Every finding on record at Fair Oaks Health and Rehabilitation

Based on interview, and review of facility documentation, the facility failed to ensure the Director of Nursing (DON) was not assigned to work as a floor nurse when the facility had an average daily census of more than 60 residents, which had the potential to affect all residents in the facility.The findings include: In interview on 04/30/2026 at 12:15 PM, the Administrator stated the facility did not have a policy related to the DON working as a floor nurse when the average daily census was more than 60 residents. Review of the facility's April 2026 Daily Densus Report documentation revealed the facility's census was greater than 60 on the following dates as follows:- 04/10/2026- 105 residents- 04/11/2026- 105 residents- 04/12/2026- 105 residents- 04/14/2026- 104 residents- 04/20/2026- 104 residents- 04/23/2026- 105 residents- 04/24/2026- 104 residents- 04/25/2026- 105 residents- 04/26/2026- 105 residents. Review of the facility's nursing schedules for the timeframe of 04/01/2026 through 04/28/2026, revealed the DON worked as a floor nurse on 04/10/2026, 04/11/2026, 04/12/2026, 04/14/2026, 04/20/2026, 04/23/2026, 04/24/2026, 04/25/2026, and 04/26/2026. Which the review of the facility's Daily Census Report documentation revealed the facility's occupancy had been more than 60 residents. During interview on 04/29/2026 at 11:55 AM, Regional Nurse stated the DON had been in that position since 03/09/2026. During interview on 04/29/2026 at 10:17 AM, the facility's Scheduler stated the DON had to work as a floor nurse if there were call-ins or if they did not have someone available to work a shift. In an additional interview on 04/30/2026 at 11:00 AM, the Scheduler stated if a staff member's name was listed on the facility's schedule, then that person worked on those dates. In the interview on 04/30/2026, the Scheduler verbally confirmed the DON had worked on the dates referenced on the schedules for April 2026. During interview on 04/29/2026 at 11:40 AM, the DON stated she had been working in her current position since 03/09/2026. She reported she had worked as a floor nurse on the dates she was listed to have worked on the April 2026 on the nursing schedules. The DON explained on those dates she had been responsible for a unit of residents and for administering those residents' medications. She said she also provided care for those residents on those dates, and verbally confirmed the facility's census had been more than 60 residents on those dates. During interview on 04/30/2026 at 11:24 AM, the Administrator stated she expected the DON to lead the facility's nursing department, and meet her requirements as the DON. She further stated she had no comment, in regard to her expectation of the DON working as a floor nurse when the facility census was greater than 60 residents.

Based on interview, record review, review of medication manufacturer's recommendations, and review of facility policy, the facility failed to ensure a resident's drug regimen was free from unnecessary medications for 1 of 5 residents sampled for unnecessary medication, out of the total sample of 49, (Resident (R)7). The findings include: Review of the facility policy titled, Medication Orders, revised 01/2026, revealed the steps to be initiated: transcribing newly prescribed medications on the residents' Medication Administration Record (MAR) or Treatment Administration Record (TAR) or electronic medical record (EMR). Per review, when a new order changed the dosage of a previously prescribed medication, the previous entry was to be discontinued by writing DCd [discontinued]' and the date and highlighting the entry in yellow. Further policy review revealed the new order was to be entered on the MAR/TAR/electronic medical record. Review of the medication, LIPITOR's (a brand name of atorvastatin) manufacturer's Highlights of Prescribing Information, revised 04/2024, revealed under, Dosage and Administration, the policy noted adults recommended starting dosage was 10 to 20 milligram (mg) once daily, and the dosage range was 10 mg to 80 mg once daily. Per review of the Highlights of Prescribing Information, under the 8.5 Geriatric Use, it documented for advanced age, [AGE] years of age or older, there was a risk factor for LIPITOR-associated myopathy and rhabdomyolysis. Continued review revealed the dose selection for an elderly patient was for caution, recognizing the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy and the higher risk of myopathy. Review of the Resident Face Sheet revealed the facility admitted R7 on 10/25/2019, with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris (presence of plaque in the native coronary arteries without chest pain), and hyperlipidemia (elevated lipid levels). Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/12/2026, revealed the facility assessed R7 to have a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severe cognitive impairment. Review of R7's Care Plan revealed it included a problem statement, initiated 06/11/2023, noting the resident had a potential for alteration in cardiac function related to diagnoses including hyperlipidemia and coronary artery disease with previous stent placement. Further review revealed the interventions included for staff to provide medications as ordered (initiated 06/11/2023). Review of R7's Order History, for the timeframe from 11/01/2025 to 04/28/2026, revealed the orders included an order dated 11/26/2022, for atorvastatin 80 mg, one tablet every night at bedtime. Continued review revealed the Order History noted the atorvastatin 80 mg order was discontinued on 02/06/2026. Review of R7's Progress Note, dated 01/23/2026 at 4:41 PM, and electronically signed by Licensed Practical Nurse (LPN) 3, revealed the nurse received a new order to decrease the resident's atorvastatin dosage to 40 mg. Review of R7's January 2026, MAR revealed a transcription of an order for atorvastatin 80 mg by mouth at bedtime, with the original start date of 11/26/2022. Per review however, the atorvastatin 80 mg order was not discontinued after receival of the order for the atorvastatin dosage to be changed to 40 mg. Continued review revealed the MAR noted transcription of an order for atorvastatin 40 mg by mouth once nightly between 7:00 PM and 11:00 PM, that was started on 01/24/2026. Further review of the January MAR revealed staff documented R7 to have received both dosages (80 mg and 40 mg), totaling 120 mg, from 01/22/2026 through 01/31/2026. Review of R7's February 2026 MAR revealed staff documented the resident as receiving both dosages from 02/01/2026 through 02/05/2026. Further review of the February MAR revealed the atorvastatin 80 mg dose was discontinued on 02/06/2026. Review of R7's Progress Note, dated 02/06/2026 at 5:04 PM, electronically signed by LPN 3, revealed the nurse received an order to discontinue the atorvastatin 80 mg dose. In interview on 04/30/2026 at 11:01 AM, Certified Medication Aide (CMA) 6, who documented on R7 receiving the 40 mg dose and 80 mg dose of the atorvastatin 10 times between 01/22/2026 and 02/05/2026, stated her role was to administer medications according to the orders on the residents' MAR. She further stated she only documented her medication administration after observing the residents take their medication. In interview on 04/29/2026 at 5:13 PM, LPN 3 stated when a provider decreased a medication dose, the process required discontinuing the higher dose and entering a new order for the lower dose. She reported she could not recall the specific orders from January or February for R7; however, if she had not discontinued R7's 80 mg dose of atorvastatin, it must have been an oversight on her part. In interview on 04/30/2026 at 12:44 PM, the Nurse Practitioner (NP) stated she followed the clinical guidelines that recommended elderly residents generally did not require high dose statin therapy. She reported she expected the facility to discontinue a higher dose of medication when she ordered to stop those medications. The NP said however, she could not recall issuing the orders to decrease R7's statin medication or ordering to discontinue the 80 mg dose of it. In interview on 04/30/2026 at 9:25 AM, the Director of Nursing (DON) stated staff reviewed all new orders during the facility's daily clinical meetings to ensure accuracy. She further stated when a provider ordered to decrease a medication dose, staff should discontinue the higher dose of the medication. In interview on 04/30/2026 at 3:44 PM, the Regional Nurse stated the clinical interdisciplinary team reviewed newly entered orders during the facility's daily clinical meetings to ensure accuracy, confirm family notification, and verify proper entry into the electronic health record. She further stated she believed staff overlooked the order to discontinue R7's atorvastatin 80 mg during the daily clinical review process. During interview on 04/30/2026 at 1:03 PM, the Administrator stated medication entry and administration were outside her scope of practice and she deferred that responsibility to the DON. She further stated she expected staff to follow the facility's policies and procedures.

Based on interview, record review, and facility policy review, the facility failed to ensure staff transcribed physicians' orders into the orders of residents' electronic medical record (EMR) for 1 of 1 residents sampled for constipation concerns out of the 49 total sampled residents (Resident (R)110).The findings include: Review of the facility policy titled, Medication Orders, revised 01/2026, revealed, under the section titled, New Handwritten Orders, received from an office visit and sent with the resident were to be noted by the nurse on duty at the time the order was received. Per review, the nurse on duty was also to enter the order on (the resident's) physician order sheet/ telephone order sheet, and electronic medical record (EMR). Continued policy review revealed the nurse on duty at the time the order was received was to also note the order as follows: ['Noted 3:00 p.m., 5/17/2011 (nurse name and title)']. Further policy review revealed if the order was from a prescriber other than the (resident's) attending physician, the order was to be verified with the current attending physician. Review of R110's hospital Discharge Documentation, dated 04/24/2026, revealed the resident's most recent bowel movement to that date had been on 04/21/2026 (three days prior to hospital discharge). Facility record review revealed R110 was admitted to the facility from the hospital. Review of the facility's, Resident Face Sheet, for R110 revealed the facility admitted the resident on 04/24/2026, with diagnoses that included left lower leg fracture and chronic pain syndrome. Review of R110's Care Plan, revealed, the facility identified included a problem of constipation that was initiated 04/27/2026, noting the resident had constipation related to impaired mobility. Continued review of the constipation problem care plan revealed the interventions included directing staff to administer medications as per orders and observing R110 for effectiveness and side effects (initiated 04/27/2026). Review of the facility's telehealth record for R110, dated 04/25/2026 at 8:56 AM, revealed a nurse contacted the telehealth provider to request pain medication on behalf of the resident. Continued review revealed the record noted the Orders included the following medication:- polyethylene glycol (a laxative) 17 grams daily for three days, then as needed (PRN);- magnesium hydroxide (a laxative) PRN for no bowel movement;- docusate (a laxative) 100 mg twice daily; and- bisacodyl (a laxative) 10 mg suppository PRN. However, review of R110's Order History, for the timeframe from 04/25/2026, through 04/30/2026, revealed no documented evidence staff transcribed the laxative orders into the resident's EMR. During interview on 04/29/2026 at 10:52 AM, Licensed Practical Nurse (LPN) 5 stated when using telehealth providers, the providers verbally communicated the orders and subsequently sent written documentation. She said the nurse was responsible for entering the orders received into the residents' EMR. LPN 5 reported on the day the laxative orders were received for R110, she had been focusing on obtaining and administering the resident pain medications. She further stated having been focused on the pain medication she failed to enter the orders for the laxatives into R110's EMR. During interview on 04/30/3036 at 3:56 PM, Unit Manager (UM) 1 stated she began her current role in March 2026 and was still learning the facility's processes. She reported in the facility's interdisciplinary team (IDT) meetings recent events, orders entered, and progress notes were reviewed. UM 1 said she was not sure whether she could access the telehealth providers' notes. She further stated she had not noticed the new orders for laxatives for R110 or that the orders had not been entered into the resident's EMR. During interview on 04/30/2026 at 9:25 AM, the Director of Nursing (DON) stated she expected nursing staff to have entered R110's orders into the resident's EMR if the resident was to receive the medication. During interview on 04/30/2026 at 12:44 PM, the Nurse Practitioner (NP) stated nurses could implement telehealth orders immediately, as they originated from licensed providers. She further stated she then reviewed the orders she had given on her next facility visit to ensure the appropriateness of the orders. During interview on 04/30/2026 at 1:03 PM, the Administrator stated medication order entry was outside her scope of practice. She said therefore, she deferred responsibility of that to the DON. The Administrator further stated she expected staff to follow the facility's policies and procedures.

Based on interview and facility document review, the facility failed to post nurse staffing data for each shift to include the resident census and the total and actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care.The findings include:In interview on 04/30/2026 at 12:15 PM, the Administrator stated the facility had no policy related to posting of nurse staffing information.Observation of the facility on 04/27/2026 at 9:05 AM and 04/28/2026 at 2:15 PM, revealed the facility's daily nursing schedule was posted. However, additional observation revealed the posting did not include the resident census, nor the total number and actual hours worked for Licensed Practical Nurses (LPN), Registered Nurses (RN), or the Certified Nursing Assistants (CNAs). During interview on 04/30/2026 at 11:00 AM, the facility Scheduler stated she always posted the daily nursing schedule. She further stated however, she was not aware there were posting requirements.During interview on 04/29/2026 at 10:00 AM, the Administrator stated she had never put the resident census, projected hours, or staff discipline on the facility's daily staff posting.

Based on observation, interview, and record review the facility failed to ensure that two of 25 sampled residents (Resident 19 and Resident 20) were treated with dignity and respect and were able to exercise their rights in a manner that upheld their individuality and quality of life. Staff failed to ensure timely assistance with grooming, hygiene, food clean up, and linen changes. These failures resulted in residents experiencing unclean conditions, emotional discomfort, and dissatisfaction with their care. The findings include: The facility's Resident Rights policy (revised 03/22/2025) revealed that all residents have the right to be treated with dignity and respect. Section 4 stated that residents have the right to hygiene and grooming support that promotes personal dignity, including shaving and bathing, and that staff are responsible for ensuring such rights are upheld. Record review of Resident (R) 19's Resident Face Sheet revealed that R19 was admitted to the facility on [DATE] with diagnoses of leukemia, hemiplegia, dysphagia, aphasia, and anxiety. Record review of R19's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/202, revealed that R19 had a Brief Interview for Mental Status (BIM) score of 3/15, which indicated that R19's cognitive ability was severely impaired. The MDS further revealed that R19 required extensive assistance with hygiene and meals. Record review of R20's Resident Face Sheet revealed that R20 was admitted to the facility on [DATE] with diagnoses of COPD, dementia, and heart failure. Record review of R20's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2025, revealed the R20 had a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated that R20 had a moderate cognitive impaired. It further revealed that R20 required extensive assistance with hygiene and meals. Observation of R19 on 04/14/2025 at 4:35 PM revealed that R19 had dried food stains on R19's face and food particles on his gown, chest, and bedding. Observations of R20 on 04/14/2025 at 4:14 PM revealed that he had orange food stains on his face and biscuit crumbs on his chest, gown, and bed linens. Further observation revealed that the right handrail on his bed was soiled with food stains and particles. Observation of R20 on 04/15/2025 at 3:30 PM revealed that R20 was asleep in bed with orange food stains on his face, side rail, clothing protector, and blanket. Observation of R20 on 04/16/2025 at 8:45 AM revealed that he was lying in bed with no meal tray in the room, visible gravy on his face, and a clothing protector still in use. During an interview with the unit manager on 04/14/2025 at 4:35 PM, she stated that the staff is expected to clean the residents' faces as they pick up the meal trays. She continued to state that staff must have skipped over R19 and R20 when cleaning up after meals. She further stated that residents feel better if they are clean. During an interview with R20 on 04/14/2025 at 6:55 PM, he stated that when he was clean, he felt better about himself and more presentable. R20 further stated that having the food on him made him feel dirty and if he had a mirror, then he would feel embarrassed. During the interview on 04/16/2025 at 4:06 PM, CNA 5 stated that staff cleaned the resident's face as they picked up the resident's meal tray. She further stated that leaving the residents with food stains on their faces and crumbs in their beds probably embarrasses them. During an interview on 04/16/2025 at 1:03 PM, the Administrator stated that cleaning the residents' faces after meals had been a concern in the facility in the past, and staff were educated on it. She further stated that she expected every resident to be treated with dignity and cleaned in a timely manner after each meal.

