Every finding on record at Colonial Manor Nursing Center

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 4 med carts reviewed for food items stored on med carts and 2 of 4 residents (Resident #8, Resident # 84) reviewed for incontinence and infection control. CNA A while providing incontinent care for Resident #8, contaminated the whole packet of wet wipes by pulling out individual wipes from the packet with unclean gloves. LVN B failed to keep away his coffee tumbler containing coffee from the medication cart CNA A and CNA C entered Resident #84's room who was on contact isolations precautions without donning PPE when delivering and retrieving meal tray.CNA A exited Resident # 84's room from delivering meal tray and did not perform hand hygiene after exiting and prior to picking up the next meal tray for delivery.This failure could place the residents at the facility at risk of transmission of disease and infection.Findings included:Record review of Resident #8's face sheet, dated 04/09/26, reflected Resident #8 admitted to the facility on [DATE]. She was a [AGE] year-old female diagnosed with dementia, lack of coordination, cognitive communication deficit, major depressive disorder, muscle weakness, hypertension, and gastro-esophageal reflux (acid reflex). Record review of Resident #8's initial MDS dated [DATE] reflected a BIMS score of 15 indicating her cognition was intact. Further review revealed that she needed assistance with toileting hygiene. Record review of Resident #8's care plan dated 11/25/25 reflected that she required assistance with toileting and incontinence care. The relevant intervention was ensuring Resident #8 received assistance when needed. During an observation conducted on 04/08/26 at 1:40 p.m., CNA A provided incontinent care to Resident #8. CNA A entered Resident #8's room, performed hand hygiene, and donned (putting on) disposable gloves. After removing the soiled brief containing urine and feces, CNA A proceeded to clean the resident's buttocks and perineal area by individually pulling wipes from the packet. During this process, she used the same soiled gloves to extract the wipes, thereby contaminating the entire packet of wet wipes. Following the completion of the cleaning, CNA A changed her gloves, dressed the resident with a new brief, and positioned the resident comfortably. She then adjusted the linens and bed linens accordingly. CNA A placed the contaminated packet of wipes on the side table, collected the used materials in a plastic bag for disposal, and exited the room. During an interview on 04/08/26 at 1:55 p.m., CNA A stated that she believed she was performing incontinent care correctly. When the HHSC investigator reviewed the process of incontinence care with CNA A, she acknowledged that she contaminated the packet of wipes by pulling wipes directly from it with gloves soiled with urine and feces. When asked about the training and in-services received related to incontinent care and infection control procedures, CNA A reported that the facility provided infection control training, including hand hygiene, appropriate use of PPE), and sanitization of surfaces and equipment periodically. She also indicated that she had received specific training on peri-care within the recent past. When asked about how her actions could impact residents, CNA A responded that there was a risk of disease transmission through contamination. Record review of Resident # 84's face sheet, dated 4/7/26, reflected Resident # 84 admitted to the facility on [DATE] with a re-admit on 4/2/26. He was an [AGE] year-old male diagnosed with necrosis of amputation stump (tissue death near surgical amputation site), methicillin resistant staphylococcus aureus infection unspecified site (type of staph bacteria resistant to many common antibiotics), unspecified open wound on right great toe, type 2 diabetes (chronic condition can't use or produce insulin effectively), acute kidney failure, disorder of the autonomic nervous system, congestive heart failure (chronic condition where the heart muscle is too weak or stiff to pump blood efficiently), Parkinson's disease (a progressive neurodegenerative disorder that impacts the central nervous system), chronic obstructive pulmonary disease (a progressive incurable lung disease making it difficult to breath). Record review of Resident # 84's initial MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Further review revealed that he was dependent on staff for transfers and toileting. He required partial to moderate assistance for bathing. He required supervision assistance for personal hygiene and oral hygiene. He required set-up assistance for eating. Record review of Resident # 84's care plan dated 4/3/26 reflected that he had an infection of the right great toe. The relevant intervention was contact isolation precautions. Record review of Resident # 84's clinical physician orders undated reflected no active orders for Transmission-Based Isolation Contact precautions documented. During an observation on 4/7/26 at 12:00 pm of Resident # 84's room door there was signage for Contact Isolation precautions. Further observation revealed no PPE bin outside of room or hanging on room door. Observation of resident room revealed package of disposable gowns on chair in resident room. Observation of resident room revealed glove holders in resident room without gloves present. During an observation on 4/7/26 at 12:08 pm CNA A went into Resident # 84's room to deliver lunch meal tray. Observation revealed CNA A not donning (putting on) PPE prior to entering resident room. Observation revealed CNA A moved resident overbed table to be across Resident # 84's lap. Observation revealed CNA A moved resident items around on overbed table for meal tray to fit. CNA A was then observed to set-up Resident # 84's meal tray. Observation revealed CNA A exited Resident # 84's room without performing hand hygiene. Observation revealed CNA A then proceeded to pick up another resident meal tray and go deliver that meal tray. During an observation on 4/7/26 at 12:17 pm CNA A went into Resident # 84's room without donning PPE to get dinner meal options. During an observation on 4/7/26 at 12:49 pm CNA C went into Resident # 84's room without donning PPE to pick up lunch meal tray. During an interview on 4/7/26 at 1:02 pm MDS revealed that yes Resident # 84 is still on Contact Isolation precautions per the ADON. During an interview on 4/9/26 at 11:21 am ADON D said that staff and visitors are made aware of a resident's isolation status by the signage on the resident room door. ADON D said if a PPE bin is not hanging on the resident door that the staff have access to the supply closets where the extra PPE is stored. ADON D said if a resident is on Contact Isolation precautions, then hand hygiene, gowns, and gloves are donned for all types of room entrances. ADON D said typically the overdoor PPE bins are placed on resident doorways by herself. ADON D said the staff receive training regarding isolation precautions monthly at all staff meetings and during their annual/upon hire infection control competency check offs. ADON D said that yes it can affect a resident negatively if isolation precautions are not followed because of the potential for infection spreading. ADON D said she was unaware that Resident # 84 did not have active orders for isolation precautions until the MDS nurse came and asked about the resident. ADON D said it is the responsibility of ADON and DON to ensure appropriate signage and PPE is available for residents on isolation precautions. During an interview on 4/9/26 at 11:50 am CNA A said they are made aware of a resident isolation status by in-services and door signage. CNA A said if a resident had isolation signage on their door but no PPE available, they would ask ADON if the resident was indeed on isolation and where a PPE door hanger and PPE was to be placed on the resident door. CNA A said it was a mistake when she did not don (put on) PPE when entering Resident # 84's room to deliver his meal tray. CNA A said she was confused as to whether this resident was on isolation precautions as the resident next door had just come off isolation the day prior. CNA A said she had asked ADON E if Resident # 84 was on isolation and was told no. CNA A said she later found out that ADON E thought CNA A was asking about the next-door resident who had recently come off of isolation precautions. CNA A said there was just miscommunication about which resident was on isolation precautions. CNA A said they have monthly in-service training with ADON D who is also the Infection Preventionist. CNA A said the proper steps for donning (put on) PPE is put on gown, mask, and then gloves. For doffing (take off) pull off gown, then gloves, then face mask, then dispose of soiled PPE in bag, tie up, then perform hand hygiene, then go place the bag of soiled PPE in the hallway trash room. CNA A said it can negatively affect a resident if the isolation precautions are not followed by the spread of infection. CNA A said it is the responsibility of ADON D to ensure that PPE is available for any residents on isolation precautions. During an interview on 4/9/26 at 12:37 pm CNA C said that they are made aware of a resident isolation status by the charge nurse and the signage on the resident door. CNA C said if a resident has isolation signage but no PPE available, she will then go clarify with the nurse if the resident was on isolation precautions. CNA C said her fellow CNA A had received guidance from ADON E that donning (put on) PPE was not needed for meal tray delivery and pick up and that is why she did not don (put on) PPE when picking up Resident # 84's meal tray. CNA C said she had received training regarding isolation precautions via in-services and the yearly competency checkoffs. CNA C said it can negatively affect a resident if isolation precautions are not followed. CNA C said DON, ADON, and nurses are responsible for ensuring PPE is available for residents on isolations precautions. During an interview on 4/9/26 at 2:07 pm DON said staff are made aware of resident isolation status by looking in the care plan, electronic health record point of care documenting Kardex, clinical orders, and signage on the resident doors. DON said if a resident had isolation signage on the door but no PPE available it would be her expectation that the staff member would gather the needed PPE and don (put on) prior to entering the room. DON said the staff receive in-services about transmission-based precautions and the proper way of donning (put on) and doffing (take off) of PPE as well as CBT course training. DON said if a resident is on isolation-based precautions the facility follows the donning and doffing covered in transmission-based precaution policy and procedure. DON said it can negatively affect a resident if isolation precautions are not followed by infection and cross contamination. DON said it is the responsibility of DON and ADON for ensuring appropriate signage and PPE are available for residents on isolation precautions. DON said she was not aware that Resident # 84 did not have active isolation status orders or about the isolation precautions confusion until staff brought it to her attention after the incident occurred. During an interview on 4/9/26 at 2:15 pm ADM said staff are made aware of resident isolation status by documentation in the electronic health record, 24-hour nurse report, and by word of mouth. ADM said if a resident has isolation signage on the door but not PPE available it would be her expectation that the staff member would notify nursing administration so the PPE can be provided. ADM said if a resident is on contact isolation precautions she expects the staff to don PPE prior to entering the resident room and doff PPE prior to exiting the room and to perform hand hygiene upon exiting the room. ADM said staff receive infection control training of in-services and hands-on examples. ADM said it can negatively affect a resident if isolation precautions and infection control precautions are not followed by spread of infection. ADM said it is the responsibility of nursing administration and the interdisciplinary team to ensure the appropriate PPE is available. ADM stated it was her expectation that staff follow infection control policies to the utmost of their ability. ADM said she was not aware of Resident # 84 not having active isolation orders or that there had been any confusion about isolation practices. On 04/09/26 at 9:10 a.m., during an observation and interview, LVN B was administering medication in the west hall. A tumbler was observed sitting on his medication cart. When asked about it, LVN B stated that it was his morning coffee. He then stored the tumbler on the nursing station and acknowledged that keeping his coffee on the med cart was a mistake. LVN B expressed concern that storing personal items on the medication cart posed a high risk of spreading infectious diseases through cross-contamination. During an interview on 04/09/26 at 2:40 p.m., the DON stated that CNA A should have changed her gloves before handling the clean packet of wipes. She said that the correct procedure involved using a new pair of gloves when transitioning from handling soiled materials to clean items. She further explained that failure to follow proper infection control protocols during incontinent care could result in the transmission of communicable diseases and infections. The DON stated that staff should not store personal belongings on the medication cart, as this increases the risk of medication contamination. The DON also stated that ADONs conduct regular rounds to identify deficiencies in nursing practices, and that targeted training and in-service education were provided to staff members exhibiting such deficiencies. Record review of facility in-service with topic of EHB/Transmission based precautions dated 11/20/25 reflected 37 staff signatures conducted by ADM. Record review of facility in-service with topic of Transmission based precautions dated 12/18/25 reflected 34 signatures conducted ADM. Record review of facility in-service topic Transmission based precautions dated 4/7/26 reflected CNA A and CNA C signatures conducted by ADON D. Review of facility's Infection Control policy revised on 04/12/24 reflected: This facility has established and maintain an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.-All staff are responsible for following all policies and procedures related to the program. -All staff shall assume that all residents are potentially infected and colonized with an organism that could be transmitted during providing resident care services. -Hand hygiene shall be performed in accordance with our facility's hand hygiene procedures. -All staff shall use protective equipment (PPE) according to the established facility policy-Direct care staff shall demonstrate competence in resident care procedures established by our facility According to the website https://apps.hhs.texas.gov/providers/NF/credentialing/cna/infection-control/module3/Module_3_PPE_122021_print.html, accessed on 04/10/26, recommended the following for gloves use. Gloves are designed to protect your hands from pathogens and to prevent the spread of pathogens. Unintentionally transferring a pathogen to your bare hands is an easy way to spread contagion through your facility -DOs: Perform hand hygiene before and after resident contact, even when gloves are worn. Work from clean to dirty. -Perform hand hygiene after glove removal. Change gloves as needed during resident care activities. -DON'Ts: Touch yourself while wearing contaminated gloves. Handle clean materials, equipment, or surfaces while wearing contaminated gloves. Wear the same pair of gloves for the care of more than one resident. Wash disposable gloves. It is important to note that gloves can spread illnesses just like bare hands. Wearing gloves does not stop the transfer of pathogens. It is very easy for cross-contamination to occur even when wearing gloves. Be mindful of the order in which you touch things (remember clean to dirty) and when you may need to change gloves mid-procedure Record review of facility Transmission Based (Isolation) Precautions policy dated 10/24/22 reflected under heading policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy. Under heading policy explanation and compliance guidelines: Facility staff will apply Transmission Based Precautions, in addition to standard precautions, to residents who are known or suspected of being infected or colonized with certain infectious agents requiring additional controls to prevent transmission.The facility will use standard approaches, as defined by CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of PPE to be used. 7. Initiation of Transmission-Based Precautions ( Isolation Precautions)- a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission-based precautions/isolation empirically while awaiting confirmation. b. An order for transmission-based precautions/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. c. The order for transmission-based precautions/isolation will specify the type of precaution and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. d. The transmission-based precaution will be the least restrictive possible for the resident under the circumstances. e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. f. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. g. Use disposable or dedicated noncritical resident-care equipment (e.g., blood pressure cuff, bedside commode). If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions with an EPA-registered disinfectant after use. 8. Contact Precautions- a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on case-by-case basis, balancing infection risks to other residents, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected or colonized resident. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination e. Residents experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions even before a specific organism has been identified. f. Contact precautions will be used for residents infected or colonized with MDROs in the following situations: i. When a resident has wounds, secretions, or excretions that are unable to be covered or contained; and ii. On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission is occurring.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three (Residents #2, #3, and #4) of 6 residents reviewed for abuse.On 01/05/2026 the facility failed to protect Resident #1 from hitting Resident #2 resulting in a scratch measuring 0.02x0.4cm to Resident #2's right eye and a scratch measuring 0.01x0.3cm to the bridge of Resident #2's nose. On 01/08/2026 the facility failed to protect Resident #4 from being called a liar by LVN A.On 01/31/2026 the facility failed to protect Resident #3 from being followed by Resident #1 down the hall to initiate a fist fight, residents' arms made contact with no injuries.This failure could place residents at risk of continued abuse and harm. Findings included: Residents #1, #2, and #3 Record review of Resident #1's face sheet, dated 02/12/2026, revealed a sixty-one-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included alcoholic polyneuropathy (nerve damage caused by chronic, heavy alcohol consumption and associated nutritional deficiencies), vascular dementia (a cognitive decline caused by reduced blood flow to the brain, damaging brain tissue and causing symptoms like memory loss, confusion, and impaired planning) and aphasia (a language disorder that impairs the ability to speak, understand, read, and write, with symptoms ranging from mild word-finding difficulties to total communication loss). Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 01/28/2026 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 0 indicating severe cognitive issues, E0200 - Behavioral Symptom - Presence and Frequency - Physical behavioral symptoms directed toward others Behavior of this type occurred 1 to 3 days. Record review of a care plan dated 12/30/2025 revealed a focus of Resident #1 had a behavioral problem as evidenced by Resident #1 hit another resident with intervention dated 02/03/2026 Resident #1 moved to a private room with a private bathroom and intervention dated 01/06/2026 staff will check on Resident #1 frequently to ensure needs are met. Record review of Resident #2's face sheet, dated 02/12/2026, revealed an eighty-three-year-old male who was admitted to the facility on [DATE] and re-admitted [DATE]. His admitting diagnoses included Alzheimer's disease (the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills), anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), and depressive episodes (a period of at least two weeks featuring persistent, severe low mood or loss of pleasure (anhedonia), along with symptoms like sleep disturbances, fatigue, guilt, and reduced concentration that impair daily functioning). Record review of Resident #2's MDS dated [DATE] Resident Comprehensive and Care Screening Section C - Cognitive Patterns revealed a score of 0 indicating severe cognitive issues, Section C - Cognitive Patterns - Delerium C1310 - signs and symptoms of delirium inattention - did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said and disorganized Thinking - was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) - behavior continuously present, did not fluctuate. Review of Resident #2's care plan dated 11/25/2025 revealed a focus for wandering/exit seeking indicated - Resident #2 wanders related to cognitive impairment and was at risk for injury with a goal dated 11/25/2025 of Resident #2 will wander in a safe environment without occurrence of injury and dignity will be maintained through the next review date of 04/23/2025 with interventions dated 11/25/2025 attempt to determine any pattern or cause of wandering, redirect if Resident #2 enters a restricted area, and distract Resident #2 from wandering by offering pleasant diversions, structured activities, food, conversation etc. Record review of Resident #3's face sheet, dated 02/12/2026, revealed a seventy-five-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included dementia (a progressive, non-normal aging condition involving a decline in mental abilities severe enough to disrupt daily life), bipolar disorder (chronic mental health condition characterized by extreme shifts between high-energy mania and low-energy depression), and anxiety disorder. Review of Resident #3's care plan revealed a focus dated 11/17/2025 Resident #3 had a behavior problem as evidenced by become agitated when staff attempted to redirect causing aggression toward staff attempted to hit resident punches at the air at times when frustrated with intervention dated 12/17/2025 monitor behavior episodes and attempt to determine underlying cause, assess and anticipate Resident #3's needs, intervention dated 11/17/2025 approach Resident #3 in a calm manner, intervention dated 11/17/2025 when Resident #3 becomes agitated intervene before the agitation escalates by guiding away from source of distress engaging calmly in conversation or attempting to [other] interventions. If response is aggressive then approach at a later time after ensuring the safety of Resident #3 and nearby residents. Record review of Resident #3's MDS (clinical assessment to determine resident's strength and needs) dated 11/16/2025 Resident Comprehensive and Care Screening Section C - Cognitive Patterns revealed a score of 0 indicating severe cognitive issues, Section C - Cognitive Patterns - Delerium C1310 - signs and symptoms of delirium inattention - did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said and disorganized Thinking - was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) - behavior continuously present, did not fluctuate. Review of Resident #2's Skin Observation Worksheet dated 01/05/2026 by ADON A reflected right eye scratch 0.02x0.4cm and bridge of nose scratch 0.01x0.3cm. Record review of a written statement dated 01/05/2026 by CNA A revealed CNA A and CNA B were outside Residents' room when they heard Resident #2 yelling out, oh, no help me ow! It sounded like Resident #2 was crying. We entered the room. Resident #1 had his hand balled into a fist and pulled back. Resident #2 was leaning over on his side with his hand over his eyes whimpering. Resident #1 walked off and said nothing. CNA A called for nurses. Resident #2 had a visible mark under his right eye and another one across the bridge of his nose. LVN C said to move Resident #1 to another room in the secured unit. Record review of written statement dated 01/05/2026 by CNA C revealed on 01/05/2026 CNA A and CNA B came to the nurse's station and said Resident #1 hit Resident #2 in the face. CNA C went to the room of Resident #1 and Resident #2, and Resident #2 was hunched over holding his face. When Resident #2 removed his hand CNA C saw Residen#2 had a cut on his nose and under his right eye. CNA C said they removed Resident #2 from the room. Record review of a written statement dated 01/05/2026 by CNA B revealed CNA B and CNA A heard someone yell for help. When they went to the room, they saw Resident #1 leaning over Resident #2's bed making a fist to hit him. CNA B and CNA A were able to move Resident #1 away from Resident #2. CNA B and CNA A looked at Resident #2's face and Resident #2 had a scratch on the lower part of the eye and the side of his nose. Record review of written statement dated 01/05/2026 by LVN C revealed a CNA (CNA not identified) came into the hallway calling and the CNA said, Hey, he just punched him. On entering the room Resident #2 was noted in bed covering his face with his hands. After moving Resident #2's hands Resident #2's nose was red with a small opening on the bridge of Resident #2's nose and another small opening under Resident #2's right eye. Resident #2 began asking, why'd he do that? Resident #1 was asked what happened and Resident #1 said he had no idea. Review of Resident #1's progress note dated 01/05/2026 by LVN D reflected Resident #1 was seen by CNA (CNA not identified) with right back arm pulled back with a balled fist. Resident #1 standing over roommate Resident #2. Resident #2 lying on left side curled up with hands covering right eye yelling, help me. Resident #1 went back to his side of the room. Resident #2 said, I don't know what happened. Resident #1 moved to another room without a roommate. Review of Resident #2's progress note dated 01/05/2026 by LVN D reflected Resident #2 was lying in bed yelling Oh no, help me. Resident #1 was standing over Resident #2 when staff walked and saw Resident #1's arm pulled back with hand balled in fist. Resident #2 was lying in bed with hands over his right eye curled up on his left side. Resident #2 repeated I don't know why, I don't know why. I don't know why. Resident #1 and roommate Resident #2 were separated. Noted small open area on bridge on nose 0.2cm x 0.8cm. and a small open area below the right eye 0.2cm x 0.7cm. Review of Resident #1's progress note dated 01/22/2026 by LVN C reflected Resident #1 following another resident into the hall, yelling at him d/t the other resident walking through restroom into his room. resident was redirected back to his room where he has since calmed down Review of Resident #1's progress note dated 01/27/2026 by LVN C reflected Resident #1 noted agitation d/t another male resident wandering into room multiple times. Review of Resident #1's progress note dated 01/27/2026 by LVN C reflected Resident #1 noted agitation d/t another male resident repeatedly coming into his room. he has been redirected by staff and is now calm in room. this behavior repeats each time. Review of Resident #1's progress note dated 01/31/2026 by LVN A reflected Resident #3 entered Resident #1's room and was asked to leave. This agitated Resident #1, and he followed Resident #3 down the hall to initiate a fist fight. Resident #1 punched Resident #3 from his wheelchair and a brief fight began until they were told to stop. Stopped on command and no signs or symptoms of injury were found. Arms made contact but no contact with face or body. No complaints of pain. Review of Resident #1's progress note dated 01/31/2026 by LVN A reflected Resident #3 wandered into Resident #1's room and was asked to leave. Resident #1 followed Resident #3 down the hall and initiated fight. The residents were redirected away from each other with no resistance. Residents were stopped on command and only arms made contact. Residents were assessed for injury with no signs or symptoms of injury. The administrator, DON, and ADONs notified. During an interview on 02/12/2026 at 12:28 PM, LVN C stated he worked with Resident #1 who was a private guy and was no longer in the secured unit. Resident #1 was moved to the general area. LVN C said he was aware that Resident #1 was involved in two resident-to-resident altercations with physical contact. LVN C said he worked on 01/05/2026 and a nurse was called by CNA A to Resident #1's room. When the staff arrived at Resident #1's room Resident #2 was covering up his face and Resident #1 had red marks on his knuckles. Resident #2 had redness under his eyes and a bruise beginning under one eye. Resident #2 was in a fetal position with his hands over his face. Resident #1 was sitting on his bed. Resident #1 said he did not hit Resident #2 and said Resident #2 would not shut up. LVN C said there had been times when Resident #1 would yell at Resident #2, but LVN C did not think Resident #1 would get physical. After they moved Resident #1 to his own room he did not think there would be additional physical altercations. LVN C said Resident #1 would yell at residents if they went into his room. LVN C said he was not surprised when Resident #1 had an incident with Resident #3 because Resident #3 had wandered in Resident #1's room a few times. When Resident #3 wandered into Resident #1's room, Resident #1 would yell at Resident #3. Resident #1 was not an elopement risk, and he was moved to the general resident area. Resident #1 was moved because he would have more privacy. LVN C said Resident #1 was not placed on 1:1 (continuous and direct supervision strategy where a dedicated staff member is assigned to observe only one patient at all times) but they added an additional CNA on the hallway. LVN C was aware that there had been other incidents where Resident #1 would yell at residents for wandering into his room, but staff intervened and de-escalated the situation before there was any physical altercation. During an interview by phone on 02/12/2026 at 12:20 PM, CNA A stated she was present the evening of the altercation on 01/05/2026 between Resident #1 and Resident #2. CNA A said she did not see Resident #1 hit Resident #2 but when she pulled back the curtain in the room Resident #1 and Resident #2 used to share, she saw Resident #1's hand was drawn back to hit Resident #2. CNA A said she heard Resident #2 crying and that was why she walked into the room. CNA A said Resident #2 had a visible injury on his eye and across the bridge of his nose. She said LVN C instructed Resident #1 to be moved to another room without a roommate. She said she was not concerned that Resident #1 would engage in another resident-to-resident altercation. She said the facility added another staff member to the unit for an additional safety precaution. She said there was not an in-service that said that staff need to make sure that Resident #1 did not have other residents go into his room but this was discussed during shift report. During an interview on 02/12/2026 at 12:56 PM, LVN A stated on 01/31/2026 Resident #3 poked his head into Resident #1's room and Resident #1 began swinging his fists at Resident #3's head. LVN A said Resident #1 and Resident #3 started to hit each other but they did not make contact. LVN A said there were no injuries and he reported the incident to the Administrator, the DON, and the ADON. During an interview by phone on 02/12/2026 at 1:51 PM, the psychiatric NP stated that Resident #1 had a history of alcoholism with vascular dementia, and he got agitated if someone came into his room. She said Resident #1 slept a lot and stayed in his room. The Psychiatric NP said the facility called her and told her about the altercations he had on 01/05/2026 and 01/31/2026. She said he was on the secured unit and after the incident on 01/05/2026 Resident #1 was moved to his own room on the secured unit. She said she did not know if it was possible to keep people away from Resident #1 on the secured unit because residents in the secured unit sometimes wandered into other residents' rooms. She said Resident #1 was not exit seeking and after the incident on 01/31/2026 he was moved to his own room on the non-secured unit. The psychiatric NP said she was not concerned about Resident #1 hurting anyone now that he was no longer in the secured unit because residents in the non-secured unit do not wander and Resident #1 stays in his room. During an interview on 02/12/2026 at 3:49 PM, Resident #1 did not respond when asked about any difficulties with other residents at the facility. When asked if he was okay, he said he was okay. During an interview on 02/12/2026 at 3:56 PM, Resident #2 did not respond when asked if he had any difficulties with other residents. Attempted an interview on 02/12/2026 at 3:59 PM, with Resident #3 but he was not interviewable. During an interview on 02/12/2026 at 4:48 PM, CNA B stated that she and CNA A heard a noise like someone was calling for help and they pulled away the privacy curtain around Resident #2's bed and Resident #1 was trying to punch Resident #2 in the face. Resident #2 had redness on his face, and a little bit of bleeding and Resident #1 was standing over Resident #2 with his fist up. She said Resident #1 did not like to be bothered. Resident #1 just wanted to stay in his room and for staff to bring him coffee. She said if a resident hits another resident, it was abuse. She said she was trained to tell the Administrator, who was the abuse and neglect coordinator, about any abuse immediately. Resident #4 Record review of Resident #4's face sheet, dated 02/13/2026, revealed a seventy-nine-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included Alzheimer's disease, dementia, and depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and, in severe cases, thoughts of suicide). Review of Resident #4's care plan revealed a focus dated 01/05/2026 of wandering/exit seeking, Resident #4 wanders related to cognitive impairment and is at risk for injury with intervention dated 01/05/2026 attempt to determine any pattern or cause of wandering. Record review of Resident #4's MDS (clinical assessment to determine resident's strength and needs) dated 01/28/2026 Resident Comprehensive and Care Screening Section C - Cognitive Patterns revealed a score of 10 indicating moderate cognitive issues. Record review of statement, undated, from CNA D reflected LVN B was yelling at Resident #4 and told Resident #4 to sit down in her chair, not move and Resident #4 was going to staying down there with her. Resident #4 kept telling LVN B that she wanted to go the restroom and had to pee real bad. LVN B told Resident #4 that she had just put her in her bed and that Resident #4 kept getting up and that LVN B was not going to keep putting her in her bed all night. Resident #4 kept repeating, I have to pee, I have to pee, I'm going to pee on myself. If you let me go to the bathroom then I'll go to bed. LVN B told Resident #4 that she was lying again. CNA D said she told LVN B that she was going to take Resident #4 to the restroom and LVN B told her no, leave her there. CNA D said that Resident #4 tried to stand up at least twice and LVN B made Resident #4 sit down. CNA D said Resident #4 stood up facing her chair and began to pull her dress up saying that she had to pee. Resident #4 threaten to pee on the floor because she could not hold it. CNA D came down to get Resident #4 again. When LVN B told CNA D to again leave Resident #4 where she was CNA D told LVN B that the girls on the other end were to be watching Resident #4 because she was a fall risk. CNA D said she took Resident #4 to the other end of the hall with the aides to remove her from the verbal abuse and neglect. Record review of statement dated 01/09/2026, written by LVN B reflected the Administrator asked LVN B what happened on 01/08/2026 and LVN B said Resident #4 was up all night and Resident #4 did not feel tired and was not staying in bed. LVN B denied she yelled at Resident #4. LVN B said she did tell Resident #4 she had just taken Resident #4 to the bathroom and would have to wait a minute before she took her again since she had just taken her out of the bathroom. LVN B stated she had taken Resident #4 to the bathroom four times. Record review of statement dated 01/09/2026, written by ADON A reflected Resident #4 was asked by ADON A if any staff was yelling at her. Resident #4 stated in one (pointed to her ear) out the other (pointed to her other ear). ADON A said she asked Resident #4 if she had any problems through the night. Resident #4 stated I don't want any trouble. ADON A assured Resident #4 she would not be in trouble, but ADON A needed to make sure she was safe. Resident #4 began joking about various topics. Review of Facility Termination Form dated 01/12/2026 revealed LVN B's employment with the facility was terminated by phone on 01/12/2026 by the DON for resident abuse. During an interview on 02/12/2026 at 5:02 PM, CNA D stated she was working with LVN B and Resident #4 came out of her room. CNA D said Resident #4 had gone back and forth from her room to the dining room several times. CNA D said LVN B yelled at Resident #4 telling her she was a fall risk and to sit down in her wheelchair and not move. CNA D said Resident #4 told LVN B that she needed to go to the bathroom. CNA D said that LVN B told Resident #4 that she was lying and if LVN B took Resident #4 back to her room, Resident #4 would just get in her bed then get up again and end up falling. CNA D said Resident #4 kept telling LVN B that she had to go to the bathroom and LVN B told Resident #4 she was nothing but a liar. CNA D said Resident #4 told LVN B that she was going to pee on herself if LVN B, who was standing in front of Resident #4's wheelchair blocking here from getting up did not let her go to the bathroom. CNA D said Resident #4 was upset, crying and begged to go to the bathroom. CNA D said she intervened and took Resident #4 to the bathroom and reported the incident to the Administrator. CNA D said that CNA E and CNA F witnessed the incident. During an interview on 02/13/2026 at 8:56 AM, LVN E said she worked with LVN B and LVN B could be hostile to residents, but she did not see LVN B deny residents' care. LVN E said she heard LVN B tell a resident (she did not recall resident's name) you need to go to your room, lay down, and stay down. LVN E said this was against residents' rights because a resident had the right to stay up as long as they wanted. She said this was about two years ago and she reported it to the former Administrator who said he would address it. During an interview on 02/13/2026 at 9:11 AM, Resident #4 said everybody was nice to her and she did not have a problem with any of the nurses telling her she had to go to bed or not letting her go to the bathroom. Attempted an interview via phone with CNA F on 02/13/2026 at 9:41 AM. Surveyor left a voice mail and sent a text message. During an interview on 02/13/2026 at 9:55 AM, the SW said she spoke with Resident #4 after the incident that involved Resident #4 and LVN B. The SW said Resident #4 said she did not remember anything that happened with LVN B and Resident #4 did not exhibit any emotional distress when the incident was discussed. During an interview on 02/13/2026 at 10:35 AM, LVN B stated on 01/08/2026, Resident #4 was restless and kept going back and forth from her room to the nurse's station and kept saying she needed to go to the bathroom. LVN B said she did tell Resident #4 she was lying when Resident #4 said she needed to go to the bathroom. LVN B said she should not have told the resident she was lying. LVN B said she did not prevent Resident #4 from leaving her wheelchair and did not yell at Resident #4. During an interview on 02/13/2026 at 10:36 AM, CNA E stated she had worked with LVN B and said that LVN B could be rude and ugly when speaking to residents, but she did not hear LVN B be verbally abusive to residents. During an interview on 02/13/2026 at 1:07 PM, the Administrator said if a nurse told a resident they were a liar that was inappropriate and a form of abuse and neglect. He said he could not imagine why someone would tell a resident they were a liar because that was a derogatory term. During an interview on 02/13/2026 at 2:03 PM, ADON B said it was not okay to tell a resident that they were a liar. She said it was abuse to tell a resident they were lying, and it might make the resident feel offended and the resident might be defensive. She said it could be considered emotional abuse to tell a resident they were a liar. During an interview on 02/13/2026 at 3:08 PM, the DON said to call a resident a liar was verbal abuse and it could possibly hurt a resident's feelings. Review of Policy and Procedures dated 09/06/2024 titled Abuse, Neglect and Exploitation revealed it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Mental Abuse'' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 4 residents (Resident #3) reviewed for reporting allegations of abuse. The facility failed to report a resident-to-resident altercation on 01/31/2026, when Resident #1 followed Resident #3 down the hall to initiate a fist fight, residents' arms made contact with no injuries. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: Record review of Resident #1's face sheet, dated 02/12/2026, revealed a sixty-one-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included alcoholic polyneuropathy (nerve damage caused by chronic, heavy alcohol consumption and associated nutritional deficiencies), vascular dementia (a cognitive decline caused by reduced blood flow to the brain, damaging brain tissue and causing symptoms like memory loss, confusion, and impaired planning) and aphasia (a language disorder that impairs the ability to speak, understand, read, and write, with symptoms ranging from mild word-finding difficulties to total communication loss). Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 01/28/2026 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 0 indicating severe cognitive issues, E0200 - Behavioral Symptom - Presence and Frequency - Physical behavioral symptoms directed toward others Behavior of this type occurred 1 to 3 days. Record review of a care plan revealed dated 12/30/2025, revealed a focus of Resident #1 had a behavioral problem as evidenced by Resident #1 hit another resident with intervention dated 02/03/2026 Resident #1 moved to a private room with a private bathroom and intervention dated 01/06/2026 staff will check on Resident #1 frequently to ensure needs are met. Record review of Resident #3's face sheet, dated 02/12/2026, revealed a seventy-five-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included dementia (a progressive, non-normal aging condition involving a decline in mental abilities severe enough to disrupt daily life), bipolar disorder (chronic mental health condition characterized by extreme shifts between high-energy mania and low-energy depression), and anxiety disorder. Review of Resident #3's care plan revealed a focus dated 12/12/2026 Resident #3 had a behavior problem as evidenced by become agitated when staff attempted to redirect causing aggression toward staff attempted to hit resident punches at the air at times when frustrated with intervention dated 12/17/2025 monitor behavior episodes and attempt to determine underlying cause, assess and anticipate Resident #3's needs, intervention dated 11/17/2025 approach Resident #3 in a calm manner, intervention dated 11/17/2025 when Resident #3 becomes agitated intervene before the agitation escalates by guiding away from source of distress engaging calmly in conversation or attempting to [other] interventions. If response is aggressive then approach at a later time after ensuring the safety of Resident #3 and nearby residents. Record review of Resident #3's MDS (clinical assessment to determine resident's strength and needs) dated 11/16/2025 Resident Comprehensive and Care Screening Section C - Cognitive Patterns revealed a score of 0 indicating severe cognitive issues, Section C - Cognitive Patterns - Delerium C1310 - signs and symptoms of delirium inattention - did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said and disorganized Thinking - was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) - behavior continuously present, did not fluctuate. Review of Resident #1's progress note dated 01/31/2026 by LVN A reflected Resident #3 entered Resident #1's room and was asked to leave. This agitated Resident #1, and he followed Resident #3 down the hall to initiate a fist fight. Resident #1 punched Resident #3 from his wheelchair and a brief fight began until they were told to stop. Stopped on command and no signs or symptoms of injury were found. Arms made contact but no contact with face or body. No complaints of pain. Review of Resident #1's progress note dated 01/31/2026 by LVN A reflected Resident #3 wandered into Resident #1's room and was asked to leave. Resident #1 followed Resident #3 down the hall and initiated fight. The residents were redirected away from each other with no resistance. Residents were stopped on command and only arms made contact. Residents were assessed for injury with no signs or symptoms of injury. The administrator, DON, and ADONs notified.Record review of TULIP (state online abuse reporting portal) did not indicate any reports from facility regarding the incident dated 01/31/2026. Resident #1 followed Resident #3 down the hall to initiate a fist fight until 02/13/2026. Record review of TULIP provider investigation report dated 02/13/2026 reflected incident dated 01/31/2026 Resident #1 history of physical aggression and Resident #3 history of wandering description of the allegation reflected there was an altercation between two male residents. Resident #3 went into Resident #1's room. Resident #1 followed Resident #3 into the hallway, and a verbal altercation took place. Resident #1 struck Resident #3 when he was seated. Staff intervened and there were no injuries. During an interview on 02/12/2025 at 12:56 PM, LVN A stated on 01/31/2026 Resident #3 poked his head into Resident #1's room and Resident #1 began swinging his fists at Resident #3's head. LVN A said Resident #1 and Resident #3 started to hit each other but they did not make contact. LVN A said there were no injuries and he reported the incident to the Administrator, the DON, and the ADON.During an interview on 02/12/26 at 2:12 PM, the Administrator said he did not self-report the incident on 01/31/2026 between Resident #1 and Resident #3 because there was no physical contact. The Administrator said it was his understanding that staff saw Resident #1 come after Resident #3, but staff intervened before there was any abuse. He said the way it was explained to him he did not think he needed to report it but if he read Resident #1's progress note dated 01/31/2026 by LVN A he probably would have reported the incident. The progress note indicated Resident #1's intent to hurt Resident #3 and Resident #1 might have frightened Resident #3 when he followed him down the hallway with intent of a fist fight. During an interview on 02/13/2026 at 3:08 PM, the DON said the incident on 01/31/2026 with Resident #1 and Resident #3 was a resident-to-resident physical altercation and it was not investigated or reported to HHS. The DON said it was the facility policy to both investigate and report all resident-to-resident abuse allegations and it should have been reported as soon as the Administrator learned about the incident. Review of the facility Policy and Procedures dated 09/06/2024 titled Abuse, Neglect and Exploitation revealed the facility reports abuse and abuse allegations that include: 1. Reporting allegations involving staff to-resident abuse, resident-to resident altercations involving allegations of abuse, injuries of unknown source, misappropriation of resident property exploitation, and mistreatment.2. It is the responsibility of the staff to immediately protect the residents by removing them from the situation providing them safety and then immediately reporting to the Abuse Coordinator (The Administrator or Designee) if they become aware of an incident of resident or patient abuse or neglect, whether alleged, suspected or observed. It is a criminal offense to be aware of suspected or observed resident or patient abuse and not rcpo1t it. Staff failure to report suspected or observed Abuse or Neglect will result in disciplinary action up to and including termination of employment3. Reporting of all alleged violations to the Adn1inistrator is in11nediate without any delay, the Administrator will then report to state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frame:a. Immediately, but not later than2 hours after the allegation is made, if the events that cause the allegation involves Abuse (with or without bodily injury)b. An Incident that results in serious bodily injury and that involves any of the following: Neglect Exploitation Mistreatment injuries of unknown source Misappropriation of resident propertyc. Not later than 24 hours after the incident occurs or is suspected. An incident that doesnot result in serious bodily injury but that involves any of the following: Neglect Exploitation A missing resident Misappropriation of resident property Drug thief

