Every finding on record at Columbia Rehabilitation and Healthcare Center

Based on observation, interview, record review, and facility policy review, the facility failed to provide daily oral care for over three weeks for a resident who was totally dependent on staff for personal hygiene and oral care. This failure resulted in visible plaque buildup and placed the resident at risk for oral infection, discomfort, and diminished quality of life for one (1) of five (5) residents reviewed for activities of daily living (ADLs). Resident #43. Findings include: A record review of the facility policy Activities of Daily Living (ADL) Supporting revised 3/2018 revealed, Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene On 9/8/25 at 1:07 PM, during an observation and interview with Resident #43, he communicated that it had been over three weeks since his teeth had last been brushed. He communicated a desire to have his teeth brushed at least once per day and revealed that he required staff assistance to complete this task. Observation revealed significant plaque buildup on both his upper and lower teeth.On 9/9/25 at 8:59 AM, during a follow-up observation and interview with Resident #43, he communicated that his oral care had still not been provided. Observation revealed plaque remained visibly built up on both his upper and lower teeth.On 9/9/25 at 2:38 PM, an interview and in-room observation were conducted with the Registered Nurse (RN) Supervisor #1, who confirmed the resident's teeth appeared as though they had not been brushed in some time. She stated that oral care should be provided daily as part of the resident's assigned ADL care.On 9/9/25, at 2:41 PM, the RN Supervisor, State Agency (SA), and Certified Nursing Assistant (CNA) #1 entered the resident's room. CNA #1 acknowledged that she was assigned to Resident #43 on both the current and previous day. She admitted that she had not brushed the resident's teeth on either day and confirmed that daily oral care was required as part of her responsibilities, given the resident's inability to perform the task independently.During an interview with the Director of Nursing (DON) on 9/11/25 at 1:41 PM, she explained that oral care is a part of the daily ADL care that the CNAs perform and that she expects them to perform it as required.A record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis following cerebral infarction affecting the left non-dominant side and Aphasia.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/25 revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Section GG Oral Care indicated the resident was totally dependent on one staff member for all personal hygiene and oral care tasks.

Based on observations, interviews, record reviews and facility policy review, the facility failed to administer medication in a manner to prevent infection for one (1) of four (4) medication administrations observed. Resident #99. Findings Include:A record review of the facility's Infection Prevention and Control Program with a revision date of 6/30/25 revealed An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection .On 09/10/25 at 8:25 AM, revealed Licensed Practical Nurse (LPN)#1 administered morning medication consisting of: Renvela Oral Tablet 800 milligrams (mg), Aspirin Enteric Coated (EC) Tablet Delayed Release 81 mg, B-Complex/Folic Acid/Vitamin C Oral Tablet Extended Release (B-Complex w/ C & Folic Acid),Clopidogrel Bisulfate Tablet 75 MG, Hydralazine HCl Oral Tablet 100 MG by mouth and Combigan Ophthalmic Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol Maleate) one drop in each eye. LPN#1 gathered the medications and entered Resident #99's room. Resident #99 poured his medication on the overbed table and picked up one pill at time and placed it in his mouth. Resident #99's breakfast tray was still on the table and three pills rolled under his tray. LPN#1 moved the tray back and picked up the pills with her bare hands and placed them back on Resident #99's overbed table. Resident #99 continued to take the medications one at a time. LPN #1 sanitized her hands and applied gloves and administered Resident #99's eye drops. LPN#1 removed her gloves and the resident stated You put the gloves on too late. You should have put them on before picking my pills up in your hands.On 09/10/25 at 8:45 AM, in an interview with LPN #1 she confirmed she was not supposed to pick up pills with her bare hands. She stated it is an infection control issue.A record review of Resident #99's Order Summary Report revealed physician orders for Renvela Oral Tablet 800 mg, Aspirin EC tablet delayed release 81 MG, B-Complex/Folic Acid/Vitamin C Oral Tablet Extended Release (B-Complex w/ C & Folic Acid),Clopidogrel Bisulfate Tablet 75 MG, Hydralazine HCl Oral Tablet 100 MG, all the above medications were by mouth and Combigan Ophthalmic Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol Maleate) one drop each eye.A record review of Resident #99 admission Record revealed an admission date of 9/5/25 with diagnoses that included Peripheral Vascular Disease, Unspecified Anemia, Chronic Kidney Disease, and Primary open-angle Glaucoma, bilateral severe stage. On 09/11/25 at 1:27 PM, in an interview Registered Nurse (RN) #3/ Infection Preventionist/Assistant Director of Nursing (IP/ADON) revealed LPN #1 should not have touched the medication with her bare hands. She should have let the resident pick them up by moving tray so the resident could get the medication. She stated that it is an infection control issue.On 09/11/25 at 1:35 PM, in an interview the Director of Nursing (DON) stated that LPN #1 should have washed her hands before picking up pills with her bare hands off the table. She stated that it is infection control issue.

Based on observation, interview, and facility policy review the facility failed to ensure that food was palatable, attractive, and served at a safe and appetizing temperature for five (5) of (5) sampled food items. Specifically, the facility failed to ensure that meals were maintained at appropriate temperatures prior to service, which had the potential to affect the taste, safety, and nutritional value of meals served to residents.Findings include:A record review of the facility policy titled Food: Quality and Palatability, dated 2/2023, revealed .Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature.Definitions.Proper (safe and appetizing) temperature. Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction.On 9/8/25 at 11:49 AM, temperatures of food items on the steam table were recorded as follows: chicken breast 109 Fahrenheit (F), pureed noodles 100 F, pureed peas 101 F, and pureed chicken 119 F. Only the chopped chicken reached a temperature of 148 F.On 9/8/25 at 12:01 PM, during an observation conducted with the Dietary Manager (DM), food items were observed being placed from the oven onto the steam table. The dietary staff then plated the food, placed onto carts, and served to residents in the dining hall at the temperatures documented as above. The DM acknowledged that steam table foods should reach and maintain at least 135 F to ensure proper holding temperature. She further confirmed that the kitchen's window air conditioning unit blows directly over the steam table, contributing to premature cooling of the food items. Despite knowing this, she stated the facility had not implemented any corrective action or reliable protocol to maintain safe, warm, and appetizing food temperatures prior to meal service.On 9/9/25 at 7:47 AM, observation revealed the window air conditioning unit was again running and blowing directly onto the steam table. Temperature checks at that time revealed scrambled eggs at 108 F and pureed eggs at 100 F. The State Agency (SA) observed during this time food being plated, placed onto carts and being served to residents in the dining hall.

Based on observations, interviews, record reviews and facility policy review the facility failed to administer medications by Percutaneous Endoscopic Gastrostomy (peg) tube according to physician orders for one (1) of four (4) medication observations. Resident #16.Findings Include:A record review of the facility's Administrating Medication through an Enteral Tube last reviewed date of 6/2025 revealed .General Guidelines.3. Administer each medication separately and flush between medications.On 09/10/25 at 9:00 AM, during an observation morning med administration by Licensed Practical Nurse (LPN) #2 revealed LPN#2 crushed the medications and placed each medication separately in a dispense cup with 5 cubic centimeters (cc) water. The following medications were given by peg tube Amiodarone HCl Oral Tablet 400 MG (Amiodarone HCl, Aspirin Oral Tablet Chewable 81 MG (Aspirin) , Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Apixaban Oral Tablet 2.5 MG (Apixaban), Furosemide Oral Tablet 20 MG (Furosemide), lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole),Potassium Chloride Oral Solution 20 MEQ/15ML, Fish Oil Oral Capsule 1000 MG (Omega-3 Fatty Acids, Vision Formula/Lutein Oral Tablet (Multiple Vitamins w/ Minerals). LPN #2 administered the medications by peg tube but did not flush with water between the medications. After administering all medications, LPN#2 then flushed the peg tube with 30cc of water. On 09/10/25 at 9:59 AM, in an interview LPN #2 stated she thought she did something wrong but was not sure. She stated, I usually flush between medications, but I am not sure. On 09/10/25 at 2:20 PM, in an interview LPN #2 confirmed that she did not flush between medications as ordered by physician. She stated she forgot to flush between medications. She stated the reason for flushing is to make sure residents get all the medication and that by not flushing the peg tubing can become clogged. On 09/11/25 at 1:30 PM, in an interview with Registered Nurse (RN) #3)/ Assistant Director of Nursing (ADON) stated LPN #2 should have followed physician orders. She stated the purpose of flushing is to keep the tube patent. She stated she expects nurses to follow physician orders.On 09/11/25 at 1:38 PM, in an interview the Director of Nursing (DON) stated LPN #2 should have flushed the peg tube between medications. She stated the purpose is to make sure medications go down and make sure tube is patent. She stated the medication may not work effectively if physician orders are not followed. She stated she expects all staff to give medications correctly and way they have been trained. A record review of Resident #16 Physician Orders revealed orders for Amiodarone HCl Oral Tablet 400 MG (Amiodarone HCl, Aspirin Oral Tablet Chewable 81 MG (Aspirin),Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Apixaban Oral Tablet 2.5 MG (Apixaban), Furosemide Oral Tablet 20 MG (Furosemide), lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole),Potassium Chloride Oral Solution 20 MEQ/15ML, Fish Oil Oral Capsule 1000 MG (Omega-3 Fatty Acids, Vision Formula/Lutein Oral Tablet (Multiple Vitamins w/ Minerals). Flush with 10 cc water of water between medications.A record review of Resident #16's admission Record revealed an admission date of 1/30/25 with diagnoses that included Chronic Respiratory Failure with Hypoxia, Dyspnea unspecified, and Encounter for attention to Tracheostomy.A record review of Resident #16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates the resident was cognitively intact.

Based on observations, interviews, record reviews and facility policy review the facility failed to follow the comprehensive care plan related to Percutaneous Endoscopic Gastrostomy (peg) tube medication for one (1) of (1) peg tube medication observations. Resident #16Findings Include:A record review of the facility's Care Plans, Comprehensive Person-Centered last review date 1/2023, revealed A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.A record review of Resident #16 comprehensive care plan created on 8/19/25 included interventions Administer (proper name of each medication) as ordered.During an observation on 09/10/25 at 9:00 AM, during morning medication administration by Licensed Practical Nurse (LPN) #2 revealed LPN#2 crushed the medications and placed each medication separately in a dispense cup with 5 cubic centimeters (cc) water. The following medications were given by peg tube Amiodarone HCl Oral Tablet 400 MG (Amiodarone HCl, Aspirin Oral Tablet Chewable 81 MG (Aspirin) , Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Apixaban Oral Tablet 2.5 MG (Apixaban), Furosemide Oral Tablet 20 MG (Furosemide), lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole),Potassium Chloride Oral Solution 20 MEQ/15ML, Fish Oil Oral Capsule 1000 MG (Omega-3 Fatty Acids, Vision Formula/Lutein Oral Tablet (Multiple Vitamins w/ Minerals). LPN #2 administered the medications by peg tube but did not flush with water between the medications. After administering all medications, LPN#2 then flushed the peg tube with 30cc of water. In an interview on 09/10/25 at 9:59 AM, LPN #2 stated she thought she did something wrong but was not sure. She stated, I usually flush between medications, but I am not sure. In an interview on 09/10/25 at 2:20 PM, LPN #2 confirmed that she did not flush between medications as ordered by physician. She stated she forgot to flush between medications. She stated the reason for flushing is to make sure residents get all the medication and that by not flushing the peg tubing can become clogged. In an interview on 09/11/25 at 1:30 PM, with Registered Nurse (RN) #3)/ Assistant Director of Nursing (ADON) stated LPN #2 should have followed physician orders. She stated the purpose of flushing is to keep the tube patent. She stated she expects nurses to follow physician orders.In an interview on 09/11/25 at 1:38 PM, the Director of Nursing (DON) stated LPN #2 should have flushed the peg tube between medications. She stated the purpose is to make sure medications go down and make sure tube is patent. She stated the medication may not work effectively if physician orders are not followed. She stated she expects all staff to give medications correctly and way they have been trained. In an interview on 09/11/25 at 1:42 PM, Registered Nurse (RN) #2/Minimum Data set (MDS)/care plan nurse stated the purpose of the care plan is an outlook of what the residents care should be for all staff to follow. She confirmed LPN#2 did not follow the care plan. She stated she expects staff to follow the care plan.A record review of Resident #16 Physician Orders revealed crushed medications and placed each medication separately in a dispense cup with 5 cc water. The following medications were given by peg tube Amiodarone HCl Oral Tablet 400 MG (Amiodarone HCl, Aspirin Oral Tablet Chewable 81 MG (Aspirin) , Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Apixaban Oral Tablet 2.5 MG (Apixaban), Furosemide Oral Tablet 20 MG (Furosemide), lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole),Potassium Chloride Oral Solution 20 MEQ/15ML, Fish Oil Oral Capsule 1000 MG (Omega-3 Fatty Acids, Vision Formula/Lutein Oral Tablet (Multiple Vitamins w/ Minerals). Flush with 10 cc water of water between medications.A record review of Resident #16's admission Record revealed an admission date of 1/30/25 with diagnoses that included Chronic Respiratory Failure with Hypoxia, Dyspnea unspecified, and Encounter for attention to Tracheostomy.

Based on record review, facility policy review, and interview, the facility failed to complete and submit a Minimum Data Set (MDS) discharge assessment in a timely manner in two (2) of (2) discharged residents reviewed. Findings include:On 09/11/2025 at 9:58 AM, during a record review and interview with Registered Nurse (RN) #2/ MDS nurse, it was revealed that Resident #98 was admitted on [DATE] and discharged home on [DATE]. The discharge assessment with an Assessment Reference Date (ARD) of 06/14/2025, was submitted on and accepted on 07/09/2025, which is 25 days after the discharge date . On 09/11/2025 at 2:10PM, in an interview with the Administrator, the MDS discrepancy was discussed and the Administrator verbalized understanding of the importance of getting MDS records submitted on time. On 09/11/2025 at 2:24 PM, in an interview with the Director of Nursing (DON), the MDS discrepancy was discussed. The DON stated that she was aware of the discrepancy and saw where it could be a problem.Record review of the Resident Assessment Instrument (RAI) Manual, a discharge assessment must be completed within 14 calendar days after the resident's discharge and submitted no later than 14 days after completion.Record review of the MDS Coding Policy, reviewed 6/2/25 revealed that the facility utilizes the most up to date Resident Assessment (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately.