Based on observation, interview, record review and review of facility policy it was determined the facility failed to provide adequate supervision to prevent resident to resident incidents for four (4) of eight (8) sampled residents, Resident #1, Resident #2, Resident #5, and Resident #7. Review of Resident #1's medical record, and interviews with staff and Resident #7, revealed Resident #1 exhibited behaviors of wandering into other residents' rooms, making sexually inappropriate comments, getting into bed with another resident and touching other residents on their leg and buttock. However, record review revealed no documented evidence the facility provided an increased level of supervision for Resident #1 to protect him/her and other residents from potential incidents/accidents. The findings include: Review of the facility's policy titled, Accidents and Supervision last reviewed on 03/23/2022 revealed the resident's environment would remain as free from accident hazards as is possible and each resident would receive adequate supervision to prevent accidents. According to the policy the facility would identify, evaluate and analyze hazards and risks in the facility. The policy also stated interventions would be implemented and monitored for effectiveness and modified when necessary. The policy defined risk as any external factor, facility characteristic or the characteristic of an individual resident that influenced the likelihood of an accident. 1(a). Review of Resident #1's medical record revealed the facility admitted the resident on 03/11/2022, with diagnoses including Unspecified Dementia with Behavioral Disturbances. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated his/her cognitive status was severely impaired. Review of the progress note for Resident #1, dated 03/12/2022 at 6:45 PM, revealed that Licensed Practical Nurse (LPN) #1 documented the resident wandered and he/she was intrusive, going into other residents' rooms. Continued review of the Note revealed LPN #1 noted the resident redirects well however resumes wandering behavior with intrusion into others rooms shortly after redirection. Review of the progress note for Resident #1, dated 03/12/2022 at 7:03 PM, revealed LPN #1 documented implementation of an intervention for the resident to be in line of sight at all times while awake and out of bed related to his/her wandering and intrusion into others rooms. Observation on 04/18/2022 at 2:00 PM, of Resident #1 revealed the resident was ambulating in his/her room with a staff person providing one on one (1:1) supervision. Interview, at the time of the observation, was attempted with Resident #1 regarding the alleged incidents; however, the resident was unable to answer questions. Continued observation on 04/18/2022 at 2:10 PM of Resident #1, revealed the resident ambulated outside his/her room, being accompanied by staff at his/her side, and entered the doorway of the resident's room across the hallway. The 1:1 staff member remained with the resident and after gently touching the resident on his/her left arm, the resident was redirected from the doorway without difficulty. Interview on 04/18/2022 at 2:30 PM with the Activity Assistant, who was providing 1:1 supervision of Resident #1, revealed staff provided the 1:1 supervision of the resident at all times due to the resident's wandering in/out of other residents' rooms. She stated Resident #1 had Dementia and was not aware of his/her surroundings. Further interview revealed Resident #1 required frequent redirection to ensure he/she did not intrude into other residents' personal space. 1(b). Review of Resident #7's medical record revealed the facility admitted him/her on 12/23/2021, with diagnoses that included Paraplegia, Incomplete and Major Depressive Disorder. Review of Resident #7's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Further review of Resident #7's medical record revealed the resident required extensive assistance of one (1) staff member for bed mobility and toileting. Interview on 04/20/2022 at 10:00 AM, with Resident #7 revealed Resident #1 wandered into his/her room and bumped his/her bed waking the resident. Resident #7 stated when he/she opened his/her eyes, Resident #1 had removed his/her bed covers from the waist down and had his/her hand on Resident #7's upper thigh area. Continued interview revealed Resident #7 stated that made him/her feel uncomfortable as he/she had not given Resident #1 permission to touch him/her. Resident #7 further stated Resident #1 had previously wandered into his/her room the day before; however, had just came in and took his/her hat off and did not touch me that time. Interview on 04/18/2022 at 3:40 PM, with Nurse Aide (NA) #2, revealed Resident #7 reported to her and another NA that Resident #1 wandered into his/her room, and removed the resident's blanket from the waist down and touched Resident #7 on the leg. NA #2 stated you could tell it bothered Resident #7 that Resident #1 had touched him/her. Continued interview revealed NA #2 felt that Resident #7's comments to the staff members had been an allegation of abuse and reported it to the nurse and the Director of Nursing (DON) immediately. NA #2 revealed Resident #1 had wandered constantly since his/her admission to the facility and was intrusive, going into other residents' rooms and getting in their personal space. Further interview revealed the only way for staff to know where Resident #1 was located, to ensure other residents were protected from the resident, was to provide him/her with the 1:1 supervision. Interview on 04/18/2022 at 9:30 PM, with NA #3 revealed Resident #7 reported to her on 03/12/2022, (she was unsure of the exact time) that Resident #1 had wandered into his/her room and woke the resident up because Resident #1 had bumped Resident #7's bed. NA #3 stated Resident #7 also informed her that Resident #1 had placed his/her hand was on Resident #7's leg. Continued interview revealed NA #3 reported the incident to Licensed Practical Nurse (LPN) #1, as well as, the Director of Nursing (DON) immediately. NA #3 stated Resident #1 had wandered into other residents' rooms off and on since his/her admission. Further interview revealed the only way to ensure the other residents were protected from Resident #1 was to provide the 1:1 supervision of him/her. Further review of Resident #7's medical record revealed no documented evidence staff had documented the resident's allegation regarding Resident #1 entering his/her room and touching his/her leg on 03/12/2022. Interview on 04/19/2022 at 9:00 PM, with Licensed Practical Nurse (LPN) #1, revealed he was responsible for Resident #1's care when he/she wandered into Resident #7's room on 03/12/2022. LPN #1 stated staff informed him Resident #7 reported that Resident #1 entered his/her room and placed his/her hand on the resident's leg which made Resident #7 feel uncomfortable. The LPN stated the DON was notified of the incident and directed LPN #1 to keep Resident #1 in line of sight due to his/her wandering behaviors. Continued interview revealed Resident #1 was difficult to redirect despite staffs attempts to redirect him/her. The LPN revealed the only way to ensure the other residents were protected from Resident #1's behaviors was to provide the resident with 1:1 supervision. He further stated the resident continued to wander and go into other residents' rooms and exhibit intrusive behaviors towards other residents. Further interview with Licensed Practical Nurse (LPN) #1, on 04/19/2022 at 9:00 PM, revealed he had not documented the incident of Resident #1 touching Resident #7 on the leg making Resident #7 feel uncomfortable, in either of the residents' medical records. LPN #1 stated he had no professional explanation as to why the incident was not documented; however, stated he should have documented it when the incident occurred. Interview on 04/22/2022 at 3:30 PM with the Director of Nursing (DON) revealed Nurse Aide (NA) #2, NA #3 and LPN #1 reported the incident to her that involved Resident #1 and Resident #7 on 03/12/2022. The DON stated, however, that when she spoke to Resident #7 on 03/12/2022, the resident informed her he/she had been asleep when Resident #1 wandered into his/her room. According to the DON, Resident #7 reported he/she woke up when Resident #1 bumped into his/her bed. She stated Resident #7 informed her he/she screamed for staff to help and the aide came in and removed Resident #1 from his/her room. The DON revealed Resident #7 reported Resident #1 had his/her hands on the blanket of Resident #7's bed. Further interview revealed the DON did not feel the incident had been a case of potential abuse, as Resident #7 informed her he/she felt safe and was not abused when Resident #1 touched his/her leg. Continued interview with the Director of Nursing (DON), on 04/22/2022 at 3:30 PM, revealed she instructed staff to implement the line of sight supervision for Resident #1 after the incident occurred until they were directed to do otherwise. However, she stated she had not provided any extra staff to the working schedule to ensure the increased level of supervision was provided to Resident #1. She further stated she did not identify the incident was not documented and revealed the facility did not investigate the incident. 2(a). Review of a facility investigation, dated 03/14/2022, for an incident that occurred on 03/14/2022 at 6:00 PM, revealed Resident #2 had been standing at the nurse's station using the phone when Resident #1 came up behind Resident #2 and hit him/her on his/her butt. Continued review of the investigation revealed Resident #2 yelled stop touching my butt at Resident #1. Additionally, the investigation documentation further revealed Resident #1 responded okay okay to Resident #2's request to stop touching his/her buttocks. Review of the investigation revealed the facility concluded they were unable to substantiate abuse occurred because the nursing notes and social service follow-ups for the days following the incident for both residents revealed no concerns. Further review revealed both residents had continued their daily routines with no signs of psychosocial distress. In addition, review revealed the investigation noted Resident #1 had been placed on 1:1 supervision following the incident until he/she was transferred/admitted to a psychiatric hospital on 03/21/2022 (seven [7] days after the second incident). Review of Resident #2's medical record revealed the facility admitted the resident on 03/09/2022, with diagnoses that included Chronic Post Traumatic Stress Disorder and Intellectual Disabilities. Review of Residents #2's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15), which indicated he/she was cognitively intact and interviewable. Continued review of the MDS revealed the facility assessed Resident #2 to require one (1) staff member to supervise him/her with bed mobility and walking on the unit. Further review of Resident #2's medical record revealed the resident had been discharged from the facility on 03/17/2022, prior to the initiation of the Abbreviated Survey (04/18/2022) investigation. Interview on 04/18/2022 at 3:00 PM, with NA #1, revealed she had been standing in the hallway when she heard Resident #2 yelling out stop touching my butt. Per interview, NA #1 had observed Resident #1 standing behind Resident #2 softly hitting him/her on the butt. Continued interview revealed Resident #1 responded okay okay when Resident #2 demanded he/she stop touching Resident #2. The NA stated staff immediately removed Resident #1 from where Resident #2 had been located. According to NA #1, Resident #1 was confused and wandered throughout the facility and frequently entered other residents' rooms. NA #1 revealed Resident #1 had been intrusive when he/she entered the other residents' room and got into their personal space prior to being placed on the 1:1 supervision. She further stated the only way to prevent Resident #1 from entering the other residents' rooms was for staff to constantly supervise the resident. She also stated she was not aware Resident #1 should have been in line of sight when the incident occurred on 03/14/2022. 2(b). Review of Resident #1's progress notes revealed a note documenting on 03/14/2022 at 6:27 PM, Resident #1 touched Resident #2 on the buttock while he/she had been using the phone at the nurse's station. Review of Resident #1's progress note dated 03/28/2022, revealed the resident returned to the facility from his/her psychiatric hospital stay, related to ongoing behaviors at the facility, at approximately 2:35 PM. Continued review revealed Resident #1 was noted to have the following level of supervision: every fifteen (15) minute checks for twenty-four (24) hours; then every thirty (30) minute checks for twenty-four (24) hours; and then every hour checks for twenty-four (24) hours. Review of Resident #1's progress note dated 03/28/2022 at 11:03 PM, revealed staff documented the resident had wandered in and out of rooms, including other residents' rooms. Per review of the note, when the nurse asked Resident #1 if he/she had any pain or bruising, the resident responded by saying, No, just this good penis. However, further review revealed staff failed to implement changes to Resident #1's level of supervision after he/she made the comment to the nurse. In addition, review revealed Resident #1 continued to exhibit the behaviors of wandering and verbalizing inappropriate sexual comments to staff. Review of Resident #1's progress note dated 03/31/2022 at 6:01 PM, revealed the Nurse Practitioner (NP) documented Resident #1's thought processes as loose and noted he/she wandered into other residents' rooms. Further review revealed the NP noted Resident #1 required constant redirection and made sexual statements to the nurse aides. Interview on 04/22/2022 at 1:30 PM, with the Nurse Practitioner (NP), revealed she evaluated Resident #1 in the facility (unable to recall specific dates) but stated she had evaluated him/her before and after the resident ' s psychiatric hospital stay and stated the resident had Dementia and had a hard time discerning which behaviors were appropriate versus inappropriate. She stated she had been notified of the incidents involving Resident #1; however, was unable to recall the specifics of what she had been notified of. Further interview revealed the NP expected staff to ensure all residents were free from abuse and stated she expected the facility to implement interventions to ensure that occurred when incidents and behaviors were identified. Continued interview with the NP revealed she increased the resident ' s antipsychotic medication, as well as his/her antidepressant (unable to recall when) in attempts to assist the facility in managing the resident's behaviors and felt Resident #1's behaviors had improved since he/she was initially admitted to the facility. Continued interview with the Director of Nursing (DON), on 04/22/2022 at 3:30 PM, revealed she had been notified of the second incident involving Resident #1 touching Resident #2 buttock on 03/14/2022. Per the DON, she determined no abuse had occurred because Resident #2 denied feeling abused. She stated she had placed Resident #1 on 1:1 supervision after the 03/14/2022 incident, which required staff to be in close proximity to the resident until the resident could be transferred to a psychiatric hospital. The DON stated Resident #1 was transferred to the psychiatric hospital on 03/21/2022, as an intervention in attempt to help the facility manage his/her behaviors at the facility. Per the DON, before Resident #1 returned to the facility on [DATE], from the psychiatric hospital, she and the members of the clinical team determined the resident would return with the necessary supervision. She stated the following level of supervision was put in place for Resident #1 after his/her return to the facility: every fifteen (15) minute checks for twenty-four (24) hours; then every checks every thirty (30) minutes for twenty-four (24) hours, and then every hour checks for twenty-four (24) hours. The DON stated she recalled reviewing the progress notes from the night Resident #1 returned to the facility (on 03/28/2022), and noted the resident continued to wander into other residents' rooms and had informed a nurse No, just this good penis when she asked if Resident #1 had any pain or bruising. Further interview revealed however, the DON had not been alarmed by Resident #1's behaviors or statements. She further revealed she had not increased Resident #1's level of supervision because the resident just referred to his/her penis, and hadn't stated he/she was gonna use it. 3. Review of a facility investigation (Dated 03/31/2022 regarding an incident involving Resident #1 on 03/31/2022 at 8:30 PM, where the resident had wandered into Resident #5's room and got in bed with Resident #5. Continued review revealed both residents were fully clothed at the time of the incident, and a complete skin assessment was performed of both residents with no concerns identified. Per review, facility staff had been unable to substantiate abuse because the nursing notes and social service follow-ups, conducted in the days after the incident for both residents, revealed no concerns as both had continued their daily routine with no signs of psychosocial distress. Further review revealed the investigation noted staff again implemented 1:1 supervision of Resident #1 following the incident. Review of Resident #5's medical record revealed the facility admitted the resident on 02/15/2022, with diagnoses that included Alzheimer's Disease and Dementia. Review of Resident #5's Admission MDS Assessment revealed the facility assessed the resident to have a BIMS score of 00 which indicated he/she was severely cognitively impaired and not interviewable. Further review revealed the facility additionally assessed Resident #5 to require extensive assistance of two (2) staff members for bed mobility and toileting. Observation on 04/18/2022 at 2:40 PM of Resident #5 revealed he/she was lying in his/her bed and was neat and clean in appearance. Interview on 04/19/2022 at 8:00 PM with Registered Nurse (RN) #1 revealed she was the staff person caring for Resident #1 and Resident #5 when the incident occurred on 03/31/2022. The RN stated Resident #1 had been at the nurse's station with her while she was completing her work duties. She stated she discovered Resident #1 was no longer in the vicinity of the nurse's station and approximately five (5) minutes had passed since she had last seen Resident #1. Continued interview revealed RN #1 walked down the hallway to determine Resident #1's whereabouts. The nurse stated she discovered the door to Resident #5's room closed which was not a normal occurrence, and when she opened the door she discovered Resident #1 lying on Resident #5's bed with him/her. She stated Resident #5 had been fully clothed and lying under the covers, while Resident #1 had been lying on top of the bed covers fully clothed. Further interview revealed RN #1 immediately removed Resident #1 from Resident #5's room and notified the administrative staff she was supposed to notify. She further stated she was then directed to implement 1:1 supervision of Resident #1 following that incident. In addition, RN #1 revealed Resident #1 had wandered into other residents' rooms off and on since his/her admission to the facility and required constant supervision to prevent him/her from entering the other residents' rooms. Further interview, on 04/22/2022 at 3:30 PM, with the DON revealed she acknowledged Resident #1 had been involved in another incident on 03/31/2022, where the resident had gotten into Resident #5's bed with him/her. The DON stated Resident #1 had remained on 1:1 supervision following that incident. She stated the facility had not substantiated abuse regarding the 03/31/2022 incident as neither resident exhibited signs of having been affected by the incident. The DON stated she had no concerns with the level of supervision the facility had provided Resident #1 since his/her admission to the facility. She additionally stated residents had the right to remain free from abuse in the facility. Interview on 04/21/2022 at 2:00 PM. with the Administrator, revealed the DON notified her on 03/12/2022 of the incident of Resident #1 wandering into Resident #7's room. The Administrator revealed however, she had not been informed Resident #7 reported to staff that Resident #1 had touched him/her. Per the Administrator, she was also notified of Resident #1 touching Resident #2 on the butt, on 03/14/2022. She stated abuse had not been substantiated during the investigation of that incident as Resident #2 denied feeling abused. Continued interview revealed Resident #1 had been provided a 1:1 level of supervision after the 03/14/2022 incident until the resident was transferred to and admitted to a psychiatric hospital on 03/21/2022 (seven [7] days later). The Administrator stated prior to Resident #1's return to the facility on [DATE], the clinical team met and determined an appropriate level of supervision for the resident. Per interview, residents' behaviors that could potentially trigger abuse were discussed every morning in the clinical meeting. She stated even though staff documented Resident #1's wandering behaviors and his/her sexually inappropriate comments towards staff she had not directed her staff to increase Resident #1's supervision any further. The Administrator acknowledged the incident that subsequently occurred on 03/31/2022, where Resident #1 entered Resident #5's room and got in bed with him/her. Further interview revealed however, she had not felt the incident on 03/31/2022 was abuse as Resident #5 had not had any apparent ill effects from the incident, because nursing and social services and followed up with the residents and no concerns were identified. The Administrator further revealed therefore the facility had not substantiated abuse. She additionally stated she felt Resident #1 had been provided adequate supervision to ensure the resident, as well as other residents, were free from abuse.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure all alleged violations involving abuse were reported immediately after the allegation was made, to the State Agency for two (2) of eight (8) sampled residents (Residents #1 and Resident #7). Interviews with staff and Resident #7 revealed Resident #1 wandered into Resident #7's room and touched his/her leg which caused Resident #7 to scream for staff ' s help to remove the resident from his/her room on 03/12/2022. Even though the allegation was immediately reported to the Director of Nursing (DON) and the Administrator, there was no evidence the incident was reported to State Agencies as required. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, last revised on 03/22/2022, revealed the facility would protect the health, welfare, and rights of the residents by developing and implementing written policies/procedures that prohibit and prevent abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy stated an Abuse Coordinator would be designated at the facility, and that individual would be responsible for reporting allegations of suspected abuse, neglect or exploitation to the state survey agency and other officials in accordance with state laws. Review of the Kentucky Revised Statutes, Section 209.030 (3) titled, Administrative Regulations-Reports of adult abuse, neglect, or exploitation, effective date June 20, 2005, revealed an oral or written report shall be made immediately to the cabinet upon knowledge or suspected abuse, neglect, or exploitation of an adult. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 03/11/2022 with diagnoses including Unspecified Dementia with Behavioral Disturbances. Review of Resident #1's Admission Minimum Data Set Assessment (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (03), which indicated his/her cognitive status was severely impaired and was not interviewable. Review of progress notes dated 03/12/2022 at 6:45 PM revealed Licensed Practical Nurse (LPN) #1 documented Resident #1 was noted to wander, and he/she was intrusive into other residents' rooms. The note also revealed staff documented Resident #1 redirects well, however, resumes wandering behavior with intrusion into others rooms shortly after redirection. Further review of Resident #1's progress notes, dated 03/12/2022 at 7:03 PM, revealed Licensed Practical Nurse (LPN) #1 documented an intervention for Resident #1 to be in line of sight at all times while awake and out of bed related to wandering and intrusion into others rooms. 2. Review of Resident #7's record revealed he/she was admitted to the facility, on 12/23/2021 with diagnoses that included Major Depressive Disorder and Paraplegia. Review of Resident #7's Quarterly MDS, dated [DATE], revealed he/she was interviewable with a BIMS score of fifteen (15) and required extensive assistance of one (1) staff member for bed mobility. Interview with Nurse Aide (NA) #2, on 04/18/2022 at 3:40 PM, revealed Resident #7 reported to her and NA#3 that Resident #1 wandered into his/her room, and removed his/her blanket from the waist down and touched Resident #7 on the leg. NA #2 stated you could tell it bothered Resident #7 also stated she felt the incident was an allegation of abuse; therefore, she reported it to the Licensed Practical Nurse (LPN) #1 and the Director of Nursing (DON) immediately. NA #2 stated she informed the DON and LPN #1 that Resident #7 reported Resident #1 had touched him/her on the leg. The NA further revealed she witnessed Resident #7 report to the DON the same information provided to her, regarding Resident #1. Interview with NA #3, on 04/18/2022 at 9:30 PM, revealed Resident #7 reported to her on 03/12/2022 that Resident #1 wandered into his/her room and woke the resident up by bumping his/her bed. Per the interview, the NA revealed Resident #7 reported to her that Resident #1's hand was on his/her leg. NA #3 stated she felt Resident #7's report was an allegation of abuse, so she reported the incident to Licensed Practical Nurse (LPN) #1 and the DON immediately. Review of Resident #7's medical record revealed staff failed to document the resident's allegation of abuse related to Resident #1 on 03/12/2022. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/2022 at 9:00 PM, revealed he was caring for Resident #7 on 03/12/2022 when Resident #1 wandered into his/her room. He stated staff informed him that Resident #7 reported that Resident #1 entered his/her room and placed his/her hand on the resident's leg, which made Resident #7 feel uncomfortable. LPN #1 stated the DON was notified of the resident's allegation that Resident #1 had entered his/her room and touched the resident on the leg. He stated the DON directed him to keep Resident #1 in line of sight due to his/her wandering behaviors after he reported that the resident had touched Resident #7 on the leg. Interview with Resident #7, on 04/20/2022 at 10:00 AM, revealed Resident #1 wandered in his/her room and woke him/her up when Resident #1 (called him/her by name) bumped his/her bed. The resident also stated when he/she woke up, he/she discovered that Resident #1 had removed his/her bed cover from the waist down, and Resident #1 had his/her hand on the resident's leg. The resident stated that made him/her feel uncomfortable and informed the surveyor he/she had not given Resident #1 permission to touch him/her. Further interview with Resident #7 revealed the DON (referred to her by name) came into his/her room after the incident occurred and he/she informed the DON that the resident had wandered into his/her room and touched him/her on the leg. Resident #7 also stated she rang his/her call light and screamed for staff's assistance and Resident #1 was immediately removed from the room. Interview with the Director of Nursing (DON), on 04/22/2022 at 3:30 PM, revealed staff reported that Resident #1 wandered into Resident #7's room and touched the resident's blanket. She also stated she spoke with Resident #7 immediately following the incident; however, stated she didn't recall staff nor the resident reporting that Resident #1 had touched Resident #7 on the leg. The DON stated if she had known Resident #1 entered Resident #7's room and touched him/her on the leg she would have felt the incident was an allegation of abuse; however, stated she didn't feel that Resident #1 wandering into Resident #7's room, waking him/her up and the resident screaming out for assistance from staff to remove the resident was anything that should have been reported to State Agencies. The DON also stated she reported the incident to the Administrator, who was the facility's Abuse Coordinator, immediately. Further interview with the DON revealed the Administrator was responsible to ensure allegations of abuse were reported to State Agencies. Interview with the Administrator, on 04/21/2022 at 2:00 PM, revealed the DON notified her on 03/12/2022 that Resident #1 wandered into Resident #7's room, and woke him/her up by bumping his/her bed and touching the resident's blanket. The Administrator stated no one informed her that Resident #1 touched Resident #7 on the leg and if staff had informed her of what the resident reported on 03/12/2022, she would have reported the incident to State Agencies. The Administrator stated she did not feel a resident wandering into another resident's room, waking him/her up from his/her sleep by bumping into his/her bed, and touching another resident's bed linen, was a reportable event; therefore, did not report the incident to State Agencies.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure all alleged violations of abuse were thoroughly investigated for two (2) of eight (8) sampled residents (Residents #1 and #7). On 03/12/2022, Resident #1 wandered into Resident #7's room and Resident #1 touched Resident #7 on his/her leg. Per interview with staff, Resident #7 screamed for staff's help to remove Resident #1 from Resident #7's room. The allegation was immediately reported to the Director of Nursing (DON) and the Administrator; however, there was no evidence provided to show the facility investigated the allegations of abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, last revised 03/22/2022, revealed the facility would implement policies and procedures to prevent and immediately investigate suspicions or reports of abuse/neglect or exploitation. The policy also stated staff should make all efforts to ensure residents were protected from physical/psychosocial harm during and after the investigation. Review of the policy also revealed staff should respond immediately after alleged violations were reported to protect the alleged victim and the integrity of the investigation. According to the policy, staff would examine the alleged victim for any sign of injury. 1. Review of Resident #1's medical record revealed he/she was admitted to the facility with diagnoses that included Unspecified Dementia with Behavioral Disturbances on 03/11/2022. Review of his/her Admission Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of three (03), which indicated he/she was not interviewable. Review of progress notes completed by Licensed Practical Nurse (LPN) #1 on 03/12/2022 at 6:45 PM revealed Resident #1 wandered and was intrusive into other residents' rooms. Review of documentation also revealed Resident #1 redirects well however resumes wandering behavior with intrusion into other rooms shortly after redirection. Further review of Resident #1's progress notes completed by LPN #1, dated 03/12/2022, at 7:03 PM revealed an intervention for Resident #1 to be in line of sight at all times while awake and out of bed related to wandering and intrusion into others rooms was implemented by staff. 2. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnose which included Paraplegia Incomplete. Review of Resident #7's Quarterly MDS, dated [DATE] revealed he/she had a BIMS score of fifteen (15) indicating he/she was interviewable and required extensive assistance of one (1) staff member for bed mobility. Interview with Nurse Aide (NA) #2, on 04/18/2022 at 3:40 PM, revealed Resident #7 reported that Resident #1 wandered into his/her room, removed the residents blanket from the waist down and touched him/her on the leg and also stated you could tell it bothered Resident #7. NA#2 also stated she felt the incident was an allegation of abuse; therefore, she immediately reported it to the nurse and the DON. NA #2 stated she informed the nurse and the DON that Resident #7 reported that Resident #1 had entered his/her room, woke him/her up by bumping his/her bed and touched the resident on the leg. The NA also stated she witnessed Resident #7, report to the DON that Resident #1 had entered his/her room, woke him/her up and had placed his/her hand on the residents' leg. The NA stated she had not been asked to complete a witness statement nor had she been interviewed by any staff member regarding the incident since 03/12/2022. Interview with NA #3 on 04/18/2022 at 9:30 PM revealed on 03/12/2022 Resident #7 reported that Resident #1 wandered into his/her room and woke him/her up by bumping his/her bed. Resident #7 also reported Resident #1's hand was on his/her leg. NA #3 stated she felt Resident #7's report was an allegation of abuse, so she immediately reported the incident to the nurse and DON. NA #3 further stated the DON was informed of Resident #7's report that Resident #1 wandered into his/her room and touched Resident #7 on the leg. According to the NA no one at the facility had instructed her to complete a witness statement and she had not been interviewed further regarding Resident #7's allegation since it occurred. Review of Resident #7's medical record revealed no evidence staff documented or investigated his/her allegation voiced on 03/12/2022. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/2022 at 9:00 PM revealed he was caring for Resident #7 on 03/12/2022 when he/she reported Resident #1 wandered into his/her room and woke him/her up by bumping the resident's bed. The nurse stated Resident #7 also reported Resident #1 placed his/her hand on the resident's leg which Resident #7 reported made him/her feel uncomfortable. LPN #1 stated the DON was notified of the resident's allegation, which included that the resident touched Resident #7 on the leg. He stated the DON directed him to keep Resident #1 in line of sight due to his/her wandering behaviors after the resident's allegation was voiced; however, he stated he was not directed to obtain or complete witness statements nor was he instructed to initiate an investigation. The nurse also stated he was directed to ensure Resident #1 was in line of sight while out of bed; however, stated Resident #1 continued to wander and intrude into other resident rooms and personal space. Interview on 04/20/2022 at 10:00 AM with Resident #7 revealed Resident #1 wandered in his/her room and woke him/her up when Resident #1 (called him/her by name) bumped the residents' bed. Resident #7 also stated when he/she woke up, Resident #1 had removed his/her bed cover from the waist down and placed his/her hand on the resident's leg which made him/her feel uncomfortable. The resident also stated the DON (referred to her by name) came in his/her room after the incident occurred and the resident reported to the DON that Resident #1 had wandered in his/her room and touched him/her on the leg. Resident #7 also stated she rang his/her call light and screamed for staff's help and Resident #1 was removed from his/her room. Interview with the Director of Nursing (DON), on 04/22/2022 at 3:30 PM, revealed staff reported that Resident #1 wandered into Resident #7's room and touched his/her blanket. The DON also stated she spoke with Resident #7 immediately following the incident; however, she did not recall staff nor Resident #7 informing her that Resident #1 touched Resident #7 on the leg. Continued interview with the Director of Nursing (DON) stated if she would have known Resident #1 entered Resident #7's room and touched him/her on the leg she would have felt the incident was an allegation of abuse; however, stated she did not feel Resident #1 wandering into Resident #7's room, waking him/her up and the resident screaming out for assistance from staff to remove him/her, was reportable to State Agencies nor did she feel like it warranted an investigation. She also stated she instructed staff to keep Resident #1 in line of sight following the incident and felt that intervention would protect other residents even though staff documented he/she continued to wander and be intrusive to other residents' personal spaces. Interview with the Administrator, on 04/21/2022 at 2:00 PM, revealed she was the facility Abuse Coordinator and was notified on 03/12/2022 that Resident #1 wandered into Resident #7's room, woke him/her up by bumping his/her bed and touched his/her blanket by the Director of Nursing (DON). The Administrator stated no one reported that Resident #1 touched Resident #7 on the leg and also stated if staff had informed her of what the resident reported on 03/12/2022 she would have reported to State Agencies and ensured a thorough investigation was conducted. However, stated she did not feel Resident #1 wandering into another resident's room, waking him/her up from sleep by bumping his/her bed, and touching another resident's bed linen was a reportable event nor did she ensure a thorough investigation was completed. However, she stated in line-of-sight supervision was implemented for Resident #1 following the incident and felt that was appropriate to ensure other residents were protected from Resident #1 even though, he/she continued to exhibit wandering/intrusive behaviors.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to develop a person-centered comprehensive care plan with specific interventions to meet the needs of one (1) of eight (8) sampled residents (Resident #8). Review of Resident #8's care plan, dated 04/06/2022, revealed the facility failed to complete the resident's initial care plan for his/her diagnosis of Human Immunodeficiency Virus (HIV). The findings include: Review of the facility's policy titled Comprehensive Care Plans, revised 03/23/2022, revealed the policy developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's needs as identified in the resident's comprehensive assessment. Further review of the policy revealed the care planning process would include an assessment of the resident strengths and needs. Review of the facility's policy titled, Admission of a Resident revised 03/22/2022, revealed the admission process was intended to obtain all the information possible about the resident, for the development of comprehensive plans of care. Further review revealed the pre-admission preparation and resident assessments on admission were to be completed to develop a plan of care to meet the needs of the resident. Review of Resident #8's medical record revealed the facility admitted the resident on 04/06/2022, with diagnoses including HIV and Chronic Viral Hepatitis C. Review of Resident #8's Hospital Discharge Summary, dated 04/06/2022, revealed the resident was to follow-up with the Infectious Disease, as well as, Neurology as an outpatient. Review of Resident #8's Admission Minimum Data Set (MDS) assessment, dated 04/15/2022, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was moderately cognitively impaired. Review of Resident #8's Plan of Care revealed interventions and goals for the resident's HIV diagnosis was added on 04/19/2022 and revised on 05/06/2022; however, there was no evidence the facility care planned for the resident's follow-up with the Infectious Disease or required treatment for the resident's Human Immunodeficiency Virus Infection (HIV). Interview with Resident #8, on 05/09/2022 at 12:30 PM, revealed he/she wanted to receive treatment for his/her HIV; however, was not receiving it. Further interview revealed no one communicated with the resident related to his/her plan of care. Interview with Minimum Data Set (MDS) nurse, on 05/09/2022 at 4:37 PM, revealed she was responsible for the resident's comprehensive care plan. Further interview with the MDS revealed she did not review the resident's admission paperwork to care plan for the resident's HIV, prior to 04/19/2022. Per interview, the MDS nurse stated the resident's care plan for his/her HIV was added on 04/19/2022, approximately thirteen (13) days after the resident's admission. Interview with the Director of Nursing (DON), on 05/10/2022 at 11:55 AM, revealed that during the admission process, the nurse that completed the admission was responsible for the resident's initial care plan. Per the interview, she revealed it was her expectation that the resident's care plan related to his/her HIV would have been developed upon admission. Interview with the Administrator on 05/09/2022 at 5:07 PM revealed she was not certain who was responsible for the resident's Plan of Care, upon admission; however, would have expected the policy related to the development of the resident's care plans would have been followed.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan for one (1) of eight (8) sampled residents (Resident #1). Resident #1 exhibited behaviors of wandering into other residents' rooms and making sexually inappropriate comments to staff; however, the facility failed to ensure the resident's care plan was revised to reflect increased supervision to ensure the safety of the resident, as well as the safety of the other residents. The findings include: Review of the facility's policy titled, Care Plan Revisions Upon Status Change last revised 03/22/2022, revealed the purpose of the policy was to provide a consistent process for reviewing and revising the care plan for residents who experienced a status change. The policy stated the Minimum Data Set (MDS) Nurse or other designated staff would update residents' comprehensive care plans with new or modified interventions when a change in the residents' status occurred. 1. Review of Resident #1's medical record revealed the facility admitted him/her on 03/11/2022 with diagnoses which included Unspecified Dementia with Behavioral Disturbances. Review of the Admission MDS assessment dated [DATE] for Resident #1 revealed the assessed the resident as severely cognitively impaired and not interviewable as evidenced by the Brief Interview for Mental Status (BIMS) score of three (03). Review of Resident #1's Comprehensive Care Plan last reviewed and revised on 04/08/2022 revealed on 03/11/2022, staff identified Resident #1 wandered about the facility and was at risk for elopement. Review of care plan interventions implemented on 03/11/2022 revealed staff was to distract Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversation, television and a book. Continued review revealed the care plan interventions implemented on 03/11/2022, also included for staff to reorient/validate and redirect Resident #1 as needed and to check the placement of his/her safety bracelet which had been placed on the resident for monitoring him/her every shift due to his/her risk for elopement. Observation of Resident #1, on 04/18/2022 at 2:00 PM, revealed a staff person providing 1:1 supervision of the resident. Continued observation at 2:10 PM on 04/18/2022 revealed the resident ambulating out into the hallway from his/her room and attempting to enter another resident's room and required the redirection of staff. Interview with the Activity Assistant, on 04/18/2022 at 2:30 PM, revealed she was the staff person assigned to provide the 1:1 supervision of Resident #1. Per interview, the 1:1 supervision was necessary because Resident #1 wandered in and out of other residents' rooms. The Activity Assistant stated Resident #1 was not aware of his/her surroundings and required frequent redirection to ensure he/she did not intrude into other residents' personal space. Review of the progress note dated 03/12/2022 at 6:45 PM revealed Licensed Practical Nurse (LPN) #1 documented Resident #1 wandered and he/she was intrusive into other residents' rooms. The note also stated Resident #1 redirects well however resumes wandering behavior with intrusion into others rooms shortly after redirection. 1. Review of Resident #1's progress note, dated 03/12/2022 timed 7:03 PM, revealed Licensed Practical Nurse (LPN) #1 documented the resident was to be in line of sight at all times while awake and out of bed related to wandering and intrusion into others rooms. However, review of Resident #1's care plan revealed no documented evidence facility staff reviewed and revised the resident's care plan with interventions to protect Resident #1 and other residents from his/her ongoing behaviors to prevent potential incidents. 2. Review of Resident #7's record revealed he/she was admitted to the facility on [DATE], with diagnoses which included Paraplegia Incomplete and Major Depressive Disorder. Review of Resident #7's Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident as cognitively intact and interviewable as evidenced by the BIMS score of fifteen (15). Continued review of the MDS Assessment further revealed the facility assessed Resident #7 to require extensive assistance of one (1) staff member for bed mobility. Interview with Resident #7, on 04/20/2022 at 10:00 AM, revealed Resident #1 wandered into his/her room and bumped his/her bed which woke him/her up. Resident #7 revealed when he/she opened his/her eyes, Resident #1 had pulled the bed covers down and had his/her hand on Resident #7's leg, on the upper thigh area. Resident #7 stated the incident made him/her feel uncomfortable and he/she had not given Resident #1 permission to touch him/her. Continued interview revealed Resident #7 stated he/she reported the allegation to the DON when the incident occurred on 03/12/2022. Resident #7 further revealed Resident #1 had also wandered into his/her room the previous day but had just taken off his/her hat and had not touched Resident #7 that time. Interview with Nurse Aide (NA) #2 on 04/18/2022 at 3:40 PM, revealed Resident #7 informed her that Resident #1 wandered into his/her room, uncovered him/her from the waist down and touched his/her leg. NA #2 stated you could tell it bothered Resident #7 that Resident #1 had done that. Continued interview revealed NA #2 reported the incident immediately to the nurse and the Director of Nursing (DON). The NA stated Resident #1 constantly wandered in and out of other residents' rooms and was intrusive and got into the other residents' personal space. Further interview revealed NA #2 stated the only way to ensure other residents were protected from Resident #1's behaviors and potential incidents was to provide the 1:1 supervision of the resident. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/2022 at 9:00 PM, revealed he had been responsible for Resident #7's care when the resident reported the incident of Resident #1 entering his/her room and placing his/her hand on Resident #7's leg. LPN #1 stated the incident had made Resident #7 feel uncomfortable. According to LPN #1, he notified the DON of the incident and the DON directed him to keep Resident #1 in line of sight due to his/her wandering behaviors. Further interview revealed however, Resident #1 continued to wander and intrude into other residents' rooms. LPN #1 further stated he had not reviewed or revised Resident #1's care plan to reflect the DON's directions for the line of sight intervention. In addition, LPN #1 stated he had not been trained or directed to make changes to residents' care plans at the facility. Continued review of Resident #1's care plan revealed no documented evidence staff reviewed or revised the resident's care plan to include interventions to protect residents from abuse after Resident #7 reported the allegation on 03/12/2022. 2. Review of Resident #2's medical record revealed he/she was admitted to the facility on [DATE], with diagnoses that included Intellectual Disabilities and Chronic Post Traumatic Stress Disorder. Review of Resident #2's Admission MDS assessment dated [DATE] revealed the facility assessed the resident as cognitively intact and interviewable as evidenced by the BIMS score of fifteen (15). Review of the MDS Assessment further revealed the facility assessed Resident #2 to require the assistance of one (1) staff member to supervise him/her when walking on the unit. Further record review revealed Resident #2 was discharged from the facility on 03/17/2022, prior to the Abbreviated Survey. Review of the facility's investigation documentation revealed on 03/14/2022 at 6:00 PM Resident #2 had been standing at the nurse's station using the telephone (phone). Per review, while Resident #2 was on the phone, Resident #1 came up behind him/her and started hitting Resident #2 on his/her butt. Continued review revealed Resident #2 yelled at Resident #1 to stop touching my butt and Resident #1 stated okay okay. Interview with Nurse Aide (NA) #1 on 04/18/2022 at 3:00 PM, revealed she had been in the hallway on 03/14/2022 and observed Resident #1 standing behind Resident #2 softly hitting him/her on the butt. Continued interview revealed Resident #2 yelled at Resident #1 to stop touching my butt. NA #1 revealed Resident #1 had stated okay okay when Resident #2 yelled for the resident to stop touching him/her. Per the NA, staff assisted Resident #1 back to his/her room following the incident. According to NA #1, Resident #1 was confused and wandered throughout the facility frequently entering other residents' rooms, prior to being placed on the 1:1 supervision. NA #1 further revealed having Resident #1 on the 1:1 supervision was the only way staff were able to prevent him/her from entering other residents' rooms. Further review of the investigation revealed the facility had not substantiated abuse regarding the 03/14/2022 incident because the nursing notes and social service follow-ups in the days following the incident had noted no concerns. Per the investigation documentation, both residents had continued their daily routines with no signs of psychosocial distress. However, further review of the investigation documentation revealed the facility placed Resident #1 on 1:1 supervision after the incident until he/she could be transferred to a psychiatric (psych) hospital. In addition, review further revealed Resident #1 was transferred and admitted to the psych hospital on 03/21/2022. However, continued review of Resident #1's care plan revealed no documented evidence staff reviewed and revised the resident's care plan to reflect the facility's increased 1:1 supervision of him/her initiated on 03/14/2022. Review of Resident #1's medical record revealed the resident returned to the facility on [DATE] at approximately 2:35 PM for readmission. Per review, Resident #1's level of supervision was for every fifteen (15) minute checks for twenty-four (24) hours: then every thirty (30) minute checks for twenty-four (24) hours; and then every hour checks for twenty-four (24) hours. Review of Resident #1's progress note dated 03/28/2022 revealed at 11:03 PM the resident was wandering in and out of rooms. Continued review revealed the nurse had asked Resident #1 is he/she had any pain or bruising, and the resident told her, No, just this good penis. Review of Resident #1's care plan revealed on 03/28/2022, when the resident returned from the psych hospitalization , staff identified he/she had behavioral problems of making sexually inappropriate comments to staff and wandering in and out of other residents' rooms. Review revealed staff implemented the following interventions for the behavior problems: Resident #1 to be seen by behavioral health services as needed; staff to administer medications as ordered and observe for effectiveness and any adverse effects; notify the resident's physician as needed; redirect/remind the resident it was inappropriate when he/she made sexual comments; and provide him/her with a busy board in his/her room. Further review of the care plan revealed no documented evidence staff revised Resident #1's care plan to include the level of supervision implemented upon his/her return from the psych hospital stay for: every fifteen (15) minute checks for twenty-four (24) hours: then every thirty (30) minute checks for twenty-four (24) hours; and then every hour checks for twenty-four (24) hours. Review of Resident #1's progress note dated 03/31/2022 at 6:01 PM, completed by the Nurse Practitioner (NP) revealed Resident #1 had loose thought processed and wandered into other residents' rooms. Per review of the NP note revealed Resident #1 required constant redirection and made sexual statements to the NA's. Interview with the Nurse Practitioner (NP), on 04/22/2022 at 1:30 PM, revealed she evaluated Resident #1 in the facility on 03/31/2022 after his/her return from the psych hospital and the resident had a hard time discerning what behaviors were appropriate versus inappropriate and a diagnosis of Dementia. Continued interview revealed the facility notified her of the incidents involving Resident #1's inappropriate behaviors; however, she was unable to recall the specifics of the notification. The NP further stated she expected staff to revise residents' care plans to include interventions for ensuring residents remained free of abuse from behaviors and incidents that occurred in the facility. Continued review of Resident #1's care plan revealed no documented evidence of interventions implemented for the resident's inappropriate behaviors and for the protection of other residents after the NP's evaluation on 03/31/2022. 3. Review of Resident #5's medical record revealed he/she was admitted to the facility on [DATE], with diagnoses that included Dementia. Review of Resident #5's Admission MDS Assessment revealed the facility assessed the resident as severely cognitively impaired and not interviewable as evidenced by the BIMS score of 00. Review of the MDS further revealed the facility assessed Resident #5 as requiring extensive assistance of two (2) staff members for bed mobility and toileting. Review of the facility investigation dated 03/31/2022 revealed at 8:30 PM, Resident #1 wandered into Resident #5's room and got in bed with Resident #5. Review of the investigation revealed Resident #5 and Resident #1 had both been fully clothed when observed by staff. Continued review revealed the residents were both assessed by staff following the incident with no concerns identified. Per review of the investigation, the facility unsubstantiated abuse related to the nursing notes and social service follow-ups in the days following the incident had revealed no concerns and both residents' daily routines occurred with no signs of psychosocial distress. The investigation further revealed however, that staff implemented 1:1 supervision for Resident #1 following the incident. Interview with Registered Nurse (RN) #1 on 04/19/2022 at 8:00 PM, revealed she had been the nurse responsible for Resident #1's and Resident #5's care when the incident occurred on 03/31/2022. RN #1 stated she had been completing her work duties at the nurse's station with Resident #1 with her. Continued interview revealed however, she discovered Resident #1 was no longer in the vicinity of the nurse's station and stated approximately five (5) minutes had passed since she had last observed Resident #1. RN #1 stated she walked down the hallway to try to determine Resident #1's whereabouts and discovered the door to Resident #5's room was closed which was not usual. Continued interview with Registered Nurse (RN) #1 stated therefore, she opened Resident #5's door and found Resident #1 lying on Resident #5's bed with him/her. Per interview, Resident #1 had been lying on top of the bed covers, with Resident #5 under the bed covers. RN #1 stated both residents had been fully clothed when she entered the room, and she removed Resident #1 from Resident #5's room. According to RN #1, after that she notified the administrative staff, she was supposed to notify of the incident and they directed her to implement 1:1 supervision of Resident #1. Further interview revealed since Resident #1 had been admitted to the facility he/she had wandered into other residents' rooms and required constant supervision by staff to prevent him/her from entering other residents' rooms. The RN further revealed however, she had not reviewed or revised Resident #1's care plan on 03/31/2022 to reflect the required increase of his/her level of supervision as she had not been trained or directed to do so. Review of Resident #1's care plan revealed staff revised his/her care plan for the identified problem regarding the 03/31/2022 incident where the resident got in bed with another resident. Per care plan review, the facility staff added the 1:1 supervision intervention for Resident #1 on 04/01/2022. Interview with the Minimum Data Set (MDS) Nurse, on 04/26/2022 at 4:00 PM, revealed she was responsible for ensuring residents' care plans were reviewed and revised when changes in the residents' condition occurred, which included any exhibited behaviors and or when incidents. She stated residents' care plans were reviewed and revised to reflect any necessary changes in the facility's Monday through Friday morning meetings. The MDS Nurse revealed however, she had not identified Resident #1's care plan had not been revised to reflect a documented change in his/her level of supervision on 03/12/2022, or after the incident on 03/14/2022. Continued interview revealed she had been aware Resident #1's level of supervision was specific upon his/her return to the facility on [DATE], after the psych hospitalization . The MDS Nurse revealed she was not aware Resident #1's care plan had not been revised to include the information for the specific level of supervision. Per the MDS Nurse, Resident #1's care should have been revised to include that information. Further interview revealed nursing documentation was reviewed during the Monday through Friday morning meetings and stated she recalled discussing Resident #1's continued wandering and inappropriate sexual comments. In addition, the MDS Nurse revealed that she had ensured that information was included on Resident #1's care plan, but acknowledged no changes had been made to the resident's care plan regarding the level of supervision. Interview with the Director of Nursing (DON), on 04/22/2022 at 3:30 PM, revealed she was aware of all the incidents involving Resident #1 which had occurred in the facility on 03/12/2022, 03/14/2022 and 03/31/2022. She stated when Resident #1 was readmitted to the facility on [DATE], after the psych hospitalization , the facility determined the resident's supervision should be for every fifteen (15) minute checks of him/her for twenty-four (24) hours; then every thirty (30) minute checks for twenty-four (24) hours; and then checks of the resident every hour for twenty-four (24) hours. Continued interview revealed residents' care plans were reviewed and revised as necessary during the facility's morning meetings, occurring Monday through Friday. The DON stated she expected her staff to revise residents' care plans to include any new interventions when residents exhibited inappropriate behaviors or were involved in incidents in the facility. According to the DON, she had not identified Resident #1's care plan had not been reviewed or revised, however, to reflect the line of sight supervision implemented on 03/12/2022; or for the 1:1 level of supervision implemented on 03/14/2022. Continued interview with the DON, on 04/22/2022 at 3:30 PM, revealed she had not identified Resident #1's care plan was not revised to reflect the interventions for every fifteen (15) minute checks of the resident for twenty-four (24) hours; then every thirty (30) minute checks for twenty-four (24) hours; and then checks of the resident every hour for twenty-four (24) hours. Per the DON, Resident #1's care plan should have been revised to include all those interventions, however. Further interview revealed recalled reviewing the progress notes for Resident #1 when he/she returned to the facility after the psych hospitalization , which noted the resident was again wandering into other residents' rooms. The DON further stated the progress notes she reviewed had additionally included the information related to the nurse asking Resident #1 if he/she had any pain or bruising, and the resident telling the nurse, No, just this good penis. The DON revealed she had not been alarmed by Resident #1's behaviors or statements and had not directed staff to increase the resident's level of supervision, the resident had just referred to his/her penis, and had not stated he/she was gonna use it. Interview with the Administrator on 04/21/2022 at 2:00 PM, revealed she expected facility staff to review and revise residents' care plans to include any new interventions when behaviors and incidents occurred. She stated residents' behaviors, nursing documentation and incidents were discussed in the facility's Monday through Friday morning meetings and residents' care plans were updated during the meeting to reflect any concerns identified. The Administrator revealed she had not identified Resident #'1 care plan had not been revised when the incidents and behaviors occurred; however, the care plan should have been revised. Further interview revealed the Administrator felt Resident #1 had been provided with adequate supervision by the facility.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (1) of eight (8) sampled residents (Resident #6). Review of Resident #6's medical record revealed he/she was evaluated by Occupational Therapy (OT) in July 2021 and again in February 2022 and his/her documented therapy goals included having a safe seating system so he/she could be mobile in the facility. However, observations and interviews with the resident and staff revealed no safe seating system had been made available for the resident. The findings include: Review of the facility policy titled, Accommodation of Needs dated 03/23/2022, revealed each resident would be treated with respect and dignity and the facility would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the resident or others would be endangered. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Depression, Morbid Obesity, and Weakness. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, dated 03/16/2022, revealed he/she was interviewable with a brief interview for mental status (BIMS) score of fifteen (15) and required extensive assistance of two (2) staff members with bed mobility and transfers. Review of Resident #6's comprehensive care plan last reviewed/revised on 03/11/2022 revealed staff identified that he/she was dependent for his/her emotional, physical, and social needs to be met in the facility due to the resident ' s physical limitation. The care plan review also revealed staff implemented the following interventions for the identified problem: Invite his/her family to attend special events, activities and meals; Introduce the resident to other residents with similar backgrounds, and interests and encourage and facilitate interactions; Invite Resident #6 to scheduled activities; Provide him/her with an activity calendar; Thank the resident for attending activity functions and assist the care plan also stated the resident needed assistance/escort to activity functions occurring in the facility. Interview with Resident #6 on 04/18/2022 at approximately 2:00 PM revealed he/she had resided in the facility for almost one (1) year and had never been provided a chair to set up, out of bed in, nor had she had a wheelchair to utilize so he/she could be out of his/her room. Resident #6 stated staff had told her on numerous occasions they would provide a seating system for him/her and the resident also stated therapy had evaluated him/her and conducted measurements to ensure he/she could comfortably set up in a chair; however, no chair had been provided. Resident #6 further stated staff had recently told him/her they had ordered a chair for him/her but the resident was not sure, as no staff member had informed the resident when the chair was scheduled to arrive to the facility, and they have been promising me a chair since I have been here. Resident #6 stated he/she was a member of the facility writing club; however, stated he/she was unable to read his/her written work out loud, as other residents had the right to do because he/she had no way of attending out of room activities. Resident #6 stated staff gave him/her an activity calendar every month however stated the calendar was full of things he/she was unable to do such as church services and movies/popcorn with other residents. Resident #6 also stated the only way he/she can be outside his/her room, was when staff transferred the resident to the shower room via his/her shower bed. The resident further stated the inability to be mobile and socialize with other residents has affected his/her quality of life in the facility. Interview with Nurse Aide (NA) #2 on 04/18/2022 at 3:40 PM revealed Resident #6 had stated to the NA that he/she wanted to be able to get out of bed in a chair and be able to be out of his/her room. She also stated the resident had wanted to go down to the activity room to be with other residents, however, stated he/she cannot go and also stated it was of course a quality of life concern for Resident #6. Interview with OT #1 on 04/22/2022 at 4:00 PM revealed she evaluated Resident # 6 in February 2022 because the resident had been requesting a chair so he/she could be out of bed. The OT stated she evaluated and provided measurements needed to ensure a safe seating system for Resident #6 to Administrative staff (unable to recall her name) immediately following the evaluation in February 2022; however, stated a chair had still not been provided to the resident and also stated Resident #6 should have had a chair by now. The OT further stated she felt by the conversations she had with Resident #6 that the failure of the facility to provide him/her with a means to be out of bed, was affecting the resident ' s quality of life in the facility. Interview with the Activity Director on 04/21/2022 at 5:30 PM revealed Resident #6 has verbalized wanting to come out of his/her room for activities; however, the Director stated Resident #6 understands that he/she cannot come out of his/her room and be with the other residents and also stated residents had the right to attend group activities if that's what they desire to do. Interview with the Account Manager at the supply company in which the order was placed for Resident #6's chair on 04/20/2022 at 12:00 PM revealed the facility placed an order for his/her chair on 04/14/2022 (2 months after the evaluation occurred). The Manager stated that due to shipping concerns the resident ' s chair would not be delivered to the facility until 06/29/2022 or 06/30/2022 (more than 4 months after the resident was evaluated). Interview with the Regional Director of Operations (RDO) on 04/21/2022 at 1:05 PM revealed she was the interim Administrator in February 2022 when OT evaluated Resident #6 for a seating system so he/she could be out of bed. She stated she sent all the measurements for his/her chair to the purchasing group for the facility on 02/16/2022 so a chair could be purchased for the resident. However, she acknowledged an order was not placed for the resident ' s chair for approximately two (2) months following the request, because she didn't feel it was an emergent get out of bed need for Resident #6 and they were trying to find a chair to purchase for the resident from different places. Interview with the Administrator on 04/21/2022 at 12:00 PM revealed the OT evaluation and the requests made to purchase his/her chair was completed prior to her employment at the facility. She also stated large purchases at the facility, required approval from Cooperate staff, and to her understanding, the purchase process for the resident ' s chair was in place when she took over as Administrator at the facility. She also stated the Residents chair had been ordered and was in process of being delivered to the facility. Interview with the Medical Director on 04/21/2022 at approximately 1:00 PM revealed she expected the facility to meet the needs of the residents and for the residents ' quality of life to be a priority in the facility. She also stated if Resident #6 was evaluated for a seating system in February, she would have expected the facility to order an appropriate chair so he/she could be out of bed within one (1) week following the evaluation.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure support for the resident in their choice of activities both facility sponsored group and individual activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident and encourage both independence and interaction in the community for one (1) of eight (8) sampled residents (Resident #6). Interview with Resident #6 and staff revealed the resident requested to participate in group activities and to have the ability to be able to interact with other residents in the facility outside of his/her room. However, the facility failed to provide the resident with a means to be mobile in the facility outside of his/her room to ensure he/she participated in the activities of his/her choice and had the opportunity to interact with other residents as requested. The findings include: A policy related to Activities was requested on 04/21/2022; however, one was not provided for review. Interview with the Director of Nursing (DON), on 04/22/2022 at 3:30 PM, revealed residents had the right to participate in activities of their choice in the facility. Review of the facility policy Accommodation of Needs dated 03/23/2022, revealed the facility would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the resident or others would be endangered. The policy also stated the facility should make efforts to reasonably accommodate the needs/preferences of the resident as they made use of their physical environment. The policy also stated the facility would assist residents in maintaining and/or achieving independent functioning, dignity and well-being to the extent possible. Review of Resident #6's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses that included Depression and Morbid Obesity. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, dated 03/16/2022, revealed Resident #6 was interviewable with a brief interview for mental status (BIMS) score of fifteen (15) and required assistance of two (2) staff members with transfers and bed mobility. Review of Resident #6's comprehensive care plan last reviewed/revised, on 03/11/2022, revealed Resident #6 was dependent for his/her emotional, physical and social needs to be met in the facility due to his/her physical limitations. The care plan also revealed staff implemented the following interventions for the identified problem: Invite the resident ' s family to attend meals, special events and activities; Introduce him/her to other residents with similar backgrounds, and interests, and encourage and facilitate interactions; Invite Resident #6 to scheduled activities; Provide him/her with an activity calendar; Thank the resident for attending activity function. Further review of the resident's care plan revealed staff would aid/escort the resident to activity functions that occurred in the facility. Interview with Resident #6, on 04/18/2022 at approximately 2:00 PM, revealed he/she had resided in the facility for almost one (1) year and had never been provided a chair so he/she could get out of bed, nor had he/she been provided a wheelchair so he/she could be out of his/her room. Resident #6 stated staff told him/her on numerous occasions they would provide a seating system for him/her and the resident also stated therapy had evaluated and conducted measurements to ensure he/she could comfortably set up in a chair; however, no chair had been provided. Resident #6 further stated staff had recently told him/her they ordered a chair for him/her but the resident was not sure, as no staff member had informed the resident when the chair was scheduled to arrive to the facility and the resident also stated: they have been promising me a chair since I have been here. Continued interview with Resident #6, on 04/18/2022 at approximately 2:00 PM, revealed he/she was a member of the facility's writing club; however, stated he/she was unable to read his/her written work out loud, as other residents have the right to do because he/she had no way of attending out of room activities. Resident #6 also stated staff gave him/her an activity calendar every month; however, stated the calendar was full of things he/she was unable to do such as church services and movies/popcorn with other residents. Resident #6 also stated the only time he/she was outside his/her room, was when staff transferred him/her to the shower room via his/her shower bed. Resident #6 further stated the inability to be mobile and socialize with other residents has affected his/her quality of life and he/she felt he/she had the right to attend group activities in the facility, as other residents were permitted to do. Interview with Nurse Aide (NA) #2, on 04/18/2022 at 3:40 PM, revealed Resident #6 had stated to the NA that he/she wanted to get out of bed in a chair and be able to be out of his/her room. She also stated the resident had wanted to go down to the activity room to be with other residents, however, stated he/she cannot go and stated it was a quality-of-life concern for Resident #6. Interview with Occupational Therapy (OT) #1, on 04/22/2022 at 4:00 PM, revealed she evaluated Resident # 6 in February 2022 because Resident #6 had been requesting a chair so he/she could be out of bed. The OT stated she evaluated and provided measurements needed to ensure a safe seating system for Resident #6 to administrative staff (unable to recall her name) immediately following the evaluation in February 2022; however, stated a chair had still not been provided to the resident and also stated Resident #6 should have had a chair by now. The OT further stated she felt by the conversations she had with Resident #6 that the failure of the facility to provide him/her with a means to be out of bed, was affecting the resident ' s quality of life in the facility. The OT also stated Resident #6 had voiced a desire to attend out-of-room activities with the other residents; however, he/she was unable to participate as requested due to no means to get up and out of his/her room. Interview with the Activity Director, on 04/21/2022 at 5:30 PM, revealed Resident #6 verbalized wanting to come out of his/her room for activities; however, the Director stated Resident #6 understands that he/she cannot come out of his/her room and be with the other residents and also stated residents had the right to attend group activities if that's what they desire. Interview with the Account Manager at the supply company where the order was placed for Resident #6's chair on, 04/20/2022 at 12:00 PM, revealed the facility placed an order for his/her chair on 04/14/2022 (2 months after the evaluation occurred). The Manager stated that due to shipping concerns the resident ' s chair would not be delivered to the facility until 06/29/2022 or 06/30/2022 (more than 4 months after the resident was evaluated). Interview with the Regional Director of Operations (RDO), on 04/21/2022 at 1:05 PM, revealed she was the interim Administrator in February 2022 when OT evaluated Resident #6 for a seating system so he/she could be out of bed. She stated she sent all the measurements for his/her chair to the purchasing group for the facility on 02/16/2022 so a chair could be purchased for the resident. However, the RDO acknowledged an order was not placed for his/her chair for approximately two (2) months following the request, because she didn't feel it was an emergent get out of bed need for Resident #6 and they were trying to find a chair to purchase for the resident from different places. Interview with the Administrator, on 04/21/2022 at 12:00 PM, revealed the OT evaluation and the requests made to purchase Resident #6's chair was completed prior to her employment at the facility. She also stated residents had the right to attend out-of-room activities in a group setting if that was their personal preference. Interview with the Medical Director, on 04/21/2022 at approximately 1:00 PM, revealed the residents ' quality of life was expected to be a priority in the facility. She also stated if Resident #6 was evaluated for a seating system in February, she would have expected the facility to order an appropriate chair within one (1) week following the evaluation. The Director also stated residents had the right to attend out-of-room activities in a group setting if that was the residents ' preference.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide medically related social services to maintain the highest practicable physical, mental and psychosocial wellbeing for one (1) of eight (8) sampled residents (Resident #6). Review of Resident #6's medical record revealed the resident's dentist documented the resident required an appointment with an oral surgeon in September 2021, to have his/her teeth extracted. However, the Social Service Director (SSD) failed to make the needed appointment for the resident, causing a delay in the resident's treatment. The findings include: Review of the facility policy titled Social Services last revised on 03/22/2022, revealed the facility would provide medically-related social services to each resident to attain or maintain the resident ' s highest practicable physical, mental and psychosocial well-being. The policy stated the Social Services Director (SSD) would make referrals and obtain needed services from outside entities for the residents. Review of Resident #6's medical record revealed the facility admitted the resident on 05/08/2021 with diagnoses that included Morbid Obesity and Weakness. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, dated 03/16/2022, revealed he/she was interviewable with a brief interview for mental status (BIMS) score of fifteen (15), indicating the resident was cognitively intact and interviewable. Interview with Resident #6, on 04/18/2022 at approximately 2:00 PM, revealed he/she had been in need of oral surgery for a long time. Resident #6 stated he/she was evaluated by a dentist at the facility seven (7) or eight (8) months ago and was informed the resident's remaining teeth needed removal by an oral surgeon. However, the resident stated no one at the facility discussed making him/her an appointment with an oral surgeon until sometime in February 2022. Resident #6 also stated his/her family member called the facility and made multiple requests for someone to make him/her the needed appointment and it still took the facility way too long to make the appointment. Further interview with Resident #6 revealed he/she was still waiting to be seen by a dentist, adding even now, he/she cannot get his/her (teeth) taken care of until July. Observations conducted with the Minimum Data Set (MDS) nurse, of Resident #6's oral cavity on 04/20/2022 at approximately 12:00 PM, revealed Resident #6 had approximately ten (10) teeth in need of removal, and several teeth were missing, broken and brown/black in color. Review of Resident #6's Summary Report from the dental medical group that provided dental care at the facility, dated 09/01/2021, revealed he/she had been seen by the Dentist, at which time the Dentist documented Resident #6 needs all remaining teeth non-restorable extracted by an oral surgeon. Additional review of the Dental Group Summary Report for Resident #6, dated 10/25/2021, revealed he evaluated the resident again and documented unable to do prophy on the patient due to patient needing a full mouth extraction, spoke with the Social Worker about extractions and she was going to work on getting the patient into an office to get the extractions completed. Review of another Dental Group Summary Report for Resident #6, dated 01/04/2022, revealed he evaluated the resident again and documentation included the resident was waiting to have remaining teeth extracted. Review of Resident #6's medical record revealed the facility obtained a follow-up appointment for Resident #6's teeth extractions on 02/21/2022, over five (5) months since the dentist recommended the resident to have his/her non-restorable teeth extracted, due to transportation issues. Further record review revealed Resident #6 was rescheduled to be evaluated by an oral surgeon in July 2022 ( ten (10) months after the dentist documented he/she needed extractions). Interview with the Social Services Director (SSD), on 04/19/2022 at 4:00 PM, revealed she was responsible for making all appointments and arranging transportation for residents ' dental needs in the facility. Per interview, the SSD revealed she had not made Resident #6's appointment to see an oral surgeon in September, as recommended by the dentist, because the resident had insurance concerns, at some point. The SSD stated she could not recall the details related to the resident's insurance. Further, she stated she had difficulty arranging transportation for the resident due to his/her size. The SSD revealed Resident #6 had refused to have an appointment made in November 2021 due to COVID risks, but stated she had not documented that in his/her medical record, but should have. The SSD stated she did not see an issue with Resident #6 waiting until July 2022 to be evaluated by an oral surgeon, because Resident #6 had bad teeth when he/she was admitted to the facility. Interview with the Business Office Manager, on 04/20/2022 at 2:50 PM, revealed she was unaware of an insurance concern related to Resident #6. She stated that if there were problems with the residents' insurance carriers, which prohibited them from receiving needed services, she would be notified by the SSD. Further interview revealed she was not notified of Resident #6's concerns, which would have prohibited the resident from seeing his/her oral surgeon. Interview with the Administrator, on 04/21/2022 at 12:00 PM, revealed she had only worked at the facility a few months and the SSD had informed her that the resident's appointment had not been made due to insurance issues, resident refusal, and transportation issues. However, she stated months to wait for a needed extraction did seem like a long time. The Administrator further revealed she expected the facility's policy to be followed and that attempts or difficulties making needed appointments for the residents should be documented in the medical record. She stated the SSD had informed her that Resident #6's initial appointment for an oral surgeon was scheduled for July 2022, due to transportation issues, due to the weight of the resident. 1Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide medically related social services to maintain the highest practicable physical, mental and psychosocial wellbeing for one (1) of eight (8) sampled residents (Resident #6). Review of Resident #6's medical record revealed the resident's dentist documented the resident required an appointment with an oral surgeon in September 2021, to have his/her teeth extracted. However, the Social Service Director failed to make the needed appointment for the resident until, February 2022, five (5) months after the dentist's recommendation.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure residents obtained needed oral surgery, following a routine dental appointment, for one (1) of eight (8) sampled residents (Resident #6). The findings include: Review of the facility policy titled, Dental Services dated 01/02/2020, revealed the facility would assist residents in obtaining routine and emergency dental care. The policy stated routine dental services included an annual inspection of the oral cavity for signs of disease, dental cleaning, and smoothing broken teeth. Continued review revealed Emergency dental services included services needed to treat an acute episode of acute pain in the teeth, gums or palate; broken or otherwise damaged teeth or any other problem of the oral cavity that required immediate attention by a dentist. The policy stated the Social Services Director would if necessary/requested would assist the resident with making dental appointments and arranging transportation to and from the dental location. According to the policy all actions and information regarding dental services, which included any delays related to obtaining dental services would be documented in the residents' medical records. Review of Resident #6's medical record revealed the facility admitted the resident on 05/08/2021 with diagnoses that included Morbid Obesity and Weakness. Review of Resident #6 ' s Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) and required extensive assistance of two (2) staff members with bed mobility and transfers. The assessment also revealed staff determined there were no concerns with the resident's dental status. Interview with Resident #6, on 04/18/2022 at approximately 2:00 PM, revealed he/she had needed oral surgery for a long time. The resident stated he/she was evaluated by a dentist at the facility seven (7) or eight (8) months ago and informed the resident the remaining teeth he/she had needed removal by an oral surgeon. Per the interview, the resident stated no one at the facility discussed making him/her an appointment with an oral surgeon until sometime in February 2022. Review of Resident #6's Summary Report from the Dental Medical Group that provided dental care, dated 09/01/2021, revealed the dentist documented the resident needed all remaining teeth non-restorable extracted by an oral surgeon and patient was still waiting on extractions. Review of another Summary Report from the Dental Medical Group for Resident #6, dated 10/25/2021, revealed he evaluated the resident again at the facility and documented unable to do prophy on the patient due to patient needing a full mouth extraction, spoke with the facility's Social Worker about extractions and she was going to work on getting patient into an office to get his/her extractions completed. Further review of the Dental Medical Group Summary, dated 01/04/2022, revealed he evaluated the resident again at the facility and documentation included the resident was waiting to have remaining teeth extracted. Interview with the Social Services Director (SSD), on 04/19/2022 at 4:00 PM, revealed she was responsible for setting up all appointments regarding the residents' dental needs. The SSD revealed she did not set up Resident #6's appointment to see an oral surgeon due to the resident's insurance and difficulty with transportation due to the resident ' s weight/size. Further interview with the SSD revealed the resident has an appointment scheduled for July 2022. Interview with the Business Office Manager, at the facility on 04/20/2022 at 2:50 PM, revealed if there were problems with the resident's insurance carriers, the SSD would notify her to assist in resolving the issue, so the resident ' s needs would be met. Further interview with the Business Office Manager revealed the resident would receive a delay in treatment if concerns related to the resident ' s insurance arise. Per the interview, the Business Office Manager revealed she was not notified of any insurance concerns but should have been so the resident would not receive a delay in care. Interview with the Administrator, on 04/21/2022 at 12:00 PM, revealed she had only worked at the facility a few months and she had been informed by the SSD that the resident ' s appointment had not been made due to insurance issues and transportation concerns. However, she stated months to wait for a needed extraction did seem like a long time; however, expected the facility's policy, related to dental services, would be followed.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to implement the plan of care for one (1) of thirteen (13) sampled resident's, Resident #1. Review of Resident #1's medical record revealed the resident had been care planned for Activities of Daily Living (ADL) which included an intervention for staff to use a mechanical lift with a small sling for his/her transfer needs. However, on 11/15/2021 staff utilized a mechanical lift and transferred Resident #1 from the bed to a reclined geri-chair (medical chair that reclines), which staff failed to lock in place. Further review and interviews indicated staff failed to utilize the appropriate size sling as directed in his/her care plan, and the resident's left lower extremity became entrapped in an open space of the geri-chair during the transfer. According to staff, the resident's left leg was crooked in appearance following the incident. Resident #1 was later transferred to the hospital for further evaluation and was subsequently diagnosed with fractures to the tibia and fibula (the shinbone and calf bone) in his/her left lower extremity. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, not dated, revealed the policy statement/purpose was to ensure a comprehensive, person-centered care plan which included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The policy also stated care plan interventions were derived from analyzing the information gathered during the resident's comprehensive assessment and the risk factors associated with identified problems would be incorporated into the resident's plan of care. Review of an email correspondence with Assistant Director of Nursing (ADON) #2 on 12/02/2021 at 3:54 PM and a follow up interview on 12/03/2021 at 1:10 PM with the ADON revealed the facility had no policy related to the use of lift slings in the facility. ADON #2 also stated staff determined the size of sling each resident should utilize by the resident's current weight. Review of information provided by facility staff from Joerns Healthcare, titled, Loop Style Sling Color/Size Chart-Standard Size, dated 2021, revealed a size small sling should be utilized for residents that weighed between seventy-five (75) and one-hundred and fifty (150) pounds and was red in color. Review of the chart also revealed an extra-large sling was blue in color and should be utilized for residents that weighed between two-hundred and seventy-five (275) and five-hundred (500) pounds. Interview with the Global Product Manager from Joerns Healthcare on 12/07/2021 at 10:50 AM, revealed staff should never use an oversized sling for residents when a mechanical lift was utilized for transfers. Further, the manager stated the facility's staff should utilize a size small lift sling, which was red in color when a resident weighed one-hundred and nineteen (119) pounds. Continued interview revealed that when the incorrect size lift was used, there would be a potential for an increased risk of accidents and injury to the residents. In addition, he stated, the resident would become unstable and the resident's legs would not be placed where they needed to be for a safe transfer, when the sling was too large in size for the resident. Review of Resident #1's medical record revealed the facility admitted the resident on 09/21/2005 with diagnoses that included Abnormal Posture and Unspecified Encephalitis and Encephalomyelitis. Further review of the record indicated the resident weighed one-hundred nineteen (119) pounds on 11/09/2021. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 11/04/2021, revealed he/she was totally dependent on two (2) staff members when transferred and he/she was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) which indicated he/she was not interviewable. Review of Resident #1's Comprehensive Care Plan, last reviewed/revised on 11/15/2021, revealed staff determined Resident #1 was unable to perform activities of daily living independently, on 08/14/2012. The care plan also indicated staff determined Resident #1 required a mechanical lift and a small size sling, with the assistance of two (2) staff members for transfers on 01/08/2015. Review of Resident #1's nurse aide care plan, Visual/Bedside Kardex Report, dated November 2021, revealed staff were directed to utilize a mechanical lift and size small sling when Resident #1 was transferred. Review of Resident #1's incident report, dated 11/15/2021 at approximately 6:54 AM, revealed staff documented his/her left lower leg appeared crooked after the resident caught his/her leg in his/her chair during transport. The report also indicated a predisposing environmental factor of the accident was furniture and staff notified the resident's physician and was ordered to transfer him/her to the hospital for an x-ray. Observations of Resident #1's reclined geri-chair conducted with the Maintenance Assistant, on 12/07/2021 at 10:25 AM, revealed a gap which measured three (3) and 5/8 inches, was visible to both sides of the chair when it was placed in the reclined position. Further observations revealed Resident #1's chair locked/ functioned properly when in the reclined position. Interview with State Registered Nurse Aide (SRNA) #1, on 11/30/2021 at 9:30 PM, revealed she was assigned to care for Resident #1 on 11/15/2021, when the incident occurred. SRNA #1 stated she and another staff (SRNA #2) member transferred Resident #1 from the bed, to a geri-chair that was reclined (due to the resident's abnormal posture) and when the chair was in the reclined position, it left an approximate four inch gap between the seat and the arm of the chair. However, the SRNA stated she forgot to ensure the geri-chair was locked/secured before she transferred the resident and stated she should have secured the resident's chair. SRNA #1 also acknowledged staff had been trained to review care plans before providing care to residents and stated she knew Resident #1 required a size small sling. However, the SRNA stated she was in hurry and grabbed a blue sling which was too big (unsure of what size sling was utilized) for Resident #1. According to the SRNA, she and State Registered Nurse Aide (SRNA) #2 that helped transfer the resident also failed to stabilize Resident #1's lower extremities to ensure a safe transfer was conducted and as a result, the resident's left leg got caught in the approximate four inch gap between the seat and the arm of the chair. Continued interview with SRNA #1, on 11/30/2021 at 9:30 PM, revealed when the lift was utilized to lower the resident's body into the chair, the chair closed, and SRNA #2 then identified that the resident's leg had got caught in the gap of the chair. Continued interview revealed when SRNA #1 raised the resident back up out of the chair, to free the resident's left leg, the resident's leg looked crooked and the nurse was notified. The SRNA stated Resident #1 was transferred to the hospital for further evaluation after the incident occurred. SRNA #1 stated she should have followed Resident #1's care plan and utilized the appropriate size sling which could have prevented the accident. Interview with State Registered Nursing Assistant (SRNA) #2, on 11/30/2021 at 2:30 PM, revealed she assisted SRNA #1 to transfer Resident #1 from the bed to a geri-chair on 11/15/2021. SRNA #2 stated SRNA #1 had retrieved a blue lift pad to transfer the resident; however she was unsure what color of lift pad Resident #1 required as she had not frequently cared for the resident. SRNA #2 stated SRNA #1 operated the lift and I stood between the Geri-chair and the bed. According to SRNA #2 the geri-chair was in the reclined position; however, neither nurse aide locked the chair to ensure it was secure, but stated someone should have. The nurse aide also stated as SRNA #1 lowered Resident #1 down into the chair, she observed that his/her left leg was caught in the gap of the chair, and when Resident #1 was lifted back up to release his/her leg, I saw his/her leg looked crooked. The SRNA stated she probably should have provided more assistance/stabilization to the residents lower extremities during the transfer and also stated staff were required to review and follow care plans when care was provided in the facility. Review Resident #1's progress notes, completed by Licensed Practical Nurse (LPN) #1 on 11/15/2021 at 6:16 AM revealed staff had transferred the resident from the bed to a chair, when his/her left lower leg got caught in the chair. The notes also indicated the nurse aide made the Registered Nurse aware of the incident and when the nurse assessed the resident his/her leg appeared crooked. The nurses documentation also indicated staff notified the physician of the resident's incident/abnormality and staff were ordered to send Resident #1 to the emergency room (ER) for x-ray evaluation and treatment. Interview with Licensed Practical Nurse (LPN) #1 on 12/05/2021 at 5:30 PM revealed she was assigned to Resident #1 on 11/15/2021, when the incident occurred. LPN #1 stated SRNA #1 informed her that something occurred when Resident #1 was transferred with a mechanical lift and his/her leg looked crooked. LPN #1 stated when she assessed the resident his/her left leg was crooked and she notified the physician and the resident was transferred to the hospital for further evaluation. The nurse stated she reported the incident and the concerns identified to the resident's left leg, when the incident occurred to the Registered Nurse (RN) #1 who was also the interim Director of Nursing (DON). LPN #1 also stated she was not sure which size/color of lift pad staff utilized during the mechanical lift transfer on 11/15/2021. The LPN stated she was not aware of any process utilized in the facility by staff nurses to ensure resident care plans were implemented, but stated nurse aides were expected to follow the residents care plans. Interview with Registered Nurse (RN) #1 on 12/01/2021 at 12:10 PM revealed he was the interim DON when the incident occurred with Resident #1 on 11/15/2021. The interim DON stated he was informed by LPN #1 staff failed to lock a geri-chair before transferring Resident #1, and the resident was injured as a result. He also stated he was not aware of what process the facility utilized to ensure resident care plans were followed; however, stated staff were expected to review/follow care plans for the residents. Review of Resident #1's progress notes revealed Resident #1 returned to the facility on [DATE] at 9:21 AM with diagnoses of comminuted displaced fractures to his/her Left Tibia and Fibula with associated soft tissue injury and a hard splint had been applied to his/her left lower extremity. The notes also indicated Resident #1 had a follow up appointment to be evaluated by Orthopedics (bone doctor). Further review of Resident #1's medical record revealed the resident was evaluated by an Orthopedic physician on 11/18/2021 (3 days after the incident occurred). Review of documentation revealed the physician documented Resident #1 apparently got his/her leg caught while transferring with a lift; however, the documentation indicated the specific details are not 100% clear. Interview with the Minimum Data Set (MDS) Coordinator on 11/15/2021 at 11:15 AM revealed staff were expected to review/follow care plans for residents in the facility. However, she stated she was unsure what the facility process was to ensure care provided in the facility was done so as outlined in the residents plan of care. Interview with the Administrator on 12/07/2021 at 1:00 PM revealed the facility conducted an investigation/root cause analysis of the incident which involved Resident #1 and the causative factor determined by the facility, was that staff failed to lock his/her geri-chair in the reclined position as required. The Administrator also stated the facility had not identified that the appropriate size/color sling was not utilized during the transfer. She also stated staff were expected to implement the residents plan of care; however, stated the facility had no process to ensure care plans were implemented in the facility.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible and residents received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents, Resident #1, who were transferred with a mechanical lift out of a total sample of thirteen (13) residents. On 11/15/2021, staff used a mechanical lift to transfer Resident #1 from the bed to a reclined geri-chair (specialized reclining chair). However, staff failed to: utilize the appropriate sized lift sling for Resident #1; provide support to the resident's lower extremities during the transfer; and ensure the geri-chair was locked prior to the transfer. As a result, Resident #1's left lower extremity became entrapped in an open space in the reclined geri-chair, which resulted in fractures to his/her left tibia and fibula (the two bones in the lower leg). The findings include: Review of the facility's policy titled, Accidents and Incidents, last revised in July 2017, revealed all accidents and incidents involving residents were to be reported to the Administrator and investigated. Per review, the information which was to be included on the incident form included some of the following: date and time of the accident or incident occurred; the circumstances that surrounded the accident or incident; and any corrective actions taken regarding the incident. The Surveyor requested a facility policy related to the use of mechanical lifts in the facility. However, interview with the Administrator on 11/30/2021 at 2:50 PM, revealed the facility had no policy regarding the use of the facility's mechanical lifts. The Administrator revealed although there was no policy, she expected her staff to utilize the facility's lifts as directed in the manufacturer's guidelines. Review of the manufacturer's guidelines for the facility's Free Spirit Bariatric Electric Resident Lift, undated, revealed no instructions were included related to transferring a patient to a geri-chair; however, direction was provided to staff on how a transfer for a resident to a wheelchair should be conducted. The guidelines stated the chair's locks MUST be in a locked position before lowering the resident into a wheelchair, otherwise it might result in injury to the resident. Per review, the guidelines also directed staff to guide the resident's hips and back, as far back into the seat of the chair, as possible, for proper positioning, before lowering the resident into the chair to complete the transfer. According to the guidelines, two (2) staff members were recommended to utilize the lift and assist with transferring the patient. Further review revealed the guidance recommended one (1) staff member should operate the lift and the other staff member should stand behind the chair and ensure the resident was placed well back into the chair. Review of the manufacturer guidelines for the facility's Invacare Reliant resident lift, dated 10/01/2018, revealed no instruction were given for staff related to transferring a resident into a geri-chair; however the guidelines recommended two (2) staff members participate in utilizing the lift for transfers. Per review of the guidelines, one (1) person was to operate the lift, with the other staff person assisting with positioning of the resident during the transfer to a wheelchair. Continued review revealed the wheelchair was to be locked before lowering the resident into the wheelchair, and if it was not locked an injury might occur. Review of information provided by the facility regarding Loop Style Sling Color/Size Chart-Standard Size, dated 2021, revealed a size small sling was red in color and was to be utilized for residents who weighed between seventy-five (75) and one-hundred fifty (150) pounds. Further review of the chart indicated a blue sling was an extra-large in size and was to be utilized for residents who weighed between two-hundred and seventy-five (275) and five-hundred (500) pounds. Review of an electronic mail (email) correspondence with Assistant Director of Nursing (ADON) #2, on 12/02/2021 at 3:54 PM, and a follow up telephonic interview on 12/03/2021 at 1:10 PM, revealed the facility had no policy regarding the general use of its mechanical lifts and slings. Further review and interview revealed staff determined what size of sling a resident needed based on the resident's most current weight. Review of Resident #1's medical record revealed the facility admitted the resident on 09/21/2005, with diagnoses which included Abnormal Posture, Unspecified Encephalitis and Encephalomyelitis, Expressive Language Disorder and Gastrostomy Status. Continued review of Resident #1's medical record revealed documentation noting the resident weighed one-hundred nineteen (119) pounds on 11/09/2021, six (6) days prior to the occurrence of incident. (Which indicated Resident #1 would require a size small sling per review of the Loop Style Sling Color/Size Chart-Standard Size, dated 2021.) Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 11/04/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated he/she chose not to answer the questions or answered in a nonsensical manner, and was unable to be interviewed. Further review of the MDS revealed Resident #1 was totally dependent on two (2) staff members for all transfers. Review of Resident #1's Comprehensive Care Plan revealed the facility had identified that the resident was completely unable to perform his/her Activities of Daily Living (ADL) on 08/14/2012. Continued review revealed the facility had care planned the resident for his/her dependence on staff for ADLs. Further review revealed on 01/08/2015, facility staff assessed Resident #1 to require an intervention related to transferring, which was the use of a mechanical lift with use of a size small sling and assistance of two (2) staff members. Review of Resident #1's Nurse Aide, Visual/Bedside Kardex Report, (facility document informing Nurse Aides of each resident's care needs) dated November 2021, revealed documentation noting staff had been directed to transfer the resident with a mechanical lift using a size small sling. Interview with the facility's healthcare equipment supplier's Global Product Manager, on 12/07/2021 at 10:50 AM, revealed you never want to use an oversized sling for residents when utilizing a mechanical lift during a transfer. Continued interview revealed when staff utilized a sling that was too large for a resident assessed to require a small sling, the resident would be unstable during the transfer. Further review revealed if a resident was in a sling that was bigger than the size the resident required, the resident's legs would not be placed where they needed to be during the transfer. Review of the facility's incident report, dated 11/15/2021 at 6:54 AM, revealed Resident #1's left lower leg appeared crooked after caught in chair during transport. Per review of the incident report, a predisposing environmental factor noted in regards to the incident was furniture. Continued review revealed the Physician had been notified, with an order for staff to have Resident #1 transported to the hospital for an x-ray, and further evaluation and treatment. However, further review of the incident report revealed no other information regarding the causative factors of the incident documented, nor notation of staff's failure to secure the chair prior to transferring. In addition, review of the incident report further revealed no documentation of the type of lift used for Resident #1's transfer, nor whether staff had failed to utilize the appropriate size lift sling for the resident. Observation on 12/07/2021 at 10:25 AM, with the Maintenance Assistant of Resident #1's reclined geri-chair revealed a gap which measured three (3) and 5/8 inches, on the bilateral sides of the resident's geri-chair while in the reclined position. Further observation revealed Resident #1's geri-chair was locked and it functioned appropriately when placed in the reclined position. Interview on 11/30/2021 at 9:30 PM, with State Registered Nurse Aide (SRNA) #1 revealed she had been assigned to Resident #1's care on 11/15/2021, the date the incident occurred. SRNA #1 stated she had placed a geri-chair in the reclining position, which she forgot to lock, prior to transferring Resident #1 from the bed to the geri-chair on 11/15/2021. Continued interview revealed she should have made sure the geri-chair was locked for Resident #1's safety. SRNA #1 revealed she knew Resident #1 required a size small sling, which were red in color. Per the SRNA, she had been in a hurry however, on 11/15/2021, when she went to get a small size red sling for Resident#1. Further interview revealed the slings in the laundry area were all cluttered together, and as she was in a hurry she just grabbed a blue sling to use instead of a red one required for transferring the resident. SRNA #1 further revealed she had been aware at the time she grabbed the blue sling that it was too big for Resident #1's use. She additionally revealed she was not sure of what size the blue sling was when transferring Resident #1. The SRNA further stated she did not know if the sling was a medium, large, or extra large sling, she just knew it was not a small sling. Continued interview with SRNA #1, on 11/30/2021 at 9:30 PM, revealed SRNA #2 had assisted her with Resident #1's transfer. Per SRNA #1, they had failed to stabilize Resident #1's lower extremities during the transfer to ensure the resident's safety. She stated when they transferred Resident #1, his/her left leg got caught in the approximate four inch gap between the geri-chair seat and arm of the geri-chair. According to the SRNA, when Resident #1's body was lowered into the geri-chair via the lift, the chair closed on the resident's leg while the leg was caught in the gap of the chair. Interview revealed when the SRNAs lifted Resident #1 back up to release his/her leg from entrapment in the geri-chair, the resident's leg looked crooked. Per the SRNA, she could not remember which type mechanical lift they had used during the transfer when the injury of Resident #1 occurred on 11/15/2021. She stated the nurse was notified of the incident and Resident #1's leg injury. Per interview, Resident #1 was transferred to the hospital for further evaluation and treatment after the nurse was notified. SRNA #1 revealed she had received training on ensuring geri-chairs and wheelchairs were locked prior to transferring a resident. SRNA #1 stated she had also been trained on: the use of the facility's mechanical lifts; on what size sling to use; and to review the nurse aide care plan prior to transferring a resident with a mechanical lift. Further interview revealed Resident #1's care plan noted staff were to use a size small sling for the resident, and small slings were red in color. SRNA #1 revealed if she had ensured she provided Resident #1's care per his/her care plan on 11/15/2021, by utilizing a small sling, this would have prevented the injury of the resident. Interview with SRNA #2, on 11/30/2021 at 2:30 PM, revealed she assisted SRNA #1 with transferring Resident #1 from the bed to the geri-chair on 11/15/2021. Per interview, SRNA #1 had already retrieved a lift pad for them to use for Resident #1's transfer, before asking her to help with the transfer. Continued interview revealed SRNA #1 had informed her a blue lift pad was utilized for Resident #1 for transfers, and as she had not frequently cared for the resident before, she was unsure what size or color the lift pad was to be. SRNA #2 revealed SRNA #1 had operated the lift while she guided the resident during the transfer on 11/15/2021. SRNA #2 stated, I stood between the geri-chair and the bed during the transfer, and the geri-chair had been in a reclined position nearby. According to SRNA #2 however, the geri-chair had not been locked in place as required, and she had been in a hurry, forgetting to ensure the chair was locked for the resident's safety. Interview revealed SRNA #2 had been trained to ensure geri-chairs and wheelchairs were locked before transferring a resident, and on the proper use of the facility's mechanical lifts which included reviewing residents' care plan to ensure the appropriate size sling was utilized. She stated as SRNA #1 was lowering Resident #1 down into the geri-chair, I saw the resident's leg was caught in the gap of the chair. Per interview of SRNA #2, when they lifted Resident #1 back up from the geri-chair, in order to release his/her leg, she observed the resident's leg looked crooked. SRNA #2 stated she, probably should have provided more assistance/stabilization for Resident #1's lower extremities during the transfer to ensure a safe transfer for the resident; however, had failed to provide it. Further interview revealed she had also failed to ensure Resident #1's geri-chair had been locked during transfer as per the training she had received. In addition, SRNA #2 stated, even though she was not that familiar with Resident #1, if the care plan directed staff to use a small sling, which was red in color, then a red colored small sling should have been used during the transfer on 11/15/2021. Review of a Progress Note for Resident #1, dated 11/15/2021 at 6:16 PM, completed by Licensed Practical Nurse (LPN) #1, revealed staff had been transferring the resident from the bed to a geri-chair, when his/her left lower leg got caught in the chair. Per review, the nurse aide, (SRNA #1), had notified the nurse of the accident and the nurse assessed Resident #1. Continued review revealed during her assessment LPN #1 observed Resident #1's leg appeared crooked. Further review of the Note revealed the Physician had been notified and an order received for staff to send Resident #1 to the emergency room (ER) for x-ray, and evaluation and treatment. Review of Resident #1's hospital ER record revealed the resident had arrived at the ER, on 11/15/2021 at 6:11 AM, with complaints of pain in his/her left lower extremity, following a twisted injury where his/her leg had gotten caught in a chair while being transferred. Per review of the ER record, x-rays had been completed of Resident #1's left lower extremity. Continued review revealed x-ray report results which noted Resident #1 had comminuted (fracture where the bones were broken in several fragments and were not aligned) displaced fractures of the mid diaphysis (the shaft or central part of a long bone) of the tibia and fibula. Further review revealed a splint (material used to immobilize a broken bone) was applied to Resident #1's left leg and the resident was transferred back to the facility with orders to be evaluated by an Orthopedic Physician. Interview on 12/05/2021 at 5:30 PM, with Licensed Practical Nurse (LPN) #1 revealed she had been assigned to Resident #1's care when the incident occurred on 11/15/2021. She stated she had been notified by SRNA #1 that something had occurred when Resident #1 was transferred with a mechanical lift and the resident's leg looked crooked. Per interview, she observed Resident #1's leg which had appeared to be crooked, so she notified the Physician of that information, and had received an order to transport the resident to the hospital for further evaluation. She stated she informed the Interim Director of Nursing (DON) at the time the incident occurred, of her observation of the abnormalities to Resident #1's left leg, and that the accident had occurred during a mechanical lift transfer of the resident. Continued interview revealed she had not been instructed by the Interim DON to initiate an investigation or take any further actions related to the incident. LPN #1 stated when the incident occurred on 11/15/2021, she was not sure what type of lift the SRNAs had used, or what size and color the lift pad was they had utilized for the transfer. Interview revealed she had been the nurse who completed the incident report, and revealed she was unsure why all the necessary information had not been included on the report as required. She stated, she was unaware she had not completed all of the information required on the incident report and no one brought the concern to her attention. Further interview revealed she had received training on the use of the facility's mechanical lifts and lift pads; however was unable to recall the specifics regarding the sizes of the lift slings used. In addition, she stated the information regarding the lifts and what size sling nursing staff was to use for Resident #1 should have been on the nurse aide care plans. Interview on 12/01/2021 at 12:10 PM, with Registered Nurse (RN) #1 revealed he had been the facility's Interim Director of Nursing (IDON), on 11/15/2021, when the incident involving Resident #1's injury had occurred. He stated Licensed Practical Nurse (LPN) #1 notified him of the incident via a phone call, as he was on his way to the facility at the time. Per interview, LPN #1 informed him staff had transferred Resident #1 to a geri-chair and an incident had occurred because the staff failed to lock the geri-chair into the reclined position prior to the transfer. He stated he had been the person responsible for investigating the incident; however, revealed he was not sure which lift staff had used during Resident #1's transfer, nor was he sure of what size lift sling they had utilized for transferring the resident when the incident occurred. Interview revealed Resident #1's incident investigation was the first investigation he had ever conducted as a nurse and stated he was not aware of the specific details concerning the resident's accident that involved the mechanical lift. According to Registered Nurse (RN) #1, a regional nurse had assisted him with the investigation, and no questions had been posed regarding the type of lift or pad staff had used when they conducted the investigation. Per interview, RN #1 revealed the Administrator had not assisted him with the investigation; however, he discussed the findings with him. Further interview with RN #1 revealed the facility's clinical team had performed a root cause analysis of the 11/15/2021 incident, and determined staffs' failure to lock and secure the geri-chair in the reclined position prior to transferring the resident had been the causative factor of the incident. Review of Resident #1's Progress Note, dated 11/15/2021, revealed Resident #1 returned to the facility from the emergency room (ER) at 9:21 AM, with diagnoses of comminuted displaced fractures to the resident's left tibia and fibula, with associated soft tissue injury and a hard splint intact to his/her left lower extremity. Further review of the Note revealed Resident #1 had a follow up appointment for evaluation by Orthopedics (a bone doctor). Further review of Resident #1's medical record revealed the Orthopedic Physician evaluated the resident on 11/18/2021, three (3) days after the incident occurred. Review of the Orthopedic Physician's documentation revealed Resident #1 apparently got his/her leg caught while transferring with a lift; however, the Physician documented the specific details were not one-hundred percent clear. Per review, the Physician also documented Resident #1 had an unstable fracture with modest swelling of the foot more than the leg. Further review revealed the Orthopedic Physician noted Resident #1 was provided with a very well-padded posterior splint to his/her left leg. Interview with the Administrator, on 12/07/2021 at 1:00 PM, revealed the facility had investigated the incident involving Resident #1 which had occurred on 11/15/2021. The Administrator revealed the staff who performed Resident #1's transfer should have ensured the geri-chair was locked before transferring the resident to maintain his/her safety. Continued interview revealed the facility had not identified staff's failure to utilize the appropriate size sling for Resident #1 during the investigation conducted into the incident. According to the Administrator, two (2) staff members were to provide assistance and support according to the needs of the resident when during any mechanical lift transfers conducted in the facility. She stated staff had been trained on how to properly utilize lifts and determine the appropriate sling size for residents. Further interview revealed during the 11/15/2021 incident investigation, staff had not been questioned regarding what type of lift they had used or what size lift pad they utilized during the transfer. The Administrator stated staff had not been questioned regarding that information because the facility had determined staff's failure to lock the geri-chair was the only causative factor. She further stated that during the facility's investigation, information related to the type of lift used, and the size of the lift pad utilized by staff utilized when the incident occurred, should have been determined to ensure a thorough investigation.

Based on observation, interview, record review, review of the facility's policy and investigations, it was determined the facility failed to ensure residents were protected from abuse for five (5) of thirteen (13) sampled residents (Resident #4, #5, #6, #7 and #8). Interview and record review revealed Resident #4 exhibited unpredictable aggressive behaviors towards other residents and staff and wandered in and out of other residents' rooms. However, the facility failed to implement effective interventions to prevent Resident #4 from displaying aggressive behaviors towards other residents, which resulted in four (4) resident to resident incidents between 06/02/2021 and 11/16/2021, a five (5) month timeframe. The findings include: Review of the facility policy titled, Abuse Prevention Program, last revised December 2016, revealed residents had the right to remain free from abuse, neglect, misappropriation of resident property and exploitation. Per review, of the policy, the facility's administration was to ensure the protection of all residents from abuse by anyone, to include staff and other residents. Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 09/03/2021, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. According to the policy, willful meant the individual acted deliberately. Further review revealed physical abuse included hitting, slapping, punching, biting and kicking. Review of the facility policy titled, Resident-to-Resident Altercations, last revised December 2016, revealed if two (2) residents were involved in an altercation, the residents were to be separated, and staff would identify what happened. Per review, staff were to determine what might have led one (1) resident or both to the aggression towards the other resident involved in the altercation. According to the policy, the events of the altercation were to be reviewed and measures were taken to prevent additional incidents. 1. Review of Resident #4's medical record revealed the facility admitted the resident on 09/14/2015, with diagnoses which included Anxiety and Dementia with Behavioral Disturbances. Review of Resident 4's Quarterly Minimum Data Set (MDS) Assessment, dated 11/25/2021, revealed the facility had assessed the resident with a Brief Interview for Mental Status (BIMS) score of four (4), indicating he/she was severely cognitively impaired. Per review, Resident #4 had not exhibited any behaviors during the assessment period. Review of Resident #4's Comprehensive Care Plan, last revised on 11/11/2021, revealed the facility had care planned the resident for his/her diagnosis of Dementia and potential for alteration in behaviors on 09/06/2021. Continued review of the care plan revealed the facility determined Resident #4 had a history of demonstrating agitation and attempting to go into other residents' rooms and he/she was not easily directed. Per review, Resident #4 was also combative with staff and had exhibited inappropriate remarks and behaviors towards other residents and staff. Further review of Resident #4's care plan revealed interventions included staff to address the resident's behaviors, and provision of a Psychiatric consult ordered 03/02/2016. Review of the care plan revealed other interventions included: staff to approach and speak to the resident in a calm manner; intervene as necessary to protect other residents' rights and safety; divert the resident's attention as possible; and remove Resident #4 from the situation and take him/her, as needed, to an alternate location (04/30/2019). Further review of the care plan revealed additional intervention which noted for staff to attempt to determine an underlying cause by utilizing non-pharmacologic approaches to address pain, repositioning, toileting, hydration; emphasize positive aspects of compliance and provide Resident #4 with positive feedback for good behavior; administer medications as ordered and keep the resident in an observable area when out of bed. Interview with Resident #4, on 11/30/2021 at 12:00 PM, revealed he/she was unable to recall any incidents that occurred in the facility and the resident denied being abused in the facility. Observations of Resident #4, on 11/30/2021 at 12:00 PM and 3:00 PM, revealed he/she was up in a wheelchair in the hallway of the facility. Continued observations revealed other residents were ambulating and propelling their wheelchairs in close proximity of the resident and no behaviors directed toward other residents occurred. 2. Review of Resident #8's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease and Muscle Weakness. Review of Resident 8's Quarterly Minimum Data Set (MDS) assessment, dated 11/26/2021, indicated he/she had a BIMS score of zero (00), which indicated he/she was cognitively impaired and was not interviewable. The MDS indicated Resident #8 had no behaviors during the assessment period. Interview with Resident #8, on 12/07/2021 at 11:00 AM, revealed the resident was unable to recall any incidents which had occurred in the facility; however, the resident stated he/she felt safe in the facility. Review of the facility investigations, dated 06/02/2021, revealed Resident #4 and Resident #8 were arguing in the hallway of the facility. The investigation stated staff heard Resident #8 shout at Resident #4, You're going to make me fall. Further review revealed staff then observed Resident #4 kick Resident #8 in the leg; however, neither resident was injured and the residents were immediately separated. According to the investigation, Resident #4's level of supervision was then increased. Review of Resident #4's care plan indicated after the incident occurred on 06/02/2021, staff added an intervention to encourage diversional activities and assist him/her away from public areas when his/her behaviors posed a risk for harm. Interview with Licensed Practical Nurse (LPN) #2, at 4:22 PM on 12/06/2021, revealed she had been trained regarding the abuse policies/procedures in the facility and was assigned to care for Resident #4 when the incident occurred on 06/02/2021. The LPN stated she was in the facility hallway and Resident #8 just walked by Resident #4, and she then overheard Resident #8 state you're going to make me fall and when she turned around, she witnessed Resident #4 kick Resident #8 in the leg. LPN #2 stated Resident #4 was agitated and kicked out and hit Resident #8 without any warning. 3. Review of Resident #7's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Major Depressive Disorder. Review of Resident #7's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility staff determined he/she was cognitively impaired with a BIMS score of three (3). Further review of the MDS revealed the resident had no behaviors during the assessment period. Interview with Resident #7, on 12/07/2021 at 10:50 AM, revealed he/she was unable to recall any incidents that had occurred in the facility. However, he/she stated no abuse had occurred and replied yes when asked if he/she felt safe in the facility. Review of the facility investigation, dated 06/28/2021 at 5:45 PM, revealed staff observed Resident #4 in Resident #7's room with his/her hand through the zipper of the resident's pants. The investigation indicated staff assessed both residents and neither resident was harmed as a result of the incident. The investigation also indicated the residents were separated and 1:1 observation was implemented for both residents and Resident #4 continued to be on an increased level of supervision for approximately one (1) week. The investigation also indicated laboratory tests were conducted for Resident #4, and results revealed he/she had a Urinary Tract Infection (UTI), which was treated with antibiotics. Interview with Licensed Practical Nurse (LPN) #2, on 12/06/2021 at 4:22 PM, revealed she was working on 06/28/2021 when staff reported to her Resident #4 was observed in Resident #7's room and his/her hand was observed in the zipper of Resident #7's pants. The nurse also stated staff reported Resident #7 was observed to lean into Resident #4 as if he/she was going to kiss the resident. However, the LPN stated staff intervened and separated the residents immediately therefore no further contact occurred. Continued interview with Licensed Practical Nurse (LPN) #2, on 12/06/2021 at 4:22 PM, stated she assessed both residents immediately following the incident and neither resident voiced they were abused and no injuries were observed to have occurred to either resident. Further interview with the LPN revealed she placed the residents on an increased level of supervision. Review of State Registered Nurse Aide (SRNA) #10's witness statement, dated 06/28/2021 at 5:45 PM, revealed she was passing supper trays and when she entered Resident #7's room she observed Resident #4 in Resident #7's room and his/her hand was observed down Resident #7's pants through the zipper. The SRNA's statement also indicated Resident #7 was observed to lean forward into Resident #4; however, staff intervened, and the residents were immediately separated and no further physical contact occurred. The surveyor was unable to interview SRNA #10 as the SRNA was no longer employed at the facility and no contact information was available to reach the nurse aide. 4. Review of Resident #6's medical record revealed the resident was admitted to the facility, on 01/20/2021, with diagnoses which included Unspecified Dementia and Anxiety. Review of Resident #6's Annual Minimum Data Set (MDS), dated [DATE], revealed he/she had a BIMS score of nine (9) which indicated he/she could be interviewed and the MDS also revealed he/she had no behaviors during the assessment period. Interview with Resident #6, on 11/30/2021 at 11:55 AM, indicated he/she was unable to recall any incidents and stated he/she felt safe and denied feeling he/she had been abused in the facility. Review of the facility investigation, dated 09/06/2021, revealed Resident #4 was in the hallway of the facility and was agitated and striking staff with a stop sign (vinyl sign put across doorways to detour wandering residents). Continued review of the investigation revealed Resident #4 was in the ice bucket and when staff attempted to redirect him/her, Resident #4 hit State Registered Nurse Aide (SRNA) #3 and also hit Resident #6. The investigation further revealed that as the staff was ensuring Resident #6 was not injured, Resident #4 threw another resident's picture frame in the hallway. According to the investigation, Resident #4's level of supervision was increased for seventy-two (72) hours after the incident. Interview with State Registered Nurse Aide (SRNA) #3, on 12/06/2021 at 4:40 PM, revealed she was working on 09/06/2021, when the incident occurred with Resident #4. The SRNA stated staff was passing ice and Resident #6 alerted staff Resident #4 was in the ice. The nurse aide stated when she attempted to redirect Resident #4, he/she became combative and attempted to hit her. SRNA #3 also stated when she moved to avoid getting hit by Resident #4, Resident #6 was in close proximity and Resident #4 hit Resident #6 on the arm. Further interview with State Registered Nurse Aide (SRNA) #3, on 12/06/2021 at 4:40 PM, revealed Resident #6 was not injured as a result and staff assisted him/her back to his/her room. According to the nurse aide, Resident #4's behaviors were impulsive and the only effective intervention to prevent incidents would be for the resident to have 1:1 supervision. She stated the resident was happy one day, mad the next, and you never know what he/she's gonna do. However, she stated Resident #4 was not aware of what he/she was doing; therefore, she did not feel his/her behaviors were abusive in nature. Review of Resident #4's progress notes completed by Registered Nurse (RN) #4 on 11/10/2021 at 2:47 PM, revealed he/she attempted to go into other residents' rooms and he/she gets agitated with redirection and was noted drawing his/her backhand at staff. Further review of the progress note revealed the resident continued with wandering behaviors. Review of Resident #4's medical record revealed the resident was evaluated on 11/11/2021, by psychiatric services at the facility. According to the evaluation Resident #4 had behaviors that cannot be redirected. The evaluation also indicated his/her medications were reviewed by the provider and his/her antipsychotic medication was increased from twice (2) a day, to three (3) times a day. 5. Review of Resident #5's record revealed he/she was admitted to the facility on [DATE] with diagnoses which included Dementia and Diabetes. Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was interviewable with a Brief Interview for Mental Status (BMS) score of nine (9), which indicated the resident was moderately impaired. According to the MDS, the resident had not exhibited any behaviors during the assessment period. Interview with Resident #5, on 11/20/2021 at 12:30 PM, revealed he/she stated Resident #4 had entered his/her room on multiple occasions before the incident occurred. The resident also stated when Resident #4 entered his/her room again on 11/16/2021, the resident was asked to leave, and Resident #5 stated Resident #4 kicked him/her on the leg. Resident #5 further stated that was when I hit [Resident #4] with a brush. Further interview revealed he/she felt safe in the facility and denied being abused by Resident #4. Review of Resident #4's progress notes and facility investigations revealed at 11:30 AM on 11/16/2021, Resident #4 wandered into Resident #5's room and kicked him/her on the knee. Resident #5 then hit Resident #4 with a hairbrush on the right wrist in response and further documentation review indicated neither resident was injured as a result of the incident. The investigation also indicated both residents were placed on fifteen (15) minute checks and psychiatric services were consulted to conduct a review of Resident #4's medications. Further record review revealed the resident's medications were reviewed on 11/18/2021, and no changes were made. Continued review revealed Resident #4 continued to be on an increased level of supervision for approximately three (3) days after the incident. Interview with State Registered Nurse Aide (SRNA) #3, on 12/06/2021 at 4:40 PM, revealed she also worked when the resident-to-resident incident occurred on 11/16/2021. The nurse aide stated Resident #5 reported Resident #4 had wandered into his/her room and kicked him/her. The nurse aide stated Resident #5 had hit Resident #4 with a brush to get him/her to leave the resident's room. SRNA #3 stated Resident #4 wandered in/out of other residents' rooms frequently and stated his/her behaviors continued even when an increased level of supervision was implemented. Review of Resident #4's progress notes dated 11/16/2021 at 7:04 PM (completed by Registered Nurse (RN #4), revealed on 11/16/2021 at 7:04 PM (approximately seven (7) hours after the resident to resident incident occurred and when the resident was on fifteen (15) minute checks) Resident #4 was propelling him/herself in a wheelchair and continued to wander and attempt to enter other resident's rooms and yelling at them. Further review of the progress note revealed the resident was agitated and striking out at staff when attempts were made to redirect the resident. The State Survey Agency (SSA) attempted to contact Registered Nurse (RN) #4 on 11/30/2021 at 4:00 PM, 12/01/2021 at 10:00 AM, and 12/02/2021 at 12:30 PM; however, those attempts were unsuccessful. Interview with Resident #4's Power of Attorney (POA), on 12/05/2021 at 7:30 PM, revealed she was aware of the resident's ongoing behaviors and the incidents that had occurred with other residents. The POA also stated Resident #4 wandered in and out of other residents' rooms and stated she felt the resident had those behaviors because the resident had worked in the laundry department at the facility for over ten (10) years prior to being diagnosed with Dementia. The POA also stated she felt like the resident still thought he/she was still at work some days and stated the facility staff should watch Resident #4 closer. Interview with Assistant Director of Nursing (ADON) #1, on 01/03/2021 at 12:15 PM, revealed Resident #4 had a history of resident-to-resident incidents and his/her behaviors were unpredictable. However, she stated she did not feel his/her behaviors were abusive or willful due to the resident's cognitive status and diagnosis of Dementia. Interview with Nurse Practitioner (NP) #1, on 01/04/2021 at 5:30 PM, revealed she was frequently consulted to evaluate Resident #4 related to his/her behaviors and/or resident to resident incidents that occurred in the facility. The NP also stated she expected facility staff to meet the residents' needs who have Dementia, with exhibited wandering behaviors. Further, the NP stated staff was expected to ensure residents were safe and free from abuse in the facility. Interview with the Administrator, on 01/03/2021 at 12:20 PM, revealed she was the Abuse Coordinator in the facility and provided oversight and reviewed the results of all investigations conducted in the facility. She acknowledged Resident #4 exhibited ongoing behaviors which resulted in resident-to-resident incidents. She also stated residents had the right to be free from abuse; however, stated she had not substantiated abuse regarding the incidents that involved Resident #4, because she did not feel Resident #4's actions were abuse. Additionally, the Administrator stated she did not consider the resident's actions as abuse because Resident #4 was not cognitively aware to be deliberate and the resident did not recall his/her actions after the incidents occurred, even though the facility policy stated physical abuse included hitting, slapping and kicking another individual. Further interview with the Administrator, on 01/03/2021 at 12:20 PM, revealed no injuries occurred, as a result of the resident-to-resident incidents. Continued interview revealed that after she interviewed the residents, following each resident-to-resident incident, the residents denied abuse occurred. However, review of the facility's abuse policy revealed abuse was defined as the willful infliction. Further review of the policy revealed physical abuse included hitting, slapping, punching, biting and kicking.

