Every finding on record at Enterprise Health & Rehabilitation Center

Based on interviews, resident's medical records, review of Facility Reported Incidents (FRIs) received by the State Agency, the facility's investigative files, and facility policies titled Abuse, Neglect, and Exploitation, Social Media Use, Cell Phones, and Confidentiality Statement, the facility failed to protect the residents' right to be free from sexual abuse perpetrated by other residents, physical abuse perpetrated by other residents, and exploitation/mental abuse perpetrated staff. Specifically:1. On 02/11/2025 the facility failed to protect Resident Identifier (RI) #168's right to be free from sexual abuse. On 02/11/2025 around 7:30 PM, Certified Nursing Assistant (CNA) #13 was making rounds on the Memory Care Unit (MCU) and observed RI #168 sitting on RI #97's bed. CNA #13 observed RI #97 fondling RI # 168's genitalia with his/her hand in RI #168's brief. RI #168 had history of wandering into other residents' rooms. RI #97 had a known history of touching staff in a sexually inappropriate manner. Following the incident RI #97 was transferred off of the MCU and was moved back to the MCU on 03/05/2025.It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation.On 01/16/2026 at 6:30 PM, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Assistant Administrator were provided a copy of the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on 02/11/2025 and continued until 01/18/2026 when the survey team verified that onsite corrective actions had been implemented.2. The facility further failed to protect RI #143 from mental abuse/exploitation when a photograph of the resident in a vulnerable position was shared on a social media site without the resident's knowledge or consent. The photo did not include the resident's face or genitalia.3. The facility failed to protect RI #11's right to be free from physical abuse perpetrated by RI #169. On 01/05/2026 CNA #17 witnessed RI #169 physically abuse RI #11 when he/she hit RI #11 on the arm in the dining room. RI #169 had a history of aggressive behaviors, which included verbal and physical aggression. The facility failed to provide adequate supervision and interventions for RI #169 to prevent other residents from being abused. RI #11 stated his/her arm hurt after being hit by RI #169.These deficient practices were cited as a result of the investigations of facility reported incident/complaint/report numbers 471526 and 271095.These failures affected five of six residents reviewed for abuse concerns during the survey. Findings include: Cross Reference F607 and F867. Review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implemented date of 04/04/2018, and a revised date of 01/01/2024, revealed: Policy: It is the policy of the facility to provide 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. Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse is non-consensual sexual contact of any type with a resident. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). Alleged Violation is a situation that is observed or reported by staff, resident. or others but has not yet been investigated and, if verified, could be indication of noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse. of residents. c. Include training for new and existing staff on activities that constitute abuse, . exploitation. dementia management and resident abuse prevention. 3. The facility will provide ongoing oversight and supervision and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: 1. Screening . B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. 1. An assessment of the individual's functional and mood/behavior status. and special needs will be reviewed prior to admission. 2. The facility will make individual determinations in consideration of current staffing patterns, . physical environment. II. Employee Training . C. Training topics will include: 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering. c. Resistance to care d. Outburst or yelling out. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent all types of abuse. and exploitation. establishing policies and protocols for preventing sexual abuse. A. Establishing a safe environment.establishing policies and protocols for preventing sexual abuse. B. Identifying, correcting and intervening in situations in which abuse.is more likely to occur. C. Assuring an assessment of the resources needed to provide care and services . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. On 02/11/2025 at 9:47 PM the State Agency received a Facility Reported Incident (FRI) alleging that RI #97 was in his/her room and was observed with his/her hand in the brief of RI #168. RI #97 was admitted to the facility on [DATE] with diagnosis to include myocardial infarction, hemiplegia affecting right dominant side, anxiety disorder, unspecified intellectual disabilities, mood disorder and mild cognitive impairment. A review of RI #97's quarterly MDS assessment with an Assessment Reference Date (ARD) of 04/04/2025 documented that RI #97 had short term and long-term memory impairment indicating cognitive impairment. RI #97's Functional Abilities indicated wheelchair use, lower extremity impairment. Mobility assessment indicated for walking was not attempted and RI #97 did not perform this activity prior to the current illness. A review of RI #97's comprehensive care plan titled Care Plan Report revealed: Focus Behaviors . AEB [as evidenced by] . yelling out without purpose, purposefully sliding him/herself to the floor out of wheelchair, refusing care/medications, verbally abusive toward, combative during care, throwing things at staff (i.e. {such as} call light, wedge, pillows bedside table, meal trays etc.), sexually inappropriate toward staff and hx. (history) of possibly other residents. He/she takes psychotropic medications for behavior. Date initiated: 08/12/2024 Revised on 10/27/2025 . Interventions . Administer medications for behavior per MD order, observing for efficacy and adverse reactions . educate on the importance of being compliant and accepting all care. Explain/reinforce why behavior is inappropriate and/or unacceptable. Notify MD, Sponsor, Psych, and Social Services of any changes. The care plan did not provide directions to staff regarding how or when RI #97 needed to be supervised. A record review (census list/room change) indicated RI #97 was moved on multiple occasions while in the facility. RI #97 was admitted on [DATE] and was not admitted to the MCU. On 01/05/2024 RI #97 was moved to the MCU, a secured unit, due to behaviors. On 02/11/2025 after the sexual abuse allegation resident was moved off the MCU until transferred to a behavioral hospital on [DATE]. Upon readmission on [DATE], RI #97 was not placed on the MCU. RI #97 was transferred back to the MCU on 03/05/2025. A review of RI #97's Progress Notes revealed the following documented behaviors from 12/18/2024 through 03/15/2025: On 12/18/2024 RN #20 documented that RI #97 was yelling out, refusing medications and care and was attempting to touch staff members inappropriately. On 12/20/2024, LPN #25 documented that RI #97 was touching staff inappropriately and then started hitting a CNA. On 01/04/2025, RN #26 documented that RI #97 was grabbing at nursing staff in sexual manner and staff were unable to redirect easily. On 01/23/2025 RN #30 documented Resident noted making loud animal like sounds this shift and staff reports resident making sexually inappropriate comments, you my girl friend and were gonna boom boom as he/she was thrusting himself/herself in the bed, staff redirected by telling the resident that it was inappropriate. On 01/29/2025 RN #10 documented that resident went to grab her breast. he/she got mad and stated no when trying to give meds. nurse tried again and RI #97 said no and continued to grab. nurse. again inappropriately. RN Supervisior and SS notified. On 01/31/2025 LPN #25 Behavior Note documented that RI #97 refused medications and when nurse attempted to perform body audit patient started swatting at nurse and trying to inappropriately touch nurse. On 02/03/2025 RN #29 documented two staff were unable to cut RI #97's (finger) nails because of how RI #97 moves hands around to tied to touch inappropriately. On 02/05/2025 Social Services Assistant (SSA) documented that in the three month look back RI #97 continued to have episodes of grabbing at staff inappropriately, combative with care (hitting, spitting, shoving items at staff) yelling out/attention seeking, verbally abusive (i.e. cursing and yelling) to staff, and non-compliant/rejecting care. RI #97 required two staff members to provide care due to inappropriate behaviors. RI #97 required a mechanical lift for transfers and was unable to ambulate. On 02/05/2025 LPN #28 documented that RI #97 had many episodes noted of being sexually inappropriate toward staff and noncompliant with care. On 02/08/2025 LPN #31 documented that RI #97 refused all medication. On 02/11/2025 RN #20 documented that an incident occurred earlier this shift with another resident, social services director notified. RI #97 was temporarily moved to room (named room number) on another unit. A Nurses Note dated 03/15/2025 documented by RN #35 documented . Inappropriate sexual behavior with new staff member. Redirected per staff and interaction stopped. (Resident) grabbed female staff members breast and patted her buttocks during care. RI #168 was admitted to the facility on [DATE] and had diagnoses to include: Alzheimer's Disease, Anxiety Disorder, Transient Ischemic Attack and Cerebral Infarction without residual deficits. A review of RI #168's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/23/2025 documented a Brief Interview for Mental Status (BIMS) score of 3 of 15, which indicated RI #168 had severe cognitive impairment. The MDS behavioral assessment indicated RI #168 wandered 4-6 days but less than daily and wandering placed RI #168 at significant risk of getting to potentially dangerous places and his/her wandering significantly intrudes on the privacy of others. A review of RI #168's Order Summary Report revealed an order dated 11/13/2024 for a Secure Care Monitor due to being at risk for elopement. A review of RI #168's Care Plans dated 02/06/2025 documented: Focus RI #168 is alert with confusion related to Alzheimer Disease. requires cueing and supervision with decision making. has episodes of wandering/exit seeking and wandering in and out of others' rooms. Secure Care Monitor was placed on 01/17/2025 to attempt to prevent elopement. Interventions Document any episodes of confusion/forgetfulness. Redirect away from exit doors as needed . A review of RI #168's progress note dated 02/04/2025 by the Hospice Nurse Practitioner documented that RI #168 was ambulatory and moved all extremities well. A review of RI #168's progress notes from 01/17/2025 to 02/28/2025 documented 36 occasions of RI #168 wandering the hallways and in and out of other resident's rooms. On 01/14/2026 at 3:17 PM an interview was conducted with CNA #13 who witnessed the incident. CNA #13 said prior to the incident on 02/11/2025 she last saw the residents around 5:30 PM. CNA #13 said about 7:30 PM, she was walking through the hall and she saw RI #168 sitting on the side of RI #97's bed. RI #97 had his/her hand in RI #168's diaper and was fondling RI #168 private parts. CNA #13 said the way RI #97's hand was positioned she could see his/her hand moving. CNA #13 said she had not been instructed on how to watch or supervise a resident who wandered other than there being photos at the nurses' desk to identify residents who wandered or were at risk for elopement. On 01/15/2026 at 9:50 AM, an interview was conducted with Registered Nurse (RN) #10 /Unit Manager. RN #10 stated RI #168 wandered almost constantly into other residents' rooms and she was not notified of each wandering episode. She stated she became aware of the 02/11/2025 incident involving RI #168 and RI #97 on 02/12/2025. RN #10 stated neither resident had the ability to consent sexually. RN #10 stated following the incident RI #97 was moved to another unit and then transferred to another facility for behavioral health services. RN #10 said RI #97 was readmitted to the facility on [DATE] to another hall then readmitted to MCU on 03/05/2025 due to disruptive behaviors such as yelling out and crying. RN #10 said the facility identified residents whose behaviors need to be reviewed by behavior management team by reviewing nursing documentation and the 24 hour report (shift to shift report) which was maintained in book at nurses' desk. RN #10 said there were two residents currently on the MCU who wandered and the facility staff monitored them and redirected them out of RI #97's room. RN #10 was asked, what actions had been implemented to ensure wandering, confused residents did not enter RI #97's room without supervision. RN #10 said the facility had training with the staff to redirect residents back to the hall or to their rooms. RN #10 said the facility monitored the residents who wandered and redirected them, but there was no staff assigned to monitor wandering residents. When asked could RI #97 sexually abuse another wandering resident, she said yes, it could happen again. On 01/15/2026 at 5:43 PM an interview was conducted with SSD/Abuse Coordinator. The SSD was asked how it would make a reasonable person feel to have someone touching or rubbing their private parts without permission. The SSD said that person would probably holler out and feel embarrassed and feel violated. On 01/16/2026 at 11:50 AM a follow-up interview was conducted with SSD who stated the staff did not observe RI #168 wander into RI #97's room because they were in other rooms at the time. The SSD stated neither RI #97 nor RI #168 had the ability to consent to sexual activity. The SSD read the facility policy and verbalized that sexual abuse was defined as non-consensual sexual contact with any resident. The SSD said non-consensual sexual contact occurred between RI #97 and RI #168. On 01/16/2026 at 2:54 PM during a follow-up interview with the DON, the DON said staff should round every two hours or more frequently to monitor or supervise a resident with history of wandering. The DON was asked what could have been done to prevent the abuse of RI #168 on 02/11/2025. The DON said more frequent monitoring of RI #168. The DON was asked how would a reasonable person feel if someone came up to them and started rubbing on their private parts; she said it would not make her feel very well and violated.On 01/16/2026 at 3:55 PM an interview was conducted with the Administrator (ADM). The ADM stated RI #97 could remain on MCU after allegations of sexual touching, allegation of sexual abuse and touching inappropriately because he did not feel like he/she posed a threat to other residents. This deficient practice was cited as a result of the investigation of a Facility Reported Incident, complaint/report number 471525.********************************************************************** On 01/18/2026 the facility submitted an acceptable removal plan which documented: ********************************************************************** Removal Plan F-600 1. Resident #97 was moved from the facility dementia unit on January 16, 2026. Resident now resides on Hall 5 unit, away from residents who have displayed active wandering behaviors. RI #97 was placed on 1:1 supervision on January 16, 2026, at approximately 5pm. January 18, 2026. Care plan updates for RI #97 were providing 1:1 care and relocating resident to a hall with non-active wandering residents. On January 17, 2026, the QAPI Committee reviewed the incident/allegation of sexual abuse incident that occurred February 11, 2025. The facility psychiatric provider, conducted a telehealth visit with RI #97 on January 16, 2026, at approximately 10pm and recommended changes to his medication regimen. These medication changes, room change, and 1:1 status were communicated to the resident's caregiver February 16, 2026. The DON/Designee updated the care plan for RI#97 January 18, 2026. Staff were notified of these updates January 16, 2026. On January 17, 2026, the QAPI Committee reviewed the incident/allegation of sexual abuse incident that occurred February 11, 2025. 2. All residents have the potential to be affected. On January 17, 2026, the facility DON/Designee reviewed all resident charts to ensure that any resident with a history of sexual behavior is appropriately placed on behavioral monitoring, has appropriate interventions in place to protect others from sexual behaviors, and will contact the physician for any resident in need orders regarding monitoring and behaviors. There were 169 residents reviewed and 4 residents identified with a history of sexual behaviors. The DON/Designee will be responsible for making any care plan revisions as needed and communicating them to the residents' caregivers and ensure communication. The only care plan update was RI #97 and the caregiver was notified on January 16, 2026 On January 18, 2026, the facility contacted Enterprise Police Department and made them aware of the incident that occurred on February 11, 2025, involving RI #97 and RI #168. Investigation case number is 2026000001962 3. On January 17, 2026, the facility administrator/designee updated the facility policy on abuse prevention, recognition, reporting and protection of residents during investigation. On January 17, 2026, the facility medical director and QAPI committee reviewed and approved the revised policy. On January 17, 2026, the facility administrator reviewed and revised the facility policy on investigating allegations of abuse. On January 17, 2026, the facility medical director and QAPI committee reviewed and approved the revised policy. On January 17, 2026, the facility administrator in-serviced QAPI committee members on the updated policy on abuse prevention, reporting, and protection of residents during investigation. On January 17, 2026, the DON/ADON/designee(s) in-serviced facility staff on the updated policy on abuse prevention, reporting, and protection of residents during investigation. These in-services will be completed on January 18, 2026. Any staff member not in-serviced by January 18, 2026, will be in-serviced prior to working their shift by DON/ADON/Designee(s). This will be accomplished by cross referencing future schedules with the in-service list to determine workers who have not yet been in-serviced. Total number of employees in-serviced is 216 with 76 employees remaining. 4. On January 17, 2026, the facility administrator in-serviced DON/designee(s), on the updated policy on abuse prevention, reporting, and protection of residents during investigation, and were made aware of their responsibility to review all investigations involving potential sexual abuse. On January 18, 2026, the facility DON/Designee began reviewing all investigations involving potential sexual abuse daily for one month to ensure that all investigations are thorough and all resident protection actions have been taken. The DON/Designee will be responsible for immediate corrective action, if needed. Results of the DON/Designee audits will be reviewed by the facility QAPI committee, which will also be responsible for corrective action, if needed. ************************************************************************************ After reviewing the facility's information provided in their Removal Plan and verifying the immediate corrective actions had been implemented as of 01/18/2026. On 01/18/2026 the Immediate Jeopardy was removed and the scope/severity level of F600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. ********************************************************************** 2. On 09/06/2024 at 11:33 AM the State Agency received a Facility Reported Incident (FRI) alleging Mental Abuse. It was reported that Former Certified Nursing Assistant (FCNA) #6 posted a picture on Snapchat of a soiled resident who the facility identified as RI #143 with the caption F**ck this job. A policy titled Social Media Use with a reviewed date of 11/24/2020 documented: Policy: It is the policy of this company to avoid inappropriate use of social media and to protect the residents, staff, visitors, volunteers, and practitioners of this facility against misuse of social media content. Taking, keeping, or distributing unauthorized photographs or recordings of residents through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality. Staff members must recognize that they have an ethical and legal obligation to maintain resident privacy and confidentiality at all times . Policy Explanation and Compliance Guidelines: 1. Employees are strictly prohibited from transmitting by way of any electronic media any resident-related image or information that may be reasonably anticipated to violate resident rights to confidentiality or privacy. This includes information that could degrade or embarrass the resident . Any employee who violates this policy may be subject to disciplinary action, up to and including termination. A facility document dated 06/06/2024 titled Cell Phones documented: Cell phones and any other smart devices (tablets, watches, etc.) are prohibited from use in all resident care areas including, but not limited to, resident rooms, showers, resident hallways, and dining areas when residents are present. Under no circumstances should employees take pictures, videos, or any other personal representations of any resident, family member, visitor, or staff member for the purpose of personal use, social media, or any other reason, Cell phones and tablets should be stored with other belongings in designated employee storage areas and not always be in possession. Devices may be used while on break so long as the previous guidelines are not violated. Failure to adhere to this policy is subject to disciplinary action up to and including termination. A facility document titled Confidentiality Statement was signed by FCNA #6 on 03/19/2024 documented: I understand and agree that the performance of my duties as an employee or contractor . I must hold resident information in confidence. I have read and understand the policy . on resident confidentiality. I understand that any violation of this policy is grounds for immediate termination of employment or of my contract, as applicable. RI #143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Anoxic brain damage, Spastic quadriplegic cerebral palsy, and Hemiplegia and hemiparesis following cerebral infraction affecting right dominant side. The Annual Minimum Data Set (MDS) for RI #143, with an Assessment Reference Date (ARD) of 08/03/2024, documented that RI #143 had unclear speech with slurred or mumbled words. The Brief Interview of Mental Status (BIMS) documented a score of 14 out of 15, indicating intact cognition. On 01/14/2026 at 3:02 PM RI #143 was questioned about the incident involving FCNA #6 that occurred in September 2024. RI #143 recalled the incident when an employee shared his/her picture on Snapchat. RI #143 said the facility notified him/her about the incident, which caused him/her to feel angry. When asked about FCNA #6 RI #143 stated she no longer worked at the facility. On 01/15/2026 at 4:25 PM during a follow up interview RI #143 stated the incident in September 2024 caused feelings of embarrassment and he/she was relieved that FCNA #6 was no longer employed at the facility. On 01/14/2026 at 5:14 PM FCNA #6 was asked about the incident involving RI #143 that occurred in September 2024. FCNA #6 recalled writing a statement and affirmed that the statement in the investigative file was correct. FCNA #6 stated she did not share a picture of RI #143 on social media. When asked about the types of social media accounts she possessed, she said Snapchat and Instagram. RI #143 was asked why someone would claim she posted a picture of RI #143 on social media to which she replied she did not know but believed it was due to being disliked by other employees. When asked to recall her experience providing care to RI #143 on 09/05/2024 she said she responded to RI #143 activating the call light and requested assistance from Certified Nursing Assistant (CNA) #9. While in the room FCNA #6 noted that RI #143 was cleaned due to feces being on his/her backside. FCNA #6 denied having her cell phone in RI #143's room while providing care and said it was against the rules to have a cell phone at work. When questioned about the training she received from the facility she indicated it included how to care for a resident, as well as training on abuse and dementia. FCNA #6 was asked about the concerns related to posting a resident's picture on social media and she stated it would be inappropriate as it would violate the rules of the facility and the resident's privacy. When asked what type of abuse this would be FCNA #6 said she did not know due to the length of time since the incident. The employee file for FCNA #6 included a signed confidentiality statement dated 03/19/2024, as well as a signed social media policy also dated 03/19/2024. On 01/15/2026 at 9:28 AM CNA #9 was questioned regarding the incident involving RI #143 that occurred in September 2024. CNA #9 indicated he was informed about the social media post and remembered providing a statement. CNA #9 confirmed that the statement in the file was his statement. He recalled being assigned to care for RI #143 and requested assistance from FCNA #6. He said RI #143 had a bowel movement, and both he and FCNA #6 attended to the resident by cleaning him/her and changing the bed linens. He said he stepped out of the room once to retrieve clean linens. When asked about FCNA #6's demeanor while caring for RI #143, he said she appeared somewhat annoyed at being asked for help but acted appropriately towards RI #143. CNA #9 said he did not observe FCNA #6 using a cell phone while providing care in the room and did not witness her taking a photograph of RI #143. CNA #9 said posting a picture of a resident on social media would constitute abuse and violate both policy and privacy regulations. A review of the facility investigative file revealed a witness statement from Licensed Practical Nurse (LPN) #7 dated 09/06/2024 that documented: FCNA #8 said Somebody must not want their job and I, LPN #7, said what do you mean and FCNA #8 said did you not see snapchat and I said what do you mean, I don't have very many people from work on my snapchat and FCNA #8 pulled up FCNA #6's snapchat with FCNA #6's name at the top. It was a picture of a resident who I could instantly point out as RI #143. In the picture was a resident with poop up his/her side and back and the caption F*** this job. FCNA #8 showed me this on 09-06-24 at approximately 8:30AM. I then reported this to my supervisor. In the picture you could clearly tell which resident it was because. part of the residents room being showed in the picture. On 01/15/2026 at 10:08 AM LPN #7 was questioned about the incident involving RI #143 that occurred on 09/06/2024. LPN #7 reviewed the statement contained in the investigative file and confirmed it was her statement. She indicated that in September 2024 she was working as a CNA and regularly provided care for RI #143. LPN #7 recalled that upon arriving at work on 09/06/2024. FCNA #8 showed her a picture on Snapchat from her phone, which she recognized as RI #143. She identified RI #143 by the personal items located on the bedside table. LPN #7 described the picture as showing a person's skin from the armpit to the ankle, which was covered in a brown substance that she identified as feces. She said no other body parts including RI #143's face were visible in the picture. When asked about the timing of the picture she assumed it had been taken the night before. LPN #7 said she would consider posting a picture of a resident on Snapchat to be a form of mental abuse and it would make a reasonable person embarrassed. On 1/15/2026 at 3:37 PM during a follow up interview LPN #7 was asked about the number of individuals who could view stories on Snapchat. She responded that friends were able to see snaps that were posted and there was an option to make snaps private or to choose specific friends to view the images. She said she was not friends on Snapchat with FCNA #6 and viewed the picture of RI #143 on FCNA #8's personal Snapchat account on her phone. She said images on Snapchat were automatically erased after a period of 24 hours. When questioned about how many individuals co