Based on observation, interview, record review and policy review, the facility failed to ensure placement was checked for a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administration of medications for one (1) of two (2) residents observed with PEG tubes. Resident #6. Findings include: Review of the facility's policy titles, Enteral Feedings Safety Precautions, reviewed January 2023, revealed, Purpose: To ensure the safe administration of enteral nutrition . General Guidelines . Prevention aspiration 1. Check enteral tube placement every 4 hours and prior to feeding or administration of medication . On 5/8/24 at 8:06 AM, in an observation of Resident #6 receiving medications per PEG tube, Licensed Practice Nurse (LPN) #1 did not confirm placement prior to administering Ferrous Sulfate solution 220 milligrams (mg), Clonidine HCL 0.1 mg, Levothyroxine Sodium 175 micrograms (mcg) and Amlodipine Besylate 10 mg. On 5/8/24 at 8:18 AM, in an interview with LPN #1, she confirmed she forgot to check PEG tube placement prior to administering medications through Resident #6's tube. She stated that by not checking placement, the resident's medication can go into the wrong area and cause the resident to become sick. On 5/9/24 at 12:40 PM, during an interview with the Director of Nurses (DON), she confirmed LPN #1 should have checked placement of the PEG tube prior to administering medications. She revealed that by not checking placement, Resident #6 could develop serious complications related to displacement of the tube. A record review of the Admission Record for Resident #6 revealed the facility admitted the resident on 8/9/22, with diagnoses that included Esophageal obstruction, Personal History of Malignant Neoplasm of Larynx, and Dysphagia, Oropharyngeal Phase. Review of the Quarterly Minimum Data Set (MDS) for Resident #6, with Assessment Reference Date (ARD) 4/2/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on interview, record review, facility investigation, and policy review the facility failed to ensure a resident was protected from sexual harassment/sexual abuse for one (1) of four (4) residents sampled. Resident #1 Findings include: A review of the facility's policy, Abuse Prohibition Policy, revised 11/7/2023, revealed, INTENT: .Each resident has the right to be free from abuse, mistreatment . DEFINITIONS: Sexual abuse includes, but is not limited to rape, sexual harassment, sexual coercion or sexual assault . Identification: 1. Any allegations of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately .Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions . Record review of the Facility Investigation with an initiation date of 11/26/23 revealed that on 11/26/23, Certified Nurse Aide (CNA) #2 reported that CNA #1 had made unwanted, inappropriate sexually, explicit suggestions toward her. The facility had initiated an investigation that included reports that CNA #1 had been asking female CNAs for their telephone numbers. The Disciplinary Action Record dated 11/26/23, signed by CNA #1 revealed a written counseling was provided by the Administrator, Director of Nurses (DON) and Assistant Director of Nurses (ADON). As part of the investigation related to the actions of CNA #1, the ADON conducted Life Satisfaction Rounds on 12/19/23 and interviewed residents with a Brief Interview for Mental Status (BIMS) score of 13 or higher that received care from CNA #1. The interviews revealed that Resident #1 reported having received inappropriate comments and text messages from CNA #1. A written statement from Resident #1, signed on 12/19/2023, revealed that the resident felt like she had been sexually harassed. Record review of the Grievance report, signed and dated 12/19/23, by the Social Services Director (SSD) revealed Resident #1 initiated a grievance of sexual harassment by CNA #1 . 4. Describe the grievance: Resident shows ADON a series of sexually explicit messages received from CNA #1 and reported feeling sexually harassed . 8. A summary of the pertinent findings and conclusions: CNA #1 already on leave pending investigation of sexual harassment of a CNA . 10.What corrective action will be taken to prevent recurrence: Assisted Resident (#1) to block his (CNA #1) number of CNA #1 . On 2/05/24 at 12:55 PM, an interview with the SSD revealed that she was made aware of the allegation of sexual abuse of Resident #1 by the ADON on 12/19/23 who presented the resident's personal cellular telephone and showed her messages that CNA #1 had sent to Resident #1. The SSD stated that she interviewed Resident #1 as quickly as possible on 12/19/23 and followed up on 12/20/23. She stated that the resident was without physical, emotional, or psychosocial harm. The SSD stated that Resident stated she was not bothered by the text messages but wanted CNA #1 to stop messaging her. Record review of the printouts of Facebook Messages provided by Resident #1, from her cell phone, revealed sexually explicit messages were received from a telephone number provided by CNA #1 as his own. On 2/05/24 at 4:05 PM, during an interview the Administrator, he confirmed that CNA #1 had been placed on suspension during an investigation involving sexual harassment of CNA #2. He stated that the last day CNA #1 worked at the facility was 12/13/23. As part of the investigation, on 12/19/23, the facility conducted Life Satisfaction Interviews with residents that CNA #1 had assisted with their care and during the interviews, Resident #1 reported feeling sexually harassed and had provided sexually explicit messaged received on Facebook Messenger from CNA #1. The Administrator reported that CNA #1 was terminated due to 'Misconduct' on 12/21/24. On 2/05/24 at 4:20 PM, during an interview with the ADON, she confirmed that on 12/19/23, Resident #1 had reported that CNA #1 had sent inappropriate sexually explicit messages to her that made her feel that she was being sexually harassed. The ADON reported that Resident #1 gave facility administration access to her personal cell phone and the messages were printed. The ADON confirmed that the photograph that accompanied the Facebook Messages received by Resident #1 was that of CNA #1. On 2/06/24 at 7:53 AM, during a telephone interview the Detective at the local police department (PD), he confirmed that the facility reported an allegation of Resident Abuse of a Vulnerable Adult alleged against CNA #1 by Resident #1. The Detective reported that he had investigated and felt he had enough evidence to substantiate the allegation of sexual harassment of a vulnerable adult as defined by the Vulnerable Adult Act. He stated that he had presented his evidence to the local District Attorney and charges were being considered. He said that he considered CNA #1 sexually abusive and stated that he did not believe that CNA #1 should be working with vulnerable adults. In a post survey telephone interview on 2/07/24 at 2:52 PM, during a telephone interview, CNA #1 stated he was familiar with Resident #1 and stated that he had sent messages to Resident #1 but denied that they were inappropriate and said he couldn't recall when he sent them. CNA #1 confirmed that the telephone number on the Facebook messages received by Resident #1 had been his telephone number but said he no longer had that number. In a post survey telephone interview on 2/07/24 at 4:48 PM, during a telephone interview with Resident #1, she reported that sexually harassing messages came to her cell phone via Facebook Messager in December of 2023, while she was a resident at the facility. She stated she had not immediately reported the messages because she had not wanted to get CNA #1 in trouble, but when the ADON interviewed her on 12/19/23 she told the ADON and showed the ADON the messages. She stated that she recognized the photograph that accompanied the messages as CNA #1 and said, I knew it was him. She said she thought it was wrong of CNA #1 to offer her a place to live in exchange for sexual favors. Resident #1 stated she felt sexually harassed by CNA #1. She stated that she was OK and said she had not experienced any negative effects related to the incident. Record review of the Admission Record for Resident #1 revealed that she was admitted by the facility on 11/01/23, and had diagnoses that included Cardiogenic Shock, Presence of Automatic (Implantable) Cardiac Defibrillator, and Unspecified Systolic (Congestive) Heart Failure. Record review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/23 for Resident #1 revealed the resident had a Brief interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Based on the facility's implementation of corrective actions completed by 12/20/23, the State Agency (SAA) determined the deficiency to be Past Non-compliance (PNC) and the deficiency was corrected as on 12/21/23, prior to the SA's entrance on 2/5/24. Validation: On 2/6/23, the SA validated through staff interviews, record review and facility policy review, the facility began an immediate investigation when the suspicion of sexual harassment involving CNA #1 was reported by CNA #2 on 11/26/23. Investigation included interviews of residents with a BIMS of 13 or higher that received care from CNA #1. The discovery of sexual misconduct of CNA #1, involving Resident #1, lead to the termination of CNA #1. The SA validated through record review of the Quality Assurance Meeting Attendance and Agenda, dated 12/19/23 that the meeting was attended by the Medical Director and Infection Preventionist (who was also the ADON), the Administrator, DON, and the rest of the facility Interdisciplinary Team (IDT) and that the Grievance/Report of Sexual Harassment by Resident #1 was reviewed at the meeting and a the committee members developed a plan to immediately address the incident to prevent it from reoccurring. The SA validated through record review of Transmission Logs dated 12/19/23 and 12/21/23, printouts of E-Mails, and interviews with the Detective and the Administrator that the facility reported allegations and investigation results to all appropriate agencies and authorities. The SA validated through record review that in-services began on 12/19/23, in which the Staff Development Coordinator (SDC) had provided training to all facility staff titled Abuse/Neglect - Vulnerable Adult Exploitation Resident Rights. The SA validated through record review that the Care Plan for Resident #1, dated 12/19/23 that the SSD updated the resident's Care Plan related to The resident has potential for a psychosocial well-being problem related to alleging sexual harassment from an employee. The SA validated through record review of the Nurse Practitioner (NP) Progress Note, that Resident #1was assessed and no physical or mental distress was noted. The SA validated through record review of the Weekly Body Skin Check for Resident #1 that Resident #1 was assessed by facility nursing staff with no adverse findings. The SA validated through record review of the 'NURSING FACILITY PSYCHIATRIC FOLLOW UP NOTE' for Resident #1 dated 12/19/23, revealed that Resident #1 was assessed by the Psychiatric Nurse Practitioner (PNP) with no untoward results related to her grievance of sexual harassment.

Based on observations, interviews, record review, and facility document review, the facility failed to protect the right of each resident to be treated with respect and dignity for one (1) resident of four (4) sampled residents, Resident #1. Findings include: Record review of the facility document titled Statement of Resident Rights, (undated) revealed, You .the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights .If anyone .violates your dignity, you have the right to file a complaint .You have a right to .be treated with courtesy, consideration, and respect . On 6/16/23 at 11:10 AM, during an interview with the Administrator, he stated that a copy of Statement of Resident Rights was included in all admission packets and provided to each resident admitted by the facility. Record review of the facility's investigation dated 6/02/23, revealed an interview with Resident #1 by the Administrator in which Resident #1 stated that CNA #1 had been disrespectful during care and had a tone and attitude that was unnecessary. The facility's investigation concluded that CNA #1 will not return to facility due to customer service. Record review of the Daily Staffing Sheet for B Wing dated 6/02/23, revealed that on the date of the incident, CNA #1 was assigned to seven (7) rooms, including that of Resident #1 for the 7AM-7PM shift. The sheet also documented the removal/replacement of CNA #1 with the Shower Team CNA. Record review of the Timeclock Record for CNA #1 for 5/25/23 through 6/07/23, revealed she clocked in at 6:40 AM on 6/02/23, and clocked out at 10:36 AM. Record review of the Admission Record for Resident #1 revealed they were admitted by the facility on 5/19/23 and had diagnoses of Malignant Neoplasm of the Breast (Left Breast Cancer), Atrial Fibrillation and End State Renal Disease. Record review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/26/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further MDS review revealed that Resident #1 required limited assistance of one-person physical assistance for surface-to-surface transfers and extensive assistance of one-person physical assistance for toilet use and personal hygiene. On 6/16/23 at 10:11 AM, a telephone interview with the facility Ombudsman revealed that she had been made aware of a grievance voiced by Resident #1 regarding disrespectful treatment by a CNA. On 6/16/23 at 10:51 AM, during a telephone interview, CNA #1 discussed the care she provided for Resident #1 on 6/02/23 and denied any disrespect or resident rights violations. She confirmed she was asked to report to the front office on 6/02/23, a little after 10:00 AM. She stated she was notified of a complaint regarding her and she was asked to write a statement regarding the interaction between herself and Resident #1, that took place on 6/02/23. She confirmed that she was asked to leave the premises. She confirmed she was not scheduled to return and that she had been notified by the Director of Nurses (DON) that her employment at the facility had been terminated. On 6/16/23 at 11:20 AM, during an interview with Resident #1, she stated that she recalled the morning of 6/02/23 when CNA #1 was assigned to her care. She stated that CNA #1 was really rude. Resident #1 stated that she had an episode of diarrhea on the morning of 6/02/23 and engaged her call light for assistance. She stated that CNA #1 was rude when she offered the option of wearing an incontinence brief and stated, I did not have a problem wearing a diaper (incontinent brief), but the CNA was bossy and rude and told me that she did not intend to keep coming in here to change me. She confirmed that after CNA #1 cleaned her and her wheelchair, she cleaned the bedside commode, and when trying to replace the bucket beneath the seat the CNA shoved the potty against the wall and tossed the bucket on the floor. Resident #1 stated she had then gone to therapy, where she reported the rude behavior to the therapists. She stated that CNA #1 needs compassion. She reported, She wasn't abusive toward me. She stated that CNA #1's attitude had caused her concern and stated, I thought I should report it because I didn't want her taking care of me again. I didn't want her in my room again. I was concerned about how she might be if she got worse. On 6/16/23 at 12:20 PM, an interview with the Rehabilitation Technician, she revealed that she recalled that she had gone to assist Resident #1 to the therapy department on the morning of 6/02/23 and that Resident #1 had reported to her that CNA #1 had been rude during care the same morning. She stated that she had immediately taken Resident #1 to the Rehabilitation Director and asked Resident #1 to repeat her concern. On 6/16/23 at 12:30 PM, an interview with the Rehabilitation Director revealed that she recalled that on the morning of 6/02/23, the Rehabilitation Technician had brought Resident #1 to her, and that Resident #1 had reported an incident during care provided by CNA #1. She stated, I immediately called the Registered Nurse (RN) Supervisor, and she came to therapy and she (Resident #1) reported what had happened to the RN Supervisor. She stated that she recalled Resident #1 saying that CNA #1 had been rude and had slammed the potty chair against the wall. She stated that Resident #1 required one-person physical assistance to stand, for surface-to-surface transfers and for other activities of daily living (ADLs), but that she was also able to participate in ADLs. On 6/16/23 at 12:45 PM, an interview with the RN Supervisor revealed that she recalled that she had supervised B Hall on 6/02/23. She stated she became aware of the report by Resident #1 between 9:30 AM and 10:00 AM, when the Rehabilitation Director summoned her to the Therapy Department. She stated that Resident #1 described the behavior of CNA #1 as rude and had forcefully pushed the bedside potty against the wall and that she (RN Supervisor) had immediately notified the Risk Manager, Social Worker, and the Staff Development Nurse, because the Administrator and the Director of Nurses (DON) were unavailable at the time. On 6/16/23 at 1:00 PM, an interview with the Risk Manager revealed she had been made aware of the incident on 6/02/23 at approximately 9:30 AM, by verbal report from the RN Supervisor. She said she immediately assessed and interviewed Resident #1 and was told that CNA #1 had been rude and had tossed the bedside commode pot on the floor out of frustration. She stated she spoke with the Staff Development Nurse shortly after speaking with Resident #1 and made sure that CNA #1 had been removed from the facility to ensure the safety of the residents. She confirmed she had conducted Life Satisfaction Rounds with residents on B Hall with BIMS of 12 or higher, with no complaints noted. She stated she had conducted Peer Review interviews with staff who had worked with CNA #1 and there were no concerns reported. She confirmed that she had reviewed the personnel file for CNA #1 and there were no disciplinary reports in CNA #1's personnel file. On 6/16/23 at 1:20 PM, an interview with the Social Worker revealed she had been made aware of the incident on 6/02/23 around 9:30 AM by verbal report from the RN Supervisor and had conducted an interview with Resident #1 who reported that CNA #1 had been gruff with her during care that morning. The Social Worker stated that the resident preferred that CNA #1 not provide care for her anymore and said that CNA #1 made her feel uncomfortable. On 6/16/23 at 1:50 PM, an interview with the Staff Development Nurse revealed she had been made aware of the incident on 6/02/23 at approximately 9:30 AM by verbal report from the RN Supervisor and had immediately summoned CNA #1 to her office and at 10:18 AM on 5/02/23, conducted an interview with CNA #1, obtained a written statement, and notified the CNA that she was suspended pending investigation and needed to leave the premises. On 6/16/23 at 2:10 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed he stated he recalled being assigned as the primary care nurse for residents on the 200 Hall, which included Resident #1, on 6/02/23. He stated that he was made aware of the incident on at approximately 10:30 AM on 6/02/23, by the facility Risk Manager. He confirmed that the facility provided mandatory in-service training on Resident Rights on 6/02/23. On 6/16/23 at 4:00 PM, an interview with the Director of Nurses (DON) revealed she was made aware of the incident on 6/02/23 shortly after 9:30 AM. She stated that she was familiar with Resident #1 and her care. She stated that Resident #1 had not displayed any behavior of making false accusations. She stated that she considered Resident #1 a reliable witness. She stated that following completion of the Facility Investigation, CNA #1 was issued a notice of termination due to Unsatisfactory Performance. She stated that Resident #1 had alleged that CNA #1 was rude and made her uncomfortable and that was not in line with facility standards or Resident Rights. She stated that the facility conducted a mandatory in-service for all staff, including contract staff, on Resident Rights on 6/02/23 and that no staff were allowed to provide care without completion of the in-service. On 6/16/23 at 4:15 PM an interview with CNA #2 revealed that she confirmed that the facility provided mandatory In-Service training on Resident Rights on 6/02/23. She stated that the facility provided In-Service training on Resident Rights monthly and as needed. Regarding Resident Rights, she stated that she had received training from the facility that residents were to be treated with courteously and respect at all times. On 6/16/23 at 4:25 PM, an interview with CNA #3 revealed that she confirmed that the facility provided mandatory In-Service training on Resident Rights on 6/02/23. She stated that the facility provided In-Service training on Resident Rights monthly and as needed. Regarding Resident Rights, she stated that she had received training from the facility that residents were to be treated with courteously and respect at all times. She confirmed that the facility provided mandatory In-Service training on Resident Rights on 6/02/23. On 6/16/23 at 4:50 PM, an interview with the Administrator revealed he had been made aware of the incident on 6/02/23, between 9:30 AM and 10:00 AM. He stated that he was the Abuse Prevention Officer at the facility and had interviewed Resident #1 on 6/02/23, and that the resident denied abuse but reported that CNA #1 was rude, and he confirmed that the resident said CNA #1 had made her uncomfortable. He stated that Resident #1 stated she felt safe at the facility but did not want CNA #1 to provide care for her anymore. He confirmed that CNA #1 had been suspended on 6/02/23 and terminated on 6/03/23 and had not worked at the facility following the report of Resident #1. He confirmed the complaint was reported to State Agency (SA) and other appropriate agencies on 6/02/23, with conclusion of the Facility Investigation reported on 6/04/23, in accordance with reporting requirements. He stated that the facility conducted a mandatory In-Service for all staff, including contract staff, on Resident Rights on 6/02/23, and that no staff were allowed to provide care without completion of the in-service. He confirmed that the facility Quality Assurance and Performance Improvement (QAPI) Committee had not met since the incident, but that the incident had been placed on the agenda for the next QAPI Committee meeting.

Based on observations, interviews, record review, and facility policy review the facility failed to prevent the possible spread of infection for two (2) of seven (7) residents observed for care. Resident #12 and #26. Findings Include: A review of the facility's policy, Hand washing/Hand Hygiene, with a revised date of 3/1/2020 revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .7. Use alcohol-based hand rub containing at least 62% alcohol; or alternatively soap and water for .l. After contact with blood or bodily fluids, and after contact with objects . m. After removing gloves . Resident #12 On 06/14/22 at 02:54 PM, the State Agency (SA) observed Certified Nursing Assistant (CNA) #2 provide incontinent care for Resident #12. While moving the overbed table, the wash basin and the resident's personal back scratcher fell on to the floor. CNA #2 retrieved the wash basin from the floor and placed it on the resident's bed, and then retrieved the residents personal back scratcher from the floor and placed it on the overbed table. She did not clean or sanitize the items after she retrieved them from the floor. Upon changing Resident #12's soiled brief, CNA #2 realized that she did not have a bag to discard the brief. She rolled the brief up and placed it on the right bottom side of Resident #12's bed. She left the room to retrieve a bag, leaving the soiled brief without a barrier, touching Resident #12's bedspread. CNA #2 returned to the room and applied a clean pair of gloves and discarded the soiled brief. While wearing the same contaminated gloves, she touched Resident #12's bed and television remote controls. She then removed and disposed of the contaminated gloves. On 06/14/22 at 3:10 PM, during an interview with CNA #2, she admitted that she should have sanitized the items before putting them back because the floor is dirty and can spread bacteria. She stated should have had everything she needed before beginning care. She stated that changing gloves and sanitizing her hands is important because she could have feces on her gloves. On 06/14/22 at 04:39 PM, in an interview with the Assistant Director of Nursing (ADON) stated that sanitizing objects is needed after retrieving items from the floor because there is a possibility of infection. She stated that CNA #2 should have brought a bag in the room to discard of brief and it is an infection control issue. On 06/14/22 at 04:43 PM, in an interview with the Director of Nursing (DON) stated that the items should have been sanitized as well as her hands before touching anything on the bed because it can be a possible cause of infection. She stated that all of these are infection control issues to the resident. On 06/14/22 at 05:13 PM, in an interview with Registered Nurse #1/Infection Preventionist, who stated that sterile and clean surfaces should be separated from the dirty. She said that not separating clean and dirty can cause cross contamination of germs. She stated that if something is dirty or contaminated it should be discarded or sanitized. She said that the person providing care should not pick it up to use it or put it on the resident's bed because it must be discarded or sanitized. She stated that CNA #2 should have washed her hands before touching anything because it is spreading germs. A record review of Resident #12's Admission Record revealed the facility admitted her on 06/22/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/22 revealed that Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. RESIDENT #26 On 06/14/22 at 02:26 PM, during incontinent care with Resident #26 the SA observed CNA #1 enter the room with her supplies and applied two pairs of gloves so that she was double gloved. While performing incontinent care CNA #1 pulled the disposable wipes from the package of wipes and placed them on Resident #26's bed with no barrier. After using the wipes that had been placed on the bed CNA #1 retrieved more wipes from the container, touching the outside of the container wearing the same contaminated gloves. After completing incontinent care, CNA #1 removed the top layer of gloves and applied the clean brief with the second layer of gloves. On 06/14/22 at 02:41 PM, in an interview with CNA #1 the SA asked her if she should have washed her hands and just used one pair of gloves. CNA #1 nodded her head yes. On 06/14/22 at 04:39 PM,in an interview with the ADON, stated that staff should not be double gloving and that they should be washing their hands. She stated that the policy is to wash hands, if not, it is a possible infection control issue. On 06/14/22 at 04:43 PM, in an interview with the DON, stated that double gloving is an infection control issue and she should have washed her hands between changing a brief and washed hands before getting out the wipes. On 06/14/22 at 05:13 PM, in an interview with the RN #1/Infection Preventionist stated staff should only wear one pair of gloves and double gloving does not replace handwashing. A record review of the Admission Record revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Quarterly MDS with an ARD of 04/14/22 revealed Resident #26 had BIMS score of 3, which indicated the resident had severe cognitive impairment.