Based on observation, interview, record review, and review of facility policy and investigations, it was determined the facility failed to ensure one (1) of thirteen (13) sampled residents (Residents #4), who was diagnosed with dementia, received appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Interviews and record reviews revealed Resident #4 wandered in/out of other residents' rooms and exhibited aggressive behaviors, which were unpredictable, towards staff and other residents. However, there was no documented evidence the facility developed or implemented a plan of care in attempts to decrease/prevent Resident #4's behaviors, even though the resident's behaviors had resulted in four (4) resident to resident incidents in five (5) months. The findings include: Interview with the Administrator on 12/07/2021 at 1:00 PM revealed the facility had no policies related to behaviors or care and treatment of residents with Dementia. Review of the facility policy titled Resident-to-Resident Altercations last revised in December 2016 revealed if two (2) residents were involved in an altercation, staff would identify what happened, including what may have led to aggressive conduct. The policy also stated staff would make any necessary changes in the care planned approaches for those involved and possible measures would be implemented to try and prevent further incidents. According to the policy, an investigation of the incident would be conducted, and the findings and any corrective measures taken would be documented in the clinical record. Review of the list of Brief Interview for Mental Status (BIMS) scores for residents in the facility revealed Resident #5 and Resident #6 had BIMS scores of nine (9) indicating moderate cognitive impairment. Further review indicated Resident #7 had a score of three (3) and Resident #8 was assessed to have a BIMS score of zero-zero (00) which indicated severe cognitive impairment. Review of Resident #4's medical record revealed the facility admitted the resident on 09/14/2015 and the resident had diagnoses that included Dementia with behavioral disturbances and Anxiety. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he/she was not interviewable, with a Brief Interview for Mental Status (BIMS) score of four (4). The MDS indicated the resident had not exhibited any behaviors during the assessment period and required the assistance of two (2) staff members when transferred/toileted. Review of Resident #4's Comprehensive Care Plan, last reviewed/revised on 11/11/2021 revealed on 09/06/2021, staff identified the resident had a diagnosis of Dementia and had a potential for alteration in behaviors. The care plan also indicated the resident was not easily redirected and had a history of demonstrating agitation and attempting to go into resident rooms. According to the care plan, Resident #4 was also combative with staff at times and exhibited inappropriate behaviors/remarks towards staff and other residents. Further review of Resident #4's care plan revealed the facility developed interventions to address the resident's behavior that included, a Psychiatric consult as ordered (03/02/2016); intervene as necessary to protect the rights/safety of others, approach/speak in a calm manner, divert the resident's attention as possible, remove the resident from the situation and take him/her to an alternate location as needed (04/30/2019); attempt to determine underlying cause with non-pharmacology approaches to address toileting, repositioning, hydration, pain, etc. (04/30/2019); provide positive feedback for good behavior, emphasize the positive aspects of compliance (not dated); and keep the resident in an observable area when out of bed (11/30/2021) and administer medications as ordered (03/04/2020). Further review of the resident's medical record revealed the resident was seen by Psychiatric Services on 06/02/2021, 07/05/2021, 07/20/2021, 08/05/2021, 09/23/2021, 10/28/2021, 11/11/2021 and 11/18/2021. Interview with Resident #4 on 11/30/2021 at 12:00 PM revealed the resident was unable to recall any incidents that had occurred in the facility; however, denied being abused in the facility. Observations of Resident #4 on 11/30/2021 at 12:00 PM and 3:00 PM revealed the resident was up in a wheelchair in the facility hallways and other residents were observed ambulating and propelling their wheelchairs in close proximity of the resident. Further observations conducted on 12/07/2021 at approximately 12:00 PM revealed the resident was in his/her wheelchair sitting toward the front entrance of the facility in close proximity of other residents. Resident #4 was not observed to wander into other resident's personal space, and was not observed to exhibit aggressive behaviors towards others. 1. Review of a facility investigation revealed on 06/02/2021 at approximately 1:45 PM, Resident #4 and Resident #8 (who was not interviewable with a BIMS of 00) were arguing in the facility hallway. Staff heard Resident #8 shout at Resident #4, You're going to make me fall. The investigation indicated staff then observed Resident #4 kick Resident #8 on the leg. According to the investigation, the residents were separated and neither resident was injured. The facility increased Resident #4's level of supervision (every fifteen (15) minute checks for twenty-four (24) hours, every (4) hour checks for the next twenty-four (24) hours, then every shift for 24 hours) and staff were required to encourage the resident to do an activity in his/her room when he/she was agitated. Review of Resident #4's care plan revealed the facility developed an intervention following the incident on 06/02/2021 that required staff to assist the resident away from public areas when behaviors posed a risk for harm and to encourage diversional activities. Interview with Licensed Practical Nurse (LPN) #2 on 12/06/2021 at 4:22 PM, revealed she had received training at the facility regarding care/treatment of resident's with Dementia and was working when the incident occurred between Resident #4 and #8 on 06/02/2021. She stated she was in the facility hallway and Resident #8 just walked by Resident #4, and she overheard Resident #8 state your're going to make me fall and when she turned around to evaluate why the resident stated that, she witnessed Resident #4 kick Resident #8 on the leg. According to the LPN, Resident #4 was agitated and just kicked out and hit Resident #8 with no warning. The LPN stated Resident #4's behaviors were impulsive and she was unable to think of an intervention that would be effective other than watching the resident when he/she was in a public area. LPN #2 stated staff nurses were not responsible for reviewing/revising resident care plans for any reason at the facility. Interview with Resident #8, on 12/07/2021 at 11:00 AM, revealed the resident was unable to recall any incidents and stated he/she felt safe in the facility. 2. Continued review of the facility incidents revealed on 06/28/2021 at approximately 5:45 PM, Resident #4 was observed in Resident #7's [not interviewable with a BIMS score of three (3)] room with his/her hand through the zipper of Resident #7's pants. The investigation indicated neither resident was harmed as a result of the incident. Staff separated the residents and placed both residents on 1:1 observation. Review of the investigation also indicated Resident #4 continued to be on an increased level of supervision for approximately one week. The facility also conducted laboratory tests for Resident #4, which indicated the resident had a Urinary Tract Infection and was subsequently treated with antibiotics. However, review of Resident #4's care plan revealed no documented evidence the resident's care plan was revised/interventions developed to further prevent resident-to-resident incidents from occurring. Interview with Licensed Practical Nurse (LPN) #2 on 12/06/2021 at 4:22 PM revealed she was working when Resident #4 was observed in Resident #7's room exhibiting inappropriate behaviors on 06/28/2021. According to the LPN, a nurse aide reported the incident to her. The residents were separated and immediately assessed to have no ill effects from the event. The LPN stated Resident #7 denied he/she felt abused to facility staff. The LPN also stated a nurse aide informed her that Resident #7 was observed to lean into Resident #4 as if he/she was going to kiss the resident but staff intervened so no further contact was made from resident to resident. The LPN stated she recalled being instructed to place the residents on an increased level of supervision; however, was unable to recall any further actions taken by the facility to ensure the resident-to resident- incidents would not reoccur. Review of a witness statement on 11/30/2021 completed by State Registered Nurse Aide (SRNA) #10 on 06/28/2021 at 5:45 PM revealed she was passing supper trays and entered Resident #7's room to deliver his/her tray and observed Resident #4 in the resident's room and his/her hand was observed down Resident #7's pants through the zipper. The statement also indicated Resident #7 was observed to lean forward into Resident #4; however, staff intervened and separated the residents therefore, no further physical contact was made. Interview with Resident #7 on 12/07/2021 at 10:50 AM revealed the resident was unable to recall any incidents that occurred in the facility. However, the resident denied ever being abused and stated yes he/she felt safe in the facility. 3. Further review of incidents revealed on 09/06/2021 at approximately 2:00 PM, Resident #4 was in the hallway of the facility, agitated, and was striking staff with a stop sign (vinyl sign put across doorways to detour wandering residents). Continued review of the investigation and witness statements obtained from staff indicated Resident #4 was in the ice bucket and when staff attempted to redirect the resident from the ice container, Resident #4 hit me and also hit Resident #6 (interviewable with a BIMS score of nine (9). The investigation also revealed as staff was ensuring Resident #6 had not been injured, Resident #4 retrieved another resident's picture frame and threw it in the hallway. Review of actions taken following the incident revealed the facility increase Resident #4's level of supervision for seventy-two (72) hours, (15) fifteen-minute checks for twenty-four (24) hours, then thirty (30) minute checks for twenty-four (24) hours, then hourly checks for twenty-four (24) hours. The facility then decreased the resident's monitoring to every shift. The investigation also indicated psychiatric services had evaluated the Resident #4; however, the resident's family refused medication adjustments and the resident's care plan was updated accordingly. Review of Resident #4's care plan revealed on 09/06/2021, the day of the incident, the facility developed an intervention that stated if Resident #4 became agitated, staff were required to move him/her to a calm/isolated environment; offer diversional activities, attempt to identify the root cause of his/her aggression; offer to assist the resident to the bathroom; assess the resident for pain; and offer the resident a snack. Interview with State Registered Nurse Aide (SRNA) #3 on 12/06/2021 at 4:40 PM revealed she was working with Resident #4 when the incident occurred on 09/06/2021. She stated staff were passing ice on 09/06/2021 and Resident #6 observed Resident #4 in the ice and alerted staff. SRNA #3 stated she attempted to redirect Resident #4 from the ice chest and the resident became combative. The nurse aide stated, when she moved in attempts to not be struck by Resident #4, Resident #6 was unknowingly in close proximity; therefore the resident struck Resident #6 in the arm. According to the nurse aide, Resident #6 was not injured and was assisted back to his/her room without incident. SRNA #3 stated Resident #4's behaviors were impulsive and the only effective intervention to prevent incidents would be for the resident to have 1:1 supervision. She stated the resident was happy one day, mad the next, and you never know what he/she's gonna do. Review of Resident #4's progress notes completed by Registered Nurse (RN) #4 on 11/10/2021 at 2:47 PM, revealed Resident #4 had attempted to go into other residents' rooms and the resident gets agitated with redirection and was noted drawing back hand at staff. The note also indicated the resident was continuing with wandering behaviors, safety measures in place. However, there was no evidence the resident's care plan was revised to include any new interventions regarding the residents identified behaviors. Interview with Resident #6 on 11/30/2021 at 11:55 AM revealed he/she was unable to recall any incidents that had occurred; however, stated he/she felt safe and denied ever being abused in the facility. Review of Resident #4's medical record revealed he/she was evaluated by psychiatric services on 11/11/2021 and the resident was noted to have behaviors that cannot be redirected. According to the evaluation, the resident's medications were reviewed by the provider and his/her antipsychotic medication was increased to three (3) times daily. 4. Continued review of progress notes and facility investigations revealed on 11/16/2021 at 11:30 AM, Resident #4 wandered into another resident's room and staff witnessed Resident #5 (Resident #5's BIMS was nine (9) which indicated the residents were interviewable) strike Resident #4 on the right wrist with a hairbrush. When staff inquired why the resident hit Resident #4 with a brush, Resident #5 informed staff that Resident #4 had entered his/her room uninvited and kicked him/her on the knee. According to the investigation, both residents were placed on fifteen-minute checks and psychiatric services were consulted to do a drug regimen review of Resident #4's medications. The investigation review also indicated interventions implemented regarding the incident included that staff continued to monitor Resident #4 for approximately three (3) days following the incident, and no other interventions were implemented to prevent further incidents from occurring. Interview with Resident #5 on 11/20/2021 at 12:30 PM revealed he/she recalled the incident when Resident #4 entered his/her room. The resident stated Resident #4 had entered his/her room on multiple occasions before the incident occurred, and on 11/16/2021 the resident entered his/her room again and the resident asked Resident #4 to leave. Resident #5 stated Resident #4 wheeled next to his/her bed, after being asked to exit his/her room, and kicked Resident #5 on the leg. Resident #5 stated that was when I hit [Resident #4] with a brush. Resident #5 stated he/she felt safe in the facility,and felt he/she had not been abused by Resident #4 in the facility; however, did not like other residents wandering into his/her room. Interview with SRNA #3 on 12/06/2021 at 4:40 PM revealed she was also working when the resident-to-resident incident occurred on 11/16/2021 between Resident #4 and #5. The nurse aide stated Resident #5 informed her that Resident #4 had wandered into his/her room and kicked the resident. Resident #5 hit Resident #4 with a brush in attempts to get the resident to leave his/her room. According to the SRNA, Resident #4 wandered in/out of other residents' rooms frequently and stated the resident's behaviors continued even when he/she was on an increased level of supervision. The nurse aide stated the resident's behaviors had been reported to nurses at the facility, but no effective interventions had been implemented regarding the resident's ongoing behaviors. Review of Resident #4's progress notes completed by RN #4, revealed on 11/16/2021 at 7:04 PM (approximately seven (7) hours after the resident/resident incident occurred and he/she was on a fifteen (15) minute checks) the resident was propelling him/herself in a wheelchair, was wandering and attempting to enter other resident's rooms and yelling at them. The notes also indicated the resident was agitated and was striking out at staff when attempts to redirect the resident occurred. The medical record and/or his/her care plan revealed no interventions were implemented regarding the resident's behaviors after the resident-to-resident incident and ongoing behaviors continued. The State Survey Agency (SSA) attempted to contact Registered Nurse (RN) #4 on 11/30/2021 at 4:00 PM, 12/01/2021 at 10:00 AM, and 12/02/2021 at 12:30 PM; however, those attempts were unsuccessful. Interview with Resident #4's Power of Attorney (POA) on 12/05/2021 at 7:30 PM revealed she was aware of the residents ongoing behaviors and the incidents that had occurred with other residents. The POA also stated Resident #4 did wander in/out of other residents rooms and stated she felt the resident had those behaviors because the resident had worked in the laundry department at the facility for over ten (10) years prior to being diagnosed with Dementia. The POA also stated she felt like the resident still thought he/she is still at work some days and stated the facility staff should watch Resident #4 closer. Interview with the Social Services Director on 12/07/2021 at 12:00 PM revealed Resident #4 exhibited ongoing unpredictable behaviors in the facility and acknowledged interventions the facility had implemented were not effective. She also stated the resident continued to wander into other residents' rooms and resident-to-resident incidents continued to occur due to his/her behaviors. She stated she attended the Monday-Friday clinical meetings and residents that exhibit behaviors were discussed. However, she also stated she was not responsible to develop/review/revise care plans for resident's in the facility. She stated she had been trained on caring for residents with Dementia and those with behaviors and also stated she was responsible to compile a list of residents that needed to be seen by Psychiatric services and relay that to the provider in attempts to manage behaviors and other resident needs in the facility. Interview with the Minimum Data Set (MDS) Coordinator on 12/07/2021 at 11:15 AM revealed clinical meetings were conducted Monday-Friday in the facility; however, stated no in-depth discussions regarding behaviors occurred during the meetings nor at any other time that she was aware. She also stated care plans were expected to be reviewed/revised after incidents occurred and stated, she, as well as the Assistant Directors of Nursing (ADON) were responsible to ensure the updates had occurred. She further stated she had not identified that Resident #4's care plan had not been reviewed/revised as required after resident-to-resident incidents, but stated it should have been. The MDS nurse stated she had been trained on caring for residents with Dementia. Interview with Assistant Director of Nursing (ADON) #1 on 12/07/2021 at 10:40 AM, revealed her responsibilities included ensuring care plans were reviewed/revised to include new interventions after resident-to-resident incidents occurred. The ADON also stated residents with Dementia/Behaviors were discussed in the Monday-Friday interdisciplinary team meetings (IDT) and acknowledged new interventions had not been implemented after each incident occurred regarding Resident #4, but stated there should have been. She also stated Resident #4 had a history of resident-to-resident incidents and that his/her behaviors were unpredictable. The ADON acknowledged Resident #4's current care plan interventions were not effective at preventing further incidents from occurring and also stated the residents care plan should include effective interventions to prevent incidents in the facility. Interview with the Administrator, on 12/07/2021 at 1:00 PM, revealed residents with Dementia should receive care/treatment as outlined in the regulatory guidelines. She also stated Resident #4 had exhibited ongoing behaviors in the facility that had resulted in resident-to-resident incidents. The Administrator was not aware of anyone in the facility that tracked/trended resident behaviors. The Administrator also stated care plans should be reviewed/revised and new interventions implemented when incidents occurred, in attempts to prevent further resident-to-resident incidents in the facility. According to the Administrator, she felt Resident #4 needed placement in a memory unit environment to address his/her exhibited behaviors.

Based on observation, interview, and review of facility's policy, it was determined the facility failed to ensure drugs and biologicals stored in the facility were not expired, labeled, and stored in accordance with currently excepted professional principles; and failed to store medications according to appropriate environmental controls to preserve their integrity for one (1) out of three (3) medication storage rooms, and one (1) out of five (5) medication carts. Observation of D hall medication cart revealed Resident #2's discontinued [MEDICATION(S)] 5/325 mg tablets were found stored in the medication cart's narcotic lock box. Per physician orders, the medication had been discontinued on 10/13/2021. Observation of D hall medication refrigerator revealed a carton of beer was being stored along with medications. The medication refrigerator was full with very little room for proper air flow compromising the integrity of the Vaccines and Medications. Additionally, one (1) multidose vial of Moderna COVID-19 Vaccine was observed in the door of the refrigerator and was expired on 10/17/2021. Four (4) packages of Flu Vaccines were stored in the refrigerator door, which closed up against carton of beer. The findings include: Review of the facility's policy titled, Storing of Medication Requiring Refrigeration, dated 03/01/2020, revealed the purpose of the policy is to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of the medications by exposure to improper temperature and environmental controls. Furthermore, the facility must ensure all drugs are stored according to manufacturer's recommendations to preserve their integrity. Additional review of the facility's policy revealed refrigerators will be used solely for the purpose of storing medications and biologicals that require refrigeration and not used for food. In addition, staff should remove any expired medication from active stock and discard medication according to facility policy. Review of facility policy Medication Storage in the Facility, dated April 2018, revealed the purpose of the policy is to ensure medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. Further, the facility should ensure outdated and discontinued medications are stored separate from active stock, and discard medication according to facility policy. Review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, updated 09/29/2021, revealed best practices for storage of Vaccines is to: 1) Monitor and comply with Vaccine expiration dates, including the COVID-19 Vaccine. 2) Don't over-pack the refrigeration unit. Place the Vaccine packages in such a way that air can circulate around the compartment and promote air circulation; 3) Position Vaccines and diluents two to three inches from the unit's walls, ceiling, floor, and door; 4) Do not store on door shelf, top shelf, or on the floor of the refrigerator as the temperature in these areas may differ significantly from the temperature in the body of the unit; and 5) Do not store Vaccines in a refrigerator with food or beverages. Review of Resident #2's clinical record revealed the facility readmitted the Resident on 01/21/2020. Resident #2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per physician orders, Resident #2's [MEDICATION(S)] 5/325 mg tablets was discontinued on 10/13/2021 and a new order for [MEDICATION(S)] 7.5/325 mg was received. Observations, on 10/20/2021 at 12:30 PM of the D hall medication cart, revealed Resident #2's discontinued [MEDICATION(S)] 5/325 mg tablets were found stored in the medication cart's narcotic lock box. Observations, on 10/20/2021 at 12:50 PM, of the D and E hall medication refrigerator revealed the refrigerator was over-packed and full with very little room for proper air flow. Further observation revealed a carton of beer was being stored with medications. Additionally, one (1) vial of Moderna COVID-19 Vaccine was observed in the door of the refrigerator and was expired on 10/17/2021. Four (4) packages of Flu Vaccine were stored in refrigerator door, which closed up against the carton of beer. Interview with Licensed Practical Nurse (LPN) #5, on 10/20/2021 at 12:38 PM, revealed she was assigned to the D hall medication cart. LPN #5 assisted the Surveyor with observation of the D hall medication cart and medication storage room. Further interview revealed Resident #2's was given a new prescription for [MEDICATION(S)], and the [MEDICATION(S)] 5/325 mg tablets, found stored in the medication cart's narcotic lock box had been discontinued. Continued interview with LPN #5, revealed it was facility policy to store expired or discontinued controlled medications in the medication cart lock box and the Director of Nurses (DON) is to be notified. LPN #5 stated the DON was to be alerted that the controlled medication needs to be disposed of, at which time the DON removes it and destroys it according to facility policy. Per physician orders, Resident #2's medication had been discontinued on 10/13/2021. LPN #5 further stated the nursing staff is responsible for ensuring medications are labeled according to facility process, which is to record the date opened on the medication package when the medication has been opened. Furthermore, LPN #5 stated if an item is found to be expired, labeled, and or stored improperly, the nursing staff is responsible to discard the medication according to policy. LPN #4 further stated the importance was to ensure the safety of all residents. Interview with LPN #2, on 10/20/2021 at 1:35 PM, revealed it is the responsibility of the nursing staff to ensure medications are stored according to facility policy and procedure; Any expired medications are discarded according to facility policy to ensure the safety of all residents. Interview with LPN #3, on 10/20/2021 at 3:00 PM, revealed it is the responsibility of the nursing staff to ensure the medication cart is clean, medications are in the proper place. Any expired scheduled medications are discarded according to facility policy, which is to notify the DON. The DON removes it and destroys it. She stated all Vaccines are stored in the D and E hall refrigerator. Interview with LPN #4, on 10/20/2021 at 3:10 PM, revealed it is facility policy to notify the DON of any discontinued controlled medication. If the DON is not available, nursing staff is to store the expired or discontinued controlled medication in the medication cart's lock box. LPN #4 stated nursing staff is to notify the DON if a controlled medication needs to be taken out of the medication cart lock box. LPN #4 stated it was the responsibility of the nursing staff to ensure medications are labeled according to facility policy and process; and expired medications are discarded according to facility policy. LPN #4 assisted SSA Surveyor with observation of D and E hall medication storage room refrigerator. Observation on 10/20/2021 at 3:10 PM revealed the Vaccines were still stored in the door shelf, and the expired COVID-19 Vaccine had not been taken out. Interview with DON, on 10/20/2021 at 3:15 PM, revealed the DON stated the beer in the D and E Hall refrigerator was ordered for a resident, and needed to be locked up according to facility policy. According to the DON, she was unaware it was a CDC guideline that Vaccines could not be stored on the shelf of the door. The DON removed the expired Moderna COVID-19 Vaccine from the refrigerator and moved the Flu Vaccine to the middle shelf. Interview with the DON, on 10/21/2021 at 10:10 AM, revealed it is her expectation all nursing staff follows facility policy and procedures related to medication storage and labeling. The DON stated, if an item is found to be expired, labeled, and or stored improperly, it is her expectation nursing staff return or discard the medication according to facility policy. Additionally, if a controlled medication is expired or discontinued, it is facility protocol for the nurse to notify the DON. The DON will lock the medication up in her office. The DON stated when she has accumulated a few cards of controlled drugs, she and the Assistant Director of Nurses (ADON) will destroy the control medications. According to the DON, it is her expectation nursing staff alert her regarding any expired or discontinued scheduled narcotic on the day it is expired or discontinued to assure all controlled drugs are accounted for and stored properly. The DON further stated the importance was to ensure the safety of all residents. Per the DON, she was not notified of Resident #2's expired medications on 10/13/2021 and was not aware until 10/21/2021 when discussed in interview. Interview with the Administrator, on 10/21/2021 at 3:50 PM, revealed it was her expectation for medication to be stored and labeled appropriately by guidelines and facility policy and nursing staff follow current policies and protocols. The Administrator further stated the importance was to ensure the safety of all residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to review and revise the comprehensive person-centered care plan to include air boots for one (1) out of twenty (21) sampled residents, (Resident #37). Observation of Resident #37 on 10/19/2021, 10/20/2021, and 10/21/2021, revealed Resident #37 was lying in bed or sitting in his/her wheelchair and was not wearing air boots as care planned. The findings include: Review of the facility's policy entitled, Pressure Injuries/Skin Breakdown - Clinical Protocol, revised March 2014, revealed the wound would be measured and documented, the physician will write orders related to wound treatments, and the care plan would be revised to reflect changes in condition and new treatment goals and approaches. Review of the facility's policy entitled, Care Plans, Comprehensive Person Centered, no date, revealed comprehensive person-centered care plans were developed and revised for each resident and included identified problem areas, associated risk factors and reflect currently recognized standards of practice for problem areas and conditions. The Interdisciplinary Team (IDT) develops and implements each resident's plan of care. The Comprehensive Care Plan (CCP) is revised as information related to the resident, treatments, and resident's conditions change. Furthermore CCPs were developed and maintained for each resident to identify the highest level of functioning. CCPs were designed to incorporate identified problem areas, risk factors associated with identified problems, and aid in preventing or reducing avoidable declines in the resident's functional status and/or functional levels. Further review revealed the IDT was responsible for the review and updating of care plans (CP) when a resident has had a significant change. Review of Resident #37's clinical record revealed the facility readmitted the Resident on 04/04/2020, from an acute care hospital. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, review of medical record revealed Resident #37 was at risk of developing a pressure ulcer. Review of Resident #37's Annual Minimum Data Set (MDS) Assessment, dated 06/09/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderately impaired cognition. Per the assessment, the resident displayed no behaviors during assessment look back timeframe. Continued review revealed, Resident #37 had treatments to include pressure reducing device for his/her chair and bed, pressure ulcer/injury care, and application of dressing to bilateral feet. The MDS did not include the use of an air boot. Review of Resident #37's Physician Orders, dated 08/13/2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the CP for Resident #37, re-admitted [DATE], revealed the facility had addressed the resident's pressure ulcer with ongoing interventions related to the resident's wound treatments. However, there was no evidence the facility reviewed/revised the CCP to include an air boot intervention to prevent further skin breakdown. Review of Resident #37's Wound Physicians' Wound Care follow up evaluations, dated 08/13/2021, 08/17/2021, 08/24/2021, 08/31/2021, 09/07/2021, 09/14/2021, 09/21/2021, 09/28/2021, 10/05/2021, 10/14/2021, and 10/19/2021, revealed the physician's plan reviewed and addressed recommendation for air boots. Further record reviewed the resident was seen at a via telehealth by a wound care physician. Review of the wound care evaluation revealed the wound care physician recommended air boots for Resident #37 during each visit on 08/13/2021, 08/17/2021, 08/24/2021, 08/31/2021, 09/07/2021, 09/14/2021, 09/21/2021, 09/28/2021, 10/05/2021, 10/14/2021, and 10/19/2021. Observation of Resident #37 on 10/19/2021 at 11:20 AM, revealed the resident was lying in bed on his/her back, with both heels against the mattress. Gauze dressings were intact on both the resident's feet. Further observation revealed the resident's ankles and heels were without support and there was no air boot, heel protectors, or off-loading of wound. Observation of Resident #37 on 10/19/2021 at 1:00 PM, revealed Resident #37 sitting up in a wheelchair for lunch. Gauze dressings were intact on bilateral feet. Bilateral feet and ankles were were supported by the wheelchair foot rests; however, the resident was not wearing air boots. Observation of Resident #37 on 10/19/2021 at 4:15 PM, revealed Resident #37 was lying in bed on his/her left side, with lateral aspect of both heels against the mattress. Gauze dressings were intact on bilateral feet. Bilateral feet and ankles were without support and the resident was not wearing air boots. Observation of Resident #37 on 10/20/2021 at 9:30 AM, revealed Resident #37 lying in bed. Resident was lying on his/her back, with both heels pressed against the mattress. Gauze dressing was intact on bilateral feet. Further observation revealed the resident's feet and ankles were without support and the resident was not wearing air boots. Observation of a dressing change performed by the Wound Care Nurse (WCN), on 10/21/2021 at approximately 9:30 AM, revealed a discolored purple irregular shaped, five (5) cm by approximately one (1) centimeters wound on the right lateral ankle. Additional observation revealed an approximately one (1) centimeters by one (1) centimeters arterial wound of the left foot. Surrounding skin on bilateral feet was clean, dry and intact. The WCN dressed all wounds, but did not place an air boot on the resident after providing care. Interview with WCN, prior to dressing change, on 10/21/2021 at approximately 9:30 AM, revealed she was aware an order had been written by the Wound Care Physicians for Resident #37's air boot. The WCN went to the resident's room to locate the air boot but was unable to locate. She stated it could be in the laundry. She stated when the Wound Physicians do telehealth visits, if orders are given, she transcribes them to the MAR and TAR and updates and revises the care plan as needed. However, the WCN stated she had not transcribed the order and did not know how she missed it. Interview with Certified Nurse Aide (CNA) #1, on 10/21/21 at 2:50 PM, revealed she routinely provides care for Resident #37 and the CNAs round on residents every two (2) hours and as needed. During rounding the residents are checked and changed if needed, and are repositioned. CNA #1 stated Resident #37 does not have an air boot, but staff prop bilateral feet up on pillows to off-load wound. Interview with Minimum Data Set (MDS) Coordinator, on 10/21/2021 at 2:30 PM, revealed nurses were responsible to make the updated changes to the CPP and the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, Both the care plan and MD orders should have been updated immediately. The MDS Coordinator stated the facility should have reviewed and revised Resident #37's CP to include an intervention to ensure the resident had an air boot to prevent further skin breakdown. Interview with the Director of Nursing, (DON), on 10/21/21 3:31 PM, regarding CP revisions and updates, revealed nurses are responsible for updating the CP with any acute changes or new interventions. She revealed monitoring was performed to ensure care of residents by rounding herself, and rounding by management staff, and discussed in the IDT meeting. Monitoring of care plans, physician orders. The DON stated Kardex were completed on a regular basis. Further interview revealed, after a wound care telemedicine visit, the wound care physicians will email the wound care follow-up evaluation to the facility. The WCN is responsible to take off orders and update and revise the CP. Continued Interview with DON, revealed it was very important to have an accurate and complete CCP. It was her expectation that nursing staff updated and revised the CP as needed. The DON reviewed Resident #37's CCP and acknowledged the care plan had not been updated to include the air boots.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to develop comprehensive person centered care plans based on resident needs identified in the comprehensive Minimum Data Set (MDS) assessment and/or implement the comprehensive care plan for twenty-four (24) of fifty five (55) sampled residents (Residents #1, #2, #3, #5, #12, #13, #16, #22, #23, #26, #30, #33, #34, #35, #36, #37, #38, #39, #40, #42, #43, #45, #46, and #48. The facility developed a care plan for Resident #16 that required staff to turn and reposition the resident every two (2) hours, provide incontinent care as needed, assist the resident with showering/bathing, and provide restorative nursing daily to assist the resident with getting dressed. Further review of the care plan revealed the resident had impaired skin integrity and the goal was for the resident to have no pressure injury. The plan directed staff to observe for impaired skin integrity, turn and reposition every two (2) hours, and assisting with brief changes and perineal care after incontinent episodes. On [DATE], the facility completed a skin assessment and Resident #16 had no pressure ulcers. On [DATE], the facility identified that the resident had two (2) pressure ulcers and two (2) other open areas to the right hip (a pressure point). The resident was transferred to the hospital on [DATE], where they identified the resident had five (5) additional pressure ulcers (ten total) that had yellow/green drainage. Record review revealed the facility provided a shower for Resident #16 on [DATE], and staff interviews revealed they provided a partial bed bath, from [DATE] to [DATE]; however, staff failed to clean the resident's breast area and was not aware the resident was wearing a bra, from [DATE] through [DATE]. On [DATE], staff found Resident #16's bra embedded in the resident's skin. Staff stated chunks of the resident's skin came off when they removed the bra, leaving open areas. The facility revised the resident's care plan to observe for effectiveness of treatment and signs and symptoms of infection and to report to Resident #16's physician as indicated. However, there was no documented evidence the facility assessed the resident's breasts or notified the resident's physician when the pressure ulcers to the breasts worsened. On [DATE], when the pressure ulcers were assessed for the first time, by the Wound Care Physician, it was identified the pressure ulcers were infected and the facility transferred the resident to the hospital. The hospital assessed Resident #16 and identified seven (7) pressure ulcers to the resident's breasts (largest was 4 x 13.8 x 2 centimeters) that were covered with dead tissue and had green drainage and a foul odor. Upon admission, the facility placed Resident #1 in a bed which had an assist handle bed rail attached (a bed rail designed to assist the occupant with bed mobility). On [DATE], the facility replaced Resident #1's mattress with an alternating pressure relief mattress (a mattress that inflates and deflates intermittently) due to declining skin integrity. However, the facility failed to develop a care plan related to the utilization of side rails for the resident including monitoring and safety measures for staff to implement to ensure the resident remained safe. In addition, although the facility documented on the resident's care plan that the alternating pressure relief mattress had been implemented on [DATE], there were no interventions implemented related to staff monitoring the resident's safety when the pressure relief mattress was in place. On [DATE], staff discovered Resident #1 deceased hanging from the bed with his/her neck/chin entrapped in the side rail. For Residents #3, #5, #12, #13, #16, #22, #23, #26, #30, #33, #34, #35, #36, #37, #38, #39, #40, #42, #43, #45, #46, and #48, the facility failed to develop the plan of care using the Minimum Data Set assessed care needs to ensure staff implemented interventions to meet resident care needs. The facility's failure to develop and implement the residents' plans of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F700). The facility was notified of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was also identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F686), 42 CFR 483.35 Nursing Services (F725), 42 CFR 483.75 Administration (F835), and additional Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. A partial extended survey conducted on [DATE] through [DATE] revealed the Immediate Jeopardy was not removed. The facility failed to ensure there was adequate staffing to provide resident care as required by the resident's assessment and care plan. The findings include: Review of the facility's policy Care Plans, Comprehensive Person-Centered revised on [DATE], revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The policy stated that the residents' comprehensive, person- centered care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; reflect treatment goals, timetables, and objectives in measurable outcomes; enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. Further review of the policy revealed assessments of resident's were ongoing and care plans were revised as information about the residents and the residents' condition changes. Review of the facility's policy Restorative Nursing Services not dated revealed resident's would receive restorative nursing care as needed to help promote optimal safety and independence. The policy stated that restorative goals and objectives were individualized and resident-centered, and were outlined in the resident's plan of care. Review of an Executive Order for Temporary COVID-19 Personal Care Attendant (PCA) dated [DATE], revealed the waiver permitted a long-term care facility to employ a trained (PCA) to perform defined resident care procedures that do not require the skill or training required for a SRNA who successfully completed the nurse aide training and competency evaluation program established by 907 [NAME] 1:450. The order stated the PCA position was a temporary accommodation made to address work increases and staffing shortages caused by the COVID-19 pandemic. The facility must fully notify the certified and licensed staff members that PCAs had limited scope of permissible work, and detail what duties may not be delegated to PCAs, if the facility discovered that any PCA was performing duties outside the limited scope of permissible work, it must immediately intervene, stop the PCA, and reassign those duties to authorized personnel. The order addressed acceptable scope of practice for PCAs to include: transferring residents that required standby assist; however, a PCA could help with residents that required more assistance as long as a SRNA or Nurse was present; help with repositioning; helping with bed baths and bed bath setup; and showers. Further review of the temporary order revealed that PCAs would not be assigned or provide care or services to a resident in Isolation Precautions. 1. Review of Resident #16's medical record revealed the facility admitted the resident on [DATE], with diagnoses which included Unspecified Kidney Failure, Osteomyelitis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertensive Heart Disease without Heart Failure, Peripheral Neuropathy, and a Right Below Knee Amputation. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was severely cognitively impaired. Further review of the assessment revealed Resident #16 required extensive assistance of two (2) staff with Activity of Daily Living (ADLs), including bed mobility, toileting, transfers, and dressing and was totally dependent on staff for bathing. The resident was incontinent of bowel/bladder. In addition, the facility assessed the resident to be at risk for developing a pressure ulcer/injury, but had no pressure ulcers when the assessment was completed. According to the assessment, the resident was on a turning and repositioning program to prevent skin breakdown. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), indicating the resident was severely impaired cognitively. Further review of the assessment revealed Resident #16 required extensive assistance of two (2) staff with showering/bathing, dressing, bed mobility, toileting, transfers, was incontinent of bowel/bladder, and the resident was at risk for developing a pressure ulcer/injury, but had no pressure ulcers. Review of Resident #16's care plan revised [DATE], revealed the resident had impaired skin integrity (diabetic ulcers) and the facility identified that the resident was at risk for further impaired skin integrity and pressure injury. The goal was for the resident to have no pressure injury. The facility developed interventions that included observing for impaired skin integrity, turning and repositioning every two (2) hours, and assisting with brief changes and perineal care after incontinent episodes. Further review of the resident's care plan revealed the facility identified the resident required the assistance of two (2) staff with bathing/showering, dressing, and toileting. The care plan also revealed that Resident #16 was on a restorative nursing program, related to weakness, which included the need for staff to cue/prompt/assist the resident with upper body dressing daily as needed for a minimum of 15 minutes a day. Review of State Registered Nurse Aide (SRNA) documentation for Resident #16 for the months of May and [DATE] revealed staff documented that the resident was turned and reposition every two (2) hours and that incontinent care was provided as needed. However, interviews with SRNA #3 on [DATE] at 3:56 PM, PCA (Personal Care Aide) #7 on [DATE] at 12:23 PM, SRNA #10 on [DATE] at 3:30 PM, SRNA #9 on [DATE] at 12:41 PM, PCA #6 on [DATE] at 7:05 PM, and SRNA #8 on [DATE] at 5:45 PM revealed there was not enough staff at the facility to provide resident incontinent care nor turn/reposition residents every two (2) hours as required. The staff stated most shifts they could only do two (2) rounds during their eight (8) hour shift. According to SRNA #3, she had noticed an increase in skin breakdown, including Resident #16, due to low staffing. Interviews with SRNA #2 on [DATE] at 3:09 PM, and [DATE] at 3:00 PM, revealed she had worked first shift (6:00 AM - 2:00 PM) and second shift (2:00 PM - 10:00 PM); and continued interview with SRNA #8 on [DATE] at 5:45 PM, revealed they had found residents soaked with urine at the beginning of first shift because there was not enough staff to provide incontinent care on the previous shift. Review of Resident #16's Weekly Skin Review, dated [DATE], and Weekly Wound/Ulcer Observation Tools (forms that are faxed to Resident #16's primary physician weekly), revealed the resident had no pressure ulcers. There was no evidence the facility completed a Weekly Skin Review as required on [DATE]. However, on [DATE], (one day later) review of a Weekly Non-Pressure and a Weekly Pressure Wound Observation Tools revealed staff identified four (4) new open areas, a Stage II pressure ulcer to the left buttock, a Stage III pressure ulcer to the coccyx, and two open areas that were described as other but were located on the hip (over the trochanter), which was a pressure point. Review of the Nurse's Notes dated [DATE], revealed the resident was transferred to the hospital (the note did not specify the reason). Review of hospital records for Resident #16, dated [DATE], revealed the hospital identified the resident had five (5) additional pressure ulcers, one to the left, upper, posterior thigh; one to the left, upper anterior thigh; two additional pressure ulcers to the left buttock; and one to the right buttock. In addition, the hospital documented that the pressure ulcers that were identified at the facility, on [DATE], the day before, now had yellow/green drainage, and the right upper, outer buttocks had black eschar that was not present the day before. Review of the Restorative Nursing Intervention/Task Form revealed Resident #16's staff documented that the resident received restorative nursing on [DATE], [DATE], [DATE], [DATE], and [DATE] through [DATE]; and refused on [DATE], and [DATE]. Review of the ADL Bathing Intervention/Task Form revealed on [DATE] staff assisted Resident #16 with a shower and with a partial bed bath on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Restorative Nursing documentation for Resident #16, revealed SRNA #18 documented that she provided restorative nursing on [DATE], [DATE], [DATE], and on [DATE]. However, interview with SRNA #18 on [DATE] at 5:22 PM, revealed even though she documented that she provided restorative nursing, the facility was short staffed on day shift; however, she could not complete restorative nursing per the plan of care. SRNA #18, stated residents had to miss a lot of restorative due to short staffing. SRNA #18 further revealed on [DATE], and [DATE], that she gave Resident #16 a partial bed bath, which only consisted of washing the resident's face, bottom, and changing the resident's clothes, if needed. Interview with SRNA #19, on [DATE] at 2:03 PM, revealed she documented she provided restorative nursing for Resident #16, on [DATE], [DATE], [DATE], ,d+[DATE], and a partial bed bath on [DATE], [DATE], and [DATE]. SRNA #19 stated they could only provide restorative nursing and resident baths if there was enough staff. The SRNA stated that staff documented that restorative nursing and baths were provided, but they really did not have time to do it. Interview with SRNA #2 on [DATE] at 3:00 PM, revealed she gave Resident #16 a partial bed bath on [DATE], [DATE], and on [DATE]. However, she stated she only washed the resident's face, hands, and bottom. She stated she had not assisted the resident with a shower because she was told therapy was providing Resident #16's showers. Interview with SRNA #8, on [DATE] at 10:20 AM, revealed she documented on [DATE], that she gave Resident #16 a shower; however, she did not give Resident #16 a bed bath or shower because she was working with a Personal Care Attendant (PCA), and there was not enough staff to provide resident showers on [DATE]. SRNA #8 further revealed most of the time there was not enough staff to provide restorative nursing; however, staff were instructed that they had to document that restorative nursing was provided even if the resident refused or they were not able to provide the service. Interview with SRNA #17, on [DATE] at 2:55 PM, who documented she provided a bed bath for Resident #16 on [DATE], revealed she was called in by the facility to work on [DATE], and arrived at the facility at 8:30 AM. SRNA #17 stated that she did not give the resident a bed bath that day because she thought therapy had assisted the resident with a shower on [DATE], and the resident was already dressed when she arrived at the facility. Review of an Event Report, dated [DATE] at 4:30 AM, revealed Resident #16 had green drainage with a scant amount of blood coming from open areas in the crease of the breasts, and circular purple, hardened areas under the breast. The note stated resident's shirt and sheet were changed due to green drainage. Continued review of Resident #16's Care Plan, revealed the facility revised the care plan on [DATE], to include an intervention for staff to apply treatment to the resident's breasts as ordered; to observe for effectiveness of treatment and signs and symptoms (s/s) of infection; and to report to Resident #16's physician as indicated. Review of Resident #16's medical record revealed no evidence the facility assessed the pressure ulcers to the resident's breasts when they were identified on [DATE]. Further, there was no evidence an assessment of the resident's breasts was completed from [DATE] through [DATE], to observe for signs and symptoms of infection, the effectiveness of the treatment, or to determine whether the resident's physician should be notified as required by the resident's care plan. On [DATE], a Wound Care Specialist assessed the resident's breasts and recommended the resident be transferred to the hospital due to infection to the pressure ulcers to the breast. Review of Resident #16's hospital record from a hospital stay, on [DATE] through [DATE], revealed the resident was admitted to the hospital to rule out any Sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). Review of the hospital's assessment of the pressure ulcers to the breasts dated [DATE] revealed the resident had four (4) pressure ulcers to the left breast that measured 1 by 4.6 centimeters (cm), 0.5 by 2.4 cm, 3.7 by 6.4 cm, and 4 by 13.8 by 2 cm. The wounds were described as being covered with slough (dead tissue that has to be removed before healing can take place), with a large amount of green drainage and a foul smelling odor. The right breast was assessed to have a 3.2 by 4 cm necrotic area, a 1 by 1.7 cm area, and a 5.9 by 7.7 cm area. The wounds were covered with non-viable tissue and had foul smelling green drainage. According to the medical record, the pressure ulcers to the breasts required surgical debridement. Interview with State Registered Nurse Aide (SRNA) #3, on [DATE] at 3:56 PM, and with SRNA #7 on [DATE] at 6:05 PM, revealed on [DATE] at approximately 2:00 AM, they removed the resident's bra after finding drainage on the resident's bed/shirt. SRNA #3 stated the resident's bra was embedded in the resident's skin. SRNA #7 stated, We took the resident's bra off, and the bra was so stiff when we got it off, the bra looked like it was still on the resident. Underneath the resident's breast, the skin peeled off, which left open areas. SRNA #3 further revealed after Resident #16's bra was removed, it smelled like rotten flesh. The SRNA stated, It didn't look like to me the resident had been getting showers or they would have seen the bra embedded into the resident's skin. According to SRNA #7, chunks of the resident's skin was sticking to the front of the resident's bra. SRNA #7 stated the open areas were extremely red, some of the areas were yellow, and in the center of the resident's breast, where the bra laid, was bleeding. The SRNA stated, I can't explain to you how bad it looked. Interview with Unit Manager (UM) #2, on [DATE] at 11:15 AM, revealed she was responsible for conducting weekly wound assessments and notifying residents' physicians of changes. UM #1 stated she did not see the resident's pressure ulcers until [DATE], and provided treatments to the resident's breasts every week thereafter. She stated she was aware the pressure ulcers were changing. She stated initially, there was sloughy drainage and before the resident was transferred to the hospital on [DATE], there was yellow/green drainage with eschar and necrotic tissue underneath the resident's breasts. UM #2 stated she never notified the resident's physician about the breast wounds getting worse. She stated she did not have an answer as to why she did not notify the physician as required by the resident's plan of care. Interview with the Director of Nursing (DON), on [DATE] at 4:05 PM, revealed she made rounds a few times daily to talk to residents, SRNA's, Unit Managers, and the Charge Nurse's. The DON stated she reviewed staffing schedules every two (2) weeks. The interview revealed that the DON was not aware of any concerns with staff not being able to turn/reposition residents, provide incontinent care, bath/showers, or restorative nursing as required by residents' care plans. Further interview with the DON revealed stated that resident skin assessments were required to be performed weekly by a licensed nurse. She stated when performing a skin assessment, every area on the resident's skin should be captured to ensure wounds could be monitored for healing/decline, and the physician should be notified of any new skin issues or changes. Continued interview with the DON, revealed the Unit Managers were responsible to ensure weekly skin assessments were conducted. Interview with the Administrator on [DATE] at 8:30 PM revealed pressure ulcers and any changes in condition were discussed daily during a morning meeting. She stated that the DON was also responsible for ensuring nursing services was provided as ordered. 2. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Aphasia, Cerebral Vascular Accident (CVA), Hemiplegia and Hemiparesis affecting Right Dominant Side, Chronic Obstructive Pulmonary Disease (COPD), and Dementia. Review of Resident #1's Significant Change Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was severely cognitively impaired, was totally dependent on staff and required extensive assistance for all activities of daily living. Resident #1 was non-ambulatory, required a mechanical lift for transfers and had no functional ability to move in bed including rolling from side to side. Continued review of the MDS revealed the resident had experienced no falls since admission to the facility, did not utilize restraints or alarms, including bed rails. Review of a Lift Observation Assessment completed in conjunction with the MDS on [DATE], revealed Resident #1 was bedridden, non-weight bearing, absent of upper body strength, and was a total body lift. Review of an Event Report, dated [DATE] at 1:10 AM, revealed staff discovered Resident #1 with his/her chin/neck entrapped in the bed rail, and the resident's body hanging off the bed with buttocks not touching the floor. The Resident had no vital signs and was pronounced deceased . Review of Resident #1's Comprehensive Care Plan revealed the resident had impaired mobility, was at risk for falls, and had recently rolled out of bed. Further review of the care plan, revealed on [DATE], the facility had initiated an alternating pressure relief mattress for Resident #1, but included no interventions for monitoring to be conducted by staff to ensure the alternating pressure relief mattress was not presenting a safety hazard for Resident #1. In addition, the facility failed to address the use of a side rail on Resident #1's bed on the Comprehensive Care Pan, provide a rational or how staff were to use the side rail for Resident #, since the resident had no functional ability to move in bed without extensive staff assistance and had no upper body strength. Review of an Event Report, dated [DATE] at 1:10 AM, revealed Resident #1 was found deceased with the resident's neck resting against the bed rail and body on the floor. However, interviews on [DATE] at 5:18 PM, with State Registered Nurse Aide (SRNA) #1 at 9:09 PM and with Licensed Practical Nurse #1 and #3, on [DATE] at 1:11 PM, revealed they were all working on [DATE], and responded to the resident's room when the incident occurred. All the staff stated Resident #1 was found with his/her neck caught in the side rail hanging off the bed without buttocks touching the floor. Further interviews with the staff revealed it took two (2) of the staff to dislodge the resident from the rail. Interview with the MDS Coordinator, on [DATE] at 6:17 PM, revealed she initiated comprehensive care plans for new admissions and updated resident care plans when she completed an MDS assessment for a resident. However, the MDS Coordinator stated she did not routinely update care plans between assessments stating nurses caring for residents would update care plans when required. The MDS Coordinator stated to her knowledge a care plan was not developed for any resident utilizing bed rails, unless the bed rail acted as a restraint for the resident. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 12:53 PM, revealed comprehensive care plans contain the information and care procedures that were required to care for residents and met the health and safety needs of the residents based on each resident's cognitive and physical functioning. Interview with the Director of Nursing (DON), on [DATE] at 3:25 PM, revealed the use of side rails was not addressed on Resident #1's care plan because the rail was considered an enabler. Interview with the Administrator on [DATE] at 5:39 PM revealed care plans were discussed daily in the morning meetings and were updated and revised as needed; however, the Administrator stated that side rails were not addressed on the care plan because they were considered enablers. 3. Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of 14, which indicated the resident was cognitively intact. Further review of the assessment revealed the facility assessed the resident to require extensive assistance of two (2) staff for transfers and total assistance of two (2) staff for bathing. Review of Resident #2's Comprehensive Care Plan for Alteration in Activities of Daily Living (ADL) related to impaired mobility and balance, diagnoses of weakness, difficulty in walking, and history of falls with a revision date of [DATE], revealed the resident required assistance of one (1) staff member for transfers, toileting, and perineal care, as needed. Interview with Resident #2, on [DATE] at 10:39 AM, revealed the facility was often short staffed. Continued interview with Resident #2 revealed he/she required two (2) staff to transfer him/her safely and frequently one (1) SRNA transferred him/her. Resident #2 stated he/she did not feel one (1) SRNA could safely transfer him/her and that it made him/her nervous. During the interview Resident #2 stated he/she needed to go to the bathroom, one (1) SRNA entered the resident's room to transfer the resident from his/her wheelchair to the commode. Resident #2 stated he/she did not feel comfortable with one (1) person transferring him/her therefore SRNA #11 got assistance from UM #3 to transfer the resident from his/her wheelchair to the commode. Interview with SRNA #11 on [DATE] at 11:40 AM revealed she often transferred Resident #2 by herself. She stated Resident #2 was care planned to require assistance of one (1) staff member as needed. Review of a Skin Care Alert for Resident #2, dated [DATE], revealed PCA #6 documented giving Resident #2 a shower. SRNA #24's name was also listed on the Skin Care Alert. Interview with SRNA #24, on [DATE] at 2:55 PM, revealed she worked with PCA #6 on [DATE]; however, she stated PCA #6 gave Resident #2 a shower unassisted. She further stated that if she did not perform a resident's shower, she did not sign the CNA Skin Care Alert. Interview with Patient Care Assistant (PCA) #6, on [DATE] at 1:42 PM, revealed she gave Resident #2 a shower unassisted by SRNA #24, on [DATE]. She stated she completed the CNA Skin Care Alert for Resident #2 and SRNA #24 did not sign it. Interview with MDS Nurse #1 on [DATE] at 6:17 PM revealed she completed the residents' care plans when she completed the MDS assessment. Per the MDS Nurse, she did not complete day-to-day revisions of the resident care plans. Interview with the ADON on [DATE] at 12:53 PM revealed she was not aware that PCA #6 gave Resident #2 a shower unassisted on [DATE]. She stated PCAs were not allowed to provide resident care without certified or licensed staff with them. She stated the SRNAs determined the amount of assistance that a resident required with ADL care depending upon the resident's physical/cognitive functioning during any given day. She stated that the ADL care plan and SRNA Kardex stated as needed because if a resident was not feeling well then they would provide assistance of two (2) with care; however, if the resident was having a good day, then they may only need one (1) person to assist with ADL care. Interview with the DON on [DATE] at 7:20 PM revealed she was not aware that PCAs were giving residents showers without certified/licensed staff assistance. She stated she had not observed PCAs providing care by themselves during rounds. The DON stated that SRNAs determined the amount of assistance that a resident required based on their cognitive/physical function. She stated the SRNAs knew the residents and knew when to provide assistance of one (1) or two (2) with ADL care. Interview with the Administrator on [DATE] at 8:30 AM revealed she was not aware that PCAs were providing resident care unassisted. She stated care plans were discussed and updated during the daily morning meetings; however, anything nursing related was left up to the DON. 4. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE] with diagnoses of Dementia, Anxiety Disorder, Depression, Osteoporosis, and Psychosis. Review of Resident #3's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of 14, indicating the resident was cognitively intact. Review of Resident #3's Baseline Care Plan dated [DATE], revealed Resident #3 had transmission precautions in place. Observation on [DATE] at 10:05 AM, revealed Resident #3 in the bed with his/her eyes closed, bed in low position, bed alarm in place, quarter side rails raised bilaterally, and call light within reach. No signage or PPE was observed outside of Resident #3's door. Continued observations on [DATE] at 1:34 PM, revealed a signage outside Resident #3's room stating to see the nurse before entering, along with a PPE (Personal Protective Equipment, [gown, mask, gloves, etc].) cart and biohazard trash can without a lid. Interviews with SRNA #15 and SRNA #16, on [DATE] at 1:34 PM, revealed they began their shift on [DATE] at 6:00 AM, and it was not reported to them that Resident #3 was in isolation precautions. They stated when they returned from lunch at approximately 11:30 AM, Resident #3 had a PPE cart with supplies, signage, and a biohazard trash can outside of his/her room. Both SRNA's stated they were not aware of what type of precautions the resident was on or the appropriate PPE to wear when providing care to the resident. Interview

