPN and S7 RN Weekend Supervisor. The area for date was blank. Further review of the form in another type of ink pen, the following was written in the areas: Action Taken: Terminated, Resolved: Yes was circled, Further Action Necessary: No was circled and Follow-up: Employee was terminated. This section was signed by S2 DON. Review of the OTIS (Online Tracking Incident/Investigation System) Report # documented an incident occurred and revealed in part: Events: Occurred on 03/23/12 at 6:00 pm, discovered 03/23/12 at 10:30 pm, Findings & determination 03/26/12 at 9:00 am and entered 03/26/12 at 12:56 pm. Contact/Reporter: _____ (named S2 DON) Accused/Allegation: ____(named S12 CNA) Abuse: Emotional Substantiated Victims: ____ (named Resident #3) Case Notes: Description: It was reported to me, the DON this morning at 8:30 a.m. that this client ____ (named Resident #3)was emotionally abused on Friday night by the aide ____ (named S12 CNA). The resident stated that she had put on her call light saying she needed to be changed. She stated the aid came into the room, wearing ear phones and began changing her. She said all of a sudden the aide raised her hand to strike her. She stated she grabbed the aides hand and told her, " You better not! " She stated she was fearful of the aide and did not want her back in her room anymore. Summary in part: The resident stated this happened about 6pm; however she did not report it to any staff member until 10:30 pm. At that time she reported it to ____ (named S8 RN) when she came into the room on her rounds. Someone did take S12 CNA Saturday shift; but she worked on Sunday evening. She was not allowed to render care to the resident. She refused to write a statement. She denied the allegation. There was no documented evidence that an incident report was completed. There was no documented evidence the incident details were noted in Resident #3's nurses notes. There was no documented evidence of follow-ups to assess, check on, and supervise or conversations with Resident #3 or S12 CNA from the initial grievance on 03/24/12 until the OTIS report on 03/26/12. During an interview on 4/2/12 at 3:00 pm with S2 DON she stated she was first made aware of the incident on 3/26/12 during the review of the weekend QA (Quality Assurance) report. She stated she began investigation and submitted an OTIS report. She stated both RN's know they should have notified her. During an interview on 04/02/12 at 3:10 pm with S9 LPN she stated the first she learned of the incident was on Saturday evening. She acknowledged signing the grievance/complaint form completed by S8 RN. She stated the weekend supervisor was made aware. She stated S12 CNA did not work on Saturday; but she did come to work on Sunday at 2:00 pm; however she and one of the other aides traded patients in this area. She acknowledged being familiar with Abuse protocol, policy and procedures. She offered no other explanation as to why she did not notify DON or administrator. During a telephone interview on 04/02/12 at 3:50 pm with S8 RN she stated she did talk with Resident #3 on Friday night about 10:30 pm. She stated the CNA was gone already and not scheduled to come back until middle of next week. She supposedly had gotten someone to work for her. She stated she completed a grievance/complaint form and gave to the weekend supervisor. She stated she was surprised when she came on duty Sunday at 7:00pm and saw _____ (named S12 CNA). She stated she ask other nurse why is she working. She stated the CNA came on at 2:00 pm and was allowed to work on the other end of unit and not area or with Resident #3. She stated she came on at 7 pm and the weekend supervisor was already gone. She acknowledged awareness of facility policy & procedure for allegations of abuse. She stated she used to be a supervisor here at the facility. She offered no explanation as to why she did not call the administrator or DON. During a telephone interview on 04/02/12 at 4:00 pm with S7 RN Weekend Supervisor she stated when she came in on Saturday morning she was told to go check on _____ (named Resident #3) by ____ (named S8 RN). She stated the resident was still asleep so she went back to S8RN and ask for specifics of what happened. She stated she told S8 RN to write it up and she would have ___ (named S9 LPN) sign also. She stated she made rounds. She stated later when she went to ask Resident #3 what happened the resident stated she didn't want to talk about it or cause trouble for anyone. She stated she did not want retaliation. S7 RN stated she assured the resident their job is to care for her. She received permission to pull up a chair and sit down. She stated Resident #3 said the CNA takes care of her, but never talks to her, she is rough with her, she raised her hand like going to hit her, but nothing happened because she was looking right at her and caught her hand, grabbed it and told her she better not ever hit her. S7 RN acknowledged she allowed S12 CNA to return to work on Sunday 03/25/12 at 2:00 pm. She stated the CNA she had swapped with couldn't fulfill the commitment so she had to come in. She stated she worked on the other end of hall/unit. She stated she was not aware she couldn't at all. She thought it just had to be in another area. She stated neither one of the nurses told her that needed to be done. She stated she was familiar with facility policy & procedures on abuse. She stated she called the DON on Saturday, but did not get a response. She stated she placed a copy of the grievance/complaint form under the door of the DON and Administrator so they would see it on Monday morning and follow up. She acknowledged that at no time did she question S12 CNA or do a formal investigation. She stated she did not try to call the Administrator or retry the DON, because she put info under their door. During an interview on 4/3/12 at 10:00 am with S2 DON she stated she had a miss call from the facility. She stated she called back and _____ (named S17 LPN) the LPN from unit IV checked all the units and stated no one needed her. She acknowledged she never asked for the weekend supervisor to see if she had called for her. She stated she learned later that it was _____ (named S9 LPN). S2 DON stated she has formal 1.5 hour detailed and informal highlighted/abbreviated in-services all the time. She stated the staff sign off acknowledging understanding. She stated the only person that does not attend in-services regularly is ___ (named S8), because she has two jobs. She stated but she knows all the rules, regulations and protocol she use to be a supervisor here. She stated she does not understand why they did not call her; but she has done a warning write-up statement on both Nurses.