Based on interviews, resident's medical records, review of Facility Reported Incidents (FRIs) received by the State Agency, the facility's investigative files, and the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure its abuse policy was implemented to establish a safe environment and implement protocols for preventing, identifying, and investigating an allegation of sexual abuse on 02/11/2025. On 12/18/2024 Resident Identifier (RI) #97 began having documented episodes of sexually inappropriate behaviors towards staff. Progress notes in RI #97's medical record included seven entries of sexually inappropriate behaviors documented by six different staff members from 12/18/2024 until 02/11/2025. At that time, RI #97's room was in the facility's Memory Care Unit (MCU) which was identified by staff as a unit with wandering residents who have decreased cognition. RI #168 was on the MCU for wandering behaviors including entering other residents' rooms. On 02/11/2025 around 7:30 PM, Certified Nursing Assistant (CNA) #13 witnessed RI #97's hand in RI #168's brief and witnessed RI #97 fondling RI #168's genitalia. Following the incident RI #97 was moved to another unit and placed on 1:1 until transferred to another facility for evaluation. On 03/05/2025 RI #97 was moved again to the facility's Memory Care Unit. The facility did not provide directions to staff to ensure supervision was provided in a manner to prevent sexual abuse and that sexual abuse did not re-occur with RI #97 and other wandering residents with who lacked the ability to consent. The facility further failed to ensure the allegation was investigated in accordance with the facility's policy. The facility's investigation did not include accurate determination that abuse occurred or the cause of the incident. It was determined the facility's noncompliance with one or more requirements of participation has cause, or likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 01/16/2026 at 6:30 PM, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Assistant Administrator were provided the Immediate Jeopardy (IJ) templates and notified of the findings of substandard quality of care at the immediate jeopardy level of F607-Development Implement Abuse/Neglect, etc. Policies. The IJ began on 02/11/2025 and continued until 01/18/2026 when the survey team verified that onsite corrective actions had been implemented. The immediate jeopardy was removed on 01/18/2026. This deficient practice affected RI #97, one of six residents sampled for abuse and was a result of the investigation of a Facility Reported Incident (FRI) incident/complaint/report number 471525.Findings Include:Cross-Reference F600 and F867.A review of the facility's policy titled, Abuse, Neglect and Exploitation with a revised date of 01/01/2024 revealed the following: Policy: 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 .Definitions: .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Sexual Abuse is non-consensual sexual contact of any type with a resident.Policy Explanation and Compliance Guidelines: . 1. The facility will develop and implement written policies and procedures that:a. Prohibit and prevent abuse. of residents.b. Establish policies and procedures to investigate such allegations .The components of the facility abuse prohibition plan are discussed herein: I. Screening .B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility.2. The facility will make individual determinations in consideration of current staffing patterns, . environment.II. Employee Training .B. Existing staff will receive annual education through planned in-services and as needed.C. Training topics will include: 1. Prohibiting and preventing all forms of abuse.2. Identifying what constitutes abuse.5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as:a. Aggressive and/or catastrophic reactions of residents;b. Wandering.c. Resistance to care;d. Outburst or yelling out. III. Prevention Of Abuse, Neglect and ExploitationThe facility will implement policies and procedures to prevent and prohibit all types of abuse. that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, . is more likely to occur with deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; . D. The identification, ongoing assessment, care planning for appropriate intervention, and monitoring of residents with needs and behaviors which might lead to conflict .IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse. This includes. certain resident to resident altercations.V. Investigation of Alleged Abuse, Neglect and Exploitation .A. An immediate investigation is warranted when. reports of abuse. occur.B. Written procedure for investigation include: .3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetration, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause: and 6. Providing complete and through documentation of the investigation .VI. Protection of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: .B. Examining the alleged victim for any sign of injury, including a physical examination or psychological assessment if needed;C. Increased supervision of the alleged victim and residents; .VII. Reporting/Response A. The facility will have written procedures that include .5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a. Analyzing the occurrence (s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be change and/or improve to protect residents receiving services;c. Training of staff on changes made and demonstration of staff competency after training is implemented;d. Identification of staff responsible for implementation of corrective actions; e. The expected date for the implementation; andf. Identification of staff responsible for monitoring the implementation of the plan. RI #168 was admitted to the facility on [DATE] with a diagnosis to include Alzheimer's Disease. RI #168's Care Plan Report included Focus: . RI #168 has episodes of wandering/exit seeking and wandering in and out of others' rooms and impeding on others privacy r/t dx of Alzheimer Disease. Secure Care Monitor was placed on 01/17/2025 to attempt to prevent elopement. The interventions for the Focus included .Redirect away from exit doors if/as needed. RI #97 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis Affecting Right Dominant Side, Unspecified Intellectual Disabilities and Mild Cognitive Impairment. A review of RI #97's comprehensive care plan titled Focus . RI #97 has episodes of attention-seeking (i.e., yelling out without purpose . refusing care/medications, verbally abusive toward staff, combative during care, throwing things at staff (i. e., call light, wedge, pillows, bedside table, meal tray, etc.) sexually inappropriate toward staff and history of possibly other residents related r/t his medical condition. Interventions . Administer medications for behaviors per Medical Doctor (MD) order, . Two staff members to provide care due to (d/t) sexually inappropriate episodes . A review of RI #97's Progress Notes revealed a Behavioral Note dated 01/29/2025 documented by RN #10, Memory Care Manager. The note included plan to speak with behavior management company about possibly starting medications to calm sexual urges and staff would continue to utilize two-persons with all care. On 02/11/2025 at 9:09 PM, the State Agency received a Facility Reported Incident (FRI) alleging that CNA #13 walked by RI #97's room and observed his/her hand in RI #168's brief. Action(s) taken by the facility in response documented RI #168 was calm and not in distress when staff member removed RI #168 from RI #97's room. RI #97 was moved to another hall for the time being while investigation was pending.The facility's investigative filed contained CNA #13's handwritten statement dated 02/11/2025. The statement included that at approximately 7:30 PM, she was making rounds and found RI #168 in RI #97's room sitting on the side of his/her bed. CNA #13 noticed RI #97's hand was inside of RI #168's pants and RI #97 was rubbing his/her private parts. CNA #13 immediately took RI #168 out of the room and reported the incident to Licensed Practical Nurse (LPN) #14. On 01/14/2026 at 3:17 PM an interview was conducted with CNA #13 regarding the incident which occurred on 02/11/2025 involving RI #97 and RI #168. CNA #13 said prior to the incident on 02/11/2025 around 7:30 PM, she last saw the residents around 5:30 PM. She said about 7:30 PM, she was walking through the hall and she saw RI #168 sitting on the side of RI #97's bed. RI #97 had his/her hand in RI #168's diaper and was fondling RI #168 private parts. CNA #13 said the way RI #97's hand was positioned she could see his/her hand moving. CNA #13 said she had not been instructed on how to watch or supervise a resident who wandered other than there being photos at the nurses' desk to identify residents who wandered or were at risk for elopement. The facility's investigative file contained one other handwritten statement dated 02/11/2025 by LPN #14. LPN #14 documented, at approximately 7:45 PM, CNA #13 reported to her an incident that occurred between RI #97 and RI #168. CNA #13 found RI #168 in RI #97's room and RI #97's hand was inside of RI #168's brief. On 01/15/2026 at 2:59 PM an interview was conducted with LPN #14 who stated that CNA #13 told her that RI #168 was standing by RI #97's bed and RI #97 had his/her hand down the front of RI #168's brief. LPN #14 stated there were three other CNA's on the unit that night. LPN #14 said she did not perform a body audit for either resident. The facility investigative file contained a typed statement, dated 02/11/2025 and signed by the Social Services Director who was the facility's Abuse Coordinator that included: Tuesday, February 11, 2025 @ (at) 7:30 PM.(Resident on Resident: Sexual Abuse Allegation)Closing Report/Plan of Action .Both residents have diagnosis of Dementia or Intellectual Disability. Staff members moved RI #97. due to the incident. The resident is not mobile and requires staff to help resident with transfers compared to RI #168 who is mobile and wanders through the memory care, which is the reason why the facility decided to move RI #97 instead of RI #168. facility will have to send resident out for a behavioral stay due to increased sexual inappropriate behaviors to staff and the incident with another resident. The facility had a staff member provide 1:1 care until . 02/17/2025.After reviewing all documents, information, and staff member interview of the allegation the facility finds the incident Sexual Abuse, resident on resident: Not Substantiated. The facility is not able to substantiate the investigation due to not enough evidence of which resident initiated the situation as well as neither resident's [sic] were seen in distress at the time the staff noted the incident. Further review of RI #97's Progress Notes revealed:A Social Services note dated 02/12/2025 and signed by the SSD/Abuse Coordinator. The note included . resident will need to be sent out for a .behavior stay due to increase behaviors of being combative, yelling out, and being sexually inappropriate with staff. Resident continues to have these behaviors and they have increased the past 1-2 weeks.A Social Services note dated 02/24/2025 documented by Social Services Assistant (SSA) #27 that documented that RI #97 was readmitted to the facility from the behavioral hospital.A Nurses Note dated 02/27/2025 documented by LPN #34 documented that Resident has been yelling out throughout the shift, attempted to re-direct/re-orient resident, noneffective. increased behaviors of hitting staff members and attempting to grab staff members inappropriately.A Nurses Note dated 02/28/2025 documented by LPN #34 documented that RI #97 had sexually inappropriately behaviors toward staff members attempts of redirection noneffective.A Nurses Note dated 03/15/2025 documented by RN #35 documented . Inappropriate sexual behavior with new staff member. Redirected per staff and interaction stopped. (Resident) grabbed female staff members breast and patted her buttocks during care.Nurses Notes dated 06/04/2025, 07/02/2025, 09/16/2025, 10/16/2025, 11/14/2025, and 12/04/2025 documented by RN #10 that included AP Med Review. Resident noted throwing meal trays to the floor, yelling out, being verbally and physically abusive to staff, touching female staff members inappropriately. These behaviors have picked back up in frequency over the last month redirection effective occasionally. On 01/15/2026 at 9:50 AM an interview was conducted with RN #10 regarding RI #97's behaviors. The surveyor read the nurses' progress notes to RN Unit Manager regarding RI #97's behaviors which started on 12/18/2024. RN #10 said before the incident she was aware of most of RI #97's documented behaviors and said RI #97 was refusing medications and touching staff and being sexually inappropriate. RN #10 said about a year ago staff they had a lot of reports of RI #97 refusing medications and touching sexually inappropriately. RN #10 said RI #97 usually attempted to touch or grab staff's breast or the private part. RN #10 stated after the incident, RI #97 was readmitted to another unit or hall at the facility on 02/24/2025. RN #10 said RI #97 was admitted to another unit because the facility was trying to ensure that the situation, sexually inappropriate behavior with another resident, did not occur again. RN #10 was asked, what was done to prevent recurrence while RI #97 was on the other unit. RN #10 said there were not that many residents who wandered on that hall. RN #10 said RI #97 was readmitted to the MCU on 03/05/2025 due to disruptive behaviors such as yelling out and crying. RN #10 was asked did the MCU have more wandering, confused residents than other units. RN #10 said, yes for the most part. RN #10 was asked had RI #97 had recent sexually inappropriate behaviors. RN #10 said, the note dated 12/05/2025 indicated RI #97 continued to touch female staff and have inappropriate behaviors that had picked up over the past few months. RN #10 was asked, what actions had been implemented to ensure wandering, confused residents did not enter RI #97's room without supervision. RN #10 said the facility had training with the staff to redirect residents back to the hall or to their rooms. RN #10 said the facility monitored the residents who wandered and redirected them, but there was no staff assigned to monitor wandering residents. When asked if RI #97 could sexually abuse another wandering resident, she said yes, it could. On 01/15/2026 at 5:43 PM an interview was conducted with the SSD/Abuse Coordinator. The SSD said the facility's behavior management team include nurse supervisors, the SSD, the DON, the Assistant DON (ADON), the Assistant ADM, and the ADM. The SSD was asked how the behavior monitoring team monitor residents with behaviors. The SSD said nurses did monthly assessments, anti-psychotic reports when behaviors were reported, and behaviors were then reported to the behavior health services, hospice, or primary care doctor. The SSD said, the behavior monitoring team discussed the behaviors displayed and determined if any medications needed to be changed. The SSD was asked what interventions were put in place from December 2024 until February 2025 related to RI #97's and RI #168's behaviors. The SSD said RI #97 required two people to provide care, he/she was offered ice cream and cookies, talked to him/her, provided activities, and redirected. When asked did the facility do to prevent the incident from occurring, she said RI #97 liked his/her door open and they needed to monitor the other residents. The SSD said RI #168 wandered a lot and they had to redirect him/her. The SSD further said, the concern of RI #97 displaying sexually inappropriate behavior toward another resident was not knowing what occurred before CNA #13 entered the room or if it happened to another resident. The SSD said a reasonable person would have holler out, felt embarrassed and violated if someone touched their private parts. On 01/16/2026 at 11:50 AM a follow-up interview was conducted with the SSD. The SSD was asked, based on the facility's investigation, what was the cause of the alleged incident on 02/11/2025 involving RI #97 and RI #168. The SSD said they had no cause and neither of the residents could tell them what happened. The SSD was asked to explain how the facility analyzed the occurrence to determine why the abuse occurred and what changes were needed to prevent future occurrence. The SSD said neither of the residents involved were able to answer so they did not know. The SSD said per the facility's investigation, staff did not observe resident RI #168 enter resident RI #97's room because they were in other residents' rooms providing care. The SSD was asked how did she know all the staff were all in rooms if they were not interviewed. The SSD said when CNA #13 went into the room that was when she witnessed the incident with RI #168 and RI #97. The SSD said neither resident had the ability to consent, so there was nonconsensual sexual contact on 02/11/2025. On 01/16/2026 at 9:44 AM an interview with conducted with RN #11 who said, the incident that occurred on 02/11/2025 when RI #97 was found with his/her hands in RI #168's brief was considered abuse. On 01/16/2026 at 3:55 PM an interview was conducted with the Administrator (ADM). The ADM was asked about his role in managing resident's behaviors. He said he was responsible for oversight of the Social Service Director and Nursing, as well as other entities such as the Behavioral Health Services to ensure they are communicating with the other providers such as the Nurse Practitioner (NP) and Medical Director (MD). He said his role in the facility's abuse prevention program was to ensure that all policies and procedures were met per protocol, investigate and report incidents and ensure the incidents are investigated thoroughly. When asked what was his role in abuse investigations, the ADM said he oversaw and reviewed the findings with the SSD/Abuse Coordinator to substantiate and/or unsubstantiate the incidents. The ADM was asked about his involvement in the investigation of 02/11/2025 allegation involving RI #97 and RI #168. He said the Abuse Coordinator conducted the investigation and the Assistant Administrator signed off on it and he did not recall reviewing the findings of the investigation before it was sent to the State Agency. He said the facility process of investigating abuse included interviews with any and all known staff members involved in the incident, notifying the sponsor, Ombudsman, MD, assess assignment sheets, timecards and if applicable notify Law Enforcement. The ADM said the goal of abuse investigations was to find out what happened to determine if the allegation was substantiated and identify means to ensure it does not happen again. When asked what could have been done to prevent this abuse from occurring, he said he did not know. ************************************************************************************************************************************************************************************************************************************************On 01/18/2026, the facility submitted an acceptable removal plan, which documented:Removal Plan for F6071. Resident #97 was moved from the facility dementia unit on January 16, 2026. Resident now resides on Hall 5 unit, away from residents who have displayed active wandering behaviors. RI #97 was placed on 1:1 supervision on January 16, 2026, at approximately 5pm.January 18, 2026. Care plan updates for RI #97 were providing 1:1 care and relocating resident to a hall with non-active wandering residents. On January 17, 2026, the QAPI Committee reviewed the incident/allegation of sexual abuse incident that occurred February 11, 2025.The facility psychiatric provider, conducted a telehealth visit with RI#97 on January 16, 2026, at approximately 10pm and recommended changes to his medication regimen. These medication changes, room change, and 1:1 status were communicated to the resident's caregiver February 16, 2026. The DON/Designee updated the care plan for RI#97 January 18, 2026. Staff were notified of these updates January 16, 2026. On January 17, 2026, the QAPI Committee reviewed the incident/allegation of sexual abuse incident that occurred February 11, 2025.2. All residents have the potential to be affected.On January 17, 2026, the facility DON/Designee reviewed all resident charts to ensure that any resident with a history of sexual behavior is appropriately placed on behavioral monitoring, has appropriate interventions in place to protect others from sexual behaviors, and will contact the physician for any resident in need orders regarding monitoring and behaviors. There were 169 residents reviewed and 4 residents identified with a history of sexual behaviors. The DON/Designee will be responsible for making any care plan revisions as needed and communicating them to the residents' caregivers and ensure communication. The only care plan update was RI #97 and the caregiver was notified on January 16, 2026On January 18, 2026, the facility contacted Enterprise Police Department and made them aware of the incident that occurred on February 11, 2025, involving RI#97 and RI#168. Investigation case number is 20260000019623. On January 17, 2026, the facility administrator/designee updated the facility policy on abuse prevention, recognition, reporting and protection of residents during investigation. On January 17, 2026, the facility medical director and QAPI committee reviewed and approved the revised policy. On January 17, 2026, the facility administrator reviewed and revised the facility policy on investigating allegations of abuse. On January 17, 2026, the facility medical director and QAPI committee reviewed and approved the revised policy.On January 17, 2026, the facility administrator in-serviced QAPI committee members on the updated policy on abuse prevention, reporting, and protection of residents during investigation.On January 17, 2026, the DON/ADON/designee(s) in-serviced facility staff on the updated policy on abuse prevention, reporting, and protection of residents during investigation. These in-services will be completed on January 18, 2026. Any staff member not in-serviced by January 18, 2026, will be in-serviced prior to working their shift by DON/ADON/Designee(s). This will be accomplished by cross referencing future schedules with the in-service list to determine workers who have not yet been in-serviced. Total number of employees in-serviced is 216 with 76 employees remaining.4. On January 17, 2026, the facility administrator in-serviced DON/designee(s), on the updated policy on abuse prevention, reporting, and protection of residents during investigation, and were made aware of their responsibility to review all investigations involving potential sexual abuse.On January 18, 2026, the facility DON/Designee began reviewing all investigations involving potential sexual abuse daily for one month to ensure that all investigations are thorough and all resident protection actions have been taken. The DON/Designee will be responsible for immediate corrective action, if needed. Results of the DON/Designee audits will be reviewed by the facility QAPI committee, which will also be responsible for corrective action, if needed. ************************************************************************************After reviewing the facility's information provided in their Removal Plan and verifying onsite through interview, observation, and record review the immediate corrective actions were implemented as of 01/18/2026.On 01/18/2026 the Immediate Jeopardy was removed and the scope/severity level of F607 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on record review, interview, the facility's policy titled Abuse, Neglect, and Exploitation, and the facility plan titled Quality Assurance and Performance Improvement (QAPI) Plan the facility failed to implement an effective QAPI program related to a resident-to-resident sexual abuse incident.Specifically, the facility's Quality Assurance Committee failed to review the incident to verify that a thorough investigation was conducted, failed to the incident as abuse, and failed to analyze contributing risk factors including residents wandering without supervision on a unit with a resident who had a documented history of sexually inappropriate behavior toward staff. Additionally QAPI failed to identify the need for systemic actions, as the involved resident was later returned to the unit without documented safeguards, and staff were not provided direction to ensure supervision of wandering, cognitively impaired residents in a manner that prevented entry into other resident's rooms without supervision. These failures allowed unsafe conditions to persist and placed residents at risk for serious harm.The facility did not provide documentation to support that the allegation of resident-on-resident abuse that occurred on 02/11/2025 was reviewed to ensure an investigation was conducted in a manner to identify contributing or causal factors to be corrected and prevent recurrence.It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.75 Quality Assurance and Performance Improvement.On 01/16/2026 at 6:30 PM, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Assistant Administrator were provided a copy of the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Quality Assurance and Performance Improvement at F867-QAPI/QAA Improvement Activities. The IJ began on 02/11/2025 and continued until 01/18/2026 when the survey team verified that onsite corrective actions had been implemented. The immediate jeopardy was removed on 01/18/2026.This deficiency was cited as the result of the investigation of complaint /report number 471525.Findings Include: Cross Reference F600 and F607. A QAPI plan dated August 27, 2025 documented: . Vision - Our facility's purpose focuses on our goals and aspirations. It is the framework for our efforts to improve processes and care. Mission - Our mission guides the actions of the organization. Our mission is to create a culture of ongoing performance improvement to support a life worth living for those entrusted to our care. Purpose - Our QAPI process will support the vision and mission of the organization. The purpose of QAPI in our facility is to focus on our vision and mission by including all residents, staff members, and family members in the performance improvement process to support a care environment that nurtures meaningful relationships. Guiding Principles - The beliefs and philosophy of our organization as it pertains to quality assurance performance improvement. Our guiding principles guide what we do, why we do it, and how we will conduct our QAPI processes. Guiding Principles #1 Our care practices are guided by a structured Quality Assurance Performance improvement process. Guiding Principle #2 All staff members acknowledge their commitment to performance improvement and their perspective roles in the process. Guiding Principle #3 We focus on systems and processes and encourage our staff to identify potential errors and system breakdowns. Guiding Principle #4 We set goals to improve performance, measure our progress towards the goals, and revise the goal when necessary. Scope of Services - The scope of services outlines the type of care and services our organization provides. These services will impact quality of care, quality of life, resident choice, and care transitions. QAPI Goals- Using the vision, mission, purpose and guiding principles we developed our goals by stating what we want to accomplish, how we will measure our progress, how we will determine an achievable goal, how the goal is determined to be relevant to the care we deliver, and how we will choose a timeline to attain the goal. A review of the facility's policy titled, Abuse, Neglect and Exploitation with a revised date of 01/01/2024 revealed the following: . VII. Reporting/Response A. The facility will have written procedures that include . 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence (s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be change and/or improve to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for the implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. VIII. Coordination with QAPI A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse. with the QAPI program. 1. Cases of physical or sexual abuse. will be reviewed for and receive corrective action and tracking by the QAA Committee. This coordinated effort results in the QAA Committee determining: a. If a thorough investigation was conducted; b. Whether the resident is protected; c. Whether an analysis was conducted as to why the situation occurred; d. Risk factors that contribute to the abuse. and; e. Whether there is a need for further systemic action such as: i. Insight on needed revisions to the policies and procedures that prohibit abuse. ii. Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about, iv. Measures to identify the implementation of corrective actions and timeframes, v. Tracking patterns of similar occurrences. On 01/16/2026 at 3:55 PM the Administrator (ADM) was questioned about the sexual abuse incident involving RI #97 and RI #168. The ADM said that all allegations of abuse are discussed in QAPI. The ADM said he did not recall reviewing the investigation before it was submitted to the State Agency. The ADM stated the incident was reviewed on 03/27/2025 in QAPI and the team discussed the people involved, what happened, how the facility would do things differently and interventions. When asked if a thorough investigation was conducted, he said not all aspects were in the documentation, but the facility believed a thorough investigation was completed when the final report was submitted. The ADM was asked if QAPI determined systemic changes were needed and he stated no because the mental capacity of both residents did not warrant any further action and separation of the residents was sufficient. The ADM was unsure what could have been done to prevent this abuse from occurring. This deficient practice was cited as a result of the investigation of a Facility Reported Incident, complaint/report number 471525. ********************************************************************** On 01/18/2026, the facility submitted an acceptable removal plan, which documented: *********************************************************************************************** Removal Plan for F867 1. Resident #97 was moved from the facility dementia unit on January 16, 2026. Resident now resides on Hall 5 unit, away from residents who have displayed active wandering behaviors. RI #97 was placed on 1:1 supervision on January 16, 2026, at approximately 5pm. January 18, 2026. Care plan updates for RI #97 were providing 1:1 care and relocating resident to a hall with non-active wandering residents. On January 17, 2026, the QAPI Committee reviewed the incident/allegation of sexual abuse incident that occurred February 11, 2025. The facility psychiatric provider, conducted a telehealth visit with RI#97 on January 16, 2026, at approximately 10pm and recommended changes to his medication regimen. These medication changes, room change, and 1:1 status were communicated to the resident's caregiver February 16, 2026. The DON/Designee updated the care plan for RI#97 January 18, 2026. Staff were notified of these updates January 16, 2026. On January 17, 2026, the QAPI Committee reviewed the incident/allegation of sexual abuse incident that occurred February 11, 2025. 2. All residents have the potential to be affected. On January 17, 2026, the facility DON/Designee reviewed all resident charts to ensure that any resident with a history of sexual behavior is appropriately placed on behavioral monitoring, has appropriate interventions in place to protect others from sexual behaviors, and will contact the physician for any resident in need orders regarding monitoring and behaviors. There were 169 residents reviewed and 4 residents identified with a history of sexual behaviors. The DON/Designee will be responsible for making any care plan revisions as needed and communicating them to the residents' caregivers and ensure communication. The only care plan update was RI #97 and the caregiver was notified on January 16, 2026 On January 18, 2026, the facility contacted Enterprise Police Department and made them aware of the incident that occurred on February 11, 2025, involving RI#97 and RI#168. Investigation case number is 2026000001962 3. On January 17, 2026, the facility administrator/designee updated the facility policy on abuse prevention, recognition, reporting and protection of residents during investigation. On January 17, 2026, the facility medical director and QAPI committee reviewed and approved the revised policy. On January 17, 2026, the facility administrator reviewed and revised the facility policy on investigating allegations of abuse. On January 17, 2026, the facility medical director and QAPI committee reviewed and approved the revised policy. On January 17, 2026, the facility administrator in-serviced QAPI committee members on the updated policy on abuse prevention, reporting, and protection of residents during investigation. On January 17, 2026, the DON/ADON/designee(s) in-serviced facility staff on the updated policy on abuse prevention, reporting, and protection of residents during investigation. These in-services will be completed on January 18, 2026. Any staff member not in-serviced by January 18, 2026, will be in-serviced prior to working their shift by DON/ADON/Designee(s). This will be accomplished by cross referencing future schedules with the in-service list to determine workers who have not yet been in-serviced. Total number of employees in-serviced is 216 with 76 employees remaining. 4. On January 17, 2026, the facility administrator in-serviced DON/designee(s), on the updated policy on abuse prevention, reporting, and protection of residents during investigation, and were made aware of their responsibility to review all investigations involving potential sexual abuse. On January 18, 2026, the facility DON/Designee began reviewing all investigations involving potential sexual abuse daily for one month to ensure that all investigations are thorough and all resident protection actions have been taken. The DON/Designee will be responsible for immediate corrective action, if needed. Results of the DON/Designee audits will be reviewed by the facility QAPI committee, which will also be responsible for corrective action, if needed. ********************************************************************************************************* After onsite review of the facility's information provided in their Removal Plan and verifying the immediate corrective actions had been implemented as of 01/18/2026. On 01/18/2026 the Immediate Jeopardy was removed and the scope/severity level of F867 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, interviews and facility policies titled, Date Marking and Food Safety, Kitchen Hood Inspection and Cleaning, and Automated Ware Washing Policy, the facility failed to ensure food items in dry storage and the freezer were labeled with use by dates; the vents in the stove hood were free of dust and grease; and plates and bowls were dried properly before being used to serve food to residents. These deficient practices created the potential for cross-contamination and/or foodborne illnesses. These deficient practices had the potential to affect 162 of 162 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Date Marking for Food Safety, with a Reviewed/Revised: dated of 10/2025, revealed. Policy The facility adheres to a date marking system to ensure the safety to. food items. Procedure and Compliance Guidelines for Staffing: . 2. The food shall be clearly marked to indicate the date by which the food was . opened.3. The individual opening . a food . shall be responsible for date marking the food at the time the food is opened . On 01/12/2026 at 2:16 PM the surveyor and the Dietary Manager (DM), toured the dry storage and freezer area. It was observed in the dry storage area a 50-pound bag of brownie mix opened with no use by date. The surveyor observed in the freezer ten chicken breast in a bag with no use by date, diced chicken with an opened date of 12/05/25 with no use by date. There were nine chicken wings in a bag and the bag was opened with no open or use by date. The surveyor observed four or five chicken breasts in a zip lock bag with no opened or use by date. On 01/15/2026 at 3:31 PM the surveyor conducted an interview with the DM. She stated that the brownie mix, chicken wings and the diced chicken breast were not labeled. According to the DM, they had an opened date but no use by dates. She stated that there was no information on the package telling staff what the items were. She stated that staff did not label the items properly. The DM stated the person who opened an item was responsible for labeling it. According to the DM, the facility policy states items should be labeled and dated when opened. She further stated the item should list the name of the product and the date it was opened. The DM stated that when items are not labeled properly, they can serve the residents something that should not be served to them.2.) A review of a Policy titled, Kitchen Hood Inspection and Cleaning, with a Reviewed/Revised: date of 10/2025 revealed, Policy The kitchen hood exhaust system will be properly cleaned and maintained to support the functioning of the kitchen hood fire suppression system and to foster a safe and healthy environment for all employees. Procedure and Compliance Guidelines: .5. If the food exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portion of the exhaust system will be cleaned by a properly trained, qualified .person (s) . On 01/12/2026 at 2:16 PM the DM and the surveyor toured the kitchen. It was observed that 18 vents under the stove hood were dusty and greasy. There were three vents over the warmer with a large among of dust and grease. On 01/15/2026 at 2:58 PM an interview was conducted with the DM. She stated that she saw grease and dust particle under the hood. According to the DM, the dust and grease was there due to not cleaning. She was asked to describe the amount of dust and grease. She stated it was a small amount around each area underneath the hood. She stated that maintenance was responsible for cleaning the vents if it was not time for the six months cleaning. She stated that maintenance should remove the vents and clean them. According to the DM, when dust and grease was on the vents, it could fall into the cooking grease. On 01/15/2026 at 3:45 PM the surveyor conducted an interview with Maintenance Director. He stated that maintenance was responsible for keeping the vents clean when it was not time for the six months scheduled cleaning. According to the Maintenance Director, the vents were cleaned on 09/17/2025. He stated the vents should be cleaned regularly to prevent cross contamination. According to Maintenance Director, when the vents have grease and dust on them it can affect the residents by giving them an infection. 3) A review of a policy titled, 1001 Automated Ware Washing Policy, with no date revealed, . B. PROCEDURE: . 8. Allow the dishes to air dry on the dish racks. Do not dry with towels. On 01/14/2026 at 10:41 PM the surveyor observed the cook, Dietary Aid/Cook #23 plating. The surveyor observed the cook put food in eight plates that were wet nesting. The surveyor observed Dietary Aid #23 leave the kitchen and come back with a towel. Dietary Aid #23 dried one plate with a towel and pulled seven small bowls off the line with water in them. On 01/15/2026 at 12:23 PM an interview was conducted with the Dietary Aid #23. She stated that water and food products were in some of the plates. She was asked why the plates were wet and she stated that the plates did not dry properly. She stated one plate was wet and she used a little rag to dry the plate. Dietary Aid #23 stated the aides were responsible for making sure the dishes were dry at the tray line. According to the Dietary Aid #23, plates should be dry at the tray line to prevent bacteria or nastiness. She stated the facility policy stated to put wet dishes to the side at the tray line. Dietary Aid #23 stated that she pulled about 15 to 20 bowls and five to six plates from the tray line with water in them. The cook stated that when dishes were wet at the tray line it was a potential harm to the resident because food from the previous meal was in the plates. On 01/15/2026 at 2:53 PM an interview was conducted with the DM. She stated that she saw water in bowls and plates. She stated that staff did not allow the dishes to dry properly. She also stated that dishes should be dry at the tray line because any debris in the plates could cause the residents to become sick. The DM was asked when was staff in-serviced on wet nesting and she stated an in-service started yesterday.