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to have an effective system in place to provide sufficient nursing staff to ensure residents received the care and services as assessed for thirty-one (31) of fifty-five (55) sampled (Resident #2, #5, #6, #8, #9, #12, #16, #18, #21, #22, #23, #26, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, and #52). Interviews with SRNA #1, #3, #5, #6, #7, #8, #9, #10, #18, #19, #20, #23, and PCA #1, and PCA #6 revealed the facility was short staffed frequently; therefore, they could not perform rounds every two (2) hours to provide resident incontinence care and repositioning. Showers and baths were not completed on scheduled days, restorative nursing services was not performed as planned, and residents that required assistance of two (2) staff for bed mobility and transfers was performed by one (1) State Registered Nurse Aide (SRNA). In addition, staff interviews revealed the facility used PCAs as regular staff (SRNAs) when there was not enough regular staff available. Resident #16 required extensive assistance of staff with dressing, bed mobility, and toileting; was totally dependent upon staff for hygiene; and was incontinent of bowel and bladder. Record review revealed the resident also required daily restorative nursing for upper body dressing. The last documented shower for Resident #16 was on 06/25/2020, and according to staff, the resident had no wounds/pressure ulcers under her breasts at that time. Although staff documented that restorative nursing, bed baths, turning and repositioning, and incontinent care were provided as required, interviews with staff revealed the care was not always provided to due lack of staff. On 07/06/2020, at approximately 2:00 AM, a staff member found Resident #16's bra was embedded in the resident's skin and a foul odor and drainage was observed. Staff stated when they removed the resident's bra, chunks of skin came off. Interviews with Resident #2, #5, #8, #9, #18, #22, #23, and #26, revealed the facility was short staffed on all shifts. The residents stated it took staff up to one and a half hours to answer call lights, and that during meal service call lights were not answered until trays were passed and residents were fed. Residents also reported they had incontinence accidents waiting for staff to respond. The facility's failure to provide sufficient staffing has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/04/2020, and determined to exist on 07/02/2020 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F700). The facility was notified of the Immediate Jeopardy on 08/04/2020. Immediate Jeopardy was also identified on 08/18/2020, and determined to exist on 07/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F686), 42 CFR 483.35 Nursing Services (F725), 42 CFR 483.75 Administration (F835); and, additional Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656). The facility was notified of the Immediate Jeopardy on 08/18/2020. An acceptable Allegation of Compliance was received on 08/28/2020, which alleged removal of the Immediate Jeopardy on 08/26/2020. A partial extended survey conducted on 09/01/2020 through 09/04/2020 revealed the Immediate Jeopardy was not removed. The facility failed to ensure there was adequate staffing to provide resident care as required by the resident's assessment and care plan. The findings include: Review of the facility policy titled Staffing, with a revision date of April 2007, revealed the facility would provide adequate staffing on each shift to ensure the needed care and services of their resident population was met. The policy stated registered and licensed nursing staff would be available to provide and monitor the delivery of resident care services. Review of the Facility Assessment, dated 11/12/2019, revealed no evidence that staffing was addressed. Review of the Facility Assessment, dated 06/01/2020, revealed the assessment did not address the amount of staff per shift required to provide sufficient resident care. Interview with the Administrator on 08/11/2020 at 3:32 PM revealed she completed the Facility Assessment on 06/01/2020 and did not address the amount of staff required to perform resident care. Interviews with the Assistant Director of Nursing (ADON) on 08/03/2020 at 2:41 PM and 08/12/2020 at 1:50 PM revealed she was responsible for the staffing schedule. She stated she was not told to staff the facility based on census or acuity. She stated she did not receive instruction on how to staff the facility. The ADON stated she went by how the facility had been staffed when the old administrators (previous owners) were there. The ADON stated there were three (3) Units in the facility with a total of five (5) halls. She stated prior to the facility's new ownership at the end of March 2020, each unit would have two (2) SRNAs per hall, one (1) Certified Medication Aide (CMA), and one (1) RN or LPN scheduled during first and second shift for a total of ten (10) SRNAs, three (3) CMAs, and three (3) nurses. She stated third shift had one (1) SRNA per hall for a total of five (5), and two (2) nurses to split A/B Unit and C/D/E Unit. Further interview with the ADON revealed she tried to staff each unit with two (2) SRNAs per hall, one (1) Certified Medication Aide (CMA), and one (1) RN or LPN during first and second shift for a total of ten (10) SRNAs, three (3) CMAs, and three (3) nurses. She stated third shift had one (1) SRNA per hall for a total of five (5), and two (2) nurses to split A/B Unit and C/D/E Unit however, it often did not work out that way. Continued interview revealed the ADON utilized PCAs to fill in when there were not enough SRNAs. Review of the facility staffing schedule revealed there were PCA's scheduled for first shift in July as follows: On 07/04/2020 three (3) PCAs; on 07/05/2020 one (1) PCA; on 07/12/2020 one (1) PCA, on 07/14/2020 three (3) PCAs; on 07/17/2020 one (1) PCA; 07/18/2020 one (1) PCA; on 07/19/2020 one (1) PCA; 07/21/2020 two (2) PCAs. PCA's scheduled for second shift in July were on 07/01/2020 one (1) PCA, on 07/02/2020 three (3) PCAs, on 07/03/2020 three (3) PCAs, on 07/07/2020 three (3) PCAs, on 07/10/2020 two (2) PCAs, on 07/11/2020 two (2) PCAs, on 07/13/2020 three (3) PCAs, on 07/14/2020 one (1) PCA, on 07/16/2020 two (2) PCAs, on 07/17/2020 two (2) PCAs, on 07/19/2020 two (2) PCAs, on 07/24/2020 two (2) PCAs, on 07/28/2020 one (1) PCA, and on 07/31/2020 one (1) PCA. One (1) PCA was scheduled for third shift in July on 07/04/2020, 07/16/2020, 07/22/2020, 07/23/2020, 07/24/2020, and 07/26/2020. Review of the facility's Resident Census and Conditions of Residents (CMS-672) dated 07/22/2020, revealed the facility had one hundred and two (102) residents. Of the 102 residents, thirty-five (35) residents required assistance of one (1) or two (2) staff for bathing, eighty-three (83) for dressing, toileting, and eating, and eighty-five (85) for transfers. While sixty-seven (67) residents were totally dependent on staff for bathing, nineteen (19) for dressing, toileting, and eating, and seventeen (17) for transfers. Review of the SRNA Master Schedule for June 2020, revealed on 06/01/2020, 06/07/2020, 06/20/2020, and 06/27/2020 there were seven (7) SRNAs total, instead of 10, on the schedule to provide care to residents. On 06/29/2020 and 06/30/2020 there were six (6) SRNAs, instead of ten (10), scheduled to provide care to residents, which averaged 17 residents for each SRNA. Review of second shift staffing schedule for the second shift (2:00 PM - 10:00 PM), revealed on 06/13/2020, 06/21/2020, 06/26/2020, 06/27/2020, 06/28/2020, 06/29/2020, and 06/30/2020, a total of seven (7) SRNAs provided resident care, instead of ten (10). On 06/05/2020, six (6) SRNAs were assigned, instead of ten (10) to care for an average 17 residents each. Review of third shift (10:00 PM - 6:00 AM) there were 12 shifts with four (4) SRNAs responsible for providing resident care which meant each SRNA was responsible for providing care to an average of 25 residents each. There were no PCA's scheduled for third shift in June 2020. Review of the Master Schedule for July 2020, revealed on 07/05/2020, 07/12/2020, 07/14/2020, 07/18/2020, 07/19/2020, 07/21/2020, and 07/24/2020 seven (7) SRNAs provided resident care. On 07/11/2020, six (6) SRNAs were responsible for resident care for 17 residents each; and on 07/04/2020 and 07/17/2020 five (5) SRNAs were responsible for providing resident care to 20 residents each. Review of second shift revealed on 07/01/2020, 07/07/2020, 07/10/2020, 07/11/2020, 07/13/2020, 07/14/2020, 07/16/2020, 07/17/2020, 07/19/2020, and 07/24/2020, revealed seven (7) SRNAs provided resident care, instead of ten (10). On 07/03/2020, 07/28/2020, and 07/31/2020 six (6) SRNAs provided resident care to 17 residents each. On 07/02/2020 five (5) SRNAs were responsible for the care of an average of 20 residents. Review of third shift revealed on 07/04/2020, 07/09/2020, 07/15/2020, 07/16/2020, 07/22/2020, 07/23/2020, 07/24/2020, and 07/26/2020 three (3) SRNAs, instead of five (5), were responsible for providing resident care to 34 residents each. 1. Review of Resident #16's medical record revealed the facility admitted the resident on 02/09/2018, with diagnoses which included Unspecified Kidney Failure, Osteomyelitis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertensive Heart Disease without Heart Failure, Other Idiopathic Peripheral Autonomic Neuropathy, and Complete Traumatic Amputation at Level Between Knee and Ankle, Right Lower Leg, Sequela. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] and 06/25/2020, revealed the resident required extensive assistance of two (2) staff with Activity of Daily Living (ADLs), including bed mobility, toileting, transfers, and dressing and was totally dependent on staff for bathing. The resident was incontinent of bowel/bladder and assessed to be at risk for developing a pressure ulcer/injury, but had no pressure ulcers when the assessment was completed. Review of Resident #16's care plan, revised 04/30/2020, revealed the resident had impaired skin integrity (diabetic ulcers) and the facility identified that the resident was at risk for further impaired skin integrity and pressure injury. The goal was for the resident to have no pressure injury and interventions directed staff to turn and reposition the resident every two (2) hours, and complete brief changes and perineal care after incontinent episodes. Further review of the resident's care plan revealed the facility identified the resident required the assistance of two (2) staff with bathing/showering, dressing, and toileting. The care plan also revealed that Resident #16 was on a restorative nursing program, related to weakness, which included the need for staff to cue/prompt/assist the resident with upper body dressing daily as needed for a minimum of 15 minutes a day. However, interviews with SRNA #3 on 08/05/2020 at 3:56 PM, PCA (Personal Care Aide) #7 on 08/04/2020 at 12:23 PM, SRNA #10 on 07/27/2020 at 3:30 PM, SRNA #9 on 07/29/2020 at 12:41 PM, PCA #6 on 07/24/2020 at 7:05 PM, and SRNA #8 on 08/11/2020 at 5:45 PM revealed there was not enough staff at the facility to provide resident incontinent care nor turn/reposition residents every two (2) hours as required. The staff stated most shifts they could only do two (2) rounds during their eight (8) hour shift. According to SRNA #3, she had noticed an increase in skin breakdown, including Resident #16, due to low staffing. In additions, interviews with SRNA #18 on 08/12/2020 at 5:22 PM, SRNA #19 on 08/15/2020 at 2:03 PM, SRNA #17 on 08/12/2020 at 2:55 PM, SRNA #2 on 08/07/2020 at 3:00 PM, and continued interview with SRNA #8 on 08/20/2020 at 10:20 AM, revealed they did not have enough staff to provide showers/bed baths as required. They stated if they had time to assist the resident with a bath on 06/26/2020, 06/27/2020, 06/29/2020, 06/30/2020, 07/01/2020, 07/02/2020, 07/03/2020, 07/04/2020, or 07/05/2020, the staff did not provide a full bed bath and only washed the resident's face, hands, and bottom, and did not wash the resident's breast area; subsequently, they did not know whether the resident was wearing a bra. In addition, interview with SRNA #8, on 08/20/2020 at 10:20 AM, revealed she documented on 07/03/2020, that she assisted resident #16 with a shower; however, there was not enough staff to provide the resident with a shower. Further, SRNA #18, SRNA #19, and SRNA #8 revealed there was not enough staff to provide restorative nursing services. Review of Resident #16's Weekly Skin Review, dated 06/09/2020, and Weekly Wound/Ulcer Observation Tools dated 06/16/2020, revealed the resident had no pressure ulcers. However, on 06/17/2020, (one day later) review of a Weekly Non-Pressure and a Weekly Pressure Wound Observation Tools, revealed staff identified four (4) new open areas, a Stage II pressure ulcer to the left buttock, a Stage III pressure ulcer to the coccyx, and two open areas that were described as other but were located on the hip (over the trochanter), which was a pressure point. Review of hospital records revealed Resident #18 was admitted to the hospital on 06/18/2020 where the hospital identified the resident had five (5) additional pressure ulcers, one to the left, upper, posterior thigh; one to the left, upper anterior thigh; two additional pressure ulcers to the left buttock; and one to the right buttock. In addition, interview with State Registered Nurse Aide (SRNA) #3, on 08/05/2020 at 3:56 PM, and with SRNA #7 on 08/05/2020 at 6:05 PM, revealed on 07/06/2020 at approximately 2:00 AM, they removed the resident's bra after finding drainage on the resident's bed/shirt. SRNA #3 stated the resident's bra was embedded in the resident's skin. SRNA #7 stated, when they removed the resident's bra the skin underneath the resident's breasts peeled off, which left open areas and chunks of the resident's skin was sticking to the front of the resident's bra. SRNA #3 stated, It didn't look like to me the resident had been getting showers or they would have seen the bra embedded into the resident's skin. Record review revealed there was no evidence the facility assessed the pressure ulcers to Resident #16's breast; however, a review of a skin assessment completed after admission to the hospital on 08/05/2020 revealed the resident had four (4) pressure ulcers to the left breast that measured 1 by 4.6 centimeters (cm), 0.5 by 2.4 cm, 3.7 by 6.4 cm, and 4 by 13.8 by 2 cm. The wounds were described as being covered with slough (dead tissue that has to be removed before healing can take place), with a large amount of green drainage and a foul smelling odor. The right breast was assessed to have a 3.2 by 4 cm necrotic area, a 1 by 1.7 cm area, and a 5.9 by 7.7 cm area. The wounds were covered with non-viable tissue and had foul smelling green drainage. According to the medical record, the pressure ulcers to the breasts required surgical debridement. Interviews with LPN #6 on 07/31/2020 at 12:34 PM, and Unit Manager (UM) #1 on 07/27/2020 at 3:13 PM, and 07/31/2020 at 2:02 PM, revealed they were aware the facility did not have enough staff to provide resident care. LPN #6 stated that during first shift they might only assist residents with care three (3) times during the eight (8) hour shift, and on second shift, they were lucky to get two (2) rounds completed. Continued interview with LPN #6 revealed residents complained about not receiving incontinence care and SRNAs had complained of finding residents urine soaked when completing their first round at the beginning of their shift. Unit Manager (UM) #1 revealed that night shift staff struggled more with being short staffed and first shift staff often found residents soaked with urine because the SRNAs could not complete every two (2) rounds. Interview with the Director of Nursing (DON), on 08/14/2020 at 4:05 PM, revealed she made rounds a few times daily to talk to residents, SRNA's, Unit Managers, and the Charge Nurses. The DON stated she reviewed staffing schedules every two (2) weeks. The interview revealed that the DON was not aware of any concerns with staff not being able to turn/reposition residents, provide incontinent care, bath/showers, or restorative nursing as required by residents' care plans. According to the DON, SRNA's had not complained of not being able to complete their rounds (incontinent care and turning and repositioning) every two (2) hour rounds. Interview with the Administrator on 08/11/2020 at 3:32 PM revealed she completed the Facility Assessment on 06/01/2020 and did not address the amount of staff required to perform resident care. According to an interview with the Administrator on 09/04/2020 at 8:30 PM, she was not aware of concerns related to Resident #16. She stated the DON took care of any nursing related concerns. 2. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses of Spinal Stenosis, Rheumatoid Arthritis, and Erosive Osteoarthritis. Review of Resident #22's quarterly MDS assessment, dated 07/22/2020, revealed the facility assessed the resident to have a BIMS score of 15, indicating the resident was cognitively intact. Continued review of the MDS assessment revealed the resident required limited assistance of one (1) staff member for ADLs. Interview with Resident #22, on 07/22/2020 at 12:13 PM, revealed the facility was very short staffed on all three (3) shifts. The resident stated a lot of the time there was only one (1) SRNA to cover the D-Hall and that it took up to forty (40) minutes for the call light to get answered. Resident #22 revealed staff completed two (2) rounds per shift to check, change and reposition residents. Continued interview with Resident #22 revealed his/her roommate Resident #6 required complete care by staff and when the facility was short staffed it took a long time for staff to provide incontinence care to Resident 6. Interview with PCA #7, on 08/04/2020 at 12:23 PM, confirmed when she was assigned to work with a SRNA, they could only complete two (2) rounds (incontinent care and turn/reposition residents) in an eight (8) hour shift. She stated multiple residents had complained that they had unmet care needs because they were so short staffed. Interview with SRNA #10, on 07/27/2020 at 3:30 PM, revealed the facility was short staffed all the time. According to the SRNA, when there was not enough staff it took up to an hour to answer residents' call lights and may only get two (2) rounds completed during her shift. Interview with LPN #2, on 07/29/2020 at 3:14 PM, revealed SRNAs had reported that they could not provide incontinent care or check on resident's every two hours because they were short staffed. She stated she told the SRNAs to do the best they could because everyone, including Administrative staff, were aware that the facility was short staffed. Interview with LPN #6 on 07/31/2020 at 12:34 PM revealed the facility was short staffed all the time. She stated she had worked first shift when they had one (1) SRNA for each hall and one (1) SRNA to float between halls to assist with resident care. She stated they might get three (3) rounds in during a shift. LPN #6 stated on second shift SRNAs were lucky to get two (2) rounds completed. 3. Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis of the Left Non-Dominant Side, Left Ankle Contracture, Contracture of the Left Wrist and Left Hand, and Generalized Muscle Weakness. Review of Resident 23's quarterly MDS assessment, dated 07/10/2020, revealed the facility assessed the resident to have a BIMS score of 15, indicating the resident was cognitively intact. Continued review of the MDS assessment revealed the resident required extensive assistance of two (2) staff for bed mobility, transfers, and toileting; and was totally dependent of two (2) staff for bathing. Further review of the MDS assessment revealed the resident was frequently incontinent of bladder. Interview with Resident #23, on 07/27/2020 10:40 AM, revealed the facility was short staffed, especially on third shift, with one (1) SRNA working on E-Hall. The resident stated staff might check on residents twice during the night. Per the resident, he/she preferred to go to bed at 8:30 PM; however, due to the facility being short staff, he/she sometimes had to go to bed at 7:30 PM. The resident stated he/she preferred to get up first thing in the morning and transferred into his/her wheelchair; however, on 06/28/2020, they were short staffed and staff could not transfer the resident to his/her wheelchair until 5:00 PM. Review of a Resident and Family/Resident Representative Concern/Grievance Report dated 06/29/2020, revealed Resident #23 wished to file a complaint related to staffing. Resident #23 reported on 06/28/2020, staff did not transfer the resident out of bed and into his/her wheelchair until 5:00 PM due to being short staffed. Resident #23 also complained that on 06/28/2020, during first shift there was a total of six (6) SRNAs in the building and that he/she discussed with his/her spouse possible transfer to another facility. Interview with SRNA #9, on 07/29/2020 at 12:41 PM, revealed on third shift there was usually only three (3) or four (4) SRNAs covering the entire building. She stated she worked by herself frequently and could usually only check on residents, provide incontinent care, and turn and reposition residents, twice during her eight (8) hour shift. Continued interview with SRNA #9, revealed she has complained about being short staff to the DON and the DON's response was that based on the census, there was enough staff working. Interview with SRNA #1, on 07/29/2020 at 11:03 PM, revealed on night shift (10:00 PM - 6:00 AM), there were times when three (3) SRNAs and two (2) nurses covered the entire facility. She stated on her scheduled shift, when there were three (3) SRNAs in the building, they were lucky to complete two (2) rounds, which included incontinence care and repositioning, in an eight (8) hour shift. Interview with LPN #3 on 07/29/2020 at 9:09 PM also revealed that frequently on third shift there were only three (3) SRNAs and two (2) nurses, which was not enough staff to provide care for residents. She stated staff could not provide incontinent care, turning/repositioning every two (2) hours as required. LPN #3 stated residents complained frequently about staffing, but stated they did the best they could with what they were given. 4. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy, Muscle Weakness, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #9's quarterly MDS assessment, dated 05/06/2020, revealed the facility assessed the resident to have a BIMS score of 15, indicating the resident was cognitively intact. Further review of the MDS assessment revealed Resident #9 required extensive assistance of two (2) staff for transfers and toileting, and was totally dependent of two (2) staff for bathing. Interview with Resident #9, on 07/22/2020 at 10:29 AM, revealed the facility was short staffed on all shifts. Resident #9 stated that he/she was left soiled for hours due to staffing and that it took a long time for staff to answer call lights, so he/she called the facility on his/her cell phone when he/she needed staff assistance. Resident #9 stated that he/she did not get a shower on 07/18/2020, due to staff telling him/her that they were short staffed; therefore, he/she received a shower on 07/20/2020. Continued interview with Resident #9 revealed he/she had reported his/her concerns to the DON in the past; however, nothing was ever done about it. Review of Resident #9's Documentation Survey Report for Bathing for July 2020, revealed Resident #9 received a shower on his/her scheduled day on 07/15/2020; however, the resident did not receive another shower until 07/20/2020 (two days after his/her next scheduled shower day). Review of Resident #9's Kardex revealed he/she preferred to take a shower. Interview with PCA #5, on 07/28/2020 at 11:34 AM, revealed the facility was very short staffed. She stated it took up to one and a half hours to answer call lights when they were short staffed. PCA #5 stated they had a hard time completing showers and had residents complain that they did not receive a shower on their scheduled day. The PCA confirmed that Resident #9 called the facility on his/her personal cell phone to get assistance because it took so long for staff to answer call lights due to short staffing. She stated she had reported to the nurses that they could not complete all the scheduled showers and nursing stated they were aware that they could not get showers completed due to working short staffed. Interview with Unit Manager (UM) #1, on 07/27/2020 at 3:13 PM, and 07/31/2020 at 2:02 PM, revealed she was aware that Resident #9 had complained about not receiving a shower on 07/18/2020, due to the facility being short staffed and he/she did not get a shower until 07/20/2020. She stated showers were an issue when the facility was short staffed, SRNAs could not perform showers for everyone that was scheduled. She stated the SRNAs were expected to report to the charge nurse if a resident did not receive a shower on their scheduled day, however she stated in all honesty, they do not report it. 5. Review of Resident #18's Significant Change MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of 13, indicating the resident was cognitively intact. Interviews with Resident #18, on 08/13/2020 at 12:38 PM, and 08/18/2020 at 10:45 AM, revealed the facility was short staffed all the time, especially on night shift. The resident stated he/she was independent and did not require staff assistance; however, when he/she did use the call light it took hours for staff to answer it. Interview with SRNA #5, on 07/29/2020 at 12:56 PM, revealed she felt the facility did not have enough staff. She stated staff could not answer call lights timely; for example, if staff were providing care for a resident for 25 minutes, there was not another SRNA to answer call lights/provide care. Interview with SRNA #7, on 07/29/2020 at 4:37 PM, revealed the facility was short staffed often and on third shift when there were on three (3) SRNAs in the building and they could not provide resident care timely. Interview with LPN #1 on 07/30/2020 at 1:11 PM also revealed the faciltiy often only had two (2) nurses and three (3) SRNAs to provide resident care on third shift. She stated the SRNAs could not check on residents and provide care every two (2) hours as required, nor were there enough staff to answer call lights. 6. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cellulitis, Age Related Physical Debility, and Low Back Pain. Review of the admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of 13, indicating the resident was cognitively intact. Continued review of the MDS assessment revealed Resident #8 was assessed to require limited assistance of one (1) staff member for bed mobility, transfers, walking, and locomotion. Resident #8 was further assessed to be totally dependent of one (1) staff member for showers. Observation and interview with Resident #8, on 08/12/2020 at 8:47 AM, revealed the resident was sitting on the side of the bed eating breakfast. The resident's hair was long and appeared greasy. Resident #8 stated that he/she had received a shower; however, he/she could not recall when it occurred, and that he/she was due another shower. Review of Resident #8's Baseline Care Plan, dated 07/15/2020, revealed the resident preferred to receive a shower versus a bath. Review of Resident #8's Kardex revealed the resident preferred to have a shower. Review of Resident #8's Documentation Survey Report for Bathing, from 07/15/2020 through 08/12/2020, revealed the last documented shower for Resident #8 was on 07/28/2020 at 1:08 PM. Interviews with SRNA #2, on 07/28/2020 at 3:09 PM and 08/07/2020 at 3:00 PM, revealed she had worked first shift (6:00 AM - 2:00 PM) and second shift (2:00 PM - 10:00 PM) revealed there was not enough staff to assist residents with showers. She stated she had complained to nursing staff and was told that there was nothing that could be done about the residents not receiving showers because the facility was short staffed. Continued interview with SRNA #10, on 07/27/2020 at 3:30 PM, revealed she she could not always complete resident showers completed because there was not enough staff to assist residents. She stated she apologized to the resdient and tried to give them a shower the next shift she worked. Continued interview with LPN #6 on 07/31/2020 at 12:34 PM revealed the facility was short staffed all the time. LPN #6 stated residents complained about not receiving a shower. However, LPN #6 stated they did the best they could. 7. Review of Resident #26's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15, indicating the resident was cognitively intact. The facility further assessed Resident #26 to require extensive assistance of two (2) staff for bed mobility, transfers, walking in room/corridor, and with dressing. Review of the SRNA Kardex revealed Resident #26 required assistance of one (1) staff for transfers, dressing, ambulation, and bed mobility, The MDS stated Resident #26 was always continent of bowel and bladder. Review of Resident #26's Comprehensive Care Plan for alteration in ADL task performance dated 05/27/2020, with a revision date of 08/05/2020, revealed the resident required assistance of one (1) staff as needed for ambulation, bed mobility, dressing, transfers, and locomotion. Continued review of Resident #26's Comprehensive Care Plan dated 05/27/15, with a revision date of 04/17/2020, revealed a care plan for alteration in continence status as evidenced by the resident was continent of bowel and bladder, however continence fluctuated at times. Interventions included staff to provide assistance of one (1) with toileting, perineal care, and brief change after incontinent episodes. Interview with Resident #26, on 07/30/2020 at 3:28 PM, revealed the facility was short staffed often and on all shifts. Resident #26 stated it took up to one (1) and a half hours (1/2) for staff to answer the call light when they were short. The resident stated that he/she had redness off and on due to having incontinent episodes when waiting for staff to answer the call light. Resident #26 stated he/she had complained several times but nothing happened. Interview with SRNA #3, on 08/05/2020 at 3:56 PM, revealed the facility was very short staffed. She stated when there were only three (3) SRNAs working during the shift, they could only do two (2) rounds (provide incontinent care and turn/reposition in their eight (8) hour shift if they were lucky. The SRNA also stated it took up to one and a one-half hours for staff to answer a call light. Continued iterviews with SRNA #2, on 07/28/2020 at 3:09 PM and 08/07/2020 at 3:00 PM, revealed she had found residents completely soaked with urine because there was not enough staff to provide incontinent care for resdients on third shift. SRNA #1 stated she had reported her co [TRUNCATED]

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the resident's physician was notified of a significant change in resident condition and a need to alter treatment for two (2) of fifty-five (55) sampled residents (Resident #8 and Resident #16). On 07/06/2020, at approximately 2:00 AM, a staff member was providing care and observed Resident #16's bra was embedded in the resident's skin; a foul odor and drainage was observed. Staff stated when they removed the resident's bra, chunks of skin came off resulting in open wounds. Although the facility notified the resident's physician of the open areas and drainage, the facility failed to notify the physician that the resident's bra had been found embedded resulting in the pressure ulcers, nor of the severity of the pressure ulcers to the breasts. Further review revealed the resident was seen by a Wound Care Physician on 07/21/2020 and 07/28/2020 due to other pressure ulcers. However, the facility failed to notify the Wound Care Physician of the pressure ulcers to the resident's breasts until 08/04/2020 at which time the physician transferred the resident to the hospital for further evaluation and treatment of the wounds to the breasts. Review of Resident #16's hospital documentation for 08/04/2020 and 08/05/2020 revealed the resident had four (4) open areas to the left breast; the largest area measured 4 by 13.8 centimeters (cm). The areas had a foul odor, with drainage and slough (dead skin or tissue) present. The right breast had three (3) open areas; one was necrotic and the largest measured 5.9 by 7.7 cm. Two (2) of the wounds required sharp (use of a scalpel) debridement. The wounds were infected and required Intravenous (IV) antibiotics. Refer to F686. In addition, On 07/16/2020, Resident #8 made statements of self-harm to Licensed Practical Nurse (LPN) #2 and she completed a Situation Background Assessment Response (SBAR) and faxed it to Physician #3's office. However, LPN #2 made no effort to follow up with the physician when the facility received no response to the fax. On 07/18/2020, Resident #8 made statements of self-harm to Physician #5 during an admission evaluation, at which time Physician #5 ordered Resident #8 to be transferred to the hospital's behavioral health unit for evaluation. However, Resident #8 refused to go to the hospital when transportation arrived, but the facility failed to notify the Physician of the resident's refusal. On 07/19/2020, Resident #8 made self-harm statements to LPN #6. However, the facility failed to notify the resident's physician of the resident's statements. The facility's failure to ensure the physician was notified of significant change in resident condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/04/2020, and determined to exist on 07/02/2020 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F700). The facility was notified of the Immediate Jeopardy on 08/04/2020. Immediate Jeopardy was also identified on 08/18/2020, and determined to exist on 07/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F686), 42 CFR 483.35 Nursing Services (F725), 42 CFR 483.75 Administration (F835); and, additional Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656). The facility was notified of the Immediate Jeopardy on 08/18/2020. An acceptable Allegation of Compliance was received on 08/28/2020, which alleged removal of the Immediate Jeopardy on 08/26/2020. A partial extended survey conducted on 09/01/2020 through 09/04/2020 revealed the Immediate Jeopardy was not removed. The facility failed to ensure there was adequate staffing to provide resident care as required by the residents' assessment and care plans. The findings include: 1. Review of the facility's policy Change in a Resident's Condition or Status revealed the facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition, and need to alter the resident's medical treatment significantly. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without interference by staff or by implementing standard disease-related clinical interventions. Review of Resident #16's medical record revealed the facility admitted the resident on 02/09/2018, with diagnoses which included Unspecified Kidney Failure, Osteomyelitis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertensive Heart Disease without Heart Failure, Other Idiopathic Peripheral Autonomic Neuropathy, and Complete Traumatic Amputation at Level Between Knee (LBKA) and Ankle, Right Lower Leg, Sequela. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), indicating the resident was severely impaired cognitively. Further review of the assessment revealed Resident #16 required extensive assistance of two (2) staff with Activity of Daily Living (ADLs). The resident was coded as being incontinent of bowel/bladder, and the resident was assessed to be at risk for developing a pressure ulcer/injury, but had no pressure ulcers. Review of Resident #16's care plan revealed the facility developed a care plan for impaired skin integrity, on 02/15/2020, related to a diabetic ulcer on the resident's left outer ankle and left heel, resulting in a LBKA due to Osteomyelitis. Further review of the care plan revealed staff would assist with position changes every two (2) hours and as needed, provide incontinent care and assist with toileting every two (2) hours, and observe for alteration in skin integrity and for skin breakdown with daily caregiving. The care plan further revealed to notify the physician as indicated. Review of the Event Report dated 07/06/2020 at 4:30 AM, revealed underneath Resident #16's bilateral breast there was green drainage with a scanty amount of blood coming from the open areas in the crease of the breast, and circular purple areas under the bilateral breasts, with hardened areas, shirt and sheet with green drainage on them, was removed and clean applied. Review of the Situation, Background, Assessment, Recommendation (SBAR) dated 07/06/2020, revealed the on call physician was sent an SBAR, for a skin wound/ulcer, discoloration, and pain to Resident #16's bilateral breast. On 07/10/2020, an SBAR revealed staff requested Resident 16's Physician to make a change in treatment for the wounds underneath the resident's bilateral breast, to clean the wounds with soap/water, pat dry, and cover with Calcium Alginate. Further review of the SBARs revealed on 07/15/2020, an SBAR was sent to Resident #16's physician stating the resident's wounds were increasing in size. Staff documented on a new wound, on the right gluteal fold; however, the resident's pressure ulcers underneath the resident's bilateral breast were not identified or documented, on the 07/15/2020 SBAR. Review of the Physician's Order dated 07/06/2020, revealed orders were obtained to apply coffee filters under Resident #16's bilateral breast every shift and as needed for saturation, and to obtain a wound culture. In addition, the physician ordered an antibiotic (Bactrim DS) and an antifungal medication (Diflucan). This order was discontinued on 07/13/2020, after the results were obtained from the wound culture obtained on 07/06/2020, and a new order was written on 07/13/2020 and started on 07/14/2020, to clean under Resident #16's breast with soap and water, pat dry, and cover with Calcium Alginate dressing, every evening shift. Review of a Physician's Order dated 07/12/2020, revealed Resident #16 was to be started on an intravenous (IV) antibiotic (Piperacillin Sodium/Tazobactam Sodium Solution). Review of a Physician's Order dated 07/13/2020, revealed the physician ordered a midline catheter to be inserted for IV antibiotic therapy. Review of the wound culture report (obtained on 07/06/2020) that was faxed to the facility on [DATE], revealed the wounds to Resident #16's bilateral breast contained a heavy growth of Pseudamonas Aeruginosa (a Gram-Negative Bacteria), a heavy growth of Proteus Mirabilis (a Gram Negative Bacteria), and a light growth of Methicillin-Resistant Staphylococcus Aureus (MRSA [a bacteria that is resistant to many antibiotics]). Further review of Resident #16's care plan revealed on 07/06/2020, staff had revised the care plan, to apply treatment to bilateral breast as ordered, observe for effectiveness of treatment, observe for signs and symptoms (s/s) of infection, and report to Resident #16's physician as indicated. Review of a Weekly Skin Review dated 07/10/2020, revealed the facility identified/documented wounds on Resident #16's right upper/lower hip, left buttock, LBKA, and the coccyx, had no s/s of infection, treatment continues, and dressings were clean, dry, and intact. However, the facility failed to identify/document the wounds underneath the resident's bilateral breast on 07/10/2020. Further review of the Weekly Skin Reviews dated 07/17/2020, 07/24/2020, and 07/31/2020 revealed the facility failed to assess and document the pressure ulcers beneath Resident #16's breast. Review of the Weekly Wound/Ulcer Observation Notes, dated 07/07/2020, revealed Resident #16's wounds on the LBKA, right upper/lower hip, left buttock, and coccyx had worsened and needed a new treatment change. However, the Weekly Wound/Ulcer Observation Note dated 07/07/2020 did not address the pressure ulcers to Resident #16 bilateral breast. Further review of the 07/07/2020 Note, revealed on 07/10/2020, the physician documented, on the 07/07/2020 Note, for the facility, to order a Wound Care Evaluation, and to treat. However, review of the Wound Care Evaluation revealed, the Wound Specialist Physician did not evaluate Resident #16's wounds until 07/21/2020, eleven (11) days after the physician had ordered the Wound Care Evaluation. Interview with the Wound Specialist on 08/07/2020 at 2:00 PM revealed he had a facsimile (fax) number, and was in the facility often. He stated he did not receive a text messages or other message, from the facility on 07/07/2020 or 07/10/2020, for a wound evaluation, for Resident #16. Review of the Wound Care Telemedicine Initial Evaluation dated 07/21/2020, revealed the Wound Specialist Physician saw and treated Resident #16's wounds, in the facility, on his/her right upper/lower hip, buttocks, and coccyx; however, the wounds underneath the resident's bilateral breast were not addressed by the Wound Specialist. Review of the Wound Evaluation and Management Summary dated 07/28/2020, revealed the Wound Specialist saw and treated Resident #16's wounds again, in the facility; however, the wounds underneath the resident's bilateral breast were not addressed by the Wound Specialist. Review of the Wound Evaluation and Summary Note dated 08/04/2020, revealed the Wound Specialist assessed the open areas on Resident #16's breast on 08/04/2020, a wound culture was obtained, and he recommended transferring the resident out to the hospital, while waiting on the wound culture results that were obtained. Review of the hospital records for Resident #16, from 08/04/2020 through 08/11/2020, revealed the resident was admitted to the hospital with open wounds on his/her left/right scalp, left breast, right breast, left leg, left buttock, right inner thigh, left hip, left thigh, and right hip. Review of a Progress Note by Physician #4, dated 08/04/2020, revealed Resident #16 had not healed an open wound to his/her LBKA, that was performed in March 2020, had bilateral inframammary (the natural lower boundary of the breast, the place where the breast and chest meet) wounds, and sacral wounds that will ultimately need surgical intervention. Further review of the Progress Note dated 08/05/2020, revealed Physician #4 would also debride the wounds on Resident #16's bilateral breast, because the areas were necrotic. Review of the History and Physical (H&P) Note, dated 08/05/2020, by Physician #2 (Resident #16's primary physician) revealed it was felt prudent to admit Resident #16 to the hospital, to rule out any sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). Interview with the Wound Care Nurse at the hospital on 08/10/2020, at 12:15 PM revealed she seen Resident #16 on 08/05/2020 at 7:00 AM. She revealed the top of the right breast was necrotic, and underneath the right breast were two (2) separate large measurable wounds. The medial wound was 1 cm by 1.7 cm, she stated she could not measure the depth of the wound because the wound had 100% nonviable tissue, with purulent green, foul odor drainage. The larger wound measured 5.9 cm by 7.7 cm, and again, she was unable to measure the depth of the wound, because it had nonviable tissue, with a large amount of green drainage, with a foul odor. The Wound Care Nurse stated she started debridement, and removed the top layer nonviable tissue, and underneath was yellow slough, that was slimy. The left breast had four (4) measurable wounds, which were measured from medial to lateral, all the wounds on the left breast were 100% nonviable, and she was unable to measure the depth of three (3) wounds. She revealed the medial wound measured 1 cm by 4.6 cm, and another wound next to it measured 0.5 cm by 2.4 cm, and slightly above was another wound that measured 3.7 cm by 6.4 cm, and the larger lateral wound, on the left breast measured 4 cm by 13.8 cm by 2.0 cm. The Wound Care Nurse revealed all the wounds had a moderate amount of purulent, green, foul odor drainage, and when she started the debridement of the wounds, even after she trimmed the yellow slough off of the wounds, the wounds still had 100% yellow slough. The Wound Care Nurse revealed the wounds were consistent with where a bra strap was, and the wounds had epithelial margins, which indicated the wounds wanted to heal; however, they could not because of the unviable tissue. Interview with LPN #8 on 08/11/2020 at 3:29 PM, revealed she received report from LPN #1, concerning Resident #16's wound areas on his/her bilateral breast. LPN #8 stated, (LPN#1) reported something about taking the resident's bra off, and there were some open areas, I can't remember her exact words. LPN #8 stated, The wounds at first were open areas, several areas among the bra line, and the wound on the right breast was oval, with a lot of yellow, foul odor drainage. I didn't notice any eschar in the breast at first, though there were darkened areas on the breast, maybe it was eschar, and the Unit Manager (UM) told me she was going to have the Wound Doctor to look at them. Review of the Unit Manager Job Description revealed the UM was responsible for making daily rounds to monitor resident care, status of residents, review charting on a weekly basis for accuracy and completeness, and document in residents' charts pertinent information about significant change in resident's condition. In addition, interview with Unit Manager #2 on 08/11/2020 at 11:15 AM revealed the UM was responsible for assessing and measuring all resident wounds weekly. The UM stated she was responsible for notifying the resident's physician on a weekly basis of all the wounds measurements, increase/decrease in sizes, drainage, and requesting a different treatment, if needed, to promote healing. Further interview with Unit Manager (UM) #2 on 08/11/2020 at 11:15 AM revealed when she did weekly wound observations she should list all the wounds and measure them, then send the report to the resident's physician. UM #2 revealed she could not answer why she did not identify/document, and send the report to the physician, concerning Resident #16's wounds to his/her bilateral breast. The UM stated she was trained to notify the physician, and the RP when a wound worsens or on any change in condition, occurred. She further revealed a wound evaluation should have been sent to the Wound Specialist, when Resident #16's wounds were declining. The UM stated she was responsible to review all new medication orders, and treatment orders, and to ensure the orders were placed on the Treatment Administration Record (TAR), and she was also responsible to revise the resident's care plan, especially when a wound was declining. UM #2 stated when Resident #16's physician ordered a wound evaluation on 07/10/2020, she tried calling the Wound Specialist and text him several times, but was unable to contact him. The UM stated she was under the assumption the wounds underneath Resident #16's breast were moisture related, until she saw the wounds and then realized the wounds were not moisture related. UM #1 further stated that 07/07/2020 was the first time she saw the wounds underneath Resident #16's breast and the wounds were open, with eschar and necrotic tissue underneath the resident's breast, with yellow drainage from each breast wound. UM #1 stated, I did treatments on the resident's breast every week, and the breast wounds were changing. In the beginning there was sloughy drainage and toward the end (before Resident #16 was transferred to the hospital on 08/04/2020) there was yellow/green drainage with eschar and necrotic tissue underneath the resident's breast. The UM revealed she sent Resident #16's physician a Weekly Pressure Wound Observation Tool every week, on Tuesdays, 07/10/2020, 07/17/2020, 07/24/2020, 07/28/2020, and 07/31/2020, with the measurements and locations of the resident's other wounds, and the date when the resident acquired the wounds, but failed to document anything concerning Resident #16's breast wounds. UM #1 stated, I never notified the resident's physician about the breast wounds getting worse, I should have notified the resident's physician about the wound changes, I do not have an answer as to why I did not notify him. She further revealed she asked the Wound Specialist to look at Resident #16's breast wounds on 07/28/2020, but she did not go into any detail, on how bad the wounds were, underneath the resident's breast. Interview with the NP on 08/07/2020 at 4:00 PM revealed a staff nurse reported to her that a SRNA had noticed some nodules in Resident #16's breast, while a SRNA was bathing the resident. The NP stated, I was not consulted at any time, concerning the resident's breast wounds, neither was I told anything about a bra being embedded into the resident's skin. Interview with Physician #2 (Resident #16's Primary Care Physician) on 08/07/2020 at 5:35 PM revealed, he was not told anything, by the facility, concerning Resident #16's bra being embedded in his/her skin, on 07/06/2020. Physician #2 further revealed he did order the facility to do a wound evaluation, but could not remember the date. Physician #2 stated he would have consulted with the Wound Specialist earlier, if he had known. Interview with the Wound Specialist on 08/07/2020 at 2:00 PM, revealed the first time he had seen Resident #16's wounds, underneath his/her breast, was on 08/04/2020, when he sent the resident to the hospital, for infection. He revealed Resident #16 needed more IV antibiotics, monitoring, and needed more care, than the facility could provide. The Wound Specialist stated he goes to the facility weekly, and treats the residents, with whom the facility has concerns. The Wound Specialist stated, If I had known about the embedded bra, which occurred on 07/06/2020, it would have had different implications, and treatment. He stated the facility told me they were concerned about breast cancer, and even ordered a mammogram, but typically breast cancer occurs in the fatty areas, of the breast, not where Resident #16's wounds were located underneath his/her breast. The Wound Specialist stated, I was not told anything about an embedded bra, nor consulted about the areas on the resident's breast, until 08/04/2020. Interview with the Director of Nursing (DON) on 08/14/2020 at 4:05 PM revealed she seen the Event Report on 07/06/2020, for Resident #16, and because staff were using coffee filters, she assumed the resident had excoriation or a fungal infection, underneath the resident's bilateral breast. The DON revealed the facility did not do an investigation, or talk to any staff concerning the areas underneath Resident #16's bilateral breast on 07/06/2020, and she did not even see the wounds on Resident #16, until the resident was being transferred to the hospital, on 08/04/2020. The DON stated the declining of the wounds, underneath Resident #16's bilateral breast, was never addressed in the morning meetings, and the resident's physician should have been notified if the resident had a change in condition. 2. Review of the facility's policy Suicide Threats dated December 2007, revealed resident suicide threats should be taken seriously and addressed appropriately. The policy stated after assessing a threat in more detail, the Nurse should notify the resident's Physician and responsible party, and seek further direction from the physician. Review of Resident #8's medical record revealed the facility admitted the resident on 07/15/2020, with diagnoses of Physical Debility, Low Back Pain, and Nicotine Dependence. Review of Resident #8's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The assessment also identified that the resident had an alteration in mood status. Resident#8 voiced having little interest or pleasure in doing things, expressed feelings of hopelessness and depression, had trouble sleeping, felt tired, had little energy, poor appetite and felt like a failure. Review of Resident #8's Comprehensive Care Plan initiated on 07/17/2020 revealed Resident #8 had a potential for alteration in mood status, and a history of self-harming thoughts, however no thought, plan, or intent at that time. Further review of the care plan revealed staff were to report to the physician when Resident #8 expressed thoughts of suicidal ideations or self-harm. Review of a Situation Background Appearance Review (SBAR) form, revealed on 07/16/2020 at 11:03 AM, Licensed Practical Nurse (LPN) #2, documented that Resident #8 was voicing thoughts of harming self, had nothing to live for and requested help. Continued review of Resident #8's medical record revealed the facility notified the resident's physician on 07/16/2020 via fax of the resident's suicidal ideations, but there was no further documentation of the physician's response, or evidence that further action was taken to address the resident's suicidal ideations. Interview with LPN #2 on 08/11/2020 at 5:10 PM revealed she faxed the SBAR to Physician #3's office, but did not follow up with the physician when she did not receive orders by 10:00 PM, when her shift ended or take any further action to ensure the resident's safety. Review of a Progress Note dated 07/18/2020 at 11:45 AM revealed Resident #8 was being seen by Physician #5, when the resident stated to the physician, When I get home I will take a gun and kill myself. The physician ordered that Resident #8 be transported to a behavioral health unit for evaluation. Further documentation revealed Resident #8 and the resident's Responsible Party (RP) were both in agreement with the intervention. Interview with Unit Manager (UM) #1 on 09/02/2020 at 12:33 PM revealed she was performing rounds with Physician #5 on 07/18/2020, when Resident #8's voiced the suicidal ideations, and the physician called the hospital and made arrangements for Resident #8 to be admitted . Review of a Progress Note dated 07/18/2020 at 4:31 PM revealed when Emergency Medical Services (EMS) arrived at the facility to transport Resident #8 to the hospital's behavioral health unit, Resident #8 refused to go stating he/she might go next week. Although the facility notified Resident #8's RP that the resident was refusing to go to the hospital, the facility did not notify the resident's physician that the resident refused to go, and remained in the facility. Interview with LPN #9 on 09/04/2020 at 5:28 PM revealed she was assigned to Resident #8 when EMS arrived to transport the resident to the hospital on 07/18/2020. LPN #9 stated when EMS arrived, Resident #8 refused transport and she notified Resident #8's RP of the resident's refusal, however did not notify Physician #5. LPN #9 stated she should have notified the resident's physician of the refusal, but that Resident #8 displayed no further suicidal ideations during her shift. Review of a Progress Note dated 07/19/2020 at 9:54 AM revealed LPN #6 documented that she assessed Resident #8's mood and the resident stated, I would like to commit suicide and get it over with. However, there was no evidence that Resident #1's physician was notified. Interview with LPN #6 on 08/11/2020 at 5:21 PM revealed when caring for Resident #8 on 07/19/2020, the resident expressed suicidal thoughts, however, she did not notify Resident #8's physician because she assumed since the physician had already been aware on 07/16/2020, that there was not a need to notify the physician again. Interview with Physician #3 on 08/12/2020 at 9:12 AM revealed she was Resident #8's physician, but was on vacation when the facility admitted the resident on 07/15/2020, and Physician #5 was providing coverage for her. She stated she had not been aware that Resident #8 had been voicing suicidal ideations until 08/11/2020 and she ordered a behavioral health evaluation for the resident. Physician #3 stated if she had of been aware that Resident #8 was stating he/she wanted to commit suicide, she would have obtained a 72-hour involuntary hold, and transferred the resident to the hospital. Physician #3 further stated that the facility should have notified Physician #5 on 07/18/2020 that the resident had refused to go to the hospital's behavioral health unit. Interview with Physician #5 on 08/14/2020 at 1:15 PM revealed on 07/18/2020 during rounds, Resident #8 told her that when he/she got home, the resident was going to kill him/herself with a gun. Physician #5 stated at that time she arranged for the resident's admission to the hospital's behavioral unit for an inpatient evaluation. However, Physician #5 stated the facility did not inform her that Resident #8 had refused transfer to the hospital, but she should have been told so further action could have been taken.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of fifty-five (55) sampled residents (Resident #16) received care consistent with professional standards of practice to prevent pressure ulcers and failed to ensure the resident's pressure ulcers received treatment and services to prevent the pressure ulcers from declining. On 06/09/2020, the facility conducted a skin assessment of Resident #16 and documented the resident had no pressure ulcers. The facility failed to conduct another skin assessment on 06/16/2020 as required and on 06/17/2020, staff found the resident had developed four new pressure ulcers. On 06/18/2020, Resident #16 was transferred to the hospital, where the hospital found five additional pressure ulcers that had not been identified by the facility. According to staff, there was not enough direct care staff to turn and reposition residents, provide incontinent care, or bath residents, as they required. Resident #16 was readmitted to the facility on [DATE] with physician orders to treat the pressure ulcers; however, the facility failed to provide the treatments on 06/22/2020, 06/23/2020, and 06/24/2020. Further, the facility failed to identify/assess/treat the resident's pressure ulcers as required by the facility's protocol and/or physician orders. Resident #16's pressure ulcers worsened and the resident developed new pressure ulcers. On 07/06/2020, at approximately 2:00 AM, a staff member was providing care and observed a brown spot on the resident's sheet at the upper back area. Then found the resident's bra, gown, and sheet were saturated with green/yellow drainage. Further observation revealed the resident's bra was embedded in the resident's skin and a foul odor with draining. Staff interviews revealed resident baths and restorative nursing was not provided per protocol or the plan of care due to shortage of staff. Staff stated when they removed the resident's bra, chunks of skin came off. Although the facility notified the resident's physician of the open areas and drainage, the facility failed to notify the physician that the resident's bra had been found embedded resulting in wounds, nor the severity of the resident's wounds. In addition, the facility failed to assess the pressure ulcers to the breasts weekly (size, appearance, drainage, odor) as required by the facility's protocol. Further review revealed the resident was seen by a Wound Care Physician on 07/21/2020 and 07/28/2020 due to other pressure ulcers; however, the facility failed to notify the Wound Care Physician of the pressure ulcers to the resident's breasts until 08/04/2020, at which time the physician transferred the resident to the hospital for further evaluation and treatment of the wounds to the breasts. Review of Resident #1's hospital documentation for 08/04/2020 and 08/05/2020 revealed the resident had four open areas to the left breast, the largest measured 4 by 13.8 centimeters (cm). The areas had a foul odor, with drainage and slough present. The right breast had three open areas; one was necrotic (dark, dead tissue) and the largest measured 5.9 by 7.7 cm. In addition, two new pressure ulcers were identified at the hospital. The pressure ulcers were infected and Resident #16 required Intravenous antibiotics to treat the ulcers. The resident's pressure ulcers also required surgical debridement (removal of dead tissue). Resident #16 was discharged from the hospital on 08/11/2020, with multiple wound care treatment orders; however, a review of the resident's August 2020 Treatment Administration Record (TAR) revealed the facility did not follow the physician's orders as prescribed for pressure ulcer treatments. The facility's failure to prevent and treat pressure ulcers has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/04/2020, and determined to exist on 07/02/2020 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F700). The facility was notified of the Immediate Jeopardy on 08/04/2020. Immediate Jeopardy was also identified on 08/18/2020, and determined to exist on 07/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F686), 42 CFR 483.35 Nursing Services (F725), 42 CFR 483.75 Administration (F835); and, additional Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656). The facility was notified of the Immediate Jeopardy on 08/18/2020. An acceptable Allegation of Compliance was received on 08/28/2020, which alleged removal of the Immediate Jeopardy on 08/26/2020. A partial extended survey conducted on 09/01/2020 through 09/04/2020 revealed the Immediate Jeopardy was not removed. The facility failed to ensure there was adequate staffing to provide resident care as required by the resident's assessment and care plan. The findings include: Review of the facility's policy Repositioning revised May 2013, revealed repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief for residents. Repositioning was critical for a resident who was immobile or dependent upon staff for repositioning, and positioning the resident on an existing pressure ulcer should be avoided, since it put additional pressure on tissue that was already compromised and may impede healing. Further review of the policy revealed frequency of repositioning a bed or chair-bound resident should be determined by the overall condition of the resident, and the condition of the resident's skin. Residents who were in bed should be on at least an every two (2) hour repositioning schedule and if ineffective, the turning and repositioning frequency would be increased. Review of the facility's policy Prevention of Pressure Ulcers/Injuries revised on October 2019, revealed the facility would monitor, evaluate, report, and document potential changes in the skin. Further review of the facility's policy revealed a resident's skin would be inspected on a daily basis when performing or assisting with personal care or Activities of Daily Living (ADLs). Staff would identify any signs of developing pressure injuries, for darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; inspect pressure points and reposition the resident as indicated on the care plan. Review of the facility's policy Wound Care revised on October 2010, revealed staff providing the wound care would document any change in the resident's condition, any assessment data obtained when inspecting the wound, as needed, and to report other information in accordance with facility policy and professional standards of practice. Interview with the Director of Nursing (DON), on 08/14/20 at 4:05 PM, revealed residents received skin assessments on a weekly basis. She stated staff nurses completed the skin assessments on the day they were assigned for the unit and documented the assessment on a Weekly Skin Review form. The DON further stated Unit Managers (UM) measured/assessed all wounds/pressure ulcers weekly and were required to document the assessment on a Non-Pressure Observation Tool or a Pressure Observation Tool. According to the DON, the Non-Pressure Observation Tool was used when a resident had a rash, scratches, Moisture Associated Skin Disease (MASD), or a surgical incision. The Pressure Observation Tool was used when a resident had an area that was pressure related (pressure ulcer). Further interview revealed the UM also completed a Non- Pressure/Pressure Tool that was sent to the resident's primary physicians weekly, to provide the physicians with the information needed to determine if they should continue with the same wound care or to alter the wound care treatment to promote healing. Review of Resident #16's medical record revealed the facility admitted the resident on 02/09/2018, with diagnoses which included Unspecified Kidney Failure, Osteomyelitis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertensive Heart Disease without Heart Failure, Other Idiopathic Peripheral Autonomic Neuropathy, and Complete Traumatic Amputation at Level Between Knee and Ankle, Right Lower Leg, Sequela. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was severely cognitively impaired. Further review of the assessment revealed Resident #16 required extensive assistance of two (2) staff with Activity of Daily Living (ADLs), including bed mobility, toileting, transfers, and dressing and was totally dependent on staff for bathing. The resident was incontinent of bowel/bladder. In addition, the facility assessed the resident to be at risk for developing a pressure ulcer/injury, but had no pressure ulcers when the assessment was completed. According to the assessment, the resident was on a turning and repositioning program to prevent skin breakdown. Review of the Braden Scale (used for predicting pressure ulcer risk) dated 02/17/2020, 04/22/2020, 06/22/2020, 06/25/2020, and 07/13/2020, revealed Resident #16 was at high risk for developing pressure ulcers. Review of Resident #16's Weekly Skin Review dated 06/09/2020, and Weekly Wound/Ulcer Observation Tool dated 06/16/2020, revealed the resident had no pressure ulcers. There was no documented evidence the facility completed a Weekly Skin Review as required on 06/16/2020. However, on 06/17/2020, (one day later) review of a Weekly Non-Pressure and a Weekly Pressure Wound Observation Tools revealed staff identified four (4) new open areas Two were described as other open areas to the right hip (trochanter, a pressure area), one to the upper right hip measuring 1x2 cm with light serous (thin, watery, clear drainage) drainage and one to the lower right hip measuring 1.5x4 cm, with a small amount of slough (dead tissue that needs to be removed for healing) and light serous drainage. Further review revealed the resident had a stage three (3) pressure ulcer to the coccyx, measuring 2x2 cm, with light serous drainage; and a stage two (2) pressure ulcer on the left buttock, measuring 1x1x0.2 cm, with light serous drainage. The documentation revealed all areas were without odor, wound edges were well defined, and no documented evidence of infection was noted. Review of the Situation, Background, Assessment, Recommendation (SBAR) dated 06/17/2020, revealed the facility sent Resident #16's primary physician notification that the facility identified four (4) new open areas (site's not documented); however, there was no documented evidence that the facility obtained physician orders to treat the pressure ulcers on 06/17/2020. Interview with LPN #8 on 08/11/2020 at 3:29 PM, revealed she was the nurse who identified the open areas on Resident #16, on 06/17/2020. LPN #8 stated she believed she was providing a treatment for the resident, when she found the pressure ulcers, but did not know why a skin assessment had not been completed the previous day. She stated she sent the SBAR to the resident's physician and notified the next shift of the pressure ulcers and the need to watch for physician orders to treat the ulcers. Review of the nurse's notes dated 06/18/2020, revealed the resident was transferred to the hospital. The note did not state the reason for the admission. Review of hospital records dated 06/18/2020 thru 06/21/200, revealed when Resident #16 was admitted to the hospital the resident had ten (10) pressure ulcers, five (5) more pressure ulcers than the facility had identified the day before. Review of the hospital's description of the pressure ulcers on 06/18/2020 revealed the resident had the following pressure ulcers: A pressure ulcer to the left, upper posterior thigh measuring 0.8 x 0.6 cm. The depth of the pressure ulcer could not be determined due to a 100 percent (%) yellow wound bed. The skin around the wound (peri-wound) was bright red. This pressure ulcer was not identified by the facility on 06/17/2020 and the hospital documented that no dressing/bandage was present when they assessed the ulcer. A nonstageable pressure ulcer to the left, upper anterior thigh measuring 1.8 x 1.0 cm with a 100% necrotic (non-viable tissue due to reduced blood supply) wound bed, with no drainage, and a bright red peri-wound, which was also a pressure ulcer that was not identified by the facility on 06/17/2020. The hospital staff also documented that no dressing/bandage was in place. In addition, three pressure ulcers to the left buttock were identified, one to the left upper buttocks, measuring 0.8 x 0.9x 0.2 cm, with a bright red peri-wound, moderate green/yellow drainage, and 80% yellow wound bed; left medial buttock, measuring 1.2 x 1.0 x 0.2 cm with moderate amount of green/yellow drainage, 90% yellow wound bed, and bright red peri-wound; and left lower buttock, measuring 2.2 x 2.8 cm with moderate amount of green/yellow drainage, 70% slough noted to a nonviable wound bed, and a bright red peri-wound. The facility identified one pressure ulcer to the left buttock on 06/17/2020; however, the wound had no yellow/green drainage at that time. A non-stageable pressure ulcer to the medial coccyx that had no dressing in place, measuring 3.2 x 0.5 cm (three small areas, measurement is for entire area), with minimal green/yellow drainage, and 100% yellow nonviable wound bed. A pressure ulcer to the coccyx had been identified by the facility on 06/17/2020; however, the wound drainage was not described as green/yellow. Two pressure ulcers to the right outer buttock. One to the lower, outer buttock, measuring 2.6 x 4.2 cm, with moderate amount of green/yellow drainage, a 90% of nonviable wound bed (two open areas, entire area measured), and red peri-wound. A pressure ulcer to the right upper, outer buttocks, with a bright red peri-wound. The pressure ulcer measured 2 x 2 cm and had a 100% black eschar (dry, black, hard necrotic tissue) wound bed and a moderate amount of green/yellow drainage. The facility had identified wounds to the upper right hip and lower right hip on 06/17/2020; however, the facility did not document that either pressure ulcer had green/yellow drainage or necrosis. A pressure ulcer to the right buttock measuring 1.4 x 0.5 cm, with minimal amount of green/yellow drainage, red peri-wound, and 100% yellow slough in wound bed, which was not identified by the facility on 06/17/2020. Review of the Admission/Re-Admission Observation dated 06/21/2020, revealed when Resident #16 was readmitted to the facility, staff documented the resident had a stage three (3) pressure ulcer on his/her coccyx measuring 2x2 cm, and two (2) pressure ulcers on the right hip measuring 1.5x4 cm, and 1.0x2.0 cm (no appearance, drainage, signs or symptoms of infection was documented). There was no evidence the facility identified/assessed the pressure ulcer to the left buttock that was initially identified by the facility on 06/17/2020, and no evidence the facility identified/assessed the pressure ulcers to the anterior and posterior left thigh or right buttock that were identified at the hospital on 06/18/2020. Review of Resident #16's physician's orders dated 06/22/2020, revealed the physician ordered daily wound care to all the pressure ulcers that had been identified at the hospital (bilateral buttocks, coccyx, left thigh, right outer buttocks) that included cleaning the pressure ulcers with normal saline, apply Hydrofera Blue, cover with Mepilex Border. However, review of the resident's June 2020 Treatment Administration Record (TAR), revealed the facility did not provide the treatment to the pressure ulcers for three days after readmission from the hospital, on 06/22/2020, 06/23/2020, nor 06/24/2020. Further review of the resident's physician orders and TAR revealed on 06/25/2020, the treatments to the pressure ulcers to the left and right buttocks, coccyx, and left thigh were discontinued and an order was written to apply antifungal powder to the resident's bilateral buttocks and coccyx for Moisture Associated Skin Damage (MASD). Interview with Licensed Practical Nurse (LPN) #6, on 08/13/2020 at 12:10 PM, revealed she was the nurse who entered the treatment orders in the facility computer on 06/21/2020, for Resident #16, when the resident returned from the hospital. LPN #6 revealed she had only worked at the facility 11 days, and 06/21/2020 was the first day she had worked by herself and had never entered readmission orders into the computer. She stated she was panicked and it was possible that she made a mistake and did not enter the orders correctly. Interview with the ADON, on 08/12/2020 at 4:25 PM, that even though the facility assessed the left buttock and coccyx to be pressure ulcers, on 06/18/2020, and the hospital assessed all the areas to be pressure ulcers (left and right buttocks, coccyx, thigh) and ordered pressure ulcer treatment, she observed Resident #16's wounds on 06/25/2020, and believed wounds to the buttocks and coccyx were Moisture-Associated Skin Damage (MASD) and did not believe any of the wounds were caused from pressure. Further interview revealed she did not identify any wounds/pressure ulcers to the resident's left thigh. Interview with LPN #8, on 08/11/2020 at 3:29 PM, revealed she did not remember seeing any pressure ulcers to the resident's thighs or any other pressure ulcers to the buttocks on 06/17/2020. LPN #8 further revealed she always checked the facility's computer system, prior to leaving the facility to ensure no treatments were missed. She stated there would be red areas on TARs if a treatment was not completed, and she would have completed Resident #16's treatments 06/23/2020 and 06/24/2020, if they had been on the resident's treatment record. Review of Resident #16's Weekly Skin Review (weekly skin assessment), dated 06/26/2020, 7/03/2020, 7/10/2020, 07/17/2020, 07/24/2020, and 07/31/2020, revealed no evidence pressure ulcers were identified to the left thigh or right buttock. Further reveiw revealed, the facility only identified one pressure ulcer to the left buttock, not three as documented by the hospital, on 06/18/2020. Review of the facility's Weekly Non-Pressure Observation Tool, dated 06/23/2020 and 06/30/2020, revealed even though the hospital identified the areas to the right upper and lower hip, coccyx, and left buttock were pressure ulcers on 06/18/2020, the facility continued to complete the Non-Pressure tool. Further review there was no assessment of the pressure ulcers (size, appearance, drainage, odor, etc.) on 06/23/2020. In addition, athough the pressure ulcers were assessed at the hospital, on 06/18/2020 upon admission, as being larger than the facility's measurements on 06/17/2020, and showing signs of infection, the facility documented on 06/23/2020 and 06/30/2020 that the pressure ulcers were the same as 06/17/2020, with no changes, including no signs or symptoms of infection. Review of Weekly Wound/Ulcer Observation Notes (the form sent to the physician weekly) dated 07/07/2020, revealed Resident #16's right upper/lower hip, left buttock, and coccyx pressure ulcers had worsened and needed a new treatment change. On 07/10/2020, the physician responded with an order for a Wound Care Evaluation; however, there was no evidence the wound care evaluation was ordered/addressed at that time. Interview with Unit Manager (UM) #2, on 08/11/2020 at 11:15 AM, revealed she attempted to notify the Wound Care Specialist of the need for a wound care evaluation for Resident #16's wounds. She stated she called and texted the physician several times, but was unable to reach the Wound Care Specialist. However, interview with the Wound Care Specialist, on 08/25/2020 at 3:50 PM, revealed he communicated often with the facility via text and phone calls and visited the facility weekly. He stated the facility did not notify him of the need to evaluate Resident #16 until 07/21/2020, 14 days after the resident's primary care physician ordered a consultation. Review of the Weekly Wound/Ulcer Observation note sent to Resident #16's physician on 07/14/2020, revealed the pressure ulcers to the right upper and lower hip and left buttock had worsened. However, there was no evidence that the pressure ulcers were assessed (no measurement, appearance, drainage, odor, etc.). The resident's physician responded and changed the treatment to the upper and lower hip; however, the treatment for antifungal powder to the buttocks and coccyx continued. In addition, there were no evidence the physician was aware that a Wound Care Evaluation had not been completed. Interview with Physician #2, on 08/07/2020 at 5:35 PM, revealed he recalled ordering a wound care evaluation, but could not remember the date. He stated he was not aware that the facility did not consult the Wound Specialist for 11 days after he ordered the consult. Review of a SBAR for Resident #16 dated 07/15/2020, revealed notification was sent to Resident #16's physician stating the resident's pressure ulcers were increasing in size (no measurements provided) and a new pressure ulcer was identified in the right gluteal fold (2 by 3.5 cm). The physician ordered for the treatment to the pressure ulcers to continue; however, there was no evidence a treatment was ordered/initiated to treat the pressure ulcer to the right gluteal fold. Further review of Resident #16's medical record revealed no documented evidence a skin assessment was completed for the resident on 07/14/2020, as required. Interview with the UM, on 08/11/2020 at 11:15 AM, confirmed that a skin assessment was not conducted. Another staff member measured the pressure ulcers on 07/14/2020, but no one had assessed the resident's skin. Review of a Weekly Wound/Ulcer Observation note for Resident #16's dated 07/17/2020, revealed the resident had pressure ulcers to the coccyx (2.5x1.6 cm), to the left buttock (0.6x0.9 cm), to the right lower hip 2.4x4.9 cm), and the right upper hip 2.1x 3.0 cm). According to the documentation, none of the pressure ulcers was showing any signs or symptoms of infection. Further, the pressure ulcer to the right gluteal fold that was identified on 7/15/2020, was not mentioned and there continued to be no treatment to the ulcer. Review of a Wound Care Telemedicine Initial Evaluation dated 07/21/2020, revealed the Wound Specialist Physician assessed and treated Resident #16's pressure ulcers to the right upper/lower hip, buttocks, and coccyx. The physician documented that the pressure ulcers to the hip and coccyx were in an inflammatory stage and unable to progress to a healing stage due to the presence of biofilms (mixed strains of bacteria, fungi, yeasts, algae, microbes, and other cellular debris). The physician documented the following related to the pressure ulcers: The upper and lower right hip, were unstageable, due to necrosis (there was no necrosis documented on the facility's last assessment on 07/17/2020) the right upper hip measured 2.5 cm by 4.0 cm by 0.2 cm and the lower right hip measured 3.5 cm by 6.0 cm (both had increased in size since 07/17/2020). Stage II pressure ulcer to the coccyx measured 4.2 by 2.0 by 0.1 cm (an increase in size since the facility's assessment on 07/17/2020). Buttocks (MASD right gluteal fold) measured 3.0 cm by 1.5 cm. The assessment stated the ulcer had 50% necrotic tissue and the depth of the pressure sore could not be determined (necrotic tissue had not been identified by the facility). Buttock (did not specify left for right or whether it was a pressure ulcer) that measured 0.5 cm by 1.0 cm. Further review of the Wound Specialist's note revealed new treatment orders were written on the 07/21/2020; however, according to the Resident #16's July 2020 TAR the treatments were not initiated until 07/24/2020, three days later. Furthermore, the Wound Specialist recommended to limit Resident #16's sitting in a chair, for no longer than 30 minutes; however, review of the resident's care plan revealed it was not revised to reflect this change. Review of the Weekly Skin Review dated 07/24/2020, revealed a scratched area was identified to the resident's anterior left thigh; however, there was no documentation that the appearance/size of the area was assessed. Review of the Wound Evaluation and Management Summary dated 07/28/2020, revealed the Wound Specialist assessed Resident #16. The pressure ulcer to the coccyx had increased in size (4.2 by 4 by 0.1) and developed necrosis. The physician also documented that the pressure ulcers to the buttocks and coccyx had deteriorated. The Wound Specialist ordered to continue Medihoney, which was a change in treatment to Resident #16's buttock (used to removed fluid and dead tissue and contributes to more conducive wound healing). However, review of Resident #16's July and August 2020 TAR, revealed the facility failed to add Medihoney to the treatment of the resident's left buttock pressure ulcer. Furthermore, the Wound Specialist recommended the facility staff to move Resident #16 from side to side, and front to back every one (1) to two (2) hours if able, for 14 days, however, review of the resident's care plan revealed the recommendation was not added to the care plan, as ordered by the Wound Specialist, on 07/28/2020. Review of the Wound Evaluation and Summary note dated 08/04/2020, revealed the Wound Specialist revealed the pressure ulcers had not increased in size; however, the pressure ulcers to the right hip, buttock (did not specify left or right), and coccyx had developed heavy, foul smelling drainage and had worsened due to infection. The pressure ulcers were debrided and the Wound Specialist's recommendation was to transfer the resident to the hospital for treatment of the pressure ulcers Review of the hospital records for Resident #16's stay from 08/04/2020 through 08/11/2020, revealed Physician #2 (Resident #16's primary physician) Resident #16 was admitted to the hospital to rule out any Sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). Review of a skin/pressure ulcer assessment completed on 08/05/2020 (the assessment was deferred until 08/05/2020 because on admission the resident's blood pressure was low and the focus was improving the blood pressure) revealed the following pressure ulcers that had not been identified by the facility prior to admission to the hospital: A 3.4x4.5 cm pressure ulcer to the left lateral thigh that had moderate green drainage with a mild odor and a red peri-wound 2.5x3.6 cm pressure ulcer to the right posterior thigh that had necrosis and slough, a foul odor, and bloody, green/yellow drainage. (Pressure ulcers to the anterior and posterior thigh were identified at the hospital on 06/18/2020, but were never identified/assessed/treated at the facility after readmission on 06/21/2020. A non-stageable pressure ulcer to the lower back that measured 5.4 cm by 2.0 cm, with moderate amount of green/yellow foul drainage. The buttocks had multiple scattered areas, mostly on left buttock, all with 100% yellow nonviable wound bases and redness around secondary to tape irritation, with moderate amount of green/yellow foul discharge. Three pressure ulcers to the right hip (the facility had only identified two). One of the areas was necrotic and measured 1.0 by 1.3 cm; the other two (possibly the two being treated at the facility) were nonstageable and measured 1.5 cm by 4.6 cm by 0.2 cm and 4.0 cm by 7.6 cm by 1.0 cm, with bloody, green/yellow foul drainage. Further review revealed the hospital assessed the pressure ulcers to the resident's sacrum (possibly coccyx pressure ulcer at the facility) as being non-stageable with two (2) areas that were measured together as 5.3 cm by 5.5 cm, with a moderate amount of bloody, green/yellow, foul drainage, which was an increase in size and was infected; and a stage III pressure ulcer to the left lower buttock that measured 2.5 cm by 2.7 cm by 0.2 cm, with green/yellow, foul drainage, which was also an increase in size and was infected. According to the hospital record, the pressure ulcers to were surgically debrided. Interview with Unit Manager (UM) #2, on 08/11/2020 at 11:15 AM, revealed she was responsible for conducting weekly wound/pressure ulcer assessments and notifying residents' physicians of changes/worsening. She stated when a pressure ulcer was identified; the nurse who conducted the skin assessment was responsible for assessing the pressure ulcer initially, sending an SBAR to the physician, and obtaining treatment orders. She then conducted subsequent weekly pressure ulcer assessments and notified the resident's physician of changes weekly by sending a report to the physician. She stated she did not identify any additional pressure ulcers after the resident was readmitted to the facility on [DATE], or before admission to the hospital on 08/04/2020. According to UM #2, she thought she told the Wound Specialist verbally, about the pressure ulcers to the resident's thigh, but could not remember the date. Further interview with UM #2 revealed she was responsible to review all new medication and treatment orders, to ensure the orders are placed on the TAR, and revising the resident's care plan, especially when a wound was declining. The UM could not explain the delay in changing the resident's treatment as ordered by the Wound Specialist on 07/21/2020, nor the failure to change the treatment as ordered by the Wound Specialist on 07/28/2020. The UM stated she was aware that the Wound Specialist recommended on 07/21/2020 and 07/28/2020 Resident #16 not sit in a chair for longer than 30 minutes and to be turned and repositioned every one (1) to two (2) hours. However, she did not think the Wound Specialist's recommendations should have been placed on Resident #16's care plan, because the SRNAs were already required to turn and reposition all residents every two (2) hours. Interview with the Wound Specialist, on 08/07/2020 at 2:00 PM, and on 08/11/2020 at 4:45 PM, revealed he provided care at the facility once a week, and only provided care to the residents/wounds for which staff were concerned. He stated he did noticed the wounds were deteriorating and that was why he sent the resident to the hospital Interview with the Director of Nursing (DON), on 08/14/2020 at 4:05 PM, revealed she was not aware that SRNA's were not able to complete rounds every two (2) hours to turn/reposition residents and provide incontinent care. According to the DON, she made rounds throughout the facility a few times daily to talk to resident's, SRNA's, UM's, and the charge nurse's, and had not identified any concerns. She stated she also reviewed the staffing schedule every two (2) weeks and had not identified any concerns with not having enough staff. Further interview with the DON revealed the Non Pressure Review and Pressure Review forms were new to the facility and staff were still confused about using them. She stated any new pressure ulcer should have been documented on a pressure ulcer sheets/skin assessment form, and should have been monitored for changes. She further revealed she and Staff Development Coordinator instructed SRNAs to report any red or open areas to a nurse. The DON stated she thought when the SRNAs seen a red area or open wound on Resident #16, they probably thought the nurse was already aware. She further revealed sometimes when a nurse, who does not routinely work on a particular hallway, identified a new red area or open wound, she probably assumed the nurse who usually worked that hall, was already aware of the area or wound. Continued interview with the DON revealed Unit Managers were responsible for ensuring physician orders were placed on the resident's MAR/TAR correctly, and the UM's could look at a resident's MAR/TAR anytime to

