Every finding on record at Decatur Wellness and Rehabilitation Center

Based on facility policy review, medical record review, facility documentation review and interviews the facility failed to protect 1 resident (Resident #1) from sexual abuse of 5 residents reviewed for abuse.The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .Sexual Abuse is non-consensual sexual contact of any type with a resident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Aphasia (difficulty communicating), Hemiplegia (paralysis of one side of the body) and Hemiparesis (muscle weakness affecting one side of the body) affecting right dominant side, and Memory Deficit following Cerebral Infarction (stroke). Review of an Admit/Readmit Assessment for Resident #1 dated 8/4/2026, revealed the resident was alert and oriented to person, place, and situation. The resident was independent with bed mobility and required limited assistance with transfers. Review of a comprehensive care plan for Resident #1 dated 8/5/2026, revealed .Resident requires assist with all ADLS .Resident has cognitive loss and poor memory r/t [related to] Cerebral Infarction .Resident has communication deficit r/t Expressive Aphasia . Medical record review revealed Resident #3 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Adjustment Disorder with Depressed Mood. Review of a comprehensive care plan for Resident #3 dated 4/8/2026, revealed .The resident [Resident #3] has a behavior problem r/t making sexually inappropriate comments to staff . Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #3 scored 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. The resident had not exhibited behaviors and was independent with mobility during the 7 day look back period. Review of Certified Nursing Assistant (CNA) B's handwritten statement dated 8/8/2026, revealed CNA B observed Resident #3 with his hands under Resident #1's covers. Continued review revealed .[Resident #1] is non ambulatory with cognitive issues. In my [CNA B] opinion he [Resident #1] could not defend or advocate for himself in his current condition. [Resident #3] had his hands under [Resident #1's] covers between groin and knee . Resident #3 left Resident #1's room as instructed by CNA B. CNA B asked Resident #1 if he was okay. He responded by saying .he didn't know . CNA B asked Resident #1 if Resident #3 had been inappropriate with him. Resident #1's response was he .wasn't sure . CNA B reported the incident to the nurse (Registered Nurse-RN C) immediately. CNA B and another CNA stayed with Resident #1. While waiting for a plan of action, Resident #3 attempted to re-enter Resident #1's room through the shared bathroom door. The attempt to re-enter Resident #1's room was immediately reported to RN C. Further review revealed .We were told that the DON [Director of Nursing]/Administrator/Abuse Coordinator had been notified and there was nothing we could really do because no one actually saw Resident #3 inappropriately touching [Resident #1]. [Resident #1] stated that he was asleep, he felt [Resident #3] sit down, [Resident #3] started talking, put his hands under the covers and then a minute later I [CNA B] came in .CNAs took turns sitting in the hallway monitoring both [Resident #3 and Resident #1] . Review of RN C's handwritten statement dated 8/8/2026 at 11:10 PM, revealed .CNA (CNA B) came to desk to get me [RN C]. [Resident #3] was found in adjoining room [Resident #1's room] sitting at another residents [Resident #1] bedside .with his [Resident #3] hands under the covers [Resident #1's covers] . RN C notified the Administrator of the incident. Staff were asked to .keep an eye out for resident [Resident #3] .CNA on the hall caught resident in question [Resident #3] trying to enter [Resident #1's] room using adjoining bathroom. Resident [Resident #3] was redirected back to his room . RN C notified the Administrator of Resident #3 attempting to re-enter Resident #1's room. RN C .was informed by admin [Administrator] to tell [Resident #3] this behavior will not be tolerated . Review of the Nurse's note for Resident #3 dated 8/10/2026 at 6:35 AM, revealed Certified Nursing Assistant (CNA) B staff notified the nurse (RN C) Resident #3 was attempting to enter other resident's rooms, specifically the adjoining room (Resident #1's room) connected by a shared bathroom. CNA staff also reported Resident #3 had previously entered Resident #1's room and was observed standing over Resident #1. During an interview on 8/12/2026 at 4:37 PM, the DON stated CNA B called him around 9:00 PM on Sunday night (8/9/2026) and told him she observed Resident #3 sitting at the foot of Resident #1's bed. The DON stated CNA B .was unsure if his [Resident #3] hands were under the covers, but she thought they were [under the covers/blanket] . The DON stated CNA B notified the charge nurse (RN C) who notified the Administrator. The DON stated he moved Resident #3 to a different room the following morning (8/10/2026). During an interview on 8/13/2026 at 7:45 AM, Resident #1 stated Resident #3's hand was under the blanket and . I think he [Resident #3] was trying to catch a feel . Resident #1 stated Resident #3 did not make contact with his private area. Resident #1 was asked if the incident made him afraid, he stated .No, I can take care of that . During an interview on 8/13/2026 at 8:00 AM, the DON confirmed the incident between Resident #1 and Resident #3 which occurred on 8/8/2026 was considered sexual abuse. During a telephone interview on 8/13/2026 at 8:38 AM, CNA B stated on the evening of 8/8/2026, she observed Resident #3 sitting around the knee area of Resident #1's bed with his [Resident #3's] hand under the cover in the area from Resident #1's hip to knee. Resident #3 left the room as instructed by CNA B. CNA B stated when she asked Resident #1 if he was okay .he said I don't know . She then asked him if Resident #3 had been inappropriate with him and he replied he .wasn't sure . CNA B notified RN C of what had happened. RN C asked CNA B to write a brief statement so she could tell the Administrator what had happened. CNA B and her hall partner sat with Resident #1 while waiting for RN C to return. CNA B stated Resident #1 started talking to them and said .I felt him [Resident #3] set down .he [Resident #3] put his hands under the covers, he started talking and a minute later you [CNA B] came in . During a telephone interview on 8/13/2026 at 10:15 AM, RN C stated CNA B reported she had observed Resident #3 sitting beside Resident #1's bed with his hand under Resident #1's covers. RN C stated she asked Resident #1 if Resident #3 had touched him inappropriately and he replied he did not know. RN C asked him if Resident #3 touched his private area and he again replied he did not know. RN C then notified the Administrator of what CNA B had observed. During an interview on 8/13/2026 at 2:12 PM, the Administrator stated RN C contacted her on Saturday (8/8/2026) at approximately 11:00 PM to notify her Resident #3 had wandered into Resident #1's room. The Administrator stated RN C informed her it had been reported Resident #3's hand was noted to be on Resident #1's covers. The Administrator stated employee statements regarding the incident were received and read on Monday (8/10/2026). The Administrator stated . in the statements there were no allegations of sexual abuse .There were no statements made to me to make me feel like there was any sexual abuse that occurred . The Administrator stated based on information gathered during the facility's investigation, which began on 8/12/2026 (4 days after the incident) she could see where the incident should have been considered sexual abuse. The Administrator further stated .If the CNAs had not intervened there's no telling what would have happened because didn't know what the intentions were at that moment .

Based on facility policy review, medical record review, and interviews the facility failed to thoroughly investigate an allegation of sexual abuse for 1 resident (Resident #1) of 5 residents reviewed for abuse.The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .Sexual Abuse is non-consensual sexual contact of any type with a resident .Investigation of Alleged Abuse .An immediate investigation is warranted when suspicion of abuse .or reports of abuse .Written procedures for investigation include .Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent, and cause .Providing complete and through documentation of the investigation .Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to .Responding immediately to protect the alleged victim and integrity of the investigation . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Aphasia (difficulty communicating), Hemiplegia (paralysis of one side of the body) and Hemiparesis (muscle weakness affecting one side of the body) affecting right dominant side, and Memory Deficit following Cerebral Infarction (stroke). Review of an Admit/Readmit Assessment for Resident #1 dated 8/4/2026, revealed the resident was alert and oriented to person, place, and situation. The resident was independent with bed mobility and required limited assistance with transfers. Review of a comprehensive care plan for Resident #1 dated 8/5/2026, revealed .Resident requires assist with all ADLS [activities of daily living] .Resident has cognitive loss and poor memory r/t [related to] Cerebral Infarction .Resident has communication deficit r/t Expressive Aphasia . Medical record review revealed Resident #3 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Adjustment Disorder with Depressed Mood. Review of a comprehensive care plan for Resident #3 dated 4/8/2026, revealed .The resident [Resident #3] has a behavior problem r/t making sexually inappropriate comments to staff . Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #3 scored 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. The resident had not exhibited behaviors and was independent with mobility during the 7-day look back period. Review of Certified Nursing Assistant (CNA) B's handwritten statement dated 8/8/2026, revealed CNA B observed Resident #3 with his hands under Resident #1's covers between Resident #3's groin and knee. Continued review revealed .[Resident #1] is non ambulatory with cognitive issues. In my [CNA B] opinion he [Resident #1] could not defend or advocate for himself in his current condition. Resident #3 left Resident #1's room as instructed by CNA B. CNA B asked Resident #1 if he was okay and he responded he did not know. CNA B asked Resident #1 if Resident #3 had been inappropriate with him. Resident #1's response was he .wasn't sure . CNA B reported the incident to the nurse (Registered Nurse-RN C) immediately. CNA B and another CNA stayed with Resident #1. While waiting for a plan of action, Resident #3 attempted to re-enter Resident #1's room through the shared bathroom door. Resident #3's attempt to re-enter Resident #1's room was immediately reported to RN C. Further review revealed .We were told that the DON [Director of Nursing]/Administrator/Abuse Coordinator had been notified and there was nothing we could really do because no one actually saw Resident #3 inappropriately touching [Resident #1]. [Resident #1] stated that he was asleep, he felt [Resident #3] sit down, [Resident #3] started talking, put his hands under the covers and then a minute later I [CNA B] came in .CNAs took turns sitting in the hallway monitoring both [Resident #3 and Resident #1] . Review of RN C's handwritten statement dated 8/8/2026 at 11:10 PM, revealed CNA A notified RN C Resident #3 had been observed sitting at Resident #1's bedside with his hand under Resident #1's covers. RN C notified the Administrator of the incident. The staff were asked to .keep an eye out . for Resident #3. A CNA on the hall caught Resident #3 trying to re-enter Resident #1's room through the adjoining bathroom. Resident #3 was redirected back to his room, and the Administrator was again notified. RN C .was informed by admin [Administrator] to tell [Resident #3] this behavior will not be tolerated . Review of the Nurse's note for Resident #3 dated 8/10/2026 at 6:35 AM, revealed CNA staff (CNA B) notified the nurse (RN C) Resident #3 was attempting to enter other resident's rooms, specifically the adjoining room (Resident #1's room) connected by a shared bathroom. CNA B also reported Resident #3 had previously entered Resident #1's room and was observed standing over Resident #1. During an interview on 8/12/2026 at 4:37 PM, the DON stated CNA B called him around 9:00 PM on Sunday night (8/9/2026) and told him she had observed Resident #3 sitting at the foot of Resident #1's bed. The DON stated CNA B .was unsure if his [Resident #3] hands were under the covers, but she thought they were [under the covers/blanket] . The DON stated CNA B notified the charge nurse (RN C) who notified the Administrator. The DON stated he moved Resident #3 to a different room the following morning (8/10/2026). During an interview on 8/13/2026 at 7:45 AM, Resident #1 stated Resident #3's hand was under the blanket and .I think he [Resident #3] was trying to catch a feel . Resident #1 stated Resident #3 did not make contact with his private area. Resident #1 was asked if the incident made him afraid, he stated .No, I can take care of that . During an interview on 8/13/2026 at 8:00 AM, the DON stated .I was not entirely aware of the situation [incident between Resident #1 and Resident #3] until I talked to [CNA B] yesterday and not until I read her statement . which had been provided at the time of the incident. The DON stated he was not aware witness statements regarding the incident had been obtained until 8/12/2026. The DON confirmed the incident between Resident #1 and Resident #3 which occurred on 8/8/2026 and reported by CNA B should have been considered resident to resident sexual abuse, confirmed the facility did not begin investigating the allegation of sexual abuse until 8/12/2026, and confirmed the facility's abuse policy was not followed. During a telephone interview on 8/13/2026 at 8:38 AM, CNA B stated on the evening of 8/8/2026, she observed Resident #3 sitting around the knee area of Resident #1's bed with his hand under the cover in the area from Resident #1's hip to knee. Resident #3 left the room as instructed by CNA B. CNA B stated when she asked Resident #1 if he was okay .he said I don't know . She then asked him if Resident #3 had been inappropriate with him and he replied he .wasn't sure . CNA B notified RN C of what had happened. RN C asked CNA B to write a brief statement so she could tell the Administrator what had happened. CNA B and her hall partner sat with Resident #1 while waiting for RN C to return. CNA B stated Resident #1 started talking to them and said .I felt him set down .he put his hands under the covers, he started talking and a minute later you [CNA B] came in . RN C told CNA B the Administrator had said there really wasn't anything they could do except keep an eye on the resident. CNA B stated no one asked her follow-up questions regarding the incident until 8/12/2026. During a telephone interview on 8/13/2026 at 10:15 AM, RN C stated CNA B reported she had observed Resident #3 sitting beside Resident #1's bed with his hand under Resident #1's covers. RN C stated she asked Resident #1 if Resident #3 had touched him inappropriately and he replied he did not know. RN C asked him if Resident #3 touched his private area and he again replied he did not know. RN C then notified the Administrator of what CNA B had observed. RN C further stated .It was a gray area for me .was trying to figure out if it was reportable .was it not reportable . RN C stated everyone wrote statements which were slid under the Administrator's door. RN C further stated no one had discussed the incident with her until the Administrator called her yesterday (8/12/2026) and went through questions on the investigation statement. During an interview on 8/13/2026 at 2:12 PM, the Administrator stated RN C contacted her on Saturday (8/8/2026) at approximately 11:00 PM to notify her Resident #3 had wandered into Resident #1's room. The Administrator stated RN C informed her it had been reported Resident #3's hand was noted to be on Resident #1's covers. The Administrator stated employee statements regarding the incident were received and read on Monday (8/10/2026). The Administrator further stated . in the statements there were no allegations of sexual abuse .There were no statements made to me to make me feel like there was any sexual abuse that occurred . The Administrator stated she had only spoken to RN C and had not interviewed other staff who were present at the time of the incident. The Administrator confirmed the facility did not thoroughly investigate the incident between Resident #3 and Resident #1 until 8/12/2026. The Administrator further stated, based on information gathered during the facility's investigation, which began on 8/12/2026 (4 days after the incident) she could see where the incident should have been considered sexual abuse. When asked if the facility had thoroughly investigated the incident between Resident #1 and Resident #3, the Administrator stated .I don't feel like I did .if I had investigated immediately it would have gone a whole lot differently .