Based on interview, review of the Online report submitted to State Agency and facility policy, titled Abuse, Neglect and Exploitation the facility failed to report an allegation of sexual abuse on 02/11/2025 to local law enforcement when Resident Identifier (RI) #97 was found with his/her hands in RI #168's brief.This affected two out of six residents sampled for abuse.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, with a revised date of 01/01/2024 documented: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident. Law enforcement is the full range of potential responders to elder abuse. including: police, sheriffs, detectives, public safety officers, corrections personnel; prosecutors, medical examiners; investigators and coroners. VII. Reporting /Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: .Review of the Online Incident Reporting System Report dated 02/11/2025, documented, . Incident Type . Abuse - Sexual . 17)Date and time of incident or alleged incident: 02/11/2025 18)Time: 07:30 PM 19)Narrative summary of incident: Staff member walked by resident, (RI #97)'s room and saw resident, (RI #168) standing over resident's bed with (RI #97)'s hand down (RI #168)'s brief. 27)Was the incident reported to a law enforcement agency? No .On 01/18/2026 at 4:47 PM an interview was conducted with Social Service Director (SSD)/Abuse Coordinator. The SSD stated law enforcement should be notified when abuse was alleged. The SSD said law enforcement was not notified of the incident that occurred on 02/11/2025 when RI #97 was found with his/her hand down RI #168's brief. The SSD said the facility's abuse policy was not followed and the concern not reporting the allegation to law enforcement was vulnerable residents were at risk.This deficient practice was cited as a result of investigation of complaint # 471525.