Based on interviews and record review, the facility failed to ensure a resident was protected from abuse for one (1) of four (4) residents reviewed for abuse. Resident #1 Record review revealed the facility policy titled POLICY FOR PROHIBITION OF ABUSE, NEGLECT AND MISAPPROPRIATTION OF PROPERTY dated 5/01/01, stated Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse . The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Review of the Mississippi State Department of Health Complaint Intake revealed the facility reported that on 9/21/21 while getting a resident ready for therapy, resident was not cooperating .Resident became agitated .the nurse grabbed resident's chin . Record review of the facility investigation revealed a timeline of events as documented and provided by the facility: TIMELINE 9/21/21 10:00 (AM)-Certified Nursing Assistant (CNA) #1 reported Licensed Practical Nurse (LPN) #1 had allegedly physically abused Resident #1, 10:01 (AM) -LPN #1 wrote statement and was immediately suspended, 10:05 (AM) -CNA #1 and CNA #2 were interviewed incident . On 2/08/22 at 1:15 PM, during an interview with Resident #1, she stated she did not remember the incident. On 2/08/22 at 2:00 PM, an interview with CNA #1 revealed she was working at the facility on 9/21/21 and was assigned to care for Resident #1. She stated after providing morning care for the resident, she and Nurse Aide (NA) #1 had explained to Resident #1 they were going to assist her to get out of bed and into her wheelchair to go to physical therapy. CNA #1 stated Resident #1 told them she didn't want to get out of bed at that time or go to therapy. CNA #1 said she encouraged the resident, but when Resident #1 continued to refuse to get out of bed she went and reported this to LPN #1 per facility policy and procedure. CNA #1 stated she and LPN #1 went to the room of Resident #1 and LPN #1 encouraged the resident to get up and when the resident continued to refuse the LPN turned the resident on her side to continue to get her ready to get up. CNA #1 stated Resident #1 was waving her hand behind her and slapping at the nurse, like to get her to leave her alone. CNA #1 said Resident #1's hand made contact with LPN #1 and (Resident #1) slapped her (LPN #1). CNA #1 said when the resident slapped LPN #1, the nurse grabbed the resident by her throat. CNA #1 stated I'm not saying she tried to choke her, like squeezed with her hand, but she definitely grabbed her (Resident #1) on her neck and it looked like she was pushing down. The CNA said she was not sure of the intention of LPN #1, she said it may have been a reaction but she remembered her training on abuse and neglect and did not wait. CNA #1 stated I wasn't going to stay there and see anymore; I got out of there. I had to take a second to calm myself down and then went immediately to the DON and reported it. On 2/08/22 at 3:00 PM, an interview with NA #1 revealed It was me, (the LPN #1) and (CNA #1) and (Resident #1) in the room. (Resident #1) stated she didn't want to get out of the bed. She said she didn't want to get up for therapy. CNA #1 went and got (LPN #1). The resident continued to decline to get up. I didn't see (LPN #1) make contact with (Resident #1), but she saw the LPN go down toward the upper part of the resident's body with her hands; after that, (CNA #1) told me 'Come on let's get out of here. I'm going to report her', then (CNA #1) told the nurse I'm going to report you. She stated she knew CNA #1 was going to report the incident and she also made a statement to the DON at 10:05 AM on 9/21/21. On 2/08/22 at 3:30 PM, an interview with the Director of Nurses (DON) revealed on 9/21/21, CNA #1 reported to her an incident in which Resident #1 had displayed unusual behavior of combativeness. CNA #1 reported to the DON Resident #1 slapped LPN #1 and LPN #1 grabbed Resident #1. The DON stated she removed LPN #1 from resident care, interviewed LPN #1 and obtained a written statement, after which she was suspended and left the facility immediately; the DON stated LPN had no further contact with any residents. She said LPN #1 was terminated 9/22/21 following completion of the investigation. The DON stated an investigation began immediately upon the report of CNA #1. The DON stated she had immediately assessed Resident #1 following the report of incident and the resident had no marks or bruises noted. Record review of LPN #1 statement revealed, I was asked by CNA to help come get resident up for therapy. When we got in there resident was already agitated. I asked her to get up so we can go tell the therapist that you don't want to come anymore. When I rolled her over to put pad under her, she rolled back and slapped me. I put my hand under her chin to stop her from hitting me. Record review of Disciplinary Action Record dated 9/23/21 which listed Termination as the SOLUTIONS & CORRECTIVE ACTION TO BE TAKEN as a result of the 9/21/21 incident, which indicated LPN #1 received disciplinary action for the incident that occurred with Resident #1. Record review of the Employee Termination Form revealed LPN #1 was terminated on 9/22/21 with Last Day worked 9/21/21 due to Substantiated Resident Abuse and Neglect and was not eligible for rehire; the form was signed by (Human Resources) on 9/27/21. Record review of The Mississippi Vulnerable Adults Act dated 8/2001 was signed by LPN #1 on 11/19/20, which indicated she was trained on hire related to the Vulnerable Adults Act. Record review of Resident's Rights Acknowledgement with a revision date of 6/16 stated I have received, read and agree to follow the enclosed Resident's Rights., and was signed by LPN #1 which revealed she had received training on Resident Rights. Record review revealed the facility policy titled Regarding the Reporting of Abuse and Associate Acknowledgement (with Revision date 11/13) revealed .Mistreatment or abuse of any nature will not be tolerated. The policy stated I have read and fully understand my legal responsibilities outlined. I have also read and understand the penalties that may be imposed if I violate the above-mentioned responsibilities followed by the signature of LPN #1 and dated 11/19/20 which indicated she had been trained on resident abuse.

Based on staff interviews, record review, facility investigation review, and policy review, the facility failed to provide adequate staff supervision to prevent Resident #1's elopement from the facility on 4/13/2020 after 5:53 AM. The facility staff were unaware Resident #1 was out of the facility until he was seen by Certified Nursing Assistant (CNA) #1 and CNA #2 coming into the building. This concern was identified for one (1) of four (4) residents reviewed for wandering behavior and risk for elopement. The State Agency (SA) conducted Complaint Investigation, CI # , from 11/23/2020 through 11/24/2020 and substantiated CI # related to an elopement due to the facility's failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 4/13/2020 from approximately 5:53 AM until 7:50 AM. Resident #1 was missing, unsupervised and away from the facility for approximately two (2) hours. The facility staff was not aware of Resident #1's absence until he was discovered walking down the road by staff coming to work at 7:50 AM. Resident #1 was returned to the facility at 7:50 AM by Certified Nurse Assistant (CNA) #1 and CNA #2. Resident #1 was assessed for any signs and symptoms of injury and pain by Licensed Practical Nurse #1 with no injury identified. The CNAs found the resident soaking wet and shaking. The facility's immediate investigation concluded Resident #1 exited the facility through a side door when the door did not lock after a staff exited the door. Resident #1 was immediately placed on one on one (1:1) supervision. During the 11/23/2020 survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) existed at 42 CFR(s): 483.25 (d)(1)(2)- Free of Accidents, Hazards/ Supervision/device (F689) due to facility's failure to provide adequate supervision to prevent an elopement for Resident #1. This situation caused the likelihood for serious injury, harm, impairment, or death for Resident #1 and other residents with wandering behaviors and at risk of elopement. The SA notified the facility's Administrator of the PNC IJ and SQC on 11/23/2020 at 2:40 PM. Based on the facility's implementation of corrective actions on 4/13/2020, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 4/14/2020, prior to the SA's first entrance on 11/23/2020. Findings include: Review of the facility's policy, Wander Management, Monitoring System & Resident Elopement Protocol, dated 1/17/18, revealed, it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. A Wandering Risk Evaluation for Resident #1 was completed on 2/14/2020 and was assessed to be forgetful and disoriented times three (3), ambulates independently and has a history of wandering. The facility initially admitted Resident #1 on 6/22/2018, approximately 2 years prior to the elopement. Resident #1's [DIAGNOSES REDACTED]. Resident #1's most recent Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated severe cognitive impairment and could not be assessed. Review of his Quarterly Minimum Data Set (MDS), dated ,[DATE] /2020, revealed the resident requires one (1) person assistance with transfers and with Activities of Daily Living (ADLs) (to include bathing, eating, and dressing). Resident #1 walks in the room and in the hall independently. Resident #1's Care Plan, was created and initiated 6/28/2018, identified Resident #1 at risk for elopement related to wandering and confusion. He was care planned for staff to place a wandering device on resident as applicable, check placement every shift, check function daily, place my demographic sheet and picture in the elopement notebook, redirect resident away from doorways and engage me in diversional activities, and wander bracelet related to wandering and exit seeking behavior. Nurse to check placement and function every shift including skin check under bracelet right wrist. The checking of placement was validated on 11/23/2020 on the Medication Administration Record [REDACTED]. A tour with the Maintenance Director on 11/23/2020, at 7:30 AM, revealed all facility doors were locked and were functioning properly. Observation revealed a keypad on the door Resident #1 was believed to exit through on 11/23/2020. The Maintenance Director confirmed an additional keypad was added to this door after the investigation of the elopement of Resident #1. During a phone interview with the Administrator on 11/23/2020 at 2:40 PM, the Administrator confirmed on 4/13/2020 at 5:53 AM, Dietary Aide (DA) # 1 reported the last known visual of Resident #1, where he was observed sitting in a chair across from the front Nurses' Station. At 7:50 AM, CNA #1 and CNA #2 stepped outside of the facility into the front parking lot and observed Resident #1 across the road, adjacent from the facility. At 7:50 AM, CNA #1 and CNA #2 were witnessed by Dietary Manager (DM), escorting Resident #1 back into the facility. The wander bracelet was attached to the Resident # 1's right wrist. The facility's front door alarm sounded as Resident #1 entered the facility noting it was working properly. The investigation revealed the facility only had one (1) available exit door, the side door, with the ability to enter and exit without supervision by use of a keypad. Investigation surmised an unknown employee input the facility code into the keypad and exited the facility without the door fully closing thus allowing Resident #1 to exit unobserved. The Administrator confirmed he initiated an investigation immediately and a head count of the other residents was conducted. In an interview with CNA #1 on 11/24/2020 at 4:36 PM, she confirmed she and CNA #2 went across the street from the facility to assist Resident #1 back into the facility. CNA #1 stated she found Resident #1 at approximately 7:50 AM. Attempted to call CNA #2 on the phone on 11/24/2020 at 9:41 AM and 11:02 AM but was unable to reach. Attempted to call Medical Director on the phone on 11/24/2020 at 3:04 PM and a message was left but was unable to reach. On 11/24/2020 the Dietary Manager (DM) confirmed she wrote a statement on 4/13/2020 that stated she observed Resident #1 across the street from the facility and two (2) CNAs ran across the street to get him. She confirmed it was about 7:50 AM. The DM also confirmed she wrote a statement for Dietary Aide #1 stating she had walked past Resident #1 at 5:53 AM. Record review of Nurses' Notes dated 4/13/2020, at 7:27 AM, Licensed Practical Nurse (LPN) #1 documented that a staff member witnessed Resident #1 walking down the street, soaked/wet and shaking. LPN #1 documented on 4/13/2020 at 18:12 PM in the Nurses Notes that Resident #1 was walking down street, wet, shivering, and cold. LPN #1 documented the morning nurse changed Resident #1 and assessed him. In an interview with the Director of Nurses (DON) on 11/24/2020 at 9:40 AM, the DON explained there was a camera in the hall that pointed at the door Resident #1 exited, but it was not recording at the time of the incident. The DON stated residents' needs are evaluated on Admission, Quarterly, and upon change in condition and the plan of care is modified as needed. Review of a written statement revealed CNA #5 wrote on 4/13/2020 at 11:00 AM, as soon as I got off my break, I went to B wing to search for Resident #1 and he was wandering around. That was around 3:30-4 AM when I saw him last. A review of a statement from LPN #2 on 4/13/2020, revealed that the alarm (wander guard alarm) went off and the Hospitality Aide turned it off as Resident #1 came back into the building. The documented weather temperature for the city on 4/13/2020 was 49 degrees fahrenheit. The approximate distance from the facility to where the resident was discovered was 155 feet from the side door near laundry. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions prior to the State Agency (SA) entrance on 11/23/2020. In response to the Past Non-compliance IJ and SQC cited at 2:40 PM on 11/23/2020, the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility to remove the IJ. Brief Summary of Events: On 11/23/2020 at 2:40 PM State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ) existed at past noncompliance and substandard quality of care. On 4/13/2020 at 5:53 AM Dietary Aide (DA) #1 reported the last known visual of the Resident # 1, where he was observed sitting in a chair across from the front Nurses' Station. At 7:50 AM Certified Nursing Assistant #1 (CNA) and CNA #2 stepped outside of the facility into the front parking lot and observed Resident # 1 across the road, adjacent from the facility. At 7:50 AM CNA #1 and CNA #2 were witnessed by Dietary Manager (DM) #1, escorting Resident #1 back into the facility. The wander bracelet was attached to the Resident # 1's right wrist. The facility's front door alarm sounded as Resident #1 entered the facility noting it was working properly. The investigation revealed the facility only had one (1) available exit door, the side door, with the ability to enter and exit without supervision by use of a keypad. Investigation surmised an unknown employee input the facility code into the keypad and exited the facility without the door fully closing thus allowing Resident #1 to exit unobserved. The facility's camera was unable to capture the exit of Resident #1 due to failure to record and inability to play back events leading to Resident #1 exit. Corrective Actions: 1. On 4/13/2020 Resident #1 was assisted back into the facility at 7:50 AM by CNA #1 and CNA #2. Resident # 1 was assessed by Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) # 1 with no injuries found. The facility has no legal representative for Resident #1. The facility initiated an investigation. 2. On 4/13/2020 at 7:55 AM RN # 1 completed a head count on all Residents to ensure everyone was accounted for with no issues identified. 3. On 4/13/2020 between 7:50 AM and 7:55 AM the Maintenance Director completed a 100 percent audit on all doors and windows in the facility. All windows were locked with security devices in place. All doors were functioning properly. All locked doors were unlocked and reset to assure they were working properly. Doors with alarms (magnet and elopement alarms using wander bracelet) were active and reset to assure proper function. 4. On 4/13/2020 at 8:00 AM LPN # 2 completed an audit with the order listings of current wander bracelets to assure they were in place. LPN # 2 reviewed the Medication Administration Record [REDACTED]. All care plans and Kardex/ task were reviewed and were current and up to date. 5. On 4/13/2020 at 8:15 AM the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) initiated in-services on Abuse, Neglect, Vulnerable Adult Act, Resident Rights, Wander Policy with Supervision, Following Care Plan, Kardex, reporting changes of conditions including behavior, and Elopement. 10 RNs, 21 LPNs, 36 CNAs, eight (8) Dietary, eight (8) Housekeeping, four (4) Hospitality Aides, one (1) Business office Manager, one (1) Human Resources, one (1) Administrator Assistant, one (1) Social Service Director, two (2) Activity, two (2) Maintenance, four (4) therapy, one (1) Nurse Practitioner, one (1) Medical Director, one (1) Director of Business Development, one (1) Administrator and eight (8) Respiratory Therapist were in serviced. No staff was allowed to work until completion of in-service. 6. On 4/13/2020 at 9:54 AM State Agency (SA) was notified. The facility investigation was completed on 4/13/2020. 7. On 4/13/2020 at 10:00 AM a new keypad on the side door was replaced by the Maintenance Director. 8. On 4/13/2020 at 9:30 AM a wander guard bracelet drill was initiated and concluded on 4/23/2020 with Ten RNs, 21 LPNs, 36 CNAs, eight (8)Dietary, eight (8) Housekeeping, four (4) Hospitality Aides, one (1) Business office Manager, one (1)Human Resources, one (1) Administrator Assistant, one (1) Social Service Director, two (2) Activity, two (2) Maintenance, four (4) therapy, one (1) Nurse Practitioner, one (1) Medical Director, one (1) Director of Business Development, one (1) Administrator and eight (8) Respiratory Therapist were in serviced. No staff was allowed to work until completion of in-service. 9. On 4/13/2020 at 10:45 AM a technician from the wander system checked all Access Control System doors and determined that all doors locked securely and that all codes worked correctly. 10. On 4/13/2020 at 3:00 PM an AD-Hoc Quality Assurance (QA) meeting was conducted by the facility Administrator that included the following participants: DON, ADON (also the Infection Control Preventionist), Director of Therapy, Medical Records, Director of Social Services, Business Office Manager, Maintenance Director, Housekeeping Manager, RN #1 (also Nurse Supervisor), Medical Director, Minimum Data Set (MDS) Coordinator, Dietary Manager, Human Resources, and the Treatment Nurse. The facility's corrective actions were initiated on 4/13/2020. All activities to remove the IJ was initiated on 4/13/2020 and completed on 4/13/2020. The facility alleges the IJ was removed on 4/14/2020. The SA validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, facility record review and interviews. 1. The SA validated by the facility's investigation and interviews that on 4/13/2020 Resident #1 was assisted back into the facility at 7:50 AM by CNA #1 and CNA #2. Resident # 1 was assessed by Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) # 1 with no injuries found. The facility has no legal representative for Resident #1 and the facility initiated an investigation. 2. The SA validated by review of the facility's investigation on 4/13/2020 at 7:55 AM RN # 1 completed a head count on all Residents to ensure everyone was accounted for with no issues identified. 3. The SA validated through interviews and facility investigation on 4/13/2020 between 7:50 AM and 7:55 AM the Maintenance Director completed a 100 percent audit on all doors and windows in the facility. All windows were locked with security devices in place. All doors were functioning properly. All locked doors were unlocked and reset to assure they were working properly. Doors with alarms (magnet and elopement alarms using wander bracelet) were active and reset to assure proper function. 4. The SA validated the facility's investigation revealed on 4/13/2020 at 8:00 AM LPN # 2 completed an audit with the order listings of current wander bracelets to assure they were in place. LPN # 2 reviewed the Medication Administration Record [REDACTED]. All care plans and Kardex/ task were reviewed and were current and up to date. 5. The SA validated by interviews and facility investigation that on 4/13/20 at 8:15 AM the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) initiated in-services on Abuse, Neglect, Vulnerable Adult Act, Resident Rights, Wander Policy with Supervision, Following Care Plan, Kardex, reporting changes of conditions including behavior, and Elopement. 10 RNs, 21 LPNs, 36 CNAs, eight (8) Dietary, eight (8) Housekeeping, four (4) Hospitality Aides, one (1) Business office Manager, one (1) Human Resources, one (1) Administrator Assistant, one (1) Social Service Director, two (2) Activity, two (2) Maintenance, four (4) therapy, one (1) Nurse Practitioner, one (1) Medical Director, one (1) Director of Business Development, one (1) Administrator and eight (8) Respiratory Therapist were in serviced. No staff was allowed to work until they completed the in-service. 6. The SA validated by interviews and record review, on 4/13/20 at 9:54 AM State Agency (SA) was notified. The facility investigation was completed on 04/13/20. 7. The SA validated by interview, tour of the facility and record review on 4/13/20 at 10:00 AM a new keypad on the side door was replaced by the Maintenance Director. 8. The SA validated by facility investigation review and interviews, on 4/13/20 at 9:30 AM a wander guard bracelet drill was initiated and concluded on 4/23/20 with 10 RNs, 21 LPNs, 36 CNAs, eight (8) Dietary, eight (8) Housekeeping, four (4) Hospitality Aides, one (1) Business office Manager, one (1)Human Resources, one (1) Administrator Assistant, one (1) Social Service Director, two (2) Activity, two (2) Maintenance, four (4) therapy, one (1) Nurse Practitioner, one (1) Medical Director, one (1) Director of Business Development, one (1) Administrator and eight (8) Respiratory Therapist were in serviced. No staff was allowed to work until completion of the in-service. 9. The SA validated by observation, facility investigation and interviews, on 4/13/20 at 10:45 AM a technician from the wander system checked all Access Control System doors and determined that all doors locked securely and that all codes worked correctly. 10. The SA validated by interviews and record review, on 4/13/20 at 3:00 PM an AD-Hoc Quality Assurance (QA) meeting was conducted by the facility Administrator that included the following participants: DON, ADON (also the Infection Control Preventionist), Director of Therapy, Medical Records, Director of Social Services, Business Office Manager, Maintenance Director, Housekeeping Manager, RN #1 (also Nurse Supervisor), Medical Director, Minimum Data Set (MDS) Coordinator, Dietary Manager, Human Resources, and the Treatment Nurse.