Based on observations, record review, and interview the facility failed to ensure the provision of care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for a resident to have decreased or no problems with anxiety for 1 (Resident #3) of 5 sampled residents (Residents #1, 2#, #3, #4, and #5). A cognitively intact resident (Resident #3) reported that on 03/23/12 at 6:00pm S12 CNA raised her hand and attempted to hit her. Resident #3 was in Immediate Jeopardy after this allegation was reported and the Registered Nurse (RN) Weekend Supervisor (S8 RN) failed to immediately remove Certified Nursing Assistant (CNA) (S12 CNA) from resident care. The facility failed to: 1. ensure the resident's right to be free from mental or emotional abuse and anxiety; 2. follow facility policy and procedure and ensure the allegation was reported immediately to the administrator or his designee; 3. follow policy and procedure and immediately begin an investigation; take all necessary steps to prevent further abuse while the investigation was in progress by not suspending the alleged perpetrator (S 12 CNA) pending the completion of the investigation. The facility allowed the alleged perpetrator (S12 CNA) to continue to work in the facility in a unit near Resident #3 after an allegation of potential physical abuse was reported to the Night Unit Nurse (S8 RN) and the Registered Nurse Weekend Supervisor (S7 RN); 4. ensure Resident #3 was observed at all times by an assigned staff member until another directive was given per policy. The Immediate Jeopardy was removed for Resident #3 on 03/25/12 at 9:53pm when S12 CNA clocked/punched out on the time clock and left the facility. The deficient practice remains for all residents as a system has not been put into place to correct the deficient practice The administrator was notified of the Immediate Jeopardy situation on 4/3/12 at 11:36 a.m. Findings: During an interview on 4/2/12 at 1:15 pm with Resident # 3 she stated last week on Friday night the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed CNA arm and told her that she better not ever try to hit her again. She stated the CNA had come in to change her. She had headphones on with plugs in her ear. She stated the CNA never talked to or greeted her, even with previous care. She sated she is usually rough and mean; but never tried to hurt her before. Resident #3 stated she waited until after 10:00 pm to report to nurse because of fear of retaliation and wanted to make sure she was off the shift. She acknowledged that S12 CNA did not work with her and she did not see her after Friday night. She states she understands she was still working, but not allowed to work with her. Observations on 4/2/12 at 1:15 pm of Resident #3 revealed her to be anxious. She verbalized she was still afraid until she heard the aide had been let go the following Monday. She states she is better now, but still concerned. She stated no one is telling her anything or her family about the outcome of her complaint/grievance. This surveyor informed her that to my understanding the aide was terminated. On 4/3/12 at 10:30 am this surveyor assured Resident #3 the aide was terminated from the documentation that was reviewed. Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3 is Vent Dependent, Tube Feed, able to Communicate with a Valve and cognitively intact. Record review of Resident #3's care plan updated on 1/28/12 with problem [DIAGNOSES REDACTED]. The approaches in part indicated monitoring and documentation of any mood/behavior, maintain a safe environment, psychotherapy and encourage to talk. Record review of the Psychotherapy Progress Notes for Resident #3 dated 3/29/12 revealed in part: Symptoms of depression, symptoms of anxiety and Strong potential for social isolation were checked. Problem: patient states she cannot talk until respiratory clears her trach. Interventions: therapist placed emphasis that resident has no history of reporting staff and she is considered a valid and reliable informant. Commended client for taking responsibility. Validation & Reality Therapy regarding incident reported. Review of the facility Resident Grievance & Complaint Form dated 3/24/12 documents in part: Person making complaint ____ (named Resident #3). Explanation/Nature of Complaint: Stated that the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed CNA arm and told her that she better not ever try to hit her again. She does not want this CNA in her room. She is very afraid of her. The form was signed by S8 RN, S9 LPN and S7 RN Weekend Supervisor. The area for date was blank. Further review of the form in another type of ink pen, the following was written in the areas: Action Taken: Terminated, Resolved: Yes was circled, Further Action Necessary: No was circled and Follow-up: Employee was terminated. This section was signed by S2 DON. There was no documented evidence that an incident report was completed. There was no documented evidence the incident details was noted in Resident # 3 ' s nurse ' s notes or communicated between shifts for follow-up. During an interview on 4/2/12 at 3:00 pm with S2 DON she stated she was first made aware of the incident on 4/26/12 during the review of the weekend QA (Quality Assurance) report. She stated she began investigation and submitted an OTIS report. She stated both RN ' s know they should have notified her. During an interview on 4/3/12 at 10:00 am with S2 DON she stated she had a miss call from the facility. She stated she called back and _____ (named S17 LPN) the LPN from unit IV checked all the units and stated no one needed her. She acknowledged she never asked for the weekend supervisor to see if she had called for her. She stated she learned later that it was _____ (named S9 LPN) that had placed a call to her. During an interview on 4/2/12 at 3:10 pm with S9 LPN she stated the first she learned of the incident was on Saturday evening. She acknowledged signing the grievance/complaint form completed by S8RN. She stated the weekend supervisor was made aware. She stated S12 CNA did not work on Saturday; but she did come to work on Sunday at 2:00 pm; however she and one of the other aides traded patients in this area. She acknowledged being familiar with Abuse protocol, policy and procedures. She offered no explanation as to why she did not notify the Administrator or DON. During a telephone interview on 4/2/12 at 3:50 pm with S8 RN she stated she did talk with Resident #3 on Friday night about 10:30 pm. She stated the CNA was gone already and not scheduled to come back until middle of next week. She supposedly had