Based on observations, interviews, and a review of facility policies titled: STORAGE OF FOOD AND SUPPLIES, DRYING OF DISHES & UTENSILS, TEMPERATURE OF WALK-IN FREEZER, WALK-IN COOLER, AND ICE CREAM FREEZER and a TEMPERATURE LOG document, the facility failed to ensure: 1. meats in the freezer were labeled and sealed; 2. the temperatures of the freezer and cooler were recorded on the temperature log; and 3. utensils were not wet in utensil bags and in a silverware holder. This had the potential to affect 184 of 184 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, STORAGE OF FOOD AND SUPPLIES with a last revised date of 2/16 revealed: . PR[NAME]EDURE . G. Cover all cooked foods with plastic wrap or other covering prior to storage to protect from dripping or contamination. H. All left overs are to be labeled with the contents and date. On 11/3/2019 at 9:34 a.m., the surveyor toured the freezer with (Employee Identifier). EI #11, Cook number one. The surveyor observed some type of cooked meat in the freezer. The meat was labeled with a date of 9/23/2019 and a use by date of 10/23/19. The foil paper was torn and the meat was exposed in the freezer. There was another type of meat in a large zip lock bag with clear plastic wrap around it. The meat had no opened or use by date on it. On 11/3/2019 at 3:02 p.m., the surveyor conducted an interview with EI #11, Cook, number one. EI #11 was asked what was wrapped in clear plastic wrap in the freezer. EI #11 replied, chicken. EI #11 was asked what was the opened and use by date on the food item wrapped in clear plastic wrap. EI #11 replied, it did not have a date on it. EI #11 replied, normally they label when they put something in there for 24-hours to three days. EI #11 was asked why was the food item not labeled. EI #11 replied, it was supposed to be labeled. EI #11 said she was not there everyday and different stock boys normally checked it when they put stuff up in the freezer. EI #11 was asked what was opened in a pan in the freezer. EI #11 replied, pork. EI #11 was asked how was the foil on the pork. EI #11 replied, it was opened on the corners. EI #11 was asked how far was the foil opened on the pan. EI #11 replied, it was enough to be noticed. EI #11 was asked how should food items be sealed. EI #11 replied, put clear plastic wrap around the food item and then foil all the way around it. EI #11 continue to say sign and date it. EI #11 was asked what was the facility policy on labeling food items and sealing food items in the freezer. EI #11 replied, they were not suppose to save food in the freezer. They can only keep food for one day or three days; it depended on what the food was. EI #11 was asked why was it important that food items were sealed and labeled. EI #11 replied, the food needed to be sealed so the food would not get freezer burned and labeled so the next cook or manager who checked it would know that the food was dated the proper way. On 11/6/2019 at 8:22 a.m., the surveyor conducted an interview with EI #2, Dietary Manager. EI #2 was asked what was the facility policy on sealing foods in the freezer. EI #2 replied, it should be properly sealed, labeled and dated. EI #2 was asked why was it important that food in the freezer be sealed. EI #2 replied, so it would not get freezer burn due to exposure, sanitation, and could cause harm. EI #2 was asked how should food be labeled in the freezer. EI #2 replied, sealed, labeled and dated. EI #2 was asked what should be on the label. EI #2 replied, the items name, the date it was stored, and the discard date. 2. A review of a policy titled, TEMPERATURE OF WALK-IN FREEZER, WALK-IN COOLER AND ICE CREAM FREEZER with a last revised date of 09/13 revealed: . PR[NAME]EDURE 1. Designated dietary staff members will check the temperature of the walk-in cooler, walk-freezer . twice per day (AM and PM) . A review of a facility document titled, TEMPERATURE LOG Walk-in Cooler, Walk-In Freezer, and Ice Cream Freezer MONTH Nov YEAR 2019. Cooler AM, Freezer AM, revealed no temperatures were documented for the morning shift on 11/2/19. On 11/5/2019 at 4:51 p.m., the surveyor conducted an interview with EI #11. EI #11 was asked why was there no temperatures recorded for 11/2/19 on the cooler and freezer log. EI #11 replied, it would have been between her and the second cook because they went into there as well. EI #11 was asked what was the facility policy regarding documenting the cooler and freezer temperatures. EI #11 replied,it should be documented by the morning cook and there were two cooks that morning, cook one and cook two. EI #11 continue too say they make sure they document it every day. EI #11 was asked what temperatures were documented on 11/2/19 log for the morning shift. EI #11 replied, nothing was recorded. EI #11 was asked why was it important that the cooler and freezer temperatures be recorded. EI #11 replied, for the safety of the food. On 11/6/2019 at 8:22 a.m., the surveyor conducted an interview with EI #2 Dietary Manager. EI #2 was asked who was responsible for recording the morning cooler and freezer temperatures on 11/2/19. EI #2 replied, the a.m., cook, cook number one, EI #11. EI #2 continue to say EI #11 was the head cook and the one in charge and she would be responsible. EI #2 was asked when should staff record the morning temperatures for the cooler. EI #2 replied, upon arrival of duty. On 11/6/2019 at 9:22 a.m., the surveyor conducted an interview with EI #13, Second Cook. EI #13 was asked who was responsible for checking temperatures in the cooler and freezer. EI #13 replied, she thought EI #11 checked the temperatures. EI #13 said she did not. EI #13 was asked why was it important to check the cooler and freezer temperatures daily. EI #13 replied, to make sure it had the right temperatures for the residents. EI #13 was asked what did the facility policy say regarding checking the cooler and freezer temperature daily. EI #13 replied, the temperatures must be checked daily. 3) A review of a facility policy titled, DRYING OF DISHES & UTENSILS with a last revised date of 1/15, revealed PURPOSE To ensure that all dishes, utensils, etc. are completely air dried . PR[NAME]EDURE 1. Any dishes, utensils, etc. coming from the dish room must be completely air dried with no water or wetness. On 11/5/2019 at 10:22 a.m, the surveyor observed six bags of silverware wet in the bags. There were spoons, forks, and knives in the bags to be placed on the residents trays. There was an adaptive spoon and fork with food debris on it in the silverware holder. Also noted, were numerous spoons, forks, and knives in one compartment of the silverware holder. On 11/5/2019 at 1:57 p.m., an interview was conducted with EI #12, tray caller. EI #12 was asked what was she putting in silverware bags. EI #12 replied, knives, spoons, and forks. EI #12 was asked was the silverware wet or dry. EI #12 replied, wet. EI #12 was asked why was the silverware wet. EI #12 replied they did not air dry fully. EI #12 was asked who was responsible for making sure silverware was dry before placing them in bags. EI #12 replied, the tray people. EI #12 was asked what was on a spoon and fork, pointed out by the surveyor. EI #12 replied, food debris. EI #12 was asked how should silverware be allowed to dry. EI #12 replied, air dry. EI #12 was asked why was it important not to give residents wet utensils. EI #12 replied, utensils have to be fully dried for them to eat off of it. EI #12 was asked to tell the surveyor about the silverware in the silverware holder. EI #12 replied, it was wet with food debris. EI #12 continue to say partial wet and partial food debris on the silverware. On 11/6/2019 at 8:22 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked what did she observe in the silverware holder. EI #2 replied, too many stored in there to air dry. EI #2 continue to say the utensils packages had spots, wet spots, which would be consider wet nesting. EI #2 was asked who was responsible for bagging utensils on 11/5/19 at the lunch meal. EI #2 replied, the tray caller, EI #12. EI #2 was asked why was it important that residents not receive wet utensils. EI #2 replied, because of sanitation reason and bacteria. EI #2 was asked why was staff bagging wet utensils on 11/5/2019. EI #2 replied, she should not have been putting them in there, she should have waited until they were dry.