Based on observation, facility staff and consulting staff interviews, record review, and facility policy review, the facility failed to provide safe medication storage and security of medications in a manner to prevent resident access, as evidenced by a drawer of the medication cart would not lock. As a result, on [DATE] at 6:45 PM, Resident #41 was observed opening the drawer of the A Wing Medication Cart 1, which contained significant medications including Insulin and [MEDICATION NAME] tablets, as well as other medications. The facility was aware of the medication cart lock not functioning for approximately two (2) months prior to this incident, as evidenced by an interview with Licensed Practical Nurse (LPN) #10, who stated the drawer would not lock when she started to work on [DATE]. Resident #41 was observed opening the unsecured medication drawer on [DATE] at approximately 6:45 PM. The failure to provide adequate storage and locking of medications to ensure Resident #41 and the other five (5) mobile residents, identified with severe cognitive impairment, did not have access to remove medications from an unsecured medication cart, placed these residents in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE], when facility staff identified the A-Wing medication Cart 1 drawer, which contained Insulin and [MEDICATION NAME] tablets, would not lock, allowing cognitively impaired residents to have access. On [DATE] at 6:50 PM, the State Agency (SA) notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.45(h)(1) F761, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's undated policy titled, Security of Medication Cart, revealed the nurse must secure the medication cart during the medication pass to prevent unauthorized entry. A review of the facility's policy titled, Safety and Supervision of Residents, with a revision date of (MONTH) 2013, revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. On [DATE] at 6:45 PM, an observation revealed Resident #41 opened the uppermost right top medication cart drawer of a medication cart as the surveyor was walking down A-wing 100 hallway. The primary medication nurse was not in sight of the medication cart at this time. Registered Nurse (RN) #3 was walking down the hallway and met the resident at the medication cart and redirected his right hand away from the cart. Shortly after, the primary Medication Nurse and the Director of Nursing (DON) came to the cart. The primary Medication Nurse verified that the drawer contained the following medications: [REDACTED]. During an interview on [DATE] at 8:30 PM, the DON revealed, We have been trying to get that medication cart fixed for the past month or so. In an interview on [DATE] at 8:40 PM, Licensed Practical Nurse (LPN) #10 revealed the facility had been having trouble with the Cart I medication cart not locking since she started to work at this facility, in (MONTH) 2019. She verified the cart drawer would not lock her first day on the cart on [DATE], and contained medications, which included the Insulin and [MEDICATION NAME] tablets. (Review of the Electronic Medical Records revealed LPN #10 began signing the Medication Administration Record [REDACTED]. In an interview on [DATE] at 8:30 AM, the DON stated that RN #3 moved the resident's hand away from the medication cart. The DON also stated, the medication cart lock had been broken for at least the past two (2) weeks. She stated the medication carts are usually kept in the medication room or in the hallway, with the lock turned towards the wall. She also stated Resident #41 could also have gotten alcohol pads from the medication cart, because he is cognitively impaired. The DON stated there was some Insulin in the medication cart, but it was in a bag, and the eye drops were in a box. She stated the resident could have taken the [MEDICATION NAME] tablets and could have been sent to the hospital. On [DATE] at 9:00 AM, an observation revealed Resident #41 lying in bed awake and alert. This Surveyor asked Resident #41 if he could make a fist and he stated, Do you mean make a fist like this and proceeded to open and close both of his hands demonstrating a fist five (5) times very quickly. Resident #41 was able to follow the command. On [DATE] at 9:30 AM, an observation revealed LPN #9 pulled on each medication drawer of the A-wing medication cart, while it was in the locked position, and only the uppermost top right drawer would open. The medications remained in the unsecured medication drawer. This was done in the presence of two (2) surveyors. Observation on [DATE] at 9:35 AM, revealed LPN #9 emptied the 0.4 MG tablets of [MEDICATION NAME] from the bottle into a plastic 30 Cubic Centimeter (CC) medication cup. This nurse then approached Resident #41 and asked the resident to open the empty [MEDICATION NAME] bottle. LPN #9 handed Resident #41 the empty [MEDICATION NAME] bottle and the resident twisted the cap off of the bottle easily. He had no difficulty in removing the cap, therefore allowing access to medication in the bottle. This was done in the presence of two (2) surveyors. Observation on [DATE] at 10:05 AM, revealed LPN #9 counted the [MEDICATION NAME] tablets that were in the [MEDICATION NAME] bottle from the top right drawer of the A-wing medication cart, with a total of 25 tablets in the bottle. This was done in the presence of two (2) surveyors. On [DATE] at 10:55 AM, interview with LPN #9 revealed she has not had to redirect any resident away from the medication cart before. She stated she has not had any problems with any resident getting into the medication cart. LPN #9 stated she had not seen any medications in any resident hands. She also stated she was just made aware of the medication cart not locking, as of last week. She stated she had called the pharmacy this past weekend and told them the top right medication cart drawer had problems with locking. LPN #9 stated the pharmacy had not called her back as of today ([DATE]). She stated she had told her Charge Nurse, LPN #4 or LPN #5, about the medication cart drawer not locking. LPN #9 stated she is not sure which of those Charge Nurses she had told. LPN #9 stated she never had gotten a chance to report the cart drawer not locking to the DON, because she had just discovered it over the weekend. On [DATE] at 11:05 AM, an interview with RN #6 revealed she had not had any residents attempting to open her medication cart. She stated she tries to anticipate what the residents need, to help prevent the resident from trying to get a medication themselves. RN #6 also stated she was not aware of any harm to residents from medications or any medications being in a resident's hands. On [DATE] at 11:15 AM, an interview with the DON revealed she had not had any problems with residents trying to get into medication carts. She stated she was about to intervene when she had seen Resident #41 open the medication cart drawer. The DON stated, if the medication cart would have been turned around towards the room, the resident would not have been able to open the drawer. On [DATE] at 11:28 AM, an interview with RN #5 revealed the nurses try to keep the medication carts within eye view. She stated the nurses started calling last week to let the pharmacy vendor know that the lock was broken on the A wing medication cart. On [DATE] at 11:40 AM, an interview with the DON revealed the facility should receive a new medication cart tonight from the pharmacy vendor. On [DATE] at 3:04 PM, an interview with LPN #10, per telephone, revealed the medication cart drawer had been broken for a couple of weeks. She stated she told the pharmacy people about the medication cart being broken. She also stated she had gone to the DON. LPN #10 stated the DON told her to call the pharmacy vendor initially, and she had started calling them last week. She also stated Maintenance attempted to fix the medication cart yesterday (referring to [DATE]). LPN #10 stated she was on the hallway and had just come out of room [ROOM NUMBER]. She stated the medication cart was parked between room [ROOM NUMBER] and room [ROOM NUMBER]. She also stated she was able to see the resident in room [ROOM NUMBER] and the medication cart at the same time. The call was disconnected at 3:15 PM, and LPN #10 called back to continue the interview. During this interview, LPN #10 stated, Yes, I said it had been broken and I think I told you (MONTH) 25th (referring to how long the A-wind medication cart 1 had been broken). She stated when she first identified the lock was broken, she asked maintenance if they could fix the lock and Maintenance stated they do not look at medication carts; and she would have to call the people they (referring to the medication carts) had come from. She also stated she was told to call the pharmacy vendor by the DON. LPN #10 stated she would keep the medication cart in view and/or turn it around. She stated, when the surveyors had come to the facility, she was just finishing her medication pass. She then stated, she was able to see the medication cart, but could not see the resident. She also stated she had seen RN #3 intervene, but she (LPN #10) did not. LPN #10 then stated, the lock was facing her and she could see the lock. LPN #10 stated the resident used his right hand and opened the medication cart drawer. She stated the medication cart was close to rooms [ROOM NUMBERS] and it was facing towards the middle of the hallway. She stated the resident could have side effects if he had taken some of the medications. She also sated the resident could have heart problems and could have died . LPN #10 stated, if she was giving medications to a resident and had the privacy curtain pulled, she would pull the medication cart to the door and she could hear if someone opened the drawer to the cart. She stated they would have to totally move the cart. She also stated, We have to keep the medications separated, so she could not have moved the medications to another drawer. She stated sometimes the other drawers would not lock and it's possible the resident could have gotten into another unlocked drawer. LPN #10 stated she tried several times to get the medication drawer fixed. On [DATE] at 4:08 PM, an interview with the DON revealed the staff reports to Maintenance or logs the problem in the maintenance book for any broken equipment. She stated the Maintenance Supervisor or Maintenance Staff #2 are always on call, even for equipment that need to be reported immediately. On [DATE] at 4:35 PM, an interview with Maintenance Staff #2 revealed he first became aware of the medication cart lock being broken on yesterday (referring to [DATE]). He stated as he was walking down the hallway, he was flagged down by RN #1 to talk to the pharmacy vendor. Maintenance Staff #2 stated pharmacy staff asked him to check out the lock on the medication cart. He stated he and the Maintenance Supervisor were unable to fix the medication cart lock. He stated he called the pharmacy back and the lady on the phone stated she would send a technician out to the facility. He also stated he does not know if the pharmacy sent the technician to the facility or not. On [DATE] at 4:40 PM, an interview with the Maintenance Supervisor revealed Maintenance Staff #2 told her about the medication cart not locking on [DATE]. She stated they (referring to her and her assistant) tried to work on it (referring to A-wing medication Cart 1's lock) and could not get it fixed. She stated Maintenance Staff #2 called the pharmacy vendor. She stated the top right drawer of the cart would not lock. On [DATE] at 4:45 PM, an interview with Maintenance Staff #2 revealed the A-wing medication cart Cart 1, was 40 and ¼ inches in height. This was observed to be easily accessible to any resident in a wheelchair. On [DATE] at 5:47 PM, an interview with Pharmacist #1, revealed the pharmacy vendor was first notified on Monday ([DATE]), of the facility having a medication cart that would not lock. She stated the facility emailed Pharmacy Staff #1 on Monday, [DATE] at 5:08 PM. She also stated she was not aware that the medication cart had been broken for two (2) weeks. She stated she called the facility Tuesday [DATE], to see if the maintenance man could fix the cart. She also stated if a resident took 25 [MEDICATION NAME] tablets, she believed they would have a headache and [MEDICAL CONDITION]. She also stated that 25 [MEDICATION NAME] tablets would be a higher than indicated. She stated it is not an indicated dose, and could lead to [MEDICAL CONDITION], Headache, and falls. On [DATE] at 5:57 PM, an interview with the Medical Director revealed she was made aware of this incident (the A-wing medication Cart 1 drawer lock being broken) today when she walked through the door at 2:00 PM. She stated there was a plan of correction in place. She also stated the Pharmacist is a major issue here at the facility. She stated if a resident had taken 25 of the 0.4 Mg [MEDICATION NAME] tablets, that could cause death. On [DATE] at 12:04 PM, an interview with RN #3 revealed she was making rounds and when she headed back, that's when she took the resident's hand and said, No, no, no, we can't do that (referring to Resident #41 opening the medication cart drawer). She stated, the resident said, all he wanted was a pencil. She stated she was headed back from the end of A-wing hallway towards the nursing station. She stated the DON was coming from the opposite direction. RN #3 stated she had not had to redirect a resident away from a medication cart before. She also stated she does not remember any other resident opening the medication cart before. She stated she does not have a clue as to how long the medication cart lock had been broken. Observation on [DATE] at 12:15 PM, revealed LPN #7 moved a medication cart, just like the cart that had the broken drawer, to the middle of A-wing hallway between rooms [ROOM NUMBERS] with the medication drawers facing the center of the hallway, just as positioned on [DATE], when the resident was observed opening the medication cart drawer. The surveyor sat at the nursing desk on A-wing and the medication cart drawers were not visible from the nursing station, with the medication cart being in this position, indicating that the cart would have been unsecured without someone directly at the cart. On [DATE] at 3:22 PM, an interview with the Consultant Pharmacist revealed there is some form of medication audit done monthly. He stated carts are checked basically once a quarter. He stated he was not aware and cannot recall the A-wing medication cart drawer being unable to be locked. On [DATE] at 1:05 PM, an interview with the Administrator revealed the DON notified him of the incident (A Wing top right medication cart drawer not locking) on [DATE]. He stated staff should not wait to report these types of issues. He stated he must be made aware for the safety and well-being of the residents. The facility provided the following Removal Plan: Brief Summary: At approximately 6:50 PM on (MONTH) 5, 2019, the facility was notified by the annual survey team that the facility was being placed in Immediate Jeopardy, due to the facility on (MONTH) 4, 2019 at approximately 6:45 PM, failed to adequately supervise to prevent a severely cognitively-impaired resident from opening a medication cart drawer where multiple medications, including 25 [MEDICATION NAME] 0.4 milligram (mg) tablets were located. The facility failed to store medications safely to prevent a cognitively impaired resident from having access to the medication cart, and the medication cart drawer would not lock. Licensed Practical Nurse (LPN) #10 stated the cart did not lock properly and has malfunctioned since she started to work in the Facility on (MONTH) 26, 2019, at approximately 7:00 AM. On the evening of (MONTH) 4, 2019, Resident #41 was witnessed by a surveyor opening the malfunctioning drawer where medication was located. The cart was locked in the medication room once medication pass was completed. (Name of Pharmacy Vendor) was contacted on (MONTH) 3, 2019 and a new cart was requested. The replacement cart arrived at the Facility on (MONTH) 5, 2019, and medications were transferred from the malfunctioning cart to the properly locking replacement cart. Corrective actions included: 1. On (MONTH) 4, 2019 at approximately 6:45 PM, Resident #41 was observed opening the malfunctioning drawer. This incident was witnessed by RN #3 and LPN #7. RN #3 immediately redirected resident. This incident was also witnessed by the annual survey team. The primary LPN #10 assigned to the cart was not present. 2. On (MONTH) 5, 2019 at approximately 1:00 PM, a new medication cart was delivered to the Facility. Medications were exchanged from the old cart into the new properly locking cart. 3. On (MONTH) 5, 2019 at approximately 2:00 PM, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the RN Supervisor (RN) #1, and the Minimum Data Set (MDS) RN #2, audited medication carts regarding proper locking and storage. No issues were identified. 4. On (MONTH) 5, 2019 at approximately 2:30 PM, the Administrator held a Quality Assurance Performance Improvement (QAPI) meeting to discuss action plan and resolution steps. The members of the committee discussed the medication cart malfunction, proper storage of medication, necessary steps in reporting issues and an audit tool developed as a tracking mechanism to ensure medication carts are in proper working order. The Members in attendance were the Administrator, DON, ADON, Medical Director, Social Services Director, Dietary Manager, Activities Director, Director of Therapy, Staff Development Coordinator LPN #7, Maintenance Director, Business Office Manager, Human Resources Generalist, Housekeeping Manager, MDS RN #2, LPN #4, LPN #5, Risk Manager RN, and the RN Supervisor (RN #1). 5. On (MONTH) 5, 2019 at approximately 3:00 PM, the Staff Development Coordinator LPN #7 in-serviced Licensed Nursing Staff on the daily audit tool used to validate that all medication carts are in proper-working order, proper storage of medication to maintain a safe environment, and proper procedure for unavailable medications. 6. No nursing staff will be permitted to work until in-serviced. 7. The facility alleges that all corrective actions to remove the immediate jeopardy was completed as of (MONTH) 5, 2019, and the immediate jeopardy removed as of (MONTH) 6, 2019. The SA validated the facility's Removal Plan and determined the facility had taken the following actions to correct the IJ: 1. Based on observations record review and staff interviews the State Agency (SA) validated Resident #41 had server cognitive impairment and was observed opening the drawer of an unsecured medication cart. The SA validated the resident was redirected by RN #3. 2. The SA validated by interview with the Director of Nurses (DON) and observation on [DATE], that a new cart had been delivered and medications were exchanged from the old cart into the new cart on [DATE], and the cart properly locked. 3. The SA validated by interview with the DON that an audit was completed on [DATE], that all carts locked appropriately. The SA found no other carts that malfunctioned. 4. The SA validated through review of the sign-in sheet and interview with the Administrator, that a QAPI meeting was held on [DATE], with all stated members, in regards to the malfunctioning medication cart, storage of medications, reporting requirements if there's a malfunction, and a tracking/audit tool for ensuring medication carts were in proper working order. 5. The SA validated through random interviews with nursing staff and review of in-service sign in sheets, that the Staff Development Coordinator, LPN #7, initiated in-services regarding use of the audit tool, proper storage of medication to maintain a safe environment for residents, and procedures for medications not available. 6. The SA validated through interview with random nursing staff that no staff was allowed to work until they were in-serviced. 7. The SA validated that all corrective actions to remove the Immediate Jeopardy were completed on [DATE], and the Immediate Jeopardy removed as of [DATE].