gotten someone to work for her. She stated she completed a grievance/complaint form and gave it to the weekend supervisor. She stated she was surprised when she came on duty Sunday at 7:00pm and saw _____ (named S12 CNA). She stated the weekend supervisor was gone already. She stated she asked the other nurse "why is she working?" She stated she was told the CNA came on at 2:00 pm and was allowed to work on the other end of unit and not the area or with Resident #3. She acknowledged awareness of facility policy & procedure for allegations of abuse. She stated she used to be a supervisor here at the facility. She offered no explanation as to why she did not call the administrator or DON. During a telephone interview on 4/2/12 at 4:00 pm with S7 RN Weekend Supervisor she stated when she came in on Saturday morning she was told to go check on _____ (named Resident #3) by ____ (named S8 RN). She stated the resident was still asleep so she went back to S8RN and ask for specifics of what happened. She stated she told S8 RN to write it up and she would have ___ (named S9 LPN) sign also. She stated she made rounds. She stated later when she went to ask Resident #3 what happened the resident stated she didn't want to talk about it, or cause trouble for anyone. She stated she did not want retaliation. S7 RN stated she assured the resident their job is to care for her. She received permission to pull up a chair and sit down. She stated Resident #3 said the CNA takes care of her, but never talks to her, she is rough with her, she raised her hand like going to hit her, but nothing happened because she was looking right at her and caught her hand, grabbed it and told her she better not ever hit her. S7 RN acknowledged she allowed S12 CNA to return to work on Sunday 3/25/12 at 2:00 pm. She stated the CNA she had swapped with couldn't fulfill the commitment so she had to come in. She stated she worked on the other end of hall/unit. She stated she was not aware she couldn't at all. She thought it just had to be in another area. She stated neither one of the nurses told her that needed to be done. She stated she was familiar with facility's policy & procedures on abuse. She stated she called the DON on Saturday, but did not get a response. She stated she placed a copy of the grievance/complaint form under the door of the DON and Administrator so they would see it on Monday morning and follow up. She acknowledged that at no time did she question S12 CNA or do a formal investigation. She stated she did not try to call the Administrator or retry the DON because she had put info under their door. Review of the facility Abuse/Neglect Reporting-Resident policy and procedure with an original date of 04/06 and latest revision date of 6/23/09 revealed in part: Page 2 of 3: 3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, an occurrence will be reported immediately to the administrator or his or her designee of the facility who will immediately notify the Regional and the appropriate state officials. 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until complete. 5. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. Review of the facility Signature Sheet & Department Head In-Service for Possible Abuse and/or Neglect on March 9, 2012 revealed in part: 1. Anytime you are the department head supervisor on the weekend and a resident or family member alleges that they have been abused in any manner, you must immediately notify the administrator and the DON. You will be given further directives from that point. 2. Alleged abuse includes physical, verbal, emotional, sexual. 3. If allegations are made, you must immediately get any witness statements from staff who saw or heard anything. These are to be given to the Administrator or DON as soon as possible. 4. Do not discuss the matter with any one not directly involved in the situation. 5. Do not call the responsible party nor MD until directed to do so by the administrator or DON. 7. If the weekend RN Supervisor is in the building, summon her to assist with the situation, but make sure you or her contact the DON or administrator immediately. During an interview on 4/3/12 at 11:36 am with S1 Administrator, S3 RN Corporate Nurse and S2 DON they all stated and agreed the policy and procedure dated 4/06 and revised 6/23/09 were the most current. They also stated, the facility is in the plan of correction mode for other outstanding concerns and the staff just had in-services covering the same issues. During an interview on 4/3/12 at 3:00 pm with S2 DON she stated she has formal 1.5 hour detailed and informal highlighted/abbreviated in-services all the time. She stated the staff sign off acknowledging understanding. She stated the only person that does not attend in-services regularly is ___ (named S8RN), because she has two jobs. She stated but she knows all the rules, regulations and protocol she use to be a supervisor here. She stated she does not understand why they did not call her; but she has done a warning write-up statement on both Nurses. During an interview on 4/3/12 at 2:10 pm with S2 DON she acknowledged there was no documented evidence that an incident report was completed, there were no details in the nurse ' s notes from 3/23/12 through 3/26/12 and there was no notification to the family or physician.

Based on record review and interview the facility failed to be administered in a manner that enabled it to effectively maintain the highest practicable well being of its residents to ensure the residents were free from mental/emotional abuse, protection after and during the investigative phase for 1 (Resident #3) of 5 sampled residents (Residents #1, 2#, #3, #4, and #5). A cognitively intact resident (Resident #3) reported that on 03/23/12 at 6:00pm S12 CNA raised her hand and attempted to hit her. Resident #3 was in Immediate Jeopardy after this allegation was reported and the Registered Nurse (RN) Weekend Supervisor (S8 RN) failed to immediately remove Certified Nursing Assistant (CNA) (S12 CNA) from resident care. The facility failed to: 1. follow facility policy and procedure and ensure the allegation was reported immediately to the administrator, DON or designee; 2. follow policy and procedure and immediately begin an investigation; take all necessary steps to prevent further abuse while the investigation was in progress by not suspending the alleged perpetrator (S 12 CNA) pending the completion of the investigation. The facility allowed the alleged perpetrator (S12 CNA) to continue to work in the facility in a unit near Resident #3 after an allegation of