Based on facility policy review, medical record review, facility documentation review, and interviews the facility failed to report an allegation of sexual abuse for 2 residents (Resident #2 and Resident #1) of 5 residents reviewed for abuse.The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .Sexual Abuse is non-consensual sexual contact of any type with a resident .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies as is required .within specified timeframes .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Traumatic Brain Injury (TBI), Conversion Disorder with Seizures, Major Depression without Psychotic Features, Post Traumatic Stress Disorder, and Unspecified Mental Disorder. Review of an Admit/Readmit Assessment for Resident #2 dated 5/7/2026, revealed Resident #2 was alert and oriented to person, place, time, and situation. The resident required limited assistance with bed mobility and was dependent on staff for transfers. Review of a comprehensive care plan for Resident #2 dated 5/8/2026, revealed .Resident at risk [for] functional decline with ADLS [activities of daily living] R/T [related to] severe traumatic brain injury .Resident has communication deficit r/t Dysarthric speech [difficulty talking] .Resident has cognitive loss and poor memory r/t .severe TBI and anoxic brain injury (occurs when brain goes without oxygen) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Aphasia (difficulty communicating), Hemiplegia (paralysis of one side of the body) and Hemiparesis (muscle weakness affecting one side of the body) affecting right dominant side, and Memory Deficit following Cerebral Infarction (stroke). Review of an Admit/Readmit Assessment for Resident #1 dated 8/4/2026, revealed the resident was alert and oriented to person, place, and situation. The resident was independent with bed mobility and required limited assistance with transfers. Review of a comprehensive care plan for Resident #1 dated 8/5/2026, revealed .Resident requires assist with all ADLS .Resident has cognitive loss and poor memory r/t Cerebral Infarction .Resident has communication deficit r/t Expressive Aphasia . Medical record review revealed Resident #3 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Adjustment Disorder with Depressed Mood. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident had not exhibited behaviors and was independent with mobility during the 7 day look back period. Review of a comprehensive care plan for Resident #3 dated 4/8/2026, revealed .The resident [Resident #3] has a behavior problem r/t making sexually inappropriate comments to staff . Continued review revealed the care plan was not updated following the incident which occurred with Resident #2 on 5/9/2026. Review of the Nurse's Note for Resident #3 dated 5/9/2026 at 8:19 PM, revealed a Certified Medication Assistant [CMA] E notified Licensed Practical Nurse (LPN) F .[Resident #3] was sitting by roommate [Resident #2] on his walker with just his underwear on . Review of facility documentation dated 5/9/2026, revealed the Regional Director of Operations was notified Resident #3 had been observed sitting on his walker by Resident #2's bed, talking with the resident and wearing only his underwear. CMA E and LPN F returned to Resident #2's and Resident #3's room and noticed Resident #3's .hand on [Resident #2's] sheet. They [CMA E and LPN F] separated the residents immediately and moved [Resident #3] to a different room . Resident #2 and Resident #3 were interviewed with both residents stating nothing sexual occurred and they were just having a conversation. All staff on duty were interviewed and reported no signs or reports of sexual abuse. Interventions included moving Resident #3 to a different room with follow up from the facility's medical provider and psychiatric nurse practitioner. Review of the medical record for Resident #3 revealed no further sexually inappropriate behaviors toward other residents from 5/9/2026-8/8/2026. Review of a quarterly MDS assessment dated [DATE], revealed Resident #3 scored 15 on the BIMS assessment which indicated the resident was cognitively intact. The resident had not exhibited behaviors and was independent with mobility during the 7 day look back period. Review of the Psychiatric Nurse Practitioner (NP) Note for Resident #3 dated 8/7/2026, revealed nursing staff reported concerns of increased restlessness at night with escalated behaviors at night. Continued review revealed Restoril (medication used to treat insomnia) was discontinued and Ambien (medication used to treat insomnia) ordered. Review of CNA B's handwritten statement dated 8/8/2026, revealed CNA B observed Resident #3 with his hands under Resident #1's covers. Continued review revealed .[Resident #1] is non ambulatory with cognitive issues. In my [CNA B] opinion he [Resident #1] could not defend or advocate for himself in his current condition. [Resident #3] had his hands under [Resident #1's] covers between groin and knee . Resident #3 left Resident #1's room as instructed by CNA B. CNA B asked Resident #1 if he was okay. He responded by saying .he didn't know . CNA B asked Resident #1 if Resident #3 had been inappropriate with him. Resident #1's response was he .wasn't sure . CNA B reported the incident to the nurse (Registered Nurse-RN C) immediately. CNA B and another CNA stayed with Resident #1. While waiting for a plan of action, Resident #3 attempted to re-enter Resident #1's room through the shared bathroom door. The attempt to re-enter Resident #1's room was immediately reported to RN C. Further review revealed .We were told that the DON [Director of Nursing]/Administrator/Abuse Coordinator had been notified and there was nothing we could really do because no one actually saw Resident #3 inappropriately touching [Resident #1]. [Resident #1] stated that he was asleep, he felt [Resident #3] sit down, [Resident #3] started talking, put his hands under the covers and then a minute later I [CNA B] came in .CNAs took turns sitting in the hallway monitoring both [Resident #3 and Resident #1] . Review of RN C's handwritten statement dated 8/8/2026 at 11:10 PM, revealed .CNA (CNA B) came to desk to get me [RN C]. [Resident #3] was found in adjoining room [Resident #1's room] sitting at another residents [Resident #1] bedside. He [Resident #3] was above knee .with his hands under the covers [Resident #1's covers] . RN C notified the Administrator of the incident. Staff were asked to .keep an eye out for resident [Resident #3] .CNA on the hall caught resident in question [Resident #3] trying to enter [Resident #1's] room using adjoining bathroom. Resident [Resident #3] was redirected back to his room . RN C notified the Administrator of Resident #3 attempting to re-enter Resident #1's room. RN C .was informed by admin [Administrator] to tell [Resident #3] this behavior will not be tolerated . Review of the Nurse's note for Resident #3 dated 8/10/2026 at 6:35 AM, revealed Certified Nursing Assistant (CNA) B staff notified the nurse (RN C) Resident #3 was attempting to enter other resident's rooms, specifically the adjoining room (Resident #1's room) connected by a shared bathroom. CNA staff also reported Resident #3 had previously entered Resident #1's room and was observed standing over Resident #1. During an interview on 8/12/2026 at 4:25 PM, the Long-Term Care Ombudsman stated the facility's Administrator contacted her .this morning [8/12/2026] . to notify her Resident #3 had been observed sitting on the edge of Resident #1's bed with his hands under the resident's (Resident #1's) blanket. During an interview on 8/12/2026 at 4:37 PM, the DON stated CNA B called him around 9:00 PM on Sunday night (8/9/2026) and told him she observed Resident #3 sitting at the foot of Resident #1's bed. The DON stated CNA B .was unsure if his [Resident #3] hands were under the covers, but she thought they were [under the covers/blanket] . The DON stated CNA B notified the charge nurse (RN C) who notified the Administrator. The DON stated he moved Resident #3 to a different room the following morning (8/10/2026). The DON confirmed the incident was not reported to the State Agency, Adult Protective Services, Ombudsman, or Law Enforcement until .today [8/12/2026] . During an interview on 8/13/2026 at 7:45 AM, Resident #1 stated Resident #3's hand was under the blanket and .He [Resident #3] was trying to catch a feel . but did not touch his private area. When Resident #1 was asked how it made him feel he stated .It pissed me off . Resident #1 was asked if the incident made him afraid he stated .No, I can take care of that . During an interview on 8/13/2026 at 8:00 AM, the DON stated .I was not entirely aware of the situation [incident between Resident #1 and Resident #3] until I talked to [CNA B] yesterday and not until I read her statement . which had been provided at the time of the incident. The DON stated he was not aware witness statements regarding the incident had been obtained until 8/12/2026. The DON confirmed the incident between Resident #1 and Resident #3 which occurred on 8/8/2026 and reported by CNA B was considered resident to resident sexual abuse and should have been reported to the State Agency immediately. During a telephone interview on 8/13/2026 at 8:38 AM, CNA B stated on the evening of 8/8/2026, she observed Resident #3 sitting around the knee area of Resident #1's bed with his hand under the cover in the area from Resident #1's hip to knee. Resident #3 left the room as instructed by CNA B. CNA B stated when she asked Resident #1 if he was okay .he said I don't know . She then asked him if Resident #3 had been inappropriate with him and he replied he .wasn't sure . CNA B notified RN C of what had happened. RN C asked CNA B to write a brief statement so she could tell the Administrator what had happened. CNA B and her hall partner sat with Resident #1 while waiting for RN C to return. CNA B stated Resident #1 started talking to them and said .I felt him set down .he put his hands under the covers, he started talking and a minute later you [CNA B] came in . RN C told CNA B the Administrator had said there really wasn't anything they could do except keep an eye on the resident. During a telephone interview on 8/13/2026 at 10:15 AM, RN C stated CNA B reported she had observed Resident #3 sitting beside Resident #1's bed with his hand under Resident #1's covers. RN C stated she asked Resident #1 if Resident #3 had touched him inappropriately and he replied he did not know. RN C asked him if Resident #3 touched his private area and he again replied he did not know. RN C then notified the Administrator of what CNA B had observed. RN C further stated .It was a gray area for me .was trying to figure out if it was reportable .was it not reportable . RN C stated everyone wrote statements which were slid under the Administrator's door. During an interview on 8/13/2026 at 2:12 PM, the Administrator stated RN C contacted her on Saturday (8/8/2026) at approximately 11:00 PM to notify her Resident #3 had wandered into Resident #1's room. The Administrator stated RN C informed her it had been reported Resident #3's hand was noted to be on Resident #1's covers. The Administrator stated Resident #3 had told RN C nothing had happened. Resident #1 had told RN C he was unaware if Resident #3 had touched him inappropriately. The Administrator further stated .I asked her [RN C] if there was any inappropriate sexual contact? Did any of the staff state they felt there was anything sexual going on? She told me no. I asked her [RN C] to have everyone write statements . The Administrator stated the employee statements were received and read on Monday (8/10/2026). The Administrator further stated . in the statements there were no allegations of sexual abuse therefore it was not reported. There were no statements made to me to make me feel like there was any sexual abuse that occurred . The Administrator confirmed the allegation of sexual abuse was not reported to the State Agency as required and according to the facility's abuse policy. During an interview on 8/13/2026 at 3:17 PM, the Regional Director of Operations stated the DON had notified her of an incident (date unknown) between Resident #3 and Resident #2. The Regional Director of Operations stated she spoke with CMA E who reported she observed Resident #3 sitting on his rolling walker, wearing only his underwear. CMA E reported she went to get the nurse (RN F) for assistance. When CMA E and RN F returned to the room, Resident #3 had his hands under Resident #1's covers. Resident #2 and Resident #3 were interviewed and both denied anything had occurred. The Regional Director of Operations stated .I asked [Resident #2] if he felt there was inappropriate sexual behavior .[Resident #2] said no . The Regional Director of Operations confirmed the incident was not reported to the State Agency.

Based on facility policy review, observations, and interviews, the facility failed to ensure medications were securely stored in 1 medication cart (100-hall) of 2 medication carts reviewed, and 1 of 1 treatment carts reviewed.The findings include: Review of the facility's undated policy titled, Medication Storage, revealed .the drugs and biologicals will be stored in locked compartments (i.e .medication carts) .only authorized personnel have access to the keys .compartments .medications must be kept under direct observation of the person administering or locked in the medication storage cart . During an observation on 4/13/2026 at 2:08 PM, revealed the 100-hall medication cart was located against the wall on the 100 hallway, the drawers were facing the hallway, and the medication cart was unlocked and unattended. Continued observation revealed the RN/ADON (Registered Nurse/Assistant Director of Nursing) returned to the medication cart, with the surveyor present, on 4/13/2026 at 2:10 PM. The RN/ADON stated, .I thought the cart was locked . The RN/ADON confirmed the medication cart for 100 hall was unlocked, unattended, and medications were not stored securely. During an observation on 4/15/2026 at 8:32 AM, the treatment cart was located against the wall on the 100 hallway near the Nurse's station, the drawers were facing the hallway, and the treatment cart was unlocked and unattended. During an observation and interview on 4/15/2026 at 8:35 AM, the Director of Nursing (DON) confirmed the treatment cart was in the hallway, unlocked, unattended, and contained medications. The DON confirmed medication and treatment carts are to be locked to securely store medications when unattended by the licensed nurse.

Based on review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, medical record reviews, and interviews, the facility failed to accurately assess residents on the Minimum Data Set (MDS) assessment for a Level II Pre-admission Screening and Resident Review (PASARR) with a serious mental illness for 2 residents (Residents #45 and #5) of 5 residents reviewed for MDS accuracy.The findings include:Review of the RAI 3.0 User's Manual, dated 10/2025, revealed .Complete if .admission assessment, Annual assessment, SCSA [Significant Change in Status assessment] .Code 1, yes: if PASRR [PASARR] Level II screening determined that the resident has a serious mental illness .Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Major Depressive Disorder, Post Traumatic Stress Disorder (PTSD), and Diabetes Mellitus.Review of a PASARR submitted to the state designated authority dated 11/10/2022, revealed Resident #45 required a Level II evaluation, which was completed on 11/16/2022 and determined the resident had a serious mental illness.Review of the comprehensive care plan for Resident #45 dated 3/2026, revealed the resident had care plans in place for mental health diagnoses including Bipolar Disorder, Major Depression, and PTSD.Review of an annual MDS assessment dated [DATE], revealed Resident #45 was coded inaccurately as not having a Level II PASARR. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Major Depressive Disorder, and Insomnia.Review of a PASARR submitted to the state designated authority dated 12/19/2023, revealed Resident #5 required a Level II evaluation, which was completed on 1/2/2024 and determined the resident had a serious mental illness.Review of the comprehensive care plan for Resident #5 dated 1/2026, revealed the resident had care plans in place for mental health diagnoses including Schizoaffective Disorder, Major Depressive Disorder, and Insomnia.Review of an annual MDS assessment dated [DATE], revealed Resident #5 was coded inaccurately as not having a Level II PASARR. During an interview on 4/15/2026 at 3:05 PM, the Licensed Practical Nurse (LPN) MDS Nurse confirmed Resident #45's annual MDS assessment dated [DATE], and Resident #5's annual MDS assessment dated [DATE], were not coded accurately for being considered by the state level II PASARR process to have a serious mental illness.

Based on facility policy review, observations, and interviews, the facility failed to maintain a safe, clean, and homelike environment for 3 of 32 rooms observed and failed to provide a safe, clean, and homelike environment for 1 resident (Resident #40) of 64 residents observed for safe, clean, homelike environment.The findings include:Review of the facility's undated policy titled, Routine Cleaning and Disinfection, revealed .it is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .consistent surface cleaning and disinfection will be conducted .high touch surfaces .toilet seats .Review of the facility's policy titled, Call Light Response System, dated 10/2022, revealed .ensure the facility is adequately equipped with a call light at each resident's bedside .to allow residents to call for assistance .Staff will ensure the call light is within reach of resident[s] and secured, as needed . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including History of a Stroke, Hemiplegia, and Chronic Kidney Disease.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During observations on 4/14/2026 at 7:58 AM, 4/14/2026 at 9:30 AM, and 4/14/2026 at 1:30 PM, revealed Resident #40 lying in bed, with the head of bed raised, and the call light on the floor behind the head of the bed, and not within Resident #40's reach. During an observation on 4/14/2026 at 3:43 PM, revealed Resident #40 lying in bed, with the head of bed raised, and the call light on the floor behind the head of the bed, and not within the resident's reach. Further observation revealed Resident #40 yelling out help.During an observation and interview on 4/14/2026 at 3:45 PM, Certified Nurse Assistant (CNA) A entered Resident #40's room, repositioned the resident, and gave the resident a soda as the resident requested. CNA A stated, .[Resident #40] usually uses the call light [instead of yelling out] . CNA A confirmed the call light was on the floor behind the head of the bed and was not within Resident #40's reach.During observations on 4/13/2026 at 11:40 AM, 4/14/2026 at 2:00 PM, and 4/15/2026 at 1:30 PM, the bathroom in room [ROOM NUMBER] revealed multiple areas of dried brown residue on the bedside commode seat over the toilet, on the metal parts beneath the commode, and on the toilet seat. The toilet seat appeared to have yellow and brown stains or discoloration, there was a dark orange/brown substance around the base of the toilet, and the bathroom had a strong foul odor.During observations on 4/13/2026 at 11:45 AM, 4/14/2026 at 2:05 PM, and 4/15/2026 at 1:35 PM, revealed the privacy curtain in room [ROOM NUMBER]-B side had multiple areas of white and dark dried substances on it.During observations on 4/13/2026 at 11:48 AM, 4/14/2026 at 2:10 PM, and 4/15/2026 at 1:39 PM, revealed the privacy curtain in room [ROOM NUMBER]-A side had multiple areas of white and dark dried substances on it.During observations on 4/13/2026 at 11:50 AM, 4/14/2026 at 9:30 AM, and 4/15/2026 at 1:48 PM, revealed the privacy curtain in room [ROOM NUMBER]-B side had multiple areas of white and dark dried substances on it.During an interview on 4/15/2026 at 2:45 PM, the Director of Nursing (DON) confirmed call lights should be within resident's reach at all times to call for assistance. During an observation and interview on 4/15/2026 at 3:15 PM, the Administrator stated the facility had a schedule for daily room and bathroom cleaning, and for cleaning and changing the privacy curtains. The Administrator confirmed white and dark colored substances were present on the privacy curtains in rooms 106-B, 108-A, and 109-B. The Administrator further confirmed the bathroom in room [ROOM NUMBER] contained a bedside commode, toilet, and base of the toilet with multiple areas of dried brown residue on the bedside commode seat over the toilet, on the metal parts beneath the commode, on the toilet seat, and the toilet seat had yellow and brown stains or discoloration. The Administrator continued to confirm there was a dark orange/brown substance around the base of the toilet, and the areas were not clean.