Based on observation, facility staff and consulting staff interviews, record review, and facility policy review, the facility failed to provide adequate supervision for a severely cognitively impaired resident, to ensure the resident did not have access to medication from an unsecured medication cart, for one (1) of five (5) residents reviewed for accidents and hazards, Resident #41. On [DATE] at 6:45 PM, Resident #41 was observed opening the drawer of the A Wing medication cart (Cart #1), which contained the significant medications Insulin and [MEDICATION NAME] tablets, along with other medications. The failure to provide adequate supervision, to ensure Resident #41 and the other five (5) residents identified with severe cognitive impairment, did not have access to remove medications from an unsecured medication cart, placed these residents in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE], when facility staff became aware that the medication cart had a drawer that would not lock and did not correct the situation. Resident #41, a resident with severe cognitive impairment, was observed to open the unsecured medication cart drawer, with accessible medications, on [DATE]. On [DATE] at 6:50 PM, the State Agency (SA) notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CRF(s) 483.25 (d)(2)-Supervision, F689, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy titled Security of Medication Cart, revised ,[DATE], revealed the nurse must secure the medication cart during the medication pass to prevent unauthorized entry. A review of the facility's policy titled, Safety and Supervision of Residents, with a revision date of (MONTH) (YEAR), revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Observation on [DATE] at 6:45 PM, revealed Resident #41 opened the uppermost right top medication cart drawer as the surveyor was walking down A-wing 100 hallway. The primary medication nurse was not present, or in sight of, the medication cart at this time. Registered Nurse (RN) #3 was walking down the hallway and met the resident at the medication cart and redirected his right hand away from the cart. Shortly after, the primary medication nurse and the Director of Nursing (DON) came to the cart. The primary medication nurse verified that the drawer contained the following medications: [REDACTED]. On [DATE] at 8:30 PM, an interview with the DON revealed, We have been trying to get that medication cart fixed for the past month or so. On [DATE] at 8:40 PM, an interview with Licensed Practical Nurse (LPN) #10 revealed the facility had been having trouble with this medication cart drawer since she started to work at this facility, in (MONTH) 2019. Review of the Electronic Medication Administration Records (MARs) revealed LPN #10 first documented medication administration on [DATE] for the 100 hall. On [DATE] at 8:50 AM, an interview with the Director of Nursing (DON) revealed, RN #3 moved the resident's hand away from the medication cart. The DON also stated the medication cart lock had been broken for at least the past two (2) weeks. She stated the medication carts are usually kept in the medication room or in the hallway with the lock turned towards the wall. She also stated Resident #41 could have gotten an alcohol pad from the medication cart, because he is cognitively impaired. The DON stated there was some Insulin in the drawer, but it was in a bag, and the eye drops were in a box. She stated the resident could have taken the [MEDICATION NAME] from the drawer and could have been sent to the hospital. Observation and interview on [DATE] at 9:00 AM, revealed Resident #41 lying in bed awake and getting ready to receive Activities of Daily Living (ADL) care. This Surveyor asked Resident #41 to make a fist and he stated, Do you mean make a fist like this and proceeded to open and close both of his hands demonstrating a fist five (5) times very quickly. He demonstrated the ability to follow a command. Observation on [DATE] at 9:30 AM, revealed LPN #9 pulled on each medication drawer of the A-wing medication cart, while it was in the locked position. Only the uppermost top right drawer would open. The same medications, including Insulin and [MEDICATION NAME] tablets, remained in the unsecured medication drawer at this time. During observation, on [DATE] at 9:35 AM, LPN #9 emptied the [MEDICATION NAME] tablets from the bottle (from the unsecured medication cart) into a plastic 30 Cubic Centimeter (CC) medication cup. LPN #9 approached Resident #41 and asked the resident to open the empty [MEDICATION NAME] bottle. The resident twisted the cap off of the [MEDICATION NAME] bottle easily. This was demonstrated in the presence of two (2) surveyors. Observation on [DATE] at 10:05 AM, revealed LPN #9 counted the [MEDICATION NAME] tablets that were in the bottle from the top right drawer of A-wing medication cart. There were a total of 25 0.4 MG tablets in the bottle. Interview on [DATE] at 10:55 AM, revealed LPN #9 had not redirected any resident away from the medication cart before. She denied any problems with residents getting into the medication cart. LPN #9 stated no resident has been harmed from any medications and she has not seen any medications in any resident hands. She also stated, she was just made aware of the medication cart not locking as of last week. She stated she had called the pharmacy this past weekend and told them the top right medication cart drawer had problems with locking and the response was they would have to give her a call back. LPN #9 stated the pharmacy had not called her back as of today ([DATE]). She stated she had told her Charge Nurse, LPN #4 or LPN #5 about the medication cart drawer not locking; she was not sure which one of those Charge Nurses she had told. LPN #9 stated she never had gotten a chance to report the drawer not locking to the DON, because she had just discovered it over the weekend. On [DATE] at 11:05 AM, an interview with RN #6 revealed she had not had any residents attempting to open her medication cart. She stated she tried to anticipate what the residents need to help prevent the residents from trying to get a medication themselves. On [DATE] at 11:15 AM, an interview with the DON revealed she had not had any problems with residents trying to get into medication carts. She stated she was about to intervene when she had seen Resident #41 open the medication cart drawer. The DON stated that if the medication cart would have been turned around towards the room, the resident would not have been able to open the drawer. On [DATE] at 11:28 AM, an interview with RN #5 revealed the nurses try to keep the medication cart within eye's view. She stated the nurses started calling last week to let the pharmacy know that the lock was broken on the A wing medication cart. On [DATE] at 11:40 AM, an interview with the DON revealed the facility should receive a new medication cart tonight from Omnicare. (Medications still remained in the cart at this time). On [DATE] at 3:04 PM, an interview with LPN #10, via telephone, revealed the medication cart drawer had been broken for a couple of weeks. She stated she told the pharmacy people about the medication cart being broken. She also stated she had gone to the DON. LPN #10 stated the DON told her to call the pharmacy initially, and she had started calling them last week. She also stated Maintenance attempted to fix the medication cart the day before (referring to [DATE]). LPN #10 stated she was on the hallway and had just came out of room [ROOM NUMBER]. She stated the medication cart was parked between room [ROOM NUMBER] and room [ROOM NUMBER]. She also stated she was able to see the resident in room [ROOM NUMBER] and the medication cart at the same time. On [DATE] at 3:15 PM, LPN #10 disconnected the telephone call. On [DATE] at 3:18 PM, LPN #10 called back to continue the interview. During this interview LPN #10 stated, Yes, I said it had been broken, and I think I told you since (MONTH) 25th (referring to how long the A-wind medication cart 1 had been broken). LPN #10 stated the cart was broken when she first started working (verified by the initials on the Electronic Medication Administration Record [REDACTED]. She stated Maintenance said they do not look at medication carts; she would have to call the people they (referring to the medication carts) had come from. She also stated the DON told her to call the pharmacy. LPN #10 stated she would keep the medication cart in view and/or turn it around. She stated when the surveyors had come to the facility, she was just finishing her medication pass. She then stated, she was able to see the medication cart, but could not see the resident. She also stated she had seen RN #3 intervene, but she (LPN #10) did not. LPN #10 then stated, the lock was facing her and she could see the lock. She stated the medication cart was close to rooms [ROOM NUMBERS] and it was facing towards the middle of the hallway. She stated the resident could have side effects if he had taken some of the medications. She also stated the resident could have heart problems and could have died . LPN #10 stated if she was giving medications to a resident and had the privacy curtain pulled, she would pull the medication cart to the door and she could hear if someone opened the drawer to the cart. She stated they would have to totally move the cart. She also stated, We have to keep the medications separated, so she could not have moved the medications to another drawer. She stated sometimes the other drawers would not lock and it's possible the resident could have gotten into another unlocked drawer. LPN #10 stated she tried several times to get the medication cart drawer fixed. On [DATE] at 4:08 PM, an interview with the DON revealed the staff reports to maintenance or puts the problem in the maintenance book for any broken equipment. She stated the Maintenance Supervisor or Maintenance Staff #2, are always on call even for equipment that need to be reported immediately. On [DATE] at 4:35 PM, an interview with Maintenance Staff #2 revealed he first became aware of the medication cart lock being broken on [DATE]. He stated as he was walking down the hallway, he was flagged down by RN #1 to talk to the pharmacy. Maintenance Staff #2 stated Omnicare staff asked him to check out the lock on the medication cart. He stated he and the Maintenance Supervisor were unable to fix the medication cart lock. He stated he called back and the lady on the phone stated she would send a technician out to the facility. He stated he had gotten the lady's first name but he was unable to get her last name. He also stated he does not know if the pharmacy sent the technician out to the facility or not. On [DATE] at 4:40 PM, an interview with the Maintenance Supervisor, revealed, Maintenance Staff #2, told her about the medication cart not being able to be locked on [DATE]. She stated, they (referring to her and her assistant) tried to work on it (referring to A-wing medication cart 1 lock) and could not get it fixed. She stated Maintenance Staff #2 called Omnicare. She stated the top right drawer would not lock. During an interview on [DATE] at 4:45 PM, Maintenance Staff #2 revealed the A-wing medication cart (Cart #1) measured 40 and ¼ inches in height. This was observed to be easily accessible to any resident, even a resident who used a wheelchair. On [DATE] at 5:47 PM, an interview with Consultant Pharmacist #2, revealed Omnicare (pharmacy) was first notified on Monday ([DATE]), of the facility having a medication cart that would not lock. She stated the facility emailed Pharmacy Staff #1 on Monday, [DATE], at 5:08 PM. She also stated she was not aware that the medication cart had been broken for two (2) weeks. She stated she called the facility Tuesday [DATE], to see if the maintenance man could fix the cart. She also stated if a resident took 25 0.4 MG [MEDICATION NAME] tablets, she believed they would have a headache and [MEDICAL CONDITION]. She also stated that 25 [MEDICATION NAME] tablets would be a higher than indicated dose. She stated it is not an indicated dose, and could lead to [MEDICAL CONDITION], Headache, and falls. On [DATE] at 5:57 PM, an interview with the Medical Director revealed she was made aware of this incident (A-wing medication Cart 1 drawer lock being broken) today when she walked through the door at 2:00 PM. She stated there was a plan of correction in place. She also stated the Pharmacist is a major issue here at the facility. She stated if a resident had taken 25 of the 0.4 Mg [MEDICATION NAME] tablets that could cause death. On [DATE] at 12:04 PM, an interview with RN #3 revealed she was making rounds and when she headed back, that's when she took the resident's hand and said, No, no, no, we can't do that (referring to Resident #41 opening the medication cart drawer). She stated Resident #41 said all he wanted was a pencil. RN #3 also stated she was headed back from the end of A-wing hallway to the nursing station. She stated the DON was coming from the opposite direction. RN #3 stated she had not had to redirect a resident away from a medication cart before. She also stated she does not remember any other resident opening the medication cart before. She stated she does not have a clue as to how long the medication cart lock had been broken. On [DATE] at 12:15 PM, observation revealed LPN #7 moved a Medication cart, just like the cart that had the broken drawer, to the middle of A-wing hallway between rooms [ROOM NUMBERS]. The medication drawers faced the center of the hallway, just as positioned on [DATE], when the resident was observed opening the medication cart drawer. The surveyor sat at the nursing desk on A-wing and the medication cart drawers were not visible from the nursing station with the medication cart being in this position. On [DATE] at 3:22 PM, an interview with Consultant Pharmacist #1 revealed there is some form of medication audit done monthly. He stated carts are checked basically once a quarter. He stated he was not aware and cannot recall the A-wing medication cart drawer being unable to be locked. On [DATE] at 11:32 AM, an interview with RN #3 revealed the staff could have supervised and redirected the resident to prevent this incident from occurring. On [DATE] at 1:28 PM, an interview with the Administrator revealed the DON notified him of the incident (A Wing top right medication cart drawer not locking) on [DATE]. He stated the expectation is not that the staff wait to report these types of issues. He stated he must be made aware for the safety and well-being of the residents. The facility identified five (5) residents, who had severe cognitive impairment and who were mobile in the facility. The facility provided the following Removal Plan: Brief Summary: At approximately 6:50 PM on (MONTH) 5, 2019, the facility was notified by the annual survey team that the facility was being placed in Immediate Jeopardy, due to the facility on (MONTH) 4, 2019 at approximately 6:45 PM, failed to adequately supervise to prevent a severely cognitively-impaired resident from opening a medication cart drawer where multiple medications, including 25 [MEDICATION NAME] 0.4 milligram (mg) tablets were located. The facility failed to store medications safely to prevent a cognitively impaired resident from having access to the medication cart, and the medication cart drawer would not lock. Licensed Practical Nurse (LPN) #10 stated the cart did not lock properly and has malfunctioned since she started to work in the Facility on (MONTH) 26, 2019, at approximately 7:00 AM. On the evening of (MONTH) 4, 2019, Resident #41 was witnessed by a surveyor opening the malfunctioning drawer where medication was located. The cart was locked in the medication room once medication pass was completed. (The name of the Pharmacy Vendor) was contacted on (MONTH) 3, 2019 and a new cart was requested. The replacement cart arrived at the Facility on (MONTH) 5, 2019, and medications were transferred from the malfunctioning cart to the properly locking replacement cart. Corrective actions included: 1. On (MONTH) 4, 2019 at approximately 6:45 PM, Resident #41 was observed opening the malfunctioning drawer. This incident was witnessed by RN #3 and LPN #7. RN #3 immediately redirected resident. This incident was also witnessed by the annual survey team. The primary LPN #10 assigned to the cart was not present. 2. On (MONTH) 5, 2019 at approximately 1:00 PM, a new medication cart was delivered to the Facility. Medications were exchanged from the old cart into the new properly locking cart. 3. On (MONTH) 5, 2019 at approximately 2:00 PM, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the RN Supervisor (RN) #1, and the Minimum Data Set (MDS) RN #2, audited medication carts regarding proper locking and storage. No issues were identified. 4. On (MONTH) 5, 2019 at approximately 2:30 PM, the Administrator held a Quality Assurance Performance Improvement (QAPI) meeting to discuss action plan and resolution steps. The members of the committee discussed the medication cart malfunction, proper storage of medication, necessary steps in reporting issues and an audit tool developed as a tracking mechanism to ensure medication carts are in proper working order. The Members in attendance were the Administrator, DON, ADON, Medical Director, Social Services Director, Dietary Manager, Activities Director, Director of Therapy, Staff Development Coordinator LPN #7, Maintenance Director, Business Office Manager, Human Resources Generalist, Housekeeping Manager, MDS RN #2, LPN #4, LPN #5, Risk Manager RN, and the RN Supervisor (RN #1). 5. On (MONTH) 5, 2019 at approximately 3:00 PM, the Staff Development Coordinator LPN #7 in-serviced Licensed Nursing Staff on the daily audit tool used to validate that all medication carts are in proper-working order, proper storage of medication to maintain a safe environment, and proper procedure for unavailable medications. 6. No nursing staff will be permitted to work until in-serviced. 7. The facility alleges that all corrective actions to remove the immediate jeopardy was completed as of (MONTH) 5, 2019, and the immediate jeopardy removed as of (MONTH) 6, 2019. The SA validated the facility's Removal Plan and determined the facility had taken the following actions to correct the IJ: 1. Based on observations record review and staff interviews the State Agency (SA) validated Resident #41 had severe cognitive impairment and was observed opening the drawer of an unsecured medication cart. The SA validated the resident was redirected by RN #3. 2. The SA validated by interview with the Director of Nurses (DON) and observation on [DATE], that a new cart had been delivered and medications were exchanged from the old cart into the new cart on [DATE], and the cart properly locked. 3. The SA validated by interview with the DON that an audit was completed on [DATE], that all carts locked appropriately. The SA found no other carts that malfunctioned. 4. The SA validated through review of the sign-in sheet and interview with the Administrator, that a QAPI meeting was held on [DATE], with all stated members, in regards to the malfunctioning medication cart, storage of medications, reporting requirements if there's a malfunction, and a tracking/audit tool for ensuring medication carts were in proper working order. 5. The SA validated through random interviews with nursing staff and review of in-service sign in sheets, that the Staff Development Coordinator, LPN #7, initiated in-services regarding use of the audit tool, proper storage of medication to maintain a safe environment for residents, and procedures for medications not available. 6. The SA validated through interview with random nursing staff that no staff was allowed to work until they were in-serviced. 7. The SA validated that all corrective actions to remove the Immediate Jeopardy were completed on [DATE], and the Immediate Jeopardy removed as of [DATE].