Based on observation, interview, record review, review of facility policies/procedures and review of the User-Service Manual for the Deluxe Assist Handle (a bed rail designed to assist the occupant with bed mobility) it was determined the facility failed to ensure bed rails were appropriately assessed and did not pose a safety hazard for one (1) of fifty-five (55) sampled residents (Resident #1). Record review revealed the facility admitted Resident #1 to the facility on [DATE]; and placed resident in a bed which was equipped with assistive handles that were attached to the left and right side of the beds' frame. Interview and record review revealed the facility failed to attempt alternatives to the bed rail or perform any type of bed rail or safety assessment for the resident. Interviews revealed the facility considered the bed rail to be an enabler. In addition, on [DATE], the facility placed an alternating pressure-relieving mattress (a mattress that inflates and deflates intermittently) on Resident #1's bed due to declining skin integrity. In addition, record review and interviews revealed the facility failed to perform a safety assessment to ensure the mattress did not create a safety hazard for the resident. On [DATE], Resident #1 was found deceased hanging off the side of the bed, being held up by the chin/neck, which was wedged in the bed rail. The resident's head was pinned down to the bed facing upward toward the ceiling. The facility's failure to ensure bed rails were appropriately assessed and did not pose a safety hazard for residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F700). The facility was notified of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was also identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F686), 42 CFR 483.35 Nursing Services (F725), 42 CFR 483.75 Administration (F835); and, additional Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. A partial extended survey conducted on [DATE] through [DATE] revealed the Immediate Jeopardy was not removed. The facility failed to ensure there was adequate staffing to provide resident care as required by the resident's assessment and care plan. The findings include: Review of the facility's policy titled Bed Safety, revised [DATE], revealed the facility would provide a safe sleeping environment for residents. The policy stated resident sleeping environments should be assessed by the interdisciplinary team (IDT), considering the residents' safety, medical conditions, and freedom of movement. According to the policy, in order to prevent deaths/injuries from the beds and related equipment (including bed rails), the facility would ensure an inspection by maintenance staff of all beds and related equipment was part of the regular bed safety program to identify risks and problems including potential entrapment risks. Further review of the policy revealed the facility would identify additional safety measure for residents who were identified as having a higher than usual risk for injury including entrapment. Staff would inform the resident/resident's family about the benefits and potential hazards associated with bed rails and obtain consent for the use of bed rails from the resident/resident's legal representative prior to use for any reason. Review of the User-Service Manual for the Deluxe Assist Handle, dated 2012, revealed a warning that a bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraint and bed system entrapment guidance. Further review of the User-Service Manual for the Deluxe Assist Handle revealed the assist device was intended for use as an aid when entering/exiting the bed as well as a stabilizer to hold on to when self-positioning while in the bed. The manual also stated the assist handle and mounting bracket should be visually inspected monthly and checked for loose hardware. Review of the User-Service Manual for the bed platform dated 2009, revealed a warning to keep the bed in the lowest position except when providing care, failure to do so could result in injury. The manual stated an important note, which stated, powered air mattress surfaces could pose a risk of entrapment. In addition, the manual stated prior to use, ensure the therapeutic benefits outweighed the risk of entrapment. Continued review revealed the bed and accessories should be visually inspected monthly to check for loose hardware, broken welds, or cracks. Interview with the facility's Maintenance Director, on [DATE] at 10:30 AM, revealed all the beds in the facility were the same and were purchased approximately eight (8) years ago. The Maintenance Director stated the bed rails came with the beds when purchased, and each bed currently being used in the facility had the bed rail installed. However, the Maintenance Director stated he did not recall performing any kind of assessment prior to the beds and bed rails being utilized. In addition, the Maintenance Director stated he did not conduct any type of routine inspection or assessment of the beds or rails, and stated his only interaction with a bed or bed rail would be if a problem were reported to him. In addition, the Maintenance Director stated if the resident received any type of new or specialized mattress, he would place the device on the resident's bed, but nursing staff would perform any assessment or set up that was required. Observation during tour of the facility, on [DATE] from 10:05 AM until 12:45 PM, revealed all the beds being used in the facility were equipped with the assist hand bed rail. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with diagnoses including Aphasia, Cerebral Vascular Accident (CVA), Hemiplegia and Hemiparesis affecting Right Dominant Side, Chronic Obstructive Pulmonary Disease (COPD), and Dementia Review of Resident #1's Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired, totally dependent upon two (2) staff members for bed mobility, and utilized a mechanical lift for transfers. In addition, Resident #1 was non-ambulatory and did not utilize bed rails as a restraint. Review of Resident #1's Comprehensive Care Plan initiated on [DATE], revealed there were no interventions related to the resident using any type of bed rails. Further review of the care plan revealed under the interventions/action section of the potential for falls/injury problem the facility had listed Alternating pressure relief mattress to bed. Continued review of Resident #1's medical record revealed a Lift Observation and a Morse Fall Scale assessments both completed on [DATE], revealed the resident was at high risk for falls, bedridden, non-weight bearing, and was absent of upper body strength. Interview with the Director of Nursing (DON), on [DATE] at 3:25 PM, revealed when admitted to the facility, Resident #1 was placed in a bed that was equipped with the bed rail. In addition, the DON stated the bed rail on Resident #1's bed was located on the left side of the bed mid-way down on the bed frame. The DON stated that was where the bed rail was located when Resident #1 was placed in the bed, and she was unaware of who or how the determination was made to place the rail in that position. Continued review of Resident #1's medical record revealed no evidence that the facility considered alternative approaches prior to placing Resident #1 in a bed equipped with a bed rail. In addition, there was no evidence the facility evaluated to ensure the bed rail was appropriately placed on the bed to meet Resident #1's needs. Nor evidence of an assessment to determine that the bed rail would be beneficial for Resident #1. Also the facility did not assess to determine if placing the resident in a bed with a rail would not pose a safety hazard for the resident. In addition there was no evidence found to indicate the risks/benefits of utilizing the bed rail was discussed with the resident or the resident's responsible party, nor any evidence that a signed consent for the use of the bed rail was obtained. Interview with Resident #1's Power of Attorney (POA), on [DATE] at 2:44 PM, revealed the facility had never discussed the use of bed rails with her or discussed the pros and cons of using bed rails. The POA stated she had not signed consent for Resident #1 to use bed rails and was not aware that she had a choice in the decision of whether or not the bed rail was used on Resident #1's bed. Continued review of Resident #1's medical record revealed on [DATE], a Physician's Order was received for the resident to have an alternating pressure relief mattress, due to a decline in skin integrity. However, there was no evidence found to indicate that the facility attempted to ensure that the alternating pressure relief mattress was compatible with the resident's bed, nor that there were no gaps wide enough to entrap the resident. Also that the inflation/deflation of the alternating pressure relief mattress did not create gaps between the mattress and bed. In addition, there was no evidence the facility considered the resident's diagnoses of Hemiparesis, Hemiplegia, or the lack of upper body strength to determine if the alternating pressure relief mattress could increase the likelihood of the resident sliding to one side of the bed or against/under the bed rail, when the mattress inflated/deflated. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 10:38 AM, revealed she was assigned to Resident #1 when the alternating pressure relief mattress arrived at the facility and was placed on the resident's bed. LPN #2 stated the mattress was new, and she had received no instruction or training on implementing or setting up the mattress. LPN #2 stated she read the manual that accompanied the mattress and set the mattress to alternate pressure but could not recall if she set the firmness of the mattress. Interview with LPN #1, on [DATE] at 1:11 PM, revealed all resident beds were equipped with the same type of bed rail to be used as an enabler, even though not all residents were cognitively or physically able to utilize the device. LPN #1 stated Resident #1 required the assistance of two staff for bed mobility, was unable to assist staff with turning/repositioning, and required a mechanical lift for transfers. In addition, LPN #1 stated Resident #1 often leaned toward the left side of the bed and had to be repositioned to the middle of the bed. Interviews on [DATE] with SRNA #4 at 11:15 AM, SRNA #6 at 3:28 PM, and SRNA #1 at 5:18 PM, revealed the staff stated Resident #1 leaned toward the left side of the bed, and often had to be re-positioned to the middle of the bed. Review of an Event Report, dated [DATE] at 1:10 AM, revealed Resident #1 was found without vital signs on the left side of the bed with his/her body on the floor and head and neck resting on the bed rail, with a red mark on the neck from resting against bed rail. Resident #1 was pronounced deceased and the body was released to the funeral home. Interview with State Registered Nursing Assistant (SRNA) #1, on [DATE] at 5:18 PM, revealed she was assigned to Resident #1 on [DATE]. She stated she had last assisted Resident #1 at approximately 12:30 AM and went back to the resident's room approximately one (1) hour later. SRNA #1 stated when she entered Resident #1's room, she could see that the resident was not in bed, but then saw the top of the resident's head on the left side of the bed and immediately left the room to get LPN #1. After returning to the room with LPN #1, SRNA #1 stated she assisted the LPN in attempting to free the resident's head from being wedged in the bed rail. The SRNA stated the resident was hanging from the bed with the back of the resident's head pinned against the mattress and facing toward the ceiling. The SRNA stated the resident's bed was not in the lowest position and not in the highest position and the resident's buttocks were not touching the floor. The SRNA stated the resident had discoloration on the neck from being caught in the bed rail. SRNA #1 stated after additional staff came to the resident's room, she left the room to calm down. Continued interview with LPN #1, on [DATE] at 1:11 PM, revealed she was assigned to care for Resident #1 on [DATE], and had last observed the resident asleep in bed at approximately 11:00 PM. LPN #1 stated at approximately 1:00 AM, SRNA #1 came and got her and when she entered Resident #1's room, she could see the top of the resident's head from the doorway. LPN #1 stated the resident's chin/neck was caught on the bottom of the bed rail, the resident's chin was elongated, and the back of the resident's head was on the bed with the resident's face toward the ceiling. LPN #1 stated the resident's bed was elevated at hip height and the resident's buttocks were not touching the floor. The LPN stated the resident's legs were positioned straight out resting on the floor. LPN #1 stated she tried to get the resident out of the bed rail but was unable to lift the resident. LPN #1 stated she called for assistance over the intercom system and LPN #3 came to assist her. She stated together they were able to get the resident's neck/chin out of the bed rail and then placed the resident onto the floor. Resident #1 was pasty white in color, cool to the touch, and was not breathing. Resident #1 was designated as Do Not Resuscitate (DNR), and therefore cardiopulmonary resuscitation was not initiated and the resident was pronounced deceased at the facility. Interview with LPN #3, on [DATE] at 9:09 PM, revealed she was providing care to another resident when LPN #1 called overhead for her, and as she got close to Resident #1's room she could hear LPN #1 screaming help me. LPN #3 stated when she arrived to Resident #1's room LPN #1 was trying her hardest to get Resident #1 out of the rail, however, LPN #3 stated Resident #1's neck/chin was caught in the lower part of the bed rail on the left side of the bed and the resident's lower body was not touching the floor. LPN #3 stated it took them both to get the resident's neck/chin out of the bed rail and then they placed Resident #1 onto the floor. LPN #3 stated Resident #1's neck/chin area was very discolored from the bed rail. Interview with SRNA #7, on [DATE] at 4:37 PM, revealed she was working on [DATE], when she heard LPN #1 page for assistance over the intercom. SRNA #7 stated as she was going toward Resident #1's room, SRNA #1 was coming toward her down the hall crying. She stated when she entered Resident #1's room, LPN #1 and LPN #3 was already in the room and she observed Resident #1 lying on the floor. SRNA #7 stated Resident #1's bed was waist high and that she had to lower the bed and along with the other staff, utilized a draw sheet to placed Resident #1 back onto the bed. She stated Resident #1 had a huge deep indention under the chin. Interviews with the ADON, on [DATE] at 3:33 PM, and [DATE] at 3:03 PM, revealed all the beds in the facility had the bed rail, however, the facility did not perform bed rail assessments for any resident, because the bed rail was considered an enabler. However, the ADON stated Resident #1 could not move him/herself in the bed and could not utilize the bed rail. The ADON stated she was notified by LPN #1 in the early morning hours of [DATE], that Resident #1 had expired, but stated she was not told that the resident was found entrapped in the bed rail and was hanging from the bed. Continued interview with the DON, on [DATE] at 3:25 PM, revealed LPN #1 notified her on [DATE] between 1:00 AM and 1:30 AM, that Resident #1 had fallen out of bed and was found with his/her head resting against the bed rail. The DON stated she was told the resident's neck was hyperextend and that there was a red area on the resident's chin due to it resting on the hand assist rail. The DON stated the facility did not perform bed rail assessments because the hand assist bed rails were considered enablers. The DON stated she did not know who or how it was decided where the bed rail would be positioned on the bed and was not aware of any safety assessment conducted related to the bed rail. The DON stated she was aware that Resident #1 was not physically or cognitively able to use the bed rail but did not realize removing the bed rail was an option. Further, the DON stated she did not consider placing an air-filled mattress on the resident's bed might increase the resident's risk for bed rail entrapment due to the mattress rising in the center and lowering on the side, making it easier for the resident to slide off the mattress or against the rail. In addition, the DON stated she was aware that resident #1 had a tendency to lean toward the left side. The DON stated to her knowledge there was no assessment performed when Resident #1 received the alternating pressure relief mattress to ensure the mattress was compatible with the bed and did not pose a safety hazard for Resident #1. Interview with the Administrator, on [DATE] at 9:59 AM and on [DATE] at 5:39 PM, revealed the prior owners of the facility had purchased the bed frames that were in use at the facility in 2012, and the assist hand bed rail had come with the beds. The Administrator stated no bed rail assessments were performed for residents utilizing the bed rails, because they were considered an enabler. The Administrator also stated she had no knowledge of why Resident #1's bed rail was located on the middle of the bed frame. The Administrator stated she had recently purchased two (2) alternating pressure relief mattresses to be used in the facility, including the one used by Resident #1. The Administrator stated she picked that mattress because it appeared to most closely resemble the air mattresses used at the facility. The DON stated she did not consult with the bed or mattress manufacturer to ensure the mattresses were compatible with the beds or conduct any assessment to ensure placing the mattress on Resident #1's bed did not create a safety hazard for the resident. Continued interview with the Administrator revealed on [DATE] when she arrived to work, she was told that Resident #1 had expired after being found in the floor with his/her head resting against the bed rail. The administrator stated she was not told that Resident #1 was found entrapped in the bed rail and took no further action to investigate the incident or ensure other resident's in the facility were not also at risk for injury or death.

Based on interview, record review, review of the facility's Allegation of Compliance, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During an abbreviated survey, initiated on 07/22/2020, Immediate Jeopardy (IJ) was identified on 08/04/2020 and 08/18/2020. The facility submitted an Allegation of Compliance (AOC) alleging that the IJ was removed on 08/26/2020. However, a partial extended survey conducted on 09/01/2020 through 09/04/2020 determined the Immediate Jeopardy was not removed. The Administrator failed to monitor staffing per the AOC to ensure there was adequate staffing to provide resident care as required by the residents' assessments and care plans. In addition, the AOC stated that Personal Care Attendants (PCA) (individuals permitted by a state waiver to perform defined resident care procedures during COVID-19 pandemic) would work with State Registered Nurse Aides (SRNA) at all times. However, on 08/28/2020, PCA #1 worked providing direct resident care (turning/repositioning residents, incontinent care and showers) independently and unassisted by a SRNA. According to staff interviews, the PCA worked independently due to lack of staffing on 08/28/2020. On 09/04/2020, PCA #6 provided direct resident care independently and on 09/03/2020, SRNA #23 was observed transferring residents independently whose care plans specified two (2) staff were required for transfers. Therefore, the Immediate Jeopardy is ongoing. The facility's failure to ensure the Administrator used resources effectively has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/04/2020, and determined to exist on 07/02/2020 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F700). The facility was notified of the Immediate Jeopardy on 08/04/2020. Immediate Jeopardy was also identified on 08/18/2020, and determined to exist on 07/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F686), 42 CFR 483.35 Nursing Services (F725), 42 CFR 483.75 Administration (F835), and additional Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656). The facility was notified of the Immediate Jeopardy on 08/18/2020. The findings include: Review of the Administrator's Job Description, dated December 2018, revealed the Administrator would direct the overall operations of the facility in accordance with resident needs and government regulations, while focusing on maintaining excellent resident care. Further review revealed the Administrator was responsible to manage turnover and solidify current and future staffing through development of recruiting sources and through appropriate selection, orientation, training, education, and development of staff. The Administrator was also required to utilize survey information in addition to other source documents to address areas of importance as defined by the residents and provide guidance and leadership to ensure state and federal regulations were met and adhered to. Review of the Executive Order for Temporary COVID-19 Personal Care Attendant (PCA) dated 04/14/2020, revealed the waiver permitted a long-term care facility to employ a trained (PCA) to perform defined resident care procedures. The order permitted the PCA to perform procedures that did not require the skill or training required for a SRNA. The order stated the PCA position was a temporary accommodation made to address work increases and staffing shortages caused by the COVID-19 pandemic. The facility must fully notify the certified and licensed staff members that PCAs had limited scope of permissible work, and detail what duties may not be delegated to PCAs, if the facility discovered that any PCA was performing duties outside the limited scope of permissible work, it must immediately intervene, stop the PCA, and reassign those duties to authorized personnel. The order addressed acceptable scope of practice for PCAs to include transfer - residents that required standby assist, however a PCA could help with residents that required more assistance as long as a SRNA or Nurse was present; help with repositioning; helping with bed baths and bed bath setup; and showers. Further review of the temporary order revealed that PCAs would not be assigned or provide care or services to a resident in Isolation Precautions. Review of the facility's AOC for staffing revealed PCAs would work with CNAs (SRNA's) at all times. The facility Administrator and staffing coordinator would review staffing sheets daily to ensure sufficient staffing for all three (3) shifts and to ensure staffing levels were in alignment with the facility self-assessment. The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and/or Unit Manager would perform audits on random shifts to ensure resident care was provided per the resident's care plan, to include showers, turning and repositioning, and incontinence care. The Facility signed a written contract on 8/21/2020 with a staffing agency to fill day-to-day open shifts in advance. The Administrator was to review staffing daily for all shifts and provide supplemental staff as needed. The date the facility alleged the removal of immediate Jeopardy was 08/26/2020. Review of the Facility Assessment revealed the facility needed 14 to 27 nurse aides to provide resident care in a 24-hour day. Review of the staff Placement Sheet for 08/27/2020 revealed PCA #6 was assigned to work E Hall on first shift with SRNA #24 for E hall. According to the Placement Sheet, PCA #2 was assigned to provide care on second shift as a SRNA. Further review of the staff Placement Sheet for 09/04/2020 revealed PCA #6 and SRNA #24 were assigned to provide care for residents on E Hall on first shift. Review of the Skin Care Alerts, dated 08/27/2020, revealed PCA #6 gave Resident #41 and Resident #47 a shower; and, PCA #2 documented that she gave Resident #48 a shower. Further review revealed on 09/04/2020, PCA #6 documented a shower for Resident #38, Resident #39, and Resident #40. Interviews with PCA #2, on 07/28/2020 at 9:12 AM, and on 09/02/2020 at 1:24 PM, revealed she confirmed that on 08/27/2020, she gave Resident #48 a shower unassisted by another staff member. Interview with PCA #6, on 09/04/2020 at 1:42 PM, revealed she gave four (4) resident showers (Residents #23, #41, #47, and #49) unassisted by another staff member, on 08/27/2020 and on 09/04/2020 (Residents #2, #38, #39, and #40). Review of the Placement Sheet for 08/28/2020 from 6:00 AM - 2:00 PM revealed four (4) SRNAs and one (1) PCA was scheduled to provide care for facility residents (SRNA #10, SRNA #18, SRNA #20, SRNA #26, and PCA #1). According to the Placement Sheet, PCA #1 was assigned to E Hall with SRNA # 26. Interviews with PCA #1, on 09/03/2020 at 11:14 AM, 1:10 PM, and on 09/04/2020 at 3:15 PM, revealed she worked A Hall, on 08/28/2020 by herself during the first shift. She stated she provided turning and repositioning and/or incontinent care to Residents #5, #12, and #21, #33, #34, #35, #36, #37, #42, #43, #44, #45 and #46 and gave showers to Resident #21 and #33 without assistance, even though the residents required the assistance of two staff. Interview with SRNA #18, on 09/03/2020 at 10:10 AM, confirmed PCA #1 worked A Hall and provided resident care by herself. Interview with SRNA #5, on 09/03/2020 at 12:25 PM, also confirmed that PCA #1 provided care to residents on A Hall without the assistance of another staff member and provided showers, transfers, incontinence care, and turning/repositioning. Interview with the Administrator, on 09/04/2020 8:30 PM, revealed she could not speak to what happened with staffing, on 08/27/2020, 08/28/2020, or 09/04/2020, other than on 08/28/2020, a SRNA called in leaving them short staffed. The Administrator stated that the facility's procedure when someone called in was to attempt to get a staffing agency to fill in; however, it was not always possible to find a replacement. The Administrator repeatedly stated she was aware that the facility had staffing problems.

Based on interview, record review, and a review of facility policy, it was determined the facility failed to have an effective system to immediately inform the physician and legal representative when there was a significant change in condition and need to alter treatment for one (1) of three (3) sampled residents (Resident #1). Record review and interview revealed Resident #1 ate only two snacks on 09/13/19, had no food intake on 09/14/19, decreased fluid intake on 09/13/19 and 09/14/19, and no urine output since 12:05 AM on 09/14/19. In addition, interviews with staff revealed the resident was unresponsive on 09/14/19, and Licensed Practical Nurse (LPN) #1 was notified of the resident's changes in condition. However, there was no documented evidence the facility notified the resident's physician or family of the changes in the resident in accordance with the facility's policies/procedures. At approximately 2:25 PM on 09/14/19, the resident's family visited, found the resident unresponsive, and notified staff. Registered Nurse (RN) #1 contacted the resident's physician and Resident #1 was transferred to a local hospital and admitted with [DIAGNOSES REDACTED]. The facility's failure to ensure the resident's physician and legal representative were notified when the resident experienced a change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/15/19 and was determined to exist on 09/13/19. The facility was notified of the Immediate Jeopardy on 11/15/19. An acceptable Allegation of Compliance was received on 11/24/19, which alleged removal of the Immediate Jeopardy on 11/21/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 11/21/19, prior to exit on 11/26/19, which lowered the scope and severity to D level while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Physician/Legal Representative Notification, last revised in August 2019, revealed staff was required to immediately inform the resident, consult with the resident's physician, and notify the resident's legal representative or interested family member when a significant change in the resident's physical, mental, or psychosocial status, which included deterioration in health, or clinical complications, was identified. Staff was also required to inform the physician when a need to significantly alter the resident's treatment occurred. Review of the medical record for Resident #1 revealed the facility admitted the resident on 08/30/18 with [DIAGNOSES REDACTED]. Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he/she required extensive assistance of two (2) staff members with bed mobility and toilet use and extensive assistance of one (1) staff member when eating. Resident #1's cognitive skills were severely impaired and his/her assessment for a Brief Interview for Mental Status (BI[CONDITION]) score was not conducted, which indicated he/she was not interviewable. Review of Resident #1's Meal and Snack Consumption record dated September 2019 revealed the resident consumed a snack on 09/13/19 at 10:25 AM and 2:40 PM, but did not eat breakfast or dinner, and only consumed 9[AGE] milliliters (ml) of fluids. The Meal and Snack Consumption record revealed the resident ate 0-25% of lunch; however, interview with SRNA #4 on 09/27/19 at 11:30 AM, revealed the resident only drank milk. Review of Resident #1's medical record for 09/13/19 revealed no documented evidence the resident's physician was notified about the resident's decreased food/fluid intake. Further review of the Meal and Snack Consumption record, dated 09/14/19, revealed the resident did not eat breakfast or lunch and consumed only 1[AGE] cubic centimeters (cc) of fluids. In addition, review of Resident #1's Bladder Continence Record for 09/14/19 revealed the resident had no urinary output after 12:05 AM. Interview with State Registered Nurse Aide (SRNA) #2 on 09/27/19 at 11:40 AM and SRNA #3 on 09/28/19 at 11:10 AM, revealed they were unable to wake Resident #1 for breakfast on 09/14/19 at approximately 7:30 AM. The SNRAs stated they reported the change in the resident's condition to LPN #1. Further interview with SRNA #3 revealed she was unable to arouse Resident #1 for the lunch meal on 09/14/19 at approximately 1:00 PM. She stated she reported the resident's condition to LPN #1 and she observed LPN #1 do a chest rub on the resident; however, the resident only responded by opening his/her eyes and made a soft noise. According to SRNA #1, LPN #1 also washed the resident's face, but the resident did not respond. Review of Resident #1's medical record, including the Progress Notes, revealed there was no documented evidence that LPN #1 notified the resident's physician or responsible party of the resident's decreased intake and urine output or that staff was unable to arouse the resident. Interview with LPN #1 on 09/27/19 at 2:20 PM, confirmed that staff reported the resident did not eat on 09/13/19, but she was unable to recall the number of meals that were not eaten. LPN #1 also confirmed that staff reported that they could not wake Resident #1 for breakfast on 09/14/19, but she did not assess the resident because she felt it was normal for the resident to be groggy. Further interview with LPN #1 revealed she recalled that staff also reported that they were unable to wake Resident #1 for the lunch meal on 09/14/19. She stated she looked at the resident after lunch and the resident was still groggy but would wake up. According to LPN #1, she believed the resident's condition was a result of being up late, and did not notify the resident's physician. LPN #1 stated her shift ended shortly after the lunch meal and she did not recall seeing the resident again before she left for the day. Review of Resident #1's Progress Notes, dated 09/14/19 at 2:25 PM, revealed Registered Nurse (RN) #1 documented that the resident's sister could not awaken the resident. Further review revealed Resident #1's skin was pale and clammy, and the resident's eyes remained closed upon verbal and physical stimuli. According to the note, the resident's heart rate was 122 (normal range [AGE]-100), respiratory rate was 35 (normal range 12-24), blood pressure was [AGE]/42 (normal range 120/[AGE]), oxygen saturation was [AGE]% (normal range 95%-100%) on room air, and his/her blood glucose level was 319 (normal range [AGE]-130). Further review of Progress Notes revealed RN #1 notified Resident #1's physician of the change in his/her condition at 2:45 PM on 09/14/19. Interview with Resident #1's Power of Attorney (POA) on 09/25/19 at 10:00 AM and on [DATE] at 8:00 AM, revealed when she visited the resident on 09/14/19, she found the resident unresponsive and had to alert staff. She stated staff had not notified the family of the resident's change in condition or that the resident had decreased food/fluid intake for two (2) days. The POA stated the resident always ate and drank well and had never had concerns with weight loss. Per interview, the facility should have known that something was wrong with the resident and called the family and the doctor when the resident was not eating or drinking. An interview with RN #1 on 11/14/19 at 10:35 AM, revealed she was the charge nurse caring for Resident #1 on 09/14/19 on the 2:00 PM to 10:00 PM shift. RN #1 stated LPN #1 told her in report that Resident #1 was out of it today but stated that the resident was sleepy due to receiving pain medication. RN #1 stated she tried to wake the resident and there was no response. The RN stated Resident #1 was clammy and had a low blood pressure. Per RN #1, there was a clear change in the resident's condition and she contacted the resident's physician and transferred the resident to the hospital for evaluation. Interview with Physician #3 on 09/30/19 at 5:15 PM, revealed she was Resident #1's primary physician at the facility and expected staff to contact her when a change in a resident's condition was identified. Interview with Physician #4 on [DATE] at 3:20 PM, revealed he had also assessed Resident #1 during the resident's stay at the facility. He stated changes in mental status, dramatic changes, or consistence changes in condition over several days should trigger physician notification. According to Physician #4, if a resident required a sternal rub, the facility should have notified him because that was definitely a dramatic change in condition. Interview with the Unit Manager on 09/27/19 at 10:30 AM, on 11/13/19 at 12:55 PM, and on 11/14/19 at 2:53 PM, revealed Resident #1's physician should have been notified on 09/13/19 when the resident had not eaten the past three (3) meals. Interview with the Director of Nursing (DON) on 10/01/19 at 1:25 PM and on 11/14/19 at 11:25 AM, revealed if a resident missed three (3) meals, the resident's physician should be notified. She also stated if SRNAs reported that a resident was unresponsive, she expected facility nurses to assess the resident and notify the resident's physician anytime a change in condition was identified. Interview with the Administrator on 10/01/19 at 4:20 PM, revealed staff was expected to notify the resident's physician and family when changes in their condition occur. Review of Resident #1's hospital record revealed the patient arrived at the Emergency Department (ED) on 09/14/19 at approximately 3:40 PM and was nonresponsive with slight moan to sternal rub. Resident #1's blood pressure on arrival at the ED was 68/38 (normal range 120/[AGE]), respiratory rate was 43 (normal range 12-24), and initially there was no urine output. Further review of Resident #1's hospital record revealed his/her blood urea nitrogen (BUN) level (kidney function test) was 181 (normal range 8-26), creatinine level (kidney function test) was 6.[AGE] (normal range .[AGE]-1.30), and [MED] level was 163 (normal range 136-144, elevated [MED] can indicate dehydration). The hospital record revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Further interview with Physician #4 on [DATE] at 3:20 PM, revealed he also saw the resident after he/she was hospitalized and did not think the resident would live. Further interview with Resident #1's POA on 09/25/19 at 10:00 AM and on [DATE] at 8:00 AM, revealed they met the resident at the hospital on [DATE] and the resident looked horrible. The POA stated the resident's mouth and lips were dry and the resident had no urinary output when hospital staff initially inserted a urinary catheter. According to the POA, the hospital physicians told the family that the resident would probably not make it through the night. Further interview revealed after a few hours of receiving Intravenous (IV) fluids, they started seeing dark brown urine in the resident's catheter bag and the resident started waking up some. The POA stated the resident's condition improved during his/her hospital stay and the resident was discharged to another nursing facility. The facility alleged the following removed Immediate Jeopardy on 11/21/19: 1. The attending physician and resident representative for Resident #1 were notified of the need to transfer the resident to the hospital on [DATE]. Resident #1 is no longer at the facility. 2. The 24 hour report sheets, from 09/15/19 to 10/15/19, were reviewed by the Director of Nursing (DON) and Unit Managers on 10/17/19 and [DATE]. 3. Residents with reduced food/fluid intake for the last seven (7) days were reviewed by the Director of Nursing (DON), Registered Dietitian (RD), and Unit Managers on 10/17/19 to identify any residents who demonstrated a change in condition. All residents demonstrating a change in condition had documentation of Physician/Advanced Practice Registered Nurse (APRN) notification in accordance with their care plans. For all residents demonstrating a change in condition, the documentation (which included the nursing notes and assessments) was audited to determine that the Physician/APRN were notified and responded timely to the notification with follow-up orders. 4. Facility licensed nursing staff have received in-service education by the Director of Nursing and Director of Clinical Services, completed on 10/17/19 and 10/22/19. Any staff that did not complete the in-service education by this date have been locked out of the time clock and cannot begin working their next shift until the in-service is completed with the DON. This education included but was not limited to: a. The definition of changes in resident condition, the need to assess the resident immediately, and report these to the attending Physician/APRN immediately in accordance with the resident care plans. b. The facility policy on notification of resident changes and the need to fully inform the Physician and Resident Representative of the assessment findings, complete the follow-up monitoring, and implement all Physician orders. c. Review for decreased food/fluid intake in the facility computer system. d. Review of the Interact STOP and WATCH program for all staff, which directs/prompts reporting any change of condition to the licensed nurse, and the need for the licensed nurse to assess the resident immediately. STOP and WATCH was covered in the in-service education on 10/17/19 for all staff, and for licensed nurses on 10/22/19. The Interact Stop and Watch forms will be used by all staff to identify/document any observed resident changes in condition. These forms are in Duplicate, with a copy being given to the licensed nurse to direct/prompt an immediate assessment, and then the copy will be placed in the unit Communication Book for review with the shift reports between shifts. The Second copy will then be turned in to the DON for monitoring, and the Director of Nursing Copy will be used for review by the DON, Unit Managers, and RD in their daily meetings during the week, and on Monday for the weekends. 5. A Specific Diabetic HS (bedtime) Snack Task for all residents who are receiving [MED] was initiated on [DATE] to further clarify meal (supplement) intake records for the residents with orders for [MED] and to alert staff if Diabetic HS Snack intake was less than 50%. 6. A Diabetic Log was initiated on 11/15/19 (and revised on 11/19/19) of meal/HS Snack intake for the residents with orders for [MED] to determine that their meal/alternative meal/supplement intake was greater than 50%. If the resident's meal/alternative/supplement intake was less than 50%, the log prompts the licensed nurse to assess the resident, and to notify the Physician prior to their [MED] administration. 7. The last three days of meal intake records for the residents with orders for [MED] were reviewed to determine that their meal/supplement intake was greater than 50% prior to their [MED] administration. This was completed on [DATE] by the RD, DON, Unit Managers, and Director of Clinical Services. 8. All licensed nurses have received in-service education by the DON and Director of Clinical Services on the following, completed on 11/19/19. Any staff that did not complete the in-service education by this date have been locked out of the time clock and cannot begin working their next shift until the in-service and competencies are completed with the Director of Nursing: a. the need to review resident food/fluid intake prior to administering any ordered [MED] and assess the resident. b. the need to hold the [MED], assess the resident, and notify the physician if the resident's meal intake was less than 50% for the meal prior to the glucose reading. c. the use of the meal intake and assessment of the resident prior to [MED] administration record for documentation of verification of the above information. d. Review of the Interact STOP and WATCH program for all staff, which directs/prompts the reporting of any change of condition to the licensed nurse, and the need for the licensed nurse to assess the resident immediately. 9. A Quality Assurance Performance Improvement (QAPI) meeting was conducted on [DATE] by the facility QAPI committee with the Medical Director to review the survey findings, this Allegation of Compliance, and the findings of the audits and currently completed QAPI tools. 10. The Director of Nursing, Registered Dietitian, and Unit Managers are reviewing all Physician orders [REDACTED]. They are then reviewing the nursing documentation (which includes the nursing notes and assessments) to determine that Physician/APRN and Resident Representative notification was completed timely, and follow-up orders obtained and implemented. Walking rounds with shift changes were initiated for the charge nurses and State Registered Nurse Aides (SRNA) to identify any residents with changes in condition. Any changes identified are to be reported immediately, Unit Managers are to follow up on any changes of condition, and report to daily meeting during the week, and the Monday Meeting for the weekend. 11. The Director of Nursing will choose one (1) resident identified with changes in status and reassess to determine that original findings were accurate. The QAPI tool for the monitoring of compliance with identification, assessment of the resident, and the QAPI tool for the monitoring of compliance with identification and notification of resident changes in condition will be utilized weekly for 2 weeks, then monthly for 2 months, and then quarterly by the Director of Nursing. Failure to meet the established 100% threshold will result in the development of an action plan. The results of the completed QAPI tools and any indicated action plans will be reviewed in the QAPI committee meetings. 12. The DON, RD, and Unit Managers are reviewing the [MED] administration forms daily during the week and on Monday for the weekends to determine that licensed nurses are reviewing resident meal/fluid intake prior to administration of any ordered [MED], and are holding the [MED], assessing the resident, and notifying the MD if the resident's meal intake is less than 50% for the meal prior to the glucose reading. The QAPI tool for the monitoring of meal intake prior to [MED] administration will be utilized weekly for 2 weeks, monthly for 2 months, and then quarterly thereafter by the Director of Nursing. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on 11/21/19, as alleged by the facility: 1. Resident #1 no longer resides in the facility after transfer to the hospital on [DATE] per physician order. 2. The Allegation of Compliance (AOC) binder revealed evidence of review of the 24-hour report sheets, dated 09/15/19 through 10/15/19. The binder also revealed evidence of documentation of physician notification of any changes in resident status as well as nurse documentation of changes. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the 24-hour report sheets from 09/15/19 to 10/15/19 to ensure physician and responsible party notification as required. Interview with the Director of Nursing on 11/25/19 at 3:18 PM, revealed on 10/17/19 and [DATE] she, along with the unit managers, reviewed the 24-hour report sheets dated 09/15/19 through 10/15/19 for physician and responsible party notification. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the 24-hour report sheets from 09/15/19 to 10/15/19 to ensure physician and responsible party notification as required. Interview with the Director of Nursing on 11/25/19 at 3:18 PM, revealed on 10/17/19 and [DATE] she, along with the unit managers, reviewed the 24-hour report sheets dated 09/15/19 through 10/15/19 for physician and responsible party notification. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the residents for decreased intake for dates of 10/10/19 through 10/16/19. The Unit Managers also revealed how the Stop and Watch forms were to be used, explaining that a copy was given to the nurse for immediate assessment and the other copy would go to the DON. They also stated the form could be completed by any staff or even family member. 3. The binder contained a printed report titled Clinical and Alert Listing Report, dated 10/10/19 through 10/16/19. The report revealed meal intake percentages of all residents in the facility. The information noted one (1) resident was identified as having refused two (2) meals on 10/13/19 and only 25% of the other meal was consumed. There was evidence of communication to the physician, by fax, of the resident's intake and the physician reply of OK. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the residents for decreased intake for dates of 10/10/19 through 10/16/19. Interview with the Director of Nursing (DON) on 11/25/19 at 3:18 PM, revealed they had audited residents, looking at meal intakes, from 10/10/19 through 10/16/19. She stated they did identify one (1) resident and the physician was notified by fax. Interview with the Registered Dietitian on 11/26/19 at 3:20 PM, revealed staff had audited residents for reduced food/fluid intakes over a seven (7) day period. 4. The AOC binder had evidence of staff sign-in sheets dated 10/17/19 and 10/22/19 with total staff attendance. The evidence included a sign-in sheet for all staff on 10/17/19 and licensed staff on 10/22/19. The evidence also included the topics educated on which included: Changes in a Resident's Condition or Status Policy; Nutrition/Fluid Task and Alert Review; Facility policy on notification of resident changes; and STOP and WATCH by Interact. Interview with the Director of Clinical Services on 11/25/19 at 3:33 PM, revealed he had provided education on 10/17/19 and 10/22/19 on the changes in resident condition policy to include reporting and documentation of changes. He further stated he also provided education to the staff on food/fluid task alert task. Interview with the DON on 11/25/19 at 3:18 PM, revealed she provided education to the staff on STOP and WATCH forms and how to use, change in resident condition policy and procedure, and how to review for decreased food/fluid intake in the computer system. Interview with State Registered Nurse Aide (SRNA) #1 on 11/25/19 at 2:35 PM, SRNA #2 at 2:20 PM, and SRNA #3 at 2:05 PM, revealed they had received education regarding changes in a resident's condition, how to use the STOP and WATCH form, and the new Nutrition/Fluid task alert task. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed education had been provided to them on the Changes in a Resident's Condition, the policy regarding notification of physician and family regarding change in condition, the STOP and WATCH form, and Nutrition/Fluid alert task in the SRNA's documentation. 5. Review of documentation for the AOC revealed the HS snack task was a computer-based task for aides to complete. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, revealed the Diabetic HS Snack Task was a tool placed on the Kiosk. This is the documentation system for the aides. This must be answered at the end of every shift. Interview with Unit Manager #1 on 11/26/19 at 2:51 PM, revealed the Diabetic HS Snack Task is on the kiosk for the aides to complete. She further stated the task must be completed prior to the aide ending their shift. 6. Review of documentation revealed a diabetic completed log for the dates of 11/15/19 to 11/21/19 for all residents on [MED]. There was also evidence of a revision of the log on 11/19/19. A revised log, dated 11/19/19 through 11/24/19, was completed for all residents on [MED]. Interviews with Unit Manager #1 on 11/26/19 at 2:51 PM and Unit Manager #3 at 3:08 PM, revealed they complete the diabetic log tool every morning, Monday through Friday, prior to attendance of the morning clinical meeting. Interview with the DON on 11/26/19 at 3:18 PM, revealed the unit managers are performing the audit tools, Resident Change of Condition, and Diabetic Management Log. 7. Review of documentation revealed evidence of a review of residents who received [MED] the last three (3) days of meal intake. The review was completed by the DON, Unit Managers #1, #2, and #3, and the RD on [DATE]. Interview with Unit Manager #1 on 11/26/19 at 2:51 PM, revealed a three (3) day lookback of residents on [MED] was performed. The binder also included the QAPI tool, Diabetic Management, which revealed six (6) residents audited on [DATE] and six (6) on 11/20/19. Both audits revealed 100% compliance. Interview with the Director of Nursing (DON) on 11/25/19 at 3:18 PM, revealed they had audited residents, looking at meal intakes, from 10/10/19 through 10/16/19. She stated they did identify one (1) resident and the physician was notified by fax. 8. The binder included evidence of education by the DON and the Director of Clinical Services on 11/19/19 by way of a sign-in sheet by licensed staff. This in-service was offered two times on 11/19/19. The AOC evidence revealed the agenda of the in-service was: Meals, [MED] and Diabetic Log; [DIAGNOSES REDACTED] and [MEDICAL CONDITION]; Diabetes Management Skills Checklist; Change in Resident's Condition and MD notification; Resident/Family/Responsible Party concern/Grievance Program; Resident Change in Condition System; Observing, Recording and Reporting; Communication Books for Aides; and STOP and WATCH. Interview with SRNA #1 on 11/25/19 at 2:35 PM, SRNA #2 at 2:20 PM, and SRNA #3 at 2:05 PM, revealed they had been educated on the initiation of walking rounds for the aides. These rounds were to occur at shift change between the offgoing and the oncoming aides. Both shifts would walk the unit and observe the residents while discussing any changes or needs. They also stated any changes were documented in the communication book. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM revealed they received education on 11/19/19 related to resident change in conditions, monitoring the meal intakes of residents, and in particular residents who received [MED]. They also revealed they received education related to the Communication for the aides, which included the walking rounds for the aides as well as the nurses. Interview with the DON on 11/15/19 at 3:18 PM and the Director of Clinical Services on 11/25/19 at 3:33 PM, revealed they had provided education to the licensed staff regarding change in conditions, monitoring of meal intake for all residents, monitoring of [MED] dependent residents to ensure adequate food intake prior to [MED] administration, walking rounds, and the use of the communication book for the aide. 9. Review of documentation revealed evidence of the QAPI meeting on [DATE] and revealed a sign-in sheet with attendees, including the DON, Unit Managers, Registered Dietitian, Administrator, and Director of Clinical Services. The Medical Director was informed by phone. Interviews with Unit Manager #1 on 11/26/19 at 2:51 PM, the DON at 3:18 PM, and the Administrator at 3:33 PM, revealed all were in attendance at the QAPI meeting on [DATE]. They stated the Immediate Jeopardy components were discussed and an action plan was initiated. 10. Review of the 24-hour report sheets, from each nurses' station, revealed that each had the statement reviewed and signature of the unit manager on each one. The copies were dated 10/17/19 through 11/25/19. Attached to each day was the daily meeting sign-in sheet as well as copies of the physician and responsible party notifications for any changes. The nurse note documentation related to the changes was also copied and attached for review. There was evidence of weekend 24-hour reports and documentation of having reviewed on Mondays as well. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they continue to review the 24-hour report sheets daily. All stated they reviewed the reports in the morning for the previous day. If the report had a resident list, they would then check the record for nursing documentation regarding the assessment and for physician and responsible party notification. They also stated the weekend reports were reviewed on Monday morning. Interview with the Registered Dietitian (RD) on 11/26/19 at 3:20 PM, revealed monitoring of any changes in food/fluid intake and monitoring those residents receiving [MED] for food intake and MD notification if required for insufficient meal intake. Interview with the DON on 11/26/19 at 3:18 PM, revealed ongoing monitoring every morning, Monday through Friday, for residents with changes in condition and/or changes in food/fluid intake. She stated this monitoring included the auditing of the record to ensure documentation in nursing notes and notification of physician and family as required. 11. Review of audits revealed the DON had audited a resident with changes in condition on [DATE]. Included in the evidence was a copy of the nurse note documentation with assessment noted and a Situation, Background, Assessment, and Recommendation (SBAR) note. The evidence also included evidence of notification to the physician and family. Interview with the DON on 11/25/19 at 3:18 PM, revealed she would continue the audit of a resident with changes in condition two (2) times a month for two (2) months, and then one (1) time a month for two (2) months. Review of a Quality Assurance (QA) tool on Notification of Change, dated [DATE], was completed on five (5) residents for week one (1). The QA tool, dated 10/22/19 and 10/23/19, revealed ten (10) residents were audited. All audits were at 100% compliance. The audits were completed by the unit managers. Interview with the DON on 11/25/19 at 3:18 PM, revealed the unit managers are performing the QA audits for Notification of Change. She further stated the audits revealed instances where the physician had been notified and the process was going well. 12. The AOC information included evidence of the diabetic/[MED] administration forms initiated 11/15/19 and revised 11/19/19. The forms are signed by the unit managers to indicate they had been reviewed. Interview with Unit Manager #1 on 11/26/19 at 2:51 PM, and Unit Manager #3 at 3:08 PM, revealed they continue to review diabetic/[MED] administration logs in the mornings, prior to the morning clinical meeting. They stated information from the reviews are discussed in the meeting. The binder also included the QAPI tool, Diabetic Management, which revealed six (6) residents were audited on [DATE] and six (6) residents on 11/20/19. Both audits revealed 100% compliance. Interview with the DON on 11/25/19 at 3:18 PM, revealed she oversees audits for QA. She stated the unit managers are completing the audit tools, Notification of Change and Diabetes Management. She further stated audit results are discussed in daily morning meetings as well as the 24-hour change reviews, the nutrition alerts, [MED] administration records, and STOP and WATCH forms.