Based on observation, interviews, review of a lab report and review of a facility policy titled, PERINEAL CARE POLICY AND PR[NAME]EDURE, the facility failed to ensure the Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #63 in a manner to assure the perineal area was thoroughly cleaned of bowel movement and in a manner to reduce the potential for urinary tract infection. This was observed on 11/3/19 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, PERINEAL CARE POLICY AND PR[NAME]EDURE with a revised date of 10/24/12 revealed Purpose: To maintain skin integrity, reduce opportunity for urinary tract infection, promote comfort. B. Performance of Perineal Care . 2. Continue procedure until perineal area thoroughly cleaned. A review of a lab report document for RI #63 revealed . specimen CLEAN CATCH URINE (collected 9/16/19) . Organism Identified . Escherichia coli . RI #63 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #63's [DIAGNOSES REDACTED]. On 11/03/19 at 5:15 PM, the surveyor observed the staff provide incontinent care for RI #63. Employee Identifier (EI) #6, CNA and EI #7, CNA gathered some supplies, washed their hands, and put on gloves. EI #7 told the surveyor that RI #63 did not wear a disposable brief; however, RI #63 used the cloth pads. Both CNAs turned RI #63 to the right side and EI #7 cleaned the buttock and anal area. EI #7 removed her gloves, washed her hands, put on clean gloves, and removed the top cover bedding. EI #7 removed the bottom sheet, the draw sheet, and the cloth pad rolling toward the center of the bed. EI #7 placed the clean bottom sheet, draw sheet, and clean cloth pad on the bed. Both CNAs assisted RI #63 to turn to the left side. EI #6 removed the soiled linens and placed them on the floor beside the bed. EI #6 rolled the clean sheets and cloth pad on the bed. EI #6 and EI #7 assisted RI #63 into position and placed the top covers. After the top covers were placed, the surveyor asked how should they clean a resident during incontinent care. EI #7 replied, clean the front then turn to the side and clean the back. The surveyor asked EI #7 if she cleaned RI #63's front area. EI #7 replied, no. EI #7 was asked why not. EI #7 replied, she was not sure. The surveyor asked EI #6 and EI #7 to turn RI #63 to the side and was then asked if the bowel movement had been removed on the first cleaning. EI #7 replied, no, she should have made sure it was cleaned the first time. EI #7 cleaned RI #63's front then the buttock area until all bowel movement was removed. The surveyor asked EI #7 what was the harm in the resident not being cleaned in the front area during incontinent care. EI #7 replied, infection. On 11/06/19 at 8:58 AM, an interview was conducted with EI #1, Staff Education. EI #1 was asked what was the policy on how staff should clean a resident during incontinent care. EI #1 replied, clean the front side first in a front to back direction using a clean wipe each time, use a minimal of three times or until wipes return clean. EI #1 said once the front was completed turn the resident to the side and clean the back side cleaning until thoroughly clean with no visible sign of bowel movement. EI #1 was asked when should the staff not clean the front area of a resident during incontinent care. EI #1 replied, never. EI #1 was asked when should the staff leave bowel movement on a resident. EI #1 replied, never. EI #1 was asked what would the harm be in the staff not assuring all the bowel movement was removed from a resident during incontinent care. EI #1 replied, skin breakdowns, infection and comfort.