Based on observation, resident interview, facility staff interview, and record review, the facility failed to provide nail care for one (1) of 18 residents reviewed, Resident #11. Findings include: Review of the facility policy, Fingernails/Toenails, Care of, dated (MONTH) (YEAR), revealed: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection. Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin. In an observation and interview on 06/04/19 at 7:19 PM, Resident #11's fingernails were dirty and uneven in length. Resident #11 stated, My nails need to be done. It is an issue for me when I play the piano. It bothers me when I try and play the piano. Resident #11's right pinky, right ring finger, and right middle fingernails were long; approximately 3/4 inches in length. The forefinger nail was approximately 1/2 inch long. The left hand had several nails broken and uneven in length. Nails were jagged on both hands. The resident stated, I like my nails longer, but they need to be done closer to same size on both hands. An interview with Resident #11, on 06/06/19 at 10:27 AM, with Registered Nurse (RN) #1 present, revealed her nails hurt. She stated her pinky was long, and had broken off, and it hurt. She stated she didn't want the nails cut off short, but did want them clean and shaped the same length. She stated she played the piano and it bothered her that her nails were in that shape. An interview on 06/06/19 at 10:35 AM, with RN #1, revealed the nurses are supposed to cut the resident's nails on the weekend. She stated she could see that Resident #11's nails were uneven, jagged, and somewhat unclean. An interview on 06/06/19 on 12:31 PM, with RN #4, revealed the facility was implementing a new schedule, where the diabetic residents nail care will be placed on the Electric Medical Record (EMAR) for the nurses to do, and the nail care the CNA can do will be placed on the point of care for them to check off that nail care was completed. RN #4 stated this was schedule at some of the facilities, but not at this one yet. An interview on 06/07/19 at 10:35 AM, with the DON, revealed Resident #11's sisters do her nails sometimes and she had supplies in her room for when they visited. The DON stated that Resident #11 liked her nails long, and she guessed it just fell through the crack and they weren't done. The DON stated the Activity Department does nails monthly and she didn't know how it fell through the crack for the nails not being done, including trimmed or cleaned.

Based on interview, record review, and facility policy review, the facility failed to submit a Level II recommendation within 30 days from the Level I Preadmission Screening and Resident Review (PASARR) screenings for Resident #4 and Resident #14; and failed to submit a Level I Pre-Admission Screening (PAS) for Resident #6 within 30 days; and failed to submit a Level 1 PAS with an accurate [DIAGNOSES REDACTED]. This affected four (4) of eight (8) resident reviews for PASARRs. Findings include: A review of the Division of Medicaid Pre-Admission Screening (PAS) Instruction Manual, revised (MONTH) 24, 2013, revealed that a Level II Referral would be completed if a person had a mental illness or diagnosed with [REDACTED]. The manual also revealed that referrals must be made even if a physician certified that, in his/her opinion, a Level II evaluation was not indicated at this time. Resident #4 and Resident #14 Record Review of Resident #14's PAS, dated 4/24/19, revealed a Level II was indicated, but had not been completed and submitted as of 6/4/19. Resident #4 was admitted to the facility on [DATE], and re-entered the facility on 2/25/19, per the Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 5/31/19. This MDS indicated Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed Resident #14's PAS, completed on 4/24/19, revealed a Level II was indicated, but had not been completed and submitted as of 6/4/19. During an interview on 06/07/19 at 2:25 PM, the Social Worker confirmed the PAS was done, but the level II's were not sent to ASCEND. The Business Office Manager did not know she was suppose to send them. The Social Worker said the Level II screen was sent to ASCEND on 6/5/2019. On 06/07/19 at 09:50 AM, interview with the Social Service Director (SSD), revealed the Business Office Manager did not submit the Level I findings that indicated a Level II assessment. The SSD stated that the Business Office Manager was not aware these had to be submitted this week. In a statement, on letterhead, provided by the Regional Reimbursement Specialist on 6/5/19, revealed on 4/24/19, a PAS was entered into the computer system for Resident #4 and Resident #14. Both had attestations stated a Level II is indicated at this time, but the PAS were never submitted. Resident #86 A review of Resident #86's PAS, dated 12/07/16, revealed the facility documented in Part B - Level II Referral Criteria was marked No, for the question person has a [DIAGNOSES REDACTED]. The attestation on the PAS was marked, A Level II evaluation is not indicated at this time and signed by the physician on 12/09/2016. A review of Resident #86's medical [DIAGNOSES REDACTED]. A review of Resident #86's MDS with an ARD of 5/22/2019, revealed Section A1500 was documented 0, which indicated the resident was not considered, by the state level II PASRR process, to have a serious mental illness and/or intellectual disability. A review of Resident #86's Admission Record indicated her initial admitted was 5/18/2001, with a readmitted [DATE]. In an interview on 06/06/19 at 3:40 PM, the Administrator (ADM) said the Business Office starts the PAS before admission. An interview with Licensed Social Worker (LSW), at the same time, revealed the Pre-Admission Screening Application for Long Term Care information was electronically entered by Medical Records after nursing and the Social Services completed the form. The LSW said Medicaid then decides who needs a Level II. The ADM confirmed this was the facility policy for completing the PAS. An interview on 6/7/2019 at 11:02 AM, with the LSW, confirmed Resident #86 had a major mental illness and developmental [DIAGNOSES REDACTED]. The LSW confirmed Resident #86's PAS was blank and was marked no on the Part B section for mental illness. The LSW said she would have marked yes if she had filled out the form and would expect Resident #86 to have a Level II referral. Resident #6 Review of Resident #6's PAS Summary and Physician Certification document or (Electronic PAS), dated 4/23/219, revealed that Resident #6 had an active medical condition of [MEDICAL CONDITION] Disorder, Depression (Major), and Anxiety Disorder. The PAS indicated in Part B of the General PASARR section that Resident #6 did not have a [DIAGNOSES REDACTED]. The PAS indicated in the Electronic Attestation section that a Level II evaluation is not indicated at this time. The PAS also indicated a signature from the physician. Review of the untitled document on the facility's letterhead, dated 6/5/19, revealed that on 4/23/2019, the PAS was entered for Resident #6. The document also indicated, The attestation stated a Level II screening is not indicated at this time. The document also indicated, The PAS was submitted on 06/05/2019. The document was signed by Registered Nurse (RN) #4, the facility's Regional Re-imbursement Specialist. Review of the facility's medical records document titled, [DIAGNOSES REDACTED].#6 was admitted to the facility with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED].#6 was given the following Diagnoses: [REDACTED]. During an interview, on 6/5/2019 at 3:59 PM, the facility's Regional Re-imbursement Specialist/RN #4, stated that the PAS was past the 30-day requirement for submission. RN #4 stated that the PAS was completed, signed by the physician, and entered into the computer on 4/23/2019. RN #4 stated that the PAS revealed that Resident #6 did not require a Level II screening. RN #4 stated that the PAS was finally submitted on 6/5/2019. During an interview, on 6/6/2019 at 10:05 AM, the facility's Social Services Director (SSD), revealed that the SSD is only responsible for a portion of a completed PAS. The SSD stated that the PASARR must be completed to determine if the resident has a Level II exemption. The SSD stated that the exception should have been marked for major mental illness in Part B and not severe physical illness in Part A. The SSD stated, I'm going to look for the original PAS, and see what it says. The SSD confirmed the resident had a [MEDICAL CONDITION] Disorder mental illness diagnosis. Review of the Face Sheet revealed Resident #6 was admitted by the facility on 1/23/2018, and re-admitted on [DATE], with [DIAGNOSES REDACTED].

Based on observation, interviews, and record review, the facility failed to have an effective pest control, as evidence by flies for three (3) of four (4) days of survey, to include two (2) of three (3) kitchen observations. All 86 residents have the potential to be affected. Findings include: The facility's policy, Pest Control, revised (MONTH) 2008, noted the facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents. On 06/04/19 at 6:20 PM, during an observation of the supper meal, Certified Nursing Assistant (CNA) #1 confirmed a fly seen on Resident #65's plate while eating. Resident #65 stated, We can't eat our food for the flies, they are everywhere. On 06/04/19 at 6:38 PM, during the initial kitchen tour, Dietary Cook/Aide #4 confirmed a fly in the kitchen area. On 06/06/19 at 11:45 AM, during an observation with the Dietary Manager (DM), a fly was visible on the rim of a desert bowl. During an interview on 6/6/19 at 11:45 AM, the DM was asked why it was important not to have flies and pests in the kitchen. The DM stated, It's unsanitary. The DM did not remove the dessert bowl from the tray line after identifying the fly on the rim of the bowl and continued to let the desert be served. On 06/07/19 at 2:09 PM, observation of a fly on an un-sampled resident's left sleeve of shirt was confirmed by Licensed Practical Nurse (LPN) #1. On 06/07/19 at 1:15 PM, the facility Administrator was asked how he knows he has an effective pest control program? The Administrator responded, By the absence of pests. The Administrator confirmed that pest control was not effective with the evidence of flies in the kitchen and throughout the facility. Record review revealed Pest Control Invoices dated 12/19/18, 1/10/19, 2/15/19, 3/19/19, 4/25/19, and 5/30/19.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide Resident #65 with a meal that was palatable, attractive and acceptable in flavor, for one (1) of 18 meal observations; and six (6) Resident Council members, during interview, also complained of food being cold and not palatable. This affected seven (7) of 86 residents in the facility. Findings include: The facility policy Food: Quality and Palatability, revised on 9/2017, noted the facility would prepare food by methods that conserve nutritive value, flavor and appearance and will be palatable, attractive, and served at a safe and appetizing temperature. This policy also noted foods and liquids are to be prepared and served in a manner, form, and texture to meet resident's needs. Resident #65 On 06/04/19 at 6:15 PM, during the dinner meal observation with Resident #65, he stated, I can't eat this mess, look at what they feed us. The resident stated the bread was hard as a rock. The bread was hard with no meat. Resident #65 complained of the taste and said he would not give this to a dog. The food was served on paper plates and disposable cups, with disposable spoons and forks. The bread on the sandwich was hard, dry (not like toast). When Resident #65 opened his sandwich, cheese was melted to both sides of the hard, dry bread, without any meat. In an observation on 06/04/19 at 6:18 PM, with Dietary Cook/Aide #3 present, the ham and cheese sandwiches had a dry-looking appearance. Dietary Cook/Aide #3 confirmed that the sandwiches in the metal tray were the ones being served to the residents. Interview with the Dietary Manager, on 06/05/19 at 4:35 PM, revealed there were concerns with one (1) Cook during the evenings. Taste of test trays on 6/6/19 at 12:30 PM, by the State Agency (SA) was acceptable in temperature, but bland with little to no seasoning. No concern with this meal appearance. The Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 5/14/19, revealed Resident #65 had a score of 15 on the Brief Interview for Mental Status (BIMS), which indicated he was cognitively intact. Resident Council Members During interview on 06/05/19 at 2:15 PM, six (6) Resident Council members revealed they have complained about the food every month for a year. The council Members also said the Dietary Manager was present for all meetings. Resident #1, the Council President, revealed the Council had complained every month about the food being cold, burnt and the meat is always hard. During an interview on 06/06/19 at 3:00 PM, the Activity Director confirmed the residents have complained about the food every month. The Activity Director also stated that she had observed cold and burnt food served during meal times. During an interview on 06/06/19 at 9:18 AM, The Dietary Manager revealed she attended all of the Resident Council meetings and the resident's had complained about the food being burnt, cold, and not tasting good. The Dietary Manager said she was working on correcting the issues.

Based on record review, Grievance Log review, resident interview, staff interview, Resident Council meeting interviews, and facility policy review, the facility failed to resolve food grievances voiced by six (6) residents in the Resident Council meeting, of 86 residents in the facility, Residents #1, #4, #23, #65, #70, and #83. Findings Include: Record Review of the facility policy, titled Grievances, undated, revealed the facility will assist residents, their representatives, other family members, or advocates, in filing grievances or complaints when such requests are made. Any resident, his or her representative, family member, or advocate may file a grievance concerning his or her treatment, medical care, behavior of other residents, staff members, theft of property without fear of discrimination, threat or reprisal of any kind. Grievances or complaints may be made orally or in writing to the Social Worker, and may be filled anonymously. Upon receipt of written grievance, the social worker or relevant department head will investigate the allegation and report the findings to the Administrator within 72 hrs to determine what corrective actions, if any, need to be taken. The resident, or the person filing the grievance on behalf of the resident, will be informed verbally and in writing (if requested) of the findings of the investigation and the actions that will be taken to correct any identified problems. Record Review of the facility's Resident Rights procedure, undated, revealed the resident is encouraged and assisted, throughout his period of stay, to exercise his rights as a resident and as a citizen, and to this end may voice grievances, has rights of action for damages or other said relief for deprivations or infringements of rights to adequate and proper treatment and care established by applicable statue, rule regulation, or contract, and to recommend changes in policies and services to facility staff and/or outside representatives of his choice, free from restraint, interference, coercion, discrimination, or reprisal. Record Review of the resident Council minutes from (MONTH) (YEAR) through (MONTH) 2019, revealed the resident's talked to The Dietary Manager on 12/8/2018, about the chicken that was hard, uncooked and/or burnt. They discussed the menu and residents not asked about food preference on 1/22/2019. Record Review of the Facility's Grievance log from (MONTH) (YEAR) through (MONTH) 2019, revealed residents complained of dietary concerns on 8/9/2018, 10/8/2018, 11/9/2018, 11/12/2018, 11/13/2018, 12/28/2018, and 4/29/2019. There was no documented evidence that the facility resolved the grievances. During an observation on 06/04/19 at 6:20 PM, of the dinner meal, Resident #65 complained that the sandwich bread was really hard and had no meat. Resident #65 complained of the taste and said he would not give this to a dog. During interview on 06/05/19 at 2:15 PM, the six (6) Resident Council members revealed they had complained about the food every month for a year. The Council Members also said the Dietary Manager was present for all Resident Council meetings. The Council Members said the Activity Director and the Assistant takes the minutes during the council meeting. During an interview on 06/05/19 at 2:22 PM, Resident #1, the Council President, revealed the Council had complained every month about the food being cold, burnt, and/or the meat is always hard. Resident #1 stated the complaints were not always documented in the minutes. During an interview on 06/06/19 at 3:00 PM, the Activity Director confirmed the residents have complained about the food every month. The Activity Director said she don't know why the residents' complaints about the food was not always put in the minutes. The Activity Director also stated that she has observed cold and burnt food served during meal times. During an interview on 06/06/19 at 9:18 AM, the Dietary Manager revealed she attended all of the Resident Council meetings. The Dietary Manager stated that the resident's had complained about the food being burnt, or cold, and does not taste good. The Dietary Manager said she was working on correcting the issues. During an interview on 06/6/19 at 10:13 AM, the Social Worker confirmed the residents had complained about the food not tasting good and/or cold for several months. The Social Worker stated the Dietary Manager reported the complaints were resolved. The Social Worker said she had not been talking to the residents to see if the complaints were resolved. The Social Worker said she will follow up with the residents as of today to make sure the complaints were addressed and/or resolved. Record Review of the most recent Minimum Data Set (MDS) of the Resident Council members that were present during interview, revealed the following Brief Interview for Mental Status (BIMS) scores: Resident #1 (BIMS=15), Resident #4 (BIMS=13), Resident #23 (BIMS=15), Resident #65 (BIMS=15), Resident #70 (BIMS=13), Resident #83 (BIMS=13). BIMS 0-6 indicates severe cognitive impairment, BIMS 7-12 indicates moderate cognitive impairment, and BIMS of 13-15 indicates no cognitive impairment.

Based on record review, facility policy review, and staff interview, the facility failed to accurately code a Quarterly Minimum Data Set (MDS) related to wounds/Stage 3 pressure ulcer, for one (1) of 22 records reviewed, Resident #46. Findings include: Review of an untitled document on the facility's letterhead, provided and signed by the facility's Administrator, dated 6/7/19, revealed that the facility follows the guidelines set forth by the Resident Assessment Instrument (RAI) Manual for coding the MDS. Review of Resident #46's Quarterly MDS with an Assessment Reference Date (ARD) of 5/3/19, revealed that Resident #46 was coded for a Stage 3 pressure ulcer in the M0300 section of this MDS. Review of a facility document titled, Skin & Wound Evaluation V5.0, dated 5/1/2019, revealed that Resident #46 had a venous ulcer to the lateral left calf. The wound evaluation did not document a Stage 3 pressure ulcer. Review of the untitled document, dated 6/5/2019, provided by the facility's Treatment Nurse, Licensed Practical Nurse (LPN) #8, revealed that Resident #46 was assessed on 5/9/2019, as having two (2) venous ulcers to the left calf. There was no pressure ulcer(s) indicated on this report. LPN #8 verified this information came from the most recent wound care report. During an interview, on 6/7/2019 at 10:33 AM, LPN #8/Treatment Nurse, revealed that Resident #46's Stage 3 pressure ulcer had been resolved in (MONTH) 2019. LPN #8 stated that the last wound evaluation indicating that Resident #46 had a Stage 3 pressure ulcer, was completed on 2/8/2019. During an interview, on 6/7/19 at 11:44 AM, Registered Nurse (RN) #2/MDS Coordinator confirmed that a Stage 3 pressure ulcer was coded on Resident #46's Quarterly MDS, with an ARD of 5/3/19. RN #2 stated that there was only two (2) venous ulcers to the left lower extremity on the weekly skin report and weekly wound evaluation report. RN #2 stated that the coding of the Stage 3 pressure ulcer was incorrect. During an interview on 6/7/2019 at 11:50 AM, RN #3/MDS Coordinator, confirmed that the Quarterly MDS completed on 5/3/19, was coded incorrectly for a Stage 3 pressure ulcer. RN #3 confirmed that Resident #46 did not have a pressure ulcer and that two (2) venous ulcers to the left lower extremity were documented on the weekly skin and wound evaluation reports. Review of the Face Sheet revealed Resident #46 was admitted by the facility on 3/6/2018, with [DIAGNOSES REDACTED].