Based on interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 4 residents (Resident #1) reviewed for self-determination. 1. The facility failed to ensure Resident #1's brief was changed when soiled when staff insisted she use the commode instead of her brief. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life.Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (neurological conditions that result from a stroke), transient cerebral ischemic attack (temporary interruption of blood flow or stroke), bipolar disorder (mood swings ranging from depressive lows to manic highs), schizoaffective disorder (mental health condition that combines symptoms of schizophrenia and depression or bipolar disorder), muscle weakness, unspecified lack of coordination, muscle wasting and atrophy right lower leg (loss of muscle mass and strengths), muscle wasting and atrophy left lower leg (loss of muscle mass and strength), and unsteadiness on feet. Review of Resident #1 quarterly MDS dated [DATE] reflected a BIMS of 15 (no cognitive impairment). Further review reflected that resident did not reject any evaluation or care such as ADL assistance. Resident #1 had functional limitation in range of motion with upper extremity impairment on both sides of her body. Review reflected a urinary toileting program had not been trialed with Resident #1 which included scheduled toileting, prompted voiding or bladder training. Review of urinary and bowel continence reflected Resident #1 was frequently incontinent for both. Review reflected Resident #1 was at risk of developing pressure ulcers but had no pressure ulcers. Review reflected Resident #1 had no skin conditions. Review of Resident #1 care plan dated 07/02/2021 reflected Resident #1 had an ADL self-care deficit and was at risk for not having her needs met in a timely manner with a goal for Resident #1 to maintain a sense of dignity by being clean, dry, odor free and well-groomed through 11/19/2025. Review reflected Resident #1 was frequently incontinent of bowel/bladder related to disease process and physical limitations and needed encouragement to get up and use her toilet with date of 06/25/2025. Goal included that resident will be clean and odor free through the next review date of 11/19/2025. Interventions included to check frequently of wetness and soiling and change as needed, use briefs or incontinent products as needed for protections, and assist to the toilet as needed. Review of care plan dated 08/03/2021 reflected Resident #1 was at risk for development of pressure ulcers with interventions to check frequently for soiling or wetness and provide incontinence care as needed, and briefs of adult incontinence products as needed for protections. Review of Resident #1 visual or bedside Kardex (electronic health record) report as of 09/04/2025 reflected under bowel and bladder Resident #1 was incontinent and to check frequently for wetness and soiling and change as needed. Review of Resident #1 bowel and bladder program screener dated 02/12/2025 reflected Resident #1 was not continent of bladder or bowel function which has remained the same since the last three months. Resident #1 was not on a toileting plan and had not been evaluated or found appropriate for a trial toileting plan. Review of bowel and bladder program screener dated 08/14/2025 reflected Resident #1 was continent of bladder and bowel function. Review of bladder continent POC (point of care or electronica health record) response history for 14 days reflected Resident #1 had a continent episode on 08/22/2025, two episodes on 08/31/2025, two episodes on 09/01/2025 and a continent episode on 09/03/2025. Further review reflected resident had 2 incontinent episodes on 08/22/2025, three on 08/23/2025, three on 08/24/2025, two on 08/25/2025, three on 08/26/2025, two on 08/27/2025, two on 08/28/2025, one on 08/30/2025, one on 08/31/2025, one on 09/01/2025, three on 09/02/2025 and one on 09/03/2025. Review of bowel continent POC response history for 14 days reflected Resident #1 had one continent episode on 08/22/2025, one on 08/28/2025, two on 08/30/2025, two on 09/01/2025 and one on 09/03/2025. Further review reflected Resident #1 had one incontinent episode on 08/22/2025, two on 08/24/2025, one on 08/25/2025, three on 08/26/2025, one on 08/27/2025, one on 08/28/2025, one on 08/31/2025, one on 09/01/2025, two on 09/02/2025 and one on 09/03/2025. Review of care plan conference notes dated 07/15/2025 reflected meeting was held on 07/14/2025 at 11:00 AM. Nursing summary reflected there were no concerns, issues or changes and discussed resident's independence. Social services summary reflected discussed resident working towards being more independent w/ADLs as well as being more self sufficient and able to do something on her own or little assistance. Resident in agreement and states she would like to be more independent. Discussed toileting and resident states she can transfer to toilet by herself but needs [assistance] wiping after urinating or having a [bowel movement]. Review did not reflect that staff would offer toileting and leave resident in brief when she requested to be changed and return later after initial refusal to be toileted. Review of Resident #1's weekly skin assessment dated [DATE] reflected there were no impairments in skin integrity. Review of nursing progress note dated 08/22/2025 at 11:20 AM by LVN B reflected resident was incontinent of bladder and bowel. Other observations reflected resident laid in bed and refused to get up. Resident #1 at times will use toilet but frequently refuses and is incontinent and required incontinent care for bowel and bladder. Review of nursing progress note dated 08/24/2025 at 9:35 AM by LVN B reflected Resident #1 was incontinent of bladder and pads or briefs were used and resident was incontinent of bowel. Review of nursing progress note dated 08/25/2025 by LVN B reflected aides attempted to toilet Resident #1 but she refused. Review of nursing progress note dated 08/25/2025 at 10:48 AM by LVN A reflected Resident #1 was continent of bladder with no changes noted and continent of bowel. Review of nursing progress note dated 08/26/2025 at 12:07 PM by LVN A reflected Resident #1 is incontinent of bladder with pads/briefs used and that resident is incontinent of bowel. Review of nursing progress note dated 08/27/2025 at 11:04 AM by LVN A reflected Resident #1 is incontinent of bladder with pads/briefs used and that resident is incontinent of bowel. Review of nursing progress note dated 08/29/2025 at 1:06 PM by LVN A reflected Resident has refused to get up out of bed and use toilet all shift. Resident states No it is y'alls job to change me in bed and that is what y'all are going to do. Both aides turned and walked out to notify supervisors. It is care plan that resident is capable to get up to use toilet. Resident has been offered several times to get up and use toilet before trays come out and has refused. During an interview on 09/04/2025 at 9:50 AM, Resident #1 stated that she and the ADM do not get along. Resident #1 stated that the ADM told everyone she had to get up and use the toilet instead of her brief, but she is incontinent. Resident #1 stated she has been incontinent since 2015 after her stroke. Resident #1 stated that she cannot tell when she urinates she just knows when she is wet and she wanted her brief changed. Resident #1 stated staff told her they were told that Resident #1 was supposed to get up and go to the toilet and that was in her care plan. Resident #1 stated that she can get in and out of bed to transfer if her wheelchair is next to her bed, but she cannot tell when she needs to get up and use the bathroom so she used her brief and asked staff to be changed. During an interview on 09/04/2025 at 12:28 PM, CNA C stated that she works PRN at the facility and is not often. CNA C stated that residents required brief change every hour and a half or two hours and that she checked the residents to see if they were dry and clean. CNA C stated that there are a few residents that will put on their call light to be changed. CNA C stated that Kardex or POC told her which residents used a brief and which needed assistance. CNA C stated that Resident #1 could get up and use the bathroom with assistance. CNA C stated Resident #1 wore briefs. CNA C stated they told CNA C that Resident #1 was supposed to get up and use the bathroom with assistance. CNA C stated by they she meant the ADM, charge nurses and ADONs. CNA C stated that when she did rounds because Resident #1 was a heavy wetter she went to see if Resident #1 had an accident. CNA C stated that if Resident #1 had an accident she would get Resident #1 up to the bathroom to get her cleaned up. CNA C stated it was a title war (conflict) with Resident #1 because she refused care often. CNA C stated Resident #1 was and was not incontinent. CNA C stated Resident #1 can get up with assistance. CNA C stated that Resident #1 refused to get up and go to the toilet. CNA C stated that they told CNA not to change Resident #1 in bed and that a refusal to go to the toilet meant a refusal to be changed and stated that Resident #1 was supposed to get up and go to the toilet. CNA C stated that if Resident #1 refused the first time to get up and use the toilet she would leave Resident #1 in her brief and return later to try and get Resident #1 to use the toilet. CNA C stated it was important for residents to get changed to prevent breakdown and irritation. CNA C stated it was in Resident #1's care plan that she can get up and use the toilet and she also had to go by what the ADM told her. During an interview on 09/04/2025 at 12:52 PM, CNA D stated a resident's needs were determined based on what their care plan said and it listed what the resident could and could not do for themselves. CNA D stated the Kardex told staff if a resident was incontinent or if they could get up and go to the toilet and what assistance from staff was needed. CNA D stated that Resident #1 was not incontinent and refused when asked to get up and go to the toilet and Resident #1 stated she did not want to sit on the toilet and wanted to use her brief. CNA D stated she knows Resident #1 is not incontinent because Resident #1 told staff when she was wet or had a BM and stated residents who are incontinent don't know that they've gone to the bathroom. CNA D stated that rounds were done at least every two hours and it included to provide anything the resident needed and check and change residents, unless they call before and ask to be changed. CNA D stated that if Resident #1 stated she was wet and refused to get up and use the toilet CNA D would leave for a few minutes and then ask Resident #1 a second time and if Resident #1 refused to get up and use the toilet again then CNA D would change Resident #1. CNA D stated that she knew residents had the right to refuse.During an interview on 09/04/2025 at 1:09 PM, COTA E stated she had worked with Resident #1 from 08/04/2025 to 08/27/2025 when Resident #1 was getting occupational therapy. COTA E stated that she was not sure if Resident #1 was continent or incontinent. COTA E stated Resident #1 was physically able to get up and go to the toilet but could not clean herself and Resident #1 was offered a tool to assist with cleaning. During an interview on 09/04/2025 at 1:10 PM, OT F stated Resident #1 was at her highest practicable level which is why she was discharged from therapy. Resident #1 was able to walk to the bathroom with aide supervision, but required max encouragement to get up. OT F stated she asked Resident #1 why she did not get up and go to the bathroom and Resident #1 told OT F it was a hassle. OT F stated that cognitively Resident #1 knows when she needs to go to the bathroom. During an interview on 09/04/2025 at 1:15 PM, LVN A stated that she has worked at the facility on and off for 17 years. LVN A stated that bowel and bladder screenings are done quarterly and with any kind of change. LVN A stated that Resident #1's recent assessment said she was continent because Resident #1 was able to go to the bathroom. LVN A stated Resident #1 used the call light and said 'I had a bowel movement I need you to change me' or calls the aides and says she is wet. LVN A stated that Resident #1 stated several times she is able to use the toilet but chose not to. LVN A stated that she was educated to try and help Resident #1 keep her independence as much as she can. LVN A stated Resident #1 was reevaluated by therapy and Resident #1 told therapy, aides and nurses she was able to get up and use the bathroom but she did not want to. LVN A stated they had a care plan meeting with Resident #1 and that LVN A was told when staff go in and Resident #1 stated she was wet to try and get her up to the toilet, so linens can be changed if needed and Resident #1 refuses and said I'm not going anywhere. LVN A stated she knew Resident #1 had mental problems but Resident #1 was hateful and only allowed certain care when it was convenient for Resident #1. LVN A stated if Resident #1 is wet and in bed and refused to go to the toilet they had to do what is in her care plan and that Resident #1 usually did not get her brief changed 9 times out of 10 because she has gotten mad with staff and aides. LVN A stated that if she refused to get up and use the toilet, staff will leave her and do not change her brief and have to go back later. LVN A stated that if she refused a 2nd time to get up and use the toilet then staff will change her brief then. LVN A stated she had not read Resident #1's care plan, but administration said she was capable to get up and go to the bathroom. LVN A stated she received an in-service about Resident #1 getting up and going to the bathroom and was instructed if Resident #1 refused the first time try again and let the nurse know and then if she refused again to let administration know. LVN A stated rounds were done every two hours or as needed when a call light is put on. During rounds residents were checked to see if they needed to be changed, needed any drinks or whatever else they may need. LVN A stated that she knew if a resident was incontinent based on information in their chart, rounds and knowing most of the residents as she has worked with them. During an interview on 09/04/2025 at 1:45 PM, LVN B stated that she completed bowel and bladder assessments when they populated in PCC (point click care or electronic health record) to be done. LVN B stated incontinent meant that a resident frequently wet their brief. LVN B stated just because a resident could tell you they had a wet brief did not mean they were continent because they may not feel the urgency. LVN B stated that she was familiar with Resident #1 and she was usually continent and could go to the bathroom. LVN B stated on 09/04/2025 Resident #1 refused to go to the bathroom when staff tried to toilet her at 9:45 AM and 10:26 AM. LVN B stated she did not think Resident #1's brief was wet during those times. LVN B Stated Resident #1 will have times she will get up and go to the bathroom and Resident #1 will say she does not want to get up and go to the bathroom. LVN B stated that if Resident #1 lets staff know her brief is wet, staff should try to get Resident #1 to the toilet, but if she refused then they were supposed to change her brief. LVN B stated rounds were done every two hours and during rounds aides checked residents to see if they needed help to the bathroom or changed residents if they needed to be changed. During an interview on 09/04/2025 at 2:19 PM, MD stated that she was familiar with Resident #1 and Resident #1 had not complained about being incontinent and had not mentioned issues about not being able to go to the bathroom. MD Stated staff should motivate Resident #1 to sit on the commode. MD stated staff should of course change Resident #1 and check her and if she was wet staff should change Resident #1. MD stated if a resident was incontinent before and is not continent the resident should be encouraged to go to the toilet. MD stated testing a resident's incontinence required urological follow up, but she had not received information about a request for a urological follow up for Resident #1. MD stated she would refer to a urologist for issue with incontinence. During an interview on 09/04/2025 at 2:33 PM, SW stated that there was a care plan meeting held with Resident #1 recently and Resident #1 thought the facility wanted her to do more than she could actually do. SW stated Resident #1 was difficult to get along with sometimes. SW stated during the care plan Resident #1 stated she needed assistance wiping after a BM and understood to push her call light for assistance. SW stated that it was discussed that when Resident #1 needed to be changed staff would offer toileting to her, which resident was in agreement with. SW stated Resident #1 stated she could transfer to toilet, but needed help with wiping and will agree, but then chooses not to do it sometimes and demands assistance from staff. SW stated if Resident #1 asked to be changed then staff should go in and change her. During an interview on 09/04/2025 at 2:33 PM, the DON stated that Resident #1 was independent with toileting and can take herself and if she needed help getting up staff could assist with that. The DON stated that on the Kardex staff marked incontinent to indicate the resident had an incontinent episode. The DON stated that a resident was incontinent when the resident could not tell you after they urinated or had a bowel movement. The DON stated that meant the resident did not have the sensation to know they needed to go. The DON stated that the resident may be able to tell after they went, but not while or when the needed to urinate or have a bowel movement The DON stated staff were supposed to offer to take Resident #1 to the toilet and if she refused they were supposed to leave and reapproach her again in thirty minutes to an hour and this included if the resident had a soiled or wet brief. The DON then stated she was not positive if staff were leaving and returning to change Resident #1 right away, but expected staff to go back and unsure what the time frame was for staff to go back. The DON stated if Resident #1 refused to go to the toilet staff would not change her because Resident #1 was independent. The DON stated she was unsure how often bowel and bladder screenings are redone. The DON stated that rounds were done every two hours and staff were to ensure residents were breathing and this included changing the resident if they were wet if they were incontinent. The DON stated that staff can find in PCC if a resident was incontinent. The DON stated that Resident #1's chart should say she is continent. The DON stated it was important that a resident be changed to prevent skin breakdown. The DON stated if a resident was incontinent they may be able to feel after they are wet or soiled, but they don't know when it is happening. During an interview on 09/04/2025 at 3:28 PM, the ADM stated Resident #1 being toileted was prompted by facility looking at residents who often needed help and that the facility wanted to ensure they rehabilitated not debilitated resident. The ADM stated that obviously residents would still be assisted, but wanted to promote residents independence who could do a lot of things on their own. The ADM stated that staff stated Resident #1 would sit and pee and let staff know to go and change her. The ADM stated that they met with ombudsman and set up care plan so aides can take care of residents who really need assistance and promote independence. The ADM stated that he expected if Resident #1 stated she was wet that he would ask why she did not get up and go to the bathroom because she can go. He stated staff should offer to take Resident #1 to the bathroom and she should get up. The ADM stated before the care plan meeting staff were going in and changing Resident #1's brief and also offering her to get up and get toiled and waiting on her hand and foot. The ADM stated he was not present during the care plan meeting. The ADM stated that if Resident #1 refused to get up and go to the toilet he expected staff to change her brief and if she starts cussing then care ends and staff could return when she was in a better mood. The ADM stated that he did not know how often staff would go back and check on Resident #1 because two staff were required and sometimes it was quick and sometimes it was 30 minutes to an hour. The ADM stated that Resident #1 admitted she was continent otherwise to determine incontinence a physician would have to be consulted. The ADM stated Resident #1 does not have issues when she goes out on pass and takes herself to the toilet then. The ADM stated it was in the POC for staff to find if a resident was continent or incontinent. The ADM stated that Resident #1's POC should say she was continent. During exit conference interview on 09/04/2025 at 4:20 PM, the ADM and DON were notified of findings. The ADM stated that surveyor was citing that she has the right to be lazy. The ADM stated that staff provided care residents needed not wanted and asked if Resident #1 asked for a colostomy bag if he would have to provide her with one. The ADM stated, I haven't even taken the briefs away from her yet. Review of facility in-service dated 07/16/2025 reflected Resident #1 required two person assist for all interactions. Review of facility in-service titled August in-service dated 08/28/2025 reflected incontinent- difference between can't and won't. Take residents to the bathroom when possible. Review of undated facility policy titled Statement of Resident Rights reflected residents had the right to all care necessary to have the highest possible level of health, and safe, clean and decent conditions. Further review reflected The facility must encourage and assist you to fully exercise your rights.

47926 Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #6, Resident #20, Resident #40, and Resident #42) reviewed for infection control. 1. MA C failed to properly sanitize the blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressures for Residents #6 and #20. 2. CNA A failed to wash or sanitize her hands while going from a dirty to clean surface while performing incontinent care on 02/05/25 at 9:20 AM for Resident #40. 3. LVN B failed to wash or sanitize his hands after removing a soiled dressing while performing wound care on Resident #42. These failures could place residents at-risk of cross contamination which could result in spreading infections or illness. Findings include: 1. Record review of Resident # 6 face sheet, dated 2/5/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Malignant neoplasm of unspecified part if the Bronchus or lung (cancer of the lung), Chronic obstructive pulmonary disease (a group of diseases of the lung causing difficulty breathing), bipolar disorder (a disorder affecting mood and behavior), and major depressive disorder. Record review of Resident #6 quarterly MDS reflected she had a BIMS score of 15, which indicated she was cognitively intact. Resident #6 was independent with eating, personal hygiene, and required set up clean-up assistance assist with bathing. Record review of Resident #6's care plan, dated 10/21/14 and revised on 03/05/24, reflected: The resident has Emphysema/ Chronic obstructive pulmonary disease ((a group of diseases of the lung causing difficulty breathing) related to Smoking. Goal: The resident, will be free of signs and symptoms of respiratory infections through review date. Interventions: Monitor/document/report to Medical Doctor PRN any signs and symptoms of respiratory infection: Fever, Chills, increase in sputum (document the amount, color, and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. 2. Record review of Resident # 20 face sheet, dated 2/5/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included atherosclerotic heart disease (a hardening of the arteries), Hypertension (elevated blood pressure), Type 2 Diabetes (elevated blood sugar), and bipolar disorder (a disorder affecting mood and behavior). Record review of Resident #20 quarterly MDS, dated [DATE], reflected he had a BIMS score of 9, which indicated he was cognitively impaired. Resident #20 required set-up or clean up assist with eating and personal hygiene, required partial to moderate assist with bathing, and was dependent on staff with toileting. Record review of Resident #20's care plan, dated 04/02/24, reflected: The resident requires Enhanced Barrier Precautions due to Vascular ulcer. Goal The resident will remain free from active infection with MDROs through the review date. Interventions: Notify the physician of any Signs and symptoms of active infection. Wear gown and gloves during high-contact resident care activities. In an observation of medication pass on 02/05/25 at 8:50 AM revealed MA C did not sanitize the blood pressure cuff when going from Resident #20 to Resident #6. In an interview on 02/05/25 at 9:27 AM, MA C stated she normally cleaned the blood pressure cuff between residents. She stated she just forgot to do it this time. MA C stated she was trained on infection control by the DON by in-services. She stated negative effects for not cleaning the blood pressure cuff between residents would be cross contamination. 3. Record review of Resident #40's face sheet, dated 02/05/25, reflected Resident #40 was an [AGE] year-old female with an admitted [DATE]. Resident #40's diagnoses included atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and osteoarthritis (a degenerative joint disease that causes the cartilage and bone in a joint to break down over time). Record review of Resident #40's most recent quarterly MDS assessment, dated 12/20/24, reflected Resident #40 had a BIMS score of 11, which indicated Resident #40 was moderately cognitively impaired. Resident #40 required set-up or clean up assist with eating and personal hygiene, required partial to moderate assist with bathing, and was dependent on staff with toileting. Resident #40 was always incontinent of bowel and bladder. Record review of Resident #40's care plan, dated 04/21/21 and revised on 07/26/21, reflected: [Resident #40] was incontinent of bowel and bladder. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through next review date. Interventions: Check frequently for wetness and soiling and change as needed. Monitor for and report to Medical Doctor signs and symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview on 02/05/25 at 9:35 AM, Resident #40 stated she was doing well, and the staff took good care of her. She stated she had no concerns for her care and her needs were met. Resident #40 was in bed with blankets that covered her to her chest area and her call light was in reach. In an observation on 02/05/25 at 09:20 AM, CNA A performed incontinent care for Resident #40. CNA A washed her hands, applied gloves, and began the incontinent care. CNA A began by cleansing the perineal area on the front of the resident then turned the resident to the side and continued incontinent care to the resident's backside. CNA A removed the residents dirty brief and applied a clean brief. CNA A did not wash her hands when she went from a dirty to clean surface. In an interview on 02/05/25 at 09:29 AM, CNA A stated she had not washed her hands when she performed incontinent care on Resident #40. She stated she usually only changed her gloves and washed or sanitized her hands during incontinent care if there was feces present. She stated she was trained on infection control, hand washing, and incontinent care, and she knew she was supposed to change her gloves and wash her hands when she went from a dirty to clean surface. She stated if incontinent care was done incorrectly or she had not washed her hands and changed her gloves when going from a dirty to clean surface, it could cause cross contamination. 4. Record review of Resident # 42 face sheet, dated 2/5/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #42 had diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Rights Dominant Side (paralysis of the right side after a stroke or brain bleed), encounter for surgical aftercare following surgery on the digestive system, Type 2 Diabetes Mellitus (elevated blood sugar), Hypertension (elevated blood pressure), and Morbid Obesity. Record review of Resident #42 quarterly MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated she was cognitively intact. Resident #42 was independent with eating and required substantial/maximal assistance with personal hygiene bathing, dressing and toileting. Resident #42 had a surgical wound that required wound care. Record review of Resident #42's care plan, dated 05/23/24 and revised on 08/28/24, reflected: Surgical Wound: Post surgical wounds of anterior abdomen Resident has a surgical wound and is at risk for infection, pain, and a decrease in functional abilities. Goal: Resident's surgical wound will show signs of healing through the next review date. Interventions: Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. In an observation of wound care on 02/05/25 at 9:37 AM revealed LVN B did not wash his hands or use hand sanitizer after he removed a soiled wound dressing, cleansed the wound, changed his gloves, and applied a clean dressing to Resident #42's abdominal wound. In an interview on 02/05/25 at 10:04 AM, LVN B stated he normally would have washed his hands between changing gloves, but the sink in the residents' room was out of order. It had a been temporarily shut off due to a leak this morning. He stated normally it was a non-issue but with the sink out he didn't think about having alcohol-based hand sanitizer in the room with him. He stated he was in serviced on infection control by the DON. He stated the risk for residents for not washing hands would be wound infection. In an interview on 02/06/25 at 12:27 PM, the DON stated it was her expectation all staff cleansed their hands in-between gloving, during peri care and wound care. She expected staff to clean hands with either soap and water or alcohol-based hand sanitizer when going from a dirty or soiled surface to a clean surface area. She stated she expected the blood pressure cuff to be cleaned in-between residents. The DON stated she in-services staff monthly and as needed on infection control. She stated the department head staff made rounds and monitored for infection control practices through observations and checking competency yearly and as needed. She stated the risk placed on residents for not washing hands and cleaning the blood pressure cuff between residents included the introduction of pathogens to staff and residents' leading to infections. Record review of the facility's Infection Prevention and Control Program policy, dated 03/26/24, reflected the following: All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . Reusable items potentially contaminated with infectious material shall be placed in an impervious clear plastic bag. Label bag as 'Contaminated' and placed in soiled utility room for pickup and processing. The central supply clerk will decontaminate equipment with a germicidal detergent prior to storing for reuse. Record review of the facility's Hand Hygiene policy, dated 11/12/2017, reflected the following: Policy Statement: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table Record review of the facility's, undated, facility form Hand Hygiene Table reflected the following for when hand hygiene should be performed: Before performing resident care procedures. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving from a contaminated body site to a clean body site. After assistance with personal body functions (elimination, hair grooming, smoking)