Based on observations, interviews, review of residents meal tray cards and review of facility policies titled, Main Dining Room Protocol and Resident Meal Tray Preparation, the facility failed to ensure residents received foods that were listed on their tray cards matched foods received on their meal trays. This was observed on 11/3/19 lunch and supper meals and affected three of 15 residents whose trays cards were reviewed for meals. This deficient practice was cited as a result of the investigation of complaint # AL 218, and affected (Resident Identifier) RI #128, RI #132 and RI #139. Findings Include: A review of a facility document titled, Main Dining Room Protocolwith a revised date of 7/25/13, revealed . 3. Nutrition Services will place all food and beverage on meal try, following tray cards and selective menus for accuracy. A review of a facility policy titled, Resident Meal Tray Preparation with a date of 11/6/09 revealed 1. Read the tray card. a. Right resident b. Right food/liquid consistency c. Correct level of assistance provided d. Correct assistive devices available e. Likes/dislikes honored . 1) RI #128 was admitted to the facility 4/11/18 and readmitted [DATE]. A [DIAGNOSES REDACTED]. A review of RI #128's tray card for 11/3/19 supper meal revealed . 2 oz (ounces) Chicken Salad Sandwich . 1 ea (each) Grilled Pimento Cheese Sandwich . A review of RI #128's (MONTH) 2019 Physician order [REDACTED]. On 11/3/19 at 4:21 PM the surveyor observed RI #128's supper meal delivered. The surveyor compared the items on the tray to the tray card which revealed RI #128 not receiving a 2 oz (ounce) chicken salad sandwich and did not receive the grilled pimento cheese sandwich. The surveyor heard the resident telling the Certified Nursing Assistant (CNA) that if he/she did not get the sandwich he/she would not have much to eat because he/she did not want that egg thing. The CNA asked the resident if the grilled pimento sandwich would be ok. RI #128 replied, yes and the CNA went to the kitchen to get it. On 11/3/19 at 5:05 PM, a brief interview was conducted with Employee Identifier (EI) #8, CN[NAME] EI #8 was asked what was supposed to be on the tray for supper. EI #8 replied, a chicken salad sandwich, soup, grilled pimento cheese sandwich, mashed potatoes, crackers, fruit cup, jello, cookie, tea, water and soda. EI #8 was asked what was on the tray. EI #8 replied, soup, quiche (egg thing), crackers, fruit cup, jello, tea, water and the soda. EI #8 was asked why were the sandwiches and mashed potatoes not on the tray. EI #8 replied, she did not know. EI #8 was asked how did she know which foods were to be on the resident tray. EI #8 replied, she looked at the tray card. EI #8 was asked what did she do if there were foods not on the tray that were on the tray card. EI #8 replied she would take the card to the kitchen and get the items. EI #8 was asked what was the harm in not having the foods on the plate that were on the tray card. EI #8 replied, not following diet and resident wants, resident could be losing weight and need those foods. EI #8 was asked what was the resident's status when the sandwich was not on the tray. EI #8 replied, RI #128 was upset and said he/she needed the sandwich or he/she would not have much to eat. On 11/5/19 at 11:58 AM, an interview was conducted with EI #5, Licensed Practical Nurse (LPN). EI #5 was asked how did he verify food on the tray was what the resident should get. EI #5 replied, they matched food listed on the tray card to that on the tray. EI #5 was asked if there were times when food or items were missing. EI #5 replied, yes. EI #5 was asked what was missing. EI #5 replied, silverware, sip cups, sandwichs and boiled eggs. EI #5 was asked who was responsible for putting items on the trays that were on the tray card. EI #5 replied, dietary. EI #5 was asked what should come from dietary. EI #5 replied, anything on the card should come on the tray. 2) RI #132 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the tray cards revealed, (RI #132's name) . Lunch: Sunday, Nov. 3 2019 Soup 3/4 C (cup) Soup of the Day Entree 3oz Pork Roast . Supper: Sunday, Nov. 3 2019 Bread 3oz Chp Half Sandwich . On 11/3/19 at 12:34 PM, an observation of RI #132's lunch tray was performed. Food items on the meal tray were compared to the items listed on the tray card. RI #132 did not receive 3/4 C Soup of the Day. RI #132 received a slice of Ham instead of Pork Roast. On 11/3/19 at 5:30 PM, an observation of RI #132's supper meal was performed. Food items on the meal tray were compared to the items listed on the tray card. RI #132 did not receive 3oz (ounce) Pimento Cheese Half Sandwich. At that time an interview was conducted with EI #4, CN[NAME] She was asked did items on the tray match the tray card. EI #4 replied, all except the Pimento Cheese Sandwich, that was the only thing missing. On 11/5/19 at 3:30 PM, a follow-up interview was conducted with EI #4. EI #4 was asked how did she know what was suppose to be on the tray. EI #4 replied, she looked at the tray card. EI #4 was asked who was responsible for making sure what was on the tray card was on the meal tray. EI #4 replied, before it left the kitchen, dietary was. EI #4 was asked who was responsible for making sure what was on the tray card was on the meal tray after it left the kitchen. EI #4 replied, the CN[NAME] EI #4 was asked what was the procedure when a food item listed on tray card was not on the meal tray. EI #4 replied, she took the tray card to the kitchen and got the missing item. EI #4 was asked how often did that happen. EI #4 replied, quite often. EI #4 was asked how many times a week did that occur. EI #4 replied, three to four times a week. EI #4 was asked why was RI #132's pimento cheese sandwich not on the meal tray. EI #4 replied, she did not know. EI #4 was asked what was the potential harm to the resident when he/she did not get the food items listed on the tray card. EI #4 replied, sometimes he/she did not like what was being served and he/she requested items that he/she would eat; if it was not there he/she may not eat. 3) RI #139 was readmitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. On 11/3/19 at 12:39 PM, the surveyor observed on RI #139's tray card to have ham instead of pork roast, as listed on the tray card. The tray did not have 1/2 cup tomato soup. The tray card revealed: whipped sweet potato , 1/2 cup seasoned zucchini, 1 roll, a slice hummingbird cake, 16 oz (ounce) milk, 8 oz water and 8 oz tea. The surveyor asked RI #139's family member if there was any tomato soup on the tray. The family member stated, No, it was always like this not having what it says on the card. On 11/6/19 at 9:10 a.m., an interview was conducted with EI #10, CN[NAME] EI #10 was asked how did she know what should be on the resident tray. EI #10 replied, by checking the book to see what type of diet the resident was on. EI #10 was asked how often did they have to go to kitchen for missing items on the tray. EI #10 replied, about twice a week. EI #10 was asked who was responsible for making sure that items on the tray and the card matched. EI #10 replied, they, the CNAs were when the trays came on the hall. EI #10 was asked what was the harm in the items not being on trays. EI #10 replied, the resident could be allergic to something or it could be something that the resident can not swallow. On 11/6/19 at 8:22 AM, an interview was conducted with EI #2, the Dietary Manager. EI #2 was asked who was responsible for putting foods on trays. EI #2 replied, the tray caller called out tray diet and requests, the cook plated the food and the end person or checker assured everything on the plate matched the card, then placed the tray on the cart. This person could be different for each meal. EI #2 was asked who placed tray cards on the trays. EI #2 replied, the tray caller. EI #2 was asked why were tray cards on trays. EI #2 replied, to identify the resident's diet by the physician orders. EI #2 was asked what was the benefits of the tray cards. EI #2 replied, to assure the resident was getting the accurate diet. EI #2 was asked when should items on the tray not match items on the tray card. EI #2 replied, food and items should match all the time. EI #2 was asked why should items on the tray card matched items on the resident tray. EI #2 replied, to assure residents were getting the correct diet, likes and dislikes were honored and everything needed was on the tray for that meal. EI #2 was told on 11/3/19 that the surveyors had observations at the lunch and supper meals of items listed on tray card that were not on the resident trays; she was then asked why would that happen. EI #2 replied, new employees, oversite and staff rushing through. EI #2 was asked who was responsible for making sure items on trays match items on the tray card. EI #2 replied, the last person, the checker. EI #2 was asked what was the harm in some foods on tray cards not being on the trays. EI #2 replied, not following special requests and honoring preferences.

Based on observation, interviews and review of a facility policy titled, Proper Linen Handling, the facility failed to ensure the Certified Nursing Assistant (CNA) did not place soiled linen she removed from Resident Identifier (RI) #63's bed, during incontinent care on the floor beside the bed. This was observed on 11/3/19 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, Proper Linen Handling with a revised date of 10/2017 revealed Purpose: To provide guidelines for handling of resident's soiled linens. In resident rooms: . 3. Deposit soiled laundry/linens . sheets . under pads in clear plastic bag . RI #63 was admitted to the facility on [DATE] and readmitted on [DATE]. Per departmental notes RI #63 had a personal history of urinary tract infections. On 11/03/19 at 5:15 PM, Employee Identifier (EI) #6 and EI #7 entered RI #63's room to provide incontinent care. EI #6 removed the soiled linens from the bed and placed the soiled linens on the floor beside the bed. On 11/3/19 at 5:40 PM, during an interview with EI #6, she was asked where was staff to place soiled linen when removed from the bed. EI #6 replied, in a plastic trash bag. EI #6 was asked where did she put the soiled linen. EI #6 replied, on the floor beside the bed. EI #6 was asked how were the linens soiled. EI #6 replied with bowel movement. EI #6 was asked what was the harm in placing the soiled linens on the floor. EI #6 replied, spread germs and what was on the pads and linens could get on the floor, then they step in it and track it to other areas. On 11/6/19 at 8:57 AM, an interview was conducted with EI #3 the Infection Control Registered Nurse (RN). EI #3 was asked what was the policy on where staff should place soiled linens when removing them from a resident's bed during incontinent care. EI #3 replied, in a plastic bag then in trash can. EI #3 was asked when should staff roll up soiled linens and place them on the floor beside the resident's bed. EI #3 replied, never. EI #3 was asked what was the harm in the CNA rolling up the soiled laundry then placing it on the floor beside the bed. EI #3 replied, infection control.

Based on observation, interview and review of the facility policy titled, FOOD TEMPERATURES, the facility failed to ensure the temperature of Brussels sprouts was taken prior to serving for lunch on 10/30/2018. This had the potential to effect 130 residents who received Brussels sprouts for the lunch meal. Finding Include: A review of the facility policy titled, FOOD TEMPURATURES, with a last revised date of 07/2014, revealed, . PR[NAME]EDURE .B. Temperature of foods must be taken from the stream table 10 minutes before the first tray assembly and must be recorded. The acceptable temperature of hot food is greater than 135 degrees Fahrenheit . On 10/30/18 at 11:04 AM, the surveyor observed Employee Indentifier EI #4, the cook, remove the Brussels sprouts from the warmer, stating, I forgot my Brussels spouts, and put them on the tray line and starting serving them without taking the temperature. On 10/30/18 at 2:47 PM, an interview was conducted with EI #4, the cook. EI #4 was asked, who was responsible for checking the temperatures on the tray line. EI #4 replied, she was. EI #4 was asked, when did she check the temperature on the Brussels sprouts on the tray line. EI #4 stated, When I took them out of the steamer. EI #4 was asked if she checked the temperature of the Brussels spouts when she removed them from the warmer. EI #4 stated, No, I did not. EI #4 was asked why did she not check the temperature on the Brussels sprouts. EI #4 replied, she was in a hurry trying to get the line started so the early trays would not be late. EI #4 was asked what was the temperature of the Brussels sprouts on the tray line. EI #4 stated, she did not check the temperature on the tray line; I checked the temperature on the steamer. EI #4 was asked what was the facility policy on checking the temperature of the food on the tray line. EI #4 stated, you are suppose to check the temps when it hits the tray line. EI #4 was asked, what was the potential harm in not checking the temperature of food on the tray line. EI #4 stated, it could cause bacterial build up and could cause harm to persons that eat them, or make them sick. On 10/30/18 at 3:04 PM, an interview was conducted with EI #5, the Dietary Manager. EI#5 was asked when was the Brussels sprouts temperature checked. EI #5 stated the temperature was taken when she took them out of the streamer, not the warmer. EI #5 was asked what was the facility policy on checking the temperatures of food on the tray line. EI #5 stated within 10 minutes before it was served.

Based on observation, interview, record review and review of a facility policy Maintaining/ Promoting Resident Dignity and Respect, the facility failed to ensure Resident Identifier (RI) #19 was not on the porch, in the facility halls and in the dining area with the suprapubic catheter, drain tubing and catheter drain bag visible to residents and visitors. This was observed on 10/30/18 and 10/31/18 and affected three unsampled residents who preferred the catheter tubing and bag not be exposed. Findings Include: A review of facility policy titled, Maintaining/ Promoting Resident Dignity and Respect with a revised date of 3/2017 revealed: Policy Statement . Residents are appropriately covered by clothing/covers to avoid inappropriate exposure . RI #19 was admitted to the facility 11/7/17 with a [DIAGNOSES REDACTED]. On 10/30/18 at 4:10 PM, RI #19 was observed on the front porch of the facility with other residents smoking. RI #19 finished smoking and walked back in the facility. While RI #19 was on the porch the surveyor observed RI #19's catheter, catheter tubing to the drain bag and the drainage bag exposed hanging from the waist of RI #19's pants. The catheter, catheter drain tubing and the drain bag were visible for other residents out on the porch, as well as visitors entering the facility. Yellow urine was visible in the drainage tubing and the drain bag. RI #19 then walked to the dining room for the supper meal. On 10/31/18 at 9:16 AM, a brief interview was conducted with RI #19 who revealed she/he liked it that way and it did not bother her/him. RI #19 was asked how it may make other residents feel. RI #19 replied, she/he did not care how others felt. On 10/31/18 at 12:00 PM, an interview was conducted with Unsampled Resident (UR) #1, who wished to remain anonymous. UR #1 was on the porch when RI #19 was out smoking on 10/30/18. UR #1 was asked how did they feel about the resident walking with the catheter and the catheter tubing visible. UR #1 replied, it was visible and would prefer to not see it hanging out from under the clothing. When UR #1 was asked how it made them feel. UR #1 replied, embarrassed. UR #1 was asked if they had discussed the concern with any staff. UR #1 replied, no, did not want to cause trouble. On 10/31/18 at 12:15 PM UR #2, who preferred to not be named, was observed in the main dining room. The surveyor observed this resident looking at RI #19. An interview was conducted with UR #2 who revealed they would prefer to not see the catheter tubing and drain bag because it made them think that resident's private area was out. On 10/31/18 at 12:30 PM, an interview with UR #3, a resident who wished to remain anonymous, who was in the dining room. UR #3 was asked if they noticed RI #19 with the catheter tubing exposed. UR #3 replied, yes and would try to avoid being around that resident because it was embarrassing to see. On 10/31/18 at 1:00 PM, an interview was conducted with Employee Identifier (EI) #3, Certified Nursing Assistant. EI #3 was asked what care RI #19 required. EI #3 replied, catheter care, help with shower and help with toileting. EI #3 was asked how RI #19 wore the catheter. EI #3 replied, out of the pants. EI #3 was asked how much of the catheter was visible. EI #3 replied, the catheter, the drain tubing and the drain bag. EI #3 reported RI #19 would not allow them to cover the catheter, tubing or the bag. EI #3 was asked if the nurse was made aware. EI #3 replied, yes. EI #3 was asked who could see the catheter, drain tubing and drain bag. EI #3 replied, anyone in the hall, on the porch or in the dining room, RI #19 walked everywhere. EI #3 was asked what was the harm in RI #19's foley catheter, drain tubing and drain bag being visible to residents and visitors. EI #3 replied, it was a dignity concern. On 11/1/18 at 8:30 AM, interview was conducted with EI #2, Registered Nurse. EI #2 was asked if RI #19 had a catheter. EI #2 replied, yes a suprapubic catheter. EI #2 was asked how should the catheter, tubing and drain bag be maintained. EI #2 replied, inside the clothing, a leg band for the tubing and the drain bag in a privacy bag. EI #2 was asked was the catheter, drain tubing and drain bag covered. EI #2 replied, no, RI #19 will have all out over the waistband of the pants. EI #2 was asked who could see the catheter, the drain tubing and drain bag. EI #2 replied, anyone RI #19 met in the hall, on the porch or in the dining room, other residents, or visitors. EI #2 was asked what was the harm in the catheter, drain tubing and drain bag being visible for all to see. EI #2 replied, it was visually unappealing and a dignity issue.