Based on review of a facility policy, medical record review and interview, the facility failed to investigate an allegation of abuse for 1 Resident (#5) of 7 residents reviewed for abuse. The findings include: Review of a facility policy titled Abuse, Neglect, Exploitation dated 10/18/2022, showed .it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . Resident #5 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Anxiety Disorder, Psychoactive Substance Dependency, Bipolar Disorder, Parkinson's Disease and Narcolepsy. Review of Resident #5's Social Service Note dated 6/14/2023 at 9:59 AM, showed .Member wanted to file a complaint and member called and left a message that after making a comment to a CNA [Certified Nursing Assistant] she started yelling at him, asked what comment and he refused to say .he stated that the CNA need not come into his room anymore and if she did he threatened he would be going to jail. Talked to member and let him know we could not threaten people and he stated he did not mean anything by it. He will not he stated do it again .wrote up a grievance report and they [the] CNA will not be going in the room anymore. Member was okay with that. He did apologize for the threat and for what he said, but he did not repeat what he commented to CNA. Report signed and placed in folder . Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview with the Administrator on 12/4/2023 at 9:31 AM, she stated .I did not receive any report about an allegation of a CNA yelling at [Resident #5]. It should have been reported to me immediately by the Social Service Director when the resident reported it to her .but she did not report it to me, and we did not investigate the incident . During the interview, the Administrator confirmed the facility failed to follow their policy for investigation of an allegation. During an interview with the Director of Nursing (DON) on 12/4/2023 at 11:10 AM, she stated .I do not know anything about [Resident #5] reporting to the Social Service Director that a CNA had yelled at him .that would have been reported to the Administrator and investigated immediately .[Resident #5] never said anything to me and I am not aware of any staff member that was not allowed in his room .to my knowledge there was no investigation . During an interview with the previous Social Service Director on 12/4/2023 at 12:10 PM, when questioned related to her 6/14/2023 documentation for Resident #5 she stated, .I turned in the grievances to the Administrator she kept the log .I don't recall the incident .I don't recall anything about that at all .

Based on review of a facility policy, facility investigation, medical record review and interview, the facility failed to report an allegation of abuse for 1 Resident (#5) of 7 residents reviewed for abuse within the required timeframe. The findings include: Review of a facility policy titled Abuse, Neglect, Exploitation dated 10/18/2022, showed .it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies .within specified timeframes .a. immediately, but no later than 2 hours after the allegation is made . Resident #5 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Anxiety Disorder, Psychoactive Substance Dependency, Bipolar Disorder, Parkinson's Disease and Narcolepsy. Review of Resident #5's Social Service Note, dated 6/14/2023 at 9:59 AM, showed .Member wanted to file a complaint and member called and left a message that after making a comment to a CNA [Certified Nursing Assistant] she started yelling at him, asked what comment and he refused to say .he stated that the CNA need not come into his room anymore and if she did he threatened he would be going to jail. Talked to member and let him know we could not threaten people and he stated he did not mean anything by it. He will not he stated do it again .wrote up a grievance report and they [the] CNA will not be going in the room anymore. Member was okay with that. He did apologize for the threat and for what he said, but he did not repeat what he commented to CNA. Report signed and placed in folder . Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview with the Administrator, on 12/4/2023 at 9:31 AM, she stated .I did not receive any report about an allegation of a CNA yelling at [Resident #5]. It should have been reported to me immediately by the Social Service Director when the resident reported it to her .but she did not report it to me . During the interview the Administrator confirmed the facility failed to follow their policy for reporting an allegation of abuse. During an interview with Licensed Practical Nurse (LPN) #1, on 12/4/2023 at 10:10 AM, the LPN confirmed she worked on 6/14/2023 from 6:00 AM-6:00 PM, and was Resident #5's nurse for the shift. During the interview, she stated .the Social Service Director did not say anything to me about [Resident #5] saying a CNA had yelled at him .I would have checked on the resident and then reported his allegation to the Administrator .I was here, and she didn't say anything to me .[Resident #5] didn't ever say anything to me about it and I am not aware of any CNA that was not allowed to be in his room . During an interview with the Director of Nursing (DON) on 12/4/2023 at 11:10 AM, she stated .I do not know anything about [Resident #5] reporting to the Social Service Director that a CNA had yelled at him .that would have been reported to the Administrator .[Resident #5] never said anything to me and I am not aware of any staff member that was not allowed in his room . During an interview with the Staffing Coordinator/LPN #2, on 12/4/2023 at 12:00 PM, she stated .I am an LPN but I do the staff scheduling .I do not recall the Social Service Director or anyone informing me that a particular CNA was not allowed to go into [Resident #5's] room to care for him .if it had been reported to me I would have questioned why, and if it had been reported to me there was an allegation against a CNA, I would have reported it to the Administrator . During an interview with the previous Social Service Director on 12/4/2023 at 12:10 PM, when questioned related to her 6/14/2023 documentation for Resident #5, she stated .I turned in the grievances to the Administrator she kept the log .I don't recall the incident .I don't recall anything about that at all . During an interview with LPN #3 on 12/4/2023 at 1:55 PM, the LPN confirmed she worked on 6/13/2023 from 6:00 PM to 6:00 AM on 6/14/2023, and was Resident #5's nurse for the shift. During the interview she stated .I don't work there anymore but I don't recall anything about a CNA not allowed to go back in his room. I don't recall [Resident #5] ever saying anything like that to me .if he had I would have charted something and if I had heard yelling I would have intervened, had a staff member stay with the resident, and the CNA would have been removed from the room and I would have called the Administrator .we would have done an assessment on the resident and monitored him and it would all have been documented .something like that would have stood out in my mind and I have no recollection of anything like that happening . During an interview with LPN #4 on 12/4/2023 at 2:05 PM, it was confirmed she worked on 6/13/2023 from 6:00 AM-6:00 PM, and was Resident #5's nurse for the shift. During the interview she stated, .I don't know anything about that, I worked all day on the 13th and was in and out of his room, he never said a word about any staff member yelling at him .I didn't get anything in report that happened the night before related to him .I would have reported that to the Administrator .I don't know anything about a CNA or any staff that was not allowed in his room .

Based on review of a facility policy, medical record review, and interviews the facility failed to protect the residents' right to be free from physical of abuse a resident for 3 residents (Residents #5, #7, #9) of 14 residents reviewed. The findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, dated 10/18/2022 showed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #5 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diverticulitis, Congestive Heart Failure, Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder, and Vascular Dementia. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 10, indicating moderate cognitive impairment. Review of Resident #5's Alert Note dated 2/6/2023 at 7:30 AM, showed .Resident was in dining room with a resident that was with 1 on 1 assigned CNA [Certified Nursing Assistant] when the other resident began spitting and acting out. This resident started going toward the resident in an attempt to reconcile him and the other resident grabbed her hair on the right side of her head and hit her on the right side of the head before the CNA [Certified Nursing Assistant] could intervene .Resident was upset stating that she thought her, and the other resident were friends . Review of Resident #5's Resident to Resident Incident Report dated 2/6/2023, showed Resident #5 tried to console/comfort/calm, Resident #4 when Resident #4 grabbed Resident #5 by her hair on the right side of her head and slapped her across her face. Residents were immediately separated .Resident #5 entered the dining room for breakfast, when she seen Resident #4 spitting, upset, and refusing medications from the nurse. Resident #5 approached Resident #4 to console/calm/comfort him, when Resident #4 grabbed her hair on the right side of her head and then slapped her across the right side of her face. CNA and nurse were in the dining room at the time of the event but were unable to intervene. Resident #4 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Lennox-Gastaut Syndrome, Moderate Protein-Calorie Malnutrition, Dysphagia, Personality and Behavioral Disorders, Impulse Disorder, Anxiety Disorder, Mood Disorder, and Intellectual Disabilities. Review of Resident #4's comprehensive care plan dated 11/16/2022, showed .has behavior problem physical aggression, hitting, spitting, yelling, running wheelchair into staff members, refusal of care, refusal of showers, refusal of medications, throwing objects, hitting self, trying to tip wheelchair backwards r/t [related to] personality and behavioral disorders due to known physiological condition; impulse disorder .generalized anxiety disorder .mood disorder due to known physiological condition .intellectual disabilities .administer medications as ordered .anticipate and meet the resident's needs .assist the resident to develop more appropriate methods of coping and interacting .caregivers to provide opportunity for positive interaction, attention .explain all procedures to the resident before starting .if reasonable, discuss behavior .minimize potential for the resident's disruptive behaviors by offering tasks which divert attention .monitor behavior episodes and attempt to determine underlying cause . Review of Resident #4's quarterly MDS assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 6 indicating severe cognitive impairment. The resident required extensive assistance of 1 person assist with transfers, and was always incontinent of both bowel and bladder. Review of Resident #4's Order Administration Note dated 1/9/2023 showed .Anxiety & agitation-whining, hitting, covering face and turning away from staff, yelling out, running into others and laughing, fast dangerous movements in w/c [wheelchair]. Trying to run over other resident's toes and laughing at them holding up fist at staff when attempting to direct from others . Review of Resident #4's Alert Note dated 1/11/2023 at 1:37 PM, showed .At beginning of shift after patient was dressed and placed to w/c (wheelchair), noted loud laughing and attempting to run into people making him laugh more . Review of Resident #4's Behavior Team Note dated 1/22/2023, showed .patient following CNA's around after lunch and playing and talking with them. When staff began their scheduled rounds were unable to continue with him, he went to group of geriatric residents and attempted to play with them. When the other residents told him 'no' he became agitated. Patient spitting and yelling at them, attempted to hit with fist and run into them with them with his w/c. Staff removed patient from the group. Other patient began to yell at this patient and this patient became more agitated. Patient began hitting staff and yelling . Review of Resident #4's Incident Report Resident to (Resident) dated 2/6/2023 showed .Location Dining room .Resident [#4] has diagnosis of cerebral palsy and intellectual disability. Often very hard to redirect. Also has hx [history of] impulsiveness and combative behaviors .Resident was one on one with staff member in the dining room when Resident [#3] entered dining room. Resident [#4] was setting in his wheelchair in the dining room, spitting. Floor nurse attempted to administer morning medications when resident continued to spit and refuse medication . During an interview with Resident #5 on 11/1/2023 at 9:00 AM, the resident recalled the incident and she stated .we were in the dining room [Resident #4] was upset .I rolled toward him to calm him down .he wasn't eating he was upset .when I got close to him he pulled my hair and slapped my face .it did hurt a little when he pulled my hair and smacked me but it didn't hurt but just a minute .I didn't have any bruises or anything like that .It hurt my feelings because he always sat by me, and we were friends .I didn't know why he acted that way .but [facility staff] explained he wasn't mad at me it was just his disease process and I was fine .I don't have any hard feelings .he isn't here anymore and I really miss him .they told me not to get to close to him anymore . During an interview with the Administrator on 11/2/2023 at 11:15 AM, she stated .[Resident #4] was on 1:1 and was in the dining room with a CNA and a nurse present, he was having behaviors and the staff had backed away from him due to his history of swing at staff, putting himself in the floor and throwing objects. [Resident #5] began to roll over toward [Resident #4] .the staff told her not to roll over to him, but she continued to go anyway in an attempt to console him that is when [Resident #4] pulled her hair and hit her in the face .[Resident #5] was assessed for injuries with no injuries noted. She was upset because she thought [Resident #4] and herself were friends .I was at the facility within 30 minutes of the incident and I went straight to [Resident #5] she had already calmed down and I explained to her that they were friends his mental status prevented him from controlling his actions and the incident had nothing to do with her personally .this was a witness event .when he was having behaviors he would sling his arms throw himself in the floor and when she rolled toward him he did grab her hair and hit her in the face .it was not a reflex .it was intentional he has cerebral palsy, intellectual disabilities and a BIMS of 0, and he cannot be educated . During the interview she confirmed the facility failed to prevent the abuse of resident #5 . During an interview with Licensed Practical Nurse (LPN) #1 on 11/8/2023 at 11:05 AM, she stated .I was in the dining room when it happened .he was 1 on 1 and was getting upset he was spitting .the CNA had backed off to give him a little space and [Resident #5] started rolling toward him .we told her to back up but rolled right up to him when she did he instantly grabbed her hair and smacked her on the face it was more of a graze but he did make contact .she didn't have a red mark but she was startled .she thought she could calm him down she is motherly and nurturing to all of the residents .she was fine within 5 minutes, she did say it hurt at the moment but nothing after that . Resident #6 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Congestive Heart Failure, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #6's annual MDS assessment dated [DATE], showed a BIMS assessment score of 6 indicating severe cognitive impairment with no behaviors noted during the assessment period. Review of Resident #6's Incident Report dated 3/18/2023, showed floor nurse heard yelling and cursing coming from resident's room. When entered resident's room, nurse found Resident #7 and Resident #6 to be yelling and calling each other [elicit name]. Floor nurse separated residents. When asked Resident #6 what happened she stated that resident #7 had entered her room and threw water on her. Resident #6 then followed Resident #7 into the room belonging to Resident #7 and began to yell and curse at resident #7 which led to both residents yelling and cursing each other. Resident #6 stated that Resident #7 had hit her with a hairbrush .Resident #7 yelled at Resident #6 to 'get the hell out of here. Floor nurse had to request and cue Resident #6 several times to exit the room belonging to Resident #7 before Resident #6 would comply with the request. Resident #7's roommate Resident #8 witnessed the entire event, stated she observed both residents entering the room shared between she and Resident #7 when they both began to argue and call each other names. Resident #8 stated she saw both residents hit each other. Residents were separated . Resident #7 was admitted to the facility on [DATE] with diagnoses including Malignant Melanoma of Skin, Atherosclerotic Heart Disease, Psychotic Disorder, Depression, Adult Failure to Thrive, Dementia, and Chronic Pain. Review of Resident #7's Alert Note dated 1/18/2023 at 12:14 PM, .resident had an episode of agitation and swinging her fist at people this AM in dining room. Resident redirected and returned to her room. NP (Nurse Practitioner) called and gave order to continue Hydroxyzine 25 mg po every 8 hours PRN [as needed] X 2 weeks. Also obtain UA [urinalysis] C&S [Culture and Sensitivity] in AM . Review of Resident #7's Alert Note dated 3/18/2023 at 4:30 PM, showed .this writer was alerted to patient's room d/t [due to] hearing female voices yelling. This writer entered room and noted that patient and resident from across hall are in room and arguing with each other. Both were verbally threatening each other and calling each other [elicit name]. This writer is able to get between them and ask them what was happening. Patient [#7] continued to yell out and tell other patient [#6] to 'get out of here.' Other patient states that this patient 'came into my room and threw water on me.' This writer able to see across hall into other room and noted that floor is covered in liquid. This patient [#7] is unable to answer questions appropriately. Other patient states she followed this patient across hall after having water thrown at her to ask her 'what the hell she was doing?' Patient [#6] states that they began to have a verbal altercation and then [Resident #6] was hit with a hairbrush. Patient denies any pain at this time. This writer was able to get other patient [#6] to exit room and go back into hallway with several request and cueing. This patient [#7] is now sitting in her w/c with eyes closed and arms crossed. Spoke to this patient's roommate [Resident #8] that was sitting in room next to window [and saw] the whole episode. Roommate states that both entered room and began to yell at each other and then 'it seemed they may have been hitting each other.' This patient [#8] has no s/s [signs and symptoms] of distress or discomfort at this time . During an interview LPN #2 on 11/1/2023 at 2:15 PM, she stated .we heard someone down the all yelling we went down the hall and [Resident #6] was in [Resident #7's] room [Resident #6] was yelling at [Resident #7] [Resident #6] was mad so we pulled her back toward the room door and [Resident #7] was up next to her headboard [Resident #6] was threatening [Resident #7] we were trying to calm her down and find out why she was mad .she was saying [Resident 7] had no right to be here, I explained that she was in her room .but what she was trying to tell me was that [Resident #7] had come in her room and had thrown tea all over her. I could see across the hall and there was tea everywhere, but I didn't see any on her .We moved [Resident #6] out in the hallway got her calmed down and cleaned up her room .we sat and talked to her for a while she had gotten upset because she and [Resident #7] used to be best friends, they would go to the dining room together they were roommates, and they did everything together. If you saw one of them, you saw the other .but due to [Resident #7]s progression in her dementia that all changed and [Resident #6] couldn't understand what was wrong. Why she had changed .one staff member stayed with [Resident #7] and within 5 minutes she had forgotten about the incident .[Resident #6] did have a very small 1 cm straight skin tear to her left posterior forearm .I had to tell her that she had a skin tear she didn't even know it was there .she was not complaining of any pain, after I cleaned the skin tear I could see there was no active bleeding or bruising and I don't recall it ever bruising .I saw the blood on her arm while she was talking with her hands .I don't know when it occurred that was just the first time I saw it .she didn't know when it happened .like I said she didn't even know it was there .she was just mad because she [Resident #7] had come in her room and threw tea .it was tea not water, but I did not see any on her just her floor .she couldn't understand the shift in their relationship . During an interview with Resident #8 (witness to the altercation) on 11/1/2023 at 12:55 PM, she stated she did recall the incident .I don't know what set it off .they use to be roommates but some time back [Resident #7] moved in with me .they use to go to the dining room together .she doesn't bother anything much she just does her own thing .she will roll over here and mess with the unit [heating/cooling unit] and just roll off, or she will come piddle in the closet and wash her hands .she is hard of hearing and will usually just answer yeah to whatever you ask her .that afternoon [Resident #7] just calmly rolled over to [Resident #6'] room and I saw her throw a cup of water .I was shocked, but then she just turned around and rolled right back like nothing .[Resident #6] followed her back in here .they were yelling at each other and [Resident #6] hit [Resident #7] then [Resident #7] hit her back .I might have yelled but I think I used my call light to call the nurse .neither of them said anything about being hurt they were just spouting off to each other .no one was crying .[Resident #7] did pick up her bed remote and hit at [Resident #6] not sure where she hit her with the remote, but she said it was a hairbrush and there was no hairbrush .the remote was just handy and when [Resident #6] hit her she just picked up the remote and hit her back .the nurse came in and separated them, after it was over [Resident #7] was just like she was before just doing her own thing . During an interview with Resident #7 on 11/1/2023 at 1:10 PM, Surveyor had to get directly in the residents' line of site to get her attention. When asked how she was doing she stated, I'm okay .I color a lot I like to color . Surveyor was unable to hold the resident's attention for any further questions. During an interview with Resident #6 on 11/2/2023 at 4:20 PM, she stated everything was going fine and she did not remember having an altercation with any resident. She stated, I get along with everybody here. During an interview with the Administrator on 11/2/2023 at 11:35 AM, she stated .[Resident #7] rolled across the hall to [Resident #6's] room and threw a cup of tea, [Resident #7] went back to her room and [Resident #6] followed. [Resident #8] witnessed [Resident #6] and [#7] arguing over the incident and stated [Resident #6] had started the physical altercation between them. [Resident #8] called for help and the nurse [LPN #2] was the first to the room to separate the residents. Both residents were assessed for injuries. [Resident #7] had no injuries. [Resident #6] had a skin tear to her left posterior forearm and was unable to say how or when the skin tear occurred. [Resident #8] said she saw [Resident #6] hit [Resident #7] first then [Resident #7] had picked up her bed remote and hit [Resident #6] back she didn't know where she hit [Resident #6] with the remote at .both [Resident #6] and [Resident #7] have a diagnosis of Alzheimer's and are unable to remember actual and current events. [Resident #7] could not give any details. [Resident #6] stated that [Resident #7] threw water on her and when she went over to ask her why [Resident #7] had hit her with a hairbrush and she could not remember where she was hit. She said she didn't know .the floor nurse had to request [Resident #6] exit [Resident #7's] room several times multiple times after they were separated .[Resident #8] reported it was a bed remote not a hairbrush .[Resident #6] denied hitting [Resident #7] but [Resident #8] with a BIMS of 15 reported [Resident #6] hit first .[Resident #7] could not recall any event and had no injuries .[Resident #8] reported she was not aware of anything that had happened prior to the incident .she stated [Resident #7] just calmly rolled over to [Resident #6's] room and threw the cup of water .based on the eye witnesses statement I cannot say there was willful intent from [Resident #7] to throw water on or at [Resident #6] or if she just threw the water, she had thrown her water pitcher in the hall a few days before, and due to earlier in the day she was noted to be crying, talking to self, arguing with self, having pacing like actions and packing her belongs. Staff did administer her PRN and noted it to be effective at the time, but that was 5 hours before the event .however [Resident #6] did willfully per witness hit [Resident #7] after water had been thrown in her room .During the interview the Administrator confirmed the facility failed to prevent abuse of Resident #7. Resident #9 was admitted to the facility on [DATE] with diagnoses including Hydrocephalus, End Stage Renal Disease, Kidney Transplant Failure, Dependence on Dialysis, Anxiety Disorder, Heart Failure, Major Depressive Disorder and Seizures. Review of Resident #9's quarterly MDS assessment dated [DATE], showed a BIMS assessment score of 15 indicating he was cognitively intact. No behaviors were noted during the assessment period. Review of Resident #9's Alert Note dated 6/4/2023 at 6:15 PM, showed .at approximately 6:15 PM, this resident was hit in the back by another resident within the facility. This resident states he is not hurt injured nor in pain. This resident states that the other resident was frustrated with him for visiting his roommate. Residents were immediately separated by facility staff member . Review of Resident #9's Incident Report dated 6/4/2023, showed Resident #10 was sitting at the nurse's station when he became agitated and started cursing Resident #9 regarding him visiting Resident #10's roommate the night prior. Resident #10 stated he did not want Resident #9 in his room because he wants to go to bed. Resident #9 was in his wheelchair and was moving away from Resident #10 when Resident #10 took his fist and struck Resident #9 once in the upper back between his shoulder blades. Resident #10 was admitted to the facility on [DATE], with diagnoses including Sjogren syndrome, Type 2 Diabetes Mellitus, Thoracic Aortic Aneurysm, Major Depressive Disorder, Parkinson's Disease, and Anxiety Disorder. Review of Resident #10's quarterly MDS assessment dated [DATE], showed a BIMS assessment score of 15 indicating he was cognitively intact. No behaviors were noted during the assessment period. Review of Resident #10's Alert Note dated 6/4/2023 at 8:33 PM, showed .at approximately 6:15 PM, this resident hit another resident on the back with his fist. This resident states he was frustrated with him for visiting his roommate at a time that he was ready to go to bed. Residents were immediately separated by facility staff member and charge nurse was notified . During an interview with Resident #10 on 11/2/2023 at 10:35 AM, he stated he would like to do the interview where he was instead of going to his room .and stated .it's fine right here .I was nothing really .I was just probably upset with him .I didn't hit him hard .things just happen sometimes .that was a long time ago and we haven't had any more problems . The resident did not provide any additional information related to the incident. During an interview with Resident #9 on 11/2/2023 at 10:50 AM, he agreed to self-propel himself into the dining room where no other residents were present for an interview. He stated .he hit me in the back .I guess with his fist I don't really know .we haven't had any more trouble .I just don't go around him anymore .I don't know what his problem was .it didn't scare me it did startle me because I wasn't expecting it .did kinda made me mad for a minute but I got over it .I was fine . During an interview on 11/2/2023 at 12:05 PM, Administrator #1 stated Resident #9 was hit in the back one time at the nurses' station by Resident #10. There were 2 CNA's that were present at the nurses' station. Resident #9 had turned up his music loud when Resident #10 asked him to turn it down. Resident #9 did not. Resident #9 instead attempted to roll away in his wheelchair that is when Resident #10 hit Resident #9 in the back . During the interview the Administrator confirmed Resident #10 did willfully hit Resident #9 and the facility failed to prevent abuse of Resident #9 . During an interview on 11/6/2023 at 4:30 PM, Registered Nurse (RN) #1 stated .[Resident #10] is normally laid-back guy, [Resident #9] just got on his nerves, I guess. [Resident #10] wanted [Resident #9] to turn his music down. [Resident #9] would visit [Resident #10's] roommate and he was already irritated with him .[Resident #9] talks loud and he likes to visit, it wasn't like a punch it was like a swat and it was not hard it was not red it wasn't scratched or bruised .he had never done anything like that before .[Resident #9] was more shocked than anything when it happened he wasn't upset. I think maybe his feelings were hurt because he is very personable with everyone .but more shocked than anything .[Resident #10] is very small and he didn't have very much strength to hit him very hard .he did mean to hit him it wasn't an accident, but it was more of a swat than anything . During an interview on 11/8/2023 at 2:35 PM, CNA #1 stated .it had been normal evening, I was just happened to be walking by [Resident #9] was blasting out his music on his phone .the next thing I knew [Resident #10] hit him in the back. I don't mean to be disrespectful but [Resident #10] moves slowly so he didn't hit him hard it was with his fist, but it was more of an attempt .his hands are sort of deformed like he has arthritis. He was in his wheelchair so he had to stretch and in slow motion to even hit him .there was no marks on [Resident #9] at all there wasn't even a reddened area .I can't be 100% sure he actually made contact, but I immediately separated them .

Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain an accurate medical record for 1 resident (#31) of 24 residents reviewed for medical records. The findings include: Review of a facility policy titled Residents' Rights Regarding Treatment and Advance Directives, undated, showed .it is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical treatment .during the care planning process, the facility will identify, clarify, and review with the resident .to make any changes .and whether the resident wishes to change or continue these instructions .the resident's choices will be documented in the resident's medical record . Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Order Summary Report for Resident #31 showed .FULL CODE . with a start date of [DATE] and no end date indicated. Review of the comprehensive care plan initiated [DATE] showed Resident #31 was .Full code . Review of the Tennessee Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Do Not Attempt Resuscitation (DNR/no CPR [cardiopulmonary resuscitation]) (Allow Natural Death) . During an interview and observation on [DATE] at 4:01 PM, the Director of Nursing (DON) confirmed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of facility policy, medical record review, review of the facility investigation, observations, review of facility floorplan, review of National Oceanic and Atmospheric Administration (NOAA) weather data, and interview, the facility failed to secure windows in the common dining area which resulted in the elopement of 1 resident (Resident #1) of 6 residents reviewed for elopement risk or accidents. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death) when Resident #1 opened an unsecured window in the common dining area, exited to the outside, and fell to the ground. The Administrator, Director of Nursing, and the Corporate Nurse were notified of the Immediate Jeopardy on 5/12/2022 at 3:55 PM, in the conference room. The facility was cited Immediate Jeopardy for F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 4/26/2022. The facility's corrective action plan was reviewed and corrective actions were validated onsite by the surveyor 5/10/2022 to 5/12/2022. The IJ was cited as Past Noncompliance for F-689 and the facility is not required to submit a Plan of Correction (POC). The findings included: Review of the facility policy Elopements and Wandering Residents (undated) revealed, .This facility ensures that residents who .are at risk for elopement receive adequate supervision to prevent accidents .the facility is equipped with door locks/alarms to help avoid elopements . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dysphagia, [CONDITION(S)] Following [CONDITION(S)] Disease, [CONDITION(S)] Disease, Other Symptoms and Signs Involving Cognitive Functions Following Cerebral Infarction, Contractures of the Right and Left Hands, Generalized Muscle Weakness, and Left Artificial Hip Joint. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #1 was severely cognitively impaired, required extensive assistance with transfers, was able to locomote about the facility in a wheelchair with set up assistance, and was dependent upon two persons for assistance with all other activities of daily living (ADLs). Resident #1 had no prior history of wandering or elopement attempts. Review of the facility investigation revealed on 4/26/2022 around 9:00 PM, Resident #1 exited the facility undetected through an unsecured window in the common dining area. The window was closed and latched shut but did not have a safety stop (a metal device affixed to the window frame that limited how high the vertically opening windows could be raised) installed. Resident #1 had unlatched the window, then exited to the outside, which was approximately 18 inches wide by 24 inches tall, with the window base situated roughly 30 inches off the ground. Resident #1 fell to the outside. Observation of the facility from 5/10/2022 - 5/12/2022 and review of the facility floorplan showed the common dining area was off the main hallway, adjacent to the front entrance and lobby, on the southeast front corner of the building. There was a centrally located nursing station located roughly 110 feet northward, towards the rear of the facility, that was situated at the junction of the clinical hallways in the L shaped facility. The dining room was out of line of sight or earshot of staff located on the clinical units and the nursing station. The window Resident #1 had eloped through was in the southeast corner of the dining area and was not visible from the main hallway or front lobby. The area near the window was an activity department workspace, which contained a desk and chair. The space was separated from the common dining area by a portable partition and prevented observation of the corner space and the windows from inside the dining room or through the windows/door which separated the dining area from the common hallway and front lobby outside. Review of NOAA weather data for 4/26/2022, revealed the sun set that day at 8:22 PM. It was 58 degrees at 9:00 PM and conditions were dry with minimal winds. Review of the Nurse Practitioner Progress Notes dated 4/28/2022 revealed .is being seen today s/p [status post] a fall on the evening of 4/26/22 .he [Resident #1] was reportedly found on the ground outside by a CNA .his room mate [Resident #1's roommate] reported he returned to his room and proceeded to talk about how he exited the facility through the window .he is not fully cooperative with questions asked about the incident .but he does state he was outside on the ground for less than 10 minutes before being found by the CNA . Interview with the Administrator on 5/10/2022 at 2:45 PM, in the conference room, confirmed Resident #1's elopement went undetected by staff and the situation constituted a risk of serious harm, impairment, injury or death to Resident #1. Interview with CNA #10 on 5/10/2022 at 6:10 PM, in the facility parking lot, revealed she was on duty and assigned to other residents when Resident #1 eloped. CNA #10 reported she last saw Resident #1 near the nursing station around 7:30 PM. CNA #10 responded to calls for help from a peer when Resident #1 was found outside around 9:00 PM. When asked why he had left by the nurse, Resident #1 stated he was going to K-Mart (there is no K-Mart in the area). CNA #10 reported she asked Resident #1 the same question the next day and he told her he left to go to any mart. She had no idea how Resident #1 opened the window as he required two-person assistance for transfers, his hands were contracted, and his range of motion limited. CNA #10 confirmed until Resident #1 was found outside and nobody knew he had eloped. Telephone interview with CNA #5 on 5/11/2022 at 8:48 PM, revealed she was the person who first responded when Resident #1 was found outside the facility. CNA #5 reported the incident happened around 9:00 PM. CNA #6 was leaving the facility to go to a local fast-food restaurant to get lunch, and as she exited the front of the building, noticed Resident #1 lying on his left side outside the open window to the dining hall. CNA #6 called inside for help and multiple staff responded. CNA #5 reported none were aware Resident #1 had exited the building at the time. CNA #5 reported Resident #1 told her he was going to K-Mart when asked what he was doing outside. As he was helped inside, Resident #1 laughed and told her he was .going home . CNA #5 stated she saw the dining room window open above where Resident #1 laid, and it was obvious Resident #1 had climbed through the window to exit. Telephone interview with Licensed Practical Nurse (LPN) #1 on 5/11/2022 at 9:25 PM, revealed she was one of the licensed nurses who responded when Resident #1 was located outside. At the time she was assigned residents on another hallway. LPN #1 confirmed at the time Resident #1 eloped, nobody inside the facility was aware he had left. LPN #1 observed Resident #1's wheelchair pushed under a table near the far side of the dining room, several feet adjacent to the window where he had exited. LPN #1 stated while investigating the incident, she determined the resident must have walked to the window to access it. LPN #1 reported she was engaged in medication pass that evening from 7:30 PM until around 9:00 PM and had noticed Resident #1 ambulating in his wheelchair on the unit near the nursing station, as was his custom, sometime between 7:30 PM and 8:00 PM. She had not seen him after that until he was located outside. Telephone interview with CNA #6 on 5/11/2022 at 9:40 PM, revealed she was the CNA who found Resident #1 outside. CNA #6 reported she came on duty around 6:00 PM and noted Resident #1 ambulating about the facility in his wheelchair, as was his custom. Around 9:00 PM, as she exited the facility for lunch, she happened to glance towards the side of the building and saw Resident #1 lying on the ground beside the building. CNA #6 immediately went to assess him and once she determined he was awake, returned to the front door and screamed for help. Resident #6 was fully dressed at the time. CNA #6 reported it was dark outside when she found Resident #1. CNA #6 reported she had last seen Resident #1 seated in his wheelchair with another resident in the front lobby (near the dining hall entrance) right at sunset a few minutes before. CNA #6 confirmed at the time she found Resident #1 outside, nobody inside the facility was aware he had exited. Telephone interview with Registered Nurse (RN) #1 on 5/11/2022 at 10:15 PM, revealed she was assigned as floating nurse on the evening of the incident and was engaged in resident care when Resident #1 eloped. RN #1 confirmed none of the staff were aware he exited. RN #1 reported the other two nurses were engaged in the evening medication passes and various treatments. RN #1 noticed Resident #1 seated in his wheelchair with two other wheelchair bound residents, near the front lobby around dusk. RN #1 reported that was customary for Resident #1. RN #1 heard CNA #6 cry for help around 9:00 PM, responded, and observed Resident #1 on the ground outside near the open dining room window. They used a wheelchair to bring Resident #1 back inside. RN #1 assessed Resident #1 in his room. Resident #1 had small abrasions on his right knee and the knuckles of right hand but was otherwise unharmed. RN #1 asked Resident #1 why he went out the window and he replied he was going to K-Mart. Resident #1's wheelchair was located near a table in the dining room, and no staff had seen him enter the dining area unsupervised that night. RN #1 stated the dining hall was out of line of sight and earshot of staff on the clinical floor and Resident #1's elopement went undetected. Interview with the Maintenance Director on 5/12/2022 at 1:22 PM, during observations of the facility window safety stops in every window of the facility, revealed he was informed of Resident #1's elopement shortly after it occurred. The Maintenance Director reported the facility discovered the windows in the common dining area did not have safety stops installed during the initial investigation, which began immediately after Resident #1 was found outside. Clinical staff locked the dining hall that night to secure the space after closing and latching the window. The Maintenance Director confirmed safety stops had been installed on all windows in clinical areas and resident rooms in 2020 but had not been installed in office spaces or the common dining area. In response to the incident, the Administrator ordered inspections of every window in the building and safety stops were installed on all windows and those safety checks had been performed and documented daily since the incident. The Maintenance Director agreed had safety stops been present on the common dining room windows on the night of 4/26/22, Resident #1's elopement would likely have been prevented. The facility corrective action plan included the following: Interview with the Administrator on 5/11/2022 at 1:43 PM, in the conference room, revealed the facility interventions to address the situation began on 4/26/2022 with the closure of the dining room by clinical staff who locked the door. The Administrator reported the space was secured on the following morning of 4/27/2022 with the addition of safety stops to all windows in the dining room. The Administrator reported an ad hoc QAPI (Quality Assurance Performance Improvement) meeting with members of the facility and corporate leadership was held by telephone around 9:30 PM that evening and the investigation launched. A second ad hoc QAPI meeting was held with the Medical Director on the morning of 4/27/2022 and was documented. Root cause analysis of the incident by the Director of Nursing (DON) and members of the QAPI team was in progress. The Administrator reported mandatory education and competency testing of all staff began on 4/27/2022 and presented supporting documentation related to all safety measures imposed in the plan of correction (POC) and related QAPI documents for review. During interview with the Maintenance Director on 5/12/2022 at 1:22 PM during observations of the facility's windows, the Maintenance Director stated he arrived to work at 5:30 AM on 4/27/2022 and secured 3 windows in the common dining area by installing new safety stops by 6:00 AM. On 4/26/2022 Resident #1 was immediately assessed for injuries and treatment initiated for scrapes to the 3rd, 4th, and 5th right knuckles and scrapes to his knees by the nurse. Clinical staff secured the window and locked the dining room within minutes of Resident #1's elopement during initial investigation of the incident. An ad hoc QAPI meeting was held between the Administrator and members of the facility and corporate leadership on 4/26/2022 at 9:35 PM. The formal investigation was launched. At 6:00 AM on 4/27/2022 the Maintenance Director secured the windows in the dining area by installing new safety stops on all unsecured windows. A second Ad hoc QAPI meeting was held with members of the facility leadership and the Medical Director on 4/27/2022. A root cause analysis of the incident was underway by the DON and her designees. A clinical review was completed by the Hospice Provider on 4/27/2022 for Resident #1. A clinical review was completed by the Medical Nurse Practitioner on 4/28/2022 for Resident #1. A clinical review was conducted by the Psychiatric Nurse Practitioner on 5/3/2022 for Resident #1. Resident #1's Elopement Status was updated, and care planned on 4/27/2022 by the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) Coordinator. Resident #1 was added to the Residents-at-Risk for wandering/elopement book at the nursing station. On 4/27/2022 all windows throughout the facility were checked to ensure locking mechanisms (safety stops) were in place by the Administrator and Maintenance Director. On 4/27/2022 all doors in the resident available areas were checked for proper alarm functions by the Administrator. On 4/28/2022 Resident #1 was encouraged to let staff know when wanting to go out of the facility by the Administrator. On 4/27/2022 a 100% review of all residents' Elopement Assessments was completed to ensure all assessments were up to date (completed quarterly) and all residents at risk or high risk were placed in the wander guard elopement book at the nursing station. All resident care plans were reviewed to ensure the current assessments reflected the care plan. Beginning 4/27/2022 the Staffing Coordinator and Administrator re-educated all staff on the Abuse, Neglect and Exploitation Policy and the Wandering and Elopement Policy. To ensure staff education was retained all staff completed written post testing that required 100 percent (%) score for the pass rate. If a staff member did not score 100%, they were re-educated and re-tested until they achieved a 100% score. All staff members employed as temporary or as needed (PRN) employees or who were out on approved leave were required to complete education and post testing before the next scheduled shift. The staffing Coordinator and ADON performed elopement drills (code pink) with staff present at the facility on the day shift of 5/4/2022 and night shift on 5/4/2022 then repeated the drills with employees on the alternate staff rotation on the day and night shifts of 5/6/2022. No irregularities were identified or corrective measures necessary after the drills were completed. Beginning on 4/27/2022 the Administrator, Maintenance Director or Environmental Supervisor will perform visual checks of all windows throughout the facility, Monday through Friday for 4 weeks, then 2 times per week for 4 weeks, then monthly for 2 months to ensure every window has a safety stop in place. Any concerns identified will be immediately reported and corrected by the Administrator or Maintenance Director. Beginning 4/27/2022 the Administrator, Maintenance Director or Environmental Supervisor and Dietary Department will perform visual checks of the dining room windows to ensure it is secure after the evening meal. The visual checks will occur daily for 4 weeks, then 2 times a week for 4 weeks then monthly for 2 months. Any issues with non-compliance will be presented to the QAPI committee (Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Director, Dietary Supervisor and Environmental Supervisor) for review and resolution. If non-compliance is identified, the audits will start back at the beginning occurring daily for 3 weeks, then 2 times per week for 4 weeks, then monthly for 2 months. The surveyor verified the facility corrective actions had been carried out as outlined in the plan of correction as follows: 1. Visual inspections and testing of window safety stops were conducted on every window in the facility on 5/12/2022 with no irregularities observed. 2. All exterior doors and alarms were observed, and alarms tested , on 5/12/2022 with the Maintenance Director. All alarms and doors functioned as intended. 3. Interviews conducted between 5/10/2022 - 5/12/2022 with 12 staff members showed training for the facility missing resident (code pink) policy, the abuse and neglect prohibition policy, and facility directives related to the dining space in response to the incident. All staff confirmed they had taken written post-tests and were required to score 100 % before they were allowed to work. Staff interviews conducted across both shifts showed code pink drills had been conducted as documented. No irregularities were noted. 4. The surveyor reviewed all facility documentation of door and window checks performed as outlined in the POC. The Surveyor also reviewed QAPI sign in sheets and verified Ad Hoc teleconferences had occurred as reported by the Administrator. 5. The surveyor reviewed staff testing results related to all education given in response to the incident, which verified all staff were tested and all staff had scored 100%. 6. Medical record reviews for Resident #1 were performed and showed the resident did not suffer serious injury because of the incident, and only required minor first aid for superficial scrapes to his knuckles and right knee. 7. The facility elopement manual was observed at the nursing station on 5/12/2022 and was updated to reflect changes in Resident #1's condition and the updated assessments of other residents as documented in the POC. 8. Review of the facility staffing data for the prior 14 days along with observations of posted staffing levels on both the day and night shifts were conducted daily during the investigation. Posted staffing matched personnel observed on the clinical units and no irregularities were noted. No evidence of insufficient staffing/resident supervision was detected.