Based on Observations, interviews, and record review, the facility failed ensure residents had the right to be free from sexual abuse for 3 of 7 residents (RES #40, RES #18, and RES #27) who were investigated for sexual abuse. 1. The facility failed to stop RES #28 from having climbed into RES #18's bed and having sexually touched RES #18 penis on 9/7/2023, which prompted to a law enforcement investigation, a facility self-reported incident of Resident Abuse, with no care plan update for behaviors to protect residents from further abuse. RES #18's LAR expressed RES #18 had no known history of homosexual behaviors. 2. The facility failed to stop RES #18 from having reached out and having grabbed RES #27's left breast on 11/20/2023, which led to a facility self-reported incident of Resident Abuse with no care plan update for RES #18's behaviors to protect residents from further abuse. RES #27 expressed that she did not remember the incident and maybe it was a good thing that I do not remember. 3. The facility failed to stop RES #28 from initially having kissed RES #40 on 8/3/2023, which did not prompt a care plan update for RES #28 inappropriate sexual behaviors to protect residents from further abuse or a facility self-reported incident for RES #28's behaviors; the facility failed to stop RES #28 from having kissed RES #40 a second time, on 9/29/2023, after the facility was aware of RES #28's previously known inappropriat sexual behaviors. While RES #40 recalled the second kissing incident but was unable to verbally express details, having had severely impaired cognitive impairment and having applied the reasonable person concept, RES #40 would not want a man having approached and kissed her on two separate occasions. An IJ, Immediate Jeopardy, was identified on 12/22/2023 at 6:30 PM. While the IJ was removed on 12/23/2023 at 4:00 PM, the facility remained out of compliance at a scope of pattern that was actual harm, due to the facility's need to protect its residents from sexual abuse. This failure placed residents in the facility at risk for sexual abuse. Findings included: Record review of the facility's PIR dated 9/7/2023, reflected RES #28 was observed in RES # 18's bed spooning, which was two bodies lying against each other, while masturbating on 9-7-2023 at 9:10 PM. The residents were immediately separated, police were called, and responded, then RES #28 was placed on ono-on-one supervision. RES #18 received a skin assessment by the ADON, which included an assessment of buttocks and penis. The assessment for RES #18 reflected no trauma. Staff were in-serviced on ANE; Residents were interviewed with no issues identified; Staff were interviewed with no issues identified; and RES #28 voluntarily admitted to a psych hospital on 9/8/2023. Attached to the PIR were signed statements from the ADM, DON, ADON, and SS. The narrative of the statements reflected CNA A entered RES #28 and RES #18's room on 9-7-2023 around 9:00 PM to 9:15 PM and discovered RES #28 laying behind RES #18 in RES #18's bed. RES #28 was observed masturbating with one hand and grabbing RES #18's penis with his other hand. The narrative continued where LVN D was notified and responded to enter RES #28 and RES #18's room. Upon entering, LVN D observed RES #28 laying behind RES #18 spooning. LVNA told RES #28 to get up and go back to bed, which he did. The narrative continued where the ADON was notified and responded to enter RES #28 and RES #18's room. RES #18 allegedly stated that someone crawled in bed with him, but could not remember who, and that he denied being in any pain. RES #28 stated that he and RES #18did not have sex, but that he, RES #28, only masturbated. Residents were separated, medically assessed, RES #28 placed on one-to-one, and police were notified. The narrative continued as the ADM wrote RES #18 showed no signs of psychological distress or pain since the incident. After multiple interviews, the ADM believed RES #28 was masturbating (on his own admission) and that RES #28 inappropriately touched RES #18. The narrative closed as the ADM stated disbelief that anything else happened between the two residents. The facility's PIR contained written interviews with CNA A, LVN D, SS, ADON, DON and the ADM. The PIR also contained RES #18's skin assessment performed by the ADON post incident on 9-7-2023. Record review of the facility's PIR dated 11/20/23 at 5:45 PM reflected RES #18 was observed reaching out and grabbing RES #27's left breast on 11/20/2023 at 4:15 PM on the facility's secure unit. The nurse immediately intervened and separated them; and no injuries for either resident. Staff received in-service for ANE; and RES #18 was to be kept more than an arms distance from other residents. Record review of RES # 27's AR, dated 11/28/2023, reflected RES # 27 was an [AGE] year-old female who was admitted to the facility on [DATE]. RES # 27 was diagnosed with (1) Alzheimer's Disease, which was a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment; and (2) Schizoaffective Disorder, which was a mental health disorder that is marked by a combination of hallucinations, delusions, depression, and mania. Record review of RES # 27's Quarterly MDS, dated [DATE], reflected RES # 27 had a BIMS of 8. A BIMS of 8 indicated RES # 27 had moderate cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #27 did not exhibit these behaviors. Record review of RES #27 CP, dated 7/10/2021, indicated RES #27 add a focus plan for behavior problems exhibited by problems associated with the cognitive decline related to Alzheimer's disease; (2) ineffective means to cope with individuals with moderate dementia; and (3) aggressive behaviors towards others due to confusion and related to dementia. Record review on 11/28/2023 of RES #27's medical records did not indicate and documentation that would suggest RES #27 possessed the cognitive ability to consent to sexual activity. Interview on 11/27/2023 at 2:28 PM with CNA B revealed staff were instructed to keep RES #18 separated from other residents after RES #18 reached out and grabbed Res #27's breast on 11/20/2023. CNA B stated staff keep a good eye on all the residents, since they were on the secure unit. Men were not allowed in women's rooms and women were not allowed in men's rooms. CNA B has been instructed that residents were not allowed to have sex. She had been instructed to intervene with residents engaged in sexual behaviors and redirect them to an alternate activity; also, to let the charge nurse know for follow up assessments. Interview on 11/27/2023 at 2:40 PM with RES #27 revealed she did not remember the incident where RES #18 reached out and touched her breast. RES #27 stated maybe it was a good thing that I do not remember. RES #27 did not demonstrate anger and she stated she felt safe at the facility. RES #27 resided in the facility's secure unit. Record review of RES #18's AR, dated 11/28/2023, reflected RES #18 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #18 was diagnosed with (1) Transient Cerebral Ischemic Attack (a brief interruption of blood flow to the brain), Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), Vascular Dementia(a description for problems with reasoning, planning, judgment, memory and other thought processes R/T impaired blood flow to the brain), Unspecified Dementia (a description for when a person lost the ability to think, remember, learn, make decisions, and solve problems). Record review of RES #18's Quarterly MDS, dated [DATE], reflected RES #18 had a BIMS of 7. A BIMS of 7 indicated RES #18 had severe cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #18 did not exhibit these behaviors. Section GG- Functional Abilities and Goals, RES #18 was coded as an 88, eighty-eight, for lying to sitting on side of bed. A code of 88, eighty-eight, indicated RES #18 did not attempt this procedure due to medical condition of safety concerns. Record Review of RES #18's CP initiated a Focus for a behavioral problem on 9/20/2023 which indicated RES #18 inappropriately touched staff's breasts, buttocks, or used sexually inappropriate verbiage. The goal, with a target date of 2/01/2024, indicated RES #18's's behavior would not interfere with the delivery of care or services, or result in harm to self or others through the target date, 2/1/2024, called for interventions such as (1) administer medications as ordered. Monitor and document for effectiveness and potential side effects- initiated 9/20/2023; (2) assess and anticipate resident's needs; food, thirst, toileting needs, comfort level, body positioning, and pain- initiated 9/20/2023; (3) approach resident in calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow tie for a response, and do not rush- initiated 9/20/2023; (4) and give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the residents as possible- initiated- 9/20/2023. Record review of RES #18's medical records did not indicate any documentation that would suggest RES #18 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 8:24 AM with RES # 18 revealed RES #28, crawled into his bed. When RES #28 was in his bed touching his penis, he said he asked RES #28 to stop, but RES #28 did not stop. RES #18 stated he did not get hurt and he was only touched. RES #18 denied his anus was penetrated by RES #28's body parts. RES #18 felt safe at the facility. RES #18 remembered the incident where he reached out and grabbed RES #27's breast. RES #18 stated that he was sitting next to her and felt like grabbing her breast, so he did it. RES#18 and RES #27 both resided in the facility's secure unit on 11/20/2023. Record review of RES #28's AR, dated 11/27/2023, reflected RES #28 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #28 was diagnosed with Schizophrenia (a serious mental illness that affected how a person thought, felt, and behaved), and Cognitive Communication Deficit (described as difficulty with a person's thought or how a person used language). Record review of RES #28's Quarterly MDS, dated [DATE], reflected RES #28 had a BIMS of 14. A BIMS of 14 indicated RES #28 was cognitively intact. Section E- Behaviors, RES #28 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #28 did not exhibit these behaviors. Section G- Functional Status , RES #28 was coded as 0, zero, for (1) bed mobility, which was how a resident moved to and from the lying position, turning side to side, and positioned body while in bed or alternative sleep furniture; (2) transfer, which was how a resident moved between surfaces to and from bed, chair, wheelchair, and standing; and (3) locomotion off the unit, which is how a resident move between locations in his room and adjacent corridor on same floor. A code of 0, zero, indicated RES #28 did not exhibit these behaviors performed independent, which meant no help or staff oversight needed. Record review of RES #28's CP did not reflect an intervention for resident-on-resident sexual abuse, which occurred on 9/7/2023 with RES #18. RES #28's CP did not reflect any interventions, for any sexual behaviors, directed towards any other residents for any previous incidents. Record review of RES #28's medical records did not indicate any documentation that would suggest RES #28 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 9:05 AM with RES #28 he revealed remembered the night when he crawled into his roommate's bed, RES #18, to engage in sexual activity. He stated, his penis did not penetrate his roommate; furthermore, there was only consensual touching. He thought it was ok to have sex in a nursing home. He stated no one ever told him he was not allowed to have sex or that he did not have the ability to consent. RES #28 did not think he was doing anything wrong. Afterwards, he thought he might have made a bad decision because everyone was asking questions, so he figured he was not supposed to do it again. He stated the DON told him he was not allowed to display sexual behaviors with anyone. RES #28 resided in his own private room since the resident-on-resident sexual abuse, with RES #18, on 9/7/2023. RES #28 stated he went to the psych hospital on 9/8/2023 and returned on 9/20/2023. Record review of RES #28's PN reflected (1) on 9/7/2023 at 9:20 PM entered by RN N, the PN indicated RES #28 was placed on one-to-one monitoring until further notice after the incident on 9-7-2023 with RES #18; (2) on 9/7/2023 at 2:00 AM entered by RN N, the PN indicated RES #28 was monitored one-to-one; (3) on 9/8/2023 at 11:13 entered by the DON, the PN indicated RES #28 continued one-to-one monitoring; (4) on 9/12/2023 at 6:04 PM entered by the SS, the PN indicated SS spoke to RES #28 on 9/8/2023, which regarded RES #28 and RES #18 being in bed on 9/7/2023. The PN reflected a discussion with RES #28 that addressed understanding of the events on 9/7/2023, mental confusion, and urges. The PN reflected the decision to send RES #28 to a psych hospital; (5) on 9/8/2023 at 9:37 PM entered by LVN M, the PN indicated RES #28 departed the facility to a psych hospital; and (6) on 9/20/2023 at 4:24 PM entered by LVN M, the PN indicated RES #28 readmitted to the facility. Interview and record review on 11/28/2023 at 2:00 PM with CNA A revealed she entered RES #28 and RES #18's room on 9-7-2023 around 9:00 PM or 9:15 PM. CNA A stated she observed RES #28 and RES #18 spooning. RES #28's hand was on RES #18's penis. CNA A stated she immediately went to LVN D to let her know what happened in the resident's room. CNA A was presented with her written interviews with the ADM on 9/8/2023 and 9/13/2023 and concurred the interviews were accurate. Interview on 11/28/2023 2:35 PM with LPN A revealed residents on the secure unit were not allowed to have sexual contact. Men and women were not allowed in each other's rooms. RES #18 was supposed to be kept separated from other residents. LPN A has been instructed that residents are not allowed to have sex. The residents were constantly watched. Interview and record review on 11/28/2023 at 3:00 PM with LVN D revealed she responded to RES #28 and RES #18's room on 9/7/2023 after being told there was an incident by CNA A. LVN D stated she went to the room, saw RES #28 and RES #18 spooning with RES #28's hand on RES #18's penis. LVN D stated she separated the residents and informed the ADON of what had occurred. LVN D was presented with her written interviews with the ADM from 9/8/2023 and 9/12/2023 and concurred the interview were accurate. The last time LVN D saw RES #28 and RES #18 was at 8:30 PM, 9-7-2023, during med pass on the night of the incident. RES #28 and RES #18 were roommates up until that night. Res #18 moved to another hall the night of the incident. Interview on 11-29-2023 with the ADON at 3:30 PM revealed she worked on 9-7-2023 and responded to the incident with RES #18 and RES #28. She stated she made sure the residents were separated immediately and checked RES #18 for any harm, she stated she placed RES #28 on a one-to-one while she performed a skin check of RES #18's body, which revealed no trauma. The ADON stated she called the police, who responded. The ADON stated the officer learned of RES #18 and RES #28's diagnosis and determined it would be too hard to try to determine consent. The ADON stated RES# 28 had not demonstrated similar behaviors prior to 9/7/2023. Interview and record review on 11/29/23 at 3:45 PM with the DON revealed there was no mention of an intervention for RES #28's behavior on 9/7/2023 with RES #18 in RES #28's current CP. The DON stated there was an intervention in RES #28's CP, but it must have been deleted when he discharged to the psych hospital on 9/8/2023 at 9:27 PM. The DON stated his orders and CP were updated upon his return on 9-20-2023 at 4:24 PM, but the intervention for what happened on 9-7-2023 (between RES #28 and RES #18) must not have been added back. The DON revealed the ADM did not want to make every detail of the incident known to everyone who had access to RES #28's CP and wanted to protect RES #28's privacy. The DON stated the interventions put in place for RES #28, which were not in RES #28's CP current care plan on 11/28/2023, were for him to have his own private room, keep him out of other people's rooms, continued psychological services, and be watched for behaviors and redirect as needed. The DON stated that the interventions in place were working. The DON stated RES #28 was placed on a medication, on 9-29-2023, called Medroxy Progesterone Acetate 5 MG by mouth daily for impulse control (a libido reducing medication.) RES #28 and RES #18 had not been evaluated, prior to 9/7/2023, for the cognitive ability to consent to sexual activity. During the interview, the DON entered a Focus, Goal, and Intervention in RES #28's CP directed at Sexual Behaviors and how RES #28's Goal, having pertained to sexual behaviors, would not interfere with the delivery of ADL care by staff. The interventions were to (1) administer medications as ordered by the physician and monitor for effectiveness and potential adverse side effects; (2) monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log; (3) approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow time for a response, and do not rush.; and (4) Give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible. The Focus, Goal, and Interventions, added to RES #28's CP on 11/29/2023 by the DON, were not the result of an IDT collaboration. The DON added them during the interview. The interview further revealed there was no intervention for RES #18's sexual behavior exhibited on 11/20/2023 in RES #18's CP. The DON stated RES #18 had exhibited groping behaviors with staff in the past and the behavior was annotated his CP on 9/20/2023; however, RES #18 having groped a resident on 11/20/2023 was a new behavior, and was not updated in RES #18's CP. The DON felt the interventions in place from 9/20/2023 would continue to provide safety to the resident, staff, and other residents. During the interview on 11/29/2023, the DON updated RES #18's CP, which addressed the Focus for behavioral problems evidenced by sexually inappropriately behaviors with a female resident witnessed by staff groping resident breast. The existing Goal from 9/20/2023 was that RES #18's behavior will not interfere with the delivery of care or services or result in harm to self or others, was not edited. The interventions, initiated on 11/29/2023, were to (1) provide resident with as many choices as possible with their daily cares and activities. Provide a program of activities that accommodates the residents cognitive and functional abilities; (2) intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others; and (3) Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. The Focus, Goal, and Interventions, added to RES #18's CP on 11/29/2023, were not the result of an IDT collaboration. The DON added them during the interview. Interview on 11/29/2023 at 4:43 PM with the ADM revealed he did not want to enter detailed information about RES #28's sexual behavior with RES #18, in his (RES #28) CP. The ADM stated he did not want everyone in the facility, with access to RES #28's CP, to have access to confidential information. The ADM stated he did not know PCC (which was the electronic platform to record facility documentation) very well and did not know why the intervention placed in RES #28's CP prior to his discharge to the psych hospital, on 9-8-2023, was not still on the care plan upon his return, on 9-20-2023. The ADM stated he feels the interventions in place, such as monitoring and redirecting as needed, were effective. The ADM considered the interaction with RES #18 and RES #28 on 9/7/2023 was consensual. Interview further revealed that the interventions in place for RES #18, such as keeping RES #18 at arm's length from other residents was working and was adequate to keep the staff and residents safe. The ADM was not aware that RS #18's care plan had not been updated for RES #18's recent behavior of groping a RES #27 on 11/20/2023. Interview on 11/30/2023 at 4:00 PM with LAR # 18 revealed the facility called her on the night on 9-7-2023 to let her know about the incident between RES# 18 and RES #28. LAR # 18 stated the initial call was made by an employee, whose name she could not recall, that stated RES #18 was heard calling out from the room on 9-7-2023; LAR # 18 stated that a secondary phone call, with the DON, also described RES #18 as having called out for help from his room on 9-7-2023. LAR # 18 expressed, to the best of her knowledge, that RES #18 had no known history of homosexual relations; furthermore, LAR # 18 expressed she did not believe that RES #18 consented to RES #28 having been in his bed and having touched his penis. Record Review on 11/30/2023 of RES #28's PN, entered on 10/2/2023 at 11:10 AM by the SS, reflected RES #28 was observed kissing a female resident (RES #40) on the mouth on 9/29/2023. The PN reflected the SS and the Administration spoke with RES #28 and RES #28 admitted he pecked a female resident (RES #40) on the mouth on 9/29/2023. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:28 AM by the SS, reflected the SS gave RES #28 specific instructions on things that were not acceptable between him and other residents in the facility. SS informed RES #28 he was not allowed to kiss, touch, hug or have physical contact at any time. RES # 28 was educated to ask nursing staff, or management, questions about anything he thought of doing with another resident. RES #28 was made aware that more inappropriate incidents could initiate a transfer to another facility. RES # 28 acknowledge he understood and stated he did not want to leave the facility. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:46 AM by the SS, reflected PS DR was contacted for a medication intervention and RES #28 moved to another room, away from the female resident he encountered (RES #40.) Record review of the facility's Abuse, Neglect, and Exploitation Policy dated, 10/24/2022, indicated it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. III. Prevention of Abuse, Neglect, and Exploitation The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a residence consensual sexual relationship and to the extent possible prevent sexual abuse. (1) The consent to sexual contact will be made by the social worker / designee completing an evaluation that determines the resident has capability to engage in consensual sexual contact, or (2) the residents representative agrees to the resident's participation in consensual sex contact, and (3) the documentation of a resident's capacity for consensual sex contact is located in the medical record. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident's property is suspected or identified by. (1) taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to residents or other residents, and (2) review and evaluation of like instances to determine if the appropriate actions to correct the noncompliance was taken and documented. V. Investigations of alleged Abuse, Neglect, and Exploitation A. An immediate thorough investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. B. Abuse investigation procedure include, (1) Identifying staff responsible for the investigation, (2) exercising caution in handling evidence that could be used in a criminal investigation, (3) investigating different types of alleged violations, (4) identifying and interviewing all involved parties, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, (5) focusing the investigation on determining if the abuse, neglect, exploitation, and or mistreatment has occurred, the extent, and cause, and (6) providing complete and thorough documentation of the investigation. VI. Protection of Resident With facility makes efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Physical exam of the alleged victim for any sign of injury. C. Increase supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. E. Protection from retaliation. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. G. Revision of the residence care plan if the residents medical, nursing, physical, mental, or psychosocial needs or preferences change as the result of an incident of abuse. Record review of the facility's Abuse and Prevention and Reporting training, dated 9/8/2023, reflected 30 staff participated in the training. Record review of the facility's Resident's Rights and Sexual Survey, dated 9/8/2023, reflected 41 staff participated in the training. Record review of the facility's Safety Patient Questionnaire, dated 9-8-23, reflected the census for 9-8-2023 was 100 residents. The QAA Patient Questionnaire reflected a sample of twenty-seven residents who responded Yes- Do you feel safe at the facility; and responded No- Has a resident ever touched you in a manner that made you feel uncomfortable. Record review of the facility Quality Assurance Staff Questionnaire, dated 9-18-23, reflected 64 facility employees who responded No-have you ever seen a resident touch a female or male in an inappropriate manner; No-Are there any patients that touch another patient in an inappropriate manner; and No- Are there any patients that say sexually inappropriate things to another. Records review of RES #28's Order Summary Report indicated RES #28 was prescribed Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder, which began on 9/29/2023. Record review of Local Police Department, Report #23-02094, dated 9/7/2023 at 10:15 PM reflected a visit by Police Officer A to the facility in response to sexual assault of a [AGE] year-old male. The report indicated that RES #18 was asked if he wanted RES #28 in his bed and RES #18's response was |I think so. | The report indicated that RES #18 has a long list of mental deficits to include Alzheimer's, dementia, cognitive communication; and RES #28 has also been diagnosed with a list of disorders to include Schizophrenia, cognitive communication deficit, and major depressive disorder. The closing statement on the report stated |With these disorders it was determined that it would be difficult to determine if there was consent or not. RES #18 was not given a sexual assault exam. Print out of each party`s diagnoses have been included with this report. My report has been uploaded; I have nothing further at this time. | Observations on 12/22/2023 at 8:29 AM of RES #28 reflected him having sat quietly on his bed, in his room watching TV, alone. Interview on 12/22/2023 at 8:30 AM with RES #28 revealed he had kissed RES #40 on 9/29/2023. After the kissing incident, which occurred on 9/29/2023, he stated he was approached by the SS, who explained that his behaviors were not acceptable. RES # 28 stated he was moved to a different room and that he started a new medication. RES # 28 thought the medication had helped him by reducing feelings of [NAME] and sexual desire, but he was still able to attain an erection and masturbate. RES #28 did not feel sedated, or different, because of the medication; in fact, RES #28 stated that his quality of life had improved. He denied any desires to kiss, or sexually touch, another resident since he started the medication on 9/29/2023. Record review on 12/22/2023 of RES #28's Medication Administration Record for December 2023, indicated RES #28 had received his Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder. Interview on 12/22/2023 at 9:30 AM with NA A revealed that she had been working at facility as a NA since 12/18/2023. She was informed that there were residents in the facility that have displayed sexual behaviors in the past and that it could still happen. If she observed sexual behavior, she was instructed to get help immediately and report it to a charge nurse or the ADM. Interview on 12/22/2023 at 10:00 AM with the SS revealed RES #18, in general, possessed the cognitive faculties to consent to sexual activity; however, the SS was unable to determine if the interaction between RES #28 and RES #18, on the night of 9/7/2023, was consensual or not consensual. The SS stated she knew about the incident on 9/7/2023 but did not participate in an IDT meeting for an CP update. The SS stated that the incident, which occurred on 9/7/2023, between RES #28 and RES #18, should have received a CP update, to include a Focus, Goal, and Intervention. The SS stated she checked on RES #28 often, after the incident on 9/7/2023, and would redirect as needed. When asked, the SS was unable to elaborate on other staff's methods of intervention. When asked if resident #28 had displayed inappropriate sexual behavior[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to develop, update, and implement a comprehensive person-centered care plan for each resident, after four separate instances of resident abuse, that included measurable objectives and time frames to meet a resident medical, nursing, mental, and psychosocial needs for 2 of 7 residents (Resident #28 and RES #18) whose CPs were reviewed for regulatory compliance. The facility failed to update RES #28 and RES #18's CP after four separate incidents of sexual abuse: 1. The facility failed to update RES #28's CP after having climbed into RES #18's bed and having sexually touched RES #18 penis on 9-7-2023. 2. The facility failed to update RES #28's CP after having kissed RES #40 on 8-3-2023 and after having kissed RES #40 on 9-29-2023. 3. The facility failed to update RES #18's CP after having reached out and having grabbed RES #27's left breast on 11-20-2023. An IJ, Immediate Jeopardy, was identified on 12/22/2023 at 6:30 PM. While the IJ was removed on 12/23/2023 at 4:00 PM, the facility remained out of compliance at a scope of pattern that was actual harm, due to the facility's need to protect its residents through measurable Focus, Goals, and Interventions in Comprehensive Care Plans for residents who exhibited inappropriate sexual behavior. This failure placed residents in the facility at risk for sexual abuse. Findings included: Record review of the facility's PIR dated 9/7/2023, reflected RES #28 was observed in RES # 18's bed spooning, which was two bodies lying against each other, while masturbating on 9-7-2023 at 9:10 PM. The residents were immediately separated, police were called, and responded, then RES #28 was placed on ono-on-one supervision. RES #18 received a skin assessment by the ADON, which included an assessment of buttocks and penis. The assessment for RES #18 reflected no trauma. Staff were in-serviced on ANE; Residents were interviewed with no issues identified; Staff were interviewed with no issues identified; and RES #28 voluntarily admitted to a psych hospital on 9/8/2023. Attached to the PIR were signed statements from the ADM, DON, ADON, and SS. The narrative of the statements reflected CNA A entered RES #28 and RES #18's room on 9-7-2023 around 9:00 PM to 9:15 PM and discovered RES #28 laying behind RES #18 in RES #18's bed. RES #28 was observed masturbating with one hand and grabbing RES #18's penis with his other hand. The narrative continued where LVN D was notified and responded to enter RES #28 and RES #18's room. Upon entering, LVN D observed RES #28 laying behind RES #18 spooning. LVNA told RES #28 to get up and go back to bed, which he did. The narrative continued where the ADON was notified and responded to enter RES #28 and RES #18's room. RES #18 allegedly stated that someone crawled in bed with him, but could not remember who, and that he denied being in any pain. RES #28 stated that he and RES #18did not have sex, but that he, RES #28, only masturbated. Residents were separated, medically assessed, RES #28 placed on one-to-one, and police were notified. The narrative continued as the ADM wrote RES #18 showed no signs of psychological distress or pain since the incident. After multiple interviews, the ADM believed RES #28 was masturbating (on his own admission) and that RES #28 inappropriately touched RES #18. The narrative closed as the ADM stated disbelief that anything else happened between the two residents. The facility's PIR contained written interviews with CNA A, LVN D, SS, ADON, DON and the ADM. The PIR also contained RES #18's skin assessment performed by the ADON post incident on 9-7-2023. Record review of the facility's PIR dated 11/20/23 at 5:45 PM reflected RES #18 was observed reaching out and grabbing RES #27's left breast on 11/20/2023 at 4:15 PM on the facility's secure unit. The nurse immediately intervened and separated them; and no injuries for either resident. Staff received in-service for ANE; and RES #18 was to be kept more than an arms distance from other residents. Record review of RES # 27's AR, dated 11/28/2023, reflected RES # 27 was an [AGE] year-old female who was admitted to the facility on [DATE]. RES # 27 was diagnosed with (1) Alzheimer's Disease, which was a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment; and (2) Schizoaffective Disorder, which was a mental health disorder that is marked by a combination of hallucinations, delusions, depression, and mania. Record review of RES # 27's Quarterly MDS, dated [DATE], reflected RES # 27 had a BIMS of 8. A BIMS of 8 indicated RES # 27 had moderate cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #27 did not exhibit these behaviors. Record review of RES #27 CP, dated 7/10/2021, indicated RES #27 add a focus plan for behavior problems exhibited by problems associated with the cognitive decline related to Alzheimer's disease; (2) ineffective means to cope with individuals with moderate dementia; and (3) aggressive behaviors towards others due to confusion and related to dementia. Record review on 11/28/2023 of RES #27's medical records did not indicate and documentation that would suggest RES #27 possessed the cognitive ability to consent to sexual activity. Interview on 11/27/2023 at 2:28 PM with CNA B revealed staff were instructed to keep RES #18 separated from other residents after RES #18 reached out and grabbed Res #27's breast on 11/20/2023. CNA B stated staff keep a good eye on all the residents, since they were on the secure unit. Men were not allowed in women's rooms and women were not allowed in men's rooms. CNA B has been instructed that residents were not allowed to have sex. She had been instructed to intervene with residents engaged in sexual behaviors and redirect them to an alternate activity; also, to let the charge nurse know for follow up assessments. Interview on 11/27/2023 at 2:40 PM with RES #27 revealed she did not remember the incident where RES #18 reached out and touched her breast. RES #27 stated maybe it was a good thing that she did not remember. RES #27 did not demonstrate anger and she stated she felt safe at the facility. RES #27 resided in the facility's secure unit. Record review of RES #18's AR, dated 11/28/2023, reflected RES #18 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #18 was diagnosed with (1) Transient Cerebral Ischemic Attack (a brief interruption of blood flow to the brain), Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), Vascular Dementia(a description for problems with reasoning, planning, judgment, memory and other thought processes R/T impaired blood flow to the brain), Unspecified Dementia (a description for when a person lost the ability to think, remember, learn, make decisions, and solve problems). Record review of RES #18's Quarterly MDS, dated [DATE], reflected RES #18 had a BIMS of 7. A BIMS of 7 indicated RES #18 had severe cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #18 did not exhibit these behaviors. Section GG- Functional Abilities and Goals, RES #18 was coded as an 88, eighty-eight, for lying to sitting on side of bed. A code of 88, eighty-eight, indicated RES #18 did not attempt this procedure due to medical condition of safety concerns. Record Review of RES #18's CP initiated a Focus for a behavioral problem on 9/20/2023 which indicated RES #18 inappropriately touched staff's breasts, buttocks, or used sexually inappropriate verbiage. The goal, with a target date of 2/01/2024, indicated RES #18's's behavior would not interfere with the delivery of care or services, or result in harm to self or others through the target date, 2/1/2024, called for interventions such as (1) administer medications as ordered. Monitor and document for effectiveness and potential side effects- initiated 9/20/2023; (2) assess and anticipate resident's needs; food, thirst, toileting needs, comfort level, body positioning, and pain- initiated 9/20/2023; (3) approach resident in calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow tie for a response, and do not rush- initiated 9/20/2023; (4) and give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the residents as possible- initiated- 9/20/2023. RES #18's CP did not contain an update after the incident on 11/20/2023, after RES #27 reached out and grabbed RES #27's left breast. Record review of RES #18's medical records did not indicate any documentation that would suggest RES #18 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 8:24 AM with RES # 18 revealed RES #28, crawled into his bed. When RES #28 was in his bed touching his penis, he said he asked RES #28 to stop, but RES #28 did not stop. RES #18 stated he did not get hurt and he was only touched. RES #18 denied his anus was penetrated by RES #28's body parts. RES #18 felt safe at the facility. RES #18 remembered the incident where he reached out and grabbed RES #27's breast. RES #18 stated that he was sitting next to her and felt like grabbing her breast, so he did it. RES#18 and RES #27 both resided in the facility's secure unit on 11/20/2023. Record review of RES #28's AR, dated 11/27/2023, reflected RES #28 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #28 was diagnosed with Schizophrenia (a serious mental illness that affected how a person thought, felt, and behaved), and Cognitive Communication Deficit (described as difficulty with a person's thought or how a person used language). Record review of RES #28's Quarterly MDS, dated [DATE], reflected RES #28 had a BIMS of 14. A BIMS of 14 indicated RES #28 was cognitively intact. Section E- Behaviors, RES #28 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #28 did not exhibit these behaviors. Section G- Functional Status , RES #28 was coded as 0, zero, for (1) bed mobility, which was how a resident moved to and from the lying position, turning side to side, and positioned body while in bed or alternative sleep furniture; (2) transfer, which was how a resident moved between surfaces to and from bed, chair, wheelchair, and standing; and (3) locomotion off the unit, which is how a resident move between locations in his room and adjacent corridor on same floor. A code of 0, zero, indicated RES #28 did not exhibit these behaviors performed independent, which meant no help or staff oversight needed. Record review of RES #28's CP did not reflect an intervention for resident-on-resident sexual abuse, which occurred on 9/7/2023 with RES #18. RES #28's CP did not reflect any interventions, for any sexual behaviors, directed towards any other residents for any previous incidents. Record review of RES #28's medical records did not indicate any documentation that would suggest RES #28 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 9:05 AM with RES #28 he revealed remembered the night when he crawled into his roommate's bed, RES #18, to engage in sexual activity. He stated, his penis did not penetrate his roommate; furthermore, there was only consensual touching. He thought it was ok to have sex in a nursing home. He stated no one ever told him he was not allowed to have sex or that he did not have the ability to consent. RES #28 did not think he was doing anything wrong. Afterwards, he thought he might have made a bad decision because everyone was asking questions, so he figured he was not supposed to do it again. He stated the DON told him he was not allowed to display sexual behaviors with anyone. RES #28 resided in his own private room since the resident-on-resident sexual abuse, with RES #18, on 9/7/2023. RES #28 stated he went to the psych hospital on 9/8/2023 and returned on 9/20/2023. Record review of RES #28's PN reflected (1) on 9/7/2023 at 9:20 PM entered by RN N, the PN indicated RES #28 was placed on one-to-one monitoring until further notice after the incident on 9-7-2023 with RES #18; (2) on 9/7/2023 at 2:00 AM entered by RN N, the PN indicated RES #28 was monitored one-to-one; (3) on 9/8/2023 at 11:13 entered by the DON, the PN indicated RES #28 continued one-to-one monitoring; (4) on 9/12/2023 at 6:04 PM entered by the SS, the PN indicated SS spoke to RES #28 on 9/8/2023, which regarded RES #28 and RES #18 being in bed on 9/7/2023. The PN reflected a discussion with RES #28 that addressed understanding of the events on 9/7/2023, mental confusion, and urges. The PN reflected the decision to send RES #28 to a psych hospital; (5) on 9/8/2023 at 9:37 PM entered by LVN M, the PN indicated RES #28 departed the facility to a psych hospital; and (6) on 9/20/2023 at 4:24 PM entered by LVN M, the PN indicated RES #28 readmitted to the facility. Interview and record review on 11/28/2023 at 2:00 PM with CNA A revealed she entered RES #28 and RES #18's room on 9-7-2023 around 9:00 PM or 9:15 PM. CNA A stated she observed RES #28 and RES #18 spooning. RES #28's hand was on RES #18's penis. CNA A stated she immediately went to LVN D to let her know what happened in the resident's room. CNA A was presented with her written interviews with the ADM on 9/8/2023 and 9/13/2023 and concurred the interviews were accurate. Interview on 11/28/2023 2:35 PM with LPN A revealed residents on the secure unit were not allowed to have sexual contact. Men and women were not allowed in each other's rooms. RES #18 was supposed to be kept separated from other residents. LPN A has been instructed that residents are not allowed to have sex. The residents were constantly watched. Interview and record review on 11/28/2023 at 3:00 PM with LVN D revealed she responded to RES #28 and RES #18's room on 9/7/2023 after being told there was an incident by CNA A. LVN D stated she went to the room, saw RES #28 and RES #18 spooning with RES #28's hand on RES #18's penis. LVN D stated she separated the residents and informed the ADON of what had occurred. LVN D was presented with her written interviews with the ADM from 9/8/2023 and 9/12/2023 and concurred the interview were accurate. The last time LVN D saw RES #28 and RES #18 was at 8:30 PM, 9-7-2023, during med pass on the night of the incident. RES #28 and RES #18 were roommates up until that night. Res #18 moved to another hall the night of the incident. Interview on 11-29-2023 with the ADON at 3:30 PM revealed she worked on 9-7-2023 and responded to the incident with RES #18 and RES #28. She stated she made sure the residents were separated immediately and checked RES #18 for any harm, she stated she placed RES #28 on a one-to-one while she performed a skin check of RES #18's body, which revealed no trauma. The ADON stated she called the police, who responded. The ADON stated the officer learned of RES #18 and RES #28's diagnosis and determined it would be too hard to try to determine consent. The ADON stated RES# 28 had not demonstrated similar behaviors prior to 9/7/2023. Interview and record review on 11/29/23 at 3:45 PM with the DON revealed there was no mention of an intervention for RES #28's behavior on 9/7/2023 with RES #18 in RES #28's current CP. The DON stated there was an intervention in RES #28's CP, but it must have been deleted when he discharged to the psych hospital on 9/8/2023 at 9:27 PM. The DON stated his orders and CP were updated upon his return on 9-20-2023 at 4:24 PM, but the intervention for what happened on 9-7-2023 (between RES #28 and RES #18) must not have been added back. The DON revealed the ADM did not want to make every detail of the incident known to everyone who had access to RES #28's CP and wanted to protect RES #28's privacy. The DON stated the interventions put in place for RES #28, which were not in RES #28's CP current care plan on 11/28/2023, were for him to have his own private room, keep him out of other people's rooms, continued psychological services, and be watched for behaviors and redirect as needed. The DON stated that the interventions in place were working. The DON stated RES #28 was placed on a medication, on 9-29-2023, called Medroxy Progesterone Acetate 5 MG by mouth daily for impulse control (a libido reducing medication.) RES #28 and RES #18 had not been evaluated, prior to 9/7/2023, for the cognitive ability to consent to sexual activity. During the interview, the DON entered a Focus, Goal, and Intervention in RES #28's CP directed at Sexual Behaviors and how RES #28's Goal, having pertained to sexual behaviors, would not interfere with the delivery of ADL care by staff. The interventions were to (1) administer medications as ordered by the physician and monitor for effectiveness and potential adverse side effects; (2) monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log; (3) approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow time for a response, and do not rush.; and (4) Give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible. The Focus, Goal, and Interventions, added to RES #28's CP on 11/29/2023 by the DON, were not the result of an IDT collaboration. The DON added them during the interview. The interview further revealed there was no intervention for RES #18's sexual behavior exhibited on 11/20/2023 in RES #18's CP. The DON stated RES #18 had exhibited groping behaviors with staff in the past and the behavior was annotated his CP on 9/20/2023; however, RES #18 having groped a resident on 11/20/2023 was a new behavior, and was not updated in RES #18's CP. The DON felt the interventions in place from 9/20/2023 would continue to provide safety to the resident, staff, and other residents. During the interview on 11/29/2023, the DON updated RES #18's CP, which addressed the Focus for behavioral problems evidenced by sexually inappropriately behaviors with a female resident witnessed by staff groping resident breast. The existing Goal from 9/20/2023 was that RES #18's behavior will not interfere with the delivery of care or services or result in harm to self or others, was not edited. The interventions, initiated on 11/29/2023, were to (1) provide resident with as many choices as possible with their daily cares and activities. Provide a program of activities that accommodates the residents cognitive and functional abilities; (2) intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others; and (3) Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. The Focus, Goal, and Interventions, added to RES #18's CP on 11/29/2023, were not the result of an IDT collaboration. The DON added them during the interview. Interview on 11/29/2023 at 4:43 PM with the ADM revealed he did not want to enter detailed information about RES #28's sexual behavior with RES #18, in his (RES #28) CP. The ADM stated he did not want everyone in the facility, with access to RES #28's CP, to have access to confidential information. The ADM stated he did not know PCC (which was the electronic platform to record facility documentation) very well and did not know why the intervention placed in RES #28's CP prior to his discharge to the psych hospital, on 9-8-2023, was not still on the care plan upon his return, on 9-20-2023. The ADM stated he feels the interventions in place, such as monitoring and redirecting as needed, were effective. The ADM considered the interaction with RES #18 and RES #28 on 9/7/2023 was consensual. Interview further revealed that the interventions in place for RES #18, such as keeping RES #18 at arm's length from other residents was working and was adequate to keep the staff and residents safe. The ADM was not aware that RS #18's care plan had not been updated for RES #18's recent behavior of groping a RES #27 on 11/20/2023. Interview on 11/30/2023 at 4:00 PM with LAR # 18 revealed the facility called her on the night on 9-7-2023 to let her know about the incident between RES# 18 and RES #28. LAR # 18 stated the initial call was made by an employee, whose name she could not recall, that stated RES #18 was heard calling out from the room on 9-7-2023; LAR # 18 stated that a secondary phone call, with the DON, also described RES #18 as having called out for help from his room on 9-7-2023. LAR # 18 stated, to the best of her knowledge, that RES #18 had not previously engaged in homosexual activity; furthermore, LAR # 18 stated she did not believe that RES #18 consented to RES #28 having been in his bed and having touched his penis. Record Review on 11/30/2023 of RES #28's PN, entered on 10/2/2023 at 11:10 AM by the SS, reflected RES #28 was observed kissing a female resident (RES #40) on the mouth on 9/29/2023. The PN reflected the SS and the Administration spoke with RES #28 and RES #28 admitted he pecked a female resident (RES #40) on the mouth on 9/29/2023. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:28 AM by the SS, reflected the SS gave RES #28 specific instructions on things that were not acceptable between him and other residents in the facility. SS informed RES #28 he was not allowed to kiss, touch, hug or have physical contact at any time. RES # 28 was educated to ask nursing staff, or management, questions about anything he thought of doing with another resident. RES #28 was made aware that more inappropriate incidents could initiate a transfer to another facility. RES # 28 acknowledge he understood and stated he did not want to leave the facility. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:46 AM by the SS, reflected PS DR was contacted for a medication intervention and RES #28 moved to another room, away from the female resident he encountered (RES #40.) Record review of the facility's Abuse, Neglect, and Exploitation Policy dated, 10/24/2022, indicated it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. III. Prevention of Abuse, Neglect, and Exploitation The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a residence consensual sexual relationship and to the extent possible prevent sexual abuse. (1) The consent to sexual contact will be made by the social worker / designee completing an evaluation that determines the resident has capability to engage in consensual sexual contact, or (2) the residents representative agrees to the resident's participation in consensual sex contact, and (3) the documentation of a resident's capacity for consensual sex contact is located in the medical record. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident's property is suspected or identified by. (1) taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to residents or other residents, and (2) review and evaluation of like instances to determine if the appropriate actions to correct the noncompliance was taken and documented. V. Investigations of alleged Abuse, Neglect, and Exploitation A. An immediate thorough investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. B. Abuse investigation procedure include, (1) Identifying staff responsible for the investigation, (2) exercising caution in handling evidence that could be used in a criminal investigation, (3) investigating different types of alleged violations, (4) identifying and interviewing all involved parties, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, (5) focusing the investigation on determining if the abuse, neglect, exploitation, and or mistreatment has occurred, the extent, and cause, and (6) providing complete and thorough documentation of the investigation. VI. Protection of Resident With facility makes efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Physical exam of the alleged victim for any sign of injury. C. Increase supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. E. Protection from retaliation. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. G. Revision of the residence care plan if the residents medical, nursing, physical, mental, or psychosocial needs or preferences change as the result of an incident of abuse. Record review of the facility's Abuse and Prevention and Reporting training, dated 9/8/2023, reflected 30 staff participated in the training. Record review of the facility's Resident's Rights and Sexual Survey, dated 9/8/2023, reflected 41 staff participated in the training. Record review of the facility's Safety Patient Questionnaire, dated 9-8-23, reflected the census for 9-8-2023 was 100 residents. The QAA Patient Questionnaire reflected a sample of twenty-seven residents who responded Yes- Do you feel safe at the facility; and responded No- Has a resident ever touched you in a manner that made you feel uncomfortable. Record review of the facility Quality Assurance Staff Questionnaire, dated 9-18-23, reflected 64 facility employees who responded No-have you ever seen a resident touch a female or male in an inappropriate manner; No-Are there any patients that touch another patient in an inappropriate manner; and No- Are there any patients that say sexually inappropriate things to another. Records review of RES #28's Order Summary Report indicated RES #28 was prescribed Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder, which began on 9/29/2023. Record review of Local Police Department, Report #23-02094, dated 9/7/2023 at 10:15 PM reflected a visit by Police Officer A to the facility in response to sexual assault of a [AGE] year-old male. The report indicated that RES #18 was asked if he wanted RES #28 in his bed and RES #18's response was |I think so. | The report indicated that RES #18 has a long list of mental deficits to include Alzheimer's, dementia, cognitive communication; and RES #28 has also been diagnosed with a list of disorders to include Schizophrenia, cognitive communication deficit, and major depressive disorder. The closing statement on the report stated |With these disorders it was determined that it would be difficult to determine if there was consent or not. RES #18 was not given a sexual assault exam. Print out of each party`s diagnoses have been included with this report. My report has been uploaded; I have nothing further at this time. Record review of the facility's Comprehensive Care Plan Policy, dated 2/10/2021, reflected (4) the comprehensive care plan will be prepared by an IDT, that includes, but is not limited to: attending physician, a nurse with knowledge of resident, the residents representative if applicable, other appropriate staff such as RAI coordinator, activities director, social services director/social worker, licensed therapist, administration, and a mental health professional; and (8) qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Observations on 12/22/2023 at 8:29 AM of RES #28 reflected him having sat quietly on his bed, in his room watching TV, alone. Interview on 12/22/2023 at 8:30 AM with RES #28 revealed he had kissed RES #40 on 9/29/2023. After the kissing incident, which occurred on 9/29/2023, he stated he was approached by the SS, who explained that his behaviors were not acceptable. RES # 28 stated he was moved to a different room and that he started a new medication. RES # 28 thought the medication had helped him by reducing feelings of [NAME] and sexual desire, but he was still able to attain an erection and masturbate. RES #28 did not feel sedated, or different, because of the medication; in fact, RES #28 stated that his quality of life had improved. He denied any desires to kiss, or sexually touch, another resident since he started the medication on 9/29/2023. Record review on 12/22/2023 of RES #28's Medication Administration Record for December 2023, indicated RES #28 had received his Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder. Interview on 12/22/2023 at 9:30 AM with NA A revealed that she had been working at facility as a NA since 12/18/2023. She was informed that there were residents in the facility that have displayed sexual behaviors in the past and that it could still happen. If she observed sexual behavior, she was instructed to get help immediately and report it to a charge nurse or the ADM. Interview on 12/22/2023 at 10:00 AM with the SS revealed RES #18, in general, possessed the cognitive faculties to consent to sexual activity; however, the SS was unable to determine if the interaction between RES #28 and RES #18, on the night of 9/7/2023, was consensual or not consensual. The SS stated she knew about the incident on 9/7/2023 but did not participate in an IDT meeting for an CP update. The SS stated that the incident, which occurred on 9/7/2023, between RES #28 and RES #18, should have received a CP update, to include a Focus, Goal, and Intervention. The SS stated she checked on RES #28 often, after the incident on 9/7/2023, and would redirect as needed. When as[TRUNCATED]

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions for 1 of 1 kitchens reviewed for dietary services. The facility failed to safely store food containers in the facility's only pantry, walk-in cooler, and freezer with labels to signify the date a product was open and a date to signify expiration. The facility failed to store food in properly sealed containers to prevent the growth of food borne pathogens. These failures could place residents at risk of exposure to food-borne pathogens. Finding include: Observations on [DATE] at 8:56 AM of the facility's refrigerator revealed: 1 package of sliced luncheon meat stored in an unsealed plastic bag without the date it was opened or the date it expired; 2 slices of a pie stored in its original pie tin loosely covered without the date it was opened or the date it expired; 1 chicken breast in a plastic bag without the date it was opened or the date it expired; a plastic tub of beef without the date it was opened or the date it expired; 1 gallon BBQ sauce without the date it was opened or the date it expired; 1 gallon of Italian dressing without the date it was opened or the date it expired; 1 plastic container of cranberries without the date it was opened or the date it expired; 1 plastic container of vegetable soup without the date it was opened or the date it expired; and 1 plastic bag of hard-boiled eggs without the date it was opened or the date it expired. Observations on [DATE] at 9:00 AM of the facility's freezer revealed: 1 clear plastic bag of frozen burritos removed from its original container without name of the product, the date it was opened or the date it expired; 1 blue plastic bag of frozen hamburger patties removed from its original container without the name of the product, the date it was opened, or the date it expired; 1 blue plastic bag of fish patties removed from its original container without the name of the product, the date it was opened, or the date it expired; 1 clear plastic bag of frozen eggrolls removed from its original container without name of the product, the date it was opened, or the date it expired; and 1 clear plastic bag of frozen sausage patties removed from its original container without the name of the product, the date it was opened, or the date it expired. Observations on [DATE] at 9:10 AM of the facility's pantry revealed: 1 open bag of dry elbow macaroni twisted to close at the top, which was not sealed properly, without the date it was opened, or the date it expired; 1 open bag of dry spaghetti twisted to close at the top, which was not sealed properly, without the date it was opened, or the date it expired; 1 open bag of tri-color pasta twisted to close, which was not sealed properly, without the date it was opened, or the date it expired; and 1 open package of lemon gelatin stored in a zip lock bag without the date it was opened or the date it expired. Interview on [DATE] at 2:47 PM with a DA revealed food stored in the facility needed to have a label with the name of the product, the date it was opened, and the date it was due to expire. The DA stated the label system was utilized for foods in the pantry, the refrigerator, and the freezer. The DA stated she was trained to label and date all food items. Interview on [DATE] at 2:58 with the KM revealed the foods in the pantry, the refrigerator, and the pantry needed labels that signified the product name, the date the product was open, and the date the product was to expire. The KM stated the dates on the labels were important to avoid the growth of foodborne pathogens. Foods that were not consumed by the end of the day on the use by date were thrown away. The KM stated food-borne pathogens would make people sick and caused diarrhea, vomiting, and unintended weight loss. KM was responsible for the daily operations in the kitchen. Interview on [DATE] at 3:45 PM with the DON revealed food storage was important to keep out bugs, dirt, and other pathogens. The DON stated the facility dated its food to keep it fresh and to avoid food-borne pathogens such as salmonella, E. coli, Norovirus. Food-borne pathogens would cause diarrhea, intestinal problems, unintended weight loss. The DON stated improper food labeling was a failure of management and lack of training. Interview on [DATE] at 4:34 PM with the ADM revealed food safety was important the residents because it reduced the opportunity for food-borne pathogens to grow. Some of the negative outcomes of residents getting sick because of food-borne pathogens were diarrhea, stomach issues, and the potential for other health concerns. Record review of the facility's policy for Frozen and Refrigerated Food Storage, dated ,d+[DATE], reflected (9) items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, cell by, best by date, or a date delivered. They must also be dated with an expiration date unless they have one from the manufacturer. (10) packaged frozen items that are open and not used in their entirety must be properly sealed, labeled, and dated for continued storage. (11) all refrigerated and frozen items in storage would contain a minimum label of common name of product and a date as noted above. Record review of the facility's policy for Dry Food and Supplies Storage, dated ,d+[DATE], reflected (9) all opened products must be sealed effectively and properly labeled, dated, and rotated for use. This may require storage in an approved container or food grade storage bag. Record review of FDA Food Code 2022 indicated [(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18]

Based on observations, interviews, and record review, the facility failed to make reasonable accommodation for residents to receive services in the facility for 3 of 6 residents (RES #18, RES #35, and RES #7) who were observed for access to facility services. The facility failed to ensure RES #18, RES #35, and RES #7 always had access to their individual call buttons. This failure could place residents at risk for unmet needs. Findings include: Record review of RES #18's AR, dated 11/28/2023, reflected RES #18 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #18 was diagnosed with Transient Cerebral Ischemic Attack (a brief interruption of blood flow to the brain), Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), Vascular Dementia (a description for problems with reasoning, planning, judgment, memory and other thought processes R/T impaired blood flow to the brain), Unspecified Dementia (a description for when a person lost the ability to think, remember, learn, make decisions, and solve problems). Record review of RES #18's Quarterly MDS, dated [DATE], reflected RES #18 had a BIMS of 7. A BIMS of 7 indicated RES #18 had severe cognitive impairment. Record review of RES #18's CP indicated a Focus area for ADL Self Care initiated on 9/25/2020. The Goals for the Focus area, revised on 9/1/2023 with a target date of 2/1/2024, indicated (1) RES #18 would be cleaned and well-groomed through next review date; (2) RES #18 would maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene; and (3) RES #18 would demonstrate the appropriate use of rolling [NAME] and wheelchair to increase ability and safety awareness and safe mobility. The intervention for the CNA, initiated on 9-25-2020, was to encourage resident to use call light to call for assistance before attempting any activities of daily living that resident cannot do independently. The CP indicated a Focus are for Falls initiated on 7/11/2022. The goal for the focus area, revised on 9/1/2023 with a target date of 2/1/2024, indicated RES #18 would be free of falls during the next 90 days. The intervention for the CNA, revised on 7-9-2021, was to be sure the residents call light is within reach and encourage and resident to use it for assistance as needed. Observations on 11/27/2023 at 10:25 AM reflected RES #18's call light button was on the floor to the resident's right side. The call light button was not in RES #18's reach. Observations and interview on 11/29/2023 at 8:28 AM reflected RES #18's call light button was clipped to the pull string that controlled the wall light behind RES #18's bed. The call light button was 3-4 feet from resident and was unreachable. Resident stated the call light being placed so far away from him makes him feel terrible. Observation on 11/29/23 at 9:38 AM reflected RES #18's call light button was clipped to the pull string that controlled the wall light behind RES #18's bed. Call device out of reach hanging on a light switch 3-4 feet from resident. Record review of RES #35's AR, dated 11/28/2023, reflected RES #35 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #35 was diagnosed with Chronic Obstructive Pulmonary Disease (which caused airflow blockage and breathing related problems), Cognitive Communication Deficit (which caused difficulty with thinking and how someone uses language) history of falling and acquired absence of right leg above knee. Record review of RES #35's Annual MDS, dated [DATE], reflected RES #35 was not assigned a BIMS Score; instead, RES #35 had a Staff Assessment for Mental Status, which indicated a score of 3. A Staff Assessment for Mental Status which resulted in a score of 3 indicated that RES #35 's cognitive skills regarding tasks of daily life were moderately impaired. Moderately impaired indicated decisions are poor / cures and supervision required. Record review of RES #35's CP indicated a focus area for ADL Self Care initiated on 2/4/2021. The goal for the Focus area, revised on 8/24/2023 with a target date of 10/6/2023, indicated RES #35 would maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. The intervention for the CNA, initiated on 4/16/2021, was to encourage resident to use call light to call for assistance before attempting any activities of daily living that resident cannot do independently. RES #35's CP indicated a Focus area for impaired respiratory status initiated 6/14/2022. The goals for the Focus area, revised on 8/24/2023 with a target date of 10/6/2023 indicated (1) RES #35 would not have reports of unrelieved shortness of breath through the next review date; (2) RES #35 would not have reports of increase anxiety due to shortness of breath through the next review date; and (3) RES #35 would not have signs or symptoms of pneumonia through the next review date. The intervention for the CNA, initiated on 6/14/2022 was to encourage and remind RES #35 to use call light to call top report of shortness of breath immediately. RES #35's CP indicated a Focus area for Behavioral problems, initiated on 9/18/2023, evidence from resident removing his call white from reach and placing it on the floor. The goals for the Focus area, initiated on 9/18/2023 with a target date of 10/6/2023, indicated RES #35's behaviors would not interfere with the delivery of ADL care by staff through the next review date. The interventions for the CNA, initiated on 9/18/2023, was for staff to monitor the call light placement and place within reach as needed. RES #35's CP indicated a Focus area for Falls initiated on 2/4/2021. The goals for the Focus area, revised on 8/24/2023 with a target date of 10/6/2023, indicated RES #35's behaviors would not sustain a fall related injury by utilizing fall precautions through the next review date. The interventions for the CNA, initiated on 2/4/2021, was to keep call light within reach when in bed. Observations on 11/27/23 at 12:21 PM reflected RES #35's call light button was on the floor under the bed on the resident's right side. The call light button was not in Res #35's reach. Observations and interview on 11/27/23 at 02:15 PM reflected RES #35's call light button was on the floor under the bed on the resident's right side. RES #35 was observed pulling at his privacy curtain and communicated through tone (verbal sounds) and body language (motioning towards the cord protruding from the wall) that he was looking for his call light button. RES #35 was cued to the location of his call light button, and he attempted to it reach it, but it was too far from his reach. RES #35 's call light button was clipped to the bottom portion of his bed without enough slack between the clip and the actual button to reach the level of RES #35's bed. RES #35 did not appear to be happy, but seemed to appear more secure when he was able to secure the call light button in his hand. After he had his call light in his hand, he was observed back under the covers resting. Record review of RES #7's AR, dated 11/28/2023, reflected RES #7 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #7 was diagnosed with Unspecified Dementia (a description for when a person lost the ability to think, remember, learn, make decisions, and solve problems), Muscle wasting and muscle deterioration, Difficulty Walking; and history of falling. Record review of RES #7's Quarterly MDS, dated [DATE], reflected RES #7 had a BIMS Score of 00. A BIMS Score of 00 indicated RES #7 had severe cognitive impairment. Record review of RES # 7's CP indicated a focus area for altered cardiovascular status initiated on 6/14/2022. The goal for the Focus area, revised on 9/1/2023 with a target date of 11/11/2023, indicated RES # 35 (1) RES # 7 would be free from signs and symptoms of complications of cardiac problems to the next review date; (2) RES # 7 will exhibit reduction of cardiac symptoms through the review date; (3) and RES # 7 will have an understanding of the disease process and the importance of compliance with treatment as evidenced by verbal feedback and compliance with treatment through the review date. The intervention for the CNA, initiated on 6/14/2022 was to enforce the need to call for assistance if pain starts. Record review of RES # 7's CP indicated a focus area for ADL Self Care initiated on 1/7/2019. The goal for the Focus area, revised on 9/1/2023 with a target date of 11/11/2023, indicated RES # 7 would maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the next review date. The intervention for the CNA, revised on 6/2/2021, was to encourage resident to use bell to call for assistance before attempting any ADLs that resident cannot do independently. RES # 7's CP indicated a Focus area for Behavioral problems, initiated on 9/18/2023, evidenced by resident removing his call white from reach and placing it on the floor. The goals for the Focus area, initiated on 9/18/2023 with a target date of 11/11/2023, indicated Res # 7's behaviors will not interfere with the delivery of ADSL care by staff through the next review date. The interventions for the CNA, initiated on 9/18/2023, was for staff to monitor the call light placement and place within reach as needed. RES # 7's CP indicated a Focus area for Falls initiated on 6/20/2022. The goals for the Focus area, initiated on 9/1/2023 with a target date of 11/11/2023, indicated Res # 7's will not sustain a fall related injury by utilizing fall precautions through next review date. The interventions for the CNA, revised on 6/2/2021 was for staff to make sure you residents call light is within reach and encourage the resident to use it for assistance as needed. Observations on 11/28/23 at 8:35 AM reflected RES # 7's call light button was on the far end of his bed near his left shin. The call light button did was not in RES #7's reach. Observations on 11/28/23 at 11:19 AM reflected RES # 7's call light button was on the far end of his bed near his left shin. The call light button did was not in RES #7's reach. Observations and interview on 11/29/23 at 8:25 AM reflected RES # 7's call light button was on the far end of his bed near his left knee. The call light button was clipped to the blanket and was not in reach. Res # 7 was able to verbalize that he gets mad when the call light button is not close enough for him to reach. Interview on 11/29/2023 at 10:40 AM with LVN A revealed Call lights were supposed to be in arms reach of the resident, whether they are in bed or in a chair. LVN A stated that staff have been instructed to go through the rooms every other hour to make sure the call light buttons are in the proper place. LVN A stated call lights were important so residents can call for help if they need something. Interview in 11/29/2023 at 3:45 PM with the DON revealed that call light buttons were used by the residents to call staff if they needed any help. The staff were trained to place the call button within arm's reach of the residents whether they are in bed or in a chair. If a resident could not reach their call light button, the DON stated the resident might try to reach for it and have an accident; may have wet clothes that could lead to skin breakdown; or get angry or frustrated because they could not call for help. Interview on 11/29/2023 with the ADM revealed call light buttons were used for resident to call for staff's help if they needed something. If the call light was not near the resident, the ADM stated a resident has the potential for falls and skin breakdown. The ADM stated the responsibility for call light placement is the last person in the room with the resident. Record review of the facility's Call Light Response, dated 2/10/2021 reflected that (1) all staff will be educated on the proper use of the resident call system, including how the system works in ensuring resident access to the call light; (2) all residents will be educated on how to call for help using the resident call system; (3) each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system; and (4) With each interaction in the residence room or bathroom, staff will ensure the call light is within reach of the resident and secured, as needed.