potential physical abuse was reported to the Registered Nurse Weekend Supervisor (S8 RN); 3. have a system in place to ensure Resident #3 was observed at all times by an assigned staff member until another directive was given per policy; 4. have a system in place to ensure adequate supervision of and conversations with Resident #3 to reduce anxiety and fears that S12 CNA had potential access to her; 5. have a system in place to ensure effectiveness of abuse trainings employees received. The Immediate Jeopardy was removed for Resident #3 on 03/25/12 at 9:53pm when S12 CNA clocked/punched out on the time clock and left the facility. The deficient practice remains for all residents as a system has not been put into place to correct the deficient practice. The administrator was notified of the Immediate Jeopardy situation on 4/3/12 at 11:36 a.m. Findings: Review of the facility's Abuse/Neglect Reporting-Resident policy and procedure with an original date of 04/06 and latest revision date of 06/23/09 revealed in part: Page 2 of 3: 3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, an occurrence will be reported immediately to the administrator or his or her designee of the facility who will immediately notify the Regional and the appropriate state officials. 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until complete. 5. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. Further review of the Abuse and Neglect Procedure revealed: If you witness any type of abuse, you must do the following: 1. Do not leave the victim alone with the predator. Put the light on and call for the nurse. 2. Call the DON and the Administrator as soon as possible. 3. You as a nurse will be given a directive if law enforcement is to be notified. 4. The MD (doctor/physician), RP (Responsible Party) must be notified immediately. 5. The predator must be observed at all times by an assigned staff member till another directive is given. 6. Any and all witnesses must give a written statement shortly after the incident which is thorough and factual. 7. The nurse is to thoroughly document all data and the entire incident in the nurses notes as soon as possible while the details are fresh in your mind. During an interview on 4/3/12 at 11:36 am with S1 Administrator, S3 RN Corporate Nurse and S2 DON they all stated and agreed the policy and procedure dated 4/06 and revised 6/23/09 were the most current. Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 is Vent Dependent, Tube Feed, able to Communicate with a Valve and cognitively intact. During an interview on 04/02/12 at 1:15 pm Resident #3 stated last week on Friday night the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed the CNA ' s arm and told her that she better not ever try to hit her again. She stated the CNA had come in to change her. Resident #3 further stated the CNA had headphones on with plugs in her ear. She stated the CNA never talked to or greeted her, even with previous care. She sated she is usually rough and mean; but never tried to hurt her before. Resident #3 stated she waited until after 10:00pm to report to the nurse because of fear of retaliation and wanted to make sure the CNA was off the shift. She stated she was still afraid until she heard she had been let go the following Monday. She acknowledged that S12 CNA did not work with her and she did not see her after Friday night. She states she understands the CNA was was still working, but not allowed to work with her. Review of the facility Time Card Alternative Report date range 3/16/12 to 3/31/12 revealed S12 CNA worked on the TDC (Technically Dependent Care) Unit. The computerized documented punches included in part: Friday 03/23/12 1:53 pm to 9:53 pm total hours = 8 Saturday 03/24/12 Blank Sunday 03/25/12 1:52 pm to 9:53 pm total hours = 8.25 Personnel record review for S12 CNA revealed in part: A date of hire 02/07/12, job description dated 02/07/12, In-services training totaling 8 hours dated 02/07/12, Criminal Background Check dated 02/07/12 with results as of 02/08/12 no record located nationwide, Sex offender Registry Search with results as of 2/8/12 no results located. Review of S12 CNA's Constitute Reasons for Immediate Termination form revealed the form was signed on 02/07/12 (Verbal and physical abuse of a resident was listed first on the list of 12 areas). A Personnel Action Form dated 3/23/12 indicated the following: Warning/Separation (with separation circled) was issued today, named S12 CNA and department. The areas checked were 9. Improper Conduct and 11. Violation of company rules. Under remarks: Employee allegedly raised her hand to physically strike a resident ___ (initials of Resident #3). See attached statement and grievance. She is terminated for mental abuse. Resident is fearful of employee. The form was signed and dated 03/26/12 by S2 DON, S12 CNA and S1 Administrator. There was a separation notice dated 04/04/12 with last day of work 03/25/12 and reason for separation was stated. Review of the facility In-Service Training & Signature Sheet revealed in part on March 5, 2012 at 10:00 am S12 CNA had additional abuse & neglect training on reporting to immediate supervisor. Review of the facility In-Service Training & Signature Sheet revealed on March 20, 2012 at 10:00 am S12 CNA had additional abuse & neglect procedure and reporting in-services. Review of the facility Signature Sheet & Department Head In-Service for Possible Abuse and/or Neglect on March 9, 2012 revealed in part: 1. Anytime you are the department head supervisor on the weekend and a resident or family member alleges that they have been abused in any manner, you must immediately notify the Administrator and the DON. You will be given further directives from that point. 2. Alleged abuse includes physical, verbal, emotional, sexual. 3. If allegations are made, you must immediately get any witness statements from staff who saw or heard anything. These are to be given to the Administrator or DON as soon as possible. 4. Do not discuss the matter with any one not directly involved in the situation. 