Based on observation, staff and resident interview, facility policy and record review, the facility failed to provide catheter care in a manner to prevent a Urinary Tract Infection [MEDICAL CONDITION]. The facility failed to provide monthly Coude catheter changes, and to secure the catheter with an anchoring device to prevent possible trauma to the resident's urethra for one (1) of five (5) residents with catheters reviewed, Resident #3. The failure to send the resident for catheter changes monthly and/or as needed, as ordered, resulted in harm to the resident as evidenced by the catheter being obstructed, and the resident experiencing pain and trauma when the catheter was removed, and replaced with another catheter. Findings include: Review of the facility's document titled, Catheterization Competency Check List, no date, revealed: Tape the catheter or apply a Velcro leg strap, never leave the room until the catheter is secured. Mechanical irritation caused by catheter movement can cause urethral and meatal tearing, accidental removal, and serious complications. The facility did not provide a policy for following physician's orders [REDACTED]. In an interview, on 02/28/18 at 2:00 PM, the Director of Nurses (DON) stated they did not have policy's covering catheter maintenance, but just usually follow the doctor's orders for catheter change. She stated, We usually change out Foley catheters monthly, and catheter drainage bags every two (2) weeks depending on what the doctor has ordered. These show up on the Medication Administration Record [REDACTED]. If a resident has to go out to have a catheter changed it will not show up on the MAR. It's easy to miss these because they do not come back from the clinic with an appointment for a catheter change. We have to call and schedule it. Observation of catheter care provided by Certified Nursing Assistants (CNAs) #1 and #2, on 2/28/18 at 11:00 AM, revealed there was no leg strap, or other type of securing device in place on Resident #3's catheter. Observation, on 03/01/18 at 10:00 AM, revealed Resident #3's catheter was not secured with a leg strap, or other securing device. An interview with Resident #3, on 2/28/18 at 11:00 AM, revealed he could not remember the catheter being changed in the emergency room , in November, but did remember the change at the office in January. Resident #3 stated the catheter was changed this past Monday, and it did not hurt that time. Interview with Registered Nurse #3, on 03/01/18 at 10:00 AM, revealed all catheters should be secured, and confirmed Resident #3 did not have a securing device, and that she would get one. Review of Resident #3's Order Summary report, with a date of 02/28/18, revealed a physician's orders [REDACTED]. Review of Resident #3's Nurse's Notes, for 11/01/17 at 6:35 PM, revealed the resident was noted in bed awake, alert, and verbally responsive. The resident was moaning loudly, the nurse entered the room, and the resident was complaining of the catheter hurting. Approximately 300 cubic centimeters (cc's) of cloudy yellow urine was in the gravity urine bag and none in the tubing. His bladder was non-distended; the facility's Certified Nurse Practitioner (CNP) was notified and gave an order to irrigate with 60 cc's sterile water. This was attempted, and catheter was unable to be irrigated. The CNP attempted unsuccessfully. An order was given to send resident to the emergency room (ER) for catheter exchange. Review of Resident #3's 11/07/17 ER records revealed the resident was sent for replacement of the Coude catheter, and the facility was not authorized to replace these. Patient complains of suprapubic discomfort. He has a [MEDICAL CONDITION] Bladder and a history of Urethral Stricture which was apparently dilated by the Urologist, and he has [DIAGNOSES REDACTED]. Catheter was replaced, and resident was sent back to the nursing home, and Urology follow up recommended. Review of the Nurse's Note, for 1/21/18 at 2:39 PM, revealed Resident #3 was noted with Foley catheter leakage, he denied pain or discomfort at present. Placed on communication board to call Urology Clinic in AM for catheter change due to type of catheter resident has, and unable to change at facility. Review of the urology clinical record for the visit, on 01/26/18, revealed the resident returned after an extended absence, and was last seen by provider in (MONTH) (YEAR). Patient was scheduled for monthly office visits for catheter exchange. The urology note stated, this cannot be done in a timely manner where patient resides. Previous issues with patient were noted of having regular monthly catheter exchanges as ordered. The last documented catheter exchange in office was (MONTH) (YEAR); patient was not brought back to office until 01/26/18. Review of electronic record revealed the catheter had been changed at a local hospital on [DATE]. The patient reported it had not been changed since November, and examination of the catheter confirmed the report. Patient presents with a Coude catheter in place with dark urine in the collection bag. A nurse at the clinic documented that he was unable to remove the catheter so he had to ask the Urologist to change it. The catheter was exchanged by Urologist with some effort. The catheter was replaced, and began draining clear yellow urine. Review of the CNP's assessment/plan revealed [MEDICAL CONDITION] Bladder Foley Catheter with monthly exchanges as ordered, as this was not being done at the patient's current facility; will plan to have him in the office every 30 days for exchange, Pyuria - will culture and adjust antibiotics as needed, and UTI - Bactrim DS twice daily, and await culture results. Interview with the Certified Nurse Practitioner (CNP), on 2/23/18 at 5:00 PM, revealed the urologist clinic was supposed to see Resident #3 for monthly and as needed (PRN) catheter changes. The CNP stated the resident has significant [DIAGNOSES REDACTED], elevated Prostate Specific [MEDICATION NAME] (PSA) levels, and frequent Urinary Tract Infections (UTIs). The nursing home staff are unable to change out Coude catheters at the facility where he resides. The facility sent him over for a catheter change due to leaking around the catheter on 01/26/18. Emergency Medical Services (EMS) brought him to the urology clinic, he did not have an appointment, and no information was sent with him. The nurse who usually does the catheter changes in the clinic was unable to remove the catheter, and the urology clinic suspected adhesions to the urethra. A urologist was able to remove the catheter after some effort. Since it was a traumatic catheter exchange, and based on the urinalysis, the clinic went ahead and put him on antibiotics. The resident said that the catheter had not been changed since November. Urinalysis done at that visit showed he had a Urinary Tract Infection. He was sent only because his catheter was leaking, not because of a scheduled catheter change. The CNP stated she was concerned that Resident #3 was not being taken care of properly because they send him back with appointments and instructions, and it just doesn't look like they are being followed. Because of his condition it is important that his catheter be changed monthly. This is a serious problem since the patient has frequent UTIs that could lead [MEDICAL CONDITION] if untreated. Interview with RN #1, on 02/28/18 at 3:25 PM, revealed the date the catheter is inserted should be on the catheter evaluation sheet. It is not on the catheter evaluation sheet. These are filled out by the floor nurses, and used for the Minimum Data Sets (MDS) and care plans. Floor nurses are responsible for orders, making sure they are done, and they should look at consults. Interview with LPN #2, on 03/01/18 at 11:45 AM, revealed doctor's orders should be followed, and if unable to follow nurse would need to contact the ordering physician. Interview with the facility's CNP, on 03/01/18 at 11:50 AM, revealed, I would expect the nurses here to follow my orders, if a resident refused and they were unable to complete because of that, or for some other reasons I should be notified that it was not done and why it could not be done If a Urologist said a catheter needed changing monthly it should be done monthly. Interview with RN #2 and LPN #3, on 03/01/18 at 11:55 AM, revealed it is the nurse's responsibility to make sure doctor's orders are being followed. Doctor's orders should be followed. Interview with the DON and Assistant DON (ADON), on 02/28/17 at 4:30 PM, revealed both confirmed the orders were not followed. Resident #3 had missed at least four (4) months of catheter changes. Resident was sent to the ER in (MONTH) for a catheter change. Resident did not have his catheter changed in July, September, (MONTH) and (MONTH) of (YEAR). Interview with the ADON, on 03/01/18 at 4:50 PM, revealed there was a change in nurses on the hall cart where Resident #3 resided. She stated some PRN staff were working, and that's probably why it was missed. Review of Resident #3's Face Sheet revealed the facility admitted the resident, on 05/07/14, with [DIAGNOSES REDACTED]. Review of the Resident #3's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/17, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, record review, policy review, and facility staff and resident interview, the facility failed to follow the comprehensive care plan for catheter changes, and for having an anchoring device for the catheter tubing for one (1) of five (5) care plans reviewed, for Resident #3. As a result of failure to follow the care plan, Resident #3 experienced harm, and pain due to prevention of urine flow when the catheter was obstructed, and not changed as care planned. Findings include: Review of a signed statement, by the Administrator, dated 3/1/18, revealed the facility did not have a policy on following care plans. Review of the facility's document titled, Catheterization Competency Check List, no date, revealed: Tape the catheter or apply a Velcro leg strap, never leave the room until the catheter is secured. Mechanical irritation caused by catheter movement can cause urethral and meatal tearing, accidental removal, and serious complications. Review of Resident #3's Care Plan, with a revision date of 01/05/18, revealed a focus area for the Foley catheter secondary to [MEDICAL CONDITION]. The goals for this focus included: free of Urinary Tract Infection [MEDICAL CONDITION] through next review, and free of injury related to catheter through next review. Interventions/ Tasks include: Coude Foley Catheter 18 French/10 cc (cubic centimeter) bulb -Do not remove Foley. Refer to Urologist every month for catheter change, and as needed for leakage, keep securing device attached to Foley to avoid injury. An observation of Resident #3's catheter care, on 2/28/18 at 11:00 AM, revealed there was no leg strap or other type of securing device in place on Resident #3's catheter tubing. The catheter care was provided by Certified Nursing Assistants (CNAs) #1 and #2. An interview with Resident #3, on 2/28/18 at 11:00 AM, revealed he could not remember the catheter being changed in the emergency room , in November, but did remember the change at the office in January. Resident #3 stated the catheter was changed this past Monday, and it did not hurt that time. Observation, on 03/01/18 at 10:00 AM, revealed the catheter tubing was not secured with leg strap or other securing device. Interview with Registered Nurse (RN) #3, on 03/01/18 at 10:00 AM, revealed all catheters should be secured. RN #3 stated there should be a securing device in place on Resident #3's catheter. RN #3 stated she would put a leg strap on the resident. RN #3 stated Resident #3's care plan was not followed due to the leg strap was not in place. Review of Resident #3's Nursing Notes for 11/01/17 at 6:35 PM, revealed the resident was in bed awake, alert, and verbally responsive. Resident #3 was noted moaning loudly, and the nurse entered the room. The resident complained of the catheter hurting, and no urine in the tubing. The staff at the facility, and the Nurse Practitioner (NP) were unable to irrigate the catheter so an order was given to send resident to the emergency room (ER) for catheter exchange. Review of Resident #3's ER records on 11/01/17 revealed documentation that the resident was sent for replacement of the Coude catheter, and the facility was not authorized to replace these. Patient complains of suprapubic discomfort. Review of a Nurse's Note for 1/21/18 at 2:39 PM, revealed resident noted with Foley catheter leaking. Placed on communication board to call Urology Clinic in AM for catheter change due to type of catheter resident has, and unable to change at facility. Review of the Urology Clinical record for the visit, on 01/26/18, revealed the resident returned after an extended absence, last seen by this provider in office was in (MONTH) (YEAR). Patient was scheduled for monthly office visits for catheter exchange. The last documented catheter exchange in office was (MONTH) (YEAR); he was not brought back to the office until 01/26/18. The catheter had been changed at a local hospital on [DATE]. The patient reported it had not been changed since November, and examination of the catheter confirmed the report. Patient presents with a Coude catheter in place with dark urine in the collection bag. The note documented difficulty removing the catheter with suspected adhesion to the urethra, but after some effort it was removed and replaced with a 20 French coude. Based on urinalysis of 01/26/18 and traumatic catheter exchange, will treat with antibiotics. Interview with a Certified Nurse Practitioner (CNP) from the Urology Clinic, on 2/23/18 at 5:00 PM, revealed they were supposed to see Resident #3 for monthly, and as needed (PRN) catheter changes. The CNP stated this is a serious problem since the patient has frequent UTIs that could lead [MEDICAL CONDITION] if untreated. Interview with RN #1/Minimum Data Set Nurse (MDS) and Care Plan Nurse on 02/28/18 at 3:25 PM, revealed nurses should follow care plans, and not sending the resident for catheter changes, or securing the catheter is not following instructions on the care plan. Interview with the DON and Assistant DON (ADON), on 02/28/17 at 4:30 PM, revealed the resident had missed at least four (4) months of catheter changes. They both confirmed Resident #3 did not have his catheter changed, as care planned, in July, September, (MONTH) and December. Interview with the ADON, on 02/28/18 at 4:50 PM, revealed there was a change in nurses on that hall cart with some PRN people working and that's probably why the catheter change was missed. The ADON stated that Care Plans should be followed. Review of Resident #3's Face Sheet revealed the facility admitted the resident on 05/07/14, with [DIAGNOSES REDACTED]. Review of the Resident #3's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/17, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to implement a plan of care for falls for three (3) of (5) five residents reviewed. (Resident #1, Resident #3 and Resident #5) Findings include: Review of the facility's policy entitled, Care Plans dated 5/28/13, revealed the facility would develop an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs for each resident. Identifying problem areas and their causes, and developing interventions that are targeted to the resident are interdisciplinary processes. Resident #1 Review of the facility's Incident report, dated 4/19/15 at 3:55 AM, revealed Certified Nursing Assistant (CNA) #1 turned and repositioned Resident #1, a resident who required two (2) person assistance for turning and positioning in the bed, to provide peri care with only one (1) person assistance. Resident #1 fell from the bed onto the floor resulting in multiple contusions documented in the Emeregency Room (ER) report on 4/19/15 at 4:55 AM. Review of Resident #1's Care Plan revealed the problems for risk for falls, and self care deficit dated of 12/5/14. Further review of the Care Plan revealed the following approaches: Incontinent care and turn every two (2) hours, and provide a safe clutter free environment. The approaches did not designate how much staff assistance was required for turning and positioning the resident in the bed. The Care Plan did not address approaches r/t applying the bolsters correctly, and monitoring them to ensure the bolsters remained secured to the bed. Another approach was added on 4/20/15 after the fall to educate staff on the proper use of bolsters. A phone interview on 5/18/15 at 5:47 PM with CNA #1, revealed she was turning Resident #1 in the bed by herself to provide peri care when the snap popped on the wedge, and Resident #1 rolled out of the bed onto the floor. CNA #1 stated she did not know if Resident #1's Care Sheet said two- person assistance, and she provided Resident #1's care alone all the time. Review of Resident #1's Nurse Aide's Information Sheet (no date) revealed she required two-person assist for turning and positioning. Review of Resident #1's Daily Care Guide dated 12/8/14 revealed she required two staff assistance with bed mobility, and had an air mattress with a roll control bolster. Falls was identified as a risk. A phone interview on 5/18/15 at 10:29 AM with Licensed Practical Nurse (LPN) #1, verified CNA #1 did not request assistance with Resident #1's peri care, and to turn and position Resident #1 which resulted in a fall from the bed to the floor. LPN #1 stated CNA #1 did not follow the plan of care for Resident #1 for two (2) person assist. LPN #1 stated, Resident #1's Care Plan did specify two (2) person assist with turning and positioning. Review of Resident #1's Face Sheet revealed the facility admitted her on 12/5/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/7/15 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #1 required two (2) person extensive assistance with bed mobility, transfers, and toileting. Resident #3 Review of the facility's Incident Report dated 3/28/15 at 2:00 AM, revealed Resident #3 was found on the floor beside the bed, with a golf ball size black and blue bruise to the left eye area, and lacerations to the left chin and left cheek. The report revealed the padded rails were in place but had slid off when Resident #3 fell . The ER Report 3/28/15 at 3:40 AM revealed the resident required sutures for three centimeter (3 cm) lacerations to the left cheek and chin. Review of Residen #3's Care Plan revealed the problem for fall risks r/t mechanical lift, and use of narcotics and psychiatric medications dated 2/12/15 with the same approaches/interventions documented on the Daily Care Guide. Further review revealed no approaches to ensure the bolster was applied correctly, and monitored to ensure it was securely in place. A phone interview on 5/18/15 at 11:10 AM with LPN #2, revealed she found Resident #3 on the floor after hearing his feeding pump alarming. LPN #2 stated the bed bolsters had slipped off the bed. LPN #2 reported she was not sure if the bed bolsters were part of Resident #3's care plan, but it was part of Resident #3's CNA Care Sheet. Review of Resident #3's Daily Care Guide dated 2/13/15 revealed the following interventions: Landing strip to both sides of the bed, may have a bed alarm, roll control bolster, air mattress, and two (2) staff assist with turning, toileting and bed mobility. Falls was not identified as a risk. Review of Resident #3's Face Sheet revealed the facility admitted her on 2/12/15 with the [DIAGNOSES REDACTED]. The Admission (MDS) with the ARD of 2/16/15 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #3 required two (2) person extensive assistance with bed mobility, transfer, toileting and personal hygiene. Resident #5 Review of the facility's Incident Report for Resident #5 revealed he had an unwittnessed fall from the bed to the floor on 3/15/15 at 3:20 PM. The report revealed Resident #5 scooted to the side of the bed, and the wedge gave way. Descriptions of injuries was documented N/A (not applicable). Review of Resident #5's Care Plan revealed fall risk dated 1/29/15 as a problem/concern with an approach for Roll Control Bolsters to the bed. Further review of the Care Plan revealed no approaches to ensure the Roll Controll Bolsters was applied correctly and monitored to ensure it was securely in place. Another approach was added on 3/16/15 after the fall to keep the bed against the wall on the right side, and reinforce roll control bolster. A phone interview with the Assistant Director of Nursing (ADON) on 5/18/15 at 10:03 AM, revealed Resident #5's bed bolster was loose which resulted in a fall from the bed to the floor. A tighter bed bolster was applied to the bed after the fall. The ADON verified Resident #5's Care Plan included the bolsters, and to maintain a clutter free enviroment. Review of Resident #5's Daily Care Guide dated 1/30/15 revealed the following interventions: May have bed alarm (discontinued (d/c'd) 3/18. Roll controll bolster on bed (no date, and is crossed out). Landing strip on floor at bedside. Air mattress (no date and crossed out). Keep the bed against the wall on right side (no date and crossed out). Regular mattress with quarter side rails X2 for positioning (no date). Review of the facility's Face Sheet revealed the facility admitted Resident #5 on 1/29/15 with the diagnoses, which included [MEDICAL CONDITIONS] Stroke, [MEDICAL CONDITIONS], High Blood Pressure (HTN) and Gastrostomy. The (MDS) with the ARD of 2/10/15 indicated Resident #5 had a Brief Interview for Mental Status (BIMS) of eight (8), which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #5 required one (1) person extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing. Review of Resident #5's Care Plan revealed fall risk dated of 1/29/15 as a problem/concern with an approach for Roll Control Bolsters to the bed. Further review of the Care Plan revealed no approaches to ensure the Roll Controll Bolsters was applied correctly and monitored to ensure it was secured in place. Another approach was added on 3/16/15 after the fall to keep the bed against the wall on the right side, and reinforce roll control bolster.