Based on observation, interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for 1 (Resident #90) of 5 residents reviewed for baseline care plans. The facility failed to develop baseline care plans within the required 48-hour timeframe for Resident #90. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Review of Resident #90's face sheet dated 11/29/23 reflected Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses including dysphagia (difficulty in swallowing), muscle wasting and atrophy (when muscles waste away, hypertension (high blood pressure), and pneumonitis (lung inflammation due to inhalation of food and vomit). Review of the admission MDS dated [DATE] reflected Resident #90 had a BIMS score of 11 indicating Resident #90 was moderately cognitively impaired. Resident # 90 was dependent on staff for toileting hygiene, showers, and upper and lower body dressing. Review of Resident #90's clinical record reviewed on 11/29/23 reflected a baseline care plan was not completed in the 48-hour timeframe. Baseline care plan was completed on 10/31/23. During an observation on 11/27/23 at 10:50 AM, Resident #90 was resting quietly in bed. Resident #90 appeared clean and comfortable with no sign of pain or distress noted. Resident #90 did not respond to verbal stimuli. Resident #90's room was clean and clutter free and the temperature was good. Resident #90's call light was in reach and head of bed was elevated. In an interview on 11/29/23 at 1:18 PM with the DON, she stated every resident that admitted to the facility should have had a baseline care plan completed within 24 to 48 hours. She stated she was responsible for completing the baseline care plans and the MDS nurse or charge nurses sometimes initiated a baseline care plan which she checked to ensure was done. She stated Resident #90's baseline care plan was completed late, and it should have been completed per policy. She stated staff responsible for completing care plans had been trained on baseline care plans. She stated if a baseline care plan was not completed in the expected timeframe, staff may not know the amount of care needed to be provided to care for residents correctly. In an interview on 11/29/23 at 1:25 PM with MDS A, she stated baseline care plans should have been completed for every resident that admitted to the facility. She stated baseline care plans should have been done within 24 to 48 hours after a resident admitted . She stated Resident #90's baseline care plan was completed on 10/31/23 and resident was admitted on [DATE] which meant the baseline care plan was done late. She stated the nurses completed the baseline care plans when they initiated an initial admission assessment after residents admitted into the facility. She stated if a baseline care plan was not completed for a resident it could be detrimental to the resident and an injury or health issue could have occurred. In an interview on 11/29/23 at 1:29 PM with MDS B, she stated baseline care plans should be completed within 24 to 48 hours for every resident that admitted into the facility. She stated if a resident did not have a baseline care plan completed, staff would not know what to do to care for the resident correctly and the baseline care plan was used as a guideline for the plan of care for the residents. In an interview on 11/29/23 at 1:35 PM with LVN C, she stated she completed baseline care plans for newly admitted residents which were assigned to her when she did the residents initial admission assessments. She stated if she could not get to a baseline care plan to complete it, the nurse on the following shift would try to get it done. She stated baseline care plans should have been done as soon as possible. She stated she had been trained on completing baseline care plans. She stated if a baseline care plan was not completed in a timely manner, the staff might have missed out on if a resident could feed themselves, if a resident was incontinent or not, or how much care a resident may have needed. Record review of the facility policy titled Baseline Care Plans dated 11/8/16 with a revision date of 05/13/21 Resident person centered baseline care plans are developed and implemented for new admission and readmission residents. Fundamental Information: Resident person centered baseline care plans communicate fundamental care approaches and goals for resident related clinical diagnosis, identified concerns and as a result of the admission evaluation/assessment of each healthcare discipline. The baseline care plans are inclusive to support effective individualized resident care that meet professional standards of quality care and services. Baseline care plans are developed and implemented within 48 hours of a resident new admission and/or readmission. The baseline care plans includes measurable objectives to address the residents' immediate medical, clinical, functional, mental, and psychosocial person centered needs. Process: The baseline care plans will be developed and implemented from minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, admission evaluation/assessments, physician orders, dietary orders, therapy services, social services, and resident choices.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for two of six residents (Residents #11 and #8) reviewed for respiratory care. A) The facility failed to ensure Resident #11's oxygen concentrator filter was clean, humidifier was dated, and tubing were dated. B) The facility failed to ensure Resident #8's oxygen concentrator filter was clean, humidifier was dated, and her oxygen tubing were dated. This failure could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Record review of Resident #11's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems) Record review of Resident #11s quarterly MDS dated [DATE] reflected resident had a BIMS score of 15 showing she was cognitively intact. Resident #11 required extensive assistance with activities of daily living, personal hygiene, toilet use, and dressing. Record Review of Resident #11s Care plan dated 12/1/21 reflected Resident required oxygen therapy routinely and is at risk for ineffective gas exchange. This is related to Chronic Obstructive Pulmonary Disease. Record review of Resident 11's Physicians Order Summary Report dated 11/28/2023 reflected an order for Oxygen at three (3) Liters per minute around the clock for treatment of shortness of breath. There were no orders to reflect the policy process of changing the tubing, washing the filter, or dating and ensuring the humidifier was full of water. Observation on 11/27/2023 at 10:30 AM revealed Resident #11 had oxygen in place on her nose. Resident #11's oxygen concentrator filter was full of white dust. Her humidifier bottle was empty and undated. Her oxygen tubing was undated. Observation on 11/28/23 at 09:53 AM Resident #11s humidifier on oxygen concentrator remained empty and undated, oxygen tubing was not dated, and the filter was full of white dust. B) Record review of Resident #8's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems). Record review of Resident #8's annual MDS dated [DATE] reflected she required extensive assistance with activities of daily living, personal hygiene, toilet use, and dressing. Record review of Resident #8's Treatment Administration Record dated 11/29/2023 reflected an order to change O2 tubing and date every night shift every Sunday. This order was signed as having been completed on 11/26/2023. There was an order to clean the O2 concentrator filters every night shift every Sunday. This order was initialed as having been completed on 11/26/2023. There was an order to change humidifier bottle every night shift every Sunday. This order was initialed as having been completed on 11/26/2023. Record review of Resident #8's Physicians Order Summary Report dated 11/28/2023 reflected Resident #8 required Oxygen at 3 liters per minute around the clock for Chronic Obstructive Pulmonary Disease. Record review of Resident #8's Order Summary Report also reflected Resident #8 had an order to change humidifier bottle on Sunday every Sunday night, change oxygen tubing every Sunday night, and clean oxygen concentrator filter every Sunday night. Observation on 011/27/2023 at 10:38 AM in Resident #8 was using her oxygen. Resident #8's room observation reflected her oxygen tubing was not dated, the oxygen concentrator filter was covered in white dust and the humidifier bottle was empty of water and undated. Interview on 11/28/2023 at 10:31 AM LVN A stated she had worked in the facility for 4 months. She stated the staff do check the oxygen tanks every shift to ensure they were on and in place. She stated staff were expected to clean the concentrators and change the tubing if needed. She stated she was not aware of any specific orders to change and date the tubing or humidifiers or clean oxygen filters. She stated she was not sure if she has been in serviced on the oxygen policy. She stated the risk to the resident for having dirty oxygen equipment would be respiratory distress. Interview on 11/29/2023 at 11:45 AM LVN B stated she had worked at the facility for 4 months. She stated she was trained to ensure oxygen tubing and tanks were clean. She stated tubing and humidifier should have a date and initials in place to reflect the most recent change. She stated the oxygen tank care was completed weekly on night shift. She stated the risk to resident for unclean oxygen equipment would be infection respiratory illness. Interview on 11/29/2023 at 12:23 PM the DON stated the tubing to respiratory equipment should be changed on Sundays and the filters washed on Sunday nights. She stated the risk to the resident if these procedures were not followed was respiratory infections. She further stated it was their policy to change tubing, clean filters and ensure humidifiers are clean and full. The DON stated she was responsible for educating and overseeing the staff regarding the oxygen administration policy. Interview on 11/29/2023 at 1:45 PM the ADM stated the expectation for the cleaning and care of the oxygen equipment was to follow facility policy. He stated the risk to the Resident for dirty filters and equipment was that it could potentially drop a residents oxygen level. He stated it was the responsibility of nursing management to ensure the staff were educated on the oxygen administration policy. Record review of facility policy titled Oxygen Administration dated 9/12/14 and revised 1/5/20 reflected: A) humidification 1.use prefilled humidifier bottle label bottle with date, change bottle when empty. B) completion of procedure 3.Change disposable parts once a week and label with date. C) Concentrator 1. clean filter weekly 2. remove filter from back of concentrator 3. rinse filter with water 4. shake off excess water

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice for one (Resident #1) of four residents reviewed for quality of care, in that: The facility failed to assess and document complete neurological assessments for Resident #1 after he experienced unwitnessed falls on 08/15/2023, 08/29/2023, and 09/14/2023. This deficient practice could place residents at risk of pain, physical harm, and a diminished quality of life. Findings included: Review of Resident #1's face sheet, dated 09/21/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node), unspecified acute kidney failure, unspecified and other lack of coordination, difficulty in walking, history of falling, cognitive communication deficit, generalized muscle weakness, and pain in unspecified joint. Review of Resident #1's quarterly MDS assessment, dated 08/11/2023, reflected he did not have a BIMS conducted because he was rarely/never understood and had a short- and long-term memory problem. Resident #1 was non-ambulatory and required extensive assistance of one staff for transfers. Review of Resident #1's quarterly care plan, dated 08/18/2023, reflected he had potential for falls related to gait/balance, exhibited verbally aggressive behavior at times and was at risk for harm and not having needs met in a timely manner, had a communication problem related to dementia, had an ADL self-care performance deficit related to dementia, had a pacemaker related to a cardiac dysrhythmia (an abnormal or irregular heartbeat) and was at risk for pacemaker failure and altered cardiac output, had impaired cognitive function/dementia or impaired thought processes related to dementia, and had a history of disorganized thinking. Review of the facility's incident logs from 08/01/2023 through 09/21/2023 reflected Resident #1 had unwitnessed falls on 08/15/2023 at 1:41 PM, 08/29/2023 at 4:30 PM, and 09/14/2023 at 5:00 PM. Review of Resident #1's incident report, dated 08/15/2023 and completed by LVN A, reflected the following: [LVN A] was called into [Resident #1]'s room and observed him laying on the floor with blood on the floor. [Resident #1] was assessed befpre rolling him on his back. Upon assesment, a skin tear was observed to left upper eye, which was cleaned and steristrips was placed. Skin tears were noted to left hand/wrist and bruising to bilateral hand/writs. [Resident #1] was assisted back to bed and is being monitired. [Resident #1] is AAOx1, and does not know wat happened . Nuero checks in progress. Review of Resident #1's neurological assessments, dated 08/15/2023, reflected completed assessments on 08/15/2023 at 1:30 PM, 1:45 PM and 2:00 PM, 08/16/2023 at 12:00 AM and 2:15 PM, and 08/17/2023 at 2:15 PM. There were incomplete assessments dated 08/15/2023 at 2:45 PM, 3:15 PM, 4:15 PM, 5:15 PM, 6:15 PM and 7:15 PM; they were missing Resident #1's current orientation, level of consciousness, pupil sizes, responses, pain level, and range of movement. Review of Resident #1's incident report, dated 08/29/2023 and completed by LVN B, reflected the following: [Resident #1] had an unwitnessed fall in which a CNA found him seated on the floor in another resident's room with his back and head laying against the wall and facing the lower side of the bed (facing dressers). She (CNA) immediately reported to the charge nurse (LVN B), who quickly moved into the room to assess [Resident #1] and ascertain any injuries he sustained. [Resident #1] told staff he wanted to get to bed. [Resident #1] was assessed by the charge nurse (LVN B), denied pain, and upon assessment, found to have two hematomas (abrasions) on the back of his head. Review of Resident #1's neurological assessments, dated 08/29/2023, reflected staff completed assessments on 08/29/2023 at 4:30 PM, 4:45 PM, 5:00 PM, 5:15 PM and 5:45 PM. There were incomplete assessments dated 08/29/2023 at 6:15 PM, 7:15 PM, 8:15 PM and 9:15 PM; they were missing Resident #1's current orientation, level of consciousness, pupil sizes, responses, pain level, and range of movement. Review of Resident #1's incident report, dated 09/14/2023 and completed by LVN B reflected the following: A nurse aide called the charge nurse (LVN B) and informed her that she found [Resident #1] on the hallway by the television area bleeding from his forehead. The charge nurse (LVN B) immediately ran to [Resident #1] and put pressure on his wound opening/injury to stop the bleeding and she called for help from the other staff. [Resident #1] told staff he fell and had a head injury. Staff called EMS and had [Resident #1] taken to the hospital for further diagnosis and evaluation. Review of Resident #1's neurological assessments, dated 09/14/2023, reflected staff completed assessments on 09/14/2023 at 9:45 PM, 10:45 PM and 11:45 PM, 09/15/2023 at 12:45 AM, 4:35 AM and 12:35 PM, 09/16/2023 at 1:00 AM, and 09/17/2023 2:08 AM. There were incomplete assessments dated 09/14/2023 at 5:00 PM, 5:15 PM, 5:30 PM, 5:45 PM, 6:15 PM, 6:45 PM, 7:45 PM and 8:45 PM; they were missing Resident #1's current orientation, level of consciousness, pupil sizes, responses, pain level, and range of movement. During an observation and interview on 09/21/2023 at 1:59 PM, Resident #1 was sitting in his wheelchair in the secure unit's living area. Resident #1 had a laceration on the right side of his forehead and bruises on the right side of his face. Resident #1 was unable to answer any questions. During an interview on 09/21/2023 at 2:02 PM, LVN A stated on 08/15/2023, Resident #1 tried to get out of bed by himself and fell . LVN A stated she was not working on the days Resident #1 had his subsequent falls. LVN A stated Resident #1 often tried to get up on his own. LVN A stated Resident #1's other falls were due to him trying to get up on his own. LVN A stated staff checked on Resident #1 every two hours or more. LVN A stated LVNs completed neurological assessments for 72 hours after a resident had an unwitnessed fall. LVN A stated she was trained and in-serviced on abuse, neglect, falls, neurological checks, and resident rights. LVN A stated if a resident was observed on the ground, she was trained to assess the resident, notify staff for assistance, assess the resident's head and pain levels, and notify all appropriate parties. During an interview on 09/21/2023 at 2:22 PM, CNA A stated on 09/14/2023, Resident #1 was taking off his shoes in the hallway. CNA A stated she took Resident #1's shoes and placed them on a nearby table. CNA A stated she had her back to Resident #1 when she placed his shoes on the table. CNA A stated as she turned back around, she observed Resident #1 on the ground. CNA A stated she notified an LVN and another CNA. CNA A stated the LVN put pressure on Resident #1's head and staff notified EMS. CNA A stated on 08/29/2023, Resident #1 attempted to get out of bed on his own, fell on his right side, and sustained bruises to the right side of his body. CNA A stated she often checked on Resident #1. CNA A stated LVNs conducted neurological checks on residents after they had a fall. During an interview on 09/21/2023 at 3:18 PM, DON stated Resident #1 often tried to get up from his bed and chair on his own. DON stated on 09/14/2023, Resident #1 was in the hallway near the dining area in the secure unit. DON stated a nurse aide was completing documentation when Resident #1 fell on the right side of his body. DON stated staff notified EMS, Resident #1 was transported to the hospital, obtained sutures to his laceration injury, and returned to the facility. DON stated she investigated the fall incident. DON stated Resident #1 could not recall his fall on 09/14/2023. DON stated she knew the neurological checks were incomplete. DON stated she did not know why the neurological checks were incomplete. DON stated she trained staff on how to complete neurological checks. During an interview on 09/21/2023 at 3:39 PM, ADM stated he was notified of Resident #1's falls on 08/15/2023, 08/29/2023, and 09/14/2023. ADM stated he was shocked the neurological checks were not completely documented. She stated a negative outcome could be a serious injury going unnoticed. Review of the facility in-services from August 2023 through September 2023 reflected staff were trained on call lights on 08/18/2023 and abuse, neglect, and resident rights on 09/08/2023. There were no in-services given to staff regarding neurological assessments. Review of the facility's neurological assessment policy and procedure, dated 04/29/2014, reflected the following: 1. Complete and document neurological assessments as indicated on Neurological Assessment Flow Sheet. Complete neurologic assessments for 72 hours and PRN with vital signs every 15 minutes for 1 hour, then every hour for 4 hours, then every eight hours for 72 hours. 2. Complete Neurological assessment with vital signs every 15 minutes times 4 equaling 1 hour, then every hour times 4 equaling 4 hours, then every 8 hours times 9 equaling a minimum of 72 hours. 3. More frequent or continued neurologic assessments may be indicated and conducted as assessment findings compared to prior assessments and evaluated. 4. Observe for any changes from baseline assessment such as refusal to eat, drink, restlessness, confusion, drowsiness or other progressive deterioration. Continue to compare assessment findings against prior assessments to determine if there has been a change. Compare current assessments to baseline assessments done prior to the incident/occurrence to determine if there is a neurological change. The elderly may experience neurologic changes later than younger people. Assessing for a minimum of 72 hours allows for possible changes to be documented and reported. 8. Communicate episode and actions taken and to be taken using Center specific systems such as shift to-shift verbal report, 24-hour report, and daily stand-up meetings, and alert charting. Suggested Documentation o Completion of assessment o Notification of Family/Legal representative, Physician notification, abnormal assessment findings, diagnostic studies ordered by Physician, and response to interventions. Review of the facility's fall management system policy and procedure, dated 02/19/2021, reflected the following: Procedure: D. Documentation requirements for residents sustaining a fall: 3. The licensed nurse will assess and document the condition of the resident at least once per shift for at least 72 hours post fall. 5. Un-witnessed falls are considered potential head injury and require completion of Neurochecks.

Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 9 residents (Resident #5, Resident #7, and Resident #9) reviewed for call lights in that: Resident #5, Resident #7, and Resident #9 were observed in their rooms with call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Review of Resident #5's face sheet dated 8/18/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar disorder), Hypertension (high blood pressure), Neuropathy (weakness, numbness, and pain from nerve damage), Chronic Obstructive Pulmonary Disease (breathing disorder), Dysphagia (difficulty swallowing), Anemia (low red blood cells), Hyperlipidemia (high cholesterol) and Cognitive Communication Deficit. Review of Resident #5's MDS dated [DATE] reflected a short and long memory problem under section Staff Assessment for Mental Status . and reflected Resident #'s functional status as: required extensive assistance with transfers, dressing, toilet use and personal hygiene. Bathing was listed as total dependence and eating listed as supervision assistance for Resident #5. Review of Resident #5's care plan dated 8/18/2023 revealed the problems: Resident has the potential for falls related to right above the knee amputation. Interventions included: Keep call light in reach when in bed; Resident has an ADL Self Care performance Deficit and is at risk for not having their needs met in a timely manner. Intervention included: Encourage resident to use call light to call for assistance before attempting any ADLs. Review of Resident #7's face sheet dated 8/18/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (breathing disorder), Type 2 Diabetes (blood sugar disorder), Hyperlipidemia (high cholesterol), Difficulty in walking, Hypertension (high blood pressure), Peripheral Vascular Disease (blood circulation disorder), and Vascular Dementia (brain damage caused by strokes). Review of Resident #7's MDS dated [DATE] reflected A BIMS score of 4 indicating severe cognitive impairment . Resident #7's functional status reflected resident required no assistance for eating, extensive assistance for dressing, toilet use, and personal hygiene; and total assistance for bathing. Review of Resident #7's care plan dated 8/18/23 revealed it did not address the use of the call light for this resident. Review of Resident #9's face sheet dated 8/18/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included: Congestive Heart Failure, Vascular Dementia (brain damage caused by strokes), History of Falling, Alzheimer's Disease (progressive memory loss disorder), Type 2 Diabetes (blood sugar disorder), Hypertension (high blood pressure), Stroke, Kidney Disease and Bipolar Disorder (behavioral health disorder). Review of Resident #9's MDS dated [DATE] reflected a BIMS of 8 indicating moderate cognitive impairment. Resident #9's function status reflected resident required no assistance for eating, extensive assistance for bathing and total dependence for dressing, toileting use and personal hygiene. Review of Resident #9's care plan dated 8/18/2023 revealed the problem: Resident has a communication problem related to Stroke; cerebral infarction. Interventions included: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, bed in lowest position and wheels locked, avoid isolation. During an observation in Resident #7's room on 8/18/2023 at 11:35 a.m., her call light was seen draped over her nightstand out of reach. During an interview with Resident #7 on 8/18/2023 at 11:35 a.m., she stated she could not reach the call light where it was laid on the nightstand and would have to yell to get help if she needed something. During an observation in Resident #9's room on 8/18/2023 at 11:58 a.m., his call light was seen clipped to the divider curtain out of reach. During an interview with Resident #9 on 8/18/2023 at 11:58 a.m., he stated he could not reach his call light from his bed but could yell if he needs help. He stated he knew how to use his call light and would get a staff to move it for him. During an observation in Resident #5's room on 8/18/2023 at 12:17 p.m., his call light was seen laying under the foot of his bed out of reach. During an interview with Resident #5 on 8/18/2023 at 12:17 p.m., Resident #5 stated he was doing ok but could not get to his call light. He stated he knew how to use the call light but would not be able to right now with it under the bed. During an interview with the DON on 8/18/2023 at 6:23 p.m., she stated her expectation was that staff would keep call lights in reach for residents to ensure their safety. She stated they have been in-serviced on this frequently and staff should follow the facility policy. Review of facility policy Call Light Response dated 2/10/2021 reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet and bathing facility to allow residents to call for assistance. And further: 5. With reach interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured as needed. Review of facility policy Resident Rights dated 2/20/2021 reflect The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation, in that: The facility failed to ensure a 50-pound bag of onions was stored properly in the dry storage area. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings include: During an observation on 8/18/2023 at 12:22 p.m., in the kitchen hallway leading to the outside, a 50-pound netted bag of yellow onions was seen sitting directly on the floor. The netted bag was on the floor and the floor was observed to have debris on it. The bag was propped up against a wall that had visible dirt on it as well as brown stains near the base and a rusty nail laying between the bag and the base of the wall. During an interview on 8/18/2023 at 12:22 p.m., the Dietary Manager was shown the bag of onions on the floor and stated, I know, I know. She stated they just had a truck come in earlier that morning. She stated they had been short staffed and had not had time to put the onions away. She stated the facility policy states nothing (food) is to be stored on the floor. She stated the onions could get dirty, could get bugs in it, and could make the residents sick. Review of the facility policy Dry Food and Supplies Storage dated 11/15/2017 reflected The focus of protection for dry storage is to keep non-refrigerated food, disposable dishware, and napkins in a clean, dry area, which is free from contaminants. Food and food products should always be kept off the floor and clear of ceiling sprinklers, sewer/waste, disposal pipes and vents to maintain food quality and prevent contamination.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #4) reviewed for blood sugar checks. LVN A failed to appropriately sanitize her hands with ABHR and failed to appropriately clean Resident #4's finger with an alcohol pad before performing a blood sugar check. This failure could result in the spread of diseases to residents which could result in decreased quality of life, illness, and hospitalization . Findings include: Review of Resident #4's face sheet dated 8/18/2023, reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar disorder), Heart Disease, Hypertension (high blood pressure), Stroke, Chronic Kidney Disease, Hyperlipidemia (elevated levels of cholesterol), Anemia (low red blood cells) and Vascular Dementia (brain damage caused by strokes). Review of Resident #4's MDS dated [DATE] reflected in the Staff Assessment for Mental Status that resident had a short- and long-term memory problem. During a blood sugar observation on 8/18/2023 at 11:22 a.m., LVN A applied ABHR to her hands and then began fanning her hands in the air to dry them. LVN A then took an alcohol prep pad and wiped Resident #4's fingertip in preparation of a blood sugar check. Immediately after wiping Resident #4's fingertip, LVN A began fanning her hand over the fingertip to dry it. During an interview on 8/18/2023 at 11:25 a.m., LVN A stated she was not sure what the facility policy was for checking blood sugars. She stated she was not sure if the policy said you could fan your hands around in the air or fan a resident's finger after wiping with alcohol pad. She stated she had received training on infection control but was not aware if she could not fan her hands in the air to dry them. She stated she was not aware if it's allowed or not, it's just a habit I have. She was not able to verbalize the procedure for properly using ABHR to sanitize one's hands. She stated it could be an infection control issue for the resident. During an interview won 8/18/2023 at 2:14 p.m., the DON stated her expectation around blood sugar checks is that the nurse would not fan their hands because it doesn't allow time for the sanitizer to work if they don't let it dry without fanning. She stated it would be an infection control issue. She stated the same with a resident's finger, after wiping with an alcohol prep pad - they should not fan it; they should let it dry then take the blood sugar. She stated a negative outcome could be that it doesn't fully disinfect the site prior to puncturing the skin. Review of facility policy Hand Hygiene dated 2/11/2022 reflected: 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. B. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. C. This should take about 20 seconds. A policy on infection control was requested but not provided by the time of facility exit.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 5 resident (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Norco medication (hydrocodone). This failure could place residents at risk for not receiving prescribed medications. Findings included: A record review of Resident #1's face sheet revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (A problem in the brain that is caused by an imbalance in the blood), cognitive communication deficit (Difficulty thinking & speaking, & chronic pain syndrome (excess and prolonged pain). A record review of physician's orders dated 01/13/23 revealed resident was prescribed Hydrocodone-Acetaminophen (10-325mg) give 1 tablet by mouth every 6 hours as needed for moderate pain. 01/23/2023 at 10:30 AM, an interview was conducted with the CN who stated she and the LVN checked the medication at 2:00pm and all medication were there, but she received a call around 10:00 pm saying 20 pills of hydrocodone were missing. CN stated that she did not take the medication and all the medications were there when she left the facility. CN stated the facility no longer lets resident use their medication from home. The facility will order the medication from pharmacy to prevent an incident like that from occurring in the future. CN stated she believed the resident are well taken care of at the facility. CN states no other medications have come up missing since this incident. 01/23/2023 at 10:45 AM, an interview was conducted with the ADON A who stated, to her knowledge of the situation was the at count at 10:00pm the count was missing 20 hydrocodone. ADON #1 stated that those were the only medications that were missing. ADON A stated the facility will not take medication from home from a resident. The facility now will call the primary care physician for an order until the resident can be seen for pain management. ADON A stated that Resident #1 did not miss any medications. Medication charts are audited weekly. At admission, resident and family were educated that no outside medication will be brought in and inventory is done at admission so outside medication would be identified at that time. ADON B did a chart audit the night of the incident and search the medication room that night too. ADON A and ADON B did a chart audit the next day and search the medication room together. The medication was not found. 01/23/2023 at 9:00 AM, an interview was conducted with the Admin who stated Resident #1's hydrocodone pills were on the medication chart and accounted for at 6:00am and 2:00pm on 01-03-22. Admin stated that it was not until shift change at 10:00pm on 01/03/23 that it was noticed that Resident #1's hydrocodone medication was missing. Admin stated that the nurses stated they never gave their keys or gave any access to the medication chart. Admin also stated that the nurses involved had no history of drug diversions. Admin stated one of the three staff involved transferred to a sister facility but the other two are still employed at this facility. A record review of the facility's Abuse policy, dated 02/02/2021, revealed, Residents have the right to be free of abuse, neglect, misappropriation of resident property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment. A record review of the facility's Drug Diversion policy, dated 02/10/2020, revealed, the following recommendations are designed to reduce and limit drug diversions: 1. Do not sign for receipt of controlled substances until you have inspected the delivery from the pharmacy that all ordered medications have arrived. 2. The narcotic count sheet should be signed and quantity received should be indicated. 3. Medications should be put in storage areas immediately and not left at nurses station or on medication room counters. 4. Controlled substances should be stored in a double locked compartment at times including discontinued and overstocked medications. 5. A drug count must be done at each shift change and should be done whenever the keys to the narcotic storage areas are exchanged from one staff to another. 6. ALL controlled substances should be counted including those in the lock box in the refrigerator and overstock narcotics in medication room. 7. Access to refrigerator lock box and overstock narcotics in medication room should be limited. 8. Signing the narcotic shift count sheet means you are accepting responsibility for the controlled substances. Therefore, do not sign unless you are certain that all of the controlled substances are present and have not been adulterated/tampered with or altered in any way. 9. Document usage both on MARs and narcotic count sheet as soon as possible after administration of medication. 1O. Document administration of PRNs controlled substances on the MARs including dose, date, time, route and effectiveness of medication. 11. Do not return capsule or tablet to a container or a medication card once it has been removed. NEVER USE TAPE ON A MEDICATION CONTAINER OR BLISTER PACK. o Do not use white-out or obliterate an entry if you make an error. Draw one line thru the error and provide an explanation with your signature. o Do not use the double locked storage areas to store personal items (keys, cash, resident/personal property, etc ). o Check medication containers and cards for signs of tampering or drug substitution (ie. tape on back of blister cards) o Check ampules to make certain they have not been opened and glued back together.

41095 Based on observations, interviews and record reviews, the facility failed to review and revise the person-centered comprehensive care plan after each assessment for 4 (Residents #23, #78, #35 and #144) of 16 residents reviewed for care plan revisions in that: 1. Resident #23's comprehensive person-centered care plan was not revised to address an order for oxygen or the admission to hospice. 2. Resident #78's comprehensive person-centered care plan contained a goal and intervention for tube feeding when resident did not have a feeding tube. 3. Resident #35's comprehensive care plan was initiated on 08/01/22 and was not closed out when the resident was discharged with return not anticipated on 08/22/22 and readmitted on [DATE]. and the previous care plan was used. 4. Resident #144's comprehensive care plan was initiated on 08/01/18 and was not closed out when Resident #144 was discharged with return not anticipated on 08/28/19. Resident #144 was readmitted on [DATE] and the previous care plan was used. These failures could place residents at risk of their needs being missed and not receiving appropriate care and treatment. The findings included: 1. Record review of Resident #23's electronic admission record dated 09/28/22 documented a [AGE] year-old male originally admitted to facility 07/12/22 and most recently admitted on [DATE] following a hospital stay. Resident #23's diagnoses included lobar pneumonia, unspecified dementia with behavioral disturbance, dysphagia, oropharyngeal phase (difficulty swallowing), cognitive communication deficit and acute and chronic systolic (congestive) heart failure (the heart does not pump blood as it should). Record review of Resident #23's Care Plan last revised on 09/27/22, did not have a plan of care for hospice or use of oxygen. Record review of Resident #23's physician orders as of 09/28/22 revealed he was admitted to hospice services on 07/18/22. There were no orders for oxygen listed. Record review of hospice orders in a separate hospice binder for Resident #23 contained an order dated 7/18/22 for Oxygen (O2) 2-3L Liter inhaled, PRN Shortness of Breath. Record review of Resident #23's Significant Change MDS assessment, dated 07/18/22, revealed the resident was marked as being on oxygen. The significant change payer was noted as Hospice Medicaid Forms Pending. During an observation of Resident #23 on 09/28/22 at 12:54 p.m., resident was noted to be in bed with his eyes closed and using oxygen. During an interview on 09/30/22 at 11:38 p.m. with ADON E, oxygen orders were discussed. ADON E stated The oxygen orders should be on PCC (Electronic Medical Record). When hospice did the admission, they talked with the charge nurses and then the orders were supposed to be put in PCC. It was an oversight that the oxygen orders were not put in PCC. ADON E also stated the orders for oxygen and hospice should have been put in the care plan. 2. Record review of Resident #78's electronic Admission Record dated 09/28/22 documented a [AGE] year-old male admitted to facility 08/24/22. The diagnoses included chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), unspecified dementia, and Tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds). Record review of Resident #78's care plan documented focus, goals and interventions initiated on 09/22/22 for a feeding tube. Record review of Resident #78's Admission MDS assessment dated [DATE] documented in section K that he did not have any complaints or difficulty or pain when swallowing but Parenteral/IV feeding and Feeding tube - nasogastric or abdominal (PEG) sections were checked Yes indicating he had a feeding tube. Record review of Resident #78's physician order summary as of 09/28/22 documented a dietary order for double portions diet mechanical soft texture, thin liquids consistency. During an interview with Resident #78 on 09/28/22 at 12:12 p.m., resident stated he was able to feed himself and was waiting for lunch to be served in his room. Resident #78 stated he did not have a feeding tube. During an interview with charge nurse, LVN F, on 09/28/22 at 12:20 p.m., LVN F was asked if Resident #78 had ever had a feeding tube. LVN F stated he was not aware he had ever had one and went to check Resident #78 to see if he had any type of scar. LVN F stated there was no scar on Resident #78 that would indicate he had a feeding tube previously. During an interview on 09/30/22 at 9:56 a.m. with LVN D, MDS Coordinator, stated she did not know why Resident #78 had a feeding tube on his care plan as well as on his MDS. LVN D stated she would modify the MDS as well as the Care Plan to ensure they were accurate. LVN D stated she did not attend the care plan meetings but the staff who attend placed a note in the electronic medical record and then changes are discussed in morning meetings. 3. Record review of Resident #35's Face Sheet dated 09/30/2022 revealed the resident was originally admitted to the facility on [DATE] and was discharge with return not anticipated on 08/22/2022 and then readmitted on [DATE] with diagnoses which included peripheral vascular disease (a slow and progressive circulation disorder. narrowing, blockage, or spasms in a blood vessel), diabetes Type 2(a chronic (long-lasting) health condition that affects how your body turns food into energy), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), pressure ulcer (localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time). Record review of Resident #35's comprehensive care plan on 09/30/2022 revealed the initiated date was 08/01/2022 with the next review date on 09/29/2022. Record review of Resident #35's Minimum Data Sets (MDS) assessment history from 07/29/2022 to 09/19/2022 revealed an MDS dated [DATE], Discharge Return Not Anticipated an MDS dated [DATE], Entry and an MDS dated [DATE], Admission. Record review of Resident #144's Face Sheet dated 09/30/2022 revealed the resident was originally admitted to the facility on [DATE] and discharged on with return not anticipated on 08/28/2019, then readmitted on [DATE] with diagnoses which included cognitive communication deficit (difficulty with thinking and how someone uses language), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Psychotic Disturbance (are severe mental disorders that cause abnormal thinking and perceptions), Mood Disturbance (can be feelings of distress, sadness or symptoms of depression, and anxiety), Anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations) and Benign Prostatic Hyperplasia (Age-associated prostate gland enlargement that can cause urination difficulty). Record review of Resident #144's comprehensive care plan on 09/30/22 revealed the initiated date was 08/01/2018 with the next review date on 09/27/2022. Record review of Resident #144's Minimum Data Sets (MDS) assessment history from 07/29/2019 to 09/19/2022 revealed an MDS dated [DATE] Discharge Return Not Anticipated an MDS dated [DATE], Entry and an MDS dated [DATE], Admission. During an interview on 09/30/2022 at 10:11a.m. with LVN D revealed if an old care plan might not have been closed out and deactivated it would go into the new care plan. LVN D stated the old care plan could be used against us and may no longer apply to the resident. LVN D confirmed the old care plans for Resident #35 and Resident #144 should have been deactivated. Record review of the Facility Care Plan Guidelines dated 01/21/2015 and revised on 05/06/2016 revealed in part and states The purpose of this is to ensure that interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CAT) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident Care Plan Updates The IDT will review the care plans Annually, Quarterly and as needed to ensure all goals and approaches are appropriate Acute Care Plans As acute problems or changes to intervention or goals are identified, as appropriate care plan will be developed or modified Procedure All comprehensive care plans will be completed utilizing the Point Click Care electronic system . Record review of the Facility Comprehensive Care Plans Policy and Procedure dated 02/10/2021 states in part 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but, are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans as appropriate . Review of the Center for Medicare Services (CMS), Resident Assessment Instrument (RAI), Version 3.0 manual, dated 10/2019 page 2-42, states in part Care Plan Completion- The care plan completion date, must be either later than or the same date as the CAA completion date but, no later than 7 calendar days after the CAA completion date. The MDS completion date must be earlier than or the same date as the care plan completion date Resident's preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident's representative, so changes can be reflected in the comprehensive care plan . Review of the facility's electronic system Point Click Care, modified 04/07/21, page 1/11 and page 6/11, the area for care plans states in part Care Plans: Navigating the Care Plan Tab . 2. Date Initiated and Review Date a. Date Initiated- Date the Care Plan was started. b. Next Review Date-Date for next Care Plan review Closing the Care Plan: Residents that are discharged without anticipated return will have their care plans closed automatically by the completion of the MDS Discharge Return not anticipated . (https://cfc.freshdesk.com/support/solutions/articles/4000171354-pcc-care-plans-and tasks)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 (#62, #41, and #13) of 3 residents reviewed for accidents, hazards, and supervision. 1. Resident #13 had a package of razors in his room. 2. Resident # 62 had a cup of razors in his room. 3. Resident #41 was unsupervised during meals. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: 1. Record review of Resident #13's MDS assessment, dated 06/24/22, revealed an admitted [DATE] and a readmitted [DATE]. Resident #13 had a diagnoses of alzheimer's disease, stroke, dementia, schizophrenia, and hip fracture. Resident #13 had a BIMS of 5 (severely impaired cognition). Under section G functional status resident was an extensive, one-person assist with personal hygiene. Observation on 09/27/22 at 10:00 a.m. revealed Resident #13's bottom dresser drawer was opened, and a package of disposable razors was observed. During an interview on 09/27/22 with Nurse Aide N and Nurse Aide O stated the razors were in the room because hospice left them there. They stated normally they kept them in a locked closet. 2. Record review of Resident #62's Admission Record dated 09/29/22, revealed an admitted [DATE]. Resident #62 has diagnoses including mild intellectual disabilities, muscle wasting and atrophy, schizoaffective disorder, and anxiety. Record review of Residents #62's MDS assessment, dated 08/24/2022, revealed a BIMS of 8 (moderately impaired cognition). Under section G functional status, resident required supervision- oversight, encouragement, or cueing and setup help for personal hygiene. Observation on 09/27/22 at 10:46 a.m. revealed Resident #62 had a cup of disposable razors on the top of his dresser. In an interview on 09/29/22 at 11:13 a.m. with LVN P revealed, residents were not supposed to have sharp objects such as scissors, knives, or razors in their possession or in their rooms. LVN P stated Resident #62 has an electric razor but not a manual one. LVN P stated this was because they could hurt themselves or someone else by using it as a weapon. LVN P stated if they have dementia, they could forget what it was used for or try to eat it. This surveyor informed LVN P a cup of razors was observed in the resident's room on 09/27/22. LVN P entered Resident #62's room and lifted some items on the resident's dresser. Under the items was one disposable razor. In an interview on 09/29/22 at 3:57 p.m., the DON stated residents were not allowed to have items such as knives, razors, disposable razors, lighters, cigarettes, vapes, guns, and medications in their possession with out supervision. The DON stated to her knowledge she does not know of any residents who were allowed to have these items unsupervised. 3. Record review of Resident #41's Admission record dated 09/28/22, revealed an admitted [DATE] and a readmitted [DATE]. Resident #41 has diagnoses of cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture.), apraxia (A neurological syndrome characterized by difficulty in performing daily tasks even if the instructions are understood. The person affected finds it difficult to tie shoelace, button the shirt, difficulty in making certain facial expressions etc.), lack of coordination, dysarthria (Difficulty in speech due to weakness of speech muscles.) and anarthria (inability to articulate remembered words as a result of a brain lesion), abnormal posture, muscle weakness, unspecified convulsions (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness.), and dysphagia oropharyngeal phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing). Record review of Resident #41's MDS assessment, dated 08/05/22, revealed under section C Cognitive Patterns the resident was severely impaired-never/rarely made decisions. Under section G Functional Status eating- limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance and One-person physical assist. Record review of Resident #41's care plan last revised on 05/16/22, stated The resident has, a swallowing problem r/t loss of food/liquids from mouth while eating, Coughing or choking during meals or swallowing med, Swallowing assessment results, Dysphagia. Resident failed swallow study and refused G-Tube. puree diet with fortified foods, divided plate .Resident to eat only with supervision. Record review of Resident #41's document labeled Restorative Care Program ST dated 06/17/2017, stated Precautions: Choke and aspiration precautions. Should be supervised for all intake .RNA training provided to all shifts as indicted. The document is signed by Speech Therapist S. An observation on 09/27/22 at 12:10 PM, revealed Resident #41 sitting in the dinning room at a table alone. The Resident had two cups in front of her with straws in them. Later RN Q served this Resident a meal tray. RN Q left the table and served approximately 4 other Residents in the dining room their lunch trays. RN Q left the area several times for various times during the meal service. No other staff were assisting with meal service in the dinning room. Resident #42 used a weighted spoon to serve herself. Resident #41's food appeared pureed (soft, moist, and smooth). Resident #41 moves the spoon slowly to her mouth while shaking and dropping food from the spoon. The Resident #41's tongue rest outside her mouth at all times and while eating. RN Q was observed standing at the Resident 41's table assisting her to place condiments on her food and overheard telling Resident #41 that she will be back later to help her finish her food. RN Q left the dining room area again. In an interview with Resident #41's Representative on 9/28/2022 at 9:46 a.m. stated Resident #41 liked her snack at night. She stated Resident #65 came in and gives it to her at night. Resident #41's Representative stated the staff could not be relied on to help her with her nightly snack, she gave a key to Resident #65 to feed Resident #41 her snack at night in her room. In an interview on 09/29/22 at 3:39 p.m. the DON stated Resident #41 was on a puree diet. She stated staff helped her set up her meal and supervised her during meals. She stated Resident #41 slept in till noon and sometimes did not get up for breakfast. Resident #41 liked a nightly snack. The kitchen staff ensured the item required for her snack follows her diet. She stated she had heard Resident #65 did assist with Resident #41's nightly snacks. She stated Resident #41 had Vienna sausages for a snack and Resident #65 prepared them for Resident #41. She stated it was not acceptable for Resident #65 to prepare the snack and assist Resident #41 with eating because she could choke or have other issues. Record review of facilities policy document titled Investigation of Incidents and Accidents dated 12/3/20, states The residents environment will remain as free of accidents hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: .3. Implementing interventions to reduce hazard(s) and risk(s).