Based on review of facility policy, medical record reviews, review of the facility investigation, and interviews, the facility failed to prevent resident abuse for 1 resident (Resident #2) of 6 residents reviewed for abuse or neglect. Resident #1 struck Resident #2 in the face with a closed fist on the morning of 5/5/22, which caused Resident #2 psychosocial harm. The findings included: Review of the facility policy, Abuse, Neglect and Exploitation revealed .policy of this facility is to provide protections .that prohibit abuse .includes but is not limited to hitting, slapping, punching . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the hospice care plan and interdisciplinary team notes showed Resident #1 was under Hospice Care for end stage [CONDITION(S)] and cardiac disease since 7/5/2021 and had suffered a series of recurrent strokes in 2020 and 2021. Review of the hospice notes showed Resident #1's condition improved over the past several months, however he had cognitive limitations and a tendency to exhibit impulsive behaviors or to have poor safety awareness. Medical record review of the Nursing Notes and Care Plan for Resident #1 showed he was involved in one resident-to-resident altercation in January 2022. The care plan showed the resident had negative behaviors that included blocking other residents with his wheelchair, placing his feet on or in front of other wheelchairs, and taunting behaviors. Interventions included behavioral monitoring, redirection, and distraction-based interventions. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #1 was severely cognitively impaired, required extensive assistance with transfers, received tube feedings, was free of behaviors directed at self or others, was able to locomote about the facility in a wheelchair with set up assistance, and was dependent upon two persons for assistance with all other activities of daily living (ADLs). Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE] showed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired, with no history of behaviors or aggression. Resident #2 ambulated independently with a wheelchair and was dependent on minimal to moderate assistance of one person for ADLs. Review of the facility investigation showed on 5/5/2022 around 8:40 AM, at the conclusion of breakfast in the common dining area, Resident #2 was seated in his wheelchair outside the dining hall, conversing with a dietary staff member just inside the dining room door. Staff observed Resident #1 roll up beside Resident #2 in his wheelchair, then without provocation, strike Resident #2 in the right jaw with a clenched fist. Staff members present in proximity immediately intervened and separated Resident #1 from Resident #2 and took Resident #1 to his room where he was maintained on direct 1 to 1 supervision (1:1) as Emergency Medical Services (EMS) and Police were summoned to the facility. Resident #2 had X-rays of his face, jaw and neck taken after the incident, which showed no injury. Review of the facility investigation showed Resident #2's initial response to the attack, was to become briefly tearful, and his right jaw had a red mark on it where he was struck that resolved with no bruising noted. Review of the investigation revealed witness statements indicated Resident #1 was the aggressor and his actions were unprovoked by Resident #2. Resident #1 reported he willfully struck Resident #2 in retaliation because Resident #2 had stolen a potato chip bag clip from him 3 weeks prior. Interview with Certified Nurse Assistant (CNA) #1 on 5/11/2022 at 4:10 PM, in the conference room, revealed she witnessed Resident #1 hit Resident #2. CNA #1 reported she had just come on duty, and she saw Resident #1 draw back his fist, and CNA #1 immediately ran down the hall to intercede, as he struck Resident #2 in the face. CNA #1 reported she helped separate the two residents and confirmed the assault of Resident #2 by Resident #1 appeared unprovoked. CNA #1 reported she consoled Resident #2 as Resident #1 was taken away by other staff who responded. CNA #1 reported Resident #2 was initially tearful but calmed. Interview with CNA #2 on 5/11/2022 at 5:00 PM, in the conference room, revealed she was in the dining room near the residents with her back turned. CNA #2 reported she heard the incident occur but did not see it, turned to see multiple staff separating Resident #1 from Resident #2, and lent assistance. CNA #2 reported she consoled Resident #2 and gave him a piece of peppermint as he calmed down and helped him to his room where the nurse examined him. Interview with Resident #2 on 5/11/2022 at 5:20 PM, in the conference room, showed he was alert and oriented. Resident #2 recounted the incident and his account of what happened. Resident #2 denied he had spoken to Resident #1 before he was assaulted by him. Resident #2 also recounted 3 weeks prior to the assault, he had inadvertently taken a potato chip bag clip from Resident #1's room while visiting Resident #1's roommate, but it was returned. Resident #2 stated he had become tearful briefly as the blow initially hurt, but his tears were caused mostly by anger. Resident #2 stated he was initially frightened by the assault. Resident #2 then stated .after I calmed down, I wasn't afraid anymore. I started crying and stuff .it didn't last long .I had an X-ray after. It was fine .no problems .I was scared a little cause he just hit me. Didn't say nothing to him for that .I got real mad after he did that .I wanted to hit him back, but I didn't .I wasn't crying because I was scared. I was crying because I was mad. And when I get real mad like that, I cry .but I am not mad anymore, especially since he is gone . Interview with CNA #3 on 5/11/2022 at 5:32 PM, in the conference room, revealed she did not witness the assault, but removed Resident #1 to his room and then monitored Resident #1 after the assault. CNA #3 reported she asked Resident #1 why he hit Resident #2 and he responded, .[Resident #2] was talking[OBSCENITY]to me . CNA #3 reported earlier that morning, Resident #2 had summoned CNAs to his room and had Resident #1 removed from the doorway where he had parked his wheelchair, to permit Resident #2 to exit the room in his wheelchair. CNA #3 reported Resident #2 had asked Resident #1 to move from the doorway and he had not done so. CNA #3 speculated the assault may have been in retaliation to this request. Interview with the Director of Nursing (DON) on 5/12/2022 at 1:10 PM, in the conference room, confirmed the facility investigation determined Resident #1's assault of Resident #2 was a willful act and the facility had failed to prevent resident abuse.