Based on staff interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent falls, and serious injuries r/t falls for three of five (3 of 5) residents reviewed. {Resident #1, Resident #3, and Resident #5} 1. Resident #1 had a fall from the bed to the floor, and sustained multiple contusions due to the facility failed to provide the required two (2) person assistance to turn and position the resident in the bed. 2. Resident #3 had a fall from the bed to the floor, and sustained lacerations to the left cheek and chin due to the facility failed to ensure the Roll-Control-Bolster was securely applied to the bed, and 3. Resident #5 had a fall from the bed to the floor due to him scooting to the side of the bed causing the bolster to slip off the bed d/t the bed bolster was not securely applied to the bed. Resident #5 did not sustain any injuries. Review of the facility's policy entitled, Accidents and Incidents (revised 7/10) revealed: Any unexpected or unintentional incident or chain of events may or may not result in injury or illness to a resident. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accord with recognized standards of practice (e.g. side effects or reaction). Regardless of how minor an accident or incident may be, it must be reported and an Incident Report completed. Immediate assistance and medical attention will be rendered to the accident/incident victim. The accident/incident will be investigated. Review of the manufacturer's recommendations for the Roll-Control Bolsters (no date) revealed: Caution: The Roll--Control Bolsters are not substitutes for bed side rails. If you plan to use the Roll-Control Bolsters and leave one of the side rails in the lowered position, it is the responsibility of the facility and its qualified healthcare professionals to evaluate the resident to determine if that resident should be permitted to leave the bed at his/her discretion. Roll-Control Bolsters are not as effective as side rails for preventing a resident from rolling off or leaving the bed. Review of the facility's Incident Report, dated 4/19/15 at 3:55 AM, revealed Certified Nursing Assistant (CNA) #1 with one (1) person assistance turned and positioned Resident #1 in the bed ( a resident who required two (2) person assistance for turning an positioning in the bed) to provide peri care. Resident #1 fell from the bed to the floor resulting in multiple contusions. Further review of the report revealed the cause of the this injury/incident: CNA turned resident while doing peri care et she went over the bed bolster on the left side of the bed. Could this injury/incident have been prevented? yes is checked, and Resident is a total care patient X2, CNA was alone. Review of the ER Notes 4/19/15 at 4:55 AM, revealed Resident #1's Bilateral Hip X-Rays, Computerized Tomography (CT) Scans of her cervical spine and head was negative for fractures. Impression/Final Diagnosis: [REDACTED]. A phone interview on 5/18/15 at 5:47 PM with CNA #1, revealed she did not know if Resident #1's Care Sheet said two (2) person assisttance, and she provided Resident #1's care alone all the time. CNA #1 said she was turning Resident #1 in the bed by herself to provide peri care when the snap popped on the wedge, and Resident #1 rolled out of the bed onto the floor. CNA #1 stated she did not know she was supposed to have help to turn residents on air mattresses. CNA #` reported she had done a checklist for the agency, but had not had any orientation by the facility prior to working at the facility. Review of Resident #1's Nurse Aide's Infomation Sheet (no date) revealed she required two (2) person assist for turning and positioning. Review of Resident #1's Daily Care Guide dated 12/8/14 revealed falls was a risk, and she required two (2) staff assistance with bed mobility, and had an air mattress with a roll control bolster. A phone interview on 5/18/15 at 10:29 AM with Licensed Practical Nurse (LPN) #1, revealed Resident #1 had a fall from the bed to the floor due to CNA #1 did not turn and position Resident #1 in the bed during peri care with two (2) person assistance. LPN #1 stated CNA #1 did not follow the plan of care for Resident #1 for two (2) person assistance, and the Care Plan did specify two (2) person assistance with turning and positioning in the bed. An interview with the Director of Nurses (DON) on 5/11/15 at 4:10 PM, revealed residents are assessed for the use of the bed bolsters as a nursing judgement as to whether they should be used., and which residents are on air mattresses. The DON stated there was no documentation for this. She stated the fall and skin assessments are done to determine the need for the air mattress. The DON revealed the facility conpletes a device assessment with any resident requiring special devices. A phone interview with the Medical Director and Primary Care Physician for Resident #1, Resident #3, and Resident #5, on 5/13/15 at 2:30 PM, revealed the use of the bed bolsters on air mattresses had been discussed during the Quality Assurance (QA) meetings. He stated the QA Committee was attempting to come up with a solution for something safe. He stated side rails can be dangerous because of entrapment and death with air mattresses, and the bed bolsters were used to define the parameters of the bed. He verified he, or his Nurse Practitioner (NP) had been notified when Resident #1 had fallen from the bed when the CNA was turning the resident alone during incontinent care. He verified he or his NP had also been notified when Resident #3 and #5 fell from the bed. An interview with the facility's Nurse Consultant on 5/11/15 at 4:10 PM, revealed the company added the use of the bed bolsters for residents on air mattresses in 2013 instead of side rails because of the potential for entrapment, but was not sure exactly when this facility started to use them. Review of the (Name of Agency) Certified Nursing Assistant Skills Checklist 1/21/14 for CNA #1 revealed no tasks addressed turning/positioning residents on air mattresses, or the use of the Roll-Control Bolsters. Review of the faciilty's Inservice Training 10/16/14 for Air Mattress reveald CNA #1's signature was not on the sign in sheets. Review of Resident #1's Face Sheet revealed the faciilty admitted her on 12/5/14 with the included Diagnoses: [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 3/7/15 revealed Resident #1's Basic Interview for Mental Status (BIMS) score was 12, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #1 required two (2) person extensive assistance with bed mobility, transfers, and toileting. Reeview of the facility's Incident Report dated for 3/28/15 at 2:00 AM, revealed Resident #3 had a fall from the bed with an air mattress to the floor, and sustained three centimeter (3 cm) lacerations to her left cheek and chin. Resident #3 was found on the floor at the bedside by LPN #2 after she heard the feeding pump alarming. Resident #3 also had a golf size black and blue bruise to the left eye area. LPN #2 documented on the Incident Report Padded side rails were in place, when resident fell it looks like they slid off. Review of the ER Notes 3/28/15 at 3:40 AM, revealed Resident #3's CT Scans for her Cervical neck and face was negative for fractures. The Emergency Physician's Record for Head Injury, dated 3/28/15, revealed after the fall, Resident #3 had a [DIAGNOSES REDACTED]. Further review of the report revealed Resident #3 required sutures to both of the lacerations. A phone interview on 5/18/15 at 11:10 AM with LPN #2, revealed she found Resident #3 on the floor on her left side with her head on the feeding pump pole legs on 3/28/15. She stated she heard the feeding pump alarm, went into the room, found Resident #3 on the floor, and her head was bleeding. LPN #2 reported the bed bolsters had slipped off the side of the bed. LPN #2 reported the facility had another in-service on the proper placement of the bed bolsters, she realized the top and bottom straps had not been secured correctly, which caused the bolster to slip, and Resident #3 to fall out of the bed. Review of the facility's Inservice Training for Air Mattresses 4 revealed LPN #2's signature on the sign in sheets. An interview with CNA #2 on 5/13/15 at 10:05 AM, revealed she had been employed since October 2014. CNA #2 stated the last in-service on the bed bolster was about a month ago. She stated, The biggest concern is to make sure they are applied right and make sure they don't slide and move underneath the resident. Make sure they are secured properly. The facilty's Face Sheet revealed the faciilty admitted Residen #3 on 2/12/15 with the included Diagnoses: [REDACTED]. The Admission MDS with ARD 2/16/15 revealed Resident #3's BIMS score was 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #3 required extensive assistance of two (2) persons with bed mobility, transfer, toileting, and personal hygiene. Review of the facility's Incident Report for Resident #5 revealed he had an unwitnessed fall without injuries from the bed to the floor on 3/15/15 at 3:20 PM. The report revealed Resident #5 scooted to the side of the bed, the bolster gave way, and he rolled out of the bed onto the floor. A phone interview with the Assistant Director of Nursing (ADON) on 5/18/15 at 10:03 AM, revealed due to the bed bolster was loose, Resident #5 rolled out of the bed unto the floor. A tighter bed bolster was applied to the bed after the fall. The ADON verified Resident #5's Care Plan included the bolsters. Review of Resident #5's Daily Care Guide dated 1/30/15 revealed the following: May have bed alarm (discontinued (d/c'd) 3/18. Roll controll bolster on bed (no date, and is crossed out). Landing strip on floor at beside. Air mattress (no date, and crossed out). Keep the bed against the wall on right side (no date and crossed out). Regular mattress with quarter side rails X2 for positioning (no date). Review of the facilty's Face Sheet revealed the facility admitted Resident #5 on 1/29/15 with the included Diagnoses: [REDACTED]. The MDS with ARD 2/10/15 indicated Resident #5 had a BIMS score of eight (8), which indicated moderate cognitive impairment. Further reveiw of the MDS revealed Resident #5 required one (1) person extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing.

CI MS #8753 Based on observation, staff and resident interview, clinical record and facility document review, the facility failed to ensure that one (1) of six (6) residents in the sample (Resident #1) was free from sexually abusive behavior inflected by Resident #2. Resident #2 allegedly entered Resident #1's room numerous times on the evening of 10/9/10 while Resident #1 was in bed and repeatedly touched Resident #1's chest and upper legs. This behavior continued until Resident #1's roommate (Resident #3) activated the call light and summoned staff to the room. The facility failed to ensure that residents with assessed behaviors were supervised closely enough to prevent this sexually abusive behavior. Facility policy addressed the fact that residents have a right to be free from abuse. The facility defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility policy added that "Sexual abuse" includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Findings Include: Resident #1 The facility failed to protect Resident #1 from sexual aggression by Resident #2 as evidenced by notice to the State Agency on 10/15/10 in which the report related that on 10/9/10 at 9:00 p.m. Resident #1 alleged that Resident #2 touched her on her chest area, thigh and leg without her permission. Resident #1 reported that Resident #2 offered her money to be his girlfriend. The report related that Resident #3, the roommate, notified staff via the call light and Resident #2 was relocated to another wing of the facility and a thorough investigation was done, resulting in a transfer of Resident #2 for evaluation and treatment. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's date of birth was 6/12/1953. Review of the Minimum Data Set ((MDS) dated [DATE] reflected that Resident #1 had no memory or cognitive decision making problems. Review of the Care Plan with a problem onset date of 10/8/10 revealed: "New admit and is adjusting to the facility life routine. Needs to continue to be active in activity involvement." Observation on 11/3/10 at 3:35 p.m. revealed that Resident #1 was sitting in an electric wheelchair in her room. Resident #1 related that Resident #2 first came into the room to get some pickled eggs from her roommate. Resident #1 stated that Resident #2 got them and went to his room across the hallway. Resident #1 stated that Resident #2 came back later and asked if she had ever been with a black man, Resident #1 stated that she told Resident #2 to get out. Resident #1 stated that Resident #2 came back again and pulled some money out of his pocket and said it was $75 and he'd give it to me if I'd be his girlfriend. Resident #1 stated that she told Resident #2 to go and he left, and then came back later. Resident #1 stated that she was in bed, covered with a sheet and that he sat by her bed and reached out, touching on her chest and whispering stuff. Resident #1 stated that she again told him to get out. Resident #1 stated that he came back later and started rubbing his hand up and down her legs and " whacking off " with his other hand. Resident #1 stated that her roommate heard him saying things and told him to get out. Resident #1 stated that the roommate used the call light to summons the staff. Resident #1 stated that she was afraid at the time but is stronger now and can defend herself. Resident #3 The roommate, Resident #3, had been discharged from the facility but consented to a telephone interview at 4:30 p.m. on 11/3/10. Resident #3 stated that Resident #2 had come to her first and was "hitting on her" and she told him she was married. Resident #3 stated that Resident #2 left, and then came back several times and approached her roommate. Resident #3 stated that Resident #2 was saying lots of sex related things and that he touched her roommate on her chest and stomach, and was told not to do that. Resident #3 stated that he started rubbing on Resident #1's legs so she used her call light to call the nurse, who got Resident #2 out of the room. Resident #3 stated that it made both of them real uncomfortable, and she doesn't want anything like that to happen to her friend again. Record review of the closed record for Resident #3 revealed that her date of birth was 6/12/65. Resident #3 was admitted to the facility on [DATE] and discharged home on[DATE]. Resident #3 was admitted with [DIAGNOSES REDACTED]. An assessment dated [DATE] reflected that Resident #3 had no problems with memory or with cognitive decision making. Resident #2 Record review for Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's date of birth was 10/17/42. Review of the Minimum Data Set with an assessment reference date of 8/30/2010 revealed that Resident #2 was moderately impaired in cognitive skills for daily decision making. Resident #2 was identified to have short term memory impairment. Resident #2 was identified as exhibiting behaviors of resisting care. There was no indication on the MDS that Resident #2 was not identified to have socially inappropriate behaviors. Review of the care plan with a problem onset date of 11/5/08 revealed: "Has hx (history) of socially inappropriate behavior - urinating in garbage cans, floor etc." There was no mention of sexually inappropriate behaviors. The resident's clinical record reflected a Psychiatric evaluation dated 10/12/10 regarding a readmission to the geripsych unit. The history reflected that Resident #2 was last at the Geri-Psych on August of 2010 with reports of inappropriate sexual behavior with a female patient at the nursing home. Review of a Psychiatrist's progress note dated 10/16/10 revealed: "The patient is readmitted to the (Name of Hospital) for the same sexually inappropriate behavior with the female staff at the nursing home. He was here in August for the same reason." Another Psychiatric Note dated 10/12/10 reflected that he gave the correct date, knows his current location and can name his nursing home. He has good recall of past events, knows the current President and last two (2) Presidents before him." A review of the "Nursing Home Psychological Services" report revealed that Resident #2 was seen on 9/4/10 for psychological assessment. The assessment stated that Resident #2 had not exhibited any episodes of inappropriate behaviors or emotional outbursts at the facility. Observation on 11/3/10 at 3:15 p.m. revealed that Resident #2 was up in a wheelchair in his room. When questioned Resident #2 stated that "yes", he touched the lady but that he has learned a lesson. Resident #2 stated that they sent him out to the hospital for two (2) weeks and they said he learned good. He stated that he must stay away from women and never touch them or say ugly things to them. Interview with the Director of Nursing (DON) on 11/3/10 at 4:00 p.m. revealed that they had done a thorough investigation of the incident and sent Resident #2 out, and when informed by the geripsych unit that he was ready for readmission they placed him on a different unit on a wing with only male residents. On 11/3/10 at 5:40 p.m., a telephone interview with a Nurse who had responded to the incident revealed that a Certified Nurse Aide (CNA) had summoned her and informed her that Resident #2 had been messing with Resident #1. The Nurse stated that Resident #1 told what had happened and she (the nurse) asked Resident #2 what happened and he stated he just brought (Resident #1) some ice water. The Nurse stated that she asked Resident #2 why he was touching Resident #1's chest and legs and he just dropped his head and stated: "You're gonna write me up for that, aren't you?" The Nurse stated that she moved Resident #2 off the hall immediately and checked Resident #1 over to see if any physical harm had occurred. The Nurse stated that Resident #1 was upset and worried about him coming back. The Nurse stated that Resident #2 told her that he just touched Resident #1 through the covers. The Nurse stated that she had not seen Resident #2 go in the room. The Nurse stated that she had seen Resident #2 at the Nursing Station earlier, giving people some deviled eggs. An interview on 11/4/10 at 11:40 a.m. with the CNA who had answered the call light at the time of the incident revealed that Resident #3 rang the light. The CNA stated that Resident #2 was not in the room when she (the CNA) got there. The CNA stated that she related that both residents stated he had been in and out of the room several times and had touched Resident #1 inappropriately. The CNA stated that she asked them to wait and tell the Nurse. The CNA stated that both residents were anxious. Review of the facility policy: "Freedom from Abuse Or Neglect" with a revision date of 7/07 revealed: "It is the policy of this facility that each resident has the right to be free from mistreatment, neglect, abuse, and misappropriation of property by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals.""Sexual abuse" includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault." Review of the facility policy "Resident's Rights" with a revision date of 07/03 revealed: "(7) Is free from mental, sexual and physical abuse, and free from chemical and physical restraints except those restraints authorized in writing by a physician....".