Based on interview, record review, and review of facility policy it was determined the facility failed to have an effective system to implement the care plan for one (1) of three (3) sampled residents (Resident #1). The facility developed a care plan for Resident #1 that required staff to assess any sedation, drowsiness, [MEDICAL CONDITIONS](fast heart rate), or loss of appetite, and to assess the resident for signs and symptoms of dehydration (dry oral mucosa, poor skin turgor, decreased urinary output, and change in urinary appearance) with daily care. The care plan also directed staff to notify the resident's physician if indicated. Staff interview revealed on 09/13/19, Resident #1 ate only two snacks and consumed only 9[AGE] milliliters (ml) of fluids, and was groggy; however, there was no documented evidence the facility assessed the resident and notified the resident's physician as required by the resident's care plan. On 09/14/19, staff was unable to wake the resident for breakfast and lunch, and the resident had no urinary output after 12:05 AM. Record review revealed there was no documented evidence the facility assessed the resident and notified the resident's physician as required by the resident's care plan. On 09/14/19 at approximately 2:25 PM, the resident's sister visited the facility and alerted staff that the resident was unresponsive. Residents #1's physician was contacted, the resident was transferred to the hospital, and was admitted with [DIAGNOSES REDACTED]. The facility's failure to ensure resident care plans were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/15/19 and was determined to exist on 09/13/19. The facility was notified of the Immediate Jeopardy on 11/15/19. An acceptable Allegation of Compliance was received on 11/24/19, which alleged removal of the Immediate Jeopardy on 11/21/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 11/21/19, prior to exit on 11/26/19, which lowered the scope and severity to D level while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Development of a Care Plan, not dated, revealed care plans were developed by the interdisciplinary team and the interventions listed on the care plans should be consistently implemented as documented. Review of the facility's Hydration Policy and Procedure, not dated, revealed if a resident was deemed at high risk for dehydration, the care plan would be developed and implemented by the Interdisciplinary Team (IDT) to correct the condition. To evaluate and measure hydration status, intake/output would be measured for patients at high risk and residents would be monitored for signs/symptoms of dehydration. Review of Resident #1's medical record revealed the facility admitted the resident on 08/30/18 with [DIAGNOSES REDACTED]. Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two (2) staff members with bed mobility and extensive assistance of one (1) staff member when eating, and was cognitively impaired. Resident #1's care plan, dated 08/30/18, revealed the facility identified that the resident had a potential for alteration in nutrition and hydration status due to multiple risk factors which included requiring assistance with eating, a mechanically altered diet, advanced dementia, and diabetes that required routine and sliding scale [MED]. The facility's goal was for the resident to meet nutritional and hydration needs, with no signs or symptoms of alteration in hydration status. The facility developed interventions that included encouraging the resident to eat/drink [AGE]-100% of foods and fluids, monitoring and recording food intake at each meal, observing for signs and symptoms of alteration in hydration status with daily caregiving, e.g., dry oral mucosa, poor skin turgor, decreased urinary output, change in urinary appearance, and notifying the resident's physician as indicated. Continued review of Resident #1's comprehensive care plan, dated 08/30/18, revealed the facility identified that the resident had the potential for adverse drug effects because the resident received routine [MEDICAL CONDITION] medications. Staff were required to observe Resident #1 for adverse drug effects such as sedation, drowsiness, [MEDICAL CONDITIONS](fast heart rate), and loss of appetite, and were directed to notify the physician as indicated. Interview with the Unit Manager on 11/14/19 at 2:53 PM revealed Resident #1's care plan interventions required staff to notify MD (the physician) as indicated, which meant staff were required to notify the resident's physician of any change, e.g., change in food intake, mood, behaviors, etc. Continued review of Resident #1's medical record revealed that according to the resident's Meal and Snack Consumption record for 09/13/19, the resident did not eat anything for the breakfast or evening meal, ate only 0-25% for lunch and two snacks, and only consumed 9[AGE] ml of fluid. However, there was no documented evidence staff observed the resident for signs and symptoms of alteration in hydration status (dry oral mucosa, poor skin turgor, decreased urinary output, or change in urinary appearance) and notified the resident's physician as indicated as required by the resident's care plan. Resident #1's consumption record further revealed the resident refused breakfast and the noon meal on 09/14/19 and only consumed 1[AGE] ml of fluid. In addition, review of the Bladder Continence form revealed Resident #1 had decreased urinary output on 09/14/19. Per the report, the resident had no urinary output on 09/14/19 after 12:05 AM. Again, there was no documented evidence the facility observed the resident for signs and symptoms of alteration in hydration status and notified the resident's physician as indicated. Interview with State Registered Nurse Aide (SRNA) #2 on 09/27/19 at 11:40 AM, revealed that Resident #1 refused breakfast on 09/13/19 and that the resident slept most of the shift. She stated she reported the change in the resident's condition to LPN #1. SRNA #2 stated that on the next morning, 09/14/19, she could not wake the resident for breakfast at approximately 7:30 AM and again reported the change in the resident's condition to LPN #1. Interview with SRNA #4 on 09/27/19 at 11:30 AM, revealed even though she documented that the resident consumed 0-25% of the lunch meal on 09/13/19, the resident only drank milk. SRNA #4 stated she reported to a nurse that the resident did not eat, but was unable to recall whom. Interview with SRNA #3 on 09/28/19 at 11:10 AM, revealed she reported a change in Resident #1's condition to LPN #1 when the resident was observed to not be his/her normal self and was definitely different when she attempted to assist the resident with breakfast on 09/14/19. SRNA #3 also stated Resident #1 was unable to be aroused for the lunch meal on 09/14/19 at approximately 1:00 PM and LPN #1 was notified. The SRNA stated she observed LPN #1 do a chest rub on the resident; however, the resident only responded by opening his/her eyes and the resident made a soft noise. SRNA #3 stated LPN #1 was not observed to obtain vital signs or conduct any further assessment of the resident on 09/14/19. Continued review of Resident #1's medical record revealed no documented evidence the facility assessed the resident's sedation, drowsiness, [MEDICAL CONDITIONS](fast heart rate), or loss of appetite as required by the resident's care plan; and no evidence the facility assessed the resident for signs and symptoms of alteration in hydration status (dry oral mucosa, poor skin turgor, decreased urinary output, change in urinary appearance) as required by the resident's care plan. Subsequently, there was no documented evidence the facility notified the resident's physician. Interview with LPN #1 on 09/27/19 at 2:20 PM, revealed staff had informed her that Resident #1 refused to eat on 09/13/19 and was groggy. In addition, LPN #1 confirmed that staff was unable to wake Resident #1 for breakfast on 09/14/19. Further interview revealed she also confirmed that staff reported that they were unable to wake Resident #1 for the lunch meal on 09/14/19. LPN #1 stated she recalled looking at the resident at lunch and the resident was still groggy but because the resident would still respond, she conducted no further assessment. According to LPN #1, nurses had not been trained to monitor residents for adverse side effects of [MEDICAL CONDITION] medication use in the facility. Further, the LPN acknowledged she did not inform the oncoming shift or the resident's physician of the change in Resident #1's condition per the plan of care. Review of Resident #1's Progress Notes dated 09/14/19 at 2:25 PM revealed Registered Nurse (RN) #1 documented that the resident's sister reported that the resident was unresponsive. According to the note, RN #1 assessed the resident as pale and clammy and the resident's eyes remained closed upon verbal and physical stimuli. RN #1 documented that the resident's heart rate was 122 (normal range [AGE]-100), respiratory rate was 35 (normal range 12-24), blood pressure was [AGE]/42 (normal range 120/[AGE]), oxygen saturation was [AGE]% (normal range 95%-100%) on room air, and blood glucose level was 319 (normal range [AGE]-130). RN #1's documentation further revealed Resident #1's physician was notified of the change in his/her condition at 2:45 PM and the resident was transferred to the hospital via Emergency Medical Services (E[CONDITION]) at 3:12 PM. Review of a hospital record revealed Resident #1 arrived at the hospital's Emergency Department (ED) on 09/14/19 at approximately 3:40 PM, not moving and nonresponsive with slight moan to sternal rub. On arrival, the resident's blood pressure was 68/38 (normal range 120/[AGE]) and his/her respiratory rate was 43 (normal range 12-24). Further review revealed upon arrival Resident #1's blood urea nitrogen (BUN) level (kidney function test) was 181 (normal range 8-26) and his/her creatinine level (kidney function test) was 6.[AGE] (normal range .[AGE]-1.30). Resident #1's hospital lab results also revealed his/her [MED] level was elevated (an electrolyte that can indicate dehydration) at 163 (normal range 136-144). Further review of the hospital record revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Interview with the Administrator on 10/01/19 at 4:20 PM, revealed staff was expected to follow a resident's plan of care and was expected to notify the resident's physician and family when changes in condition occurred. *The facility alleged the following removed Immediate Jeopardy on 11/21/19: 1. The attending physician and resident representative for Resident #1 were notified of the need to transfer the resident to the hospital on [DATE]. Resident #1 is no longer at the facility. 2. The 24 hour report sheets, from 09/15/19 to 10/15/19, were reviewed by the Director of Nursing (DON) and Unit Managers on 10/17/19 and [DATE]. 3. Residents with reduced food/fluid intake for the last seven (7) days were reviewed by the Director of Nursing (DON), Registered Dietitian (RD), and Unit Managers on 10/17/19 to identify any residents who demonstrated a change in condition. All residents demonstrating a change in condition had documentation of Physician/Advanced Practice Registered Nurse (APRN) notification in accordance with their care plans. For all residents demonstrating a change in condition, the documentation (which included the nursing notes and assessments) was audited to determine that the Physician/APRN were notified and responded timely to the notification with follow-up orders. 4. Facility licensed nursing staff have received in-service education by the Director of Nursing and Director of Clinical Services, completed on 10/17/19 and 10/22/19. Any staff that did not complete the in-service education by this date have been locked out of the time clock and cannot begin working their next shift until the in-service is completed with the DON. This education included but was not limited to: a. The definition of changes in resident condition, the need to assess the resident immediately, and report these to the attending Physician/APRN immediately in accordance with the resident care plans. b. The facility policy on notification of resident changes and the need to fully inform the Physician and Resident Representative of the assessment findings, complete the follow-up monitoring, and implement all Physician orders. c. Review for decreased food/fluid intake in the facility computer system. d. Review of the Interact STOP and WATCH program for all staff, which directs/prompts reporting any change of condition to the licensed nurse, and the need for the licensed nurse to assess the resident immediately. STOP and WATCH was covered in the in-service education on 10/17/19 for all staff, and for licensed nurses on 10/22/19. The Interact Stop and Watch forms will be used by all staff to identify/document any observed resident changes in condition. These forms are in Duplicate, with a copy being given to the licensed nurse to direct/prompt an immediate assessment, and then the copy will be placed in the unit Communication Book for review with the shift reports between shifts. The Second copy will then be turned in to the DON for monitoring, and the Director of Nursing Copy will be used for review by the DON, Unit Managers, and RD in their daily meetings during the week, and on Monday for the weekends. 5. A Specific Diabetic HS (bedtime) Snack Task for all residents who are receiving [MED] was initiated on [DATE] to further clarify meal (supplement) intake records for the residents with orders for [MED] and to alert staff if Diabetic HS Snack intake was less than 50%. 6. A Diabetic Log was initiated on 11/15/19 (and revised on 11/19/19) of meal/HS Snack intake for the residents with orders for [MED] to determine that their meal/alternative meal/supplement intake was greater than 50%. If the resident's meal/alternative/supplement intake was less than 50%, the log prompts the licensed nurse to assess the resident, and to notify the Physician prior to their [MED] administration. 7. The last three days of meal intake records for the residents with orders for [MED] were reviewed to determine that their meal/supplement intake was greater than 50% prior to their [MED] administration. This was completed on [DATE] by the RD, DON, Unit Managers, and Director of Clinical Services. 8. All licensed nurses have received in-service education by the DON and Director of Clinical Services on the following, completed on 11/19/19. Any staff that did not complete the in-service education by this date have been locked out of the time clock and cannot begin working their next shift until the in-service and competencies are completed with the Director of Nursing: a. the need to review resident food/fluid intake prior to administering any ordered [MED] and assess the resident. b. the need to hold the [MED], assess the resident, and notify the physician if the resident's meal intake was less than 50% for the meal prior to the glucose reading. c. the use of the meal intake and assessment of the resident prior to [MED] administration record for documentation of verification of the above information. d. Review of the Interact STOP and WATCH program for all staff, which directs/prompts the reporting of any change of condition to the licensed nurse, and the need for the licensed nurse to assess the resident immediately. 9. A Quality Assurance Performance Improvement (QAPI) meeting was conducted on [DATE] by the facility QAPI committee with the Medical Director to review the survey findings, this Allegation of Compliance, and the findings of the audits and currently completed QAPI tools. 10. The Director of Nursing, Registered Dietitian, and Unit Managers are reviewing all Physician orders [REDACTED]. They are then reviewing the nursing documentation (which includes the nursing notes and assessments) to determine that Physician/APRN and Resident Representative notification was completed timely, and follow-up orders obtained and implemented. Walking rounds with shift changes were initiated for the charge nurses and State Registered Nurse Aides (SRNA) to identify any residents with changes in condition. Any changes identified are to be reported immediately, Unit Managers are to follow up on any changes of condition, and report to daily meeting during the week, and the Monday Meeting for the weekend. 11. The Director of Nursing will choose one (1) resident identified with changes in status and reassess to determine that original findings were accurate. The QAPI tool for the monitoring of compliance with identification, assessment of the resident, and the QAPI tool for the monitoring of compliance with identification and notification of resident changes in condition will be utilized weekly for 2 weeks, then monthly for 2 months, and then quarterly by the Director of Nursing. Failure to meet the established 100% threshold will result in the development of an action plan. The results of the completed QAPI tools and any indicated action plans will be reviewed in the QAPI committee meetings. 12. The DON, RD, and Unit Managers are reviewing the [MED] administration forms daily during the week and on Monday for the weekends to determine that licensed nurses are reviewing resident meal/fluid intake prior to administration of any ordered [MED], and are holding the [MED], assessing the resident, and notifying the MD if the resident's meal intake is less than 50% for the meal prior to the glucose reading. The QAPI tool for the monitoring of meal intake prior to [MED] administration will be utilized weekly for 2 weeks, monthly for 2 months, and then quarterly thereafter by the Director of Nursing. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on 11/21/19, as alleged by the facility: 1. Resident #1 no longer resides in the facility after transfer to the hospital on [DATE] per physician order. 2. The Allegation of Compliance (AOC) binder revealed evidence of review of the 24-hour report sheets, dated 09/15/19 through 10/15/19. The binder also revealed evidence of documentation of physician notification of any changes in resident status as well as nurse documentation of changes. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the 24-hour report sheets from 09/15/19 to 10/15/19 to ensure physician and responsible party notification as required. Interview with the Director of Nursing on 11/25/19 at 3:18 PM, revealed on 10/17/19 and [DATE] she, along with the unit managers, reviewed the 24-hour report sheets dated 09/15/19 through 10/15/19 for physician and responsible party notification. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the 24-hour report sheets from 09/15/19 to 10/15/19 to ensure physician and responsible party notification as required. Interview with the Director of Nursing on 11/25/19 at 3:18 PM, revealed on 10/17/19 and [DATE] she, along with the unit managers, reviewed the 24-hour report sheets dated 09/15/19 through 10/15/19 for physician and responsible party notification. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the residents for decreased intake for dates of 10/10/19 through 10/16/19. The Unit Managers also revealed how the Stop and Watch forms were to be used, explaining that a copy was given to the nurse for immediate assessment and the other copy would go to the DON. They also stated the form could be completed by any staff or even family member. 3. The binder contained a printed report titled Clinical and Alert Listing Report, dated 10/10/19 through 10/16/19. The report revealed meal intake percentages of all residents in the facility. The information noted one (1) resident was identified as having refused two (2) meals on 10/13/19 and only 25% of the other meal was consumed. There was evidence of communication to the physician, by fax, of the resident's intake and the physician reply of OK. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the residents for decreased intake for dates of 10/10/19 through 10/16/19. Interview with the Director of Nursing (DON) on 11/25/19 at 3:18 PM, revealed they had audited residents, looking at meal intakes, from 10/10/19 through 10/16/19. She stated they did identify one (1) resident and the physician was notified by fax. Interview with the Registered Dietitian on 11/26/19 at 3:20 PM, revealed staff had audited residents for reduced food/fluid intakes over a seven (7) day period. 4. The AOC binder had evidence of staff sign-in sheets dated 10/17/19 and 10/22/19 with total staff attendance. The evidence included a sign-in sheet for all staff on 10/17/19 and licensed staff on 10/22/19. The evidence also included the topics educated on which included: Changes in a Resident's Condition or Status Policy; Nutrition/Fluid Task and Alert Review; Facility policy on notification of resident changes; and STOP and WATCH by Interact. Interview with the Director of Clinical Services on 11/25/19 at 3:33 PM, revealed he had provided education on 10/17/19 and 10/22/19 on the changes in resident condition policy to include reporting and documentation of changes. He further stated he also provided education to the staff on food/fluid task alert task. Interview with the DON on 11/25/19 at 3:18 PM, revealed she provided education to the staff on STOP and WATCH forms and how to use, change in resident condition policy and procedure, and how to review for decreased food/fluid intake in the computer system. Interview with State Registered Nurse Aide (SRNA) #1 on 11/25/19 at 2:35 PM, SRNA #2 at 2:20 PM, and SRNA #3 at 2:05 PM, revealed they had received education regarding changes in a resident's condition, how to use the STOP and WATCH form, and the new Nutrition/Fluid task alert task. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed education had been provided to them on the Changes in a Resident's Condition, the policy regarding notification of physician and family regarding change in condition, the STOP and WATCH form, and Nutrition/Fluid alert task in the SRNA's documentation. 5. Review of documentation for the AOC revealed the HS snack task was a computer-based task for aides to complete. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, revealed the Diabetic HS Snack Task was a tool placed on the Kiosk. This is the documentation system for the aides. This must be answered at the end of every shift. Interview with Unit Manager #1 on 11/26/19 at 2:51 PM, revealed the Diabetic HS Snack Task is on the kiosk for the aides to complete. She further stated the task must be completed prior to the aide ending their shift. 6. Review of documentation revealed a diabetic completed log for the dates of 11/15/19 to 11/21/19 for all residents on [MED]. There was also evidence of a revision of the log on 11/19/19. A revised log, dated 11/19/19 through 11/24/19, was completed for all residents on [MED]. Interviews with Unit Manager #1 on 11/26/19 at 2:51 PM and Unit Manager #3 at 3:08 PM, revealed they complete the diabetic log tool every morning, Monday through Friday, prior to attendance of the morning clinical meeting. Interview with the DON on 11/26/19 at 3:18 PM, revealed the unit managers are performing the audit tools, Resident Change of Condition, and Diabetic Management Log. 7. Review of documentation revealed evidence of a review of residents who received [MED] the last three (3) days of meal intake. The review was completed by the DON, Unit Managers #1, #2, and #3, and the RD on [DATE]. Interview with Unit Manager #1 on 11/26/19 at 2:51 PM, revealed a three (3) day lookback of residents on [MED] was performed. The binder also included the QAPI tool, Diabetic Management, which revealed six (6) residents audited on [DATE] and six (6) on 11/20/19. Both audits revealed 100% compliance. Interview with the Director of Nursing (DON) on 11/25/19 at 3:18 PM, revealed they had audited residents, looking at meal intakes, from 10/10/19 through 10/16/19. She stated they did identify one (1) resident and the physician was notified by fax. 8. The binder included evidence of education by the DON and the Director of Clinical Services on 11/19/19 by way of a sign-in sheet by licensed staff. This in-service was offered two times on 11/19/19. The AOC evidence revealed the agenda of the in-service was: Meals, [MED] and Diabetic Log; [DIAGNOSES REDACTED] and [MEDICAL CONDITION]; Diabetes Management Skills Checklist; Change in Resident's Condition and MD notification; Resident/Family/Responsible Party concern/Grievance Program; Resident Change in Condition System; Observing, Recording and Reporting; Communication Books for Aides; and STOP and WATCH. Interview with SRNA #1 on 11/25/19 at 2:35 PM, SRNA #2 at 2:20 PM, and SRNA #3 at 2:05 PM, revealed they had been educated on the initiation of walking rounds for the aides. These rounds were to occur at shift change between the offgoing and the oncoming aides. Both shifts would walk the unit and observe the residents while discussing any changes or needs. They also stated any changes were documented in the communication book. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM revealed they received education on 11/19/19 related to resident change in conditions, monitoring the meal intakes of residents, and in particular residents who received [MED]. They also revealed they received education related to the Communication for the aides, which included the walking rounds for the aides as well as the nurses. Interview with the DON on 11/15/19 at 3:18 PM and the Director of Clinical Services on 11/25/19 at 3:33 PM, revealed they had provided education to the licensed staff regarding change in conditions, monitoring of meal intake for all residents, monitoring of [MED] dependent residents to ensure adequate food intake prior to [MED] administration, walking rounds, and the use of the communication book for the aide. 9. Review of documentation revealed evidence of the QAPI meeting on [DATE] and revealed a sign-in sheet with attendees, including the DON, Unit Managers, Registered Dietitian, Administrator, and Director of Clinical Services. The Medical Director was informed by phone. Interviews with Unit Manager #1 on 11/26/19 at 2:51 PM, the DON at 3:18 PM, and the Administrator at 3:33 PM, revealed all were in attendance at the QAPI meeting on [DATE]. They stated the Immediate Jeopardy components were discussed and an action plan was initiated. 10. Review of the 24-hour report sheets, from each nurses' station, revealed that each had the statement reviewed and signature of the unit manager on each one. The copies were dated 10/17/19 through 11/25/19. Attached to each day was the daily meeting sign-in sheet as well as copies of the physician and responsible party notifications for any changes. The nurse note documentation related to the changes was also copied and attached for review. There was evidence of weekend 24-hour reports and documentation of having reviewed on Mondays as well. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they continue to review the 24-hour report sheets daily. All stated they reviewed the reports in the morning for the previous day. If the report had a resident list, they would then check the record for nursing documentation regarding the assessment and for physician and responsible party notification. They also stated the weekend reports were reviewed on Monday morning. Interview with the Registered Dietitian (RD) on 11/26/19 at 3:20 PM, revealed monitoring of any changes in food/fluid intake and monitoring those residents receiving [MED] for food intake and MD notification if required for insufficient meal intake. Interview with the DON on 11/26/19 at 3:18 PM, revealed ongoing monitoring every morning, Monday through Friday, for residents with changes in condition and/or changes in food/fluid intake. She stated this monitoring included the auditing of the record to ensure documentation in nursing notes and notification of physician and family as required. 11. Review of audits revealed the DON had audited a resident with changes in condition on [DATE]. Included in the evidence was a copy of the nurse note documentation with assessment noted and a Situation, Background, Assessment, and Recommendation (SBAR) note. The evidence also included evidence of notification to the physician and family. Interview with the DON on 11/25/19 at 3:18 PM, revealed she would continue the audit of a resident with changes in condition two (2) times a month for two (2) months, and then one (1) time a month for two (2) months. Review of a Quality Assurance (QA) tool on Notification of Change, dated [DATE], was completed on five (5) residents for week one (1). The QA tool, dated 10/22/19 and 10/23/19, revealed ten (10) residents were audited. All audits were at 100% compliance. The audits were completed by the unit managers. Interview with the DON on 11/25/19 at 3:18 PM, revealed the unit managers are performing the QA audits for Notification of Change. She further stated the audits revealed instances where the physician had been notified and the process was going well. 12. The AOC information included evidence of the diabetic/[MED] administration forms initiated 11/15/19 and revised 11/19/19. The forms are signed by the unit managers to indicate they had been reviewed. Interview with Unit Manager #1 on 11/26/19 at 2:51 PM, and Unit Manager #3 at 3:08 PM, revealed they continue to review diabetic/[MED] administration logs in the mornings, prior to the morning clinical meeting. They stated information from the reviews are discussed in the meeting. The binder also included the QAPI tool, Diabetic Management, which revealed six (6) residents were audited on [DATE] and six (6) residents on 11/20/19. Both audits revealed 100% compliance. Interview with the DON on 11/25/19 at 3:18 PM, revealed she oversees audits for QA. She stated the unit managers are completing the audit tools, Notification of Change and Diabetes Management. She further stated audit results are discussed in daily morning meetings as well as the 24-hour change reviews, the nutrition alerts, [MED] administration records, and STOP and WATCH forms.

Based on interview, record review, and a review of facility policies, it was determined the facility failed to have an effective system to provide care and services when a change in condition occurred for one (1) of three (3) sampled residents (Resident #1). Resident #1 had decreased food/fluid intake on 09/13/19; however, the facility failed to identify the change in the resident and assess the resident's hydration status. On 09/14/19, staff were unable to wake the resident at approximately 7:30 AM for breakfast, nor at approximately 1:00 PM for lunch. In addition, the resident did not have any urinary output after 12:05 AM on 09/14/19. However, the facility failed to assess the resident's condition. Interviews with staff revealed at approximately 1:00 PM, Licensed Practical Nurse (LPN) #1 was observed to do a chest rub (a sternal rub consists of taking a fist and applying firm, direct, rotating pressure with the knuckles of one hand over the sternum to see if an individual responds to pain) and wash the resident's face. Staff stated the resident's only response was to make a soft noise and open his/her eyes; however, there was no documented evidence the LPN conducted any further assessment of the resident. In addition, the facility continued to administer [MED] to the resident on 09/13/19 and 09/14/19, even though the resident failed to eat any meals on either day. The facility failed to assess Resident #1 until 2:25 PM on 09/14/19 after the resident's family visited and found the resident unresponsive. Staff then assessed the resident and found the resident was pale and clammy, with abnormal vital signs. Resident #1 was transferred to a local hospital and admitted with [DIAGNOSES REDACTED]. The facility's failure to ensure residents were assessed when a change in condition occurred has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/15/19 and was determined to exist on 09/13/19. The facility was notified of the Immediate Jeopardy on 11/15/19. An acceptable Allegation of Compliance was received on 11/24/19, which alleged removal of the Immediate Jeopardy on 11/21/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 11/21/19, prior to exit on 11/26/19, which lowered the scope and severity to D level while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Administrator on 11/13/19 at 4:40 PM, revealed the facility did not have a policy related to resident assessment. Review of the facility's policy/process titled Hydration Alert, not dated, revealed all residents should be monitored for adequate fluid intake to prevent dehydration. The policy also stated all residents' daily fluid intake, as well as their food consumption records, would be entered in the Electronic Health Record (EHR) daily. According to the policy, meal totals and the daily amount of liquids consumed by the resident were calculated in the EHR system and the system should trigger alerts to staff when fluid or food intake was inadequate. According to the policy, nursing personnel would monitor daily for signs and symptoms associated with dehydration, including dry oral mucosa, concentrated urine/decreased urinary output, and lethargy. Review of the Manufacturer's specifications for [MEDICATION NAME] [MED] (rapid acting [MED] that starts to work in 15 minutes and peaks in one (1) hour) revealed the medication should be administered 5-10 minutes before a meal. Per the medication specifications, the dosage of the [MED] should be adjusted if there was a change in meal patterns, including a change in food intake. Review of Resident #1's medical record revealed the facility admitted the resident on 08/30/18 with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two (2) staff members with bed mobility and extensive assistance of one (1) staff member when eating. Further review revealed Resident #1's cognitive skills were severely impaired and a Brief Interview for Mental Status (BI[CONDITION]) was not conducted, which indicated Resident #1 was not interviewable. Resident #1's care plan, dated 08/30/18, revealed the facility identified that the resident had a potential for alteration in nutrition and hydration status due to multiple risk factors which included requiring assistance with eating, a mechanically altered diet, advanced dementia, and diabetes that required routine and sliding scale [MED]. The facility's goal was for the resident to meet nutritional and hydration needs, with no signs or symptoms of alteration in hydration status. The facility developed interventions that included encouraging the resident to eat/drink [AGE]-100% of foods and fluids, monitoring and recording food intake at each meal, observing for signs and symptoms of alteration in hydration status with daily caregiving, e.g., dry oral mucosa, poor skin turgor, decreased urinary output, change in urinary appearance, and notifying the resident's physician as indicated. Review of Resident #1's Nutritional Risk assessment dated [DATE] revealed the resident was assessed to require more than 1,500 milliliters (ml) of fluid daily. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Meal and Snack Consumption record dated September 2019 revealed the resident did not eat the breakfast meal or evening meal on 09/13/19, and only ate 0-25% of the noon meal. However, interview with State Registered Nurse Aide (SRNA) #4 on 09/27/19 at 11:30 AM, revealed she documented that the resident ate 0-25% of the noon meal, but the resident only consumed milk. Resident #1's record further revealed the resident ate two snacks, but only consumed 9[AGE] ml of fluids on 09/13/19. Interview with SRNA #2 on 09/27/19 at 11:40 AM, revealed Resident #1 did not eat breakfast on 09/13/19 and slept most of the shift. The SRNA stated she reported the resident's meal refusal and that the resident seemed more sleepy to LPN #1. Interview with SRNA #4 on 09/27/19 at 11:30 AM, revealed she reported that the resident only drank milk for the noon meal on 09/13/19 to a nurse, but was unable to recall whom. Interview with LPN #1 on 09/27/19 at 2:20 PM, revealed she recalled someone telling her that Resident #1 refused to eat on 09/13/19; however, she was unable to recall the details. However, a review of Resident #1's Progress Notes revealed no entries were made on 09/13/19, and there was no documented evidence in the resident's medical record that the facility identified that the resident had poor food and fluid intake on 09/13/19, nor assessed the resident for signs and symptoms of dehydration as required by the facility's Hydration Alert Policy. In addition, review of the Blood Sugar Record for Resident #1 revealed the resident's finger stick blood sugar on 09/13/19 at 4:00 PM was 215 (normal fasting blood sugar is 70-100 and normal blood sugar three hours after eating is 120-140), and the resident received four (4) units of [MEDICATION NAME] [MED] subcutaneous. At 8:00 PM on 09/13/19, the resident received six (6) units of [MEDICATION NAME] [MED] for a finger stick blood sugar reading of 250, even though the resident did not eat a meal. Interview with [ENTITY] #1 on 09/26/19 at 9:30 PM, revealed she administered Resident #1's medications on the day shift of 09/13/19. The [ENTITY] stated Resident #1 was sleepier and groggy during the morning med pass and spit some of his/her medications out. However, the [ENTITY] did not report the resident's behavior to the nurse because she did not feel it was unusual behavior. Interview with LPN #2 on 09/29/19 at 5:10 PM and on 11/13/19 at 11:59 PM, revealed she worked the night shift at the facility and stated night shift nurses were responsible for monitoring residents' food and fluid intake every night to ensure residents were meeting their needs. LPN #2 stated she worked the night of 09/13/19; however, she did not identify that Resident #1 had decreased intake or that the resident had not met his/her estimated fluid needs for that day. Further, the LPN stated no one communicated to her that the resident had not eaten/drunk well on 09/13/19. LPN #2 stated Resident #1 was normally agitated, but was quiet, rested, and had one of the best nights during the night shift that started on 09/13/19 at 10:00 PM. According to the LPN, even though the resident was normally agitated, she did not recognize or assess the resident for a change in condition when the resident rested all night. Continued review of Resident #1's Meal and Snack Consumption record revealed the resident did not consume anything for breakfast nor for the noon meal on 09/14/19, and only consumed 1[AGE] ml of fluid. Further review of Resident #1's medical record revealed no documented evidence that the facility had identified that Resident #1 was a hydration alert per the facility policy, nor was there evidence the facility had assessed the resident's nutrition or hydration status based on the resident's decreased intake of food and fluids. Interview with the Registered Dietitian (RD) on 09/27/19 at 1:15 PM, revealed staff was required to monitor resident meal intake and monitor to ensure they were meeting their estimated fluid needs daily. The RD stated when physicians were notified of hydration concerns for residents, they typically ordered laboratory testing, increased the resident's fluids, or implemented some type of intervention. She also stated when residents failed to meet their estimated fluid needs, a hydration alert should trigger in the facility's computer system, which would have indicated the need for a hydration assessment to be completed by nursing staff. Interview with the Director of Nursing (DON) on 10/01/19 at 1:25 PM and on 11/14/19 at 11:25 AM, revealed nurses were expected to monitor residents' hydration status on a nightly basis. The DON stated for any resident who had not met their estimated fluid needs for the previous 24 hours, or had not had adequate food intake the day before, staff should document the concern on the 24-hour report sheet. She stated a hydration alert should also populate on the computer, which should alert staff that an assessment was needed. The DON stated after the State Agency began an investigation, she reviewed Resident #1's medical record and confirmed that based on the resident's meal intake and fluid consumption, a hydration alert should have popped up on the computer and staff should have documented the alert on the 24-hour report. Then, day shift nurses would have known that the resident had not met his/her estimated fluid needs and assessed the resident. However, according to the DON, the alert never showed up for Resident #1. Review of Resident #1's Bladder Function Record, dated 09/14/19, revealed the resident had no urine output after 12:05 AM on 09/14/19. Staff documented at 12:05 AM that the resident had urinated three (3) times. However, further review revealed staff documented at 1:07 PM that the resident had not had any urine output. Interview with SRNA #3 on 11/13/19 at 12:20 PM revealed she cared for Resident #1 on 09/14/19 on the dayshift and did not remember the resident having any urine incontinence episodes. Further review of Resident #1's Progress Notes revealed on 09/14/19 at 8:00 AM, the Unit Manager (UM) documented that pain medication was administered to the resident due to increased facial grimacing/moaning and rubbing/guarding (left) arm. According to the note, the resident took the medication without difficulty and there were no signs or symptoms of distress. At 8:45 AM on 09/14/19, the UM documented that Resident #1 was resting in bed with no signs or symptoms of pain and no facial grimacing noted. Interview with Unit Manager on 09/27/19 at 10:30 AM, on 11/13/19 at 12:55 PM, and on 11/14/19 at 2:53 PM, revealed she administered medications to Resident #1 on 09/14/19 because there was no medication aide available. She stated Resident #1 exhibited signs of pain at approximately 8:00 AM and she administered pain medication to the resident, but stated she did not identify any change in the resident's condition at that time. Continued review of Resident #1's Blood Sugar Record revealed on 09/14/19, at 11:00 AM, Resident #1 received eight (8) units of [MEDICATION NAME]for a blood sugar reading of 264, even though this was the second day that the resident had not eaten well and had not consumed the required amount of fluids. Further interview with Unit Manager on 09/27/19 at 10:30 AM, on 11/13/19 at 12:55 PM, and on 11/14/19 at 2:53 PM, revealed she administered sliding scale [MED] to Resident #1 at 11:00 AM. The Unit Manager stated she was not aware the resident had not eaten and no one had reported any concerns during shift communication. She stated she would not have administered [MED] to the resident if she had known the resident had not eaten. She explained that if a resident missed a meal, the nurse should assess/evaluate before giving [MED] and if the resident missed two (2) meals, the physician should be contacted before administering [MED]. According to the Unit Manager, she did not conduct any further assessment or identify any changes in the resident's condition. Continued interview with SRNA #2 on 09/27/19 at 11:40 AM, revealed she could not wake Resident #1 for the breakfast meal on 09/14/19 at approximately 7:30 AM on 09/14/19. SRNA #2 stated she reported the change in the resident's condition to LPN #1 and was directed to give the resident a mighty shake (a nutritional supplement) if the resident woke up. Further interview with SRNA #2 confirmed that Resident #1 did not have any urine output on 09/14/19. The SRNA stated she did not observe LPN #1 assess the resident and stated nurses often ignored nurse aides. Interview with SRNA #3 on 09/28/19 at 11:10 AM, revealed Resident #1 was definitely different when she was unable to wake the resident for breakfast at approximately 7:30 AM on 09/14/19. She stated she also reported the change in the resident's condition to LPN #1, who directed her to give the resident something to drink if the SRNA could arouse the resident. The SRNA also stated she did not observe LPN #1 assess the resident after the change in condition was reported. SRNA #3 further stated Resident #1 was unable to be aroused for the lunch meal on 09/14/19 at approximately 1:00 PM. She stated she reported the resident's condition to LPN #1 again and she observed LPN #1 do a chest rub on the resident. However, the resident's only response was to open his/her eyes and make a soft noise. The SRNA stated LPN #1 then washed the resident's face; however, the resident did not respond. SRNA #3 stated she never observed LPN #1 obtain vital signs or conduct any further assessment of the resident. Further interview with LPN #1 on 09/27/19 at 2:20 PM, revealed staff reported they could not wake Resident #1 for breakfast on 09/14/19; however, she did not assess the resident because she felt that was normal behavior for the resident. Further interview with LPN #1 revealed staff also reported that they were unable to wake Resident #1 for the lunch meal on 09/14/19, and she recalled looking at the resident and the resident was still groggy but would awaken. The LPN stated her shift ended shortly after lunch and she did not recall seeing the resident again before she left for the day. Further, the LPN did not recall reporting the resident's change in condition to the nurse on the oncoming shift. Continued interview with the DON on 10/01/19 at 1:25 PM and on 11/14/19 at 11:25 AM, revealed if SRNAs reported that they could not wake a resident, she expected facility nurses to assess the resident. Interview with the Administrator on 10/01/19 at 4:20 PM, revealed he also expected licensed nurses to do a proper assessment if an SRNA reported a change in the resident's condition. Interview with Registered Nurse (RN) #1 on 11/14/19 at 10:35 AM, revealed she was the charge nurse caring for Resident #1 on 09/14/19 on the 2:00 PM to 10:00 PM shift. She stated LPN #1 reported Resident #1 was out of it today and stated that the nurse explained that the resident was sleepy due to receiving pain medication. She stated the LPN did not report that the resident had decreased food and fluid intake or that the resident had no urinary output during her shift. RN #1 stated after receiving report, another resident sustained [REDACTED].#1's sister reported she could not wake Resident #1. The RN stated she had not worked with Resident #1 for a couple weeks prior to 09/14/19, and when she assessed the resident there was a clear change in the resident's condition. RN #1 stated she tried to wake the resident; however, the resident was unresponsive. The RN stated Resident #1 was clammy and had a low blood pressure. RN #1 stated she contacted the resident's physician and transferred the resident to the hospital for evaluation. Review of Resident #1's nurse's notes dated 09/14/19 at 2:25 PM revealed Resident #1's sister reported that she could not awaken Resident #1. RN #1 documented that the resident's skin was warm, pale, and clammy, and the resident's eyes remained closed upon verbal and physical stimuli. Resident #1's heart rate was 122 (normal range [AGE]-100), respiratory rate was 35 (normal range 12-24), blood pressure was [AGE]/42 (normal range 120/[AGE]), oxygen saturation on room air was [AGE]% (normal range 95%-100%), and his/her blood glucose level was 319 (normal range [AGE]-130). Further review of the documentation revealed the resident's physician was notified of the change in his/her condition at 2:45 PM and the resident left the facility with Emergency Medical Services (E[CONDITION]) at 3:12 PM. Review of Resident #1's E[CONDITION] transportation sheet dated 09/14/19 revealed E[CONDITION] arrived at the facility at 3:07 PM and observed the resident to be unresponsive. The resident had no eye movement when assessed by E[CONDITION] and had a Glasgow Coma Scale of three (3), which indicated the resident was in a state of deep unconsciousness. E[CONDITION] documentation also revealed his/her systolic blood pressure (the top reading on a blood pressure that measures the pressure in the blood vessels when the heart beats) was 78 (normal range 120) and his/her blood glucose reading was 400. E[CONDITION] also documented that nursing home staff reported to them that the resident was normally alert but confused. Review of Resident #1's hospital record revealed the resident arrived on 09/14/19 at approximately 3:40 PM and was not moving his/her extremities and was nonresponsive with slight moan to sternal rub. The resident's blood pressure on arrival was 68/38 and his/her respiratory rate was 43. Review of the resident's laboratory results from the Emergency Department (ED) revealed the resident's blood urea nitrogen (BUN) level (kidney function test) was 181 (normal range 8-26) and his/her creatinine level (kidney function test) was 6.[AGE] (normal range .[AGE]-1.30). Resident #1's hospital lab results also revealed his/her [MED] level was also elevated (can indicate dehydration) at 163 (normal range 136-144). Resident #1 was admitted to the hospital with [REDACTED]. Review of Resident #1's History and Physical (H&P) dated 09/15/19 at 11:34 AM revealed Resident #1's mouth/throat was dry and the resident was poorly responsive. According to the H&P, the resident had critical metabolic abnormalities (elevated BUN and Creatinine) that would take several days to resolve, [MEDICAL CONDITION] with septic shock, and acute [MEDICAL CONDITION]. Interview with Physician #1 on 09/30/19 at 3:30 PM, revealed he was the Emergency Department (ED) physician who evaluated Resident #1 on 09/14/19. Physician #1 stated that due to the resident's BUN and Creatinine results, there was no way someone suddenly became that dehydrated. The physician also added that the resident was seen at the hospital ED two (2) months earlier, and the resident's BUN and Creatinine were within normal range. Interview with Physician #2 on 10/01/19 at 1:50 PM, revealed she admitted Resident #1 to the hospital on [DATE]. She stated when the hospital called her about accepting the patient, she had to clarify the resident's laboratory results because she had never seen anyone's BUN that high. Physician #2 stated the resident's [MED] level was also elevated, the resident's lips were dry, and the resident appeared dry on evaluation, which were indicators of dehydration. Physician #2 also stated Resident #1's family informed her that the resident had not eaten well the past few days. The physician further stated she assessed Resident #1 before admission and the resident had not had any urinary output, only a brown substance in the catheter bag. Physician #2 stated that Resident #1's prognosis was poor, and that she honestly did not think the resident would make it. Physician #2 stated in her opinion it would take longer than a day for dehydration to that extent to occur, especially since the resident improved almost immediately when they began hydration. She stated Resident #1 began having urinary output and the resident's laboratory results improved while at the hospital. Physician #2 stated that miraculously the resident was able to be discharged from the hospital and his/her BUN was almost back down to normal upon discharge. *The facility alleged the following removed Immediate Jeopardy on 11/21/19: 1. The attending physician and resident representative for Resident #1 were notified of the need to transfer the resident to the hospital on [DATE]. Resident #1 is no longer at the facility. 2. The 24 hour report sheets, from 09/15/19 to 10/15/19, were reviewed by the Director of Nursing (DON) and Unit Managers on 10/17/19 and [DATE]. 3. Residents with reduced food/fluid intake for the last seven (7) days were reviewed by the Director of Nursing (DON), Registered Dietitian (RD), and Unit Managers on 10/17/19 to identify any residents who demonstrated a change in condition. All residents demonstrating a change in condition had documentation of Physician/Advanced Practice Registered Nurse (APRN) notification in accordance with their care plans. For all residents demonstrating a change in condition, the documentation (which included the nursing notes and assessments) was audited to determine that the Physician/APRN were notified and responded timely to the notification with follow-up orders. 4. Facility licensed nursing staff have received in-service education by the Director of Nursing and Director of Clinical Services, completed on 10/17/19 and 10/22/19. Any staff that did not complete the in-service education by this date have been locked out of the time clock and cannot begin working their next shift until the in-service is completed with the DON. This education included but was not limited to: a. The definition of changes in resident condition, the need to assess the resident immediately, and report these to the attending Physician/APRN immediately in accordance with the resident care plans. b. The facility policy on notification of resident changes and the need to fully inform the Physician and Resident Representative of the assessment findings, complete the follow-up monitoring, and implement all Physician orders. c. Review for decreased food/fluid intake in the facility computer system. d. Review of the Interact STOP and WATCH program for all staff, which directs/prompts reporting any change of condition to the licensed nurse, and the need for the licensed nurse to assess the resident immediately. STOP and WATCH was covered in the in-service education on 10/17/19 for all staff, and for licensed nurses on 10/22/19. The Interact Stop and Watch forms will be used by all staff to identify/document any observed resident changes in condition. These forms are in Duplicate, with a copy being given to the licensed nurse to direct/prompt an immediate assessment, and then the copy will be placed in the unit Communication Book for review with the shift reports between shifts. The Second copy will then be turned in to the DON for monitoring, and the Director of Nursing Copy will be used for review by the DON, Unit Managers, and RD in their daily meetings during the week, and on Monday for the weekends. 5. A Specific Diabetic HS (bedtime) Snack Task for all residents who are receiving [MED] was initiated on [DATE] to further clarify meal (supplement) intake records for the residents with orders for [MED] and to alert staff if Diabetic HS Snack intake was less than 50%. 6. A Diabetic Log was initiated on 11/15/19 (and revised on 11/19/19) of meal/HS Snack intake for the residents with orders for [MED] to determine that their meal/alternative meal/supplement intake was greater than 50%. If the resident's meal/alternative/supplement intake was less than 50%, the log prompts the licensed nurse to assess the resident, and to notify the Physician prior to their [MED] administration. 7. The last three days of meal intake records for the residents with orders for [MED] were reviewed to determine that their meal/supplement intake was greater than 50% prior to their [MED] administration. This was completed on [DATE] by the RD, DON, Unit Managers, and Director of Clinical Services. 8. All licensed nurses have received in-service education by the DON and Director of Clinical Services on the following, completed on 11/19/19. Any staff that did not complete the in-service education by this date have been locked out of the time clock and cannot begin working their next shift until the in-service and competencies are completed with the Director of Nursing: a. the need to review resident food/fluid intake prior to administering any ordered [MED] and assess the resident. b. the need to hold the [MED], assess the resident, and notify the physician if the resident's meal intake was less than 50% for the meal prior to the glucose reading. c. the use of the meal intake and assessment of the resident prior to [MED] administration record for documentation of verification of the above information. d. Review of the Interact STOP and WATCH program for all staff, which directs/prompts the reporting of any change of condition to the licensed nurse, and the need for the licensed nurse to assess the resident immediately. 9. A Quality Assurance Performance Improvement (QAPI) meeting was conducted on [DATE] by the facility QAPI committee with the Medical Director to review the survey findings, this Allegation of Compliance, and the findings of the audits and currently completed QAPI tools. 10. The Director of Nursing, Registered Dietitian, and Unit Managers are reviewing all Physician orders [REDACTED]. They are then reviewing the nursing documentation (which includes the nursing notes and assessments) to determine that Physician/APRN and Resident Representative notification was completed timely, and follow-up orders obtained and implemented. Walking rounds with shift changes were initiated for the charge nurses and State Registered Nurse Aides (SRNA) to identify any residents with changes in condition. Any changes identified are to be reported immediately, Unit Managers are to follow up on any changes of condition, and report to daily meeting during the week, and the Monday Meeting for the weekend. 11. The Director of Nursing will choose one (1) resident identified with changes in status and reassess to determine that original findings were accurate. The QAPI tool for the monitoring of compliance with identification, assessment of the resident, and the QAPI tool for the monitoring of compliance with identification and notification of resident changes in condition will be utilized weekly for 2 weeks, then monthly for 2 months, and then quarterly by the Director of Nursing. Failure to meet the established 100% threshold will result in the development of an action plan. The results of the completed QAPI tools and any indicated action plans will be reviewed in the QAPI committee meetings. 12. The DON, RD, and Unit Managers are reviewing the [MED] administration forms daily during the week and on Monday for the weekends to determine that licensed nurses are reviewing resident meal/fluid intake prior to administration of any ordered [MED], and are holding the [MED], assessing the resident, and notifying the MD if the resident's meal intake is less than 50% for the meal prior to the glucose reading. The QAPI tool for the monitoring of meal intake prior to [MED] administration will be utilized weekly for 2 weeks, monthly for 2 months, and then quarterly thereafter by the Director of Nursing. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on 11/21/19, as alleged by the facility: 1. Resident #1 no longer resides in the facility after transfer to the hospital on [DATE] per physician order. 2. The Allegation of Compliance (AOC) binder revealed evidence of review of the 24-hour report sheets, dated 09/15/19 through 10/15/19. The binder also revealed evidence of documentation of physician notification of any changes in resident status as well as nurse documentation of changes. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the 24-hour report sheets from 09/15/19 to 10/15/19 to ensure physician and responsible party notification as required. Interview with the Director of Nursing on 11/25/19 at 3:18 PM, revealed on 10/17/19 and [DATE] she, along with the unit managers, reviewed the 24-hour report sheets dated 09/15/19 through 10/15/19 for physician and responsible party notification. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the 24-hour report sheets from 09/15/19 to 10/15/19 to ensure physician and responsible party notification as required. Interview with the Director of Nursing on 11/25/19 at 3:18 PM, revealed on 10/17/19 and [DATE] she, along with the unit managers, reviewed the 24-hour report sheets dated 09/15/19 through 10/15/19 for physician and responsible party notification. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the residents for decreased intake for dates of 10/10/19 through 10/16/19. The Unit Managers also revealed how the Stop and Watch forms were to be used, explaining that a copy was given to the nurse for immediate assessment and the other copy would go to the DON. They also stated the form could be completed by any staff or even family member. 3. The binder contained a printed report titled Clinical and Alert Listing Report, dated 10/10/19 through 10/16/19. The report revealed meal intake percentages of all residents in the facility. The information noted one (1) resident was identified as having refused two (2) meals on 10/13/19 and only 25% of the other meal was consumed. There was evidence of communication to the physician, by fax, of the resident's intake and the physician reply of OK. Interview with Unit Manager #1 on 11/25/19 at 2:51 PM, Unit Manager #3 at 3:08 PM, and Unit Manager #2 at 3:00 PM, revealed they had reviewed the resid