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled drugs for 3 of 10 (#3, #37, #74) residents reviewed for medication administration in that: The medication cart for rooms 137-154, contained an inaccurate narcotic log for Residents #3, #37, and #74. This deficient practice could place residents at risk of inaccurate care due to improper procedures. The findings were: Record review of Resident #3's Admission Record, dated 09/29/2022, revealed an admitted [DATE], and a readmitted [DATE], with diagnoses that included stroke affecting the right side, speech and language deficits, pain, heart failure, high blood pressure, and muscle weakness. Record review of Resident #3's physician orders for September 2022 revealed an order for Acetaminophen-Codeine #4 Tablet 300-60MG (a narcotic used to treat moderate to severe pain) Give 1 tablet by mouth four times a day for pain, with an order date 10/29/21 and no end date. Record review of Resident #37's Admission record, dated 09/29/22, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that cellulitis of unspecified part of limb (A serious bacterial infection of the skin.), peripheral vascular disease (affects the blood vessels), chronic pain, and pressure ulcer of the left heel stage 4. Record review of Resident #37's physician orders for September 2022 revealed an order for Oxycodone HCl Tablet 20 MG (a narcotic used to treat severe pain) Give 1 tablet by mouth five times a day for chronic pain, with an order date 09/13/22 and no end date. Record review of Resident #74's Admission Record, dated 09/29/2022, revealed an admitted [DATE], with diagnoses that included chronic pain syndrome, glaucoma, muscle weakness, and stroke. Record review of Resident #74's physician orders for September 2022 revealed an order for Morphine Sulfate Tablet 15 MG (a narcotic used to treat severe pain) Give 1 tablet via G-Tube every 4 hours for pain, with an order date 06/30/22 and no end date. During an observation on 09/28/22 at 12:19 p.m., LVN P administered Resident #37 20 MG of Oxycodone from a blister pack that contained 17 remaining pills after administration. LVN P did not document in the MAR or narcotic logbook at this time and continued down the hallway to administer medications to a different resident. During an observation on 09/28/22 at 12:36 p.m., LVN P administered Resident #3 1 tablet of 300-60MG of Acetaminophen-Codeine from a blister pack that contained 28 remaining pills after administration. LVN P did not document in the MAR or narcotic logbook at this time and continued down the hallway to administer medications to a different resident. During an observation on 09/28/22 at 12:40 p.m., LVN P administered Resident #74 15 MG of Morphine Sulfate tablet from a blister pack that contained 15 remaining pills after administration. LVN P did not document in the MAR or narcotic logbook at this time and stated she was done with medication administration at that time. Record review on 09/28/22 at 12:56 p.m. of the narcotic count logbook located on nurse cart for rooms 137-154 showed Resident #37's count sheet for 20 mg of Oxycodone documented 2 blister packs of 30 and one with 18 remaining pills. The blister pack had 17 remaining. 1 pill was not signed out on the count sheet. Record review on 09/28/22 at 12:57 p.m. of the narcotic count logbook located on nurse cart for rooms 137-154 showed Resident #3's count sheet for 300-60MG of Acetaminophen-Codeine documented 3 blister packs of 30. 1 Blister pack had 29 remaining. 1 pill was not signed out on the count sheet. Observation on 09/28/22 from 12:08 p.m. to 12:46 p.m. revealed LVN P did not document any medications administered to residents between these times. During an interview on 09/28/22 at 12:56 p.m., LVN P stated she was supposed to document medications in the narcotic count logbook and medication administration record as she gave them. She stated if she did not document at the time she gave the medication, she could forget to sign them out, she could be pulled away, forget she gave something, and it would not be signed out. She stated she did not have a pen on her, it was at her desk, to document in the paper medication records located on the nursing cart. During an interview on 09/29/22 at 4:03 p.m. the DON stated staff should follow the medication administration, administer the medications, and then sign them out. The DON stated it would not be acceptable for a nurse to administer medication to the whole hallway then document after. The DON stated if they did not have a pen, then they needed to get one. The DON stated the process for narcotics was to sign it out whenever was it popped out of the blister pack. Record review of the Facilities Policy titled Medication- Treatment Administration and Documentation Guidelines, dated 2/2/2014, stated Anticipated Outcome, to provide a process for accurate, timely administration and documentation of medication and treatments .5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. 6. When controlled medication is administered the licensed nurse obtains the medication from the locked area. The licensed nurse administering the medication immediately enters the following information on the accountability record when removing the dose from controlled storage; date and time of administration, amount administered, signature of the nurse administering the dose. (Also document controlled medication dose administered on the MAR).

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. 3 of 4 food racks in the dry storage area were rusted. 2. Ice machine had dust buildup on the left vent and a heavy buildup of a gray substance running down the right side of the ice machine. 3. Refrigerator #4 had 3 of 3 doors with a brown color midway up each door and the rubber gasket inside the right door was broken. 4. Freezer #2 did not have a thermometer. 5. Floor drain in front of the walk-in Refrigerator #5 had pooled water beside the floor drain. 6. The drain from the vegetable preparation sink had the ice machine drain connected to the side of the sink drain and was connected directly to the floor drain. The drain pipe was covered with a black substance. 7. Air conditioner vent on the left side of the steam table was covered with a black substance. This failure could place residents who ate from the kitchen at risk for cross-contamination and food-borne illnesses. The Findings included: Observations on 09/28/2022 from 08:39 a.m. to 09:07 a.m. revealed the following: 1. Dry food storage area- 3 of 4 racks use to store food were rusted. 2. The ice machine had a buildup of dust on the left vent and a heavy buildup of a gray substance running down the right side. 3. Refrigerator #4 had 3 of 3 doors with a brown color midway up each door and the rubber gasket was broken on the inside right door causing ice buildup along the door edge and condensation. 4. Freezer #2 did not have a thermometer. 5. Floor drain in front of walk-in Refrigerator#5 had pooled water beside the floor drain. 6. The drainpipe from the ice machine was attached to the vegetable preparation sink drainpipe and draining directly into a floor drain and was also covered with a black substance. 7. The air conditioner vent on the left side of the stem table was covered with a black substance. Observations on 09/28/2022 at 08:50 a.m. at the vegetable preparation sink and the ice machine revealed the drainpipe from the ice machine was connected to the drainpipe from the vegetable preparation sink straight into the drainpipe into the floor. The drainpipe from the ice machine to the other drainpipe was covered in a black substance. Observation on 09/28/2022 at 9:07 a.m. revealed the air conditioner vent on the left side of the steam table was heavily covered with a black substance. During an interview on 09/08/2022 at 8:48 a.m. with the Food Service Supervisor (FSS), she confirmed there were 3 of 4 racks used for dry food storage was rusted, the ice machine had a buildup of dust on the left vent and a heavy buildup of a gray substance running down the right side and no thermometer in freezer#2. The FSS stated further the rubber gasket for the right door on freezer#2 was broken and was ordered yesterday, 10/27/2022 and had been like that since she came to work on 10/2020. The FSS stated she knows the rusted racks in the dry storage area can cause rust to get into food and the seal on the door not being fixed can cause food to ruin. The FSS stated the water pooled by the floor drain by the walk-in refrigerator #5 has been that way for years and it is coming from the sewer. She stated it does that every time it rains or if you use the vegetable prep sink. During an interview on 09/28/2022 at 8:55 a.m. with the FSS revealed the drain had been connected directly to the vegetable preparation sink and the black substance on the pipes since she had been working at the facility. The FSS further stated when the vegetable preparation sink was used, the drain in the floor by the walk-in freezer will also have water coming up. During an interview on 09/28/2022 at 9:00 a.m. with the cook/dietary aide revealed she had worked at the facility for 3 years, the drainpipe from the vegetable preparation sink and the ice machine drainpipe have been connected straight into the drainpipe. During an interview on 09/28/2022 at 09:10 a.m. with the FSS confirmed the air conditioner vent was covered with a black substance and was the only vent operating in the kitchen. The FSS stated maintenance was in charge of cleaning the air conditioner vent and did not know when it was to be cleaned. Further the FSS stated the black substance could possibly blow down into the food on the steam table. During an interview on 09/30/2022 at 8:15 a.m. with the Administrator stated the air conditioner vent was not taken care of on 09/29/2022 because the vent was going to have to be cut out and replaced and did not want to remove it while cooking was going on. Review of the Facility Policy for Food Service Safety and Sanitation Plan dated 09/2005 and revised on 11/20/2017, pages 1 of 8, 2 of 8, 7 of 8 and 8 of 8, stated in part: It is the policy of the facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur Food contaminations means the unintended presence of potentially harmful substance including but not limited to microorganisms, chemicals or physical objects in food Ice- Appropriate ice and water handling practices prevent contamination and the potential for waterborne illness. Keeping the ice machine clean and sanitary will help prevent contamination of the ice. Contamination risks associated with ice and water handling practices may include but, are not limited to: Unclean equipment, to include internal components of ice machines that are not drained and sanitized as needed according to manufacturer's specifications . Review of the Easyice Ice Machine Safety requirements dated 05/16/2018, states in part: What is an Air Gap? An air gap is the amount of space that separates a water line from an ice machine drain to a sewer. Proper air gap installation makes sure dirty water does not contaminate the municipal water supply According to health codes, any piece of equipment where food, drinkable liquids or eating utensils are placed cannot have a direct line into the sewage system. Since the Food and Drug Administration classifies ice as a food, ice machines must follow these guidelines as well. Health codes require two air gap instillations for each ice machine. The first air gap must exist between an ice machine's drain lines and the water supply line that directly connects to the city water supply. The other air gap, or backflow prevention, must be between an ice machine drain and the sewer drain. This makes sure the sewer lines can't create a vacuum which allows water to flow back up into the machine contaminating ice that could end up in someone's drink . (https://Easyice.com/air-gap-tips-health inspector) Review of the Texas Commission on Environmental Quality Chapter 290- Public Water System Effective 01/03/2019, 290.38 Definitions states in part: 2. Air gap- The unobstructed vertical distance through the free atmosphere between the lowest opening from any pipe The vertical, physical separation must be at least twice the diameter of the pipe . (www.aitceq.texas.gov)

Based on observation, interview, and record review, the facility failed to ensure the rights of one (Resident #1) of 18 residents reviewed for abuse, was free from mental/verbal abuse. On 04/26/13, the Administrator shook his fore finger in Resident #1's face and called the resident a trouble-maker, told her she was "running people off" and it was her fault for the situation created with Resident #2. Resident #1 cried and experienced mental anguish and fear as recently as 05/31/13. The Administrator returned to work on 05/02/13 with no evidence of having attended any inservices, any re-education and/or continued education courses. The Administrator had access to the facility's 108 residents until he was suspended again on 07/08/13. An Immediate Jeopardy (IJ) was identified on 07/08/13. While the IJ was removed on 07/11/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern" because the facility was still in-servicing the staff and the facility was monitoring the implementation of the Plan of Removal. This failure placed he facility's 108 residents at risk for the potential of verbal and/or mental abuse due to the Administrator's continued presence in the facility, which could result in emotional upset, development or worsening of Depression, fear of staff and retaliation, and could have a negative impact on their quality of life. Findings Included: Following administrative review, it was determined SQC had occurred during the survey, more investigation was required and the survey team returned to the facility. Resident #1's Admission Record, dated 05/06/13, reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had adequate heearing, had clear speech, was able to make herself understood and she had the ability to understand others and she did not exhibit any physical, verbal or other behaviors. The MDS assessment further reflected Resident #2 required limited to extensive assistance of one person for her ADLs and used a wheelchair for mobility. Active [DIAGNOSES REDACTED]. Resident #1's Care Plan dated 04/27/13 reflected the resident was upset because on 04/26/13, she received a roommate and allegedly was told to quit running off roommates. The Goal was for Resident #1 to be calm and reassured using the following interventions: Talk with resident, Reassure resident it was not her fault roommate situation did not work out. Contact MD if PRN medication was needed. ADON B was the author of this care plan. During an interview with Resident #1 on 05/31/13 at 10:15 AM, she told the surveyor, approximately one month ago (04/26/13), the Administrator caused her to cry. She explained the incident occurred on 04/26/13 when she received a new roommate. She stated staff brought Resident #2 to the room, which did not have a bed for the resident and just left her there. She said she (Resident #1) requested staff to bring her roommate a bed, because she (Resident #2) was sick. She said her new roommate's family arrived and were upset about the resident's move and began yelling. She said the ADM then arrived and told her (Resident #1) the situation was her fault. She said the ADM telling her Resident #2's moving back to her original room and "running residents off" was her fault and caused her to cry. Resident #1 stated she was still concerned about how the ADM might react if she (Resident #1) brings up another concern. Resident #1 then added the ADM had been "really nice" since the incident, but she still felt "staff would side with him," if she had a problem. The surveyor assessed Resident #1 as being alert and oriented to person, place and time and was a reasonable historian of the events of 04/26/13. The facility's Provider Investigation Report, dated 05/01/13, and signed by the RDO/Interim Administrator reflected an incident occurred on 04/26/13, and an allegation of verbal abuse was made on 04/29/13. Family Member #1A called the facility's corporate office to report verbal abuse involving Resident #1, which occurred on 04/26/13. (Note: No facility staff called in an allegation of abuse.) A Description of the Allegation reflected Family Member #1A stated an incident had occurred when Resident #2 was moved into Resident #1's room, and the family of Resident #2 was upset and "caused a scene." The Administrator was told there was a problem, and when he entered Resident #1's room, he pointed his finger at Resident #1 and told her she was a trouble maker and had "run off every roommate assigned to her room." Resident #1 then began to cry. Family Member #1A and the Administrator left the room and a "heated verbal exchange" was made about the Administrator's "conversation and tone (of voice)" used with Resident #1. The facility's Provider Investigation Report reflected in determining whether Resident #1 had suffered injury or an adverse effect, the following was written: "There was some initial anguish that lingered more than 8 hours... (Note: The incident occurred on 04/26/13 at 6:30 PM. An Investigation Follow-up reflected on Monday, 04/29/13, three days later, Resident #1 was still upset.) The facility's Provider Investigation Report reflected the family (of Resident #1) asked that she (Resident #1) not be asked anymore questions about the incident so she could calm down. She was assessed for (sic) and Social Services will continue to follow her for her sense of safety and she is doing well." The facility's Provider Investigation Report included the facility's response to the incident: "The Administrator was suspended pending investigation (on 04/30/13, four days after the incident and one day after the allegation of abuse was received). The Resident was assessed and monitored for sense of safety and security after the incident... The Community Staff was re-educated by the DON, the Environmental Supervisor and the DM on Abuse and Neglect, Signs and Symptoms of Stress, How to Handle Customer Complaints with Care and Resident Rights as it related to Room relocations, choice and inter-office communication (sic) for changes. (The Administrator's name was not on the sign-in sheet for having attended this training.)... The Administrator will be re-instated with a recommendation to attend Continued Education Courses at his expense for Conflict Resolution and Abuse and Neglect." The facility's Provider Investigation Report indicated in the Investigation Summary "the Administrator did not have all the facts as to what occurred and entered the room speaking with her (Resident #1's) family and the resident. He (the ADM) admits tempers flared and he denies calling her a Trouble Maker and is extremely remorseful that this conversation became heated with (Resident #1's) family and having Resident #1 cry...." The Investigation Summary further indicated the Administrator was in stress due to being on call 24-7. "I (RDO) know this was late in the evening on a Friday (6:30 PM) and he was called back to the building to diffuse the situation. We acknowledge this incident was handled in a unprofessional manner...." The facility's Provider Investigation Report's Investigation findings confirmed the Administrator was abusive to Resident #1. The facility's Provider Investigation Report included the Provider Action Taken Post-Investigation and reflected: "The Administrator will be re-instated on May 2nd, with the stipulation he completes continued education course on Conflict Resolution and Abuse and Neglect." Further review of the facility's Provider Investigation Report revealed there were statements from Family Member #1A and the SW, a Grievance/Complaint Report dated 04/27/13 written by ADON B (incomplete), an Investigation Follow-Up signed by the DON on 04/30/13, which was completed by ADON B and reflected the DON had been informed of the Grievance/Complaint Report regarding Resident #1. There were interviews conducted by the DON dated 04/28/13 with Residents #1 and #2. The interview conducted with Resident #1 on 04/28/13 by the DON, which was included with the facility's Provider Investigation Report, reflected the following: "States Admin told her it was her fault the roommate was upset and had to be moved out. (Resident #1) became tearful and said he (the Administrator) should not talk to anybody like that." This was told to the DON on 04/28/13, but she did not report this incident of abuse to the State Office. Also included with the facility's Provider Investigation Report were Social Service Progress Notes for both Residents #1 and #2. A Grievance/Complaint Report, completed by ADON B on 04/27/13, reflected the following: - Grievance/Complaint: "Resident (#1) told me she was still upset and scared because yesterday a roommate was put in her room without her being told first and then the roommate was moved. The Administrator then told her it was her fault that the other resident was moved out of the room and he scared (Resident #1) and made her cry." - Facility Follow-up: "(Resident #1) did state on 04/27/13 that Administrator did apologize for his remark but she was still upset by the remark." Despite the interview with Resident #1 resulting in ADON B documenting a Grievance/Complaint Report, ADON B did not identify the Abuse, which Resident #1 was subjected to. The Grievance/Complaint Report's Documentation of the Facility Follow-Up had incorrect information documented. The Report was not completed, and there was no resolution of the grievance/complaint. The facility's Investigation Follow-up was signed by ADON B and the DON, but the signatures were not dated. The Investigation Follow-Up included the following: - Description of Situation - A resident moved into Resident #1's room. Resident #1 was upset by the new roommate's family member cursing and throwing clothes on other resident's bed. NOTE: There was no mention made of the ADM coming into Resident #1's room calling her a trouble maker and shaking his finger in her face. - Summary of Investigation - Resident #1 was "still upset on Monday, 04/29/13 (three days after the incident), by her perception of how the Administrator shook his finger in her face and said this was all her fault by complaining of roommate." Resident #1's Social Service Progress Notes, dated 04/28/13, reflected the DON had notified the Social Worker on Friday (04/26/13), Resident #1 received a new roommate and that "there had been issues." There was no information including the ADM's actions of going into Resident #1's room, calling her a trouble maker and shaking his finger in her face causing the resident to cry. Resident #1's family member, Family Member #1A, took the time and effort to write a statement regarding the incident, which occurred, whe the Administrator verbally/mentally abused Resident #1 on 04/26/13. Her statement reflected they (Resident #1's family members) were visiting Resident #1 and met Resident #2, her new roommate, who was a very nice woman and Resident #1 and Resident #2 were getting along "very well." Approximately 5-10 minutes later, Family Member #2A stormed in to the room in a "violoent fashion slamming the doors, hitting the walls, tearing" Resident #2's belongings out of the closet and drawers, piling them on top of Resident #2, who was in bed and kept screaming, "I can't believe they moved you (Resident #2) without telling me." She was screaming and cursing and being very violent. Resident #2 was breathing very heavily nad was getting upset and Resident #2 was also getting upset. I was afraid for our safety. The CNAs came in to the room trying to calm down Family Member #2A, but she continued to yell and scream, calling for the "boss" and kept repeating she was going to call a family member. The CNAs got Resident #2 unburied from all the clothes piled on her and tranferred her to a wheelchair to move her back to her original room. They got everything moved and Family Member #2A calmed down. Another 30 minutes or so went by and Resident #1 was eating her dinner. Resident #1 said she really like Resident #2, but was afraid "they" were going to think it was her fault. (Earlier that day, a resident had been moved into Resident #1's room but was transferred out because she was a smoker. The nurse had insisted it was unacceptable, with Resident #1's [MEDICAL CONDITION], it was not an option.) Family Member #1A and Family Member #1B tried to reassure Resident #2 the problem had nothing to do with her. The Administrator then walked straight into Resident #1's room and rudely pointed at Resident #1 and asked Family Members #1A and #!B if they knew her, to which they both said "Yes." The Administrator then asked if they were family members, and they said "Yes." The Administrator then stepped around the family members and pointed directly at Resident #1 and in a very rude and condescending tone, told Resident #1, "I am tired of you being a troublemaker, and being mean. You keep running people out of this room." Resident #1 immediately broke down in tears and Family Member #1A told him to walk in the hallway, this was over, and they were going to talk alone. Resident #1 had never met the Administrator and did not know who he was, he never introduced himself or identified himself and Resident #1 assumed he was a member of Resident #2's family. Resident #1 was about to call the police when the nurse told Resident #1 he was the Administrator. When Family Member #1A and the Administrator entered the hallway, he had a"very smug attitude" and was innow way trying to reconcile the situation or showing any signs of remorse. When Family Member #1A asked him if he thought his behavior was appropriate, his only response was, "I am a professional" or "oh really what did I say." Family Member #1A told the Administrator there was no excuse for the kind of behavior and he needed to walk back into the resident's room and apologize to Resident #1. Family Member #1A told the Aministrator he should respect Resident #1 as a human being, not to mention also his elder. When the Administrator and Family Member #1A walked back into Resident #1's room, a nurse was trying to calm the resident down. The nurse kept telling Resident #1, "I think it was an ill attempt at a joke." The Administrator walked in, handed her a new tissue and just kept saying, "Stop crying" and "don't be upset." He never tried to reconcile the situation or apologize. Resident #1 continued to cry, sayng no one had ever spoken to her like that. They finally got Resident #1 to stop crying and the nurse in the room went in to the hallway with the Administrator. The family members continued to talk to Resident #1, reassuring her it was not her fault. The nurse, who had been in the room with Resident #1, later spoke with Family Member #1A, telling the family member she really thought it an ill attempt at a joke. Family Member #1A told the nurse it wasn't and that was the end of that conversation. The family members left to get other family members with one of the CNAs saying he would look after her. When they returned to the facility, Resident #1 told her family members the Administrator had returned and tried to apologize. Family Member #1A then wrote, "A line of decency was crossed and no one deserves to be verbally abused that way let along a defenseless [AGE] year old woman with health issues." During an interview with Family Member #1A on 06/06/13 at 8:20 AM, the family member stated he/she was with Resident #1 at the time of the incident on 04/26/13. Family Member #1A said facility staff had moved another resident into Resident #1's room. Family Member #1 said they had been in Resident #1's room for about 15 minutes when Family Member #2A came into the room and started yelling and throwing things around in the room. Family Member #2A was upset because "they" had not told her Resident #2 was being moved. At that time, Resident #1 said she was concerned about the reaction of Family Member #2A and went and got some facility staff. Family Member #1A said Resident #2 was moved back to her other room everything calmed down for about 30 minutes. The Administrator came into the room and asked if Resident #1 and Family Member #1A knew Resident #2. Family Member #1A said the ADM pointed his finger at Resident #1 and said, "She's (Resident #1) a troublemaker, and she can't keep causing problems." Resident #1 then started to cry. He/she stated Resident #1 kept asking the Administrator who he was. The ADM never answered and never introduced himself. He never apologized to Resident #1 and/or Family Member #1A. He/she stated he/she felt concerned leaving Resident #1 there. He/she said if the ADM acted that way in front of other people, how would he act when no one was there. Resident #1's family member said Resident #1 was also upset, because she was blamed for the situation, which occurred. During an interview with the Administrator on 05/31/13 at 9:45 AM, he stated staff moved a resident into Resident #1's room. He stated Resident #1 always had a reason why the roommates did not work for her. He stated he spoke with Resident #1 first, but could not remember the exact conversation. He said he was a little frustrated with multiple residents moving in and out of Resident #1's room. He denied pointing his finger in Resident #1's face. He said Resident #1 was upset. After things calmed down, he went back to Resident #1's room and apologized to her, and she seemed fine. He did not think he raised his voice at the resident, but spoke in a "matter of fact" tone (of voice). He stated he also dealt with Family Member #2A, who was upset about Resident #2's move. No evidence was provided by the Administrator regarding the Administrator's attendance at continuing education classes involving Conflict Resolution and Abuse and Neglect. A "stickie note" reflected cost information for the course entitled, "Dealing With People You Can't Stand." It was an on-line computer training course for behaviors for the Administrator. Nothing else was provided in regard to the Administrator's training. During an in interview with the ADON B, on 06/20/13 at 11:30 AM, she confirmed she was present the Friday evening the incident occurred with Resident #1 and the Administrator. She stated one of the CNAs came to her and told her there was a problem with two residents. The family member of Resident #2 (Family Member #2A) was out of control, yelling and throwing things, threatening to move Resident #2 if they didn't take care of the problem. The CNA said Family Member #2A started to cry. Family Member #2A then went and got the orderly to come and move Resident #2 back to her old room. ADON B said she spoke with Family Member #2A, who told her (ADON B) Resident #2 was supposed to have a private room through the weekend. ADON B said the SW was supposed to notify the family on the day of the room move. ADON B stated she called the Administrator to come to the facility. When asked about the incident, which occurred between Resident #1 and the ADM, ADON B indicated she did not witness what was said by the Administrator to Resident #1 because she was busy moving Resident #2 back to her room. ADON B told the surveyor the Administrator had a history of [REDACTED]." During an interview with the RDO/Interim ADM, on 06/20/13 at 1:05 PM, she confirmed an individual had contacted and made her aware of the incident, which took place at the facility and involved the Administrator and Resident #1. She stated she had suspended the Administrator on 04/30/13 as soon as she became aware of what had occurred on 04/26/13. The RDO/Interim ADM stated she initiated an investigation on 04/29/13. She stated there were quite a few failures involved in the incident. The Administrator failed to get the facts before he entered the building or before going to Resident #1's room. She said the Administrator did admit to telling Resident #1 she was "running people off," and Family Member #1A was upset. The Administrator also admitted he "barged" into the building without being informed of the incident and the actual events of the situation. The Administrator should have listened to all the facts before he entered Resident #1's room. The Administrator's choice of words were not the best. The RDO/Interim ADM stated it was a bad situation all the way around and was fueled by other residents. RDO/Interim ADM stated corporate had concerns about the Administrator being aggressive with residents/staff and were considering termination amd had been in the process of gathering evidence. She stated the Ombudsman also got involved in an effort to assist the facility in resolution of what occurred with the families. The RDO/Interim ADM added she was concerned Family Member #2A was throwing things around in Resident #1's room and Family Member #2A could have harmed someone. The RDO/Interim ADM further stated "someone" moved Resident #2 without following the facility's Policy and Procedures for a room move, and adequate notice was not given. The RDO/Interim ADM stated in a room move, the SW was supposed to initiate contact when a change in room assignments or roommates was about to occur. Then Nursing staff was to follow-up with the family to ensure the family knew about the upcoming room change and/or roommates. This did not occur. If the room change had been done the way it was supposed to, the whole incident would never have occurred. The RDO/Interim ADM stated it was a system failure by not following the facility's policy and procedures for a room change. The RDO/Interim ADM stated she spoke to Family Member #1B, who requested the Administrator not be allowed in Resident #1's room, and the corporate office agreed to the stipulation. The facility's current Abuse Prohibition Policy and Procedures with the most recent review and revision dates being July 2012, reflected the following: Policy Residents have the right to be free from abuse...residents will not be subject to abuse by anyone, including, but not limited to, facility staff.... ATTACHMENT A DEFINITIONS Abuse* - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes verbal./.. mental/psychological... including ...any other actions within this definition. ...(B) 'Mental/psychological abuse'* - Mistreatment within the definition of 'abuse' not resulting in physical harm, including, but not limited to, humiliation, harassment... or intimidation. ...(E) 'Verbal abuse'* - the use of any oral... or gestured language that includes disparaging or derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. ...Mistreatment - Any malicious and/or deliberate demonstration of disrespect toward a resident. ...Any degrading body language or verbal communication. ...upsetting a resident unnecessarily.... *From Nursing Facility Requirements for Licensure & Medicals Certification 19.101 TDHS. On 07/08/13, an Immediate Jeopardy was identified. At 5:49 PM on 07/08/13, the DON was informed an Immediate Jeopardy (IJ) had been identified. At 5:53 PM, the Administrator joined the meeting and he was notified of the IJ. A request was made for a Plan of Removal for the IJ. The facility's Plan of Removal dated 07/08/13 was accepted on 07/10/13. The plan included the following: The Administrator was suspended pending investigation on 04/30/13 (returned to work on 05/02/13) and was suspended again on 07/08/13. The Administrator was required to complete training by an outside agency on Abuse and Neglect and Dispute Resolution and How to Handle Complaints with Care. Termination of the Administrator was recommended and approved at the conclusion of the progressive discipline by the Governing body. All facility staff was re-educated on Reporting Abuse and Neglect and Resident Rights on 07/08/13, 07/09/13, 07/10/13 and had previously received in-services immediately following the incident in question on 04/30/13 and 05/01/13. The training was provided by the DON and a Post Test was used to validate staff's understanding. Future concerns of abuse will be investigated immediately upon learning of the incident. Staff understanding was verified by skills validation on what constitutes abuse and how to report abuse. The RDO/Interim ADM is the Abuse Coordinator and is responsible for investigating allegations of abuse and ensuring the abuse is reported timely. Each Manager will be responsible for conducting investigations within their departments and the Abuse Coordinator, the Interim Administrator, will oversee the investigations are thorough and completed. Department Managers include: the DON, the Dietary Manager (DM), the Social Worker (SW), and the Compliance Officers, the Business Office Manager and ADON A. Phone numbers to the State Agency, Ombudsman, Compliance and Elder Abuse Laws are posted throughout the community. Letters outlining several reporting avenues as mentioned previously were mailed on 05/03/13 to each resident and family member, giving them additional opportunities to voice their concerns and to ensure them the facility and governing body takes all allegations seriously. Resident #1 was initially interviewed on 04/29/13 with follow-up observations of the resident conducted by the DON and SW. Resident #1's legal representative requested no further interviews/conversations to be conducted with Resident #1 regarding the incident. Because of the IJ, a safety interview was conducted with Resident #1 on 07/08/13 by the DON using a questionnaire with six questions regarding the resident's sense of safety. Resident #1 showed no evidence of residual effects from the incident. Resident #1 indicated she was comfortable at the facility and was not planning on relocating to another facility. Resident #1's legal representative was contacted on 07/09/13 at 3:55 PM and repeated her desire for not further interviews/conversations to be conducted with the resident regarding the incident with the ex-Administrator. This interview was conducted by Regional Nurse F. Using a sense of safety questionnaire, the SW interviewed the alert and cognizant residents as identified by their MDS clinical assessments. A total of 101 residents were interviewed. The residents were asked about their sense of safety and the right to report abuse or neglect without fear of reprisal. They were also questioned whether anyone had experienced abuse of any kind and/or mental anguish, intentionally or unintentionally by any of the facility staff. These interviews occurred immediately after the incident on 04/26/13 and again on 07/08/13. The Clinical team assessed other residents, who were not interviewable and observed them for changes in behavior, mood and/or appetite. The Quality Assurance Assessment process will be used to validate ongoing compliance and using the facility's systemic process to identify and investigate abuse. Abuse and Neglect education were provided to facility staff on 04/30/13 and 07/08/13. Sixteen employees still needed to be re-educated on Abuse and Neglect. The DON will continue to contact staff by phone. Any staff who have not been re-educated will received the mandatory training when they return to work. Training on Abuse and Neglect topics was provided on the following dates: 04/11/12 - Neglect and Abuse from the DON 04/30/12 - Resident Rights from the DON 05/01/13 - Resident Discharges, Transfers and Relocations from the SW 06/07/13 - Concept of "Abuse is Abuse" and Customer Service "Reach" from the DON 07/08/13 - Abuse Prohibition and Neglect System with Post Test from the DON 07/09/13 - Abuse and Neglect from the DON 07/09/13 - Abuse and Neglect from the DM 07/09/13 - Abuse and Neglect from the Environmental Supervisor 07/10/13 - Abuse and Neglect from the DON The HR Manager will ensure background checks and drug screens will be conducted for all new hires. The HR Manager also conducts general Orientation, which includes Abuse and Neglect for new hires. The QA Committee will ensure Abuse Prohibition policies/procedures are part of Orientation for new hires and are part of ongoing education for current employees as required periodically and annually. The QA Committee will ensure Notices for reporting abuse/neglect in both English and Spanish are posted throughout the facility and are updated periodically. A posting for the facility's Internal Compliance Line is provided to indicate the commitment to provide a safe and secure environment when concerns are not addressed at the facility level. The postings are the responsibility of the RDO/Interim ADM and will be checked periodically by the QA Team. Abuse Prohibition policies are distributed to all new admissions by the Business Development Specialist and Admission Coordinator. The QA Team includes the following individuals: RDO/Interim ADM/ADM DON Medical Director Business Development Specialist HR Manager ADON A ADON B Medical Records DM Maintenance Activities Environmental Supervisor Case Manager C Case Manager D Regional Support Teams include: Regional Director Regional Nurse E Regional Nurse F Incident/Accident Reports will be reviewed by the DON and/or designee and the RDO/Interim ADM within 24 hours to identify potential Abuse and Neglect triggers. Concern forms and bruises of unknown origin will be reviewed in the daily Start-Up meetings everyday by the DON and the RDO/Interim ADM. All allegations of Abuse/Neglect will be investigated immediately upon hearing of allegations and removal of the immediate threat to protect the resident. All staff will be responsible for taking action to report timely and appropriately to protect the residents. Notification guidelines will be posted at every Nursing Station and throughout the facility for reporting. Staff understands abuse must be reported at all times and all hours. The Designated Compliance Officers: the Business Office Manager and ADON A are responsible for reviewing allegations of abuse and neglect and issues of compliance. The Compliance Officers, the RDO/Interim ADM, Regional Nurse E and the Attorney make up the Compliance Committee as part of the new Compliance Program. The Compliance Committee acts above and beyond the facility to monitor compliance with the Abuse Prohibition policies to ensure fair and consistent application; and meets monthly. Review of the facility's inservices provided to all facility staff revealed the following: On 04/30/13, an inservice was conducted on the Statement of Resident Rights with emphasis on #3 (Be free from abuse and exploitation), #4 (Be treated with courtesy, consideration, and respect), #7 (The residents have the right to complain about the facility and to organize or participate in any program that presents residents' concerns to the administrator of the facility), #15 (Not be relocated within the facility, except in accordance with nursing facility regulations) and #21 (The resident has the right to not be discharged from the facility, except as provided in the nursing facility regulation). There was a discussion and answer session with questions answered. Staff were receptive and indicated their understanding. Forty-three staff signed the sign-in sheets. An inservice on the facility's Abuse and Neglect Prohibition System was conducted with a discussion of the post test and staff verbalizing their understanding. This inservice was held at the following dates and times: 07/08/13 at 7:45 PM - 15 staff attended;