5. Do not call the responsible party nor MD until directed to do so by the Administrator or DON. 7. If the weekend RN Supervisor is in the building, summon her to assist with the situation, but make sure you or her contact the DON or Administrator immediately. Review of the facility's Resident Grievance & Complaint Form dated 03/24/12 documents in part: Person making complaint ____ (named Resident #3). Explanation/Nature of Complaint: Stated that the CNA ___ (named S12 CNA) raised her hand to hit her and she grabbed CNA arm and told her that she better not ever try to hit her again. She does not want this CNA in her room. She is very afraid of her. The form was signed by S8 RN, S9 LPN and S7 RN Weekend Supervisor. The area for date was blank. Further review of the form in another type of ink pen, the following was written in the areas: Action Taken: Terminated, Resolved: Yes was circled, Further Action Necessary: No was circled and Follow-up: Employee was terminated. This section was signed by S2 DON. Review of the OTIS (Online Tracking Incident/Investigation System) Report # documented an incident occurred and revealed in part: Events: Occurred on 03/23/12 at 6:00 pm, discovered 03/23/12 at 10:30 pm, Findings & determination 03/26/12 at 9:00 am and entered 03/26/12 at 12:56 pm. Contact/Reporter: _____ (named S2 DON) Accused/Allegation: ____(named S12 CNA) Abuse: Emotional Substantiated Victims: ____ (named Resident #3) Case Notes: Description: It was reported to me, the DON this morning at 8:30 a.m. that this client ____ (named Resident #3)was emotionally abused on Friday night by the aide ____ (named S12 CNA). The resident stated that she had put on her call light saying she needed to be changed. She stated the aid came into the room, wearing ear phones and began changing her. She said all of a sudden the aide raised her hand to strike her. She stated she grabbed the aides hand and told her, " You better not! " She stated she was fearful of the aide and did not want her back in her room anymore. Summary in part: The resident stated this happened about 6:00pm; however she did not report it to any staff member until 10:30 pm. At that time she reported it to ____ (named S8 RN) when she came into the room on her rounds. Someone did take S12 CNA Saturday shift; but she worked on Sunday evening. She was not allowed to render care to the resident. She refused to write a statement. She denied the allegation. There was no documented evidence that an incident report was completed. There was no documented evidence the incident details was noted in Resident #3 ' s nurses notes. There was no documented evidence of follow-ups to assess, check on, and supervise or conversations with Resident #3 or S12 CNA from the initial grievance on 03/24/12 until the OTIS report on 03/26/12. During an interview on 04/02/12 at 3:10 pm with S9 LPN she stated the first she learned of the incident was on Saturday evening. She acknowledged signing the grievance/complaint form completed by S8 RN. She stated the weekend supervisor was made aware. She stated S12 CNA did not work on Saturday; but she did come to work on Sunday at 2:00 pm; however she and one of the other aides traded patients in this area. She acknowledged being familiar with Abuse protocol, policy and procedures. She offered no other explanation as to why she did not notify DON or Administrator. During a telephone interview on 04/02/12 at 3:50 pm with S8 RN she stated she did talk with Resident #3 on Friday night about 10:30 pm. She stated the CNA was gone already and not scheduled to come back until middle of next week. She supposedly had gotten someone to work for her. She stated she completed a grievance/complaint form and gave to the weekend supervisor. She stated she was surprised when she came on duty Sunday at 7:00pm and saw _____ (named S12 CNA). She stated she ask other nurse why is she working. She stated the CNA came on at 2:00 pm and was allowed to work on the other end of unit and not area or with Resident #3. She stated she came on at 7 pm and the weekend supervisor was already gone. She acknowledged awareness of facility policy & procedure for allegations of abuse. She stated she used to be a supervisor here at the facility. She offered no explanation as to why she did not call the Administrator or DON. During a telephone interview on 04/02/12 at 4:00 pm with S7 RN Weekend Supervisor she stated when she came in on Saturday morning she was told to go check on _____ (named Resident #3) by ____ (named S8 RN). She stated the resident was still asleep so she went back to S8RN and ask for specifics of what happened. She stated she told S8 RN to write it up and she would have ___ (named S9 LPN) sign also. She stated she made rounds. She stated later when she went to ask Resident #3 what happened the resident stated she didn ' t want to talk about it or cause trouble for anyone. She stated she did not want retaliation. S7 RN stated she assured the resident their job is to care for her. She received permission to pull up a chair and sit down. She stated Resident #3 said the CNA takes care of her, but never talks to her, she is rough with her, she raised her hand like going to hit her, but nothing happened because she was looking right at her and caught her hand, grabbed it and told her she better not ever hit her. S7 RN acknowledged she allowed S12 CNA to return to work on Sunday 03/25/12 at 2:00 pm. She stated the CNA she had swapped with couldn ' t fulfill the commitment so she had to come in. She stated she worked on the other end of hall/unit. She stated she was not aware she couldn ' t at all. She thought it just had to be in another area. She stated neither one of the nurses told her that needed to be done. She stated she was familiar with facility policy & procedures on abuse. She stated she called the DON on Saturday, but did not get a response. She stated she placed a copy of the grievance/complaint form under the door of the DON and Administrator so they would see it on Monday morning and follow up. She acknowledged that at no time did she question S12 CNA or do a formal investigation. She stated she did not try to call the Administrator or retry the DON, because she put info under their door. During an interview on 4/3/12 at 10:00 am with S2 DON she stated she had a miss call from the facility. She stated she called back and _____ (named S17 LPN) the LPN from unit IV checked all the units and stated no one needed her. She acknowledged she never asked for the weekend supervisor to see if she had called for her. She stated she learned later that it was _____ (named S9 LPN). S2 DON stated she has formal 1.5 hour detailed and informal highlighted/abbreviated in-services all the time. She stated the staff sign off acknowledging understanding. She stated the only person that does not attend in-services regularly is ___ (named S8RN), because she has two jobs. She stated but she knows all the rules, regulations and protocol she use to be a supervisor here. She stated she does not understand why they did not call her; but she has done a warning write-up statement on both Nurses.