Based on observation, interview, record review and review of a facility policy titled, Resident Smoking, the facility failed to ensure a safe smoking assessment was completed for Resident Identifier (RI) #145 in a timely manner. Findings Include: A review of a facility policy titled, Resident Smoking, with a revised date of 7/2/18 revealed: .Policy: .6. All residents will be asked about tobacco use during the admission process, during each quarterly or comprehensive MDS (Minimum Data Set) assessment process. 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, . RI #145 was admitted to the facility 1/8/18 with a [DIAGNOSES REDACTED]. A review of RI #145's care plan dated 1/15/18 revealed, .is a smoker . Reassess residents' safety with smoking as indicated. A review of RI #145's Safe Smoking Assessment form, dated 10/11/18, revealed the form was completed. A form on the electronic health record dated 6/14/18 was reviewed which revealed a blank form, no date and no signature. On 10/31/18 at 11:15 AM, the surveyor observed RI #145 on the porch smoking with another resident. RI #145 was observed picking up an extinguished cigarette butt from the butt can on the porch. RI #145 placed the extinguished butt on the smoking apron. On 10/31/18 at 2:00 PM, a review of RI #145's Safe Smoking Assessments and Care Plan was conducted. A Safe Smoking Assessment, dated 6/14/18, on the Electronic Health Record was observed not completed. A Safe Smoking Assessment, dated 10/11/18, was completed. The surveyor asked for a printed copy of assessment dated [DATE] from the electronic record, which was not completed. On 10/31/18 at 5:15 PM an interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN). EI #1 reviewed the copy of the Safe Smoking Assessment that was not completed on the Electronic Health Record. EI #1 was asked if the assessment had been done. EI #1 replied, it appeared someone pulled it up but did not complete it. EI #1 was asked who was responsible for completing the smoking assessment. EI #1 replied, the RN on the unit or the RN on the resident admission would sometimes do it. EI #1 was asked how often smoke assessments were done. EI #1 replied, every quarter, and if there was a change in the resident status or if staff felt the resident to be unsafe. EI #1 was asked what were indicators to determine if residents were safe to independently smoke. EI #1 replied, the resident's short and long term memory should be ok, if the resident could verbalize what to do while smoking, how to light, and what to do with the equipment when finished smoking. EI #1 was asked what was the policy on resident cognitive status for independent smoking. EI #1 replied, the resident must be alert, know who they are, where they are, be able to light and dump ashes. EI #1 was asked what was the policy on resident smoking equipment. EI #1 replied, the resident was to return it to the nurse when finished. EI #1 was asked if RI #145 returned cigarettes and lighter promptly. EI #1 replied, yes. EI #1 was asked what were safe smoking measures. EI #1 replied, residents wear smoking aprons, return equipment, and staff to do assessments quarterly. If residents have a change, more often. EI #1 was asked when was RI #145's Smoking Assessment due. EI #1 replied, January, April, (MONTH) and one for October, after a change in status. EI #1 was asked if the (MONTH) Assessment was completed. EI #1 replied, no. EI #1 was asked if accurate assessments were completed. EI #1 replied, no. EI #1 was asked what was the risk of an assessment not being completed timely. EI #1 replied, the resident could have had a change, which could result in injury to self or another resident and the resident was not accurately assessed.

Based on record review, staff interviews, a record review of the facility's policy and procedure titled, Notification of Changes in Resident Status, the facility failed to ensure licensed staff notified Resident Identifier (RI) #1's physician and family that the resident had some bleeding after being toileted by staff. This affected RI #1, one of one resident sampled for a change in condition. Findings Include: A review of the facility's policy and procedure titled, Notification of Changes in Resident Status dated 03/01, revealed the following: . Policy: The residents family and/or attending . physician will be notified of any event . that might possibly require medical intervention . This notification should take place as soon as possible after the incident. 1. Attend to the immediate needs of the resident. 2. Alert MD (Medical Doctor) in regards to the incident and assessment findings, as indicated. 3. Alert the family or sponsor in regards to the incident and assessment findings . RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #1 had short and long term memory problems and was moderately impaired in cognitive skills for daily decision making. The MDS also assessed RI #1 as requiring extensive assistant with toileting and was frequently incontinent of bowel and bladder. On 11/14/17 at 4:00 PM, during an interview with Employee Identifier (EI) #8, Certified Nursing Assistant/CNA, EI #8 stated on 10/19/17, she reported to EI #7, Licensed Practical Nurse/LPN, after toileting RI #1 three times, she observed blood in the toilet and in the resident's brief. On 11/14/17 at 5:25 PM, during an interview with EI #9, LPN, EI #9 stated EI #8 informed her on 10/19/17 that RI #1 had some blood in the toilet and in RI #1's brief after being toileted. The surveyor asked when was the physician and the resident's family/sponsor notified. EI #9 stated she did not know when the family or the physician was notified. On 11/15/17 at 3:20 PM, during an interview with EI #7, stated on 10/19/17, EI #8, informed her that she (EI) #8 saw blood in the toilet and in RI #1's brief after the resident was toileted. EI #7 stated she did assess the resident, but did not document her assessment. EI #8 also stated she did not notify RI #1's doctor or RI #1's sponsor/family regarding EI #8's report of the resident's bleeding.

Based on observation, a review of a facility's policy, without a title, and staff interview, the facility failed to ensure licensed staff did not leave privacy screen up and open to public view. This affected one of five nurses observed during medication administration and one of four halls. Findings Include: A review of a facility policy, without a title, dated 11/16/2017 documented: . Policy: (name of facility) will keep residents Protected Health Information private and confidential. Procedure: Prior to leaving the area of the medication cart nurses will push the privacy screen button at the bottom of the computer causing the computer screen to lock and black out, no longer displaying resident health information. On 11/14/17 at 12:29 PM, the following was observed on the hall: Employee Identifier (EI) #6, Licensed Practical Nurse/LPN. EI #6 left the medication cart with the Medication Administration Record [REDACTED]. Other facility staff observed on the hall. An interview was conducted with EI #6 on 11/14/2017 at 12:30 p.m. EI #6 was asked what did she do when she stepped away from the medication cart. EI #6 said she did not close the privacy screen. EI #6 was asked what should she have done prior to leaving the medication cart. EI #6 said ensure the privacy screen was on due to resident confidentiality. EI #6 also stated the medication the cart was not in her view at all times.

Based on staff interviews and a review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation Prohibition Policy, the facility failed to ensure licensed staff reported and an investigation was completed regarding an allegation of physical and verbal abuse. This affected Resident Identifier (RI) #32, one of two residents sampled for Abuse. Findings Include: A review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation Prohibition Policy revealed the following: . III. Procedure for Reporting Alleged Abuse & (and) Neglect a) Report any suspected abuse and/or neglect to your direct supervisor, . IMMEDIATELY. b) The facility has 2 hours to report allegations of abuse, neglect, . or mistreatment . to ADPH (Alabama Department of Public Health) . a) Abuse, Neglect, & . b) All allegations of abuse and/or neglect MUST be reported to your immediate supervisor; . IMMEDIATELY. A review of the facility's investigation submitted to the State Agency on 10/23/17, regarding mistreatment of [REDACTED].#10, Licensed Practical Nurse/LPN, revealed the following: 10/24/17 (EI #10) . On Sunday night in the dining room, (EI #7 (LPN)), was hollering at the residents and sat down by (RI #32) and began poking food in (RI #32) mouth, saying take it, eat it, you could here (hear) her down the hall. I told (EI #7) to leave resident alone that I would feed her in a few minutes. RI #32 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/2017 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS also assessed RI #32 as requiring total assistance for all Activities of Daily Living (ADL) and was assessed as having a swallowing disorder. In an interview on 11/15/2017 at 11:13 a.m., EI #10 said on 10/22/2017, she observed EI #7, LPN, in the dining room feeding RI #32. EI #7 was hollering at the resident while feeding the resident. RI #32 had food coming out the sides of her/him mouth because EI #7 was putting too much food in RI #32's mouth. EI #10 also stated the resident was turning him/her head away when EI #7 was packing food in the resident's mouth and saying to the resident in a loud voice, take it and eat it. EI #10 was asked if she reported this incident and she said she did not because she was busy. EI #10 was asked what would this be considered as. EI #10 said putting too much food in someone's mouth would be considered abuse.

Based on staff interviews and record review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation Prohibition Policy, the facility failed to ensure an allegation of abuse were reported to the State Agency within two hours. This affected RI #1, one of two residents sampled for Abuse. The facility further failed to ensure licensed staff reported an observation of staff being physically and verbally abusive to RI #32. This affected RI #32, one of two residents sampled for Abuse. Findings Include: A review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation Prohibition Policy revealed the following: . III. Procedure for Reporting Alleged Abuse & (and) Neglect a) Report any suspected abuse and/or neglect to your direct supervisor, . IMMEDIATELY. b) The facility has 2 hours to report allegations of abuse, neglect, exploitation or mistreatment . to ADPH (Alabama Department of Public Health) . a) Abuse, Neglect, & . b) All allegations of abuse and/or neglect MUST be reported to your immediate supervisor; . IMMEDIATELY. A review of ADPH Online Incident Reporting System revealed the following: . Date/Time Submitted: Monday, October 23, 2017 . Incident Type . Mistreatment . Names of resident(s) involved: (RI #1) . Narrative summary of incident: Report received today 10/23/17 that on 10/17/17 (10/19/17) at 04:40 p.m., (EI #7) LPN was considered to be rough as observed by (EI#8), CNA when attempting to obtain an in and out catheter on this resident. 1. RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #1 had short and long term memory problems and was moderately impaired in cognitive skills for daily decision making. The MDS also assessed RI #1 as requiring extensive assistant with toileting and was frequently incontinent of bowel and bladder. On 11/14/17 at 4:00 PM, during an interview with Employee Identifier (EI) #8, Certified Nursing Assistant/CNA, EI #8 stated on 10/19/17, she reported to EI #9, LPN, that during an in and out cath on RI #1, EI #7 had pulled RI #1's perineal area and the resident started screaming. EI #8 also stated that she informed EI #9 that EI #7 had been verbally abusive to the resident during the catheter procedure. EI #8 also stated on 10/21/17 she reported the same incident to EI #11, Registered Nurse/RN Supervisor. On 11/14/17 at 5:25 PM, during an interview with EI #9, EI #9 stated EI #8, CNA, informed her that during a catheter procedure on RI #1, EI #7, LPN, was rough and the resident was complaining that he/she was hurting. EI #9 stated she told EI #7 that EI #8 had done wrong and that she needed to report the information to the RN Supervisor. EI #9 stated she did not report this information to no one. When asked why she did not report this information to any one. EI #9 replied, I was not thinking this way. On 11/16/17 at 8:30 AM, during an interview with EI #11, EI #11 stated on 10/21/17, EI #8 did report to her the incident regarding EI #7 catheterizing RI #1. EI #11 stated she did not report the above incident because she felt like EI #8 had already reported the incident. EI #11 also stated she did not follow up on the information received by EI #8 to ensure the report had been done. EI #11 also stated she should have made administration aware as soon as the report was given to her from EI #8, because this was an allegation of abuse. EI #11 stated it was the responsibility of the shift supervisor to ensure residents care was provided as ordered and to ensure residents are safe, but that was not done during her shift. Based on medical record review, review of a facility policy titled Abuse, Neglect, and Exploitation Prohibition Policy and staff interview the facility failed to ensure Licensed staff reported an investigate of physical and verbal abuse. This affected Resident Identifier (RI) #32, one of two residents sampled for abuse. Findings Include: A review of a facility policy titled Abuse, Neglect, and Exploitation Prohibition Policy with a review and revised date of 11/2016 documented: . Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations.7. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency . RI #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/2017 revealed RI #32 Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS further revealed RI #32 was totally dependent for all Activities of Daily Living (ADL) and was checked for having a swallowing disorder. In an interview on 11/14/2017 at 5:25 p.m., Employee Identifier (EI) #9 Licensed Practical Nurse (LPN) was asked when were you aware that RI #32 had some bleeding after catherization had been attempted. EI #9 said I did not know about the bleeding but Employee Identifier (EI) #8 Certified Nursing Assistant (CNA) had told me that the nurse was rough and the resident had stated he/she was hurting and crying when the nurse had attempted the catherization and the nurse had continued to try and catherize RI #32. EI #9 said she had not reported this incident to anyone because I was not thinking this way. EI #9 was asked when did she assess the resident. EI #9 said I did not assess the resident and the doctor and family were not notified. In an interview on 11/15/2017 at 11:13 a.m., EI #10 LPN said that EI #8 CNA had made her aware of the catherization that was attempted several times by the nurse and EI #8 had seen some bleeding, but she never assessed RI #32's peri-area I did report this to EI #11 Registered Nurse (RN) Supervisor. EI #10 said on 10/22/2017 the same nurse was in the dining room feeding RI #32, and was hollering at the resident while feeding the resident. RI #32 had food coming out the sides of her/him mouth because she was putting to much food in RI #32's mouth at a time. EI #10 was asked if she reported this incident and she said she did not because she was busy. EI #10 was asked what was, or might be considered abuse. EI #10 said putting to much food in someone's mouth would be abuse. EI #10 said she did not report this incident.