Based on observation, interview and record review, the facility failed to implement their policies and procedures, which prohibit verbal/mental abuse of residents for one (Resident #1) of 18 residents reviewed for abuse, who was not free from mental/verbal abuse. When Resident #2's family member screamed, yelled, cursed and threw the resident's belongings in Resident #1's room, the Administrator failed to get the full story about the incident, and verbally and mentally abused Resident #1 on 04/26/13. Resident #1 cried and experienced mental anguish and fear as recently as 05/31/13. Facility staff, including ADON B and the DON failed to recognize the Administrator's actions on 04/26/13 as abuse. An investigation was not conducted and the incident was not reported to the State Agency until a family member contacted the facility's corporate office with an allegation of abuse on 04/29/13. The Administrator was initially suspended for three days and returned to work on 05/02/13 without any training or re-education of abuse at that time. The Administrator had access to the facility's 108 residents until he was suspended again on 07/08/13. An Immediate Jeopardy (IJ) was identified on 07/08/13. While the IJ was removed on 07/11/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern" because the facility was still in-servicing the staff and the facility was monitoring the implementation of the Plan of Removal. These failures placed he facility's 108 residents at risk for the potential of verbal and/or mental abuse due to the Administrator's continued presence in the facility, which could result in emotional upset, development or worsening of Depression, fear of staff and retaliation, and could have a negative impact on their quality of life. Findings Included: Following administrative review, it was determined SQC had occurred during the survey, more investigation was required and the survey team returned to the facility. Resident #1's Admission Record, dated 05/06/13, reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had adequate heearing, had clear speech, was able to make herself understood and she had the ability to understand others and she did not exhibit any physical, verbal or other behaviors. The MDS assessment further reflected Resident #2 required limited to extensive assistance of one person for her ADLs and used a wheelchair for mobility. Active [DIAGNOSES REDACTED]. Resident #1's Care Plan dated 04/27/13 reflected the resident was upset because on 04/26/13, she received a roommate and allegedly was told to quit running off roommates. The Goal was for Resident #1 to be calm and reassured using the following interventions: Talk with resident, Reassure resident it was not her fault roommate situation did not work out. Contact MD if PRN medication was needed. ADON B was the author of this care plan. During an interview with Resident #1 on 05/31/13 at 10:15 AM, she told the surveyor, approximately one month ago (04/26/13), the Administrator caused her to cry. She explained the incident occurred on 04/26/13 when she received a new roommate. She stated staff brought Resident #2 to the room, which did not have a bed for the resident and just left her there. She said she (Resident #1) requested staff to bring her roommate a bed, because she (Resident #2) was sick. She said her new roommate's family arrived and were upset about the resident's move and began yelling. She said the ADM then arrived and told her (Resident #1) the situation was her fault. She said the ADM telling her Resident #2's moving back to her original room and "running residents off" was her fault and caused her to cry. Resident #1 stated she was still concerned about how the ADM might react if she (Resident #1) brings up another concern. Resident #1 then added the ADM had been "really nice" since the incident, but she still felt "staff would side with him," if she had a problem. The surveyor assessed Resident #1 as being alert and oriented to person, place and time and was a reasonable historian of the events of 04/26/13. The facility's Provider Investigation Report, dated 05/01/13, and signed by the RDO/Interim Administrator reflected an incident occurred on 04/26/13, and an allegation of verbal abuse was made on 04/29/13. Family Member #1A called the facility's corporate office to report verbal abuse involving Resident #1, which occurred on 04/26/13. (Note: No facility staff called in an allegation of abuse.) A Description of the Allegation reflected Family Member #1A stated an incident had occurred when Resident #2 was moved into Resident #1's room, and the family of Resident #2 was upset and "caused a scene." The Administrator was told there was a problem, and when he entered Resident #1's room, he pointed his finger at Resident #1 and told her she was a trouble maker and had "run off every roommate assigned to her room." Resident #1 then began to cry. Family Member #1A and the Administrator left the room and a "heated verbal exchange" was made about the Administrator's "conversation and tone (of voice)" used with Resident #1. The facility's Provider Investigation Report reflected in determining whether Resident #1 had suffered injury or an adverse effect, the following was written: "There was some initial anguish that lingered more than 8 hours... (Note: The incident occurred on 04/26/13 at 6:30 PM. An Investigation Follow-up reflected on Monday, 04/29/13, three days later, Resident #1 was still upset.) The facility's Provider Investigation Report reflected the family (of Resident #1) asked that she (Resident #1) not be asked anymore questions about the incident so she could calm down. She was assessed for (sic) and Social Services will continue to follow her for her sense of safety and she is doing well." The facility's Provider Investigation Report included the facility's response to the incident: "The Administrator was suspended pending investigation (on 04/30/13, four days after the incident and one day after the allegation of abuse was received). The Resident was assessed and monitored for sense of safety and security after the incident... The Community Staff was re-educated by the DON, the Environmental Supervisor and the DM on Abuse and Neglect, Signs and Symptoms of Stress, How to Handle Customer Complaints with Care and Resident Rights as it related to Room relocations, choice and inter-office communication (sic) for changes. (The Administrator's name was not on the sign-in sheet for having attended this training.)... The Administrator will be re-instated with a recommendation to attend Continued Education Courses at his expense for Conflict Resolution and Abuse and Neglect." The facility's Provider Investigation Report indicated in the Investigation Summary "the Administrator did not have all the facts as to what occurred and entered the room speaking with her (Resident #1's) family and the resident. He (the ADM) admits tempers flared and he denies calling her a Trouble Maker and is extremely remorseful that this conversation became heated with (Resident #1's) family and having Resident #1 cry...." The Investigation Summary further indicated the Administrator was in stress due to being on call 24-7. "I (RDO) know this was late in the evening on a Friday (6:30 PM) and he was called back to the building to diffuse the situation. We acknowledge this incident was handled in a unprofessional manner...." The facility's Provider Investigation Report's Investigation findings confirmed the Administrator was abusive to Resident #1. The facility's Provider Investigation Report included the Provider Action Taken Post-Investigation and reflected: "The Administrator will be re-instated on May 2nd, with the stipulation he completes continued education course on Conflict Resolution and Abuse and Neglect." Further review of the facility's Provider Investigation Report revealed there were statements from Family Member #1A and the SW, a Grievance/Complaint Report dated 04/27/13 written by ADON B (incomplete), an Investigation Follow-Up signed by the DON on 04/30/13, which was completed by ADON B and reflected the DON had been informed of the Grievance/Complaint Report regarding Resident #1. There were interviews conducted by the DON dated 04/28/13 with Residents #1 and #2. The interview conducted with Resident #1 on 04/28/13 by the DON, which was included with the facility's Provider Investigation Report, reflected the following: "States Admin told her it was her fault the roommate was upset and had to be moved out. (Resident #1) became tearful and said he (the Administrator) should not talk to anybody like that." This was told to the DON on 04/28/13, but she did not report this incident of abuse to the State Office. Also included with the facility's Provider Investigation Report were Social Service Progress Notes for both Residents #1 and #2. A Grievance/Complaint Report, completed by ADON B on 04/27/13, reflected the following: - Grievance/Complaint: "Resident (#1) told me she was still upset and scared because yesterday a roommate was put in her room without her being told first and then the roommate was moved. The Administrator then told her it was her fault that the other resident was moved out of the room and he scared (Resident #1) and made her cry." - Facility Follow-up: "(Resident #1) did state on 04/27/13 that Administrator did apologize for his remark but she was still upset by the remark." Despite the interview with Resident #1 resulting in ADON B documenting a Grievance/Complaint Report, ADON B did not identify the Abuse, which Resident #1 was subjected to. The Grievance/Complaint Report's Documentation of the Facility Follow-Up had incorrect information documented. The Report was not completed, and there was no resolution of the grievance/complaint. The facility's Investigation Follow-up was signed by ADON B and the DON, but the signatures were not dated. The Investigation Follow-Up included the following: - Description of Situation - A resident moved into Resident #1's room. Resident #1 was upset by the new roommate's family member cursing and throwing clothes on other resident's bed. NOTE: There was no mention made of the ADM coming into Resident #1's room calling her a trouble maker and shaking his finger in her face. - Summary of Investigation - Resident #1 was "still upset on Monday, 04/29/13 (three days after the incident), by her perception of how the Administrator shook his finger in her face and said this was all her fault by complaining of roommate." Resident #1's Social Service Progress Notes, dated 04/28/13, reflected the DON had notified the Social Worker on Friday (04/26/13), Resident #1 received a new roommate and that "there had been issues." There was no information including the ADM's actions of going into Resident #1's room, calling her a trouble maker and shaking his finger in her face causing the resident to cry. Resident #1's family member, Family Member #1A, took the time and effort to write a statement regarding the incident, which occurred, whe the Administrator verbally/mentally abused Resident #1 on 04/26/13. Her statement reflected they (Resident #1's family members) were visiting Resident #1 and met Resident #2, her new roommate, who was a very nice woman and Resident #1 and Resident #2 were getting along "very well." Approximately 5-10 minutes later, Family Member #2A stormed in to the room in a "violoent fashion slamming the doors, hitting the walls, tearing" Resident #2's belongings out of the closet and drawers, piling them on top of Resident #2, who was in bed and kept screaming, "I can't believe they moved you (Resident #2) without telling me." She was screaming and cursing and being very violent. Resident #2 was breathing very heavily nad was getting upset and Resident #2 was also getting upset. I was afraid for our safety. The CNAs came in to the room trying to calm down Family Member #2A, but she continued to yell and scream, calling for the "boss" and kept repeating she was going to call a family member. The CNAs got Resident #2 unburied from all the clothes piled on her and tranferred her to a wheelchair to move her back to her original room. They got everything moved and Family Member #2A calmed down. Another 30 minutes or so went by and Resident #1 was eating her dinner. Resident #1 said she really like Resident #2, but was afraid "they" were going to think it was her fault. (Earlier that day, a resident had been moved into Resident #1's room but was transferred out because she was a smoker. The nurse had insisted it was unacceptable, with Resident #1's [MEDICAL CONDITION], it was not an option.) Family Member #1A and Family Member #1B tried to reassure Resident #2 the problem had nothing to do with her. The Administrator then walked straight into Resident #1's room and rudely pointed at Resident #1 and asked Family Members #1A and #!B if they knew her, to which they both said "Yes." The Administrator then asked if they were family members, and they said "Yes." The Administrator then stepped around the family members and pointed directly at Resident #1 and in a very rude and condescending tone, told Resident #1, "I am tired of you being a troublemaker, and being mean. You keep running people out of this room." Resident #1 immediately broke down in tears and Family Member #1A told him to walk in the hallway, this was over, and they were going to talk alone. Resident #1 had never met the Administrator and did not know who he was, he never introduced himself or identified himself and Resident #1 assumed he was a member of Resident #2's family. Resident #1 was about to call the police when the nurse told Resident #1 he was the Administrator. When Family Member #1A and the Administrator entered the hallway, he had a"very smug attitude" and was innow way trying to reconcile the situation or showing any signs of remorse. When Family Member #1A asked him if he thought his behavior was appropriate, his only response was, "I am a professional" or "oh really what did I say." Family Member #1A told the Administrator there was no excuse for the kind of behavior and he needed to walk back into the resident's room and apologize to Resident #1. Family Member #1A told the Aministrator he should respect Resident #1 as a human being, not to mention also his elder. When the Administrator and Family Member #1A walked back into Resident #1's room, a nurse was trying to calm the resident down. The nurse kept telling Resident #1, "I think it was an ill attempt at a joke." The Administrator walked in, handed her a new tissue and just kept saying, "Stop crying" and "don't be upset." He never tried to reconcile the situation or apologize. Resident #1 continued to cry, sayng no one had ever spoken to her like that. They finally got Resident #1 to stop crying and the nurse in the room went in to the hallway with the Administrator. The family members continued to talk to Resident #1, reassuring her it was not her fault. The nurse, who had been in the room with Resident #1, later spoke with Family Member #1A, telling the family member she really thought it an ill attempt at a joke. Family Member #1A told the nurse it wasn't and that was the end of that conversation. The family members left to get other family members with one of the CNAs saying he would look after her. When they returned to the facility, Resident #1 told her family members the Administrator had returned and tried to apologize. Family Member #1A then wrote, "A line of decency was crossed and no one deserves to be verbally abused that way let along a defenseless [AGE] year old woman with health issues." During an interview with Family Member #1A on 06/06/13 at 8:20 AM, the family member stated he/she was with Resident #1 at the time of the incident on 04/26/13. Family Member #1A said facility staff had moved another resident into Resident #1's room. Family Member #1 said they had been in Resident #1's room for about 15 minutes when Family Member #2A came into the room and started yelling and throwing things around in the room. Family Member #2A was upset because "they" had not told her Resident #2 was being moved. At that time, Resident #1 said she was concerned about the reaction of Family Member #2A and went and got some facility staff. Family Member #1A said Resident #2 was moved back to her other room everything calmed down for about 30 minutes. The Administrator came into the room and asked if Resident #1 and Family Member #1A knew Resident #2. Family Member #1A said the ADM pointed his finger at Resident #1 and said, "She's (Resident #1) a troublemaker, and she can't keep causing problems." Resident #1 then started to cry. He/she stated Resident #1 kept asking the Administrator who he was. The ADM never answered and never introduced himself. He never apologized to Resident #1 and/or Family Member #1A. He/she stated he/she felt concerned leaving Resident #1 there. He/she said if the ADM acted that way in front of other people, how would he act when no one was there. Resident #1's family member said Resident #1 was also upset, because she was blamed for the situation, which occurred. During an interview with the Administrator on 05/31/13 at 9:45 AM, he stated staff moved a resident into Resident #1's room. He stated Resident #1 always had a reason why the roommates did not work for her. He stated he spoke with Resident #1 first, but could not remember the exact conversation. He said he was a little frustrated with multiple residents moving in and out of Resident #1's room. He denied pointing his finger in Resident #1's face. He said Resident #1 was upset. After things calmed down, he went back to Resident #1's room and apologized to her, and she seemed fine. He did not think he raised his voice at the resident, but spoke in a "matter of fact" tone (of voice). He stated he also dealt with Family Member #2A, who was upset about Resident #2's move. No evidence was provided by the Administrator regarding the Administrator's attendance at continuing education classes involving Conflict Resolution and Abuse and Neglect. A "stickie note" reflected cost information for the course entitled, "Dealing With People You Can't Stand." It was an on-line computer training course for behaviors for the Administrator. Nothing else was provided in regard to the Administrator's training. During an in interview with the ADON B, on 06/20/13 at 11:30 AM, she confirmed she was present the Friday evening the incident occurred with Resident #1 and the Administrator. She stated one of the CNAs came to her and told her there was a problem with two residents. The family member of Resident #2 (Family Member #2A) was out of control, yelling and throwing things, threatening to move Resident #2 if they didn't take care of the problem. The CNA said Family Member #2A started to cry. Family Member #2A then went and got the orderly to come and move Resident #2 back to her old room. ADON B said she spoke with Family Member #2A, who told her (ADON B) Resident #2 was supposed to have a private room through the weekend. ADON B said the SW was supposed to notify the family on the day of the room move. ADON B stated she called the Administrator to come to the facility. When asked about the incident, which occurred between Resident #1 and the ADM, ADON B indicated she did not witness what was said by the Administrator to Resident #1 because she was busy moving Resident #2 back to her room. ADON B told the surveyor the Administrator had a history of [REDACTED]." During an interview with the RDO/Interim ADM, on 06/20/13 at 1:05 PM, she confirmed an individual had contacted and made her aware of the incident, which took place at the facility and involved the Administrator and Resident #1. She stated she had suspended the Administrator on 04/30/13 as soon as she became aware of what had occurred on 04/26/13. The RDO/Interim ADM stated she initiated an investigation on 04/29/13. She stated there were quite a few failures involved in the incident. The Administrator failed to get the facts before he entered the building or before going to Resident #1's room. She said the Administrator did admit to telling Resident #1 she was "running people off," and Family Member #1A was upset. The Administrator also admitted he "barged" into the building without being informed of the incident and the actual events of the situation. The Administrator should have listened to all the facts before he entered Resident #1's room. The Administrator's choice of words were not the best. The RDO/Interim ADM stated it was a bad situation all the way around and was fueled by other residents. RDO/Interim ADM stated corporate had concerns about the Administrator being aggressive with residents/staff and were considering termination amd had been in the process of gathering evidence. She stated the Ombudsman also got involved in an effort to assist the facility in resolution of what occurred with the families. The RDO/Interim ADM added she was concerned Family Member #2A was throwing things around in Resident #1's room and Family Member #2A could have harmed someone. The RDO/Interim ADM further stated "someone" moved Resident #2 without following the facility's Policy and Procedures for a room move, and adequate notice was not given. The RDO/Interim ADM stated in a room move, the SW was supposed to initiate contact when a change in room assignments or roommates was about to occur. Then Nursing staff was to follow-up with the family to ensure the family knew about the upcoming room change and/or roommates. This did not occur. If the room change had been done the way it was supposed to, the whole incident would never have occurred. The RDO/Interim ADM stated it was a system failure by not following the facility's policy and procedures for a room change. The RDO/Interim ADM stated she spoke to Family Member #1B, who requested the Administrator not be allowed in Resident #1's room, and the corporate office agreed to the stipulation. The facility's current Abuse Prohibition Policy and Procedures with the most recent review and revision dates being July 2012, reflected the following: Policy Residents have the right to be free from abuse... The following procedures will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designees. Local law enforcement, the state survey agency... will be notified in accordance with federal and state law. Procedure ...III. Prevention of Abuse: ...B. The Administrator or designee will be responsible to provide feedback regarding concerns expressed by the resident, families... C. A committee selected and chaired by the Administrator or designated representative will function under the Quality Assurance and Assessment committee and meet, as needed, to: Identify, correct and intervene in situations in which abuse, neglect... is more likely to occur... D. The facilities (sic) interdisciplinary team in conjunction with the facilities (sic) administrative team will: ...And will re-assess interventions at a minimum during quarterly care planning conferences and/or as needed; based on the individuals (sic) response to interventions. ...VI. Protection: In order to provide protection to the resident during an investigation the following will be done: A. The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation. B. The Administrator or designee will be assigned throughout the investigation to follow-up with the person or persons involved with the concern, incident or grievance... VII. Reporting and Response to Alleged Incidents: ...B. All alleged violations involving mistreatment, neglect, or abuse... shall be reported immediately to the Administrator or the DON. NOTE: If the alleged abuse/neglect involves the Administrator, report the incident immediately to the Regional Vice President or Regional Nurse Consultant...." ATTACHMENT A DEFINITIONS Abuse* - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes verbal./.. mental/psychological... including ...any other actions within this definition. ...(B) 'Mental/psychological abuse'* - Mistreatment within the definition of 'abuse' not resulting in physical harm, including, but not limited to, humiliation, harassment... or intimidation. ...(E) 'Verbal abuse'* - the use of any oral... or gestured language that includes disparaging or derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. ...Mistreatment - Any malicious and/or deliberate demonstration of disrespect toward a resident. ...Any degrading body language or verbal communication. ...upsetting a resident unnecessarily.... *From Nursing Facility Requirements for Licensure & Medicals Certification 19.101 TDHS. ...ATTACHMENT D FACILITY INVESTIGATION PROCEDURES The purpose of this investigation is to address all types of abuse (verbal, physical, mental)... 1. THE RESIDENT: ...b. If the resident is able, conduct an interview about the incident...Some key questions to ask are: 1. What happened? 2. When did the incident occur? 3. Were any other present when the incident occurred? 4. Has the resident had any previous problems? c. ...If the resident cannot physically write a statement, prepare the statement and have the resident review, sign and date the statement... 2. THE ACCUSED EMPLOYEE(S): a. Thoroughly interview the employee(s) concerning the incident 1. What happened? 2. When did the incident happen? 3. Who was present when the incident happened? 4. Has this employee(s) had any previous problems with this resident? b. The suspected employee should be immediately placed o a leave of absence with pay pending the outcome of the investigation. ...d. Ask the suspected employee to prepare and sign a statement. 3. WITNESSES TO THE INCIDENT: a. Interview each witness... b. Each witness should prepare and sign a statement. ...5. CRITICAL INVESTIGATION APPROACHES: a. Begin investigation immediately upon notification that an incident has occurred. b. Review all statements for any needed clarification or expansion. c. Immediately follow up on all information gathered during the investigation. c. Notify the appropriate agencies, family members, physicians... in a timely fashion... Attachment H FREEDOM FROM ABUSE NOTICE TO EMPLOYEES RESIDENT/PATIENT ABUSE, NEGLECT AND MIStreatment of [REDACTED]. Any person who observes or becomes aware of an incident of resident/patient abuse, neglect or mistreatment of [REDACTED]. Among the rights specified in the federal and state laws, each resident... has a right to a dignified existence and to be free from verbal, ...mental abuse...." On 07/08/13, an Immediate Jeopardy was identified. At 5:49 PM on 07/08/13, the DON was informed an Immediate Jeopardy (IJ) had been identified. At 5:53 PM, the Administrator joined the meeting and he was notified of the IJ. A request was made for a Plan of Removal for the IJ. The facility's Plan of Removal dated 07/08/13 was accepted on 07/10/13. The plan included the following: The Administrator was suspended pending investigation on 04/30/13 (returned to work on 05/02/13) and was suspended again on 07/08/13. The Administrator was required to complete training by an outside agency on Abuse and Neglect and Dispute Resolution and How to Handle Complaints with Care. Termination of the Administrator was recommended and approved at the conclusion of the progressive discipline by the Governing body. All facility staff was re-educated on Reporting Abuse and Neglect and Resident Rights on 07/08/13, 07/09/13, 07/10/13 and had previously received in-services immediately following the incident in question on 04/30/13 and 05/01/13. The training was provided by the DON and a Post Test was used to validate staff's understanding. Future concerns of abuse will be investigated immediately upon learning of the incident. Staff understanding was verified by skills validation on what constitutes abuse and how to report abuse. The RDO/Interim ADM is the Abuse Coordinator and is responsible for investigating allegations of abuse and ensuring the abuse is reported timely. Each Manager will be responsible for conducting investigations within their departments and the Abuse Coordinator, the Interim Administrator, will oversee the investigations are thorough and completed. Department Managers include: the DON, the Dietary Manager (DM), the Social Worker (SW), and the Compliance Officers, the Business Office Manager and ADON A. Phone numbers to the State Agency, Ombudsman, Compliance and Elder Abuse Laws are posted throughout the community. Letters outlining several reporting avenues as mentioned previously were mailed on 05/03/13 to each resident and family member, giving them additional opportunities to voice their concerns and to ensure them the facility and governing body takes all allegations seriously. Resident #1 was initially interviewed on 04/29/13 with follow-up observations of the resident conducted by the DON and SW. Resident #1's legal representative requested no further interviews/conversations to be conducted with Resident #1 regarding the incident. Because of the IJ, a safety interview was conducted with Resident #1 on 07/08/13 by the DON using a questionnaire with six questions regarding the resident's sense of safety. Resident #1 showed no evidence of residual effects from the incident. Resident #1 indicated she was comfortable at the facility and was not planning on relocating to another facility. Resident #1's legal representative was contacted on 07/09/13 at 3:55 PM and repeated her desire for not further interviews/conversations to be conducted with the resident regarding the incident with the ex-Administrator. This interview was conducted by Regional Nurse F. Using a sense of safety questionnaire, the SW interviewed the alert and cognizant residents as identified by their MDS clinical assessments. A total of 101 residents were interviewed. The residents were asked about their sense of safety and the right to report abuse or neglect without fear of reprisal. They were also questioned whether anyone had experienced abuse of any kind and/or mental anguish, intentionally or unintentionally by any of the facility staff. These interviews occurred immediately after the incident on 04/26/13 and again on 07/08/13. The Clinical team assessed other residents, who were not interviewable and observed them for changes in behavior, mood and/or appetite. The Quality Assurance Assessment process will be used to validate ongoing compliance and using the facility's systemic process to identify and investigate abuse. Abuse and Neglect education were provided to facility staff on 04/30/13 and 07/08/13. Sixteen employees still needed to be re-educated on Abuse and Neglect. The DON will continue to contact staff by phone. Any staff who have not been re-educated will received the mandatory training when they return

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect or abuse were reported immediately to other officials in acccordance with State law through established procedures including the State survey and certification agency, there was evidence all alleged violations were thoroughly investigated, and when the alleged violation was verified, appropriate corrective action was taken. The Administrator verbally and mentally abused Resident #1 on 04/26/13. Resident #1 cried and experienced mental anguish and fear as recently as 05/31/13. Facility staff, including ADON B and the DON failed to recognize the Administrator's actions on 04/26/13 as abuse and failed to report the abuse. The incident was not reported to the State Agency and an investigation was not conducted until a family member contacted the facility's corporate office with an allegation of abuse on 04/29/13. The investigation did not include an interview with the Administrator, the alleged perpetrator. The Administrator was initially suspended for three days and returned to work on 05/02/13 without any training or re-education of abuse at that time. The Administrator had access to the facility's 108 residents until he was suspended again on 07/08/13. An Immediate Jeopardy (IJ) was identified on 07/08/13. While the IJ was removed on 07/11/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern" because the facility was still in-servicing the staff and the facility was monitoring the implementation of the Plan of Removal. These failures placed he facility's 108 residents at risk for the potential of verbal and/or mental abuse due to the Administrator's continued presence in the facility, which could result in emotional upset, development or worsening of Depression, fear of staff and retaliation, and could have a negative impact on their quality of life. Findings Included: Following administrative review, it was determined SQC had occurred during the survey, more investigation was required and the survey team returned to the facility. Resident #1's Admission Record, dated 05/06/13, reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had adequate heearing, had clear speech, was able to make herself understood and she had the ability to understand others and she did not exhibit any physical, verbal or other behaviors. The MDS assessment further reflected Resident #2 required limited to extensive assistance of one person for her ADLs and used a wheelchair for mobility. Active [DIAGNOSES REDACTED]. Resident #1's Care Plan dated 04/27/13 reflected the resident was upset because on 04/26/13, she received a roommate and allegedly was told to quit running off roommates. The Goal was for Resident #1 to be calm and reassured using the following interventions: Talk with resident, Reassure resident it was not her fault roommate situation did not work out. Contact MD if PRN medication was needed. ADON B was the author of this care plan. During an interview with Resident #1 on 05/31/13 at 10:15 AM, she told the surveyor, approximately one month ago (04/26/13), the Administrator caused her to cry. She explained the incident occurred on 04/26/13 when she received a new roommate. She stated staff brought Resident #2 to the room, which did not have a bed for the resident and just left her there. She said she (Resident #1) requested staff to bring her roommate a bed, because she (Resident #2) was sick. She said her new roommate's family arrived and were upset about the resident's move and began yelling. She said the ADM then arrived and told her (Resident #1) the situation was her fault. She said the ADM telling her Resident #2's moving back to her original room and "running residents off" was her fault and caused her to cry. Resident #1 stated she was still concerned about how the ADM might react if she (Resident #1) brings up another concern. Resident #1 then added the ADM had been "really nice" since the incident, but she still felt "staff would side with him," if she had a problem. The surveyor assessed Resident #1 as being alert and oriented to person, place and time and was a reasonable historian of the events of 04/26/13. The facility's Provider Investigation Report, dated 05/01/13, and signed by the RDO/Interim Administrator reflected an incident occurred on 04/26/13, and an allegation of verbal abuse was made on 04/29/13. Family Member #1A called the facility's corporate office to report verbal abuse involving Resident #1, which occurred on 04/26/13. (Note: No facility staff called in an allegation of abuse.) A Description of the Allegation reflected Family Member #1A stated an incident had occurred when Resident #2 was moved into Resident #1's room, and the family of Resident #2 was upset and "caused a scene." The Administrator was told there was a problem, and when he entered Resident #1's room, he pointed his finger at Resident #1 and told her she was a trouble maker and had "run off every roommate assigned to her room." Resident #1 then began to cry. Family Member #1A and the Administrator left the room and a "heated verbal exchange" was made about the Administrator's "conversation and tone (of voice)" used with Resident #1. The facility's Provider Investigation Report reflected in determining whether Resident #1 had suffered injury or an adverse effect, the following was written: "There was some initial anguish that lingered more than 8 hours... (Note: The incident occurred on 04/26/13 at 6:30 PM. An Investigation Follow-up reflected on Monday, 04/29/13, three days later, Resident #1 was still upset.) The facility's Provider Investigation Report reflected the family (of Resident #1) asked that she (Resident #1) not be asked anymore questions about the incident so she could calm down. She was assessed for (sic) and Social Services will continue to follow her for her sense of safety and she is doing well." The facility's Provider Investigation Report included the facility's response to the incident: "The Administrator was suspended pending investigation (on 04/30/13, four days after the incident and one day after the allegation of abuse was received). The Resident was assessed and monitored for sense of safety and security after the incident... The Community Staff was re-educated by the DON, the Environmental Supervisor and the DM on Abuse and Neglect, Signs and Symptoms of Stress, How to Handle Customer Complaints with Care and Resident Rights as it related to Room relocations, choice and inter-office communication (sic) for changes. (The Administrator's name was not on the sign-in sheet for having attended this training.)... The Administrator will be re-instated with a recommendation to attend Continued Education Courses at his expense for Conflict Resolution and Abuse and Neglect." The facility's Provider Investigation Report indicated in the Investigation Summary "the Administrator did not have all the facts as to what occurred and entered the room speaking with her (Resident #1's) family and the resident. He (the ADM) admits tempers flared and he denies calling her a Trouble Maker and is extremely remorseful that this conversation became heated with (Resident #1's) family and having Resident #1 cry...." The Investigation Summary further indicated the Administrator was in stress due to being on call 24-7. "I (RDO) know this was late in the evening on a Friday (6:30 PM) and he was called back to the building to diffuse the situation. We acknowledge this incident was handled in a unprofessional manner...." The facility's Provider Investigation Report's Investigation findings confirmed the Administrator was abusive to Resident #1. The facility's Provider Investigation Report included the Provider Action Taken Post-Investigation and reflected: "The Administrator will be re-instated on May 2nd, with the stipulation he completes continued education course on Conflict Resolution and Abuse and Neglect." Further review of the facility's Provider Investigation Report revealed there were statements from Family Member #1A and the SW, a Grievance/Complaint Report dated 04/27/13 written by ADON B (incomplete), an Investigation Follow-Up signed by the DON on 04/30/13, which was completed by ADON B and reflected the DON had been informed of the Grievance/Complaint Report regarding Resident #1. There were interviews conducted by the DON dated 04/28/13 with Residents #1 and #2. The interview conducted with Resident #1 on 04/28/13 by the DON, which was included with the facility's Provider Investigation Report, reflected the following: "States Admin told her it was her fault the roommate was upset and had to be moved out. (Resident #1) became tearful and said he (the Administrator) should not talk to anybody like that." This was told to the DON on 04/28/13, but she did not report this incident of abuse to the State Office. Also included with the facility's Provider Investigation Report were Social Service Progress Notes for both Residents #1 and #2. A Grievance/Complaint Report, completed by ADON B on 04/27/13, reflected the following: - Grievance/Complaint: "Resident (#1) told me she was still upset and scared because yesterday a roommate was put in her room without her being told first and then the roommate was moved. The Administrator then told her it was her fault that the other resident was moved out of the room and he scared (Resident #1) and made her cry." - Facility Follow-up: "(Resident #1) did state on 04/27/13 that Administrator did apologize for his remark but she was still upset by the remark." Despite the interview with Resident #1 resulting in ADON B documenting a Grievance/Complaint Report, ADON B did not identify the Abuse, which Resident #1 was subjected to. The Grievance/Complaint Report's Documentation of the Facility Follow-Up had incorrect information documented. The Report was not completed, and there was no resolution of the grievance/complaint. The facility's Investigation Follow-up was signed by ADON B and the DON, but the signatures were not dated. The Investigation Follow-Up included the following: - Description of Situation - A resident moved into Resident #1's room. Resident #1 was upset by the new roommate's family member cursing and throwing clothes on other resident's bed. NOTE: There was no mention made of the ADM coming into Resident #1's room calling her a trouble maker and shaking his finger in her face. - Summary of Investigation - Resident #1 was "still upset on Monday, 04/29/13 (three days after the incident), by her perception of how the Administrator shook his finger in her face and said this was all her fault by complaining of roommate." Resident #1's Social Service Progress Notes, dated 04/28/13, reflected the DON had notified the Social Worker on Friday (04/26/13), Resident #1 received a new roommate and that "there had been issues." There was no information including the ADM's actions of going into Resident #1's room, calling her a trouble maker and shaking his finger in her face causing the resident to cry. Resident #1's family member, Family Member #1A, took the time and effort to write a statement regarding the incident, which occurred, whe the Administrator verbally/mentally abused Resident #1 on 04/26/13. Her statement reflected they (Resident #1's family members) were visiting Resident #1 and met Resident #2, her new roommate, who was a very nice woman and Resident #1 and Resident #2 were getting along "very well." Approximately 5-10 minutes later, Family Member #2A stormed in to the room in a "violoent fashion slamming the doors, hitting the walls, tearing" Resident #2's belongings out of the closet and drawers, piling them on top of Resident #2, who was in bed and kept screaming, "I can't believe they moved you (Resident #2) without telling me." She was screaming and cursing and being very violent. Resident #2 was breathing very heavily nad was getting upset and Resident #2 was also getting upset. I was afraid for our safety. The CNAs came in to the room trying to calm down Family Member #2A, but she continued to yell and scream, calling for the "boss" and kept repeating she was going to call a family member. The CNAs got Resident #2 unburied from all the clothes piled on her and tranferred her to a wheelchair to move her back to her original room. They got everything moved and Family Member #2A calmed down. Another 30 minutes or so went by and Resident #1 was eating her dinner. Resident #1 said she really like Resident #2, but was afraid "they" were going to think it was her fault. (Earlier that day, a resident had been moved into Resident #1's room but was transferred out because she was a smoker. The nurse had insisted it was unacceptable, with Resident #1's [MEDICAL CONDITION], it was not an option.) Family Member #1A and Family Member #1B tried to reassure Resident #2 the problem had nothing to do with her. The Administrator then walked straight into Resident #1's room and rudely pointed at Resident #1 and asked Family Members #1A and #!B if they knew her, to which they both said "Yes." The Administrator then asked if they were family members, and they said "Yes." The Administrator then stepped around the family members and pointed directly at Resident #1 and in a very rude and condescending tone, told Resident #1, "I am tired of you being a troublemaker, and being mean. You keep running people out of this room." Resident #1 immediately broke down in tears and Family Member #1A told him to walk in the hallway, this was over, and they were going to talk alone. Resident #1 had never met the Administrator and did not know who he was, he never introduced himself or identified himself and Resident #1 assumed he was a member of Resident #2's family. Resident #1 was about to call the police when the nurse told Resident #1 he was the Administrator. When Family Member #1A and the Administrator entered the hallway, he had a"very smug attitude" and was innow way trying to reconcile the situation or showing any signs of remorse. When Family Member #1A asked him if he thought his behavior was appropriate, his only response was, "I am a professional" or "oh really what did I say." Family Member #1A told the Administrator there was no excuse for the kind of behavior and he needed to walk back into the resident's room and apologize to Resident #1. Family Member #1A told the Aministrator he should respect Resident #1 as a human being, not to mention also his elder. When the Administrator and Family Member #1A walked back into Resident #1's room, a nurse was trying to calm the resident down. The nurse kept telling Resident #1, "I think it was an ill attempt at a joke." The Administrator walked in, handed her a new tissue and just kept saying, "Stop crying" and "don't be upset." He never tried to reconcile the situation or apologize. Resident #1 continued to cry, sayng no one had ever spoken to her like that. They finally got Resident #1 to stop crying and the nurse in the room went in to the hallway with the Administrator. The family members continued to talk to Resident #1, reassuring her it was not her fault. The nurse, who had been in the room with Resident #1, later spoke with Family Member #1A, telling the family member she really thought it an ill attempt at a joke. Family Member #1A told the nurse it wasn't and that was the end of that conversation. The family members left to get other family members with one of the CNAs saying he would look after her. When they returned to the facility, Resident #1 told her family members the Administrator had returned and tried to apologize. Family Member #1A then wrote, "A line of decency was crossed and no one deserves to be verbally abused that way let along a defenseless [AGE] year old woman with health issues." During an interview with Family Member #1A on 06/06/13 at 8:20 AM, the family member stated he/she was with Resident #1 at the time of the incident on 04/26/13. Family Member #1A said facility staff had moved another resident into Resident #1's room. Family Member #1 said they had been in Resident #1's room for about 15 minutes when Family Member #2A came into the room and started yelling and throwing things around in the room. Family Member #2A was upset because "they" had not told her Resident #2 was being moved. At that time, Resident #1 said she was concerned about the reaction of Family Member #2A and went and got some facility staff. Family Member #1A said Resident #2 was moved back to her other room everything calmed down for about 30 minutes. The Administrator came into the room and asked if Resident #1 and Family Member #1A knew Resident #2. Family Member #1A said the ADM pointed his finger at Resident #1 and said, "She's (Resident #1) a troublemaker, and she can't keep causing problems." Resident #1 then started to cry. He/she stated Resident #1 kept asking the Administrator who he was. The ADM never answered and never introduced himself. He never apologized to Resident #1 and/or Family Member #1A. He/she stated he/she felt concerned leaving Resident #1 there. He/she said if the ADM acted that way in front of other people, how would he act when no one was there. Resident #1's family member said Resident #1 was also upset, because she was blamed for the situation, which occurred. During an interview with the Administrator on 05/31/13 at 9:45 AM, he stated staff moved a resident into Resident #1's room. He stated Resident #1 always had a reason why the roommates did not work for her. He stated he spoke with Resident #1 first, but could not remember the exact conversation. He said he was a little frustrated with multiple residents moving in and out of Resident #1's room. He denied pointing his finger in Resident #1's face. He said Resident #1 was upset. After things calmed down, he went back to Resident #1's room and apologized to her, and she seemed fine. He did not think he raised his voice at the resident, but spoke in a "matter of fact" tone (of voice). He stated he also dealt with Family Member #2A, who was upset about Resident #2's move. No evidence was provided by the Administrator regarding the Administrator's attendance at continuing education classes involving Conflict Resolution and Abuse and Neglect. A "stickie note" reflected cost information for the course entitled, "Dealing With People You Can't Stand." It was an on-line computer training course for behaviors for the Administrator. Nothing else was provided in regard to the Administrator's training. During an in interview with the ADON B, on 06/20/13 at 11:30 AM, she confirmed she was present the Friday evening the incident occurred with Resident #1 and the Administrator. She stated one of the CNAs came to her and told her there was a problem with two residents. The family member of Resident #2 (Family Member #2A) was out of control, yelling and throwing things, threatening to move Resident #2 if they didn't take care of the problem. The CNA said Family Member #2A started to cry. Family Member #2A then went and got the orderly to come and move Resident #2 back to her old room. ADON B said she spoke with Family Member #2A, who told her (ADON B) Resident #2 was supposed to have a private room through the weekend. ADON B said the SW was supposed to notify the family on the day of the room move. ADON B stated she called the Administrator to come to the facility. When asked about the incident, which occurred between Resident #1 and the ADM, ADON B indicated she did not witness what was said by the Administrator to Resident #1 because she was busy moving Resident #2 back to her room. ADON B told the surveyor the Administrator had a history of [REDACTED]." During an interview with the RDO/Interim ADM, on 06/20/13 at 1:05 PM, she confirmed an individual had contacted and made her aware of the incident, which took place at the facility and involved the Administrator and Resident #1. She stated she had suspended the Administrator on 04/30/13 as soon as she became aware of what had occurred on 04/26/13. The RDO/Interim ADM stated she initiated an investigation on 04/29/13. She stated there were quite a few failures involved in the incident. The Administrator failed to get the facts before he entered the building or before going to Resident #1's room. She said the Administrator did admit to telling Resident #1 she was "running people off," and Family Member #1A was upset. The Administrator also admitted he "barged" into the building without being informed of the incident and the actual events of the situation. The Administrator should have listened to all the facts before he entered Resident #1's room. The Administrator's choice of words were not the best. The RDO/Interim ADM stated it was a bad situation all the way around and was fueled by other residents. RDO/Interim ADM stated corporate had concerns about the Administrator being aggressive with residents/staff and were considering termination amd had been in the process of gathering evidence. She stated the Ombudsman also got involved in an effort to assist the facility in resolution of what occurred with the families. The RDO/Interim ADM added she was concerned Family Member #2A was throwing things around in Resident #1's room and Family Member #2A could have harmed someone. The RDO/Interim ADM further stated "someone" moved Resident #2 without following the facility's Policy and Procedures for a room move, and adequate notice was not given. The RDO/Interim ADM stated in a room move, the SW was supposed to initiate contact when a change in room assignments or roommates was about to occur. Then Nursing staff was to follow-up with the family to ensure the family knew about the upcoming room change and/or roommates. This did not occur. If the room change had been done the way it was supposed to, the whole incident would never have occurred. The RDO/Interim ADM stated it was a system failure by not following the facility's policy and procedures for a room change. The RDO/Interim ADM stated she spoke to Family Member #1B, who requested the Administrator not be allowed in Resident #1's room, and the corporate office agreed to the stipulation. The facility's current Abuse Prohibition Policy and Procedures with the most recent review and revision dates being July 2012, reflected the following: Policy Residents have the right to be free from abuse... The following procedures will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designees. Local law enforcement, the state survey agency... will be notified in accordance with federal and state law. Procedure ...III. Prevention of Abuse: ...B. The Administrator or designee will be responsible to provide feedback regarding concerns expressed by the resident, families... C. A committee selected and chaired by the Administrator or designated representative will function under the Quality Assurance and Assessment committee and meet, as needed, to: Identify, correct and intervene in situations in which abuse, neglect... is more likely to occur... D. The facilities (sic) interdisciplinary team in conjunction with the facilities (sic) administrative team will: ...And will re-assess interventions at a minimum during quarterly care planning conferences and/or as needed; based on the individuals (sic) response to interventions. ...VI. Protection: In order to provide protection to the resident during an investigation the following will be done: A. The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation. B. The Administrator or designee will be assigned throughout the investigation to follow-up with the person or persons involved with the concern, incident or grievance... VII. Reporting and Response to Alleged Incidents: ...B. All alleged violations involving mistreatment, neglect, or abuse... shall be reported immediately to the Administrator or the DON. NOTE: If the alleged abuse/neglect involves the Administrator, report the incident immediately to the Regional Vice President or Regional Nurse Consultant...." ATTACHMENT A DEFINITIONS Abuse* - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes verbal./.. mental/psychological... including ...any other actions within this definition. ...(B) 'Mental/psychological abuse'* - Mistreatment within the definition of 'abuse' not resulting in physical harm, including, but not limited to, humiliation, harassment... or intimidation. ...(E) 'Verbal abuse'* - the use of any oral... or gestured language that includes disparaging or derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. ...Mistreatment - Any malicious and/or deliberate demonstration of disrespect toward a resident. ...Any degrading body language or verbal communication. ...upsetting a resident unnecessarily.... *From Nursing Facility Requirements for Licensure & Medicals Certification 19.101 TDHS. ...ATTACHMENT D FACILITY INVESTIGATION PROCEDURES The purpose of this investigation is to address all types of abuse (verbal, physical, mental)... 1. THE RESIDENT: ...b. If the resident is able, conduct an interview about the incident...Some key questions to ask are: 1. What happened? 2. When did the incident occur? 3. Were any other present when the incident occurred? 4. Has the resident had any previous problems? c. ...If the resident cannot physically write a statement, prepare the statement and have the resident review, sign and date the statement... 2. THE ACCUSED EMPLOYEE(S): a. Thoroughly interview the employee(s) concerning the incident 1. What happened? 2. When did the incident happen? 3. Who was present when the incident happened? 4. Has this employee(s) had any previous problems with this resident? b. The suspected employee should be immediately placed o a leave of absence with pay pending the outcome of the investigation. ...d. Ask the suspected employee to prepare and sign a statement. 3. WITNESSES TO THE INCIDENT: a. Interview each witness... b. Each witness should prepare and sign a statement. ...5. CRITICAL INVESTIGATION APPROACHES: a. Begin investigation immediately upon notification that an incident has occurred. b. Review all statements for any needed clarification or expansion. c. Immediately follow up on all information gathered during the investigation. c. Notify the appropriate agencies, family members, physicians... in a timely fashion... Attachment H FREEDOM FROM ABUSE NOTICE TO EMPLOYEES RESIDENT/PATIENT ABUSE, NEGLECT AND MIStreatment of [REDACTED]. Any person who observes or becomes aware of an incident of resident/patient abuse, neglect or mistreatment of [REDACTED]. Among the rights specified in the federal and state laws, each resident... has a right to a dignified existence and to be free from verbal, ...mental abuse...." On 07/08/13, an Immediate Jeopardy was identified. At 5:49 PM on 07/08/13, the DON was informed an Immediate Jeopardy (IJ) had been identified. At 5:53 PM, the Administrator joined the meeting and he was notified of the IJ. A request was made for a Plan of Removal for the IJ. The facility's Plan of Removal dated 07/08/13 was accepted on 07/10/13. The plan included the following: The Administrator was suspended pending investigation on 04/30/13 (returned to work on 05/02/13) and was suspended again on 07/08/13. The Administrator was required to complete training by an outside agency on Abuse and Neglect and Dispute Resolution and How to Handle Complaints with Care. Termination of the Administrator was recommended and approved at the conclusion of the progressive discipline by the Governing body. All facility staff was re-educated on Reporting Abuse and Neglect and Resident Rights on 07/08/13, 07/09/13, 07/10/13 and had previously received in-services immediately following the incident in question on 04/30/13 and 05/01/13. The training was provided by the DON and a Post Test was used to validate staff's understanding. Future concerns of abuse will be investigated immediately upon learning of the incident. Staff understanding was verified by skills validation on what constitutes abuse and how to report abuse. The RDO/Interim ADM is the Abuse Coordinator and is responsible for investigating allegations of abuse and ensuring the abuse is reported timely. Each Manager will be responsible for conducting investigations within their departments and the Abuse Coordinator, the Interim Administrator, will oversee the investigations are thorough and completed. Department Managers include: the DON, the Dietary Manager (DM), the Social Worker (SW), and the Compliance Officers, the Business Office Manager and ADON A. Phone numbers to the State Agency, Ombudsman, Compliance and Elder Abuse Laws are posted throughout the community. Letters outlining several reporting avenues as mentioned previously were mailed on 05/03/13 to each resident and family member, giving them additional opportunities to voice their concerns and to ensure them the facility and governing body takes all allegations seriously. Resident #1 was initially interviewed on 04/29/13 with follow-up observations of the resident conducted by the DON and SW. Resident #1's legal representative requested no further interviews/conversations to be conducted with Resident #1 regarding the incident. Because of the IJ, a safety interview was conducted with Resident #1 on 07/08/13 by the DON using a questionnaire with six questions regarding the resident's sense of safety. Resident #1 showed no evidence of residual effects from the incident. Resident #1 indicated she was comfortable at the facility and was not planning on relocating to another facility. Resident #1's legal representative was contacted on 07/09/13 at 3:55 PM and repeated her desire for not further interviews/conversations to be conducted with the resident regarding the incident with the ex-Administrator. This interview was conducted by Regional Nurse F. Using a sense of safety questionnaire, the SW interviewed the alert and cognizant residents as identified by their MDS clinical assessments. A total of 101 residents were interviewed. The residents were asked about their sense of safety and the right to report abuse or neglect without fear of reprisal. They were also questioned whether anyone had experienced abuse of any kind and/or mental anguish, intentionally or unintentionally by any of the facility staff. These interviews occurred immediately after the incident on 04/26/13 and again on 07/08/13. The Clinical team assessed other residents, who were not interviewable and observed them for changes in behavior, mood and/or appetite. The Quality Assurance Assessment process will be used to validate ongoing compliance and using the facility's systemic process to identify and investigate abuse. Abuse and Neglect education were provided to facility staff on 04/30/13 and 07/08/13. Sixteen employees still needed to be re-educated on Abuse a