Based on observation, interview, record review, review of outpatient psychiatric notes, and review of the facility's policies and procedures, it was determined the facility failed to protect one (1) of three (3) sampled residents (Resident #2) from abuse. Resident #1, whom the facility assessed as cognitively intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), had a history of [REDACTED]. On at least two (2) prior occasions in the facility, in (MONTH) (YEAR) and (MONTH) (YEAR), Resident #1 was observed purposefully fondling and having inappropriate sexual behaviors toward a cognitively impaired resident. The facility implemented interventions to prevent Resident #1 from abusing other female residents that included placing an alarming mesh stop sign across Resident #1's room door; implementing anti-psychotic medication; arranging psychiatric treatment; and issuing Resident #1 a 30-day discharge notice. However, interview with the Administrator revealed Resident #1 was not discharged from the facility because placement for the resident could not be found at another facility. On 09/26/18, two (2) staff members observed Resident #1 fondling and playing with Resident #2's breasts. The facility assessed Resident #2 to be cognitively impaired with a BIMS score of three (3). The facility transferred Resident #1 to a psychiatric unit for evaluation on 09/26/18, where the resident was prescribed an anti-depressant medication and admitted back to the facility on [DATE]. However, the only interventions implemented by the facility to prevent Resident #1 from sexually abusing peers again were the same interventions that were in place at the time of the incident on 09/26/18, which were ineffective in protecting female residents from Resident #1. The facility implemented no increased supervision for Resident #1 and the resident was able to move freely about the facility at will. The facility's failure to ensure residents were protected from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/18, and determined to exist on 09/26/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/18. An acceptable Allegation of Compliance was received on 10/25/18, which alleged removal of the Immediate Jeopardy on 10/20/18. The State Survey Agency determined the Immediate Jeopardy was removed on 10/20/18, prior to exit on 10/31/18, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Prohibiting Abuse, Neglect, Misappropriation and Exploitation, dated 04/20/17, revealed each resident has the right to be free from verbal, sexual, physical, and mental abuse. The policy stated the facility would not condone abuse by anyone, including other residents. Further review of the policy revealed sexual abuse was defined as non-consensual contact of any type with a resident. Review of Resident #1's medical record revealed the facility admitted the resident on 02/14/15. Further review of the resident's medical records revealed the resident had [DIAGNOSES REDACTED]. Continued review of Resident #1's medical record revealed that in (MONTH) (YEAR) Resident #1 was observed purposefully fondling and having inappropriate sexual behaviors toward a cognitively impaired resident. Further review of the medical record revealed in (MONTH) (YEAR) Resident #1 was observed by staff to enter his/her room, peek his/her head out the door of the room, and look around in what appeared to be an effort to see if anyone was around. The staff member entered the resident's room and found Resident #1 with his/her arm around a cognitively impaired resident and his/her hand up the resident's shirt. Further review of Resident #1's medical record revealed the interventions put in place by the facility to prevent re-occurrence and protect other residents from Resident #1 included placing an alarming mesh stop sign across Resident #1's room door and the door to the adjoining bathroom; and medication adjustments. Additionally, Resident #1 was to attend outpatient psychiatric treatment three (3) times a week, and the resident was moved to a different hall. Furthermore, the facility issued a 30-day discharge notice to Resident #1, due to his/her repeated behaviors. However, interview with the Administrator on 10/18/18 at 1:25 PM revealed Resident #1 was not discharged from the facility because placement for the resident could not be found at another facility. Further record review revealed no additional interventions were implemented to protect other residents from Resident #1, since the resident was remaining in the facility. Review of a Psychiatric Evaluation dated 01/06/17 revealed the facility referred Resident #1 for treatment due to the resident exhibiting increased inappropriate sexual behaviors, specifically touching and groping another resident. The evaluation quoted the resident as stating, I was sent here because I was messing with a woman. The evaluation also stated the patient had a history of [REDACTED]. The evaluation stated the patient had been redirected on several occasions by facility staff; however, the resident continued the behavior. The evaluation quoted the resident as stating, I was caught twice. The patient continued, stating, My mind tells me that it is okay even though I know it is not; I chose her because she was easy and available. Further review of the evaluation revealed Resident #1 stated that he/she felt he/she needed to be moved far away and that would improve his/her behaviors. Review of Resident #1's Outpatient Psychiatric Notes from 01/03/18 through 09/26/18 revealed all the Notes assessed the resident to have normal speech, and that the resident's insight, perception, and judgement were intact. Further review of the session notes revealed repeated documentation that Resident #1 had no human emotions, was highly intelligent, and was at risk for inpatient treatment. Continued review of the documentation throughout the session notes revealed Resident #1 stated, I say lie, and try to get away with as much as you can. The session notes also included documentation by the Therapist that stated Resident #1 .could come up with answers immediately and was very alert. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed Resident #1 to display physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, and abusing others sexually). The facility also assessed the resident to have verbal behavioral symptoms directed toward others (e.g., threatening, screaming, and cursing at others). Review of Resident #1's Comprehensive Care Plan initiated on 04/11/17, with a target date of 01/09/19, revealed the facility identified that the resident had a history of [REDACTED]. The care plan indicated Resident #1 had targeted the female resident because she couldn't fight back. Review of interventions implemented for Resident #1 to protect other residents in the facility included placing an alarming stop sign across Resident #1's door and to observe/be aware of others in/out of room, convey personal acceptance during periods of inappropriate behavior and discourage actual behavior, observe and remove from public area when behaviors pose a risk for harm and intervene and separate as indicated, observe for inappropriate behaviors/comments while out of room during activities with peers, and intervene as necessary to protect the rights and safety of others. Review of a facility investigation dated 09/27/18 revealed on 09/26/18 at 1:30 PM, Housekeeper #1 reported seeing Resident #2 roll his/her wheelchair into Resident #1's room and witnessed Resident #1 place his/her hands under Resident #2's shirt and Resident #1 was playing with Resident #2's breast. Housekeeper #1 immediately alerted State Registered Nurse Aide (SRNA) #1, and removed Resident #2 from Resident #1's room. Review of a witness statement given by SRNA #1 on 09/26/18 (time unknown), revealed she observed Resident #2 sitting in Resident #1's doorway, and Resident #1 had both hands under Resident #2's shirt fondling (his/her) breast. Interview with Housekeeper #1 on 10/15/18 at 11:22 AM revealed she was leaving a resident's room when she noticed Resident #2 in his/her wheelchair in the doorway of Resident #1's room. She stated Resident #1 was standing in front of Resident #2 with his/her hands up Resident #2's shirt playing with the resident's breasts. She stated the alarming stop sign was not in place on Resident #1's door when she witnessed the incident on 09/26/18. Housekeeper #1 stated she yelled for SRNA #1, who was nearby in the hallway, and the SRNA separated the residents and put the alarming stop sign in place on Resident #1's door. Interview with SRNA #1 on 10/15/18 at 11:33 AM revealed she was in the hallway when Housekeeper #1 yelled for her to come to Resident #1's room. She stated when she arrived at the resident's room, Resident #2 was in his/her wheelchair in the doorway of Resident #1's room, and Resident #1 was standing in front of Resident #2 with his/her hands up Resident #2's shirt fondling his/her breasts. SRNA #1 stated she separated the residents and took Resident #2 to his/her room. SRNA #1 stated that Resident #1 denied touching Resident #2's breast. However, SRNA#1 stated she could see what the resident was doing. SRNA #1 stated she immediately notified the Charge Nurse of the incident. Interview with Unit Manager (UM) #1 on 10/15/18 at 11:42 AM revealed she was at the nurses' station when SRNA #1 yelled for her to go to Resident #1's room. She stated SRNA #1 and Housekeeper #1 both reported to her that they observed Resident #2 in his/her wheelchair in Resident #1's doorway and Resident #1 had his/her hands up Resident #2's shirt playing with/fondling Resident #2's breasts. She stated SRNA #1 took Resident #2 back to his/her room and the UM performed a head to toe skin assessment on Resident #2 and did not find any injuries. The UM stated she spoke with Resident #1 and he/she stated that Resident #2 had entered the doorway of Resident #1's room and pulled his/her shirt up, and Resident #1 was attempting to assist the resident pull his/her shirt down. The UM stated she notified the physician and both of the residents' responsible parties. She stated the physician gave orders for Resident #1 to be monitored hourly, and to undergo a psychiatric evaluation. The UM stated Resident #1 knows the right things to say and knows what you want to hear. She stated Resident #1 had a history of [REDACTED]. In addition, review of a Psychiatric History and Physical, dated 09/27/18, revealed when UM #1 called to request the psychiatric evaluation for Resident #1 on 09/26/18, the nurse reported that Resident #1 had a history of [REDACTED]. The nurse also reported that Resident #1 was manipulative and will tell you what you want to hear. Further review of Resident #1's medical record revealed the facility transferred the resident to an inpatient psychiatric unit on 09/26/18 at approximately 9:50 PM. Review of Hospital Psychiatric records for Resident #1 revealed a Treatment Plan dated 09/27/18, which stated the patient had been admitted to a secure inpatient unit due to being a danger to self and others. Continued review of Hospital Psychiatric Notes for Resident #1, dated 09/28/18 revealed the inpatient Psychiatrist spoke with Resident #1's Outpatient Therapist. The resident's Outpatient Therapist stated he had been treating Resident #1 for approximately three (3) years and the resident only violated women with dementia. The Therapist also informed the Hospital Psychiatrist that Resident #1 had a way of telling staff what they wanted to hear in order to be discharged quickly. Further review of Resident #1's Hospital Psychiatric records revealed the only change made in Resident #1's treatment plan was to decrease the resident's [MEDICATION NAME] (an anti-psychotic) and add [MEDICATION NAME] (an anti-depressant) to the resident's medication regimen. Further review of Resident #1's medical record revealed the facility readmitted Resident #1 on 10/03/18. However, the only interventions implemented by the facility to prevent Resident #1 from sexually abusing peers again were the interventions that were in place at the time of the incident on 09/26/18, which were ineffective in protecting peers from Resident #1. The facility implemented no increased supervision for Resident #1 and the resident was able to move freely about the facility at will. Interview with Resident #1 on 10/16/18 at 2:56 PM revealed the resident was alert and willing to answer questions. The resident stated the day Resident #2 wheeled himself/herself into his/her room, the alarming stop sign was pushed back to the side of the door. Resident #1 stated when Resident #2 wheeled into his/her room (he/she) pulled (his/her) shirt up and showed me (his/her) titties; the opportunity presented itself. Resident #1 stated he/she attempted to push Resident #2 out of his/her room, but before he/she could, two (2) staff members entered the room and separated them. Continued interview with Resident #1 revealed the facility had accused him/her in the past of touching his/her ex-spouse (who also resided at the facility). Although the resident denied the allegation, he/she stated, And even if I did she would not have known it; she is not in her right mind; she has Alzheimer's 100 percent. Resident #1 also stated he/she had told the outpatient psychiatric physician earlier in the day (10/16/18) that he/she liked to touch women, especially if they have Alzheimer's, that is the smart thing to do. Resident #1 stated that he/she had not been to Resident #2's room; however, he/she was able to correctly describe exactly where Resident #2's room was located in the facility. The resident stated he/she was able to walk down the halls of the facility by himself/herself using his/her walker. Resident #1 stated the alarming stop sign was usually pushed back behind the door .so I don't have to worry about it. Interview with State Registered Nurse Aide (SRNA) #8 on 10/16/18 at 12:53 PM revealed she had not witnessed Resident #1 touch other residents inappropriately. However, she was aware of incidents in the past involving another cognitively impaired resident (unsampled Resident A). She stated she had heard that Resident #1 would pull the resident into his/her room and inappropriately touch the resident under his/her shirt and in his/her pants. SRNA #8 stated it happened quite often and had been reported several times. However, SRNA #8 stated the Administrator did not do anything at first, stating it was not until (MONTH) (YEAR) that Resident A was moved to the front of the building and Resident #1 was moved to a different hall. SRNA #8 also stated Resident #1 had not been placed on special or increased supervision since returning to the facility on [DATE]. Interviews on 10/15/18 with SRNA #2 at 2:22 PM, SRNA #3 at 3:10 PM, SRNA #4 at 3:17 PM, and on 10/16/18 with SRNA #7 at 11:32 AM, SRNA #5 at 11:46 AM, SRNA #9 at 12:26 PM, SRNA #11 at 1:53 PM, SRNA #12 at 3:24 PM, and SRNA #6 at 3:35 PM, revealed none of the staff interviewed were aware of Resident #1 being placed on any special or increased supervision since returning to the facility on [DATE], and had never witnessed or had any knowledge of Resident #2 having any inappropriate behaviors including raising his/her shirt up to expose his/her breasts. SRNA #2, SRNA #5, SRNA #6, SRNA #7, SRNA #10, and SRNA #11 all stated they were aware that Resident #1 had a history of [REDACTED]. In addition SRNA #9 stated she had heard from other staff that when they gave Resident #1 a shower he/she would play with himself/herself and wanted staff to wash his/her genital area, even though the resident was able to wash himself/herself. Interviews on 10/16/18 with Registered Nurse (RN) #1 at 1:19 PM and RN #2 at 1:37 PM revealed Resident #1 was not placed on any special or increased supervision after returning to the facility on [DATE]. Additional interview revealed both nurses stated they had never observed Resident #2 expose his/her breast to any other resident in the past. RN #1 did state she had observed Resident #1 masturbating in his/her room with the door open in the past. Interviews with the Director of Nursing (DON) on 10/15/18 at 4:08 PM, on 10/16/18 at 10:57 AM, 11:50 AM, 3:20 PM, and 4:15 PM, on 10/17/18 at 5:37 PM, and on 10/18/18 at 1:17 PM, revealed she was made aware of the allegation of abuse related to Resident #1 and Resident #2 on 09/26/18 immediately after it occurred. She stated she began the investigation into the incident and interviewed Resident #1 about what had occurred. The DON stated she asked Resident #1 what happened and if staff had removed Resident #2 from his/her room. According to the DON, Resident #1 told her that Resident #2 wheeled into his/her room and raised his/her shirt. Resident #1 stated that he/she did not touch Resident #2's breasts, but he/she was assisting him/her to pull his/her shirt down. The DON stated she did not interview Resident #2 because he/she was cognitively impaired. She stated Resident #1 had attended outpatient psychiatric visits two (2) or three (3) times per week since (MONTH) (YEAR). The DON stated the resident was prescribed [MEDICATION NAME] medication for his/her sexual behaviors which he/she had been taking prior to the incident on 09/26/18. Further interview with the DON revealed the only new intervention initiated after Resident #1 was readmitted back to the facility on [DATE] was the initiation of [MEDICATION NAME] (an anti-depressant) medication and decreasing the resident's [MEDICATION NAME]. Continued interview with the DON revealed both Resident #1 and Resident #2 continued to reside on the same hall even after Resident #1 was readmitted back to the facility on [DATE]. The DON stated that Resident #2's spouse had visited earlier in the day on 09/26/18, and she thought Resident #2 was looking for his/her spouse when he/she wandered into Resident #1's doorway. She stated Resident #2 was cognitively impaired and could not consent to any type of sexual act/relations. However, the DON stated that because Resident #2 had entered Resident #1's room, and because Resident #1 had not exhibited any sexually inappropriate behaviors to her knowledge in over a year, she and the Administrator made the decision that the allegation of abuse by Resident #1 to Resident #2 was unsubstantiated. The DON further stated that the staff who observed the incident on 09/26/18 could have taken what they observed out of context due to Resident #1's prior sexual history. Further interview with the DON revealed that the facility did not receive a copy of Resident #1's psychiatric progress notes and she had never reviewed the notes. She stated the only communication that the facility had related to Resident #1's psychiatric treatment was if a medication change or adjustment was recommended. The DON stated the facility did not consider or utilize Resident #1's psychiatric treatment plan or progress notes when deciding on the care provided to Resident #1 at the facility, or in order to develop interventions to protect other residents in the facility from being sexually abused by Resident #1. Interview with the Licensed Clinical Social Worker (LCSW), who was on Resident #1's outpatient psychiatric team, on 10/22/18 at 4:04 PM revealed Resident #1 was very intelligent, guarded, and did not volunteer information during his/her sessions. He stated the facility had never requested any documentation related to Resident #1's visits. Continued interview revealed he had not observed Resident #1 out of a controlled environment (in the facility); however, he stated if a cognitively impaired person wandered into Resident #1's room unsupervised, Resident #1 would be likely to display sexually inappropriate behavior. Interview on 10/18/18 at 11:48 AM, with the Nurse Practitioner (NP) who cared for Resident #1 in the facility revealed that to her knowledge Resident #1's last incident involving inappropriate sexual contact with a cognitively impaired resident was in (MONTH) (YEAR). She stated that prior to the incident on 09/26/18, Resident #1 was involved in outpatient psychiatric services three (3) times per week and that the resident was prescribed [MEDICATION NAME] (an anti-psychotic medication) to treat his/her inappropriate sexual behaviors. She stated she did not receive Resident #1's outpatient psychiatric visits unless there was a change made in the resident's medications. She further stated she was not aware of the resident's [DIAGNOSES REDACTED]. The NP stated she felt Resident #1 was in control of his/her actions and that the facility should entertain the fact that the resident was not appropriately placed in the facility. The NP stated that due to his/her history of targeting cognitively impaired female residents, the female population in the facility was at risk. The NP further stated she would not tolerate the behaviors exhibited by Resident #1. Interviews with the Administrator on 10/16/18 at 2:21 PM and 3:43 PM, on 10/17/18 at 4:42 PM and 6:45 PM, and on 10/18/18 at 1:33 PM, revealed Resident #1's past history of sexually inappropriate behaviors toward vulnerable, cognitively impaired residents was due to Resident A seeking Resident #1 out. He stated that he felt the interventions that were in place at the time of the incident with Resident #2 on 09/26/18 (alarming stop sign and medications) were effective. The Administrator stated that prior to the incident on 09/26/18, Resident #1 had the same supervision as other residents, and that level of supervision was continued when Resident #1 returned to the facility on [DATE]. He stated that he interviewed Resident #1 on 09/26/18 and that the resident explained to him that he/she was assisting Resident #2 with pulling down his/her shirt. The Administrator stated that Resident #1 told him Resident #2 came into his/her room, and he/she did not touch Resident #2's breasts. Further interview revealed Resident #1 had a BIMS score of fifteen (15) and, I took (him/her) at (his/her) word; why would (he/she) want to lie? The Administrator stated that he did not feel that abuse should have been substantiated against Resident #1 because (he/she) was in (his/her) room minding (his/her) own business and Resident #2 came to him/her, and in addition Resident #1 denied the allegation and he/she was an alert and oriented resident. Further interview with the Administrator revealed he had never reviewed progress notes or discussed Resident #1's progress with any member of the outpatient psychiatric team. When asked if he was aware that Resident #1 had been characterized in the psychiatric sessions to have no human emotions, be highly intelligent, able to come up with answers immediately, only violated women with dementia, and would tell staff what they wanted to hear, the Administrator replied he had never reviewed any of the documentation. Continued interview with the Administrator revealed that even though two (2) facility staff members both witnessed and documented that Resident #1 was touching Resident #2's breast, the Administrator stated that they had observed the interaction from behind Resident #2, and he believed the staff did not actually observe what they reported and documented that they saw. When asked if he was aware that Resident #1 had admitted to the outpatient psychiatric team that he/she lied to get away with as much as he/she could, the Administrator stated that Resident #1 had never lied to him and he had no reason not to believe Resident #1's account of the incident on 09/26/18. Therefore, the Administrator stated there was no reason to implement any new interventions to protect other facility residents from Resident #1 when he/she was admitted back to the facility on [DATE], other than the medication changes. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 10/20/18: 1. Resident #1 was transferred out of the facility to an in-patient psychiatric facility on 09/26/18 for evaluation. 2. Resident #1 was readmitted to the facility on [DATE], after medication adjustments were made during the resident's stay in the psychiatric unit. 3. The intervention of an alarming stop sign was re-implemented upon the resident's return to the facility on [DATE], to alert staff of anyone entering or exiting Resident #1's room. 4. A second alarming stop sign was placed on the door of Resident #1's room on 10/17/18 to prevent any resident access below the alarming stop sign already in place. 5. Bells were placed on the walker of Resident #1 on 10/17/18, to alert staff of Resident #1's whereabouts whenever he/she was outside of his/her room. 6. A motion detecting alarm was placed above Resident #1's room door on 10/19/18, to alert staff to anyone entering or exiting the resident's room. 7. An alarm was added to the adjoining bathroom door of Resident #1's room on 10/18/18 to alert staff if the resident exits through the bathroom. 8. All interventions implemented had been added to Resident #1's plan of care as of 10/19/18. 9. A PHQ-9 (a questionnaire that assesses a resident's degree of depression) interview was conducted by the SSD for Resident #2 on 10/16/18. A comparison to the previous PHQ-9 assessment for Resident #2 revealed no changes were identified in the resident's mood or depression level. 10. Upon evaluation of all of the above interventions put in place for Resident #1 on 10/22/18, it was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of Resident #1. Therefore, the interventions were revised. Resident #1 was placed on 1:1 supervision at all times on 10/22/18. 11. Resident #1 indicated to the facility that he/she would prefer to be transferred to another facility, rather than have the increased 1:1 supervision; and the resident's representative was in agreement with this decision. The facility is contacting all facilities that provide the psychiatric services needed for Resident #1, and will discuss any facility that has available placement with the guardian and Resident #1 for approval. 12. The alarming stop signs to Resident #1's room and the alarm on the adjoining bathroom were removed on 10/22/18. 13. The bells on the walker of Resident #1 were removed on 10/22/18. 14. The motion detector alarm on Resident #1's doorway was left in place to alert the assigned 1:1 staff to any resident approaching the doorway of Resident #1, so the resident may be redirected. 15. On 10/19/18, all residents with severely impaired cognition, as determined by a BIMS score below eight (8) on the most recent MDS, who have been identified as having the potential to wander via a wheelchair or with a walker onto the hall of Resident #1, have been evaluated for a sound alerting device (such as bells) to alert staff to their whereabouts when outside of their rooms. The devices were put into place and addressed on the residents' care plans. 16. Residents who are ambulatory have been included in the Ambulatory Alert binder, which alerts staff to monitor the residents if they are in the vicinity of Resident #1's room. 17. On 10/22/18, an evaluation of all of the above interventions put in place for residents who have the potential to wander with impaired cognition was conducted. It was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of the residents. Therefore, the interventions were revised. The bells were removed from the walkers and wheelchair of the residents. 18. Residents who are severely cognitively impaired and ambulatory remain in the Ambulatory Alert binder, to alert staff to be aware of the location when they are out of their rooms. 19. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers received education from the contracted Nurse Consultant on 10/18/18 on how to complete a comprehensive investigation. The education included conducting a detailed interview, conducting a follow-up interview if new information is identified, how and when to utilize re-enactments to clarify and demonstrate key facts, and how to document investigation findings. 20. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers on the facility's abuse policy, including what constitutes abuse, resident to resident altercations and the need to protect the residents, and the need to immediately report all allegations of abuse. 21. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers related to the alerting devices implemented for Resident #1 including the need to make sure the alarming stop signs and bathroom door alarm are in place whenever the resident is in the room, the need for staff to remain alert to the resident's whereabouts when he/she is outside of his/her room and they hear the bells on his/her walker, the need to immediately respond to the sound of the motion alarm over the room entrance of Resident #1's door to determine who is approaching the room, and if any immediate intervention is indicated. 22. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers regarding the Ambulatory Alert binder and residents with sound alerting devices who have severe cognitive impairment and may wander down the hallway of Resident #1, and to be alert to their whereabouts when the residents are in the vicinity of the room of Resident #1. 23. As of 10/22/18, education was conducted with all staff on the revisions to the original interventions for Resident #1; including the resident being placed on 1:1 supervision at all times, the removal of all devices except for the motion detector alarm on Resident #1's door, and the removal of the bells from all severely cognitively impaired resident walkers and wheelchairs. Staff were also instructed that the use of the Ambulatory Alert binder for severely cognitively impaired residents who wander would continue. 24. The Administrator, Director of Clinical Servi

Based on interview, record review, review of the facility's policy and procedures, and review of the Elder Justice Act, it was determined the facility failed to report a reasonable suspicion of a crime to local Law Enforcement when one (1) of three (3) sampled residents (Resident #2) was sexually abused by Resident #1. Resident #1, who was assessed by the facility to be cognitively intact and who had a history of [REDACTED].#2's breasts. The facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of three (3) and was severely cognitively impaired. However, the facility failed to notify local Law Enforcement of the sexual assault of Resident #2 by Resident #1. The facility's failure to ensure reporting of a reasonable suspicion of a crime against a resident in a federally funded long-term care facility has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/18, and determined to exist on 09/26/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/18. An acceptable Allegation of Compliance was received on 10/25/18, which alleged removal of the Immediate Jeopardy on 10/20/18. The State Survey Agency determined the Immediate Jeopardy was removed on 10/20/18, prior to exit on 10/31/18, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of The Elder Justice Act, enacted in (MONTH) of 2010, revealed residential care facilities were required to report any reasonable suspicion of a crime against a resident or person who is receiving care from a federally funded long-term care facility to local Law Enforcement. Review of the facility's policy titled Elder Justice Act, dated 04/20/17, revealed the facility would comply with the Elder Justice Act related to reporting a reasonable suspicion of crime and adhere to the Centers for Medicare and Medicaid Services and the State's existing policies and procedures for reporting alleged incidents of abuse to local Law Enforcement. Review of Resident #1's medical record revealed the facility admitted the resident on 02/14/15. Further review of the medical record revealed Resident #1 had [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed the resident had a history of [REDACTED]. In (MONTH) (YEAR) and (MONTH) (YEAR), Resident #1 was observed to be purposefully fondling a female resident because she couldn't fight back. Review of a Psychiatric Evaluation dated 01/06/17 revealed the facility referred Resident #1 for treatment due to the resident touching and groping another resident. The evaluation quoted the resident as stating, I was sent here because I was messing with a woman .I was caught twice. My mind tells me that it is okay even though I know it is not; I chose her because she was easy and available. Review of Resident #1's Outpatient Psychiatric Notes from 01/03/18 through 09/26/18 revealed all the notes stated that the resident's insight, perception, and judgment were intact. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Review of a facility investigation dated 09/27/18 revealed Resident #1 was observed by two (2) staff members to have his/her hands under Resident #2's shirt and Resident #1 was playing with the resident's breasts. The facility assessed Resident #2 to have a BIMS score of three (3) indicating the resident was severely cognitively impaired. The staff members who witnessed the incident documented that Resident #1 was fondling and playing with Resident #2's breasts. However, the facility failed to notify local Law Enforcement of the incident, despite Resident #1 being alert and oriented, having a clear understanding of his/her actions and a history of targeting vulnerable female residents. Interviews with the Administrator on 10/16/18 at 2:21 PM and 3:43 PM, on 10/17/18 at 4:42 PM and 6:45 PM, and on 10/18/18 at 1:33 PM, revealed he did not view the actions of Resident #1 toward Resident #2 as an act of sexual abuse. However, the facility's policy and procedure defined sexual abuse as the non-consensual contact of any type with a resident. The Administrator stated Law Enforcement was not notified because the incident did not meet the criteria. Further interview with the Administrator revealed the only time Law Enforcement would be involved was if a major event occurred, such as battery. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 10/20/18: 1. Resident #1 was transferred out of the facility to an in-patient psychiatric facility on 09/26/18 for evaluation. 2. Resident #1 was readmitted to the facility on [DATE], after medication adjustments were made during the resident's stay in the psychiatric unit. 3. The intervention of an alarming stop sign was re-implemented upon the resident's return to the facility on [DATE], to alert staff of anyone entering or exiting Resident #1's room. 4. A second alarming stop sign was placed on the door of Resident #1's room on 10/17/18 to prevent any resident access below the alarming stop sign already in place. 5. Bells were placed on the walker of Resident #1 on 10/17/18, to alert staff of Resident #1's whereabouts whenever he/she was outside of his/her room. 6. A motion detecting alarm was placed above Resident #1's room door on 10/19/18, to alert staff to anyone entering or exiting the resident's room. 7. An alarm was added to the adjoining bathroom door of Resident #1's room on 10/18/18 to alert staff if the resident exits through the bathroom. 8. All interventions implemented had been added to Resident #1's plan of care as of 10/19/18. 9. A PHQ-9 (a questionnaire that assesses a resident's degree of depression) interview was conducted by the SSD for Resident #2 on 10/16/18. A comparison to the previous PHQ-9 assessment for Resident #2 revealed no changes were identified in the resident's mood or depression level. 10. Upon evaluation of all of the above interventions put in place for Resident #1 on 10/22/18, it was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of Resident #1. Therefore, the interventions were revised. Resident #1 was placed on 1:1 supervision at all times on 10/22/18. 11. Resident #1 indicated to the facility that he/she would prefer to be transferred to another facility, rather than have the increased 1:1 supervision; and the resident's representative was in agreement with this decision. The facility is contacting all facilities that provide the psychiatric services needed for Resident #1, and will discuss any facility that has available placement with the guardian and Resident #1 for approval. 12. The alarming stop signs to Resident #1's room and the alarm on the adjoining bathroom were removed on 10/22/18. 13. The bells on the walker of Resident #1 were removed on 10/22/18. 14. The motion detector alarm on Resident #1's doorway was left in place to alert the assigned 1:1 staff to any resident approaching the doorway of Resident #1, so the resident may be redirected. 15. On 10/19/18, all residents with severely impaired cognition, as determined by a BIMS score below eight (8) on the most recent MDS, who have been identified as having the potential to wander via a wheelchair or with a walker onto the hall of Resident #1, have been evaluated for a sound alerting device (such as bells) to alert staff to their whereabouts when outside of their rooms. The devices were put into place and addressed on the residents' care plans. 16. Residents who are ambulatory have been included in the Ambulatory Alert binder, which alerts staff to monitor the residents if they are in the vicinity of Resident #1's room. 17. On 10/22/18, an evaluation of all of the above interventions put in place for residents who have the potential to wander with impaired cognition was conducted. It was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of the residents. Therefore, the interventions were revised. The bells were removed from the walkers and wheelchair of the residents. 18. Residents who are severely cognitively impaired and ambulatory remain in the Ambulatory Alert binder, to alert staff to be aware of the location when they are out of their rooms. 19. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers received education from the contracted Nurse Consultant on 10/18/18 on how to complete a comprehensive investigation. The education included conducting a detailed interview, conducting a follow-up interview if new information is identified, how and when to utilize re-enactments to clarify and demonstrate key facts, and how to document investigation findings. 20. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers on the facility's abuse policy, including what constitutes abuse, resident to resident altercations and the need to protect the residents, and the need to immediately report all allegations of abuse. 21. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers related to the alerting devices implemented for Resident #1 including the need to make sure the alarming stop signs and bathroom door alarm are in place whenever the resident is in the room, the need for staff to remain alert to the resident's whereabouts when he/she is outside of his/her room and they hear the bells on his/her walker, the need to immediately respond to the sound of the motion alarm over the room entrance of Resident #1's door to determine who is approaching the room, and if any immediate intervention is indicated. 22. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers regarding the Ambulatory Alert binder and residents with sound alerting devices who have severe cognitive impairment and may wander down the hallway of Resident #1, and to be alert to their whereabouts when the residents are in the vicinity of the room of Resident #1. 23. As of 10/22/18, education was conducted with all staff on the revisions to the original interventions for Resident #1; including the resident being placed on 1:1 supervision at all times, the removal of all devices except for the motion detector alarm on Resident #1's door, and the removal of the bells from all severely cognitively impaired resident walkers and wheelchairs. Staff were also instructed that the use of the Ambulatory Alert binder for severely cognitively impaired residents who wander would continue. 24. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers will review the findings from all abuse investigations as part of the daily morning meeting, including all interventions that are necessary and implemented to address investigation findings and protect the residents. 25. The investigative staff on the facility Quality Assurance and Performance Improvement (QAPI) team including the Administrator, Director of Clinical Services, Director of Nursing, and Director of Social Services along with the Unit Managers, Minimum Data Set Nurses, and the Medical Director met on 10/19/18 to review the circumstances of the allegation and all of the Allegation of Compliance interventions which have been implemented by the facility. 26. The QAPI tool to monitor compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, will be utilized with each allegation of abuse until the immediate jeopardy is lifted under the supervision of the Administrator. A plan of action will be developed for any issues identified. This tool directs the review of up to five (5) allegations, if five have occurred since the last review, to ensure that all of the required abuse policy components, including those specific to resident-to-resident altercations, have been implemented including protection of all residents. Results of each Abuse Allegation QAPI tool along with any plans of Actions implemented will be reviewed with the QAPI team as part of the monthly QAPI meetings. 27. The facility contacted local Law Enforcement on 10/18/18 and an officer completed a report on the self-reported allegation of abuse involving Resident #1. 28. The facility has implemented a new Abuse Investigation Check List to be utilized with every allegation of abuse. This check list includes contacting local Law Enforcement per the regulatory requirement as part of the agency reporting process. 29. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers have received education from the contracted Nurse Consultant on 10/18/18 on the new Abuse Investigation Check List, which includes contacting local Law Enforcement per the regulatory requirement, and the need to utilize this with allegations of abuse. ****The State Survey Agency determined Immediate Jeopardy was removed on 10/20/18 based on the following: 1. Review of Resident #1's medical record revealed the resident was sent out of the facility and admitted to an outpatient psychiatric unit on 09/26/18 at approximately 10:00 PM. 2. Review of Resident #1's medical record revealed the resident was readmitted back to the facility on [DATE] from an inpatient psychiatric unit. The resident had medications adjusted while in the inpatient psychiatric unit that included a decrease in the resident's [MEDICATION NAME] to 50 milligrams (mg) daily, and the resident started [MEDICATION NAME] 20 mg daily. 3. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility re-implemented an alarming stop sign to Resident #1's doorway on 10/03/18 when the resident was readmitted to the facility, to alert staff of anyone entering or exiting Resident #1's room. 4. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to prevent access underneath the current stop sign. Interviews on 10/31/18 with the DON at 2:48 PM, the SSD at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, UM #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a second alarming stop sign to Resident #1's doorway to prevent residents from entering below the alarming stop sign already in place on 10/17/18. 5. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to notify staff of the resident's whereabouts when he/she was outside of his/her room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the bells were added to Resident #1's walker on 10/17/18. 6. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to alert staff of anyone entering or exiting Resident #1's room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a motion sensor alarm at Resident #1's doorway to alert staff of anyone entering or exiting Resident #1's room on 10/19/18. 7. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to alert staff of Resident #1 exiting through the bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the facility placed an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of Resident #1 exiting through the bathroom. 8. Review of Resident #1's medical record revealed the resident's comprehensive care plan was updated on 10/17/18 with interventions of a second alarming stop sign at the doorway to reduce access underneath the current stop sign and bells to Resident #1's walker to notify staff of the resident's whereabouts. On 10/18/18, the comprehensive care plan was updated with an intervention of an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of anyone entering or exiting the bathroom. On 10/19/18, the resident's comprehensive care plan was updated with an intervention of a motion detector alarm at the doorway of Resident #1's room to alert staff of anyone approaching the doorway of Resident #1 or leaving Resident #1's room. Interviews on 10/31/18, with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed all the interventions had been added to Resident #1's care plan when implemented. 9. Interview with the SSD on 10/31/18 at 2:40 PM revealed a PHQ-9 was conducted for Resident #2 on 10/16/18. The SSD revealed she compared it to the previous PHQ-9 assessment for Resident #2 and no changes were identified in Resident #2's mood or depression level. Review of Resident #2's previous PHQ-9 and the assessment conducted on 10/16/18 confirmed no change in the assessment. 10. Review of facility incident reports revealed no inappropriate behaviors had been documented for Resident #1. Review of Resident #1's medical record revealed the comprehensive care plan was updated on 10/22/18 for Resident #1 to have 1:1 supervision by staff at all times. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed no knowledge of any inappropriate behaviors being displayed by Resident #1 since returning to the facility on [DATE]. Further interviews revealed Resident #1 was placed on 1:1 supervision on 10/22/18. No observations were made of Resident #1 because the resident was discharged to another facility on 10/25/18. 11. Review of Resident #1's medical record revealed a behavior note documented by the Social Services Director on 10/19/18 at 3:00 PM stating Resident #1 was upset with his/her current situation. The resident stated he/she had been interviewed five times and now had a Seeing Eye above his/her door. The resident requested to be transferred to another facility that had a men's unit because he/she felt he/she had been treated unfairly since the incident on 09/26/18. Resident #1's responsible party was also in agreement with this decision. Further review of the medical record revealed Resident #1 was discharged to a facility that had a men's behavioral health unit on 10/25/18. 12. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway and to the doorway of the adjoining bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the alarms were removed on 10/22/18. 13. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's walker. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the bells on Resident t#1's walker were removed on 10/22/18. 14. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#'1s doorway to notify assigned 1:1 staff of any residents approaching the doorway of Resident #1, so the resident could be redirected. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the sensor alarm at Resident #1's doorway was left in place until the resident was discharged from the facility on 10/25/18. 15. Review of the comprehensive care plans of all residents that were assessed by the facility to be severely cognitively impaired as determined by a Brief Interview for Mental Status (BIMS) score below eight (8), and identified to have the potential to wander utilizing a wheelchair or walker onto the hallway of Resident #1, revealed the care plans were updated to include a sound alerting device (bells) which was placed on their wheelchair/walker to alert staff to their whereabouts when outside of their rooms on 10/19/18. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the residents were provided with a sound alerting device. 16. Review of the Ambulatory Alert binder on 10/31/18, revealed pictures and names of the severely cognitively impaired and ambulatory residents, to alert staff to be aware of their location when they were out of their rooms; and in the vicinity of Resident #1's room. 17. Due to Resident #1's Physician order [REDACTED].#1's room, the facility determined that the residents no longer required the use of bells on their wheelchairs/walkers to prevent inappropriate contact with Resident #1. The bells were removed from the wheelchairs/walkers of these residents. Observations on 10/31/18 revealed no cognitively impaired, ambulatory residents that were assessed to wander were utilizing bells on their wheelchairs/walkers. 18. Review of the Ambulatory Alert binder on 10/31/18, revealed pictures and names of the severely cognitively impaired and ambulatory residents, to alert staff to be aware of the location when they are out of their rooms. 19. Interviews on 10/31/18 with the Administrator at 3:13 PM, Director of Clinical Services at 3:00 PM, DON at 2:48 PM, SSD at 2:40 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, and UM #3 at 12:15 PM, revealed they received education from the Nurse Consultant on 10/18/18, regarding completing a thorough investigation. The education included how to conduct interviews, utilizing re-enactments when necessary, and how to document investigation findings. 20. Interviews on 10/31/18 with SRNA #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, SRNA #16 at 11:35 AM, RN #1 at 12:06 PM, LPN #2 at 12:26 PM, and LPN #3 at 12:34 PM revealed they were educated by Administrative staff on 10/18/18 concerning the facility's abuse policy, including what constitutes abuse, resident to resident altercations, the need to protect the residents, and the need to immediately report all allegations of abuse to the appropriate staff. 21. Interviews on 10/31/18 with SRNA #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, SRNA #16 at 11:35 AM, RN #1 at 12:06 PM, LPN #2 at 12:26 PM, and LPN #3 at 12:34 PM revealed they were educated by Administrative staff on 10/18/18 concerning the alerting devices implemented for Resident #1, including the need to ensure the alarming stop signs and the bathroom door alarm were in place whenever the resident was in his/her room, the need for staff to remain alert to the resident's whereabouts when he/she was outside of his/her room, and for staff to listen for the bells on Resident #1's walker, and to immediately respond to the sound of the motion alarm over the entrance of Resident #1's door to determine who was approaching the room. 22. Interviews on 10/31/18 with SRNA #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, SRNA #16 at 11:35 AM, RN #1 at 12:06 PM, LPN #2 at 12:26 PM, and LPN #3 at 12:34 PM revealed they were educated by Administrative staff on 10/18/18 concerning the Ambulatory Alert Binder and residents with sound alerting devices who were assessed to have severe cognitive impairment and to be alert to their whereabouts when the residents were in the vicinity of the room of Resident #1. 23. Interviews on 10/31/18 with SRNA #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, SRNA #16 at 11:35 AM, RN #1 at 12:06 PM, LPN #2 at 12:26 PM, and LPN #3 at 12:34 PM revealed they were educated on the revisions to the original interventions for Resident #1 on 10/22/18, which included Resident #1 being on 1:1 supervision at all times, the removal of all devices except for the motion detector alarm on Resident #1's door, and the removal of the bells from all severely cognitively impaired residents' walkers and wheelchairs. Staff were also instructed to continue to utilize the Ambulatory Alert binder for severely cognitively impaired residents who wander. 24. Interviews on 10/31/18 with the Administrator at 3:13 PM, Director of Clinical Services at 3:00 PM, DON at 2:48 PM, SSD at 2:40 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, and UM #3 at 12:15 PM, revealed all abuse investigations would be reviewed in the daily morning meetings, including interventions that were necessary and implemented to address investigation findings and protect the residents. Further interviews revealed there had not been any allegations of abuse since 10/18/18. 25. Review of the QAPI team attendance record dated 10/19/18, revealed the investigative staff reviewed the circumstances of the allegation and all of the Allegation of Compliance interventions implemented by the facility. 26. Interview with the Administrator on 10/31/18 at 3:13 PM, revealed the facility has not had any allegations of abuse reported since 10/18/18. However, the Administrator was able to verbally communicate how the QAPI tool would be utilized to monitor compliance. 27. Interview with the Administrator on 10/31/18 at 3:13 PM, revealed he contacted local Law Enforcement on 10/18/18 concerning the self-reported allegation of abuse involving Resident #1. Review of a police report dated 10/31/18, revealed local Law Enforcement implemented an investigation on 10/18/18 concerning an allegation of abuse involving Resident #1. 28. Review of the Abuse Investigation Check List on 10/31/18 revealed it would be utilized with any allegation of abuse. Further review of the check list revealed it included contacting local Law Enforcement as part of the agency reporting process. 29. Interviews on 10/31/18 with the Administr

Based on interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure an allegation of resident-to-resident abuse was thoroughly investigated for one (1) of three (3) sampled residents (Resident #2) when the resident sustained [REDACTED].#1. On 09/26/18, Resident #1, who had a known history of sexually inappropriate behaviors with cognitively impaired female residents, was observed by facility staff fondling and playing with Resident #2's breasts. Although the facility initiated an investigation and interviewed the staff and residents involved, there was no evidence that the facility expanded the investigation to ensure other possible victims of abuse by Resident #1 were identified. The facility also failed to interview other staff members to ensure they were not aware of other potential abuse by Resident #1 that had not been reported or investigated. In addition, the facility's investigation concluded that abuse could not be substantiated, despite two (2) facility staff members witnessing the incident and the known history of Resident #1. The facility's failure to ensure a thorough abuse investigation was conducted has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/18, and determined to exist on 09/26/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/18. An acceptable Allegation of Compliance was received on 10/25/18, which alleged removal of the Immediate Jeopardy on 10/20/18. The State Survey Agency determined the Immediate Jeopardy was removed on 10/20/18, prior to exit on 10/31/18, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Prohibiting Abuse, Neglect, Misappropriation, and Exploitation Policy, revised 04/20/17, revealed any incidents of suspected abuse, including sexual abuse, would be immediately reported to the supervisor and the Administrator, at which time an investigation would begin. However, interview with Nurse Consultant #1 on 10/17/18 at 4:42 PM revealed the facility did not have a policy on how to conduct an abuse investigation. Review of Resident #1's medical record revealed the facility assessed Resident #1 on the Minimum Data Set (MDS) assessment dated [DATE], to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Further review of the resident's medical record revealed [REDACTED]. Further review of Resident #1's medical record revealed the resident had a history of [REDACTED]. The medical record revealed the female resident was unable to consent to sexual contact, and had been targeted by Resident #1 because she could not fight back. Further review of Resident #1's medical record revealed that due to the resident's sexually inappropriate behaviors with vulnerable female residents in the facility, he was subsequently referred to outpatient psychiatric therapy two to three times per week. Review of the psychiatric session notes revealed the resident admitted to messing with a woman in the facility, stating he/she was caught twice. The resident also revealed during the sessions that he/she chose women who were easy and available. The notes stated Resident #1 was evaluated to be very intelligent, manipulative, and would tell staff what they wanted to hear. Review of a facility investigation concluded on 09/27/18 revealed that on 09/26/18, two (2) facility staff members observed Resident #1 fondling and playing with Resident #2's breasts, in the doorway of Resident #1's room. The facility assessed Resident #2 to be severely cognitively impaired. The staff immediately reported the incident to Unit Manager (UM) #1. The residents were separated. Resident #1 denied the allegation. Resident #2 was assessed and found to have sustained no physical injury. The investigation revealed that interviews were conducted with the staff who were directly involved with the incident. However, the facility failed to interview other staff members to ensure they had no knowledge of other incidents of abuse to other residents by Resident #1 that had not been reported or investigated. In addition, there was no evidence found to indicate that other facility residents were interviewed to determine if Resident #1 had abused them. The facility also failed to interview Resident #1's roommate, whom the facility assessed to have a BIMS score of ten (10), indicating the roommate was moderately cognitively impaired, related to the incident or other possible occurrences of abuse by Resident #1 that the roommate may be knowledgeable of. In addition there was no evidence that the facility assessed residents in the facility who were non-interviewable to ensure those residents had not been victims of abuse by Resident #1. Further review of the facility's investigation concluded on 09/27/18, revealed that because Resident #1, who had a BIMS score of fifteen (15) and had no cognitive impairment, denied the allegation, stating he/she was assisting Resident #2 to pull his/her shirt down, and the fact that Resident #2 had wheeled into Resident #1's room, the allegation of abuse could not be substantiated. The investigation stated that no evidence of abuse could be established despite two (2) facility staff members verbally reporting and documenting in witness statements that they had both visualized/witnessed Resident #1 fondling and playing with Resident #2's breasts. There was no documented evidence found to indicate that the facility took into consideration Resident #1's [DIAGNOSES REDACTED]. Interviews with the Director of Nursing (DON) on 10/15/18 at 4:08 PM, on 10/16/18 at 10:57 AM, 11:50 AM, 3:20 PM, and 4:15 PM, on 10/17/18 at 5:37 PM and 6:45 PM, and on 10/18/18 at 1:17 PM, revealed she was responsible to initiate all investigations. The DON stated when she investigated an allegation of abuse she would write down the witness statements or have the witnesses write down their own statements. She would interview the residents that were involved and the staff that were working in the area when the incident occurred. However, according to the DON, no other staff or residents would be interviewed. The DON stated she would ensure notifications were made to the physician and the responsible party. She stated she was responsible to fill out the Resident Abuse Investigation Report Form and document any new interventions that the facility would implement, after the investigation was completed. The DON further revealed the Administrator was responsible to notify the appropriate State agencies, and when the investigation was completed the Administrator, the owner of the facility, and she would discuss the findings of the investigation. She stated that during the investigation for Resident #1 and Resident #2, she interviewed Resident #1 but could not interview Resident #2 because of the resident's cognition. The DON stated Resident #1 told her that Resident #2 rolled his/her wheelchair into Resident #1's room and pulled his/her shirt up. Resident #1 further told her that he/she was trying to pull Resident #2's shirt back down. The DON stated no other residents were interviewed or assessed because, (Resident #1) did not leave (his/her) room to try and touch another resident inappropriately, (Resident #2) went into (Resident #1's) room. Further interview with the DON revealed she did not interview Resident #1's roommate because the roommate was not in the room when the incident occurred. The DON stated she did not interview family members or visitors because only two staff members witnessed the incident. She further stated that staff had been instructed to educate and encourage the wanderers not to enter other residents' rooms. However, the DON was unable to state how this would protect residents in the facility due to the wandering residents' cognition being impaired and unable to comprehend the education or encouragement. Despite the facility failing to interview other cognitively intact residents, failing to physically assess other cognitively impaired residents, failing to interview other staff members regarding their knowledge of abuse by Resident #1, and failing to consider Resident #1's [DIAGNOSES REDACTED]. Interview with the Administrator on 10/17/18 at 6:45 PM, revealed that during an investigation he was responsible to notify the appropriate State agencies. He further stated, When the investigation is complete, I will review it, and will interview any staff or residents to get whatever answers I need. The Administrator stated, I interviewed (Resident #1) myself, (he/she) has a BIMS of 15, so I took the resident at (his/her) word, that (he/she) was not playing with (Resident #2's) breasts. Why would (he/she) lie about it? The Administrator further stated, No other residents should have been interviewed, because (Resident #1) did not have any contact with them. He also stated that no further staff should have been interviewed and he agreed with the DON that a thorough investigation had been completed. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 10/20/18: 1. Resident #1 was transferred out of the facility to an in-patient psychiatric facility on 09/26/18 for evaluation. 2. Resident #1 was readmitted to the facility on [DATE], after medication adjustments were made during the resident's stay in the psychiatric unit. 3. The intervention of an alarming stop sign was re-implemented upon the resident's return to the facility on [DATE], to alert staff of anyone entering or exiting Resident #1's room. 4. A second alarming stop sign was placed on the door of Resident #1's room on 10/17/18 to prevent any resident access below the alarming stop sign already in place. 5. Bells were placed on the walker of Resident #1 on 10/17/18, to alert staff of Resident #1's whereabouts whenever he/she was outside of his/her room. 6. A motion detecting alarm was placed above Resident #1's room door on 10/19/18, to alert staff to anyone entering or exiting the resident's room. 7. An alarm was added to the adjoining bathroom door of Resident #1's room on 10/18/18 to alert staff if the resident exits through the bathroom. 8. All interventions implemented had been added to Resident #1's plan of care as of 10/19/18. 9. A PHQ-9 (a questionnaire that assesses a resident's degree of depression) interview was conducted by the SSD for Resident #2 on 10/16/18. A comparison to the previous PHQ-9 assessment for Resident #2 revealed no changes were identified in the resident's mood or depression level. 10. Upon evaluation of all of the above interventions put in place for Resident #1 on 10/22/18, it was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of Resident #1. Therefore, the interventions were revised. Resident #1 was placed on 1:1 supervision at all times on 10/22/18. 11. Resident #1 indicated to the facility that he/she would prefer to be transferred to another facility, rather than have the increased 1:1 supervision; and the resident's representative was in agreement with this decision. The facility is contacting all facilities that provide the psychiatric services needed for Resident #1, and will discuss any facility that has available placement with the guardian and Resident #1 for approval. 12. The alarming stop signs to Resident #1's room and the alarm on the adjoining bathroom were removed on 10/22/18. 13. The bells on the walker of Resident #1 were removed on 10/22/18. 14. The motion detector alarm on Resident #1's doorway was left in place to alert the assigned 1:1 staff to any resident approaching the doorway of Resident #1, so the resident may be redirected. 15. On 10/19/18, all residents with severely impaired cognition, as determined by a BIMS score below eight (8) on the most recent MDS, who have been identified as having the potential to wander via a wheelchair or with a walker onto the hall of Resident #1, have been evaluated for a sound alerting device (such as bells) to alert staff to their whereabouts when outside of their rooms. The devices were put into place and addressed on the residents' care plans. 16. Residents who are ambulatory have been included in the Ambulatory Alert binder, which alerts staff to monitor the residents if they are in the vicinity of Resident #1's room. 17. On 10/22/18, an evaluation of all of the above interventions put in place for residents who have the potential to wander with impaired cognition was conducted. It was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of the residents. Therefore, the interventions were revised. The bells were removed from the walkers and wheelchair of the residents. 18. Residents who are severely cognitively impaired and ambulatory remain in the Ambulatory Alert binder, to alert staff to be aware of the location when they are out of their rooms. 19. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers received education from the contracted Nurse Consultant on 10/18/18 on how to complete a comprehensive investigation. The education included conducting a detailed interview, conducting a follow-up interview if new information is identified, how and when to utilize re-enactments to clarify and demonstrate key facts, and how to document investigation findings. 20. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers on the facility's abuse policy, including what constitutes abuse, resident to resident altercations and the need to protect the residents, and the need to immediately report all allegations of abuse. 21. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers related to the alerting devices implemented for Resident #1 including the need to make sure the alarming stop signs and bathroom door alarm are in place whenever the resident is in the room, the need for staff to remain alert to the resident's whereabouts when he/she is outside of his/her room and they hear the bells on his/her walker, the need to immediately respond to the sound of the motion alarm over the room entrance of Resident #1's door to determine who is approaching the room, and if any immediate intervention is indicated. 22. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers regarding the Ambulatory Alert binder and residents with sound alerting devices who have severe cognitive impairment and may wander down the hallway of Resident #1, and to be alert to their whereabouts when the residents are in the vicinity of the room of Resident #1. 23. As of 10/22/18, education was conducted with all staff on the revisions to the original interventions for Resident #1; including the resident being placed on 1:1 supervision at all times, the removal of all devices except for the motion detector alarm on Resident #1's door, and the removal of the bells from all severely cognitively impaired resident walkers and wheelchairs. Staff were also instructed that the use of the Ambulatory Alert binder for severely cognitively impaired residents who wander would continue. 24. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers will review the findings from all abuse investigations as part of the daily morning meeting, including all interventions that are necessary and implemented to address investigation findings and protect the residents. 25. The investigative staff on the facility Quality Assurance and Performance Improvement (QAPI) team including the Administrator, Director of Clinical Services, Director of Nursing, and Director of Social Services along with the Unit Managers, Minimum Data Set Nurses, and the Medical Director met on 10/19/18 to review the circumstances of the allegation and all of the Allegation of Compliance interventions which have been implemented by the facility. 26. The QAPI tool to monitor compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, will be utilized with each allegation of abuse until the immediate jeopardy is lifted under the supervision of the Administrator. A plan of action will be developed for any issues identified. This tool directs the review of up to five (5) allegations, if five have occurred since the last review, to ensure that all of the required abuse policy components, including those specific to resident-to-resident altercations, have been implemented including protection of all residents. Results of each Abuse Allegation QAPI tool along with any plans of Actions implemented will be reviewed with the QAPI team as part of the monthly QAPI meetings. 27. The facility contacted local Law Enforcement on 10/18/18 and an officer completed a report on the self-reported allegation of abuse involving Resident #1. 28. The facility has implemented a new Abuse Investigation Check List to be utilized with every allegation of abuse. This check list includes contacting local Law Enforcement per the regulatory requirement as part of the agency reporting process. 29. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers have received education from the contracted Nurse Consultant on 10/18/18 on the new Abuse Investigation Check List, which includes contacting local Law Enforcement per the regulatory requirement, and the need to utilize this with allegations of abuse. ****The State Survey Agency determined Immediate Jeopardy was removed on 10/20/18 based on the following: 1. Review of Resident #1's medical record revealed the resident was sent out of the facility and admitted to an outpatient psychiatric unit on 09/26/18 at approximately 10:00 PM. 2. Review of Resident #1's medical record revealed the resident was readmitted back to the facility on [DATE] from an inpatient psychiatric unit. The resident had medications adjusted while in the inpatient psychiatric unit that included a decrease in the resident's [MEDICATION NAME] to 50 milligrams (mg) daily, and the resident started [MEDICATION NAME] 20 mg daily. 3. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility re-implemented an alarming stop sign to Resident #1's doorway on 10/03/18 when the resident was readmitted to the facility, to alert staff of anyone entering or exiting Resident #1's room. 4. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to prevent access underneath the current stop sign. Interviews on 10/31/18 with the DON at 2:48 PM, the SSD at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, UM #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a second alarming stop sign to Resident #1's doorway to prevent residents from entering below the alarming stop sign already in place on 10/17/18. 5. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to notify staff of the resident's whereabouts when he/she was outside of his/her room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the bells were added to Resident #1's walker on 10/17/18. 6. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to alert staff of anyone entering or exiting Resident #1's room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a motion sensor alarm at Resident #1's doorway to alert staff of anyone entering or exiting Resident #1's room on 10/19/18. 7. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to alert staff of Resident #1 exiting through the bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the facility placed an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of Resident #1 exiting through the bathroom. 8. Review of Resident #1's medical record revealed the resident's comprehensive care plan was updated on 10/17/18 with interventions of a second alarming stop sign at the doorway to reduce access underneath the current stop sign and bells to Resident #1's walker to notify staff of the resident's whereabouts. On 10/18/18, the comprehensive care plan was updated with an intervention of an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of anyone entering or exiting the bathroom. On 10/19/18, the resident's comprehensive care plan was updated with an intervention of a motion detector alarm at the doorway of Resident #1's room to alert staff of anyone approaching the doorway of Resident #1 or leaving Resident #1's room. Interviews on 10/31/18, with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed all the interventions had been added to Resident #1's care plan when implemented. 9. Interview with the SSD on 10/31/18 at 2:40 PM revealed a PHQ-9 was conducted for Resident #2 on 10/16/18. The SSD revealed she compared it to the previous PHQ-9 assessment for Resident #2 and no changes were identified in Resident #2's mood or depression level. Review of Resident #2's previous PHQ-9 and the assessment conducted on 10/16/18 confirmed no change in the assessment. 10. Review of facility incident reports revealed no inappropriate behaviors had been documented for Resident #1. Review of Resident #1's medical record revealed the comprehensive care plan was updated on 10/22/18 for Resident #1 to have 1:1 supervision by staff at all times. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed no knowledge of any inappropriate behaviors being displayed by Resident #1 since returning to the facility on [DATE]. Further interviews revealed Resident #1 was placed on 1:1 supervision on 10/22/18. No observations were made of Resident #1 because the resident was discharged to another facility on 10/25/18. 11. Review of Resident #1's medical record revealed a behavior note documented by the Social Services Director on 10/19/18 at 3:00 PM stating Resident #1 was upset with his/her current situation. The resident stated he/she had been interviewed five times and now had a Seeing Eye above his/her door. The resident requested to be transferred to another facility that had a men's unit because he/she felt he/she had been treated unfairly since the incident on 09/26/18. Resident #1's responsible party was also in agreement with this decision. Further review of the medical record revealed Resident #1 was discharged to a facility that had a men's behavioral health unit on 10/25/18. 12. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway and to the doorway of the adjoining bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the alarms were removed on 10/22/18. 13. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's walker. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the bells on Resident t#1's walker were removed on 10/22/18. 14. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#'1s doorway to notify assigned 1:1 staff of any residents approaching the doorway of Resident #1, so the resident could be redirected. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the sensor alarm at Resident #1's doorway was left in place until the resident was discharged from the facility on 10/25/18. 15. Review of the comprehensive care plans of all residents that were assessed by the facility to be severely cognitively impaired as determined by a Brief Interview for Mental Status (BIMS) score below eight (8), and identified to have the potential to wander utilizing a wheelchair or walker onto the hallway of Resident #1, revealed the care plans were updated to include a sound alerting device (bells) which was placed on their wheelchair/walker to alert staff to their whereabouts when outside of their rooms on 10/19/18. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the residents were provided with a sound alerting device. 16. Review of the Ambulatory Alert binder on 10/31/18, revealed pictures and names of the severely cognitively impaired and ambulatory residents, to alert staff to be aware of their location when they were out of their rooms; and in the vicinity of Resident #1's room. 17. Due to Resident #1's Physician order [REDACTED].#1's room, the facility determined that the residents no longer required the use of bells on their wheelchairs/walkers to prevent inappropriate contact with Resident #1. The bells were removed from the wheelchairs/walkers of these residents. Observations on 10/31/18 revealed no cognitively impaired, ambulatory residents that were assessed to wander were utilizing bells on their wheelchairs/walkers. 18. Review of the Ambulatory Alert binder on 10/31/18, revealed pictures and names of the severely cognitively impaired and ambulatory residents, to alert staff to be aware of the location when they are out of t