Based on record review and interview the facility failed to ensure a resident's right to be free from sexual abuse for 3 of 3 (Resident's #1, #7 and R4) cognitively impaired residents who are bedbound, for 1 of 7 sampled residents (Resident #2) who is unable to verbalize but is able to communicate by writing and is only able to get out of bed with total assistance in a universe of 7 and a resident's right to interventions to prevent this resident from sexually abusing another resident for 1 resident (Resident #6) in a sample of 7. On 02/25/12, Resident #7 alleged Resident #6 sexually abused him. The facility investigation did not determine if this allegation did or did not occur. On 02/28/12 the Care Plan of Resident #6 was updated to redirect and remove from inappropriate behavior occurrences. Resident #1 is cognitively impaired and bedbound. Resident #1, Resident #2, Resident #6, Resident #7 and R4 were in Immediate Jeopardy of possible sexual abuse when the care plan for Resident #6 was updated on 02/28/12 and the facility failed to care plan and implement interventions to increase supervision and prevent Resident #6 from inappropriate sexual behavior occurrences to residents who are bedbound and cognitively impaired or unable to verbalize. The IJ continued on 03/13/12 and Resident #1 and Resident #2 were in an Immediate Jeopardy when S11/CNA Supervisor observed Resident #6 in Resident #1's room standing next to Resident #1's bed but did not immediately intervene, then returned and Resident #6 had his hand in Resident #1's diaper, and did not immediately intervene. When S11/CNA Supervisor and the nurse returned, Resident #6 had shut the door and was standing by Resident #2's bed and repeated, "I'll be back, I'll be back" as he was removed from the room. The IJ ended on 03/13/12 at 9:00 pm for Resident #1, Resident #2 , Resident #6, Resident #7 and R4 when the facility implemented 1 to 1 supervision for Resident #6. The facility failed to follow Resident 36's plan of care to remove him from inappropriate behavior occurrences. Findings: Record review revealed on 02/25/12 an incident of alleged sexual abuse to Resident #7 by Resident #6 was reported and investigated. The facility could or could not determine if this allegation had or had not occurred. Review of the Care Plan for Resident #6, dated 12/23/11, revealed under Problem Onset of, in part, history of being verbally abusive and physically confrontational with staff and other residents, the Care Plan had been updated in writing to provide redirection and removal from inappropriate behavior occurrences. In an interview on 03/20/12 11:45 am, S10/RN Care Plan stated, "I updated Resident #6's care plan with the intervention on 02/28/12 after our department head meeting and we were informed about the alleged incident with Resident #7. I did not have an IDT meeting but some of the other nurses and myself discussed the problem. I did not care plan other interventions such as increasing supervision." Review of an OTIS report revealed on 03/13/12 a resident to resident sexual abuse had occurred to Resident #1 by Resident #6. This was documented as witnessed by S11/CNA Supervisor. In an interview on 03/19/12 at S11/ CNA Supervisor stated, "I had an aide to call in the night of 03/13/12 and I took her place on Wing 1. I was going down the hall at about 8:25 pm, when I noticed out of the corner of my eye Resident #6 was in Resident #1' and #2's room. He was standing by his (Resident #1) bed with one hand on the head board. I walked on by then I thought, "What's he doing in Resident #1's room?' I turned around and went back and then I saw Resident #6's hand in Resident #1's diaper. I know Resident #6 can be verbally abusive to women so I went to get the male LPN, S14/LPN, who was on that Wing. It was about 2 minutes and when we go back, the door was closed. I opened it and Resident #6 was then standing by Resident #2's bed with his hands on the side rails. Resident #6 kept saying, "he can't talk, he can't talk". Resident #6 said to Resident #2, "I'll be back. I'll be back" then he exited the building to the patio in the back of the building to smoke. I called S1/Administrator and S2/DON immediately and spoke to S2/DON but couldn't reach S1/Administrator. S2/DON gave me instructions to have S14/LPN to call the police and to get Resident #6 and bring him to the front Day Room in the Main Building. and sit there with him until the police arrived. Then S1/Administrator was here in about 5 minutes. I then stayed with Resident #6 until the police arrived, which was an hour and a half later. After police came, we gave our statements. After that, S1/Administrator went to get later. After police came, we gave our statements. After that, S1/Administrator went to get Resident #6 from S14/LPN, who was 1 on 1 with him, and explained that they moving Resident #6 to another room. Resident #6 was upset. S1/Administrator went out with him to smoke and then we gave him a cup of coffee. Then S1/Administrator and I walked Resident #6 to .... (a semi-private room which was not occupied in the Annex). Then I instructed S17/CNA to stay at his room and make sure he didn't come out of the room but to check on him to see if he needed anything. Then I left for the night." Review of an IDT Team Note dated 02/29/12 and signed as completed by S2/DON, revealed, in part, she had verbally inserviced the CNAs in the Main Building about the incident of 02/25/12. It further stated they were advised to immediately report anything inappropriate from a resident or staff member to their immediate supervisor. The note continued that S11/CNA Supervisor had been directed to inservice the evening and night shifts. There was no documented evidence interventions to supervise and prevent inappropriate behavior occurrences were implemented. In an interview on 03/20/12 at 10:00 am, S2/DON acknowledged specific interventions were not put in place for Resident #6. Review of a written " Verbal Inservice " dated 02/29/12 2-10 shift and signed by S11/CNA Supervisor, revealed, in part, they were to pay special attention to Resident #6 and his whereabouts and if they saw him in any other resident ' s room or bathroom, to report it to the nurse immediately." In an interview on 03/20/12 at 12:35 pm, S11/CNA Supervisor acknowledged she did not go into the room when she first saw Resident #6 at Resident #1's bed and then did not stop Resident #6 when she saw his hand in Resident #1's diaper.