Based on observation, interview and record review, the facility failed to implement their written policies and procedures, which prohibit verbal/mental abuse of residents for one (Resident #1) of 18 residents reviewed for abuse, who was verbally/mentally abused. When Resident #2's family member screamed, yelled, cursed and threw the resident's belongings in Resident #1's room, the Administrator failed to get the full story about the incident, and verbally and mentally abused Resident #1 on 04/26/13. Resident #1 cried and experienced mental anguish and fear as recently as 05/31/13. Facility staff, including ADON B and the DON failed to recognize the Administrator's actions on 04/26/13 as abuse. An investigation was not conducted and the incident was not reported to the State Agency until a family member contacted the facility's corporate office with an allegation of abuse on 04/29/13. The Administrator was initially suspended for three days and returned to work on 05/02/13 without any training or re-education of abuse at that time. The Administrator had access to the facility's 108 residents until he was suspended again on 07/08/13. An Immediate Jeopardy (IJ) was identified on 07/08/13. While the IJ was removed on 07/11/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern" because the facility was still in-servicing the staff and the facility was monitoring the implementation of the Plan of Removal. These failures placed he facility's 108 residents at risk for the potential of verbal and/or mental abuse due to the Administrator's continued presence in the facility, which could result in emotional upset, development or worsening of Depression, fear of staff and retaliation, and could have a negative impact on their quality of life. Findings Included: Following administrative review, it was determined SQC had occurred during the survey, more investigation was required and the survey team returned to the facility. The facility's current Abuse Prohibition Policy and Procedures with the most recent review and revision dates being July 2012, reflected the following: Policy Residents have the right to be free from abuse... The following procedures will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designees. Local law enforcement, the state survey agency... will be notified in accordance with federal and state law. Procedure ...III. Prevention of Abuse: ...B. The Administrator or designee will be responsible to provide feedback regarding concerns expressed by the resident, families... C. A committee selected and chaired by the Administrator or designated representative will function under the Quality Assurance and Assessment committee and meet, as needed, to: Identify, correct and intervene in situations in which abuse, neglect... is more likely to occur... D. The facilities (sic) interdisciplinary team in conjunction with the facilities (sic) administrative team will: ...And will re-assess interventions at a minimum during quarterly care planning conferences and/or as needed; based on the individuals (sic) response to interventions. ...VI. Protection: In order to provide protection to the resident during an investigation the following will be done: A. The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation. B. The Administrator or designee will be assigned throughout the investigation to follow-up with the person or persons involved with the concern, incident or grievance... VII. Reporting and Response to Alleged Incidents: ...B. All alleged violations involving mistreatment, neglect, or abuse... shall be reported immediately to the Administrator or the DON. NOTE: If the alleged abuse/neglect involves the Administrator, report the incident immediately to the Regional Vice President or Regional Nurse Consultant...." ATTACHMENT A DEFINITIONS Abuse* - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes verbal./.. mental/psychological... including ...any other actions within this definition. ...(B) 'Mental/psychological abuse'* - Mistreatment within the definition of 'abuse' not resulting in physical harm, including, but not limited to, humiliation, harassment... or intimidation. ...(E) 'Verbal abuse'* - the use of any oral... or gestured language that includes disparaging or derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. ...Mistreatment - Any malicious and/or deliberate demonstration of disrespect toward a resident. ...Any degrading body language or verbal communication. ...upsetting a resident unnecessarily.... *From Nursing Facility Requirements for Licensure & Medicals Certification 19.101 TDHS. ...ATTACHMENT D FACILITY INVESTIGATION PROCEDURES The purpose of this investigation is to address all types of abuse (verbal, physical, mental)... 1. THE RESIDENT: ...b. If the resident is able, conduct an interview about the incident...Some key questions to ask are: 1. What happened? 2. When did the incident occur? 3. Were any other present when the incident occurred? 4. Has the resident had any previous problems? c. ...If the resident cannot physically write a statement, prepare the statement and have the resident review, sign and date the statement... 2. THE ACCUSED EMPLOYEE(S): a. Thoroughly interview the employee(s) concerning the incident 1. What happened? 2. When did the incident happen? 3. Who was present when the incident happened? 4. Has this employee(s) had any previous problems with this resident? b. The suspected employee should be immediately placed o a leave of absence with pay pending the outcome of the investigation. ...d. Ask the suspected employee to prepare and sign a statement. 3. WITNESSES TO THE INCIDENT: a. Interview each witness... b. Each witness should prepare and sign a statement. ...5. CRITICAL INVESTIGATION APPROACHES: a. Begin investigation immediately upon notification that an incident has occurred. b. Review all statements for any needed clarification or expansion. c. Immediately follow up on all information gathered during the investigation. c. Notify the appropriate agencies, family members, physicians... in a timely fashion... Attachment H FREEDOM FROM ABUSE NOTICE TO EMPLOYEES RESIDENT/PATIENT ABUSE, NEGLECT AND MIStreatment of [REDACTED]. Any person who observes or becomes aware of an incident of resident/patient abuse, neglect or mistreatment of [REDACTED]. Among the rights specified in the federal and state laws, each resident... has a right to a dignified existence and to be free from verbal, ...mental abuse...." Resident #1's Admission Record, dated 05/06/13, reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had adequate heearing, had clear speech, was able to make herself understood and she had the ability to understand others and she did not exhibit any physical, verbal or other behaviors. The MDS assessment further reflected Resident #2 required limited to extensive assistance of one person for her ADLs and used a wheelchair for mobility. Active [DIAGNOSES REDACTED]. Resident #1's Care Plan dated 04/27/13 reflected the resident was upset because on 04/26/13, she received a roommate and allegedly was told to quit running off roommates. The Goal was for Resident #1 to be calm and reassured using the following interventions: Talk with resident, Reassure resident it was not her fault roommate situation did not work out. Contact MD if PRN medication was needed. ADON B was the author of this care plan. During an interview with Resident #1 on 05/31/13 at 10:15 AM, she told the surveyor, approximately one month ago (04/26/13), the Administrator caused her to cry. She explained the incident occurred on 04/26/13 when she received a new roommate. She stated staff brought Resident #2 to the room, which did not have a bed for the resident and just left her there. She said she (Resident #1) requested staff to bring her roommate a bed, because she (Resident #2) was sick. She said her new roommate's family arrived and were upset about the resident's move and began yelling. She said the ADM then arrived and told her (Resident #1) the situation was her fault. She said the ADM telling her Resident #2's moving back to her original room and "running residents off" was her fault and caused her to cry. Resident #1 stated she was still concerned about how the ADM might react if she (Resident #1) brings up another concern. Resident #1 then added the ADM had been "really nice" since the incident, but she still felt "staff would side with him," if she had a problem. The surveyor assessed Resident #1 as being alert and oriented to person, place and time and was a reasonable historian of the events of 04/26/13. The facility's Provider Investigation Report, dated 05/01/13, and signed by the RDO/Interim Administrator reflected an incident occurred on 04/26/13, and an allegation of verbal abuse was made on 04/29/13. Family Member #1A called the facility's corporate office to report verbal abuse involving Resident #1, which occurred on 04/26/13. (Note: No facility staff called in an allegation of abuse.) A Description of the Allegation reflected Family Member #1A stated an incident had occurred when Resident #2 was moved into Resident #1's room, and the family of Resident #2 was upset and "caused a scene." The Administrator was told there was a problem, and when he entered Resident #1's room, he pointed his finger at Resident #1 and told her she was a trouble maker and had "run off every roommate assigned to her room." Resident #1 then began to cry. Family Member #1A and the Administrator left the room and a "heated verbal exchange" was made about the Administrator's "conversation and tone (of voice)" used with Resident #1. The facility's Provider Investigation Report reflected in determining whether Resident #1 had suffered injury or an adverse effect, the following was written: "There was some initial anguish that lingered more than 8 hours... (Note: The incident occurred on 04/26/13 at 6:30 PM. An Investigation Follow-up reflected on Monday, 04/29/13, three days later, Resident #1 was still upset.) The facility's Provider Investigation Report reflected the family (of Resident #1) asked that she (Resident #1) not be asked anymore questions about the incident so she could calm down. She was assessed for (sic) and Social Services will continue to follow her for her sense of safety and she is doing well." The facility's Provider Investigation Report included the facility's response to the incident: "The Administrator was suspended pending investigation (on 04/30/13, four days after the incident and one day after the allegation of abuse was received). The Resident was assessed and monitored for sense of safety and security after the incident... The Community Staff was re-educated by the DON, the Environmental Supervisor and the DM on Abuse and Neglect, Signs and Symptoms of Stress, How to Handle Customer Complaints with Care and Resident Rights as it related to Room relocations, choice and inter-office communication (sic) for changes. (The Administrator's name was not on the sign-in sheet for having attended this training.)... The Administrator will be re-instated with a recommendation to attend Continued Education Courses at his expense for Conflict Resolution and Abuse and Neglect." The facility's Provider Investigation Report indicated in the Investigation Summary "the Administrator did not have all the facts as to what occurred and entered the room speaking with her (Resident #1's) family and the resident. He (the ADM) admits tempers flared and he denies calling her a Trouble Maker and is extremely remorseful that this conversation became heated with (Resident #1's) family and having Resident #1 cry...." The Investigation Summary further indicated the Administrator was in stress due to being on call 24-7. "I (RDO) know this was late in the evening on a Friday (6:30 PM) and he was called back to the building to diffuse the situation. We acknowledge this incident was handled in a unprofessional manner...." The facility's Provider Investigation Report's Investigation findings confirmed the Administrator was abusive to Resident #1. The facility's Provider Investigation Report included the Provider Action Taken Post-Investigation and reflected: "The Administrator will be re-instated on May 2nd, with the stipulation he completes continued education course on Conflict Resolution and Abuse and Neglect." Further review of the facility's Provider Investigation Report revealed there were statements from Family Member #1A and the SW, a Grievance/Complaint Report dated 04/27/13 written by ADON B (incomplete), an Investigation Follow-Up signed by the DON on 04/30/13, which was completed by ADON B and reflected the DON had been informed of the Grievance/Complaint Report regarding Resident #1. There were interviews conducted by the DON dated 04/28/13 with Residents #1 and #2. The interview conducted with Resident #1 on 04/28/13 by the DON, which was included with the facility's Provider Investigation Report, reflected the following: "States Admin told her it was her fault the roommate was upset and had to be moved out. (Resident #1) became tearful and said he (the Administrator) should not talk to anybody like that." This was told to the DON on 04/28/13, but she did not report this incident of abuse to the State Office. Also included with the facility's Provider Investigation Report were Social Service Progress Notes for both Residents #1 and #2. A Grievance/Complaint Report, completed by ADON B on 04/27/13, reflected the following: - Grievance/Complaint: "Resident (#1) told me she was still upset and scared because yesterday a roommate was put in her room without her being told first and then the roommate was moved. The Administrator then told her it was her fault that the other resident was moved out of the room and he scared (Resident #1) and made her cry." - Facility Follow-up: "(Resident #1) did state on 04/27/13 that Administrator did apologize for his remark but she was still upset by the remark." Despite the interview with Resident #1 resulting in ADON B documenting a Grievance/Complaint Report, ADON B did not identify the Abuse, which Resident #1 was subjected to. The Grievance/Complaint Report's Documentation of the Facility Follow-Up had incorrect information documented. The Report was not completed, and there was no resolution of the grievance/complaint. The facility's Investigation Follow-up was signed by ADON B and the DON, but the signatures were not dated. The Investigation Follow-Up included the following: - Description of Situation - A resident moved into Resident #1's room. Resident #1 was upset by the new roommate's family member cursing and throwing clothes on other resident's bed. NOTE: There was no mention made of the ADM coming into Resident #1's room calling her a trouble maker and shaking his finger in her face. - Summary of Investigation - Resident #1 was "still upset on Monday, 04/29/13 (three days after the incident), by her perception of how the Administrator shook his finger in her face and said this was all her fault by complaining of roommate." Resident #1's Social Service Progress Notes, dated 04/28/13, reflected the DON had notified the Social Worker on Friday (04/26/13), Resident #1 received a new roommate and that "there had been issues." There was no information including the ADM's actions of going into Resident #1's room, calling her a trouble maker and shaking his finger in her face causing the resident to cry. Resident #1's family member, Family Member #1A, took the time and effort to write a statement regarding the incident, which occurred, whe the Administrator verbally/mentally abused Resident #1 on 04/26/13. Her statement reflected they (Resident #1's family members) were visiting Resident #1 and met Resident #2, her new roommate, who was a very nice woman and Resident #1 and Resident #2 were getting along "very well." Approximately 5-10 minutes later, Family Member #2A stormed in to the room in a "violoent fashion slamming the doors, hitting the walls, tearing" Resident #2's belongings out of the closet and drawers, piling them on top of Resident #2, who was in bed and kept screaming, "I can't believe they moved you (Resident #2) without telling me." She was screaming and cursing and being very violent. Resident #2 was breathing very heavily nad was getting upset and Resident #2 was also getting upset. I was afraid for our safety. The CNAs came in to the room trying to calm down Family Member #2A, but she continued to yell and scream, calling for the "boss" and kept repeating she was going to call a family member. The CNAs got Resident #2 unburied from all the clothes piled on her and tranferred her to a wheelchair to move her back to her original room. They got everything moved and Family Member #2A calmed down. Another 30 minutes or so went by and Resident #1 was eating her dinner. Resident #1 said she really like Resident #2, but was afraid "they" were going to think it was her fault. (Earlier that day, a resident had been moved into Resident #1's room but was transferred out because she was a smoker. The nurse had insisted it was unacceptable, with Resident #1's [MEDICAL CONDITION], it was not an option.) Family Member #1A and Family Member #1B tried to reassure Resident #2 the problem had nothing to do with her. The Administrator then walked straight into Resident #1's room and rudely pointed at Resident #1 and asked Family Members #1A and #!B if they knew her, to which they both said "Yes." The Administrator then asked if they were family members, and they said "Yes." The Administrator then stepped around the family members and pointed directly at Resident #1 and in a very rude and condescending tone, told Resident #1, "I am tired of you being a troublemaker, and being mean. You keep running people out of this room." Resident #1 immediately broke down in tears and Family Member #1A told him to walk in the hallway, this was over, and they were going to talk alone. Resident #1 had never met the Administrator and did not know who he was, he never introduced himself or identified himself and Resident #1 assumed he was a member of Resident #2's family. Resident #1 was about to call the police when the nurse told Resident #1 he was the Administrator. When Family Member #1A and the Administrator entered the hallway, he had a"very smug attitude" and was innow way trying to reconcile the situation or showing any signs of remorse. When Family Member #1A asked him if he thought his behavior was appropriate, his only response was, "I am a professional" or "oh really what did I say." Family Member #1A told the Administrator there was no excuse for the kind of behavior and he needed to walk back into the resident's room and apologize to Resident #1. Family Member #1A told the Aministrator he should respect Resident #1 as a human being, not to mention also his elder. When the Administrator and Family Member #1A walked back into Resident #1's room, a nurse was trying to calm the resident down. The nurse kept telling Resident #1, "I think it was an ill attempt at a joke." The Administrator walked in, handed her a new tissue and just kept saying, "Stop crying" and "don't be upset." He never tried to reconcile the situation or apologize. Resident #1 continued to cry, sayng no one had ever spoken to her like that. They finally got Resident #1 to stop crying and the nurse in the room went in to the hallway with the Administrator. The family members continued to talk to Resident #1, reassuring her it was not her fault. The nurse, who had been in the room with Resident #1, later spoke with Family Member #1A, telling the family member she really thought it an ill attempt at a joke. Family Member #1A told the nurse it wasn't and that was the end of that conversation. The family members left to get other family members with one of the CNAs saying he would look after her. When they returned to the facility, Resident #1 told her family members the Administrator had returned and tried to apologize. Family Member #1A then wrote, "A line of decency was crossed and no one deserves to be verbally abused that way let along a defenseless [AGE] year old woman with health issues." During an interview with Family Member #1A on 06/06/13 at 8:20 AM, the family member stated he/she was with Resident #1 at the time of the incident on 04/26/13. Family Member #1A said facility staff had moved another resident into Resident #1's room. Family Member #1 said they had been in Resident #1's room for about 15 minutes when Family Member #2A came into the room and started yelling and throwing things around in the room. Family Member #2A was upset because "they" had not told her Resident #2 was being moved. At that time, Resident #1 said she was concerned about the reaction of Family Member #2A and went and got some facility staff. Family Member #1A said Resident #2 was moved back to her other room everything calmed down for about 30 minutes. The Administrator came into the room and asked if Resident #1 and Family Member #1A knew Resident #2. Family Member #1A said the ADM pointed his finger at Resident #1 and said, "She's (Resident #1) a troublemaker, and she can't keep causing problems." Resident #1 then started to cry. He/she stated Resident #1 kept asking the Administrator who he was. The ADM never answered and never introduced himself. He never apologized to Resident #1 and/or Family Member #1A. He/she stated he/she felt concerned leaving Resident #1 there. He/she said if the ADM acted that way in front of other people, how would he act when no one was there. Resident #1's family member said Resident #1 was also upset, because she was blamed for the situation, which occurred. During an interview with the Administrator on 05/31/13 at 9:45 AM, he stated staff moved a resident into Resident #1's room. He stated Resident #1 always had a reason why the roommates did not work for her. He stated he spoke with Resident #1 first, but could not remember the exact conversation. He said he was a little frustrated with multiple residents moving in and out of Resident #1's room. He denied pointing his finger in Resident #1's face. He said Resident #1 was upset. After things calmed down, he went back to Resident #1's room and apologized to her, and she seemed fine. He did not think he raised his voice at the resident, but spoke in a "matter of fact" tone (of voice). He stated he also dealt with Family Member #2A, who was upset about Resident #2's move. No evidence was provided by the Administrator regarding the Administrator's attendance at continuing education classes involving Conflict Resolution and Abuse and Neglect. A "stickie note" reflected cost information for the course entitled, "Dealing With People You Can't Stand." It was an on-line computer training course for behaviors for the Administrator. Nothing else was provided in regard to the Administrator's training. During an in interview with the ADON B, on 06/20/13 at 11:30 AM, she confirmed she was present the Friday evening the incident occurred with Resident #1 and the Administrator. She stated one of the CNAs came to her and told her there was a problem with two residents. The family member of Resident #2 (Family Member #2A) was out of control, yelling and throwing things, threatening to move Resident #2 if they didn't take care of the problem. The CNA said Family Member #2A started to cry. Family Member #2A then went and got the orderly to come and move Resident #2 back to her old room. ADON B said she spoke with Family Member #2A, who told her (ADON B) Resident #2 was supposed to have a private room through the weekend. ADON B said the SW was supposed to notify the family on the day of the room move. ADON B stated she called the Administrator to come to the facility. When asked about the incident, which occurred between Resident #1 and the ADM, ADON B indicated she did not witness what was said by the Administrator to Resident #1 because she was busy moving Resident #2 back to her room. ADON B told the surveyor the Administrator had a history of [REDACTED]." During an interview with the RDO/Interim ADM, on 06/20/13 at 1:05 PM, she confirmed an individual had contacted and made her aware of the incident, which took place at the facility and involved the Administrator and Resident #1. She stated she had suspended the Administrator on 04/30/13 as soon as she became aware of what had occurred on 04/26/13. The RDO/Interim ADM stated she initiated an investigation on 04/29/13. She stated there were quite a few failures involved in the incident. The Administrator failed to get the facts before he entered the building or before going to Resident #1's room. She said the Administrator did admit to telling Resident #1 she was "running people off," and Family Member #1A was upset. The Administrator also admitted he "barged" into the building without being informed of the incident and the actual events of the situation. The Administrator should have listened to all the facts before he entered Resident #1's room. The Administrator's choice of words were not the best. The RDO/Interim ADM stated it was a bad situation all the way around and was fueled by other residents. RDO/Interim ADM stated corporate had concerns about the Administrator being aggressive with residents/staff and were considering termination amd had been in the process of gathering evidence. She stated the Ombudsman also got involved in an effort to assist the facility in resolution of what occurred with the families. The RDO/Interim ADM added she was concerned Family Member #2A was throwing things around in Resident #1's room and Family Member #2A could have harmed someone. The RDO/Interim ADM further stated "someone" moved Resident #2 without following the facility's Policy and Procedures for a room move, and adequate notice was not given. The RDO/Interim ADM stated in a room move, the SW was supposed to initiate contact when a change in room assignments or roommates was about to occur. Then Nursing staff was to follow-up with the family to ensure the family knew about the upcoming room change and/or roommates. This did not occur. If the room change had been done the way it was supposed to, the whole incident would never have occurred. The RDO/Interim ADM stated it was a system failure by not following the facility's policy and procedures for a room change. The RDO/Interim ADM stated she spoke to Family Member #1B, who requested the Administrator not be allowed in Resident #1's room, and the corporate office agreed to the stipulation. On 07/08/13, an Immediate Jeopardy was identified. At 5:49 PM on 07/08/13, the DON was informed an Immediate Jeopardy (IJ) had been identified. At 5:53 PM, the Administrator joined the meeting and he was notified of the IJ. A request was made for a Plan of Removal for the IJ. The facility's Plan of Removal dated 07/08/13 was accepted on 07/10/13. The plan included the following: The Administrator was suspended pending investigation on 04/30/13 (returned to work on 05/02/13) and was suspended again on 07/08/13. The Administrator was required to complete training by an outside agency on Abuse and Neglect and Dispute Resolution and How to Handle Complaints with Care. Termination of the Administrator was recommended and approved at the conclusion of the progressive discipline by the Governing body. All facility staff was re-educated on Reporting Abuse and Neglect and Resident Rights on 07/08/13, 07/09/13, 07/10/13 and had previously received in-services immediately following the incident in question on 04/30/13 and 05/01/13. The training was provided by the DON and a Post Test was used to validate staff's understanding. Future concerns of abuse will be investigated immediately upon learning of the incident. Staff understanding was verified by skills validation on what constitutes abuse and how to report abuse. The RDO/Interim ADM is the Abuse Coordinator and is responsible for investigating allegations of abuse and ensuring the abuse is reported timely. Each Manager will be responsible for conducting investigations within their departments and the Abuse Coordinator, the Interim Administrator, will oversee the investigations are thorough and completed. Department Managers include: the DON, the Dietary Manager (DM), the Social Worker (SW), and the Compliance Officers, the Business Office Manager and ADON A. Phone numbers to the State Agency, Ombudsman, Compliance and Elder Abuse Laws are posted throughout the community. Letters outlining several reporting avenues as mentioned previously were mailed on 05/03/13 to each resident and family member, giving them additional opportunities to voice their concerns and to ensure them the facility and governing body takes all allegations seriously. Resident #1 was initially interviewed on 04/29/13 with follow-up observations of the resident conducted by the DON and SW. Resident #1's legal representative requested no further interviews/conversations to be conducted with Resident #1 regarding the incident. Because of the IJ, a safety interview was conducted with Resident #1 on 07/08/13 by the DON using a questionnaire with six questions regarding the resident's sense of safety. Resident #1 showed no evidence of residual effects from the incident. Resident #1 indicated she was comfortable at the facility and was not planning on relocating to another facility. Resident #1's legal representative was contacted on 07/09/13 at 3:55 PM and repeated her desire for not further interviews/conversations to be conducted with the resident regarding the incident with the ex-Administrator. This interview was conducted by Regional Nurse F. Using a sense of safety questionnaire, the SW interviewed the alert and cognizant residents as identified by their MDS clinical assessments. A total of 101 residents were interviewed. The residents were asked about their sense of safety and the right to report abuse or neglect without fear of reprisal. They were also questioned whether anyone had experienced abuse of any kind and/or mental anguish, intentionally or unintentionally by any of the facility staff. These interviews occurred immediately after the incident on 04/26/13 and again on 07/08/13. The Clinical team assessed other residents, who were not interviewable and observed them for changes in behavior, mood and/or appetite. The Quality Assurance Assessment process will be used to validate ongoing compliance and using the facility's systemic process to identify and investigate abuse. Abuse and Neglect education were provided to facility staff on 04/30/13 and 07/08/13. Sixteen employees still needed to be re-educated on Abuse and Neglect. The DON will continue to contact staff by phone. Any staff who have not been re-educated will received the mandatory training when they return

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #8) of eight residents reviewed for pain/comfort. 1. Staff failed to assess Resident #8's constant pain and notify the physician of the pain. These failures resulted in Resident #8's continuing constant and severe pain. 2. Facility staff failed to administer pain medication timely to Resident #8 to prevent pain during care. Resident #8 received pain medication one hour and 15 minutes prior to Stage IV pressure ulcer wound care. This failure resulted in Resident #8 grimacing, moaning loudly, and gasping during wound care. 3. Facility staff failed to care plan interventions to address Resident #8's pain related to her Stage IV wounds and fractured ankle, until after surveyor intervention. Staff failed to care plan interventions related to pain from Resident #8's [DIAGNOSES REDACTED]. These failures resulted in Resident #8 continuing to experience uncontrolled, severe pain and discomfort. An Immediate Jeopardy (IJ) was identified on 09/20/12. While the IJ was removed on 09/21/12, the facility remained out of compliance a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the other 53 residents, who were on a pain management program, by placing them at risk for uncontrolled pain, continued pain, discomfort, and decreased quality of life. Findings included: 1. Resident #8's Admission Record dated 09/19/12 reflected the resident was an [AGE] year-old female, who was originally admitted to the facility on [DATE] and then readmitted on [DATE]. The Record reflected her [DIAGNOSES REDACTED]. An Oncology Consult Note dated 04/20/12 reflected Resident #8 was diagnosed with [REDACTED]. Resident #8's Nurse's Progress Note/Summary dated 04/24/12 reflected she was in pain as evidenced by irritability and restlessness, and the pain was in her lower back. The Summary also reflected the pain was episodic and the worst pain was rated a 9 out of possible 10, with 10 being the worst possible pain, and the best the pain was rated a 5 out of 10. Resident #8's significant change MDS assessment dated [DATE] reflected the resident's cognition was severely impaired, and she frequently had moderate pain, which made it difficult for her to sleep at night. The MDS assessment indicated her pain was related to a fracture and her pain was addressed in her Comprehensive Care Plan. Resident #8's Social Services Progress Note dated 05/29/12 reflected she was confused and had some pain in her lower back. An interview with the DON and the Corporate Nurse on 09/19/12 at 2:54 p.m. revealed Resident #8 had routine pain medication initiated. Resident #8's MDS assessment dated [DATE] reflected she frequently had moderate pain, which limited her day-to-day activities. Further review of the MDS assessment revealed the resident's cognition was moderately impaired. An observation on 09/18/12 at 9:40 a.m. with LVN D revealed Resident #8 sitting in a Geri-chair in her room. LVN D described the resident as being confused and incontinent of bowel and bladder and totally dependent on staff for all activities of daily living. LVN D stated the resident recently fractured her ankle and had a leg wound. Resident #8's Nurse's Progress Note/Summary dated 08/06/12 reflected she was in pain as evidenced by moaning/crying, irritability, and anger. The Summary reflected she had pain "all over" and pain was from being moved around in bed. Further review of the Progress Note/Summary revealed the pain was continuous and the worst pain was rate a 10 out of 10. Resident #8's Physician's Progress Notes dated 08/07/12 reflected the resident had back pain and pressure ulcers. Resident #8's Physician's Progress Notes dated 08/18/12 reflected Tylenol 325 mg 2 tablets every 4 hours as needed for her [MEDICAL CONDITION] and [MEDICATION NAME] (narcotic pain medication) 7.5/325 mg every six hours as needed for her backache. Resident #8's September 2012 MAR indicated [REDACTED]. An observation on 09/20/12 at 1:05 p.m. revealed Resident #8 was in her room and stated she was experiencing pain in her back and "All over." The resident further stated on a 1-10 pain scale the pain was at a level of 8. Resident #8's Wound Care Specialist's Note dated 09/19/12 reflected her left lateral calf wound measured 18.5 cm x 2.5 cm x 1.8 cm (length x width x depth). An observation of wound care provided by LVN E with the assistance of LVN D on 09/19/12 at 1:15 p.m. revealed Resident #8 had a large, deep, Stage IV pressure ulcer with visible tendons on her left lateral calf. LVN E stated at that time that the Wound Care Physician saw the resident earlier that day and performed a debridement of the wound. While LVN E was cleansing and wiping the wound with a 4x4 pad saturated with normal saline, Resident #8 started grimacing, gasping, and moaning loudly. The surveyor queried LVN E about providing pain medication prior to the wound care, and she replied the resident received her routine pain medication at 12:00 p.m. (One hour and fifteen minutes prior). When queried during this time about having any orders to address breakthrough pain, LVN E stated the only other pain medication ordered was Tylenol. LVN E continued to perform the treatment without any other pain interventions being implemented. LVN E and LVN D were asked at that time about any special care and/or services Resident #8 was receiving as a result of being placed on Palliative Care. The nurses stated they provided no special care other than providing routine/scheduled pain medication. An interview with the DON and the Corporate Nurse on 09/19/12 at 2:54 p.m. revealed Resident #8, "Probably could use something for breakthrough pain" before wound care. An interview with Resident #8's primary Physician on 09/19/12 at 6:00 p.m. revealed he had not received any calls or messages regarding the resident's pain. On 09/20/12 ADON A provided Resident #8's current Comprehensive Care Plan. The Care Plan Review Form dated 08/29/12 reflected on 08/29/12 Nursing and Social Services discussed different topics regarding Resident #8's care, but pain management was not included. Further review of Resident #8's Care Plan revealed a problem of alteration in musculoskeletal status related to ankle fracture and [MEDICAL CONDITION]. The Care Plan reflected the resident would remain free of pain or at least at a level of discomfort acceptable to the resident. The Interventions included administering [MEDICATION NAME] as ordered by the physician, monitoring and documenting side effects and effectiveness. The Comprehensive Care Plan did not address notifying the physician if the medication was not effective, assessment of pain, and assessment and management of breakthrough pain. Resident #8's September 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #8's September 2012 Pain Management Flowsheet was blank. The Instructions on the Flowsheet reflected for each medication given the medication name, date, dose, time, pain rating score, other related behaviors and vital signs should be documented on the flow sheet. On 09/20/12 at 10:00 a.m., LVN E stated no daily pain assessments were completed for Resident #8. She stated she notes if the resident appeared to be in pain. She further stated all residents were assessed for pain every three months, and residents, who were ordered routine pain medications, were assessed weekly. She revealed the assessments were also documented. According to LVN E, the Pain Management Flowsheet was only used for residents, who received as needed pain medication and not for residents who received routine pain medications. <http://consultgerirn.org/topics/pain/want_to_know_more> reflected, " B. Strategies for Pain Assessment 1. Initial, quick pain assessment (Ref 9) a. Assess older adults who who present with acute pain of moderate-to-severe intensity or who appear to be in distress. b. Assess pain localization, intensity, duration, quality, and onset. c. Assess vital signs. If changes in vital signs are absent, do not assume that pain is absent (Ref 8). 2. Comprehensive pain assessment (Ref 2; 6; 8) ... b. ...If there is evidence of cognitive impairment, do not assume that the patient cannot provide a self-report of pain. Be prepared to augment self-report with observational measures... c. Assess pain regularly and frequently but at least every 4 hours. Monitor pain intensity after giving medications to evaluate effectiveness ... h. Observe for nonverbal and behavioral signs of pain, such as facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalizations, and crying. Also watch for changes in behavior from the patient's usual patterns ... B. Pain Prevention ...2. Assess pain regularly and frequently to facilitate appropriate treatment. 3. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. Administer [MEDICATION NAME] 30 minutes prior to activities .... " (Retrieved on 10/05/12.) Resident #8's Weekly Pain Assessments dated 09/06/12 and 09/13/12 reflected she was in constant pain at a level of 10 on a 1 to 10 pain scale, with 10 being very severe, horrible pain. The scale used for these assessments was the Numeric Scale. The Assessments also reflected Resident #8's pain level one hour after receiving pain medications was at a level of 8 and at a level of 5 three hours after receiving pain medication. The assessments further reflected the worst Resident #8's pain got was at a level of 10 plus. An interview with LVN F on 09/21/12 at 2:50 p.m. revealed she was the nurse who Resident #8's completed the Weekly Pain Assessments on 09/06/12 and 09/13/12. She stated she documented constant pain on the assessment because Resident #8 was always in pain. When asked what she did for Resident #8's constant pain, LVN F replied, "She was receiving routine pain medication." Further interview with LVN F on 09/21/12 at 4:15 p.m. revealed she reported Resident #8's constant pain to the Charge Nurse who no longer worked at the facility. During this interview, LVN F stated she realized "now" that as a nurse she could have notified the physician herself. An interview with CNA G on 09/21/12 at 1:00 p.m. revealed in the past she noticed at times Resident #8 "Cried or yelled out" as if she was in pain during care. The CNA further stated when she noticed the resident in pain, she reported it to the nurse. Resident #8's Licensed Professional Counselor's Clinical Progress Note dated 09/20/12 reflected, "...she says her back hurts...Counselor told the nurse that (Resident #8) was complaining of pain with her back." The facility's Pain Management policy and procedure, dated November 2009, was provided by the Administrator of 09/21/12 and identified as current. The policy/procedure reflected, "All residents shall be assessed for pain factors and history upon admission to the facility and subsequently thereafter according to the findings of the assessment. All residents shall receive treatment for [REDACTED]. Intervening to treat pain before the pain becomes moderate is expected. The facility's expectations for pain management shall include but not limited to: 1) Identifying and intervening to treat pain aggressively and before the pain becomes moderate. 2) Documenting pain assessment(s), intervention(s), and evaluation activities in a clear and concise manner and using the information collected to implement a multidisciplinary individualized plan of care. 3) Staff recognizing that pain medications may be given around-the-clock. 4) The use of non-drug interventions to assist pain alleviation is appropriate...Licensed Nursing staff will complete the 'Pain Data Collection Tool' on admission, readmission, quarterly and any change in condition that has the potential to cause pain. 2) The resident's descriptive words regarding the quality and/or patterns of [MEDICAL CONDITION], duration and/or participating factors, and location of pain shall be used to evaluate the pain and identify changes in pain. 3) For the resident who has difficulty communicating due to cognitive impairment as indicated on the MDS, the LN shall access (sic) for physical signs of pain such as grimacing, limping, changes in vital signs (respirations, pulse or Blood pressure readings), or behavioral changes (loud outbursts, pulling or pushing away, striking out) by utilizing the 'Pain Collection Tool for Use in Advanced Cognitive Impairment'...8) The pain shall be re-evaluated thirty (30) minutes to one hour after medication administration for effectiveness and documented in the medical record, or on a specified alternate schedule when appropriate depending on the type of pain and medication administered. 9) The 'Pain Management Flow Sheet' shall be completed each a time a 'PRN' pain medication is administered for acute as well as breakthrough chronic pain and reviewed weekly to determine if the resident's pain is adequately controlled by occasional 'PRN' pain medication and if not, would a regular regimen of routine pain medications be more appropriate. 10) The physician shall be notified when any type of prescribed pain medication management regimen is not effective in relieving resident's pain...." An IJ was identified on 09/20/12. The Administrator and DON were notified on 09/20/12 at 11:30 a.m. of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal accepted on 09/20/12 at 6:33 p.m. reflected, "The facility has notified the physician and he has been in to assess the level of pain for (Resident #8). He has ordered additional narcotic [MEDICATION NAME] for break through pain. He ordered X rays (sic) based on her complaint of having back and shoulder pain. All residents are going to be considered at risk for pain and ADONs and Case Mix Managers will reassess all residents for pain using the pain data collection tool and completed (sic) by 09/20/12. Any resident identified with pain that is not adequately controlled with the current pain management plan will have their physician contacted by licensed nurse for additional pain interventions. All residents receiving routine pain medications will be monitored for break through pain by the licensed nurses utilizing the pain management flow show sheets daily. Nursing management: DON, ADONs and weekend supervisor will monitor the pain management flow sheets for timeliness of assessment and proper interventions for identified pain...Licensed nurses will notify physician anytime current pain management preventions are inadequate to control a resident's pain for additional pain management interventions. Documentation of notification of physician will be recorded in the resident's medical record by the licensed nurse by 09/20/12. All licensed staff will be in serviced on pain assessment, documentation of pain management, physician notification by Regional Nurse Consultant by 09/20/12 and no licensed nurse will be allowed to work the floor until they have been in serviced...." On 09/21/12 at approximately 10:15 a.m., the DON provided a Care Plan for Resident #8 dated 09/20/12. The Care Plan reflected, "Potential for pain R/T wounds, hx (history of) arthritis, and hx fx (fracture) - 9/20/12 Will have decreased facial grimace moans and c/o pain ? Assess Daily for Breaththrough pain. ? Admin (Administer) meds, Routine & PRN [MEDICATION NAME] as ordered ? Report abnormals & (symbol for increased) c/o pain to MD." The handwritten Care Plan was signed by the DON. The Care Plan did not address the resident's potential and/or actual pain related to [MEDICAL CONDITION]. At this time, the DON agreed the resident's [MEDICAL CONDITION] would also be a potential for pain and should be reflected on the Care Plan. Interview with LVN C on 09/21/12 at 12:45 PM revealed, as a Charge Nurse, he was to monitor his residents who needed PRN pain medication for pain levels, medications and effectiveness. He added he would also conduct pain assessments quarterly, with any change of condition, or as needed. LVN C stated the medication nurses monitored the effectiveness of scheduled pain medications and would alert him if not effective. He also revealed residents on routine pain medications were to be assessed weekly as well as before and after the administration of medication. During an interview on 09/21/12 at 1:00 PM, LVN H identified the pain assessment and flow sheet forms she was to use for pain assessment documentation. LVN H stated she was to check all residents daily for pain, perform weekly pain assessments on residents receiving scheduled pain medications as well as pre and post assessments on all scheduled and PRN pain medication administration. Interview with LVN I on 09/21/12 at 1:21 PM revealed she was to do weekly pain assessments on all residents receiving scheduled pain medication as well as daily assessments for breakthrough pain. LVN I stated pain would be reassessed one hour after medication administration and a call placed for additional medications if necessary. Interview with LVN E on 09/21/12 at 1:49 PM revealed she would assess residents' pain daily using a pain scale appropriate to the resident. She stated if a resident had pain, who was already medicated, the physician should be called for break through pain relief. LVN E also revealed all pain should be assessed and documented on the flow sheet before and after medication administration, and daily, for breakthrough pain and weekly pain assessments should be completed as well. Interview with LVN O on 09/21/12 at 1:49 PM revealed the Pain Management Flowsheet should be completed for all prn medication administered and once per day for routine pain medication. LVN O explained the difference between the pain assessment tools used for alert and oriented residents and cognitively impaired residents. LVN O described the signs and symptoms to look for when assessing non-verbal residents for pain. LVN O stated the physician should be notified of break through pain when a resident did not have a prn pain medication order. LVN O revealed all residents receiving routine pain medications should be assessed daily for relief and weekly using the Pain Data Collection Tool. Interview with ADON A on 09/21/12 at 2:13 PM revealed all residents receiving routine pain medications should be assessed daily for relief and weekly using the Pain Data Collection Tool. She stated residents on prn pain medication should be assessed quarterly using the Pain Data Collection Tool. ADON A revealed the Pain Management Flowsheet should be completed for all prn medication administered and once per day for routine pain medication. ADON A also revealed the physician should be notified of break through pain when a resident did not have a prn pain medication order. ADON A explained the difference between the pain assessment tools used for alert and oriented residents and cognitively impaired residents and described the signs and symptoms to look for when assessing non-verbal residents for pain. Interview with LVN F on 09/21/12 at 2:33 PM revealed all pain medications were to be documented on the pain flow sheets before and after administration with assessments for effectiveness. She stated the physician should be notified of break through pain. LVN F revealed the Pain Data Tool should be completed on admission, weekly and with a change in condition. Interview with LVN P on 09/21/12 at 2:33 PM revealed the Pain Management Flowsheet should be completed for all prn medication administered and once per day for routine pain medication. LVN P stated the residents should be assessed for break through pain and one hour after pain medication was administered. LVN P revealed the physician should be notified of break through pain when a resident did not have a prn pain medication order. LVN P stated if the physician could not be reached, nurses were to call the DON. LVN P explained the difference between the pain assessment tools used for alert and oriented residents and cognitively impaired residents and described the signs and symptoms to look for when assessing non-verbal residents for pain. LVN P revealed all residents receiving routine pain medications should be assessed daily for relief and weekly using the Pain Data Collection Tool. Interview with LVN Q on 09/21/12 at 2:40 PM revealed the Pain Management Flowsheet should be completed for all prn medication administered and once per day for routine pain medication. LVN Q also revealed post assessment signs and symptoms should be assessed one hour after medication was administered and should be described on the Pain Management Flowsheet instead of " just writing effective. " LVN P stated the physician should be notified of break through pain when a resident did not have an order for [REDACTED]. LVN Q revealed all residents receiving routine pain medications should be assessed daily for relief and weekly using the Pain Data Collection Tool. Interview with ADON B on 09/21/12 at 2:50 PM revealed the Pain Management Flowsheet should be completed for all prn and once per day for routine pain medication administered. ADON B also revealed all residents receiving routine pain medications should be assessed daily for relief and weekly using the Pain Data Collection Tool. ADON B stated residents on prn pain medications should be assessed quarterly using the Pain Data Collection Tool. ADON B revealed residents experiencing break through pain or experiencing a significant change in condition should also be assessed using the Pain Data Collection Tool. ADON B explained the difference between the pain assessment tools used for alert and oriented residents and cognitively impaired residents and described the signs and symptoms to look for when assessing non-verbal residents for pain. Interview with LVN J on 09/21/12 at 3:02 PM revealed all residents receiving a pain medication should be assessed for effectiveness one hour after administration and documentation made on the flow sheet. LVN J also revealed the physician should be notified for break through pain and weekly assessments were to be done using the Pain Data Collection Tool. Interview with LVN K on 09/21/12 at 3:32 PM revealed all residents were to be assessed for pain at least weekly, or daily if indicated. LVN K stated all residents receiving pain medication were to be assessed before and after for effectiveness and documentation made on the pain flow sheet, and if no relief, the physician should be notified. Interview with LVN L on 09/21/12 at 3:35 PM revealed residents on routine pain medications should be assessed daily for effectiveness as well as before and after medication administration using the appropriate assessment scale. LVN L stated the physician should be notified of break through pain and weekly assessments should be completed using the Pain Data Collection Tool. Interview with LVN M on 09/21/12 at 3:42 PM revealed residents receiving routine pain medications would be assessed daily and weekly. LVN M also stated all residents receiving any pain medication should be assessed before and after administration for effectiveness and the physician should be notified of break through pain. Interview with LVN N on 09/21/12 at 3:46 PM revealed all residents should be assessed before and after the administration of pain medication for effectiveness. LVN N stated the physician should be notified of break through pain and all residents receiving routine pain medications should be assessed daily for relief and weekly using the Pain Data Collection Tool. The IJ was removed on 09/20/12. The Administrator, DON, Regional Organizational Director, and RN C were notified on 09/21/12 at 5:30 p.m. that IJ was removed. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the implementation of the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the Case Mix Manager on 09/18/12, reflected 54 residents on a Pain Management Program.