Based on review of facility policy, review of the facility investigation, medical record review, observation, and interview, the facility failed to prevent abuse for one Resident (#1) of 6 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect, and Exploitation not dated showed .It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment .'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of a facility investigation dated 1/5/2022 showed .Resident #1 was struck in the face by Resident #2. The nurse assigned to both residents had just walked away from the nurses' station and did not witness an exchange of words or the event. A Certified Nursing Assistant [CNA] was nearby and witnessed only Resident #2 attempt to partially stand and swing at Resident #1 .Resident #1 is a hospice patient with a Brief Interview for Mental Status [BIMS] score of 15. When .[Resident #1] was interviewed he stated he did not remember calling .[ Resident #2] a [racial slur] but stated he may have accidentally done so .[Resident #1] did have a nosebleed from a small scratch on the right edge of his nose with no other injuries .[Resident #1] did not have a history of physical altercations but does have a history of verbally aggressive behavior .[Resident #2] had been identified as having poor judgement and will often not follow commands and will often be non-verbal .[Resident #2] did state in an interview that he hit .[Resident #1] because .[Resident #1] called him a [racial slur] .[Resident #2] does not have a history of physical altercations . Review of CNA #1's witness statement dated 1/5/2022 showed .I was setting doing my charting and was looking up threw [through] the glass windows in front of me and seen .[Resident #2] lunge at .[Resident #1] .[Resident #1] was caught off guard of the situation .[NAME] [heard] .[Resident #1] saying that he wasn't going to put up with .[Resident #2] hitting him . Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive care plan dated 4/16/2021 and revised on 6/28/2021 showed .is/has potential to be verbally aggressive and confabulation of facts and events .resisting care from staff, yelling, and cursing as well as wandering through the facility. The care plan was revised on 1/5/2022 .has experienced incident with another resident .Residents immediately separated, MD notified CBC [Complete Blood Count], BMP [Basic Metabloic Panel], UA [urinalysis] C&S [culture and sensitivity] ordered, Psych [psychiatric] evaluation with no medication changes. All staff educated to re-direct residents away from one another due to previous incident . Review of Resident #1's significant change in status MDS (Minimum Data Set) dated 11/13/2021 showed a BIMS score of 15 indicating the resident was cognitively intact, the resident had exhibited behaviors of physical behavioral symptoms directed towards others, verbal behaviors directed towards others, and rejection of care 4 to 6 days during the review period. Review of Resident #1's Progress Note dated 1/5/2022 at 11:00 AM, showed .Resident .was setting in his wheelchair in front of the window by the dayroom, Resident .[#2] rolled over to Resident .[#1] in his wheelchair and hit him in his face with his fist. Resident .[#1] picked up a chair and writer encouraged him to put it down . Review of Resident #1's Psych Progress Note dated 1/5/2022 showed .care was provided from a remote location .Staff contacted requestion evaluation post physical assault by another resident. Staff report that resident was sitting in his wheelchair when another resident hit him in the face with his fist causing nosebleed. At time of encounter resident is noted to be alert and oriented to person, place, and time. Spoke with resident who reports that he is unsure why the other resident assaulted him, reports that the other resident frequently aggravates him by blocking him with his wheelchair . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive care plan dated 12/18/2020 and revised on 6/24/2021 showed .has behavior problem non-compliant with food med [medications] positioning, removing PEG [percutaneous endoscopic gastrostomy] . The care plan was revised on 1/6/2022 and showed .incident with another resident .Residents separated immediately, resident 1 on 1 with Activities Assistant, MD notified with CBC, BMP, UA C&S ordered, Psych Evaluation with medication changes, Administrator monitored resident in dining room until night shift/hospice arrived for evaluation after 1 on 1 with Activities completed, Administrator assisted resident back to room after dinner per his request. All staff educated to re-direct residents away from one another due to previous incident . The care plan was revised on 1/11/2022 and showed .Psych referral sent to .Geri-psych unit and was denied as resident did not met criteria . Review of Resident #2's quarterly MDS dated [DATE] showed a staff assessment was completed for mental status showing no short or long-term memory problems. No behaviors were observed during the assessment period. Review of Resident #2's Progress Note dated 1/5/2022 at 10:28 AM, showed .Resident rolled his wheelchair over in front of the dayroom window where resident .[#1] was sitting in his wheelchair and hit him in the face . Review of Resident #2's Psych Progress Note dated 1/5/2021 showed .Staff contacted reporting that resident physically attacked a fell ow resident, hitting him in the face with fist causing nosebleed .Staff report that the resident told them the other resident was saying racial slurs and being verbally aggressive. Staff report that prior to physical assault resident [#2] saw the other resident [#1] laughing and felt that this was directed towards him, and that is when he hit him in the face with fist .At time of encounter resident does not verbally speak, he communicates by grunting and shakes/nods head to answer yes/no . During an interview with Registered Nurse (RN) #1 on 1/20/2022 at 10:00 AM, she stated .[Resident #1] was sitting across from the nurses' station in front of the day room window and .[Resident #2] was sitting at the nurses' station I had not heard them exchange any words. I had gotten up from the nurses and turned my back to them to go to the Cubex [medicine tower]. I heard a commotion Resident #1 said he hit me I came out of the Cubex room and .[Resident #1] had setting chair lifted to hit .[Resident #2] I ran over there and said put that down. And before I could get to him, he had sat the chair down. He said he hit me .[Resident #1] had a small scratch on the tip of his nose. I thought it was a nosebleed, but it wasn't it was just a small scratch. I wiped his nose and the bleeding stopped immediately. There was no bruising, swelling or redness .When I interviewed .[Resident #1] he denied calling .[Resident #2] a [racial slur] .[Resident #2] admitted to hitting .[Resident #1] because he had called him a [racial slur] . Observation of Resident #2 on 1/20/2022 at 10:30 AM, in his room, showed the resident to be seated in a wheelchair, the resident was awake and alert. No behaviors were observed. During an interview with Resident #2 on 1/20/2022 at 10:30 AM, in his room, showed the resident spoke soft, slow, in broken sentences with long pauses between remarks. He stated .dining room by door talking to .[Resident #3] .eating .[Resident #1] came up and said get your ass away [racial slur] didn't really pay attention, but he said it again that was earlier. I moved I finished breakfast. Sitting in front of window he was talking to somebody and laughing at me. He didn't call me any names just looking at me and laughing. I hit him in the nose . When surveyor asked did you mean to hit him, he said .hmm yes . The resident stated I'm alright now he felt safe in the facility, and he had not had any further problems with anyone including Resident #1. Observation of Resident #1 on 1/20/2022 at 11:00 AM in the day room with no one else present showed the resident to be seated in a wheelchair. Resident #1 was awake, alert and no scratch or redness was observed on the resident's nose. During an interview with Resident #1 on 1/20/2022 at 11:00 AM, in the day room, with no one else present, Resident #1 stated .he said I called him a [racial slur] and he hit me in the nose. I never said that to him. He kept pulling his wheelchair in front of me and wouldn't let me out of the dining room. Then when we were setting outside by the nurses' station he rolled over and hit me in the nose it didn't hurt .I just avoid him .I didn't call him no name or tell him to move I just kept trying to get around him . During the interview the resident stated he had not had any further problems with Resident #2, he felt safe in the facility, and he had no concerns. During an interview with Resident #3 on 1/20/2022 at 12:00 PM, in the sitting area, with no one else present, he stated he did recall the incident between Resident #1 and Resident #2.they are both crippled .[Resident #1] is a smart [NAME] .[Resident #2] raised up and socked him [Resident #1] in the nose. During the interview he stated he had been sitting with Resident #2 earlier in the dining room and he had not heard the two residents exchange words or Resident #1 call Resident #2 any names, and he had not previously heard Resident #1 say any racial slurs toward anyone .He [Resident #1] didn't call him [Resident #2] anything that I heard . During an interview with the Administrator on 1/20/2022 at 3:15 PM, she stated .the staff notified me of a resident-to-resident altercation at the nurses' station, I went to the nurses' station there were several staff members in the area, the residents had been separated. The nurse was assessing .[Resident #2] who had a scratch to his nose. I immediately interviewed .[Resident #2] I asked him what had happened he stated .[Resident #1] called him a [racial slur] and that he deserved it. Meaning that .[Resident #1] deserved being hit because he had called him that. I was not able to find any staff or resident who heard .[Resident #2] say any racial remarks. I then interviewed .[Resident #1] he stated he was just sitting at the nurses' station and .[Resident #2] rolled up and partially stood up and swung at him .[Resident #2] did make contact with .[Resident #1] resulting in a small scratch to the right edge of his nose. Then I interviewed the CNA that witnessed the incident she stated that she saw .[Resident #2] roll up towards .[Resident #1] attempt to partially stand and swing at .[Resident #1]. The CNA stated she did not witness any verbal communication or altercation prior to this incident .The nurse assigned to the residents stated she did not witness the verbal or physical altercation, but she did witness .[Resident #1] pick up a chair she then instructed .[Resident #1] to put the chair down .Both residents were taken to their rooms full body assessments were completed with no identified injuries to .[Resident #2] .[Resident #1] had a small scratch to the right edge of his nose with no other injuries .A couple of days later during my follow up visit . [Resident #1] stated he did not remember calling him names but that he could have . During the interview the Administrator confirmed Resident #2 had willfully hit Resident #1 and the facility failed to prevent abuse for Resident #1.

Based on review of a facility policy, medical record review, facility documents, and interviews, the facility failed to provide showers 2 times per week for 3 Residents (#1, #2, #3) of 8 residents reviewed for Activities of Daily Living. The findings included: Review of the facility's stated policy Activities of Daily Living Critical Pathway dated 5/2021 showed .Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the resident's choices and preferences . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's comprehensive care plan dated 5/27/2021 showed .requires assist with ADL's [Activities of Daily Living] r/t[related to] left BKA [below knee amputation] .Bathing per resident requested schedule(days of showers/baths .resident needs (extensive) assist of (1) for personal hygiene .Resident needs (total) with assist of (2) for transfers via Hoyer lift .Resident needs (total) assist of (2) for bathing . Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The resident required limited assistance of 2 for toilet use, extensive assistance of 2 for personal hygiene, and total dependence assist of two plus persons physical assist for transfer. The resident was frequently incontinent of bladder, and always incontinent of bowel. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive care plan dated 4/23/2021 showed .Resident requires assistance with ADLS .bathing per resident requested schedule (days of shower/baths) .extensive with 2 assist for personal hygiene .extensive assist of 2 for toileting .total with 2 assist for transfers using mechanical lift . Review of Resident #2's quarterly MDS dated [DATE] showed a BIMS score of 15 indicating the resident was cognitively intact. The resident was dependent with 2 plus person physical assist for transfers, extensive assist of 2 plus person physical assist for toilet use and personal hygiene and was always incontinent of both bowel and bladder. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's comprehensive care plan dated 12/10/2021 and revised on 4/27/2021 showed .Resident requires assist with ADL's .assist resident to be up in motorized wheelchair daily as tolerated .bathing per resident requested schedule (days of showers/baths) .resident needs extensive assist of 1 for personal hygiene .extensive assist of 2 for bathing .assist of 2 for toileting . Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 15, indicating the resident was cognitively intact. The resident required total assist of 2 plus persons for transfers, and extensive assistance of 2 plus persons for toilet use and personal hygiene. The resident was occasionally incontinent of bowel and bladder. Review of Resident #1's Point of Care Response History for Bathing/Showering dated 9/12/2021-10/9/2021 showed 9/12/2021-9/18/2021 Resident #1 had 1 documented shower. 9/19/2021-9/25/2021 Resident #1 had no documented shower. 9/26/2021-10/2/2021 Resident #1 had 3 documented showers. 10/3/2021-10/9/2021 Resident #1 had no documented showers. Review of Resident #2's Point of Care Response History for Bathing/showering dated 9/12/2021-10/9/2021 showed 9/12/2021-9/18/2021 Resident #2 had 1 documented shower. 9/19/2021-9/25/2021 Resident #2 had no documented shower. 9/26/2021-10/2/2021 Resident #1 had 2 documented showers. 10/3/2021-10/9/2021 Resident #1 had no documented showers. Review of Resident #3's Point of Care Response History for Bathing/showering dated 9/12/2021-10/9/2021 showed 9/12/2021-9/18/2021 Resident #3 had 2 documented showers. 9/19/2021-9/25/2021 Resident #2 had 1 documented shower. 9/26/2021-10/2/2021 Resident #3 had 2 documented showers. 10/3/2021-10/9/2021 Resident #3 had no documented showers. Review of a facility document CNA Daily Group Assignments showed Resident #1, Resident #2, and Resident #3 were scheduled to be offered a shower on Monday, Wednesday, and Friday on second shift. During an interview with Resident #1 on 10/13/2021 at 10:55 AM, she stated .I usually get 3 showers a week, but sometimes I don't. I haven't had a shower yet this week . During an interview with Resident #2 on 10/13/2021 at 11:15 AM, she stated .I am supposed to get a shower 2 times a week on second shift. I have gone 2 weeks without a shower before . During an interview with Resident #3 on 10/13/2021 at 11:25 AM, she stated .I have gone over a week before without a shower. I prefer showers 2 times a week, I don't think I get a bed bath . During an interview with the Administrator on 10/13/2021 at 4:25 PM, she stated .We follow the Activities of Daily Living Critical Pathway for our ADL policy. Which states ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the resident's choices and preferences. Residents are scheduled to be offered showers 3 times per week with the expectation they will receive a minimum of 2 showers/bed baths per week, based resident's preference . During the interview the Administrator confirmed Resident #1, Resident #2, and Resident #3 did not receive showers in accordance with acceptable standards of practice and the facility's expectation of residents receiving at least 2 showers and or bed baths per week during the last 30 days.