Based on record review and interview the facility failed to be administered in a manner that enabled it to effectively maintain the highest practicable wellbeing of its residents to ensure those residents were free from sexual abuse. The facility failed to ensure a resident's right to be free from sexual abuse for 3 of 3 (Resident's #1, #7 and R4) cognitively impaired residents who are bedbound, for 1 of 7 sampled residents (Resident #2) who is unable to verbalize but is able to communicate by writing and is only able to get out of bed with total assistance in a universe of 7 and a resident's right to interventions to prevent this resident from sexually abusing another resident for 1 resident (Resident #6) in a sample of 7. On 02/25/12, Resident #7 alleged Resident #6 sexually abused him. The facility investigation did not determine if this allegation did or did not occur. On 02/28/12 the Care Plan of Resident #6 was updated to redirect and remove from inappropriate behavior occurrences. Resident #1 is cognitively impaired and bedbound. Resident #1, Resident #2, Resident #6, Resident #7 and R4 were in Immediate Jeopardy of possible sexual abuse when the care plan for Resident #6 was updated on 02/28/12 and the facility failed to care plan and implement interventions to increase supervision and prevent Resident #6 from inappropriate sexual behavior occurrences to residents who are bedbound and cognitively impaired or unable to verbalize. The IJ continued on 03/13/12 and Resident #1 and Resident #2 were in an Immediate Jeopardy when S11/CNA Supervisor observed Resident #6 in Resident #1's room standing next to Resident #1's bed with his hand in Resident #1's diaper and left him unattended and did not intervene or redirect Resident #6. When S11/CNA Supervisor and the nurse returned, Resident #6 had shut the door and was standing by Resident #2's bed and repeated, "I'll be back, I'll be back" as he was removed from the room. The IJ ended on 03/13/12 at 9:00 pm for Resident #1, Resident #2 , Resident #6, Resident #7 and R4 when the facility implemented 1 to 1 supervision for Resident #6. The facility failed to: 1) have a system in place to identify hazards and risks in the bed bound resident's environment related to resident to resident abuse; 2) have a system in place to develop interventions to prevent the occurrence of resident to resident sexual abuse once the potential risk was identified; 3) have a system in place to ensure adequate supervision of Resident #6 to reduce other residents' risk of unwanted sexual advances; 4) have a system in place to identify bed bound, cognitively impaired residents as being high risk to sexual abuse from other resident; 5) have a system in place to ensure effectiveness of abuse training to immediately remove Resident #6 from inappropriate sexual behavior occurrences. Findings: Review of the facility's Abuse and Neglect policy, dated 04/06 and latest revision date of 06/23/09, revealed, in part, "5. During and after the investigation, the residents will be protected from harm through frequent supervision by staff." Review of an inservice training dated 03/05/12 at 10:00 am for all employees revealed, in part, alleged incidences of any type were to be reported to the supervisor immediately when the allegation was made. An attachment revealed "Recognizing the signs and Symptoms of Abuse/Neglect. Review of an Inservice Training as defined for possible abuse/and/or neglect, dated 03/12/12 and identified by the facility for department heads, revealed, in part, the procedure to follow if they were the department head supervisor and any allegation of abuse, including physical, verbal, emotional or sexual were made Record review revealed on 02/25/12 an incident of alleged sexual abuse to Resident #7 by Resident #6 was reported and investigated. The facility could or could not determine if this allegation had or had not occurred. Review of the Care Plan for Resident #6, dated 12/23/11, revealed under Problem Onset of, in part, history of being verbally abusive and physically confrontational with staff and other residents, the Care Plan had been updated in writing to provide redirection and removal from inappropriate behavior occurrences. In an interview on 03/20/12 11:45 am, S10/RN Care Plan stated, "I updated Resident #6's care plan with the intervention on 02/28/12 after our department head meeting and we were informed about the alleged incident with Resident #7. I did not have an IDT meeting but some of the other nurses and myself discussed the problem. I did not care plan other interventions such as increasing supervision." Review of an OTIS report revealed on 03/13/12 a resident to resident sexual abuse had occurred to Resident #1 by Resident #6. This was documented as witnessed by S11/CNA Supervisor. In an interview on 03/19/12 at S11/ CNA Supervisor stated, "I had an aide to call in the night of 03/13/12 and I took her place on Wing 1. I was going down the hall at about 8:25 pm, when I noticed out of the corner of my eye Resident #6 was in Resident #1's room. He was standing by his bed with one hand on the head board. I walked on by then I thought, "What's he doing in Resident #1's room?' I turned around and went back and then I saw Resident #6 s hand in Resident #1's diaper. I know Resident #6 can be verbally abusive to women so I went to get the male LPN, S14/LPN, who was on that Wing. It was about 2 minutes and when we go back, the door was closed. I opened it and Resident #6 was then standing by Resident #2's bed with his hands on the side rails. Resident #6 kept saying, "he can't talk, he can't talk". Resident #6 said to Resident #2, "I will be back. I will be back" then he exited the building to the patio in the back of the building to smoke. I called S1/Administrator and S2/DON immediately and spoke to S2/DON but couldn't reach S1/Administrator. S2/DON gave me instructions to have S14/LPN to call the police and to get Resident #6 and bring him to the front Day Room in the Main Building. and sit there with him until the police arrived. Then Mr. S1/Administrator was here in about 5 minutes. I then stayed with Resident #6 until the police arrived, which was an hour and a half later. After police came, we gave our statements. After that, S1/Administrator went to get later. After police came, we gave our statements. After that, S1/Administrator went to get Resident #6 from S14/LPN, who was 1on1 with him, and explained that they moving Resident #6 to another room. Resident #6 was upset. S1/Administrator went out with him to smoke and then we gave him a cup of coffee. Then S1/Administrator and I walked Resident #6 to .... (a semi-private room which was not occupied in the Annex). Then I instructed S17/CNA to stay at his room and make sure he didn't come out of the room but to check on him to see if he needed anything. Then I left for the night. " Review of an IDT Team Note dated 02/29/12 and signed as completed by S2/DON, revealed, in part, she had verbally inserviced the CNAs in the Main Building about the incident of 02/25/12. It further stated they were advised to immediately report anything inappropriate from a resident or staff member to their immediate supervisor. The note continued that S11/CNA Supervisor had been directed to inservice the evening and night shifts. There was no documented evidence interventions to supervise and prevent inappropriate behavior occurrences were implemented. In an interview on 03/20/12 at 10:00 am, S2/DON acknowledged specific interventions were not put in place for Resident #6. Review of a written " Verbal Inservice " dated 02/29/12 2-10 shift and signed by S11/CNA Supervisor, revealed, in part, they were to pay special attention to Resident #6 and his whereabouts and if they saw him in any other resident's room or bathroom, to report it to the nurse immediately." In an interview on 03/20/12 at 12:35 pm, S11/CNA Supervisor acknowledged she did not go into the room when she first saw Resident #6 at Resident #1's bed and then did not stop Resident #6 when she saw his hand in Resident #1's diaper. There was no documented evidence the facility put a system in place to identify hazards and risks in the bed bound resident's environment related to resident to resident abuse; put a system in place to develop interventions to prevent the occurrence of resident to resident sexual abuse once the potential risk was identified; put a system in place to ensure adequate supervision of Resident #6 to reduce other residents' risk of unwanted sexual advances; put a system in place to identify bed bound, cognitively impaired residents as being high risk to sexual abuse from other resident; put a system in place to ensure effectiveness of abuse training to immediately remove Resident #6 from inappropriate sexual behavior occurrences.