Based on observation, interview and record review, it was determined the facility failed to ensure two (Residents #3 and #7) of 13 residents reviewed received adequate supervision to prevent the potential for accidents. Resident #3 eloped from the facility on 11/27/10. The alarm sounded, staff failed to see Resident #3 outside, and the resident was returned by the police approximately 30 minutes later. On 12/14/10, Resident #3 eloped from the facility, and the alarm sounded. ADON A went to the door, did not check outside to see if a resident had left the facility, reset the alarm and started to return to the lobby. The surveyor intervened and informed ADON A a resident had left the facility. ADON A and PR B went after Resident #3, who had crossed the street by then, and returned her to the facility. On 12/14/10, Resident #7 left the facility independently wheeling himself out the door. He had no wander guard on, but his care plan dated 08/01/10 reflected a wander guard was to be used as an intervention. Resident #7 did not have a current elopement assessment. The wander guard alarm did not sound when wander guards were being tested on [DATE] at 11:05 a.m., 11:20 a.m. and 11:23 a.m. An Immediate Jeopardy (IJ) was identified on 12/14/10. While the IJ was removed on 12/16/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" and a scope of "pattern," because staff were still being in-serviced and the facility was still monitoring for implementation of the Plan of Removal. These failures could affect the 14 residents, who required wander guards, including Residents #3 and #7, and placed them at risk for elopment without staff knowledge, resulting in accidents, injuries, or death to any of the 14 residents identified by the facility as being at high risk for elopement. Findings included: 1) Interview on 12/14/10 at 9:25 a.m. with Maint C revealed all doors and alarms worked properly and no adjustments or repairs were needed the day before Resident #3 eloped (on 11/27/10) and when she returned. Maint C stated the company had come to check everything the day before Resident #3 eloped (11/26/10) and after she returned. Maint C stated a resident with a wander guard would be able to exit a door without an alarm sounding if the door was not closed, or if the alarm had been silenced instead of being reset. 2) Review of the Admission Record dated 12/15/10 revealed Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An Admission Nursing assessment dated [DATE] reflected Resident #3 was able to ambulate and transfer independently. Resident #3's Elopement/Wandering Assessment Tool dated 11/28/10 reflected the resident had scored a "7" which equated to the resident being a high risk for elopement. The Elopement/Wandering Assessment Tool reflected Resident #3 was cognitively impaired with poor decision-making skills. Resident #3's nurses' notes reflected the following: 11/25/10 at 1:00 a.m. - Resident #3 brought all her personal belongings to the lobby. At 8:40 a.m., Resident #3 was in the lobby and a wander guard was placed on her. 11/26/10 at midnight - Resident #3 tried to go outside. At 10:00 a.m., Resident #3 wandered (in the facility). 11/27/10 at midnight - Resident #3 wandered into other residents' rooms. At 5:00 a.m., Resident #3 went into other residents' rooms and tried to go outside. At 1:00 p.m., Resident #3 wandered and said she was going home to see her mother. Resident #3 was with the nurse around 4:40 p.m. The alarm sounded at approximately 4:50 p.m. while the nurse was in another resident's room. The CNA, who was with the nurse at the time the alarm sounded, checked the door that caused the alarm to sound and reported to the nurse no resident was seen outside the door. At approximately 5:20 p.m., staff realized Resident #3 was missing and began searching for her inside and outside the facility. The police found Resident #3, returned her to the facility, and assessment revealed no injury. One-on-one monitoring was initiated. Interview on 12/14/10 at 2:45 p.m. with CNA R revealed when Resident #3 eloped last month (11/27/10), the CNA observed Resident #3 walking around with all her things inside a pillowcase and a blanket inside facility prior to elopement. CNA R stated Resident #3 had to be re-directed at least half a dozen times that day, and Resident #3 would say she needed to go home and would curse when staff told Resident #3 she lived at the facility. CNA R stated when the alarm sounded that day (11/27/10), CNA R was in a resident's room with another CNA transferring a resident and could not immediately look out the door until they transferred the resident. CNA R stated after the transfer was completed, she ran to the same door she had seen Resident #3 trying to leave from several times that day and looked outside. CNA R stated she did not see anyone outside, and staff looked for Resident #3 in each room, outside, at the gas station on the corner, in the field, and another staff drove up and down the streets. CNA R stated the police brought Resident #3 back to the facility after they had searched for her for about 30 minutes. CNA R stated when the alarm sounded, the CNA was sure Resident #3 had gone out the door, because Resident #3 had been trying to leave the facility all day. CNA R stated the in-service, which was given after the incident was the same information they had previously been given regarding the procedure for responding to alarms. CNA R stated staff were to check outside to see if a resident went out when an alarm sounded and count every resident to make sure all residents were in the facility. Nurse's Notes for Resident #3 reflected the following: 11/28/10 - Resident #3 was being monitored one-on-one; the resident said she was going home. 12/01/10 at 8:00 a.m. - Resident #3 removed the wander guard. At 9:15 p.m., Resident #3 continued to take off the wander guard and broke the strap. At 10:15 p.m., there was no replacement wander guard available and the resident was placed on one-on-one supervision. 12/03/10 at midnight - Resident #3 with wander guard on. Fifteen minute checks for elopement continued. Review of the 15 Minute Surveillance Logs revealed Resident #3 was checked every 15 minutes from 11/29/10 through 12/05/10. Nurse's Notes dated 12/08/10 reflected the first time there was no documentation regarding 15-minute checks being conducted. Resident #3's TAR for December 2010 reflected the resident's wander guard was checked for placement every shift. Observation on 12/14/10 at 9:00 a.m., 9:30 a.m., and 10:00 a.m. revealed Resident #3 was sitting on a couch in the lobby with Resident #2. Resident #2 and Resident #3 were both observed to be wearing a wander guard. On 12/14/10 at 10:05 a.m., Resident #3 was observed getting up quickly from the couch, ambulating rapidly to the front door and opening the door. The alarm sounded and Resident #3 immediately exited through the door. Resident #10, who did not have a wander guard, was observed sitting near the door. At that time, ADON A was in the lobby. She went to the door, looked at Resident #10, and reset the alarm at the front door keypad without checking outside to see if any resident had left the facility. As ADON A walked away from the door to return to the lobby, the surveyor informed ADON A a resident had just left the building. ADON A and PR B immediately ran outside just as Resident #3 crossed the street. ADON A and PR B brought Resident #3 back to the facility from the corner yard of a private residence across the street. Nurses' notes dated 12/14/10 at 10:05 a.m. reflected Resident #3 eloped, crossed the street, was retrieved by staff, no injury was noted, and Resident #3 was placed on one-on-one monitoring. On 12/14/10 at 11:00 a.m., Resident #3 was observed sitting at a table in the lobby with CNA D. Interview on 12/14/10 at 10:45 a.m. with the ADM and the DON revealed Resident #3 had a history of [REDACTED]. The ADM stated Resident #3 was checked every 15 minutes since Resident #3 eloped last month, was being monitored one-on-one since Resident #3 eloped a few minutes ago, and the Social Worker was seeking alternative placement for a secured unit for Resident #3. The ADM stated Resident #3 was the only resident at that time who needed alternative placement, but all residents would be assessed today to see if alternative placement was needed for any other residents. The surveyor informed the ADM and DON Resident #3 had exited the front door, the alarm sounded, and ADON A reset the alarm keypad at the door without looking out the door to check for any resident and had then turned toward the lobby. The surveyor told the ADM and the DON she had informed ADON A Resident #3 had left the facility when the ADON turned away from the door and went towards the facility's lobby. On 12/14/10 at 11:02 a.m. the ADM brought ADON A to the surveyor to verify she was the person who had reset the alarm to the front door without checking outside for the presence of a resident. The surveyor verified ADON A had reset the alarm without looking outside. At that time, ADON A stated she had reset the alarm, because Resident #10 was sitting near the front door. Note: Resident #10 did not have a wander guard. 3) Review of the list provided by the facility on 12/14/10 at 9:30 a.m. revealed Residents #1, #2, #3, #13, #14, #15, and #16 had wander guards. Resident #10 was not on the list of residents with wander guards. 4) The facility's current Policy and Procedure for Elopement/Missing Resident with the most recent revision dated July 2006 reflected the following: "Policy To formulate an assessment of a resident's potential to elope from the facility and have a plan in place to assure appropriate steps are taken to protect the resident from an elopement. Fundamental Information Elopement assessment will be completed on admission, quarterly and as needed. If the resident is assessed as moderate to high risk the monitoring procedure will be implemented. Procedure 1. Complete the Elopement Assessment Tool. 2. Within 3-5 days of admission, the Interdisciplinary Team (IDT) will evaluate the resident's risk potential and determine the need for further monitoring. 3. If it is determined that the electronic monitoring device is required: ? the monitoring device will be monitored every shift for placement and documented on the MAR's ? the monitoring device will be checked every day for functioning and documented on the MAR's ? the electronic monitoring system will be checked every week for operable functioning 4. The Care Plan will be initiated for those residents identified at risk by the IDT. 5. When a door alarm sounds, ALL facility staff will immediately respond. UNDER NO CIRCUMSTANCES should an alarm be treated as a "FALSE ALARM":... Documentation The Elopement/Wandering Assessment Tool will be completed by the licensed nurse and re-evaluated by the IDT quarterly and as needed...." 5) An IJ was identified on 12/14/10. The ADM and the DON were notified of the IJ in the area of Quality of Care with Substandard Quality of Care with a Partial Extended Survey on 12/14/10 at 10:50 AM. A Plan of Removal for the IJ was requested at that time. 6) During an interview on 12/14/10 at 10:58 a.m. with Maint C, he stated the wander guard would cause the alarm to sound when it was approximately 15 feet away from the door whether the door was opened or closed. After the alarm sounded, the door would lock for 15 seconds and could then be opened. Maint C then demonstrated how the wander guard worked with the locking door alarm. 7) The Admission Record dated 10/22/10 reflected Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. A Resident Transfer Form dated 11/21/10 reflected Resident #1 had [DIAGNOSES REDACTED]. Resident #1's Elopement/Wandering Assessment Tool dated 10/21/10 reflected his score was a "7" placing him at high risk for eloping. The form reflected a wander guard was applied on 10/21/10. Observation on 12/14/10 at 11:05 a.m. revealed Resident #1 had a wander guard on his wrist, and he ambulated independently on the hall. CNA E took Resident #1's hand and walked with him to the front door to check the wander guard. The alarm did not sound, but the door locked. Interview on 12/14/10 at 11:15 a.m. with the DON revealed the alarm should have sounded when the wander guard was near the door, but the door locked, and maintenance would be notified. 8) Review of the Admission Record dated 08/26/10 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Elopement/Wandering Assessment Tools dated 10/19/09, 01/08/10, 04/10/10, 07/01/10 and 12/14/10 reflected her scores varied from "5" to "7" placing her at high risk for eloping. The quarterly assessment due in October 2010 was not done. Observation on 12/14/10 at 11:20 a.m. revealed the door alarm sounded in the Coffee Cup lobby, and CNA F reset the alarm at the door keypad. At that time Resident #2 had a wander guard on, ambulated near the door and the alarm remained silent. Observation on 12/14/10 at 11:23 a.m. revealed Resident #2 had a wander guard on, was beside the Coffee Cup lobby door, and the alarm was silent. 09) Interview on 12/14/10 at 12:08 p.m. with the DON revealed it made her "sick" Resident #3 had eloped, because she wanted the residents to be safe. The DON stated she had only been at the facility for a week, and if she had her way, all residents at risk for elopement would be discharged , because she would not want anything to happen to them. The DON stated the only safe place for Resident #3 was a locked unit. 10) During an interview on 12/14/10 at 3:00 p.m. with Maint C, he revealed alarms had often been found silenced but not reset, and residents would be able to elope because the alarm would not sound if not reset. Maint C stated staff had been told many times the alarms must be reset, but Maint C continued to find alarms not reset. At this time alarm system REP verified all Maint C reported was true regarding how the system functioned. 11) On 12/14/10 at 4:50 p.m., the ADM was notified the Plan of Removal for the IJ was accepted. Review of the Plan of Removal dated 12/14/10 revealed: All staff scheduled to work on 12/14/10 were in-serviced on the elopement policy and appropriate response to door alarms and all other staff would be in-serviced by 12/18/10. All staff in-serviced were able to verbalize understanding and repeat process to be followed. New residents would be assessed for elopement potential and appropriate interventions put into place. The wander guard exit alarm system would be checked by the system's company representative for proper function, all wander guard bracelets had been checked for proper function, and all exit doors had a staff member in place until the system was verified to function properly. All residents were assessed for elopement risk. Resident #3, who eloped on 12/14/10, was monitored one-on-one until discharged to another facility with locking doors on 12/14/10. The facility consulted with the Medical Director to ensure an effective system was in place to address residents at risk for elopement on 12/14/10. The ADM and the DON would monitor compliance of staff with the elopement policy. The effectiveness of the plan will be reviewed and modified as needed. The nurse who failed to check for the missing resident when the alarm sounded was suspended pending investigation. 12) Interview on 12/14/10 at 11:30 a.m. with the ADM revealed the wander guards had been checked for all residents with wander guards. 13) Observation on 12/14/10 at 1:00 p.m. revealed the alarm was sounding and HSK H sat in a chair in front of the exit door on the front hall, left of the lobby area. Interview with HSK H at this time revealed she had to guard the door because the alarm was not working properly. HSK H stated Maint C checked the doors and alarms often to make sure they functioned properly. Observation on 12/14/10 at 1:10 p.m. revealed Maint C sat in a chair near the door in the Coffee Cup lobby. At this time Resident #1 ambulated independently in this lobby. Interview on 12/14/10 at 1:20 p.m. that verified understanding of the elopement policy with CK I and CK J revealed they checked outside the doors in their area when they heard the alarm sound to make sure nobody had gone outside. Observation on 12/14/10 at 1:25 p.m. revealed HSK K sat in a chair in front of the back hall exit door, left of the entrance. Interview with HSK K at this time that verified understanding of the elopement policy revealed he looked at the door closest to him to see if the light was blinking when the alarm sounded. If the light was blinking, he would look outside the door to see if a resident had gone outside. If the light was not blinking at that door, he would go to the nurses' station to see which door caused the alarm to sound and would look out of that door to see if anyone had gone out. Observation on 12/14/10 at 1:30 p.m. revealed MR L sat in a chair near the back hall exit door, right of the entrance. Interview with MR L at this time that verified understanding of the elopement policy revealed staff were to check outside the door near them when the alarm sounded. Observation on 12/14/10 at 1:35 p.m. revealed Resident #3 sat at a table in the lobby with CNA D. Interview on 12/14/10 at 1:37 p.m. with CNA D that verified understanding of the elopement policy revealed when the alarm sounded, he would check the panel to see which door caused the alarm to sound and would look outside to see if anyone had gone out. If nobody was found outside, he would notify the nurse and all residents would be counted to make sure all were in the facility. Interview on 12/14/10 at 1:40 p.m. with LVN M that verified understanding of the elopement policy revealed when the alarm sounded, staff checked the door closest to them to see if anyone went out and checked the panel at either one of the two nurses' stations to see which door caused the alarm to sound. If no residents were found outside, all residents were to be counted to make sure all were in the facility. If a resident was missing, the DON was to be notified and all searched for the resident. If no resident was found missing, the DON was notified the alarm sounded and no residents were missing. Interview on 12/14/10 at 1:55 p.m. with CNA N that verified understanding of the elopement policy revealed if the alarm sounded, staff checked outside to see if any residents had gone outside. If no residents were found outside, all residents were to be counted to make sure all were in the facility. Interview on 12/14/10 at 2:00 p.m. with CNA O that verified understanding of the elopement policy revealed if the alarm sounded staff, staff checked outside to see if any residents had gone outside. If no residents were found outside, all residents were to be counted to make sure all were in the facility. If a resident was found missing, the charge nurse and DON were to be notified. Interview on 12/14/10 at 2:05 p.m. with CNA P that verified understanding of the elopement policy revealed if the alarm sounded, staff checked outside to see if any residents had gone outside. If no residents were found outside, all residents were to be counted to make sure all were in the facility. Interview on 12/14/10 at 2:35 p.m. with CNA Q that verified understanding of the elopement policy revealed if the alarm sounded staff checked the panel at one of the two nurses' stations to see which door caused the alarm to sound, then looked outside that door to see if a resident had gone outside. If no resident was found outside, all residents were to be counted to make sure all were in the facility. Interview on 12/14/10 at 3:00 p.m. with Maint C revealed all doors and wander guards had been checked that afternoon and functioned properly without any repairs or resets. At this time REP verified all Maint C reported was true regarding how the system functioned and that no repairs or resets were needed that day. Interview on 12/14/10 at 3:15 p.m. with HSK S that verified understanding of the elopement policy revealed if the alarm sounded, staff checked outside to see if any residents had gone outside. If no residents were found outside, all residents were counted to make sure all were in the facility. Observation on 12/14/10 at 4:00 p.m. revealed Resident #3 was transferred to another facility. Interview on 12/14/10 at 4:55 p.m. with RN T that verified understanding of the elopement policy revealed another in-service was presented today regarding elopement and alarms. RN T stated staff were to walk around outside to look for residents when the alarm sounded. If no residents were found outside, all residents were to be counted to ensure none were missing. If a resident was missing, the ADM and DON were to be notified while staff looked for the resident. If the resident was not found within 30 minutes, 911 was to be called. RN T stated the alarm was to be reset after the resident was found or after it was determined no resident was missing. Interview on 12/14/10 at 5:05 p.m. with LVN U that verified understanding of the elopement policy revealed staff were to go outside when the alarm sounded to see if a resident had gone outside. LVN U stated all staff were to search for a missing resident. Interview on 12/14/10 at 5:10 p.m. with CNA V that verified understanding of the elopement policy revealed staff were to look outside when the alarm sounded and could silence the alarm only if a resident was found outside. CNA V stated the alarm must also be reset at the nurses' station. Interview on 12/14/10 at 5:15 p.m. with LVN W that verified understanding of the elopement policy revealed staff were to look outside when the alarm sounded and the alarm was to be reset if no residents were missing. Review of the list provided by the facility on 12/15/10 at 6:45 a.m. revealed five additional residents were assessed to need wander guards (Residents #5, #6, #7, #9, and #12). Interview on 12/15/10 at 7:55 a.m. with the ADM revealed ADON A presented the in-services in December 2010 for the day and evening shifts that covered the policy and procedures for elopement and alarms, which included looking outside the door when the alarm sounded. Telephone interview on 12/15/10 at 9:00 a.m. with RN T revealed she presented the in-services in December 2010 for the night shift, weekend staff, and kitchen staff. The in-services covered the policy and procedures for elopement and alarms, which included looking outside the door when the alarm sounded. RN T stated if a resident was not found outside, all residents were to be counted. If a resident was missing, all staff looked for the resident, the ADM and the DON would be notified, and 911 called if the resident was not found. Telephone interview on 12/15/10 at 9:05 a.m. with ADON A revealed she presented the in-service on the elopement policy and documentation of elopement to the nurses, from the 11/27/10 elopement incident. ADON A stated when the alarm sounded, staff were to check the residents and the doors and count the residents to see if anyone was missing. When queried if staff should look outside the door when the alarm sounded, ADON A replied, "I guess." When queried if ADON A told the staff they should look outside the door when the alarm sounded, ADON A replied she could not remember but had given staff a copy of the policy. ADON A stated it was an ongoing problem of alarms sounding a lot, and nobody would be at the door since the construction started. 14) Observation on 12/15/10 at 9:47 a.m. revealed Resident #2 had a wander guard on, ambulated in the hall and sat in a chair in the front lobby. Observation on 12/15/10 at 9:50 a.m. revealed Resident #9 had a wander guard on and sat in the wheelchair in the Coffee Cup lobby. Review of the face sheet dated 08/26/10 revealed Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation on 12/15/10 from 9:50 a.m. to 9:55 a.m. revealed the alarm sounded twice in the Coffee Cup lobby, the AD was present in the room, looked outside both times, and reset the alarm. Interview with the AD at this time revealed the alarm sounded because the residents were close to the door. Interview on 12/15/10 at 10:00 a.m. with LVN X revealed Resident #7 was usually in a wheelchair but took opportunities to get up and walk around. LVN X stated she had observed Resident #7 out in the enclosed patio for supervised smoking, had never observed Resident #7 go out any other doors, and did not know if Resident #7 ever had a wander guard. LVN X stated since the construction began, the alarms went off constantly. Observation on 12/15/10 at 10:05 a.m. revealed Resident #7 had a wander guard on, stood at the kitchen door and asked for a cup of tea. The wheelchair was about 10 feet away from Resident #7. Interview on 12/15/10 at 10:10 a.m. with LVN Y revealed Resident #7 was usually in a wheelchair but could independently transfer and ambulate to the bathroom. LVN Y stated it was reported to LVN Y Resident #7 previously had a wander guard, but Resident #7 would take it off and throw it. LVN Y stated Resident #7 had a wander guard today and had not yet taken it off. Interview on 12/15/10 at 10:25 a.m. with LVN G revealed today was the first time LVN G observed Resident #7 go out any door except for the door to the enclosed patio. LVN G did not know if Resident #7 had a wander guard in the past. Interview on 12/15/10 at 10:35 a.m. with CNA O revealed CNA O observed Resident #7 go outside the front door about a month ago to eat cigarette butts. CNA O stated a wander guard was put on Resident #7's wheelchair at that time, but the CNA did not know when it was taken off. Interview on 12/16/10 at 1:40 p.m. with LVN Y revealed nurses did elopement assessments upon Admission. Nurses also did them quarterly if there was a change. Nurses also communicated with the Social Worker so they could have a care plan and address the need for interventions. When the surveyor queried how they knew to do these assessments, LVN Y replied, "We just know." Interview on 12/16/10 at 1:45 p.m. with LVN X revealed the admitting nurse did the elopement risk assessment depending on the score then, it was care planned. The quarterly updates were done by the nurses. When asked about elopement risk assessments during an interview on 12/16/10 at 1:54 p.m., LVN G stated, "We do those on admission and then we have to do them quarterly." 15) Review of the Admission Record dated 08/26/10 revealed Resident #7 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's Elopement/Wandering Assessment Tool was dated with completed assessments on 11/20/09, 02/08/10, and 07/01/10. The assessment due in October 2010 was not done. The resident was assessed with [REDACTED]. Review of Resident #7's clinical record revealed physicians' consolidated monthly orders dated August 2010 through November 2010 that reflected no orders for wander guard placement or monitoring. Resident #7's MDS assessment dated [DATE] reflected wandering behavior occurred daily, but "the wandering does not place the resident at significant risk of getting to a potentially dangerous place." The MDS assessment further reflected the resident's behavior of wandering had not changed since the prior assessment. The MDS assessment reflected the resident required the supervision of one person for locomotion on and off the unit and used a wheelchair for mobility. On 12/15/10, a review of Resident #7's care plan dated 08/01/10 revealed the resident was to wear a wander guard bracelet and was at risk for injury from wandering in an un-safe environment. The care plan further reflected Resident #7's wander guard was to be monitored for placement and proper functioning. These goals and approaches were updated on 11/10/10. An undated care plan with the same previous goals and approaches was provided by the facility on 12/15/10, as the new reevaluated care plan for Resident #7. Observation on 12/14/10 at 4:02 p.m. revealed Resident #7, who was seated in a wheelchair, independently wheeled himself out the front door of the facility. No alarm sounded. There was no wander guard observed on Resident #7 or on the wheelchair. RN T immediately went outside after Resident #7 and asked him what was in his hand. Resident #7 showed RN T the cigarette butts in his hand. RN T took the cigarette butts from Resident #7 and wheeled the resident inside. Interview at that time with RN T revealed Resident #7 liked to eat cigarette butts. RN T stated the resident functioned and acted like a child, because Resident #7 had been in an automobile accident. RN T stated Resident #7 often took off his wander guard and sometimes the facility would put the wander guard on Resident #7's wheelchair. Review of Resident #7's clinical record revealed MARs/TARs documentation for the wander guard placement dated 12/14/10. Review of Resident #7's clinical record revealed MARs/TARs for August 2010 through November 2010 reflected no documentation for the wander guard placement. Review of Resident #7's clinical record revealed physicians' order dated 12/14/10 that reflected wander guard bracelet at all times, verify placement every shift, and verify functionality every shift. Further review revealed a physicians' order to monitor Resident #7 every fifteen minutes until wander guard was placed. Review of Resident #7's clinical record revealed nurse's notes dated 12/14/10 monitoring the wander guard on the resident. Nurse's Notes at 10:00 p.m. on 12/14/10 reflected no wander guard was observed on Resident #7. The on-call supervisor was informed and every fifteen minute checks began. 16) On 12/15/10 at 10:50 a.m., the ADM, the DON, and the facility's Regional Director were notified Resident #7 was added to the Immediate Jeopardy action and a Plan of Removal was required to address Resident #7's needs as an elopement risk. 17) Review of the Plan of Removal dated 12/14/10 revealed it was revised with interventions for Resident #7, which included: A wander guard was placed on both Resident #7 and on his wheelchair. The resident was immediately placed on one-on-one supervision until appropriate discharge could occur. The facility would actively seek to find placement for Resident #7 in a more secured setting. The resident's family and physician have been notified. 18) The facility was notified at approximately 1:00 p.m. on 12/15/10 of the acceptance of the revised Plan of Removal. 19) Observation on 12/15/10 at 9:45 a.m. revealed Resident #7 had a wander guard on, wheeled the wheelchair to the front door and tried to open it. The alarm sounded, staff looked outside, reset the alarm, and re-directed Resident #7 away from the door. Observation on 12/16/10 at 7:00 a.m. revealed Resident #7 was sleeping in his room and a sitter was in the room. At 8:16 a.m., Resident #7 was sleeping in his room. An interview at that time with the sitter (unidentified staff member) revealed Resident #7 was being monitored one-on-one until the facility found another place for Resident #7 to live, which was safer. Observation on 12/16/10 at 8:55 a.m. revealed HSK K was monitoring Resident #7 one-on-one while he was outside the Coffee Cup lobby smoking with other residents. Observation on 12/16/10 at 9:23 a.m. revealed Resident #7 was wheeling down the hallway with the wander guard on his left ankle. 20) Interview on 12/16/10 at 11:00 a.m. with Corp. RN revealed Resident #9 w

Based on interview and record review, the facility failed to notify one (Resident #1) of one resident's physician and/or PA when Resident #1 had an injury and had the potential for requiring physician intervention for three days. Resident #1's family member informed LVN A Resident #1 had pain in her right leg on 10/25/10. Resident #1's family member told LVN A again and the CNAs caring for Resident #1 told LVN A the resident's knee was red and there was swelling on the side. LVN A did not contact Resident #1's physician or PA. CNA D informed LVN C of Resident #1's knee injury on 10/28/10 and LVN C attempted to notify the PA but the PA did not return the call. The DON notified the PA of Resident #1's red and swollen knee and the PA ordered the resident to be seen by an Orthopedic Surgeon. The DON scheduled the appointment for 10/29/10. The Orthopedic Surgeon discovered Resident #1's right femur was fractured and she was sent from his office to the hospital for treatment. The failure to notify Resident #1's physician and/or PA of the injury placed Resident #1 at risk for complications related to the fracture such as a [MEDICAL CONDITION] and at risk for undue pain. This failure had the potential to affect all 76 residents residing in the facility. Findings included: The facility Record of admitted d 04/30/10 reflected Resident #1 was admitted on [DATE]. The consolidated Physician order [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had memory problems and was modified independent with her cognitive skills for daily decision-making. She was dependent on staff for toileting, personal hygiene and bathing. She needed the assistance of 2 or more staff with transfers and she was unable to walk. Resident #1 had no impairment of the upper and lower extremities and she utilized a wheelchair. Resident #1 was incontinent of bowel and bladder. The facility Provider Investigation Report dated 11/02/10 reflected Resident #1 sustained a significant injury of unknown origin. The report also reflected family member #1 informed (no date) to the 2:00 PM to 10:00 PM LVN, (LVN A), Resident #1 was having complaints of pain. The Investigation Summary reflected, "Resident suffered significant injury. Unknown how this occurred. No fall reported. Resident complained of pain and swelling noted on legs. No follow-up done to assess extent of injury in timely manner. No Nursing documentation done. Injury discovered during routine Dr. Appt." The Report reflected the resident sustained [REDACTED]. The Report also reflected Resident #1 was sent to the hospital by Physician B for treatment. A telephone interview conducted with Family Member #1 on 11/10/10 at 2:30 PM revealed the family member said on October 25, 2010 (Monday) he/she told a nurse Resident #1 was having pain in her knee and thought it was broken. Family Member #1 stated Resident #1 told the family member she did not remember a fall and it did not happen in bed. He/she stated at that time he/she asked the nurse to put Resident #1 in bed and check her leg. He/she was unable to state which nurse. The family member further stated he/she told the same nurse a second time either the next day or the following day when he/she came in for a visit. Family member #1 stated the LVN was going to put Resident #1 to bed to rest which was unusual. He/she went on to say Resident #1 usually sat up all day in the wheelchair and was able to use her feet some to move herself. A telephone interview conducted with LVN A on 11/12/10 at 11:55 AM revealed Family Member #1 came to her on Tuesday, 10/26/10, after dinner and told her Resident #1 was complaining of knee pain. She stated Family Member #1 asked her to check the knee later after she left. LVN A stated she assessed Resident #1's knee. She stated it looked a little swollen but was intact and showed no redness. She stated one knee was swollen slightly more than the other but not significantly. LVN A asked Resident #1 if she was in pain and she said no. LVN A stated after dinner on (Wednesday) 10/27/10 the CNAs, who were assisting Resident #1 to bed, informed her Resident #1's knee was red and had swelling on the side. LVN A stated she looked at the knee and once again felt around and found the knee intact with swelling and redness. She told the CNAs to place a pillow between her legs because she thought the redness was from Resident #1 clenching her legs together and her knees rubbing back and forth. The LVN stated she was going to document and put the information in the 24 hour book, but she was distracted by some construction in the building and she ran out of time. LVN A stated upon arriving on 10/28/10 (Thursday) she was informed Resident #1 was not to get out of bed and she had a Doctor's appointment on 10/29/10 (Friday) at 10:30 AM. During the interview, the LVN stated in hind sight she should have consulted the physician for an x-ray on 10/26/10 and documented in the resident's chart she had noticed slight swelling. An interview conducted with CNA I, who worked the 2:00 PM to 10:00 PM shift on Resident #1's hall, on 11/12/10 at 2:35 PM revealed she reported to LVN A on Wednesday, 10/27/10, Resident #1's knee was red and there was swelling on the side of her knee. She stated Resident #1 always kept her legs together, but her leg had redness on the inner right knee, but it was not open. She further stated it looked indented. CNA I stated LVN A came and put a pillow between her knees. The CNA stated when they sat her in bed she complained of her knees hurting. An interview conducted with CNA J, who worked the 2:00 PM to 10:00 PM shift on Resident #1's hall, on 11/10/10 at 4:15 PM revealed the resident's knees were contracted and the resident complained about them hurting. CNA J stated Resident #1 had some scars on her knees and a red spot between her knees. CNA J stated she told LVN A about the red spot and was told to put a pillow between her knees because of the contraction. An interview conducted on 11/12/10 at 10:15 AM with CNA D (who reported the knee injury to LVN C on 10/28/10) revealed she reported it to LVN C on her first round at 11:30 PM. She stated the knee was bruised red/purple. CNA D stated it looked really bad and looked like the bone was going to pop out. The CNA stated Resident #1 normally clenched her legs together. The CNA stated she asked Resident #1 if she was in pain and where. She stated she asked the resident if it hurt when she moved her and the resident stated, "Yeah." She stated Resident #1 had to be rolled in bed during incontinent care because she was not able to move herself. CNA D stated that at that time she was afraid to roll Resident #1 because something might pop out. A telephone interview conducted with LVN C on 11/12/10 at 2:45 PM revealed on 10/28/10 CNA D came to her and told her about Resident #1's leg. LVN C stated the previous nurse, LVN A, did not report anything about the knee. She stated Resident #1's leg was red and she could see something moving. She stated there was no open area. The LVN also stated there was no obvious pain. During the interview the LVN was asked to further describe the area involved and she stated the hardware was sticking out in the area of the medial aspect of the right knee and had redness possibly 3.0 x 3.0 cm in diameter and was a pinkish red in color. The LVN stated she called the PA about getting an x-ray but did not hear back from him. LVN C passed the information on to LVN E, the 6:00 AM to 2:00 PM shift nurse. LVN C stated that it was decided by the PA Resident #1 needed to be seen by an Orthopedic surgeon right away. An interview conducted with the DON on 11/10/10 at 3:05 PM revealed she received a note from the night nurse, LVN C, that some of Resident #1's hardware from a previous knee replacement was protruding from the leg. She stated it was reported the skin was not broken at that time. The DON stated she looked at the knee and it was swollen, not noticeably red, a protrusion was observed and the skin was not broken. She stated the resident was not complaining of pain that morning. The DON stated she notified the PA who ordered Resident #1 see an Orthopedic Surgeon. The DON stated an appointment was made with Physician B for 10:30 AM on 10/29/10. The DON further stated during the interview no one else reported anything previously. An interview conducted with LVN E on 11/12/10 at 12:30 PM revealed she gave Resident #1 pain medication on Thursday, 10/28/10, and Friday, 10/29/10 when the resident went to the doctor. She stated when she observed the knee, the resident was not complaining of pain but due to how the knee looked, she thought the resident was probably in pain and she gave her some pain medication. A telephone interview conducted with Physician B on 11/12/10 at 4:25 PM revealed he was the surgeon who evaluated Resident #1's leg. He stated Resident #1 sustained a Distal Femur fracture which appeared to have been there for a few days. It was more than an acute fracture and it did not happen that day. He stated it occurred a few days prior. Physician B stated the fracture was not a spontaneous osteopenic break, but most likely a patient related incident. He stated it was a hard break such as a fall or being dropped in a bad transfer. Physician B also stated there were no signs of a previous knee replacement. The Nurse's Notes dated 10/28/10 (Thursday) at 4:30 AM, written by LVN C (10:00 PM to 6:00 AM shift nurse) reflected, "Called in Rm (room) by CNA R (right) knee red SL (slightly) [MEDICAL CONDITION] looking. S/P (status [REDACTED]. Call to ____(PA)." The Nurse's Notes dated 10/28/10 at 8:30 AM written by LVN E, the 6:00 AM to 2:00 PM nurse, reflected, " _______ (PA) returned phone call to DON. Said to refer resident to former surgeon. Unable to determine surgeon. Refer to Physician B. Family notified of appointment 10/29 @ (at) 1030." The Nurse's Notes dated 10/29/10 at 12:00 AM signed by LVN C, the 10:00 PM to 6:00 AM nurse, reflected, "R (right) knee w/ (with) wrap intact resting ou (both eyes) closed. Skin WD (warm and dry) no c/o pain." There was no further documentation after the 10/29/10 entry. An Incident/Accident Report dated 10/29/10 was included in the facility Provider Report which documented Resident #1 was transferred from the bed to the wheelchair and taken to the physician's office. The Report also reflected the right femur fracture was found while at the physician's office and the resident was sent to the hospital. The report further reflected an investigation was in progress. The hospital History and Physical dated 10/29/10 reflected, "Right thigh is somewhat swollen, especially around the distal thigh and knee region, where she has significant [DIAGNOSES REDACTED] and [MEDICAL CONDITION], with questionable fluctance and underlying hematoma. She does have an obvious deformity to the distal thigh region at the knee level." The report also reflected the radiographs showed the presence of right distal femur fracture and she would be admitted for surgical repair and management. The report reflected Resident #1 would require close monitoring of her blood pressure as well as her mental status and pain management. The History and Physical also reflected Resident #1 was anemic and would require monitoring of her Hemoglobin and Hematocrit (H/H) and her renal functions. The Orthopedic Consult Note dated 10/29/10 reflected the x-ray results showed a displaced distal femur fracture and tenting of the skin with [DIAGNOSES REDACTED] and blistering. The x-ray results dated 10/29/10 reflected, "Two views of the right femur demonstrated a severely displaced [MEDICATION NAME] oriented [MEDICAL CONDITION] femoral diametaphyseal region with comminution at the fracture site and possibly one full width bony displacement. Impression: Comminuted (breaking into pieces such as shattered bone) and displaced distal femoral fracture. " The Resident Census and Conditions of Residents form (CMS-672) dated 11/10/10 and signed by the MDS Coordinator reflected the facility had a census of 76 residents.