Based on record reviews, staff and residents interviews, the facility failed to meet residents' interest on weekends with a variety of activities. This affected two of nine residents, Resident Indentifer (RI) #20 and RI #22, two of nine residents present during resident council. Findings Include: On 11/16/2017 at 10:45 a.m., a review of residents activity calendars for the weekend activities revealed the following: September 2017 9/3/2017-all religious activities 9/10/2017-all religious activities 9/24/2017-all religious activities November 2017 11/04/2017-all religious activities 11/05/2017-all religious activities 11/12/2017-all religious activities 11/26/2017-all religious activities On 11/14/2017 at 3:30 p.m., a Group Meeting was held. During the Group meeting there were nine residents in attendance. Residents voiced that the quality of the activities had declined. On weekends there was nothing but religious activities. Residents voiced they would like to have more than just religious activities on the weekend. 1. RI #20 was admitted to the facility 09/05/2012 with a [DIAGNOSES REDACTED]. A review of RI #20's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. A review of a facility's interview obtained from RI #20 documented RI #20 would like to go on shopping trips to the mall. On 11/15/2017 at 5:05 p.m., an interview was conducted with RI #20. RI #20 was asked how he/she felt that there were no activities besides church functions on the weekends. RI #20 stated he/she felt there were not enough activities stimulating to him/her. RI #20 was asked what he/she would enjoy doing on Saturdays and Sundays that was currently not available. RI #20 stated that Bingo would be fun. RI #20 was asked if he/she felt there should be more activities than church activities on Saturdays and Sundays. RI #20 answered, Yes. RI #20 was asked if he/she told anyone about him/her concerns related to activities. RI #20 replied that he/she had told Activities personnel. 2. RI #22 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the RI #22's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #22 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. A review of a facility's interview obtained from RI #22 documented RI #22 would like to go on bowling trips. On 11/16/2017 at 7:57 a.m., an interview was conducted with RI #22. RI #22 was asked should there be more activities than church on Saturdays and Sundays. RI #22 said yes. RI #22 was asked if she had told anyone about her activity concerns. RI #22 stated he/she had informed the Activities Director a few weeks ago. When asked if there was some activity he/she would like to do on Saturdays and Sundays other than what was offered or available. RI #22 stated yes, fishing trips, eating out and shopping trips. On 11/16/2017 at 2:02 p.m., an interview was conducted with Employee Identifier (EI) #3, Activity Assistant. EI #3 was asked who was responsible for providing activities per resident's request. EI #3 replied the Activity Director. According to EI #3, there had been no request from the residents since the Activity Director left the position. EI #3 was asked if she had received any complaints regarding the quality of the activities. EI #3 stated that she was not aware of any complaints. EI #3 stated that most singing and Bible activities are enjoyed by the residents, as well as arts and crafts. EI #3 was asked if she was aware of complaints regarding too much religious activities. EI #3 said she was not aware of any concerns of too many religious activities. The surveyor reviewed the facility calendars with EI #3. The surveyor showed EI #3 the activities on the weekends and asked what was available on the weekends. EI #3 stated church was offered, singing and devotional. EI #3 was asked if there were any activities besides singing, devotional and church. EI #3 responded nothing was available other than these activities. EI #3 was asked should there be more activities available on weekends besides devotion, singing and church. EI #3 replied yes it should be. EI #3 was asked what was the responsibility of the Activities Department regarding residents and activities. EI #3 stated to provide activities based on residents' preferences.

Based on interview, a record review of the facility's policy and procedure titled, Notification of Changes in Resident Status, the facility failed to ensure licensed staff assessed Resident Identifier (RI) #1 after staff reported the resident had bleeding after being toileted three times. This affected RI #1, one of one resident sampled for a change in condition. Findings Include: A review of the facility's policy and procedure titled, Notification of Changes in Resident Status dated 03/01, revealed the following: . Policy: 1. Attend to the immediate needs of the resident. RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #1 had short and long term memory problems and was moderately impaired in cognitive skills for daily decision making. The MDS also assessed RI #1 as requiring extensive assistant with toileting and was frequently incontinent of bowel and bladder. On 11/14/17 at 4:00 PM, during an interview with Employee Identifier (EI) #8, Certified Nursing Assistant/CNA, EI #8 stated on 10/19/17, she reported to EI #7, Licensed Practical Nurse/LPN, that after toileting RI #1 three times, she observed blood in the toilet and in the resident's brief. EI #8 also stated she reported this information to EI #9, LPN on 10/19/17 and EI #11, Registered Nurse/RN Supervisor, on 10/21/17. On 11/14/17 at 5:25 PM, during an interview with EI #9, EI #9 stated EI #8 informed her on 10/19/17, that RI #1 had some blood in the toilet and in RI #1's brief after being toileted. The surveyor asked when did she (EI #9) assess the resident. EI #9 replied she did not assess the resident. On 11/15/17 at 3:20 PM, during an interview with (EI) #7, LPN, stated on 10/19/17, EI #8, ,CNA, informed her that she (EI) #8 saw blood in the toilet and in RI #1's brief after the resident was toileted. EI #7 stated she did assess the resident, but did not document her assessment. On 11/16/17 at 8:30 AM, during an interview with EI #11, RN Supervisor, EI #11 stated on 10/21/17, EI #8 reported to her the incident regarding EI #7 catheterizing RI #1. The surveyor asked when did she assess the resident after EI #8 informed her that the resident had some bleeding episodes on 10/19/17 after being toileted three times. EI #11 stated she did not assess the resident. When asked what was her responsibility as shift supervisor. EI #11 replied to ensure resident care is provided as ordered and residents are safe. EI #11 stated but that was not what she had done during her shift.

Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #8 had a medical [DIAGNOSES REDACTED]. This affected one of five residents sampled with the use of a catheter. Findings Include: RI #8 was readmitted to the facility on [DATE] with an indwelling Foley Catheter. Admitting [DIAGNOSES REDACTED]. A wound assessment completed on 10/31/17 identified the Stage 2 areas to both the right and left inner buttocks had resolved, with one remaining open area, 0.2 x 0.2 (centimeter/cm) related to yeast. Bowel status was identified as incontinent. The care plan dated 10/24/17 remained in place for the use of the indwelling catheter, due to WCM (Wound Care Management). The Wound Assessment Form dated 11/13/17 included the following: (IDENTIFIED 11/9/2017 IN HOUSE) STAGE 2 ACROSS MID SACRUM DOWN RIGHT BUTT(NAME)KS A 14.0 CM RAISED RED AREA WITH MULTIPLE <0.1 (less than 0.1 cm) MOIST PINK AREAS WITHIN, NO DRAINAGE, TENDER TO TOUCH, PERIWOUND SKIN INTACT NORMAL FOR RESIDENT.RESIDENT HAS HAD FOLEY CATH IN PLACE FOR WCM D/T (due to) EXCORIATION AND OPEN AREAS R/T (related to) YEAST. On 11/14/17 at 11:00 a.m., perineal care was provided by a Nursing Assistant and observed by the surveyor. No skin irritation was noted in the perineal, buttocks, or thigh areas. On 11/14/17 at 11:05 a.m., wound care was provided by Licensed Nursing staff in the presence of a surveyor. One Stage 2 area 13.6 cm X (by) 1.3 cm (no depth), which included multiple open areas each less than 0.1 cm was observed on RI #8's coccyx and right buttock. The Unit Manager (Employee Identifier/EI #4) responsible for RI #8 was asked on 11/15/17 at 1:15 p.m., what [DIAGNOSES REDACTED]. EI #4 stated, Wound Care Management, excoriation with yeast in the abdominal folds and thighs, and a 0.2 cm open area to the left buttock. EI #4 also clarified the resident had never had a Stage 3 or greater pressure area on this admission or any previous admission. On 11/15/17 at 3:11 p.m., the Medical Director (EI #5) affirmed RI #8 had a skin irritation caused by yeast from the use of oral antibiotics. When asked if he was aware that Federal guidelines required the presence of a Stage 3 or greater pressure ulcer prior to the use of a Foley catheter, EI #5 replied, Yes. The surveyor explained the observation of perineal care earlier that morning, finding no skin irritation in the perineal area, and asked whether that would justify the continued use of the catheter. EI #5 responded the resident still had an area on the sacrum and right buttocks.

Based on observations, staff interviews and a record review of a facility's policy titled, Blood Glucose Monitoring- Fingerstick (Germicidal Cleaning of Glucose Monitor), the facility failed to ensure: 1. A Licensed Practical Nurse (LPN) wore gloves while performing a fingerstick blood sugar check on Resident Identifier (RI) #31 during observation of medication administration; This affected one of one resident's sampled who received a finger stick blood sugar, and 2. A hospice CNA (Certified Nursing Assistant) did not transport soiled bed linens down the hall in a plastic bag. This affected one of four residents sampled for activities of daily living and one of three residents observed during incontinent care Findings Include: A review of the facility's policy and procedure titled, Blood Glucose Monitoring - Fingerstick (Germicidal Cleaning of Glucose Monitor) dated 04/26/10, revealed the following: . Procedure: . 5 . DON gloves, . 1. RI #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/17 revealed RI # 31 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. On 11/14/2017 at 3:40 p.m., the following was observed: Employee Identifier (EI) #1, LPN washed her hands and obtained a fingerstick blood sugar check on RI # 31. EI #1 did not wear gloves prior to and during the blood sugar check for RI # 31. On 11/14/17 at 3:42 p.m., an interview was conducted with EI # 1. EI #1 was asked why should she wear gloves when checking blood glucose levels. EI#1 replied for my own protection and to protect the resident. EI #1 was asked did she wear gloves when she check RI #31's blood sugar. EI #1 answered no. EI #1 was asked what the potential for harm is in not wearing gloves when checking blood sugar levels. EI #1 stated cross contamination. EI #1 was asked what the facility's policy was for wearing gloves when checking blood sugars. EI #1 responded we are supposed to wear gloves every time we check it. On 11/16/17 at 8:00 a.m., an interview was conducted with the Infection Control Nurse, EI #2. EI #2 was asked to describe how nurses should check blood sugar levels. EI #2 replied, they should gather equipment and clean items, all supplies, barrier down, and wear gloves. EI #2 was asked should nurses wear gloves during blood sugar checks. EI #2 replied yes. EI# 2 was asked what was the potential for harm when a nurse does not wear gloves to perform blood sugar checks. EI# 2 stated risk of spreading bacteria or germs from one resident to another. 2. A review of the Hospice Services Agreement with an effective date of 2/18/2009 revealed: . 2A. Responsibilities of HOSPICE . 2.08A Hospice Services. HOSPICE will provide services at the same level and to the same extent as those services would be provided if the FACILITY . 2.12A Policies and Procedures. HOSPICES established policies and patient care procedures . RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/14/17 at 4:30 p.m., Hospice CNA was observed transporting soiled bed linens from RI #12's room down the hall to the soiled utility room. The linens were not in a plastic bag. On 11/14/17 at 4:40 p.m., an interview was conducted with the Hospice Aide. She was asked, how was she trained to transport soiled linens to the soiled utility room. The Hospice Aide replied in a plastic bag. The Hospice Aide was asked if she had the soiled linens in a plastic bag. She replied no. The Hospice Aide was asked what the harm was in carrying soiled linens not in a plastic bag down the hall. Hospice Aide replied contamination. On 11/15/17 at 3:55 p.m., a phone interview was conducted with the Hospice Nurse supervising the hospice CNA. She was asked how should the hospice aide transport soiled bed linens down the hall to the soiled utility room. The Hospice Nurse replied in a plastic bag. She was asked who trained the Hospice CNA's. The Hospice Nurse replied the Hospice staff had quarterly training by the Hospice facility. The Hospice Nurse was asked what the harm was in a hospice CNA transporting soiled linens down the hall not in a plastic bag. The hospice nurse replied it would be an infection control issue. On 11/15/17 at 4:30 p.m., an interview was conducted with EI #2, Infection Control Nurse. EI #2 was asked if Hospice services was contracted by the facility and if so who trained them. EI #2 replied the Hospice staff was trained through the Hospice company. EI #2 was asked how should soiled linens be transported down the hall. EI #2 replied in a plastic bag. EI #2 was asked what was the harm in transporting soiled linens down the hall not in a plastic bag. EI #2 replied the possibility of transmitting germs to other residents.