Based on record review and interview the facility failed to ensure a resident's right to be free from sexual abuse for 3 of 3 (Resident's #1, #7 and R4) cognitively impaired residents who are bedbound, for 1 of 7 sampled residents (Resident #2) who is unable to verbalize but is able to communicate by writing and is only able to get out of bed with total assistance in a universe of 7 and a resident's right to interventions to prevent this resident from sexually abusing another resident for 1 resident (Resident #6) in a sample of 7. On 02/25/12, Resident #7 alleged Resident #6 sexually abused him. The facility investigation did not determine if this allegation did or did not occur. On 02/28/12 the Care Plan of Resident #6 was updated to redirect and remove from inappropriate behavior occurrences. Resident #1 is cognitively impaired and bedbound. Resident #1, Resident #2, Resident #6, Resident #7 and R4 were in Immediate Jeopardy of possible sexual abuse when the care plan for Resident #6 was updated on 02/28/12 and the facility failed to care plan and implement interventions to increase supervision and prevent Resident #6 from inappropriate sexual behavior occurrences to residents who are bedbound and cognitively impaired or unable to verbalize. The IJ continued on 03/13/12 and Resident #1 and Resident #2 were in an Immediate Jeopardy when S11/CNA Supervisor observed Resident #6 in Resident #1's room standing next to Resident #1's bed but did not immediately intervene, then returned and Resident #6 had his hand in Resident #1's diaper, and did not immediately intervene. When S11/CNA Supervisor and the nurse returned, Resident #6 had shut the door and was standing by Resident #2's bed and repeated, "I'll be back, I'll be back" as he was removed from the room. The IJ ended on 03/13/12 at 9:00 pm for Resident #1, Resident #2 , Resident #6, Resident #7 and R4 when the facility implemented 1 to 1 supervision for Resident #6. The facility failed to follow Resident 36's plan of care to remove him from inappropriate behavior occurrences. Findings: Record review revealed on 02/25/12 an incident of alleged sexual abuse to Resident #7 by Resident #6 was reported and investigated. The facility could or could not determine if this allegation had or had not occurred. Review of the Care Plan for Resident #6, dated 12/23/11, revealed under Problem Onset of, in part, history of being verbally abusive and physically confrontational with staff and other residents, the Care Plan had been updated in writing to provide redirection and removal from inappropriate behavior occurrences. In an interview on 03/20/12 11:45 am, S10/RN Care Plan stated, "I updated Resident #6's care plan with the intervention on 02/28/12 after our department head meeting and we were informed about the alleged incident with Resident #7. I did not have an IDT meeting but some of the other nurses and myself discussed the problem. I did not care plan other interventions such as increasing supervision." Review of an OTIS report revealed on 03/13/12 a resident to resident sexual abuse had occurred to Resident #1 by Resident #6. This was documented as witnessed by S11/CNA Supervisor. In an interview on 03/19/12 at S11/ CNA Supervisor stated, "I had an aide to call in the night of 03/13/12 and I took her place on Wing 1. I was going down the hall at about 8:25 pm, when I noticed out of the corner of my eye Resident #6 was in Resident #1's room. He was standing by his bed with one hand on the head board. I walked on by then I thought, "What's he doing in Resident #1's room?' I turned around and went back and then I saw Resident #6 s hand in Resident #1's diaper. I know Resident #6 can be verbally abusive to women so I went to get the male LPN, S14/LPN, who was on that Wing. It was about 2 minutes and when we go back, the door was closed. I opened it and Resident #6 was then standing by Resident #2's bed with his hands on the side rails. Resident #6 kept saying, "he can't talk, he can't talk". Resident #6 said to Resident #2, "I will be back. I will be back" then he exited the building to the patio in the back of the building to smoke. I called S1/Administrator and S2/DON immediately and spoke to S2/DON but couldn't reach S1/Administrator. S2/DON gave me instructions to have S14/LPN to call the police and to get Resident #6 and bring him to the front Day Room in the Main Building. and sit there with him until the police arrived. Then Mr. S1/Administrator was here in about 5 minutes. I then stayed with Resident #6 until the police arrived, which was an hour and a half later. After police came, we gave our statements. After that, S1/Administrator went to get later. After police came, we gave our statements. After that, S1/Administrator went to get Resident #6 from S14/LPN, who was 1on1 with him, and explained that they moving Resident #6 to another room. Resident #6 was upset. S1/Administrator went out with him to smoke and then we gave him a cup of coffee. Then S1/Administrator and I walked Resident #6 to .... (a semi-private room which was not occupied in the Annex). Then I instructed S17/CNA to stay at his room and make sure he didn't come out of the room but to check on him to see if he needed anything. Then I left for the night. " Review of an IDT Team Note dated 02/29/12 and signed as completed by S2/DON, revealed, in part, she had verbally inserviced the CNAs in the Main Building about the incident of 02/25/12. It further stated they were advised to immediately report anything inappropriate from a resident or staff member to their immediate supervisor. The note continued that S11/CNA Supervisor had been directed to inservice the evening and night shifts. There was no documented evidence interventions to supervise and prevent inappropriate behavior occurrences were implemented. In an interview on 03/20/12 at 10:00 am, S2/DON acknowledged specific interventions were not put in place for Resident #6. Review of a written " Verbal Inservice " dated 02/29/12 2-10 shift and signed by S11/CNA Supervisor, revealed, in part, they were to pay special attention to Resident #6 and his whereabouts and if they saw him in any other resident's room or bathroom, to report it to the nurse immediately." In an interview on 03/20/12 at 12:35 pm, S11/CNA Supervisor acknowledged she did not go into the room when she first saw Resident #6 at Resident #1's bed and then did not stop Resident #6 when she saw his hand in Resident #1's diaper.