Based on observation, interview, record review, and review of a facility investigation, it was determined the facility failed to ensure the care plan was implemented for one (1) of three (3) sampled residents (Resident #1). On 11/23/17, the facility developed a care plan intervention for Resident #1 to have an alarming stop sign (a banner-like device that attaches to the sides of the door and alarms when detached) placed across the resident's door and to observe/be aware of others in/out of the resident's room because the resident had a history of [REDACTED]. The facility failed to ensure the alarming stop sign was in place. On 09/26/18, Resident #2, a cognitively impaired resident, went into Resident #1's room and staff observed Resident #1 playing with/fondling Resident #2's breasts. The facility's failure to ensure care plans were implemented to protect residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/18, and determined to exist on 09/26/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/18. An acceptable Allegation of Compliance was received on 10/25/18, which alleged removal of the Immediate Jeopardy on 10/20/18. The State Survey Agency determined the Immediate Jeopardy was removed on 10/20/18, prior to exit on 10/31/18, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Nurse Consultant on 10/17/18 at 4:42 PM, revealed the facility did not have a policy related to Care Plans. Review of the facility's Behavior Management policy, dated (MONTH) 2011, revealed Behavior Management was an individualized plan of care for specific residents with specific mood/behavior issues. The policy stated the plan of care was included in the Interdisciplinary Care Plan that was initiated upon admission/readmission and reviewed/revised at least quarterly and with an identified change of condition of the resident. Further review revealed the Interdisciplinary Care Plan listed goals and interventions related to individualized behavior issues of specific residents. The policy stated the Nursing Assistant Care Plan identified individualized interventions to be completed by nursing assistants for specific residents. Review of Resident #1's medical record revealed the facility admitted the resident on 02/14/15. Further review of the medical record revealed Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Further review of the Quarterly MDS revealed Resident #1 had a history of [REDACTED]. The facility also assessed the resident to have verbal behavior symptoms directed toward others, which included threatening, screaming, and cursing at others. Review of Resident #1's Comprehensive Care Plan initiated on 04/11/17, revealed the facility identified that the resident had the potential for alteration in behaviors, as evidenced by a history of acting out sexually toward another female resident who was unable to communicate or consent. The care plan stated that Resident #1 stated, Because she couldn't fight back. Further review of the Comprehensive Care Plan revealed the facility implemented interventions on 11/23/17, which included placing an alarming stop sign across Resident #1's door and to observe/be aware of others in/out of the resident's room. Review of the State Registered Nurse Aide (SRNA) Kardex, not dated, revealed the facility documented under the Special Needs section that Resident #1 was required to have a stop sign with an alarm at his/her doorway to alert staff of wandering residents. The facility also documented under the Behaviors/Mood section that Resident #1 required an alarming stop sign and staff were required to observe/be aware of others in/out of his/her room. Further review of the SRNA Kardex dated (MONTH) (YEAR) thru (MONTH) (YEAR) revealed the SRNAs had initialed/signed that all care (including the alarming stop sign across Resident #1's door) had been in place during their shift. Review of a facility investigation dated 09/27/18 revealed on 09/26/18 at 1:30 PM, Housekeeper #1 reported seeing Resident #2 roll his/her wheelchair into Resident #1's room. Housekeeper #1 witnessed Resident #1 place his/her hands under Resident #2's shirt and Resident #1 was playing with Resident #2's breasts. The investigation revealed Housekeeper #1 immediately alerted State Registered Nurse Aide (SRNA) #1. Review of SNRA #1's witness statement dated 09/26/18 (time unknown) revealed she saw Resident #2 sitting in Resident #1's doorway. SRNA #1 stated Resident #1 had both hands under Resident #2's shirt fondling his/her breasts. Interview with Housekeeper #1 on 10/15/18 at 11:22 AM, and with SRNA #1 on 10/15/18 at 11:33 AM revealed they observed Resident #1 fondling Resident #2's breasts on 09/26/18 in the doorway of Resident #1's room. The Housekeeper stated she did not see an alarming stop sign across Resident #1's doorway prior to the incident. SRNA #2 stated she could not remember if an alarming stop sign was in place on 09/26/18, but stated she did not hear it alarm. SRNA #2 stated the stop sign was often hanging on the hand rail next to Resident #1's door, not in use. Interview with the Unit Manager (UM) on 10/15/18 at 11:42 AM, revealed when SRNA #1 notified her of the incident, the alarming stop sign was already placed back on Resident #1's door, when she arrived at the resident's room. The UM stated she was not sure if the alarming stop sign was in place prior to the incident, but she did not hear an alarm sounding when the incident occurred. Interview with a Medication Technician on 10/15/18 at 2:13 PM, SRNA #8 on 10/16/18 at 12:53 PM, SRNA #11 on 10/16/18 at 1:53 PM, and SRNA #6 on 10/16/18 at 3:35 PM, revealed an alarming stop sign was not in use when this incident occurred. SRNA #6 stated the alarming stop sign had been taken down because Resident #1 .had not done anything inappropriate to another resident for a while. SRNA #8 also stated the stop sign was hanging on the hand rail by the resident's door, but was never placed across the door. The staff stated an alarming stop sign was not utilized for Resident #1 until after the incident occurred with Resident #2 on 09/26/18. Interview with Resident #1 on 10/16/18 at 2:56 PM revealed that the alarming stop sign was not always in use across his/her door and was usually pushed behind the door. The resident stated the day Resident #2 entered his/her room, the alarming stop sign was pushed back to the side of the door. Resident #1 further stated Resident #2 entered his/her room and the opportunity presented itself. Interview with the Director of Nursing (DON) on 10/16 18 at 3:20 PM, revealed an alarming stop sign was implemented for Resident #1 more than one year prior to the incident with Resident #2. The stop sign was implemented after another incident that involved Resident #1 and another cognitively impaired resident. The DON stated when nurses made rounds they should have ensured the alarming device was in place and functioning accordingly. She further stated SRNAs also signed the Kardex, indicating all alarming devices were in place and functioning. Interview with the Administrator on 10/16/18 at 3:43 PM, revealed the intervention for an alarming stop sign had been in place a long time and during his observations the stop sign had been in place. The Administrator stated if an intervention was required by the resident's care plan, it was the staff's job to ensure the alarming stop sign was in place. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 10/20/18: 1. Resident #1 was transferred out of the facility to an in-patient psychiatric facility on 09/26/18 for evaluation. 2. Resident #1 was readmitted to the facility on [DATE], after medication adjustments were made during the resident's stay in the psychiatric unit. 3. The intervention of an alarming stop sign was re-implemented upon the resident's return to the facility on [DATE], to alert staff of anyone entering or exiting Resident #1's room. 4. A second alarming stop sign was placed on the door of Resident #1's room on 10/17/18 to prevent any resident access below the alarming stop sign already in place. 5. Bells were placed on the walker of Resident #1 on 10/17/18, to alert staff of Resident #1's whereabouts whenever he/she was outside of his/her room. 6. A motion detecting alarm was placed above Resident #1's room door on 10/19/18, to alert staff to anyone entering or exiting the resident's room. 7. An alarm was added to the adjoining bathroom door of Resident #1's room on 10/18/18 to alert staff if the resident exits through the bathroom. 8. All interventions implemented had been added to Resident #1's plan of care as of 10/19/18. 9. A PHQ-9 (a questionnaire that assesses a resident's degree of depression) interview was conducted by the SSD for Resident #2 on 10/16/18. A comparison to the previous PHQ-9 assessment for Resident #2 revealed no changes were identified in the resident's mood or depression level. 10. Upon evaluation of all of the above interventions put in place for Resident #1 on 10/22/18, it was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of Resident #1. Therefore, the interventions were revised. Resident #1 was placed on 1:1 supervision at all times on 10/22/18. 11. Resident #1 indicated to the facility that he/she would prefer to be transferred to another facility, rather than have the increased 1:1 supervision; and the resident's representative was in agreement with this decision. The facility is contacting all facilities that provide the psychiatric services needed for Resident #1, and will discuss any facility that has available placement with the guardian and Resident #1 for approval. 12. The alarming stop signs to Resident #1's room and the alarm on the adjoining bathroom were removed on 10/22/18. 13. The bells on the walker of Resident #1 were removed on 10/22/18. 14. The motion detector alarm on Resident #1's doorway was left in place to alert the assigned 1:1 staff to any resident approaching the doorway of Resident #1, so the resident may be redirected. 15. On 10/19/18, all residents with severely impaired cognition, as determined by a BIMS score below eight (8) on the most recent MDS, who have been identified as having the potential to wander via a wheelchair or with a walker onto the hall of Resident #1, have been evaluated for a sound alerting device (such as bells) to alert staff to their whereabouts when outside of their rooms. The devices were put into place and addressed on the residents' care plans. 16. Residents who are ambulatory have been included in the Ambulatory Alert binder, which alerts staff to monitor the residents if they are in the vicinity of Resident #1's room. 17. On 10/22/18, an evaluation of all of the above interventions put in place for residents who have the potential to wander with impaired cognition was conducted. It was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of the residents. Therefore, the interventions were revised. The bells were removed from the walkers and wheelchair of the residents. 18. Residents who are severely cognitively impaired and ambulatory remain in the Ambulatory Alert binder, to alert staff to be aware of the location when they are out of their rooms. 19. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers received education from the contracted Nurse Consultant on 10/18/18 on how to complete a comprehensive investigation. The education included conducting a detailed interview, conducting a follow-up interview if new information is identified, how and when to utilize re-enactments to clarify and demonstrate key facts, and how to document investigation findings. 20. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers on the facility's abuse policy, including what constitutes abuse, resident to resident altercations and the need to protect the residents, and the need to immediately report all allegations of abuse. 21. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers related to the alerting devices implemented for Resident #1 including the need to make sure the alarming stop signs and bathroom door alarm are in place whenever the resident is in the room, the need for staff to remain alert to the resident's whereabouts when he/she is outside of his/her room and they hear the bells on his/her walker, the need to immediately respond to the sound of the motion alarm over the room entrance of Resident #1's door to determine who is approaching the room, and if any immediate intervention is indicated. 22. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers regarding the Ambulatory Alert binder and residents with sound alerting devices who have severe cognitive impairment and may wander down the hallway of Resident #1, and to be alert to their whereabouts when the residents are in the vicinity of the room of Resident #1. 23. As of 10/22/18, education was conducted with all staff on the revisions to the original interventions for Resident #1; including the resident being placed on 1:1 supervision at all times, the removal of all devices except for the motion detector alarm on Resident #1's door, and the removal of the bells from all severely cognitively impaired resident walkers and wheelchairs. Staff were also instructed that the use of the Ambulatory Alert binder for severely cognitively impaired residents who wander would continue. 24. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers will review the findings from all abuse investigations as part of the daily morning meeting, including all interventions that are necessary and implemented to address investigation findings and protect the residents. 25. The investigative staff on the facility Quality Assurance and Performance Improvement (QAPI) team including the Administrator, Director of Clinical Services, Director of Nursing, and Director of Social Services along with the Unit Managers, Minimum Data Set Nurses, and the Medical Director met on 10/19/18 to review the circumstances of the allegation and all of the Allegation of Compliance interventions which have been implemented by the facility. 26. The QAPI tool to monitor compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, will be utilized with each allegation of abuse until the immediate jeopardy is lifted under the supervision of the Administrator. A plan of action will be developed for any issues identified. This tool directs the review of up to five (5) allegations, if five have occurred since the last review, to ensure that all of the required abuse policy components, including those specific to resident-to-resident altercations, have been implemented including protection of all residents. Results of each Abuse Allegation QAPI tool along with any plans of Actions implemented will be reviewed with the QAPI team as part of the monthly QAPI meetings. 27. The facility contacted local Law Enforcement on 10/18/18 and an officer completed a report on the self-reported allegation of abuse involving Resident #1. 28. The facility has implemented a new Abuse Investigation Check List to be utilized with every allegation of abuse. This check list includes contacting local Law Enforcement per the regulatory requirement as part of the agency reporting process. 29. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers have received education from the contracted Nurse Consultant on 10/18/18 on the new Abuse Investigation Check List, which includes contacting local Law Enforcement per the regulatory requirement, and the need to utilize this with allegations of abuse. ****The State Survey Agency determined Immediate Jeopardy was removed on 10/20/18 based on the following: 1. Review of Resident #1's medical record revealed the resident was sent out of the facility and admitted to an outpatient psychiatric unit on 09/26/18 at approximately 10:00 PM. 2. Review of Resident #1's medical record revealed the resident was readmitted back to the facility on [DATE] from an inpatient psychiatric unit. The resident had medications adjusted while in the inpatient psychiatric unit that included a decrease in the resident's [MEDICATION NAME] to 50 milligrams (mg) daily, and the resident started [MEDICATION NAME] 20 mg daily. 3. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility re-implemented an alarming stop sign to Resident #1's doorway on 10/03/18 when the resident was readmitted to the facility, to alert staff of anyone entering or exiting Resident #1's room. 4. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to prevent access underneath the current stop sign. Interviews on 10/31/18 with the DON at 2:48 PM, the SSD at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, UM #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a second alarming stop sign to Resident #1's doorway to prevent residents from entering below the alarming stop sign already in place on 10/17/18. 5. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to notify staff of the resident's whereabouts when he/she was outside of his/her room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the bells were added to Resident #1's walker on 10/17/18. 6. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to alert staff of anyone entering or exiting Resident #1's room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a motion sensor alarm at Resident #1's doorway to alert staff of anyone entering or exiting Resident #1's room on 10/19/18. 7. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to alert staff of Resident #1 exiting through the bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the facility placed an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of Resident #1 exiting through the bathroom. 8. Review of Resident #1's medical record revealed the resident's comprehensive care plan was updated on 10/17/18 with interventions of a second alarming stop sign at the doorway to reduce access underneath the current stop sign and bells to Resident #1's walker to notify staff of the resident's whereabouts. On 10/18/18, the comprehensive care plan was updated with an intervention of an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of anyone entering or exiting the bathroom. On 10/19/18, the resident's comprehensive care plan was updated with an intervention of a motion detector alarm at the doorway of Resident #1's room to alert staff of anyone approaching the doorway of Resident #1 or leaving Resident #1's room. Interviews on 10/31/18, with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed all the interventions had been added to Resident #1's care plan when implemented. 9. Interview with the SSD on 10/31/18 at 2:40 PM revealed a PHQ-9 was conducted for Resident #2 on 10/16/18. The SSD revealed she compared it to the previous PHQ-9 assessment for Resident #2 and no changes were identified in Resident #2's mood or depression level. Review of Resident #2's previous PHQ-9 and the assessment conducted on 10/16/18 confirmed no change in the assessment. 10. Review of facility incident reports revealed no inappropriate behaviors had been documented for Resident #1. Review of Resident #1's medical record revealed the comprehensive care plan was updated on 10/22/18 for Resident #1 to have 1:1 supervision by staff at all times. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed no knowledge of any inappropriate behaviors being displayed by Resident #1 since returning to the facility on [DATE]. Further interviews revealed Resident #1 was placed on 1:1 supervision on 10/22/18. No observations were made of Resident #1 because the resident was discharged to another facility on 10/25/18. 11. Review of Resident #1's medical record revealed a behavior note documented by the Social Services Director on 10/19/18 at 3:00 PM stating Resident #1 was upset with his/her current situation. The resident stated he/she had been interviewed five times and now had a Seeing Eye above his/her door. The resident requested to be transferred to another facility that had a men's unit because he/she felt he/she had been treated unfairly since the incident on 09/26/18. Resident #1's responsible party was also in agreement with this decision. Further review of the medical record revealed Resident #1 was discharged to a facility that had a men's behavioral health unit on 10/25/18. 12. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway and to the doorway of the adjoining bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the alarms were removed on 10/22/18. 13. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's walker. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the bells on Resident t#1's walker were removed on 10/22/18. 14. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#'1s doorway to notify assigned 1:1 staff of any residents approaching the doorway of Resident #1, so the resident could be redirected. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the sensor alarm at Resident #1's doorway was left in place until the resident was discharged from the facility on 10/25/18. 15. Review of the comprehensive care plans of all residents that were assessed by the facility to be severely cognitively impaired as determined by a Brief Interview for Mental Status (BIMS) score below eight (8), and identified to have the potential to wander utilizing a wheelchair or walker onto the hallway of Resident #1, revealed the care plans were updated to include a sound alerting device (bells) which was placed on their wheelchair/walker to alert staff to their whereabouts when outside of their rooms on 10/19/18. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the residents were provided with a sound alerting device. 16. Review of the Ambulatory Alert binder on 10/31/18, revealed pictures and names of the severely cognitively impaired and ambulatory residents, to alert staff to be aware of their location when they were out of their rooms; and in the vicinity of Resident #1's room. 17. Due to Resident #1's Physician order [REDACTED].#1's room, the facility determined that the residents no longer required the use of bells on their wheelchairs/walkers to prevent inappropriate contact with Resident #1. The bells were removed from the wheelchairs/walkers of these residents. Observations on 10/31/18 revealed no cognitively impaired, ambulatory residents that were assessed to wander were utilizing bells on their wheelchairs/walkers. 18. Review of the Ambulatory Alert binder on 10/31/18, revealed pictures and names of the severely cognitively impaired and ambulatory residents, to alert staff to be aware of the location when they are out of their rooms. 19. Interviews on 10/31/18 with the Administrator at 3:13 PM, Director of Clinical Services at 3:00 PM, DON at 2:48 PM, SSD at 2:40 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, and UM #3 at 12:15 PM, revealed they received education from the Nurse Consultant on 10/18/18, regarding completing a thorough investigation. The education included how to conduct interviews, utilizing re-enactments when necessary, and how to document investigation findings. 20. Interviews on 10/31/18 with SRNA #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, SRNA #16 at 11:35 AM, RN #1 at 12:06 PM, LPN #2 at 12:26 PM, and LPN #3 at 12:34 PM revealed they were educated by Administrative staff on 10/18/18 concerning the facility's abuse policy, including what constitutes abuse, resident to resident altercations, the need to protect the residents, and the need to immediately report all allegations of abuse to the appropriate staff. 21. Interviews on 10/31/18 with SRNA #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, SRNA #16 at 11:35 AM, RN #1 at 12:06 PM, LPN #2 at 12:26 PM, and LPN #3 at 12:34 PM revealed they were educated by Administrative staff on 10/18/18 concerning the alerting devices implemented for Resident #1, including the need to ensure the alarming stop signs and the bathroom door alarm were in place whenever the resident was in his/her room, the need for staff to remain alert to the resident's whereabouts when he/she was outside of his/her room, and for staff to listen for the bells on Resident #1's walker, and to immediately respond to th

Based on interview, record review, review of outpatient psychiatric notes, review of the Elder Justice Act, review of the facility's policies, and review of the Administrator's Job Description, it was determined the Administrator failed to ensure the facility was administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Resident #1 had a known history of displaying sexually inappropriate behaviors with cognitively impaired female residents. Although the facility had arranged for Resident #1 to receive treatment at an outpatient psychiatric center weekly, in an effort to diminish the risk of Resident #1 continuing to exhibit the sexually inappropriate behaviors, no effort was made to coordinate the care of Resident #1 based on the resident's progress of the treatment in an effort to protect vulnerable female residents in the facility. On 09/26/18, Resident #1, for the minimum of a third time, sexually abused a cognitively impaired female resident. An investigation was initiated by the facility, but the Administrator failed to ensure the investigation was conducted thoroughly in order to ensure all the information was obtained to identify all possible victims of Resident #1 and ensure cognitively impaired female residents in the facility were safe from abuse by Resident #1. The Administrator also failed to ensure the facility notified Law Enforcement of the possible criminal act committed against Resident #2 by Resident #1. The facility did transfer Resident #1 to a psychiatric unit on 09/26/18, after the incident occurred with Resident #2. However, they readmitted the resident on 10/03/18, without initiating any additional interventions other than the interventions that were in place when the incident occurred on 09/26/18, which had been ineffective in protecting residents from abuse. The Administrator's failure to ensure the facility was administered in an effective manner has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/18, and determined to exist on 09/26/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/18. An acceptable Allegation of Compliance was received on 10/25/18, which alleged removal of the Immediate Jeopardy on 10/20/18. The State Survey Agency determined the Immediate Jeopardy was removed on 10/20/18, prior to exit on 10/31/18, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F608, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator Job Position, not dated, revealed the primary purpose of the Administrator's position was to direct the day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure the highest degree of quality care can be provided to residents at all times. Review of Resident #1's medical record revealed the facility admitted the resident on 02/14/15. Further review of the resident's medical record revealed [REDACTED]. The facility assessed Resident #1 to be cognitively intact with a Brief Interview for Mental Status score of fifteen (15). Continued review of Resident #1's medical record revealed that in (MONTH) (YEAR) and (MONTH) (YEAR) Resident #1 was discovered by facility staff having inappropriate sexual contact with unsampled Resident A, who was severely cognitively impaired with a BIMS score of three (3). However, both allegations that Resident #1 abused Resident A were unsubstantiated by the facility. Interventions initiated included Resident #1 attending outpatient psychiatric treatment three (3) times a week, and issuing the resident a 30-day discharge notice. Interview with the Administrator on 10/18/18 at 1:25 PM, revealed Resident #1 was not discharged from the facility because placement for the resident could not be found at another facility. However, there was no evidence that the facility re-evaluated the safety of cognitively impaired female residents in the facility once the decision was made that Resident #1 would remain in the facility. Review of a Psychiatric Evaluation dated 01/06/17 revealed the facility referred Resident #1 for treatment due to the resident exhibiting increased inappropriate sexual behaviors, specifically touching and groping another resident. The evaluation quoted the resident as stating, I was sent here because I was messing with a woman. The History of Present Illness portion of the evaluation stated Resident #1 had a history of [REDACTED]. The evaluation stated the patient had been redirected on several occasions by facility staff; however, the resident continued the behavior. The evaluation quoted the resident as stating, I was caught twice. Review of Resident #1's Outpatient Psychiatric notes from 01/03/18 through 09/26/18 revealed all the notes assessed Resident #1's insight, perception, and judgment to be intact. Further review of the session notes revealed repeated documentation that Resident #1 .had no human emotions and was highly intelligent. The session notes also revealed Resident #1 stated, I say lie and try to get away with as much as you can. Review of a facility investigation dated 09/27/18 revealed on 09/26/18 two (2) facility staff members observed Resident #1 fondling and playing with Resident #2's breasts in the doorway of Resident #1's room. Review of Resident #2's medical record revealed the facility assessed Resident #2 to be severely cognitively impaired, with a BIMS score of three (3). The incident was immediately reported to the Director of Nursing and the Administrator. An investigation was initiated. However, there was no evidence that the facility expanded the investigation to ensure other possible victims of abuse by Resident #1 were identified; and the facility failed to interview other staff to ensure they were not aware of other potential abuse by Resident #1 that had not been reported or investigated. Continued review of the investigation revealed the facility concluded that abuse could not be substantiated, despite two (2) facility staff members witnessing the incident and the known history of Resident #1. In addition, the facility also failed to notify local Law Enforcement to report that Resident #1 had been observed to sexually abuse Resident #2. Continued review of Resident #1's medical record revealed on 09/26/18, Resident #1 was transferred from the facility to the hospital and admitted to a psychiatric unit for evaluation and treatment. Review of the hospital documentation revealed Resident #1 was prescribed an antidepressant medication and readmitted back to the facility on [DATE]. However, the only interventions implemented by the facility to prevent Resident #1 from sexually abusing vulnerable female residents again were the interventions that were in place at the time of the incident on 09/26/18, which were ineffective in protecting cognitively impaired female residents in the facility. Further review of Resident #1's medical record and staff interviews revealed the facility implemented no increased supervision for Resident #1 after readmission on 10/03/18, and the resident was able to move freely about the facility at will. Interviews with the Administrator on 10/16/18 at 2:21 PM and 3:43 PM, on 10/17/18 at 4:42 PM and 6:45 PM, and on 10/18/18 at 1:33 PM, revealed the Administrator believed that Resident #1's history of sexually inappropriate behaviors with Resident A was due to the resident seeking (Resident #1) out. The Administrator stated that each time Resident #1 had been observed by staff to be sexually fondling other residents, it had occurred when the cognitively impaired residents had wandered into Resident #1's room. The Administrator stated that after the incident occurred in (MONTH) (YEAR), the facility attempted to find alternative placement for Resident #1, but was unable to find a facility that would accept the resident. Therefore, the Administrator stated he made the decision that Resident #1 would remain in the facility and no further attempts to find placement for the resident in another facility were pursued. The Administrator stated he did not feel that the facility needed to implement any increased supervision for Resident #1 or develop a plan to ensure the safety of cognitively impaired female residents when he decided that Resident #1 would remain in the facility, because Resident #1 was not the instigator of the incidents. Continued interview with the Administrator revealed that although the facility had arranged for Resident #1 to attend outpatient psychiatric therapy two to three times per week, the facility had no mutual contract with the psychiatric facility in order to coordinate the care for Resident #1. The Administrator stated the only information exchanged between the facility and the psychiatric clinic was when a medication change was recommended. The Administrator stated he had never reviewed progress notes or discussed Resident #1's treatment or progress with any member of the outpatient psychiatric team. The Administrator also stated that the facility had never requested the progress notes or made any attempt to review them to ensure the care being provided to Resident #1 in the facility was appropriate and that all necessary action was being taken to ensure the safety of cognitively impaired female residents in the facility. Further interview with the Administrator revealed he was notified on 09/26/18 of the interaction between Resident #1 and Resident #2. The Administrator stated that although the Director of Nursing (DON) may initiate an investigation and gather information, he was the one who ultimately made the decisions regarding how the investigation would be conducted, and if an allegation of abuse would be substantiated or unsubstantiated and any subsequent action taken. The Administrator stated he reviewed the completed investigation and thought that is was conducted thoroughly. He stated that no other residents or staff should have been interviewed because they were not involved in the incident. The Administrator stated he interviewed Resident #1 regarding the incident, and Resident #1 told him that Resident #2 had come into his/her room, pulled his/her shirt up, and showed him/her his/her breasts. The resident denied touching the resident's breasts and stated that he/she was assisting Resident #2 to pull his/her shirt down. The Administrator stated that Resident #1 was alert and oriented and had a BIMS score of fifteen (15) and I took (him/her) at (his/her) word; why would (he/she) want to lie? When asked if he was aware that Resident #1 had admitted to the outpatient psychiatric team that he/she lied to get away with as much as (he/she) could, the Administrator stated that (Resident #1) had never lied to me, so why shouldn't I believe (him/her)? When questioned related to two (2) facility staff members both witnessing the interaction and documenting that Resident #1 was touching Resident #2's breasts, the Administrator stated that they had observed the interaction from behind Resident #2, and he did believe the staff actually observed what they reported and documented. The Administrator went on to say that he along with the DON made the decision to unsubstantiate the allegation of abuse of Resident #2 by Resident #1 because Resident #1 did not leave his/her room and initiate the interaction. Continued interview with the Administrator revealed he was aware of the Elder Justice Act, and that he had a responsibility to notify local Law Enforcement of any reasonable suspicion of a crime committed against any resident residing in the facility. However, the Administrator stated that the police had never been notified of any inappropriate actions between Resident #1 and cognitively impaired female residents. The Administrator stated he did not view the actions of Resident #1 toward Resident #2 as an act of sexual abuse, despite the facility's policy defining sexual abuse as the non-consensual contact of any type with a resident; therefore, he stated he was not required to notify Law Enforcement of the incident because it did not meet the criteria. Further interview with the Administrator revealed the only time the facility would notify Law Enforcement would be if a major event occurred, such as battery. The Administrator stated that he was the facility staff person who made the decision as to whether or not an incident occurring in the facility would be reported to authorities, and which authorities would be notified. Further interview with the Administrator revealed that after Resident #1 was readmitted to the facility on [DATE], he did not feel that additional interventions needed to be implemented to protect cognitively impaired residents in the facility, because he felt the interventions that were in place at the time of the incident on 09/26/18 had been effective because Resident #2 had wandered into Resident #1's room when Resident #1 was minding (his/her) own business. The Administrator stated that prior to the incident on 09/26/18, Resident #1 had the same supervision as other residents in the facility, and that level of supervision was continued when Resident #1 returned to the facility on [DATE]. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 10/20/18: 1. Resident #1 was transferred out of the facility to an in-patient psychiatric facility on 09/26/18 for evaluation. 2. Resident #1 was readmitted to the facility on [DATE], after medication adjustments were made during the resident's stay in the psychiatric unit. 3. The intervention of an alarming stop sign was re-implemented upon the resident's return to the facility on [DATE], to alert staff of anyone entering or exiting Resident #1's room. 4. A second alarming stop sign was placed on the door of Resident #1's room on 10/17/18 to prevent any resident access below the alarming stop sign already in place. 5. Bells were placed on the walker of Resident #1 on 10/17/18, to alert staff of Resident #1's whereabouts whenever he/she was outside of his/her room. 6. A motion detecting alarm was placed above Resident #1's room door on 10/19/18, to alert staff to anyone entering or exiting the resident's room. 7. An alarm was added to the adjoining bathroom door of Resident #1's room on 10/18/18 to alert staff if the resident exits through the bathroom. 8. All interventions implemented had been added to Resident #1's plan of care as of 10/19/18. 9. A PHQ-9 (a questionnaire that assesses a resident's degree of depression) interview was conducted by the SSD for Resident #2 on 10/16/18. A comparison to the previous PHQ-9 assessment for Resident #2 revealed no changes were identified in the resident's mood or depression level. 10. Upon evaluation of all of the above interventions put in place for Resident #1 on 10/22/18, it was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of Resident #1. Therefore, the interventions were revised. Resident #1 was placed on 1:1 supervision at all times on 10/22/18. 11. Resident #1 indicated to the facility that he/she would prefer to be transferred to another facility, rather than have the increased 1:1 supervision; and the resident's representative was in agreement with this decision. The facility is contacting all facilities that provide the psychiatric services needed for Resident #1, and will discuss any facility that has available placement with the guardian and Resident #1 for approval. 12. The alarming stop signs to Resident #1's room and the alarm on the adjoining bathroom were removed on 10/22/18. 13. The bells on the walker of Resident #1 were removed on 10/22/18. 14. The motion detector alarm on Resident #1's doorway was left in place to alert the assigned 1:1 staff to any resident approaching the doorway of Resident #1, so the resident may be redirected. 15. On 10/19/18, all residents with severely impaired cognition, as determined by a BIMS score below eight (8) on the most recent MDS, who have been identified as having the potential to wander via a wheelchair or with a walker onto the hall of Resident #1, have been evaluated for a sound alerting device (such as bells) to alert staff to their whereabouts when outside of their rooms. The devices were put into place and addressed on the residents' care plans. 16. Residents who are ambulatory have been included in the Ambulatory Alert binder, which alerts staff to monitor the residents if they are in the vicinity of Resident #1's room. 17. On 10/22/18, an evaluation of all of the above interventions put in place for residents who have the potential to wander with impaired cognition was conducted. It was determined that while the interventions served to prevent any inappropriate contact between Resident #1 and any cognitively impaired residents, they did not meet the psychosocial needs of the residents. Therefore, the interventions were revised. The bells were removed from the walkers and wheelchair of the residents. 18. Residents who are severely cognitively impaired and ambulatory remain in the Ambulatory Alert binder, to alert staff to be aware of the location when they are out of their rooms. 19. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers received education from the contracted Nurse Consultant on 10/18/18 on how to complete a comprehensive investigation. The education included conducting a detailed interview, conducting a follow-up interview if new information is identified, how and when to utilize re-enactments to clarify and demonstrate key facts, and how to document investigation findings. 20. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers on the facility's abuse policy, including what constitutes abuse, resident to resident altercations and the need to protect the residents, and the need to immediately report all allegations of abuse. 21. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers related to the alerting devices implemented for Resident #1 including the need to make sure the alarming stop signs and bathroom door alarm are in place whenever the resident is in the room, the need for staff to remain alert to the resident's whereabouts when he/she is outside of his/her room and they hear the bells on his/her walker, the need to immediately respond to the sound of the motion alarm over the room entrance of Resident #1's door to determine who is approaching the room, and if any immediate intervention is indicated. 22. As of 10/18/18, all facility staff have received education by the Administrator, Director of Clinical Services, Director of Nursing, and Unit Managers regarding the Ambulatory Alert binder and residents with sound alerting devices who have severe cognitive impairment and may wander down the hallway of Resident #1, and to be alert to their whereabouts when the residents are in the vicinity of the room of Resident #1. 23. As of 10/22/18, education was conducted with all staff on the revisions to the original interventions for Resident #1; including the resident being placed on 1:1 supervision at all times, the removal of all devices except for the motion detector alarm on Resident #1's door, and the removal of the bells from all severely cognitively impaired resident walkers and wheelchairs. Staff were also instructed that the use of the Ambulatory Alert binder for severely cognitively impaired residents who wander would continue. 24. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers will review the findings from all abuse investigations as part of the daily morning meeting, including all interventions that are necessary and implemented to address investigation findings and protect the residents. 25. The investigative staff on the facility Quality Assurance and Performance Improvement (QAPI) team including the Administrator, Director of Clinical Services, Director of Nursing, and Director of Social Services along with the Unit Managers, Minimum Data Set Nurses, and the Medical Director met on 10/19/18 to review the circumstances of the allegation and all of the Allegation of Compliance interventions which have been implemented by the facility. 26. The QAPI tool to monitor compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, will be utilized with each allegation of abuse until the immediate jeopardy is lifted under the supervision of the Administrator. A plan of action will be developed for any issues identified. This tool directs the review of up to five (5) allegations, if five have occurred since the last review, to ensure that all of the required abuse policy components, including those specific to resident-to-resident altercations, have been implemented including protection of all residents. Results of each Abuse Allegation QAPI tool along with any plans of Actions implemented will be reviewed with the QAPI team as part of the monthly QAPI meetings. 27. The facility contacted local Law Enforcement on 10/18/18 and an officer completed a report on the self-reported allegation of abuse involving Resident #1. 28. The facility has implemented a new Abuse Investigation Check List to be utilized with every allegation of abuse. This check list includes contacting local Law Enforcement per the regulatory requirement as part of the agency reporting process. 29. The Administrator, Director of Clinical Services, Director of Nursing, Director of Social Services, and Unit Managers have received education from the contracted Nurse Consultant on 10/18/18 on the new Abuse Investigation Check List, which includes contacting local Law Enforcement per the regulatory requirement, and the need to utilize this with allegations of abuse. ****The State Survey Agency determined Immediate Jeopardy was removed on 10/20/18 based on the following: 1. Review of Resident #1's medical record revealed the resident was sent out of the facility and admitted to an outpatient psychiatric unit on 09/26/18 at approximately 10:00 PM. 2. Review of Resident #1's medical record revealed the resident was readmitted back to the facility on [DATE] from an inpatient psychiatric unit. The resident had medications adjusted while in the inpatient psychiatric unit that included a decrease in the resident's [MEDICATION NAME] to 50 milligrams (mg) daily, and the resident started [MEDICATION NAME] 20 mg daily. 3. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility re-implemented an alarming stop sign to Resident #1's doorway on 10/03/18 when the resident was readmitted to the facility, to alert staff of anyone entering or exiting Resident #1's room. 4. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to prevent access underneath the current stop sign. Interviews on 10/31/18 with the DON at 2:48 PM, the SSD at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, UM #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a second alarming stop sign to Resident #1's doorway to prevent residents from entering below the alarming stop sign already in place on 10/17/18. 5. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to notify staff of the resident's whereabouts when he/she was outside of his/her room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the bells were added to Resident #1's walker on 10/17/18. 6. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway to alert staff of anyone entering or exiting Resident #1's room. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, SRNA #15 at 11:30 AM, and SRNA #16 at 11:35 AM, revealed the facility placed a motion sensor alarm at Resident #1's doorway to alert staff of anyone entering or exiting Resident #1's room on 10/19/18. 7. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1 to alert staff of Resident #1 exiting through the bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed the facility placed an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of Resident #1 exiting through the bathroom. 8. Review of Resident #1's medical record revealed the resident's comprehensive care plan was updated on 10/17/18 with interventions of a second alarming stop sign at the doorway to reduce access underneath the current stop sign and bells to Resident #1's walker to notify staff of the resident's whereabouts. On 10/18/18, the comprehensive care plan was updated with an intervention of an alarming stop sign at the bathroom door adjoining Resident #1's room to alert staff of anyone entering or exiting the bathroom. On 10/19/18, the resident's comprehensive care plan was updated with an intervention of a motion detector alarm at the doorway of Resident #1's room to alert staff of anyone approaching the doorway of Resident #1 or leaving Resident #1's room. Interviews on 10/31/18, with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed all the interventions had been added to Resident #1's care plan when implemented. 9. Interview with the SSD on 10/31/18 at 2:40 PM revealed a PHQ-9 was conducted for Resident #2 on 10/16/18. The SSD revealed she compared it to the previous PHQ-9 assessment for Resident #2 and no changes were identified in Resident #2's mood or depression level. Review of Resident #2's previous PHQ-9 and the assessment conducted on 10/16/18 confirmed no change in the assessment. 10. Review of facility incident reports revealed no inappropriate behaviors had been documented for Resident #1. Review of Resident #1's medical record revealed the comprehensive care plan was updated on 10/22/18 for Resident #1 to have 1:1 supervision by staff at all times. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed no knowledge of any inappropriate behaviors being displayed by Resident #1 since returning to the facility on [DATE]. Further interviews revealed Resident #1 was placed on 1:1 supervision on 10/22/18. No observations were made of Resident #1 because the resident was discharged to another facility on 10/25/18. 11. Review of Resident #1's medical record revealed a behavior note documented by the Social Services Director on 10/19/18 at 3:00 PM stating Resident #1 was upset with his/her current situation. The resident stated he/she had been interviewed five times and now had a Seeing Eye above his/her door. The resident requested to be transferred to another facility that had a men's unit because he/she felt he/she had been treated unfairly since the incident on 09/26/18. Resident #1's responsible party was also in agreement with this decision. Further review of the medical record revealed Resident #1 was discharged to a facility that had a men's behavioral health unit on 10/25/18. 12. Review of Resident #1's medical record revealed a physician's orders [REDACTED].#1's doorway and to the doorway of the adjoining bathroom. Interviews on 10/31/18 with the Director of Nursing (DON) at 2:48 PM, the Social Services Director (SSD) at 2:40 PM, the Director of Clinical Services at 3:00 PM, the Administrator at 3:13 PM, Unit Manager (UM) #1 at 11:40 AM, UM #2 at 11:52 AM, UM #3 at 12:15 PM, Registered Nurse (RN) #1 at 12:06 PM, Licensed Practical Nurse (LPN) #2 at 12:26 PM, LPN #3 at 12:34 PM, State Registered Nurse Aide (SRNA) #1 at 11:06 AM, SRNA #13 at 11:13 AM, SRNA #14 at 11:25 AM, and SRNA #15 at 11:30 AM, revealed

Based on observation, interview, record review, and review of facility policies, it was determined facility staff failed to ensure care was provided in accordance with the written plan of care for one of three sampled residents (Resident #1). Facility staff assessed Resident #1 to be at risk for the development of pressure ulcers and developed care plan interventions that included observation/assessment of the resident's skin on a daily basis, during the provision of personal care, to determine skin breakdown. On [DATE], Resident #1's care plan was revised to apply soft hand rolls to the resident's hands and assess the resident's skin on a daily basis when care was provided. Record review revealed no documented evidence the resident's skin was assessed per the plan of care. On [DATE], Resident #1 was admitted to an acute care facility and was assessed to have pressure ulcers, with exposed tendon and bone to the right hand. However, interview and record review revealed the facility was unaware Resident #1 had pressure ulcers to the right hand when transported to an acute care facility on [DATE] (refer to F314). The resident expired at the hospital on [DATE]. The findings include: A review of the facility's undated "Patient Comprehensive Care Plans" policy revealed an interdisciplinary team would develop, review, and revise resident care plans after each resident assessment. The policy revealed the care plans would describe the services to be furnished to attain/maintain the resident's highest practicable physical, mental, and psychosocial well-being. A review of the closed medical record revealed Resident #1 was transferred and admitted to an acute care facility on [DATE], due to respiratory distress. A review of Resident #1's acute care record, and pictures of the resident's wounds obtained by the acute care staff, revealed upon admission to the acute care facility on [DATE], Resident #1 was assessed to have a Stage IV pressure ulcer to the right thumb with a white tendon exposed on the inner section of the thumb; a Stage IV pressure area to the right index finger with white bone exposed to the right side of the middle knuckle of the index finger; a Stage II pressure area to the resident's right middle finger with a darkened area to the left side of the middle knuckle of the finger; and an unstageable area to the resident's sacrum. A review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to be at risk for the development of pressure ulcers. The Comprehensive MDS Assessment revealed Resident #1 was assessed to have an unstageable pressure ulcer to the coccyx upon readmission from an acute care facility on [DATE]. A review of the resident's Care Area Assessment (CAA) Summary dated [DATE], revealed the facility assessed Resident #1 to require assistance with bed mobility, was incontinent of bowel and as a result was at risk for impaired skin integrity and pressures ulcers. According to the CAA, staff was to provide preventive skin care precautions and to observe for signs/symptoms of skin breakdown with daily care. A review of Resident #1's Comprehensive Care Plan dated [DATE], revealed Resident #1 was care planned for Potential for Alteration in Skin Integrity and was At Risk for Pressure Ulcers related to multiple risk factors which included the resident's fragile skin, his/her [DIAGNOSES REDACTED]. Interventions on the care plan revealed staff was to observe/assess Resident #1 for skin tears, bruises, impaired skin integrity/skin breakdown when providing daily care, and to provide preventive care precautions daily with care and as needed. Continued review of the care plan revealed, based on the facility's assessment, Resident #1 required a restorative nursing program due to stiffness of his/her joints, dysarthria (having problems with articulating), and the fact that the resident was nonambulatory. Documentation in Resident #1's closed medical record revealed staff updated the care plan on [DATE], and noted due to the stiffness in both of Resident #1's hands, staff was to apply soft hand rolls to the resident's hands and assess the resident's skin on a daily basis when they provided care. Continued review of documentation in the closed medical record of Resident #1 revealed from [DATE] through [DATE], staff assessed the resident's skin as "warm," "dry," and/or "pale." However, there was no documented evidence staff had observed/assessed Resident #1 for skin tears, bruises, impaired skin integrity/skin breakdown when providing daily care or that they had provided preventive care precautions when daily care was provided in accordance with the care plan. In addition, the review revealed no documentation after [DATE], following the addition of the soft hand rolls, of daily skin assessments of the hands as per the plan of care. Interviews conducted on [DATE], with State Registered Nursing Assistant (SRNA) #1 at 2:40 PM, with SRNA #2 at 3:00 PM, with SRNA #3 at 3:10 PM, and with SRNA #4 at 3:20 PM, revealed staff placed hand rolls or washcloths in the palm of Resident #1's right hand to prevent pressure areas to the resident's palm as a result of the resident "clenching" his/her fist. According to the SRNAs, Resident #1's hands were washed at least once per shift, a skin audit was performed on his/her hands at that time, and any skin issues were to be reported to the nurse. In addition, the SRNAs stated they had not observed any skin breakdown to Resident #1's hands when they provided care to the resident. Interview conducted on [DATE], at 3:30 PM, with Licensed Practical Nurse (LPN) #1 revealed she had performed skin assessments on Resident #1 on the days she provided care to the resident and documented these assessments in the nurse's notes. LPN #1 stated she performed an assessment of Resident #1's skin on [DATE], prior to transporting the resident to the acute care facility, and had not observed any skin breakdown to the resident's hands. However, record review revealed no documented evidence the skin assessments were completed. Interviews conducted on [DATE], at 5:20 PM, with the Assistant Director of Nursing (ADON) and at 5:45 PM, with the Director of Nursing (DON) confirmed SRNAs were required to perform skin audits every day when they provided resident care and to report any identified concerns related to the resident's skin to the charge nurses. The interview revealed nurses were also required to perform a "head to toe" skin assessment every shift for all residents with gastrostomy tubes ([DEVICE]s), with pressure ulcers, or that were identified to be a high level of care. According to the DON and the ADON, nurses were to document each skin assessment in the nurse's notes in the medical record. The interviews revealed random chart audits were completed weekly; however, the facility had failed to identify nurses were not documenting "head to toe" skin assessments.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure a resident who entered the facility without pressure sores did not develop pressure sores and that a resident having pressure sores received the necessary treatment and services to prevent the development of new pressure sores based on the resident's comprehensive assessment for one of three sampled residents (Resident #1). The facility assessed Resident #1 to have impaired skin integrity, a pressure sore to the coccyx, and was at risk for the development of pressure sores. The facility developed a care plan with interventions to observe and assess the resident for signs/symptoms of skin breakdown when daily care was provided. However, the facility failed to ensure policy and procedures and care plan interventions were implemented related to monitoring skin integrity for Resident #1. Resident #1 was transferred and admitted to an acute care facility on [DATE], and upon admission was assessed to have pressure ulcers to the right hand with bone and tendons exposed. Interview and record review revealed facility staff was unaware Resident #1 had pressure ulcers to the right hand and there was no documented evidence the resident's hand had been assessed per the plan of care (refer to F282). The resident expired at the hospital on [DATE]. The findings include: A review of the facility's undated Preventive Skin Protocol revealed staff was responsible to assess the resident's skin integrity every shift and monitor for discoloration, irritation, and breaks in the skin. A review of the facility's undated policy, Prevention of Pressure Ulcers, revealed as a preventive action staff was to inspect the resident's skin at least once per shift. Review of Resident #1's nurse's notes revealed the resident was transferred and admitted to an acute care facility on [DATE], due to Respiratory Distress. A review of Resident #1's acute care nurse's notes and pictures of the resident's wounds obtained by the acute care staff on [DATE], revealed upon admission to the acute care facility Resident #1 was assessed to have a Stage IV pressure ulcer to the right thumb with a white tendon exposed on the inner section of the thumb; a Stage IV pressure area to the right index finger with white bone exposed to the right side of the middle knuckle of the index finger; a Stage II pressure area to the resident's right middle finger with a darkened area to the left side of the middle knuckle of the finger; and an unstageable area to the resident's coccyx. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. A review of Resident #1's Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be at risk for development of pressure ulcers. The assessment revealed Resident #1 had an unstageable pressure ulcer to the coccyx that had been assessed upon the resident's readmission from an acute care facility on [DATE]. Review of the resident's Care Area Assessment (CAA) Summary dated [DATE], revealed the facility assessed Resident #1 to be at risk for impaired skin integrity and pressures ulcers due to the resident's bowel incontinence and the resident's need for assistance with bed mobility. In accordance with the resident's CAA, staff was to provide preventive skin care and was to observe for signs/symptoms of skin breakdown when they provided daily care. Review of Resident #1's care plan dated [DATE], revealed the facility addressed the resident's Potential for an Alteration in Skin Integrity and had identified the resident to be At Risk for the Development of Pressure Ulcers. The facility identified the resident's risk factors for the development of pressure sores as the resident's fragile skin, his/her [DIAGNOSES REDACTED]. Based on the identified risk factors, the facility developed interventions for staff to utilize to aid in the prevention of pressure sores which included daily observations of the resident for skin tears, bruises, impaired and/or breakdown of skin, and the provision of care as needed. Continued review of the care plan revealed Resident #1 required a restorative nursing program due to the resident's inability to ambulate, stiffness of his/her joints, and dysarthria (having problems to articulate). Further review of Resident #1's closed medical record revealed staff updated the care plan on [DATE], and noted, due to the stiffness in both of Resident #1's hands, staff was to apply soft hand rolls to the resident's hands and assess the resident's skin on a daily basis when they provided care. A review of nurse's notes in Resident #1's medical record from [DATE] through [DATE], revealed staff assessed the resident's skin as "warm," "dry," and/or "pale," however, there was no documented evidence facility staff had performed a skin observation/assessment every shift as required. The review revealed no documentation after [DATE], following the addition of the soft hand rolls of daily skin assessments of the hands. There was no documented evidence the facility had identified skin breakdown to the resident's hand. According to the nurse's notes, Resident #1 was transported to the local hospital on [DATE], at 12:30 PM, for respiratory distress. Interviews conducted on [DATE], at 2:40 PM, with State Registered Nursing Assistant (SRNA) #1 and at 3:00 PM with SRNA #2, revealed the SRNAs worked the first shift on the D Wing, the unit where Resident #1 resided prior to his/her hospitalization . Interviews conducted on [DATE], at 3:10 PM, with SRNA #3 and at 3:20 PM, with SRNA #4 revealed the SRNAs worked the second shift on the D Wing. The interviews revealed the SRNAs performed skin audits each time care was provided to the residents. The interviews revealed if skin issues were identified the SRNA would report the skin issue to the charge nurse and document the skin issue in the communication book. In addition, the interviews revealed the SRNAs placed hand rolls or washcloths in the palm of Resident #1's right hand to prevent the development of pressure areas to the resident's hand as a result of the resident "clenching" his/her fist. According to interview with the SRNAs, Resident #1's hands were washed at least once per shift and a skin audit was performed of his/her hands at that time. The SRNAs denied any skin breakdown to Resident #1's hands. Interview conducted on [DATE], at 3:30 PM, with Licensed Practical Nurse (LPN) #1 revealed nursing staff was to conduct a "head to toe" skin assessment of residents with pressure ulcers or [DEVICE]s or residents that received skilled services and were to document the assessment in the nurse's notes. LPN #1 stated she had assessed Resident #1 on a daily basis and, based on documentation, had noted the resident's skin was pale or pink, warm, and dry. The interview revealed the LPN had not assessed the resident to have skin breakdown on the hands. LPN #1 stated she performed a skin assessment on Resident #1 on [DATE], prior to the resident's transfer to the acute care facility and there was no skin breakdown to the resident's hands at that time. However, there was no documented evidence of a skin assessment being completed. Interviews conducted on [DATE], at 5:45 PM, with the Director of Nursing (DON) and at 5:20 PM, with the Assistant Director of Nursing (ADON) revealed SRNAs were required to perform skin audits every day when they provided personal care to residents and were to report any skin issues to the charge nurses. In addition, the interview revealed the nurses were also required to perform a "head to toe" skin assessment each shift for all residents with pressure ulcers or [DEVICE]s or who received skilled services and document the skin assessments in the nurse's notes. The interviews revealed random chart audits were completed weekly; however, the facility failed to identify that nurses were not documenting the skin assessments.

Based on observation, interview, and record review, the facility failed to ensure that services were provided to one of twenty-three residents in accordance with the resident's plan of care. The facility failed to ensure the care plan intervention for one-to-one supervision to prevent falls was continuously implemented and staff was knowledgeable of the intervention. Resident #7 sustained a fall on January 9, 2011, at which time the facility initiated and care planned for staff to provide one-to-one supervision to prevent falls. The facility failed to provide one-to-one supervision after 1:00 p.m. on January 9, 2011. On January 13, 2011, the resident fell and sustained a [MEDICAL CONDITION] requiring surgical repair. Upon return, the facility maintained the intervention for one-to-one supervision, however, failed to ensure staff was implementing the care plan as written. The findings include: A review of the medical record for resident #7 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed resident #7 as at risk for falls due to impaired balance during transitions, an unsteady gait, use of anti-anxiety agents, antidepressant agents, antipsychotic agents, diuretic medications, cognitive impairment, and a history of falls within the previous 180 days. A review of the comprehensive care plan revealed interventions including: provide assistance of one staff person for transfers and ambulation, keep the call light within reach, reinforce the need to call for assistance, provide a safe environment, and encourage the proper use of handrails and/or assistive devices. A review of the plan of care revealed resident #7 sustained a fall on January 9, 2011, and an intervention was added to "Apply one on one with resident" on January 9, 2011; however, review of the "Event Report Investigation" dated January 9, 2011, revealed the staff observed resident #7 one to one at the nurses' station from 11:30 a.m. until 1:00 p.m. on January 9, 2011. There was no evidence staff provided one-to-one supervision after 1:00 p.m. on January 9, 2011. An interview with the Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDS) for D Wing was conducted on February 16, 2011, at 10:40 a.m. The LPN/MDS stated resident #7 walked with a walker and was very unsteady but the LPN/MDS felt the resident was safe to ambulate with the assistance of one staff member as care planned. The LPN/MDS stated he/she was responsible for updating the resident's care plan following falls and had added the intervention to "Apply one-on-one with the resident." An interview with the Director of Nursing (DON) conducted on February 16, 2011, at 10:45 a.m., revealed the IDT reviewed the Event Report Investigation after resident #7 fell on [DATE]. The DON stated the IDT was aware resident #7 was assisted to the nurses' station on January 9, 2011, and staff provided one-on-one supervision for one and one-half hours following the resident's fall. According to the DON, he/she did not realize the care plan required continuous supervision. A review of the "Event Report Investigation" dated January 13, 2011, revealed resident #7 sustained a fall at 3:30 a.m. in the resident's room. According to the investigation, at 3:15 a.m., resident #7 was sitting in the bedside chair and declined to go to bed; at 3:30 a.m., the resident was found on the floor, and staff assisted the resident back to bed and sat with the resident for one hour. According to the event report, the resident was transferred to the hospital due to being unable to bear weight. According to resident #7's care plan, the resident was diagnosed with [REDACTED]. There was no evidence one-on-one supervision was being provided prior to the January 13, 2011 fall. A review of the plan of care for resident #7 following the resident's return from the hospital on January 19, 2011, revealed the resident continued to require one-to-one supervision and physical therapy for evaluation and treatment. In addition, the facility implemented a personal alarm for resident #7. Observations of resident #7 on February 17, 2011, at 2:53 p.m., revealed the resident was lying in a low bed with a fall mat to the right side of the bed and a personal alarm in use. Resident #7 was alert and responded to questions; however, content of the responses was not always appropriate. Continued observations throughout the day at 4:08 p.m., 5:45 p.m., and 7:15 p.m., revealed a personal alarm was in use for resident #7; however, there were no observations of continuous one-to-one supervision being provided by facility staff. An interview with Certified Nursing Assistant (CNA) #2 conducted on February 17, 2011, at 11:50 a.m., revealed resident #7 attempted to ambulate and transfer often without staff assistance prior to the falls. CNA #2 also stated the resident was not as unsteady then. CNA #2 further stated the staff was to provide assistance with transfers and ambulation; however, CNA #2 was unaware one-to-one supervision was required for resident #7.

Based on observation, interview, and record review, the facility failed to provide a safe environment and adequate supervision to prevent accidents for one of twenty-three sampled residents. The facility failed to follow the "Accident Prevention Policy." The facility assessed and identified resident #7 was at risk for falls. On January 9, 2011, resident #7 sustained a fall. While the facility developed an intervention for one-to-one supervision to prevent further falls, the facility failed to implement the intervention. This failure resulted in resident #7 falling on January 13, 2011, sustaining a hip fracture which required surgical repair. Additionally, while the facility maintained one-to-one supervision as an intervention for resident #7 upon return to the facility, the facility failed to ensure staff was knowledgeable of the intervention and that it was implemented. The findings include: A review of the facility's "Accident Prevention Policy", no date given, revealed the staff's actions following a fall should include: 1. Ascertaining if there were injuries, provide treatment as necessary, 2. Determining what may have caused/contributed to the fall, 3. Addressing the factors for the fall, and 4. Revising the resident's plan of care and/or facility practices as needed to reduce the likelihood of another fall. Further review of the "Policy on Post Falls/Accidents," no date given, revealed the Interdisciplinary Team (IDT) was to investigate Post Falls/Accidents. The IDT was to: 1. Review falls for contributing factors, 2. Evaluate and analyze hazards and risks of falls/accidents., 3. Implement interventions to reduce hazards and risks for falls/accidents, 6. Assess for appropriate assistive devices/alarms to prevent falls/accidents, and 7. Modify interventions as necessary. There was no evidence the facility followed their policies to address resident #7's falls. A review of the medical record for resident #7 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed resident #7 as at risk for falls due to impaired balance during transitions, an unsteady gait, use of anti-anxiety agents, antidepressant agents, antipsychotic agents, diuretic medications, cognitive impairment, and a history of falls within the previous 180 days. A review of the comprehensive care plan initiated on January 16, 2007, revealed the facility identified resident #7 was at risk for falls and developed interventions including: provide assistance of one staff person for transfers and ambulation, keep the call light within reach, reinforce the need to call for assistance, provide a safe environment, and encourage the proper use of handrails and/or assistive devices. A review of the Event Report Investigation, dated January 9, 2011, revealed the resident was found on the floor in the resident's room. According to the investigation, the facility assessed resident #7, noted initially no discolored areas, and the resident denied pain/discomfort. Possible causative factors were listed as "started to set in bedside chair and misjudged the distance, missing the front of the chair." Other causes/contributors were listed as "Unsteady gait, non-compliance with assisted transfers, does not recognize physical limitations and thinks he/she can still be independent." While the "Event Report Investigation" revealed staff observed resident #7 one-to-one at the nurses' station from 11:30 a.m. until 1:00 p.m. on January 9, 2011, record review of the falls risk care plan, updated on January 9, 2011, after resident #7 sustained the fall, revealed an intervention was added of, "Apply one on one with resident." There was no documented evidence staff provided one-to-one supervision after 1 p.m. on January 9, 2011. An interview conducted on February 16, 2011, at 11:50 a.m., with Certified Nursing Assistant (CNA) #2, the CNA providing care for resident #7, revealed the CNA was unaware resident #7 required one-on-one supervision. An interview with the Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDS) for D Wing was conducted on February 16, 2011, at 10:40 a.m. The LPN/MDS stated resident #7 walked with a walker and was very unsteady but the LPN/MDS felt the resident was safe to ambulate with the assistance of one staff member as care planned. The LPN/MDS stated he/she was responsible to update the resident's care plan following the falls and had added the intervention to "Apply one-on-one with the resident." The LPN/MDS further stated he/she did not set a timeframe regarding the intervention; however, the one-to-one was continued for one and one-half hours following the fall on January 9, 2011. An interview with the Director of Nursing (DON) conducted on February 16, 2011, at 10:45 a.m., revealed the Interdisciplinary Team (IDT) consisting of department heads and administration met weekly to discuss care issues/concerns including falls that occurred the previous week. According to the DON, documentation, including nurse's notes, care plans, and Event Report Investigations, was to be reviewed during these meetings. According to the DON, the IDT would have met on Monday, January 10, 2011, following the first fall sustained by resident #7 on January 9, 2011. The DON stated the IDT reviewed the Event Report Investigation after resident #7 fell on [DATE]. The DON stated the IDT was aware resident #7 was assisted to the nurses' station on January 9, 2011, and staff provided one-on-one supervision for one and one-half hours following the resident's fall. According to the DON, the IDT did not realize the care plan required continuous supervision; however, there was no documented evidence that the IDT met and discussed the resident's January 9, 2011 fall. Furthermore, interview on February 16, 2011, at 3:00 p.m., with the Physical Therapist Aide (PTA), who is a part of the IDT, revealed that she was unaware of the fall occurring on January 9, 2011. A review of an Event Report Investigation, dated January 13, 2011, revealed the resident was found on the floor near the entrance of the resident's room with the walker in front of the resident at 3:30 a.m. Possible causative factors for the fall were listed as dementia and progressing Alzheimer's and noncompliance with assistance for transfers. The recommended intervention was "Staff to sit one-on-one with the resident till ready to go to bed when he/she declines to go to bed at the routine bedtime. Provide calming." According to the care plan updated on January 13, 2011, staff was to "Apply 1:1 staffing with resident, assist back to bed to rest." A review of the nurse's notes, dated January 14, 2011, at 5:00 p.m., revealed resident #7 complained of pain and the nurse observed the resident's right leg was not extending normally. The facility notified the physician and transferred resident #7 to the emergency room for an evaluation. The resident was found to have sustained a fractured right hip which required surgical repair. An interview with the Director of Nursing (DON) conducted on February 16, 2011, at 10:45 a.m., revealed the IDT should have met again on Monday, January 17, 2011, following the second fall sustained by the resident on January 13, 2011, and reviewed the resident's fall. However, there was no documented evidence the facility updated the resident's care plan with other interventions to prevent falls or reviewed, and there was no documented evidence that the facility's IDT met regarding resident #7's January 13, 2011 fall. Additionally, further interview with the PTA revealed the staff was to notify PT of any falls sustained by residents to ensure an evaluation was completed by the Physical Therapy Department; however, the PTA stated she did not receive any notification of either of resident #7's falls and therefore no assessment was completed by the Physical Therapy Department. Record review revealed resident #7 returned to the facility on [DATE]. A review of the plan of care for resident #7 following the resident's return from the hospital revealed the resident continued to require one-to-one supervision and physical therapy for evaluation and treatment. In addition, the facility implemented a personal alarm for resident #7. Observations of resident #7 on February 16, 2011, at 2:53 p.m., revealed the resident was in a low bed with a fall mat to the right side of the bed and a personal alarm in use. Continued observations throughout the day at 4:08 p.m., 5:45 p.m., and 7:15 p.m., revealed a personal alarm was in use for resident #7. There were no observations of one-to-one supervision provided for resident #7 by facility staff. An interview conducted with Certified Nursing Assistant (CNA) #2 on February 16, 2011, at 11:50 a.m., revealed resident #7 was often noncompliant. CNA #2 stated the resident would get up without staff assistance frequently but at that time, before the fracture occurred, the resident was not as unsteady as he/she has been since returning from the hospital and was unaware the resident required one-to-one supervision after both falls and at present time. CNA #2 further stated the resident had not utilized a personal alarm until after he/she returned from the hospital. While the facility's event investigation detailed that the interventions prior to the fall were effective, the investigation did not identify that staff had not been providing the care planned intervention of one-to-one supervision. Furthermore, interview with the LPN/MDS also revealed he/she was responsible to ensure that documentation related to the fall was in the nurse's notes; however, she did not complete the required documentation. An interview with the facility Administrator on February 16, 2011, at 3:15 p.m., revealed the facility did not follow their Accident Prevention Policy.