Based on review of facility policies, medical record review, review of facility investigation, interviews, and review of employee personnel files, the facility failed to ensure staff were adequately trained and could demonstrate the job skills necessary to provide safe transfers using a mechanical lift for 3 residents (Resident #1, Resident #3, and Resident #5) of 7 residents reviewed for transfers, resulting in Residents #1, #3, and #5 sustaining falls. The facility's failure placed Resident #1, Resident #3, and Resident #5 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 6/24/2021 at 2:20 PM, in the therapy gym (used as a conference room during the survey). The facility was cited Immediate Jeopardy for F-726 at a scope and severity of J. The IJ was effective 5/13/2021 - 6/24/2021 and was removed on 6/25/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/25/2021 at 2:00 PM, and the corrective actions were validated on-site by the surveyor on 6/25/2021. The findings included: Review of the facility's policy titled Accidents and Supervision, not dated, showed .each resident receives supervision and assistive devices to prevent accidents .Providing training as needed . Review of the facility's policy titled Lifting Machine-Using a Portable dated 12/2017 showed .To promote safe lifting procedures .The portable lift requires 2 people assist, that have completed competency training on the lift . Review of the facility's policy titled Orientation Policy, not dated, showed .Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities .checklists will be used to document training and competency evaluations conducted during the orientation process .A preceptor will be assigned to each new employee. This person is assigned oversight responsibility of the new employee and will facilitate completion of each employee's competency evaluation form .Each new employee is responsible for keeping track of his/her competency evaluation form throughout the orientation process .The preceptor, or designee, shall verify competency in each skill or content area at the time competency is demonstrated. The preceptor's initials/signature indicates competency .The completed form is forwarded to the Human Resource Director to place in the employee's personnel file .The completed form represents initial competency in the skills needed to care for residents and perform job functions . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation dated 6/10/2021 showed .a CNA [Certified Nursing Assistant] [CNA #1] and her spotter [CNA #2] were performing a Hoyer lift [mechanical lift] transfer with the resident [Resident #1] from the shower chair to the resident's bed. During the transfer, the spotter [CNA #2] stepped away upon hearing a resident call for assistance. The CNA [CNA #1] experienced difficulty maneuvering the Hoyer lift when she met resistance from the wall causing the lift to tilt and the resident to make contact with the floor . Review of Resident #1's Physician Documentation dated 6/11/2021, from Hospital #1, showed .patient fell from seated position, while transferring .and struck a tile surface .The patient sustained injury to the head, contusion, pain, swelling, tenderness .Noted is contusion of the right temple, swelling, of the right temporal area, right occipital area and right ear, tenderness of the right temple, above right ear, right lateral orbital above eyebrow, over right maxillary [MEDICATION(S)] . During an interview on 6/21/2021 at 10:32 AM, CNA #1 stated CNA #1 and CNA #2 were transferring Resident #1 from a shower chair to the bed using a mechanical lift when CNA #2 left the room to assist another resident. CNA #1 continued the transfer process alone and the mechanical lift .become unbalanced and it tipped sideways and the resident hit the floor .The lift was hovering over her, so I was pulling the lift so it didn't fall on her .I should have not continued the transfer when [CNA #2] left the room . During an interview on 6/23/2021 at 7:00 AM, Registered Nurse (RN) #1 stated CNA #2 had left the room and CNA #1 had continued to transfer the resident with the Hoyer lift by herself, resulting in the lift tilting and Resident #1 landing in the floor. During an interview on 6/23/2021 at 10:35 AM, RN #3 stated Resident #1 had swelling to the right side of her face. RN #3 stated .It is not okay for one CNA to leave the room during a mechanical lift transfer . Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Witnessed Fall report dated 6/15/2021 showed .Pt. [patient] reported that [CNA #1] and another girl [identified as CNA #5] were getting her ready for bed, transferring her from her wheelchair to her bed, Pt. reports they had her under each arm and her legs started to 'give out' . Review of a witness statement from CNA #1 dated 6/17/2021 showed On June 15, 2021, [CNA #5] and I were in [Resident #3]'s room to assist her back to bed. She was in her wheelchair with the Hoyer pad underneath her. The Hoyer pad was not underneath her the correct way. So [CNA #5] and I decided to 'two person' assist [Resident #3] into the bed. We got her up, but her legs started to give out so [CNA #5] and I slowly lowered her to the ground so she could sit up. Then we get the Hoyer lift pad and asked [Resident #3] if she could lay down and roll [to] her side to get the Hoyer pad under her. We got the Hoyer pad positioned correctly under her, and hooked the pad to the lift and lifted her into bed . During an interview on 6/21/2021 at 2:20 PM, CNA #1 stated .[Resident #3] was physically assisted to her wheelchair when we got her up [earlier in the day, 1st transfer of the day]. It was me and [CNA #3]. We physically assisted her to the wheelchair. We did put the lift sling in under her, but we did not have the lift sling positioned good. So when [CNA #5] and I were going to put her back in the bed [2nd transfer], we had to physically assist her again. When we got her up [CNA #5] wasn't strong enough and [Resident #3] couldn't help so we lowered her to the floor .I knew she was supposed to be transferred with a Hoyer lift . During observation and interview on 6/23/2021 at 8:45 AM with Resident #3, the resident stated .Some of the CNA's transfer me with the lift and some have [transferred] by holding me up under my arms . During an interview on 6/23/2021 at 10:00 AM, CNA #3 confirmed she was aware Resident #3 was to be transferred with a mechanical lift, but CNA #3 and CNA #1 did not use the mechanical lift for the first transfer that occurred on 6/15/2021. CNA #3 stated .I just didn't think about it placing [Resident #3] at risk for a fall . Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Witnessed Fall report dated 5/13/2021 showed .Resident sitting in the floor in front of wheelchair. CNA states 'we were unable to assist her back into the wheelchair, when she slid into the floor' . During an interview on 6/23/2021 at 3:30 PM, Licensed Practical Nurse (LPN) #1 stated .I was told by the CNA's [CNA #1, CNA #6] they were transferring her with the lift to her wheelchair. When they lowered her to the chair, they had sat her too close to the edge, and when they tried to physically pull her back in the wheelchair, the resident had slid to the floor . During an interview on 6/21/2021 at 10:32 AM, CNA #1, who was involved in the transfer procedure for Resident #1 on 6/10/2021, two transfer procedures for Resident #3 on 6/15/2021, and the transfer procedure for Resident #5 on 5/13/2021, stated .I had received training on the Hoyer lift from my CNA classes and another facility. I have not received training from this facility on the use of a mechanical lift for transfers, and I have not received a CNA Competency Skills Check List to be checked off on . Review of CNA #1's personnel file showed her hire date as 4/19/2021. The personnel file did not contain a CNA Skills Check List for competencies and no documentation the CNA had received training on transferring of a non-ambulatory resident from chair to bed and bed to chair. Interview with the Administrator or 6/21/2021 at 3:34 PM, confirmed CNA #1 had not received competency training on transferring a non-ambulatory resident using the mechanical lift. During an interview on 6/21/2021 at 3:50 PM, the Employee Relations Leader (ERL) stated .the process for hiring is the candidate completes an application, we do reference checks, background check, TB [Tuberculosis] skin test, drug test, and we bring the candidate in for paperwork. They complete training on [facility's training website] .the competency skills check off list is given to the employee during the hiring process .they have 30 days to have the competency skills checked off as demonstrated correctly and give it back to me. This is for all clinical staff .We were without an ERL when [CNA #1] was hired and she fell through the cracks . During an interview with CNA #4 on 6/24/2001 at 12:30 PM, she stated .I did not receive a CNA competency check list when I was hired. I received training on using the Hoyer lift on 6/11/2021 .my competency skills check off was done on 6/22/2021 . Review of 23 active employee files on 6/24/2021 - 6/25/2021 showed 4 CNA's (CNA #1, CNA #4, CNA #9, and CNA #10) had not completed their competency skills within 30 days of being hired. During an interview on 6/24/2021 at 11:20 AM, the Administrator stated the facility procedure for licensed staff and CNAs was for the employee to receive a blank skills competency check list (which included training on transferring non-ambulatory residents using the Hoyer lift) upon hire. The employee was responsible for ensuring all competencies were met and having the trainers initial on each competency. The form was to be returned to the Human Resource (HR) Department within 30 days of the employee's hire date. The Administrator confirmed CNA #1, CNA #4, CNA #9, and CNA #10 had not completed skills competencies within 30 days of being hired. The facility's Removal Plan included the following: Audit of current resident transfer status was completed on 6/12/2021 with IDT (interdisciplinary team) review of 100% of residents. IDT in attendance consisted of Regional Director of Clinical Service, Life Enrichment Director/Nursing Assistant, Director of Rehabilitation, and the Administrator. IDT utilized current Resident Roster, medical records, therapy documentation, and reviewed residents' transfer status (mechanical lift versus non mechanical) and discussed if there were any significant mobility/transfer status changes. Then IDT ensured Care plans and Kardex (summary of care plan) were reflective of transfer status as discussed. One resident required care plan update to reflect current transfer status. IDT meeting was verified by staff signatures and review of the resident roster utilized during the meeting showed each resident had been reviewed. Six resident care plans were reviewed to verify the discussed resident transfer method matched the care plan. Interviews obtained from 6 CNA's confirmed they were aware of the resident Kardex system and confirmed the Kardex contained information related to the resident's care, including the assistance the resident needed with ADL's. Beginning 6/11/2021, current clinical staff were educated on use of the mechanical lift with return demonstration to ensure staff were adequately trained to provide safe care to the residents, completed 6/20/2021. Education was verified by cross referencing the facility's Active Employee List dated 6/24/2021 with the signed in-service and return demonstration sheets dated 6/11/2021-6/15/2021, and interviews with 6 CNA's, 4 LPNs, and 1 RN. Two clinical staff members were found to have not completed the education - 1 CNA who was on leave and one RN who worked PRN (as needed) and had not worked since the training was completed and was not scheduled to work. To monitor and improve systems related to Nursing Services Skills/Competencies and Orientation, the facility had pre-arranged for training of the new HR Coordinator on 6/18/2021. 100% Clinical staff file audits were initiated 6/21/2021 for completed competencies by the HR Trainer and new HR Coordinator. Audit was completed by 6/24/2021 with some files lacking completion and the employees were required to complete prior to working their next shift. Director of Nursing and/or designee completed competencies. To ensure future compliance, the HR Coordinator and Administrator will review new hire files within first 30 days of hire to assure completed skills check off list. If any discrepancies, then employee must complete prior to working next shift. Review of the facility's new hires from 3/1/2021-6/21/2021 identified 15 clinical staff had been hired since 3/1/2021. Of the 15 clinical staff members, 4 were identified as not completing skills competencies withing 30 days of being hired and were required to complete competencies prior to working their next shift. Nine clinical staff members had not completed skills competencies but were within 30 days of being hired. Two clinical staff members had completed skills competencies within 30 days of being hired. Surveyor conducted 100% audit of clinical staff who had not completed skills competencies. Completion of competencies was confirmed by review of completed skills competencies check lists with trainer initials and interviews with 3 clinical staff on completion of skills competency check lists. Observation of Resident #2 on 6/21/2021 at 10:50 AM, in her room, with CNA # 3 and CNA #4, showed the resident being transferred from her bed to her wheelchair. Both CNAs followed the manufacturer's recommendations for the Hoyer lift for transferring a resident from the bed to a chair. Observation on 6/25/2021 at 1:30 PM, with CNA #7 and CNA #8 in an empty resident room, utilizing the Rehab Manager as a resident, showed the CNAs utilized the Hoyer lift according to the manufacturer's recommendations for transferring a non-ambulatory resident from the bed to the chair and from the chair to the bed. Noncompliance at F-726 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-689.

Based on review of facility policies, medical record review, review of facility investigations, observations, and interviews, the facility failed to utilize safe transfer techniques for 3 residents (Resident #1, Resident #3, and Resident #5) of 7 residents reviewed for transfers, resulting in Residents #1, #3, and #5 sustaining falls. Resident #1 was being transferred with a mechanical lift by Certified Nursing Assistant (CNA) #1 and #2 when CNA #2 left the room and CNA #1 completed the 2-person transfer alone, resulting in the mechanical lift tipping over. Resident #1 was dropped to the floor and sustained facial swelling. Resident #3 required a mechanical lift for all transfers. CNA #1 and #5 were transferring Resident #3 from the wheelchair to the bed by holding the resident under the arms, instead of using the mechanical lift. The resident's legs gave out and Resident #3 had to be lowered to the floor. Resident #5 was being transferred from the bed to the wheelchair with a mechanical lift by CNA #1 and #6 when the CNAs positioned the resident too close to the edge of the wheelchair and the resident slid to the floor. The facility's failure to provide safe transfers placed Residents #1, #3, and #5 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 6/24/2021 at 2:20 PM, in the therapy gym (used as a conference room during the survey). The facility was cited F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 5/13/2021 - 6/24/2021 and was removed on 6/25/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/25/2021 at 2:00 PM, and the corrective actions were validated on-site by the surveyor on 6/25/2021. The findings included: Review of the facility's policy titled Accidents and Supervision, not dated, showed .The resident environment remains as free of accident hazards as is possible; and each resident receives supervision and assistive devices to prevent accidents .using specific interventions to try to reduce a resident's risk from hazards . Review of the facility's policy titled Lifting Machine-Using a Portable dated 12/2017 showed .To promote safe lifting procedures .The portable lift requires 2 people assist .To transfer a resident from a bed to a chair, you should Position the chair. If it is a wheelchair, be sure the wheels are locked .Roll the resident toward you on his or her side. Place the sling, fan-folded along the back of the resident. (Note: Be sure the top of the sling is at the head of the resident and the bottom at the resident's knees.). Roll the resident to the other side and position the sling flat on the bed. Attach the hooks to the sling .Bring the lifter into position over the resident. Be sure the arm of the lifter is in the low position. Attach the sling to the lift .Instruct the resident to fold both arms across his or her chest, if possible. Using the device raise the resident from the bed. Assist the resident in moving his or her legs off the bed. Move the lift away from the bed. Be sure that the resident is turned in such a manner that he/she is facing you. Do not pull the resident backwards. Position the lift over the chair. Be sure that the resident is positioned over the seat of the chair. To position the resident comfortably in the chair, grasp the top of the sling with one hand and pull back on the sling while lowering the resident into the chair. (Note you can also push gently on the resident's knees while lowering the resident into the chair.) Be sure the resident is comfortable. Remove the hooks from the lift. Remove the lifter. Remove the hooks from the sling .To put the resident back to bed, you should: Attach the hooks to the sling .Bring the lifter into position over the resident. Be sure the lifter is in the low position. Attach the sling to the lift. Instruct the resident to fold both arms over his or her chest, if possible. Using the device, raise the resident from the chair. Assist the resident in guiding his or her legs. Move the lift away from the chair. Be sure the resident is turned in such a manner that the resident is facing you. Do not pull the resident backwards. Position the lift over the bed. Lower the resident into the center of the bed. Remove the hooks from the lift. Remove the hooks from the sling. Remove the sling from under the resident. Remove the lifter. Position the resident in a comfortable position . Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (stroke), Non-traumatic Subdural Hemorrhage (bleeding in the brain), [CONDITION(S)] (fluid on the brain), Dysphagia (trouble swallowing), [CONDITION(S)] (one sided paralysis), Compression of Brain, and Seizures. Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The MDS indicated transfer activity had not occurred during the assessment period. Review of Resident #1's Nurse's Note dated 6/10/2021 at 10:30 PM, showed .Hoyer lift [mechanical lift] tilted and fell over while patient was in sling of lift. Patient without any injury, didn't hit head during fall. Pt [patient] reports she hit the right side of her face. No redness, bruising or swelling present . Review of Resident #1's Witnessed Fall report dated 6/10/2021 showed .Patient [Resident #1] was in Hoyer lift being put back to bed after her shower when lift tilted and fell over while patient was still in lift sling . Review of a facility investigation dated 6/10/2021 showed .a CNA [CNA #1] and her spotter [CNA #2] were performing a Hoyer lift transfer with the resident [Resident #1] from the shower chair to the resident's bed. During the transfer, the spotter [CNA #2] stepped away upon hearing a resident call for assistance. The CNA [CNA #1] experienced difficulty maneuvering the Hoyer lift when she met resistance from the wall causing the lift to tilt and the resident to make contact with the floor . Review of CNA #1's Investigation Statement dated 6/11/2021 showed .Using Hoyer lift to transfer resident [#1] from shower chair to bed .[CNA #2] was in the room with me when I started to lift resident. He left to help another resident. I went to pull her back with back of her pad to get her feet around the middle pole because the top of the lift wouldn't spin, and the lift flipped over completely. She hit on her right side but then landed on her back. Still laying on the shower pad we unhooked the pad from the lift and lifted her with the pad back into bed .As soon as it happened [Registered Nurse (RN) #1] heard the lift fall and came into the room . Review of Resident #1's Nurse's Note dated 6/11/2021 at 9:00 AM, showed .This nurse went in to assess resident. Upon assessment bump noted to right side of head and face with swelling noted, speech slightly slurred with change mental status with increased confusion noted. MD [Medical Doctor] notified with new order received to send to ER [emergency room ] for further evaluation . Review of Resident #1's Nurse's Note dated 6/11/2021 at 10:30 PM, showed .Resident sent out to hospital .per MD request. Resident had a fall at approximately 8:00 PM in her room on 6/10/2021. Resident has a bump on the right side of the head. Resident presents with confusion and slightly slurred speech . Review of Resident #1's Physician Documentation dated 6/11/2021 from Hospital #1 showed .patient fell from seated position, while transferring .and struck a tile surface .The patient sustained injury to the head, contusion, pain, swelling, tenderness .Noted is contusion of the right temple, swelling, of the right temporal area, right occipital area and right ear, tenderness of the right temple, above right ear, right lateral orbital above eyebrow, over right maxillary [MEDICATION(S)] .Per Radiologist's finding(s) .extensive postsurgical [surgery prior to admission to the nursing home] changes of the right cerebral hemisphere temporal lobe of uncertain etiology or significance. There are subtle areas of high attenuation within this region which may reflect postsurgical change. Minimal subarachnoid hemorrhage not as clearly correlation and follow-up is recommended .Disposition Summary: Diagnosis: Traumatic subarachnoid hemorrhage . Hospital #1 transferred Resident #1 to Hospital #2 for further evaluation. Review of Resident #1's After Visit Summary from Hospital #2 dated 6/11/2021 showed .Your CT [Computed Tomography] does not show any injury or intracranial bleed .Use a helmet to prevent other unintentional injury to your head with your missing skull bone flap [prior to admission to the nursing facility] .Imaging Results .CT brain without IV contrast .1. No acute intracranial hemorrhage identified 2. Postoperative changes of right hemicraniectomy with extensive encephalomalacia throughout the right MCA [middle cerebral artery] and portions of the right PCA [posterior cerebral artery] vascular territories. 3. Aneurysm clip in the expected location of the right posterior communicating artery 4. Partially 1.2 cm [centimeter] calcified mass in the inferomedial aspect of the right orbit is unchanged from exams dating back to 10/27/2020 . Resident #1's care plan was revised on 6/12/2021 to include, .Resident requires assistance with ADL's [Activities of Daily Living] R/T [Related to] decreased mobility and functionality secondary to [CONDITION(S)] [paralysis on one side] .needs (total/maximum assistance) with (2) assist for transfers using Hoyer lift . The care plan was updated again on 6/14/2021, .Resident to wear padded helmet when oob [out of bed] when resident will allow . During an interview on 6/21/2021 at 10:32 AM, CNA #1 stated .we had gotten [Resident #1] out of the shower and taken her to her room. She was still in the shower chair. I opened the legs on the lift and locked it. I hooked the sling straps to the Hoyer lift. As I lifted her and she was in the air, [CNA #2] pulled the shower chair out of the way. While she was still in the air, [CNA #2] heard another resident's call light [for another] resident who needed assistance .so he left the room. I proceeded to go ahead and put [Resident #1] in the bed. She [Resident #1] was complaining of being cold. Her feet were on the left side of the lift pole. I took a hold of the handles on the back of the pad, and I pulled out to get her feet across the pole. The right lift leg was against the wall, which caused the lift to become unbalanced and it tipped sideways and the resident hit the floor .The lift was hovering over her, so I was pulling the lift so it didn't fall on her .[CNA #2] heard the noise and came back in. We unhooked the straps from the lift and l pulled the lift back up .I should have not continued the transfer when [CNA #2] left the room . Observation and interview on 6/21/2021 at 11:45 AM with Resident #1, showed the resident was sitting upright in the bed and was awake and alert. The resident was unable to recall the specifics of the incident but stated, .back from the shower .was just a sophisticated machine . During an interview on 6/23/2021 at 7:00 AM, RN #1 stated .the CNA's [CNA #1, CNA #2] had brought back [Resident #1] from the shower and were transferring back to the bed. [CNA #2] had left the room and [CNA #1] had continued to transfer the resident with the Hoyer lift by herself. The lift tilted over and [Resident #1] landed in the floor . During an interview on 6/23/2021 at 10:35 AM, RN #3 stated .I was here when she [Resident #1] returned [from the hospital] .The right side of her face around her ear level had noticeable swelling. I guess it would have been a moderate amount .Dr [doctor] .ordered for a follow up CT [Computed Tomography] .It is not okay for one CNA to leave the room during a mechanical lift transfer . During an interview on 6/23/2021 at 12:30 PM, the Medical Director stated .The DON [Director of Nursing] contacted me the morning after [Resident #1's] fall. The DON had received in report the night before the resident was not injured, she had not hit her head, and was in no pain. The next morning when the DON went in to check on her [Resident #1], she identified swelling to the right side of her face. It was hard to evaluate her due to her history of neuro [neurological] injury, so I instructed the DON to send her to the hospital for evaluation. Initially the hospital reported a subarachnoid hemorrhage. They sent her to the second hospital for further evaluation. The records from the second hospital showed no changes from her scans in October [2020] .Neurologically there were no changes .God was with us, it could have been worse . Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including [CONDITION(S)] ([CONDITION(S)]), Chronic Pulmonary [CONDITION(S)], Congestive Heart Failure (CHF) Stage 5, Chronic Kidney Disease (CKD), Abnormalities of Gait, and Lack of Coordination. Review of Resident #3's comprehensive care plan dated 12/22/2020 and revised on 3/8/2021 showed .Resident requires assistance with ADL's r/t [related to] [CONDITION(S)], CHF, CKD .Resident needs 2 person assist [assistance] with mechanical lift for transfers . Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 15, indicating the resident was cognitively intact. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of a Witnessed Fall report for Resident #3 dated 6/15/2021 at 2:32 PM, showed .Pt. [patient] reported that [CNA #1] and another girl [identified as CNA #5] were getting her [Resident #3] ready for bed, transferring her from her wheelchair to her bed, Pt. reports they had her under each arm and her legs started to 'give out' .Pt. reports that she was lowered to the ground by the staff. She reports, 'I am not hurt' Adamantly denies hitting her head .Full body assessment and vitals taken .Transfer training per therapy initiated .No injuries at time of incident . Review of Resident #3's Nurses' Note dated 6/15/2021 at 11:40 PM, showed .CNA's reported that patient says she fell on 2nd shift. Nurse to room to examine patient for injuries. Denies any pain .Patient was asked by myself to tell me what happened earlier today when she fell . Pt reports that [CNA #1] and another girl were getting her ready for bed, transferring her from her wheelchair to her bed, Pt reports they had her under each arm and her legs started to give out. Pt reports that she was lowered to the ground by the staff. She reports, I'm not hurt. Full body assessment done no new areas found .Patient was adamant she didn't hit her head, head checked anyway for hematomas-nothing noted . Review of a witness statement from CNA #1 dated 6/17/2021 showed On June 15, 2021, [CNA #5] and I were in [Resident #3]'s room to assist her back to bed. She was in her wheelchair with the Hoyer pad underneath her. The Hoyer pad was not underneath her the correct way. So [CNA #5] and I decided to two person assist [Resident #3] into the bed. We got her up, but her legs started to give out so [CNA #5] and I slowly lowered her to the ground so she could sit up. Then we get the Hoyer lift pad and asked [Resident #3] if she could lay down and roll [to] her side to get the Hoyer pad under her. We got the Hoyer pad positioned correctly under her, and hooked the pad to the lift and lifted her into bed . During an interview on 6/21/2021 at 2:20 PM, CNA #1 stated .[Resident #3] was physically assisted to her wheelchair when we got her up [1st transfer at the beginning of the day, prior to the transfer resulting in the fall]. It was me and [CNA #3]. We physically assisted her to the wheelchair. We did put the lift sling in under her, but we did not have the lift sling positioned good. So when [CNA #5] and I were going to put her back in the bed [later in the day, the 2nd transfer of the day], we had to physically assist her again. When we got her up [CNA #5] wasn't strong enough and [Resident #3] couldn't help so we lowered her to the floor .I knew she was supposed to be transferred with a Hoyer lift . During observation and interview on 6/23/2021 at 8:45 AM with Resident #3, the resident was in a wheelchair, awake and alert. The resident stated .I don't really think I fell . I just sat down in the floor. I wasn't hurt. I didn't have time to be scared at the time. The girls were transferring me by holding me up under my arms and my legs just gave out. They are just like spaghetti. Some of the CNAs transfer me with the lift and some have [transferred] by holding me up under arms, lately they have used the lift. I haven't had any falls like that before . During an interview on 6/23/2021 at 10:00 AM, CNA #3 stated .no we did not use the lift when we transferred [Resident #3] to her wheelchair [1st transfer of the day]. I knew she was a Hoyer lift transfer, but we were in a hurry because the bus was here to get her for [CONDITION(S)] .I just didn't think about it placing [Resident #3] at risk for a fall . During an interview on 6/23/2021 at 7:00 PM, RN #1 stated .She [Resident #3] told me her legs just gave out and the girls sat her in the floor .Yes I was told they did not use the Hoyer lift for the transfer . Resident #5 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and Reduced Mobility. Review of Resident #5's admission MDS dated [DATE] showed a BIMS score of 10, indicating the resident had moderate cognitive impairment. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #5's comprehensive care plan dated 4/23/2021 and revised on 5/13/2021 showed .Resident requires assistance with ADL's R/T [CONDITION(S)], Chronic Obstruction Pulmonary Disease [[CONDITION(S)]], and Arthrodesis [surgical immobilization of bones] .Resident needs extensive [assistance] with 2 assist for transfers using mechanical lift .Resident is at risk for falls r/t [CONDITION(S)] [Hypertension], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Reduced Mobility . Review of a Witnessed Fall report for Resident #5 dated 5/13/2021 showed .CNA called nurse to room. Resident sitting in the floor in front of wheelchair. CNA states 'we were unable to assist her back into the wheelchair, when she slid into the floor' .Resident states 'I didn't fall, I just slid into the floor onto my butt.' .Resident positioned back into bed via Hoyer lift, care plan for dycem [nonslip pad] in wheelchair .No Injuries observed at time of incident .Environmental factors: None .Predisposing Situation Factors: During transfer . Review of a Nurses' Progress Note dated 5/13/2021 showed .CNA called nurse to room. Resident observed to be sitting in front of wheelchair on the floor with two aides on each side of her. CNA states, .We were unable to pull her back in her wheelchair and when we tried to straighten her, she slid into the floor .Resident denies any out of the ordinary pain. Head to toe completed. No new injuries apparent. VSS [vital signs stable] . Review of a Nurses' Progress Note dated 5/14/2021 showed .Denies any injury or pain from sitting down in floor yesterday. Continues to move all extremities as before being sat down in floor . During an interview on 6/23/2021 at 3:30 PM, Licensed Practical Nurse (LPN) #1 stated .I was told by the CNAs [CNA #1, CNA #6] they were transferring her with the lift to her wheelchair. When they lowered her to the chair, they had sat her too close to the edge, and when they tried to physically pull her back in the wheelchair, the resident had slid to the floor . During observation and interview on 6/23/2021 at 3:45 with Resident #5, the resident was awake and alert and lying in a bariatric bed. The resident stated .It was a while ago, but as I recall, they couldn't get me in my wheelchair right. I was just too close to the edge and when they tried to scoot me back in the wheelchair, I just slid out in the floor . During an interview on 6/24/2021 at 11:30 AM, the Administrator confirmed the facility failed to provide safe transfers for Resident #1, Resident #3, and Resident #5, resulting in each resident's fall. The facility's Removal Plan included the following: On 6/11/2021, the Administrator was notified of an inappropriate lift transfer for Resident #1 and suspended CNA #1 and #2 pending investigation, as well as initiated education related to mechanical lifts. CNA #1 and #2 are no longer employed. Review of the facility's Active Employee List dated 6/24/2021 confirmed CNA #1 and CNA #2 were no longer employed at the facility. On 6/11/2021, the Director of Nursing and clinical designees initiated education with clinical staff (Nurses and Nursing Assistants) on mechanical lift procedures. Education inclusive of: Positioning of Resident, Sling, Bed and or Chair; appropriate way to adhere hooks; always assure two staff members for lifts; and ensure resident feels safe. Clinical staff education on mechanical lifts was completed by 6/20/2021. Administrator crossed referenced current staff roster and signed in-service forms to assure 100% education. Surveyors verified education was completed by cross referencing the facility's Active Employee List dated 6/24/2021 with the signed in-service sheets dated 6/11/2021-6/15/2021, and by interviews with 6 CNA's, 4 LPN's, and 1 RN. Two clinical staff members were found to have not completed the education - 1 CNA who was on leave and one RN who worked PRN (as needed) and had not worked since the training was implemented and was not currently scheduled for work. Director of Nursing or designee will assure care plans reflect accurate transfer methods. Director of Nursing and clinical designees will observe and document ten resident transfers per week for four weeks, then five transfers per week for four weeks. Audits/observations were initiated 6/17/2021 with trained experienced Nursing Assistant (as Train the Trainer), Director of Nursing, Assistant Director of Nursing and Director of Rehabilitation. Results of audit: 1 transfer was halted with direction given to staff; further observations had no concerns noted. Surveyors verified audits by review of completed audits dated 6/17/2021-6/19/2021 with a concern reported on 6/17/2021 with one transfer. It was confirmed with CNA #3 the transfer was stopped and education was provided, and completed audits dated 6/21/2021-6/24/2021 showed no concerns. Observations/audits will be reviewed during Quality Assurance and Performance Improvement (QAPI). Any concerns identified will be addressed immediately and reviewed during QAPI. Initial Ad Hoc QAPI occurred 6/11/2021, with next quarterly review 6/30/2021, and quarterly thereafter for continued review of Mechanical Lifts, Nursing skills/competency, and other improvement plans. Observation of Resident #2 on 6/21/2021 at 10:50 AM, in her room, with CNA # 3 and CNA #4, showed the resident being transferred from her bed to her wheelchair. Both CNAs followed the manufacturer's recommendations for the Hoyer lift for transferring a resident from the bed to a chair. Interview with the Medical Director on 6/23/2021 at 12:30 PM, confirmed he was involved in the Ad Hoc meeting held on 6/11/2021 and participated in the quarterly QAPI meetings in person or by telephone. This was also confirmed by presence of his signature. Observation on 6/25/2021 at 1:30 PM, with CNA #7 and CNA #8 in an empty resident room, utilizing the Rehab Manager as a resident, showed the CNAs utilized the Hoyer lift according to the manufacturer's recommendations for transferring a non-ambulatory resident from the bed to the chair and from the chair to the bed. Noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on observation and interview, the facility failed to timely repair an air condition ventilation system in 1 of 1 dietary department to prevent water from dripping onto the kitchen ceiling and drywall in the walk in cooler and dry storage area. The findings included: Observation of the dietary department on 6/9/2021 between 1:00 and 1:20 PM showed drywall damage and yellow stains on the ceiling above the walk-in cooler unit. Continued observations inside the dry storage area adjacent to the walk-cooler showed drywall damage and yellow stains extending inside the room around the air conditioning ventilation system located in the front corner of the dry storage area. Continued observations showed water was dripping from the air conditioning ventilation system onto sealed plastic bags of plastic utensils and sealed plastic bins of paper goods and emergency supplies stored in the dry storage area and were available for resident use. During an interview on 6/9/2021 at 1:30 PM, the Maintenance Director confirmed a malfunction in the air conditioning drainage system had led to condensation forming in the ceiling above the dry storage area, which had caused the leak The Maintenance Director confirmed the issue had existed for a month but had not yet been repaired.

Based on facility policy review, medical record review, observation, and interview, the facility failed to obtain a Physician's order for the use of [REDACTED]. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Oxygen Administration dated 10/2010 revealed .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Medical record review of the Comprehensive Care Plan dated 5/29/19 revealed .Administer/monitor effectiveness of treatments .Oxygen . Medical record review of the Significant Change of Status Minimum (MDS) data set [DATE] revealed Resident #4 received oxygen therapy. Medical record review of the Physician Orders dated 9/2019 revealed no order for oxygen therapy. Observation of Resident #4 on 9/22/19 at 9:45 AM, in resident's room, revealed the resident lying in bed with oxygen administered via nasal cannula at 2 liters per minute. Observation of Resident #4 on 9/22/19 at 1:35 PM, in resident's room, revealed the resident lying in bed with oxygen administered via nasal cannula at 2 liters per minute. Interview with the Director of Nursing (DON) on 9/22/19 at 1:40 PM, in the resident's room, confirmed Resident #4 was receiving oxygen at 2 liters per minute. Continued interview with the DON confirmed Resident #4 had no Physician's order for the use of [REDACTED]

Based on medical record review, facility investigation, observation, and interview, the facility failed to ensure the safety of 1 resident (#10) of 5 residents for accidents. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan, dated 1/17/19, revealed interventions for .ADLs (Activities of Daily Living) = Dependent on staff assistance for ADL's r/t (related to) to maintain daily needs .Bed Mobility: Two person extensive assistance . Medical record review of a Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Continued review revealed Resident #10 required extensive 2 person physical assist for bed mobility. Medical record review of a progress note dated 7/8/19 revealed, .CNA (Certified Nursing Assistant #1) called nurse to room .CNA reported to this nurse while giving .bed bath .resident was rolled .left leg began to slide over the side .slid onto the floor . Review of a fall investigation dated 7/9/19 revealed .Skin tear to upper right side, under breastbone and lower right abdominal folds .intervention .staff education .2 person assist c (with) toileting/changing/bed bath . Observation and interview with Resident #10 on 09/22/19 at 9:24 AM, in her room, revealed she had fallen out of bed when only one CNA was performing ADL care. Interview with Director of the Nursing (DON) on 9/23/19 at 2:30 PM, in the Administrators office, confirmed Resident #10 was an extensive 2 person assist with bed mobility prior to fall on 7/8/19. Continued interview confirmed Resident #10 on 7/8/19 was given a bed bath without 2 staff members present resulting in a fall. Telephone interview with CNA #1 on 9/23/19 at 3:18 PM, confirmed she provided personal hygiene care for Resident #10 on 7/8/19, without assistance from other staff resulting in a fall.

Based on facility policy review, medical record review and interview the facility failed to ensure pneumococcal vaccinations were administered to 4 residents (#6, #7,#11, #13) of 5 residents reviewed for vaccinations. The findings include: Review of the facility policy, Pneumococcal Vaccine revised 8/2016 revealed .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 3/26/18 revealed the consent was signed to receive the pneumonia vaccination. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 3/26/18 revealed the consent was signed to receive the pneumonia vaccination. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 4/5/18 revealed the consent was signed to receive the pneumonia vaccination. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Influenza, Pneumonia Vaccine Consent/Declination form dated 4/13/18 revealed the consent was signed to receive the pneumonia vaccination. Interview with the Director of Nursing (DON) on 11/28/18 at 1:45 PM, in the conference room, confirmed the facility failed to administer the pneumococcal vaccinations as per the facility policy.